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We thank Dr Higgins and Gordon for their observations with which we agree completely. The opening paragraph of the article was not written by us but added as a 'standfirst' by the BMJ after we had agreed the proofs. We believe that this paragraph could be taken to mean that treatment could be harmful when the reverse is true. We concur that avoidance of flare and continuation of treatment is appropriate and have asked the BMJ to publish an addendum as soon as possible.

Competing interests: None declared

Competing interests: None declared

Lucy H Mackillop, Obstetric Medicine Registrar

Sarah J Germain and Catherine Nelson-Piercy

Queen Charlotte's Hospital, Du Cane Road, London, W12 0HS

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We would like to clarify the opening statement in this article that states that treatment of Systemic Lupus Erythematosus (SLE) disease activity in pregnancy may harm the baby.

Whilst published evidence is conflicting on whether pregnancy is associated with increased disease flare, it must be remembered that management of SLE, both in general and during pregnancy, has vastly progressed since the early 1990's when women were advised to stop all medications for pregnancy, resulting in flares which could have been prevented by maintenance therapy [1]. There is substantial evidence that the majority of flares occurring during pregnancy and the puerperium are mild/moderate, although patients with a history of renal involvement are at higher risk of deterioration [2]. It is clear that disease activity during pregnancy brings additional harm to baby over the baseline risk in quiescent SLE, being associated with prematurity and fetal loss [3 - 4]. Good control of disease activity in early pregnancy is essential to reduce these risks. Therapy may include low dose prednisolone [2], azathioprine [5], and /or hydroxychloroquine [6 - 8] as these have proved safe and efficacious in pregnancy [5]. Hydroxychloroquine in particular is associated with improved obstetric outcomes in SLE [9].

Chloroquine, although grouped with hydroxychloroquine in table 2 of this article, is not routinely used in the management of SLE either in or out of pregnancy due to increased tissue deposition and increased risk of retinal toxicity and of fetal abnormalities [10 - 11]. Women on cloroquine therapy should be converted to hydroxychloroquine with adequate time (several months) before conception to avoid fetal exposure [12].

In conclusion the overriding message for clinicians involved in the care of pregnant women with SLE is that close monitoring of maternal disease activity and fetal wellbeing is essential, and that continued maintenance therapy and prompt treatment of flares with appropriate medications is key to preventing excessive morbidity and mortality for mother and baby.

References:

[1] Gayed M, Gordon C. Pregnancy and Rheumatic Diseases. Rheumatol 2007;46:1634-40

[2] Petri M. Pregnancy in SLE. Bailliere's Clinical Rheumatology 1998;12:449-76

[3] Chakravarty E, Colon I, Langen E, Nix D, El-Sayed Y, Genovese M, Druzin M. Factors that predict prematurity and preeclampsia in pregnancies that are complicated by systemic lupus erythematosus. AJOG 2005;192(6):1897-1904

[4] Clowse M, Magder L, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthitis Rheum 2005;52(2):514-521

[5] Ostensen M, Khamashta M, Lockshin M, Parke A, Brucato A, Carp H, Doria A, Rai R, Meroni P, Cetin I, Derksen R, Branch W, Motta M, Gordon C, Ruiz- Irastorza G, Spinillo A, Friedman D, Cimaz R, Czeizel A, Piette JC, Cervera R, Levy RA, Clementi M, De CS, Petri M, Shoenfeld Y, Faden D, Valesini G, Tincani A: Anti-inflammatory and immunosuppressive drugs and reproduction. Arthritis Res Ther 2006; 8(3):209.

[6] Levy R, Viela V, Cataldo M et al. Hydroxychloroquine in lupus pregnancy; double blind and placebo-controlled study. Lupus 2001;10:401-404

[7] Clowse M, Magder L, Witter F, Petri M. Hydroxychloroquine in lupus pregnancy. Arthritis Rheum 2006;54(11):3640-7

[8] Costedoat-Chalumeau N, Amoura Z, Huong DL, Lechat P, Piette JC: Safety of hydroxychloroquine in pregnant patients with connective tissue diseases. Review of the literature. Autoimmun Rev 2005; 4(2):111-115

[9] Paufique L, Magnard P. Retinal degeneration in 2 children following preventative antimalarial treatment of the mother during pregnancy. Bull Soc Ophthal Fr 1969;69:466-7

[10] Ullberg S, Lindquist N, Sjostrand S. Accumulation of chorioretinotoxic drugs in the foetal eye. Nature 1970;227:1257-8

[11] Gordon C. Pregnancy and autoimmune diseases. Best Practice and Research in Clinial Rheumatology 2004;18(3):359-379

Competing interests: None declared

Competing interests: None declared

Lucy E Higgins, F2 Academic Rheumatology

Caroline Gordon

City Hospital, Birmingham, B18 7QH

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