As states ban or limit abortion in the wake of the demise of Roe v. Wade, physicians are turning their attention to widely used drugs that can cause birth defects. At issue: Should these drugs still be prescribed to women of childbearing age if they don't have the option of terminating their pregnancies?
"Doctors are going to understandably be terrified that a patient may become pregnant using a teratogen that they have prescribed," said University of Pittsburgh School of Medicine rheumatologist Mehret Birru Talabi, MD, PhD, who works in a state where the future of abortion rights is uncertain. "While this was a feared outcome before Roe v. Wade was overturned, abortion provided an escape hatch by which women could avoid having to continue a pregnancy and potentially raise a child with congenital anomalies. I believe that prescribing is going to become much more defensive and conservative. Some clinicians may choose not to prescribe these medications to patients who have childbearing potential, even if they don't have much risk for pregnancy."
Other physicians expressed similar concerns in interviews. Duke University rheumatologist Megan E. B. Clowse, MD, MPH, fears that physicians will be wary of prescribing a variety of medications ― including new ones for which there are few pregnancy data ― if abortion is unavailable. "Women who receive these new or teratogenic medications will likely lose their reproductive autonomy and be forced to choose between having sexual relationships with men, obtaining procedures that make them permanently sterile, or using contraception that may cause intolerable side effects," she said. "I am very concerned that young women with rheumatic disease will now be left with active disease resulting in joint damage and renal failure."
Abortion is now banned in at least six states. That number may rise to 16 as more restrictions become law. Another five states aren't expected to ban abortion soon but have implemented gestational age limits on abortion or are expected to adopt them. In another nine states, courts or lawmakers will decide whether abortion remains legal.
Only 20 states and the District of Columbia have firm abortion protections in place.
Numerous drugs are considered teratogens, which means they may cause birth defects. Thalidomide is the most infamous, but there are many more, including several used in rheumatology, dermatology, and gastroenterology. Among the most widely used teratogenic medications are the acne drug isotretinoin and methotrexate, which is used to treat a variety of conditions, such as cancer, rheumatoid arthritis, and psoriasis.
Clowse, who helps manage an industry-supported website devoted to reproductive care for women with lupus (www.LupusPregnancy.org), noted that several drugs linked to birth defects and pregnancy loss are commonly prescribed in rheumatology.
"Methotrexate is the most common medication and has been the cornerstone of rheumatoid arthritis for at least two decades," she said. "Mycophenolate is our best medication to treat lupus nephritis, which is inflammation in the kidneys caused by lupus. This is a common complication for young women with lupus, and all of our guideline-recommended treatment regimens include a medication that causes pregnancy loss and birth defects, either mycophenolate or cyclophosphamide."
Rheumatologists also prescribe a large number of new drugs for which there are few data about pregnancy risks. "It typically takes about two decades to have sufficient data about the safety of our medications," she said.
Reflecting the sensitivity of the topic, Clowse made clear that her opinions don't represent the views of her institution. She works in North Carolina, where the fate of abortion rights is uncertain.
What about alternatives? "The short answer is that some of these medications work really well, and sometimes much better than the nonteratogenic alternatives," said Birru Talabi. "I'm worried about methotrexate. It has been used to induce abortions but is primarily used in the US as a highly effective treatment for cancer as well as a myriad of rheumatic diseases. If legislators try to restrict access to methotrexate, we may see increasing disability and even death among people who need this medication but cannot access it."
Rheumatologists aren't the only physicians who are worrying about the fates of their patients in a new era of abortion restrictions. Gastroenterologist Sunanda Kane, MD, MSPH, of the Mayo Clinic in Rochester, Minnesota, said several teratogenic medications are used in her field to treat constipation, viral hepatitis, and inflammatory bowel disease.
"When treating women of childbearing age, there are usually alternatives. If we do prescribe a medication with a high teratogenic potential, we counsel and document that we have discussed two forms of birth control to avoid pregnancy. We usually do not prescribe a drug with teratogenic potential with the 'out' being an abortion if a pregnancy does occur," she said. However, "if abortion is not even on the table as an option, we may be much less likely to prescribe these medications. This will be particularly true in patients who clearly do not have the means to travel to have an abortion in any situation."
Abortion is expected to remain legal in Minnesota, where Kane practices, but it may be restricted or banned in nearby Wisconsin, depending on the state legislature. None of her patients have had abortions after becoming pregnant while taking the medications, she said, although she said, "I did have a patient who because of her religious faith did not have an abortion after exposure and ended up with a stillbirth."
The crackdown on abortion won't just pose risks to patients who take potentially dangerous medications, physicians said. Kane said pregnancy itself is a significant risk for patients with "very active, uncontrolled gastrointestinal conditions where a pregnancy could be harmful to the mother's health or result in offspring that are very unhealthy." These include decompensated cirrhosis, uncontrolled Crohn's disease or ulcerative colitis, refractory gastroparesis, uncontrolled celiac sprue, and chronic pancreatitis, she said.
"There have been times when after shared decision-making, a patient with very active inflammatory bowel disease has decided to terminate the pregnancy because of her own ongoing health issues," she said. "Not having this option will potentially lead to disastrous results."
Clowse, the Duke University rheumatologist, echoed Kane's concerns about women who are too sick to bear children. "The removal of abortion rights puts the lives and quality of life for women with rheumatic disease at risk. For patients with lupus and other systemic rheumatic disease, pregnancy can be medically catastrophic, leading to permanent harm and even death to the woman and her offspring. I am worried that women in these conditions will die without lifesaving pregnancy terminations, due to worries about the legal consequences for their physicians."
The US Supreme Court's ruling that overturned Roe v. Wade has also raised the prospect that the court could ultimately allow birth control to be restricted or outlawed.
While the ruling states that "nothing in this opinion should be understood to cast doubt on precedents that do not concern abortion," Justice Clarence Thomas wrote a concurrence in which he said that the court should reconsider a 1960s ruling that forbids the banning of contraceptives. Republicans have dismissed concerns about bans being allowed, although Democrats, including the president and vice president, starkly warn that they could happen.
"If we as providers have to be concerned that there will be an unplanned pregnancy because of the lack of access to contraception," Kane said, "this will have significant downstream consequences to the kind of care we can provide and might just drive some providers to not give care to female patients at all given this concern."
The physicians quoted in this article report no relevant financial relationships.
Randy Dotinga is a freelance journalist who specializes in health and medicine.
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Cite this: No More 'Escape Hatch': Post Roe, New Worries About Meds Linked to Birth Defects - Medscape - Jun 29, 2022.