Probleme in der Adoleszenz: Sexualität und Reproduktion bei Patienten mit juveniler idiopathischer Arthritis (JIA)

Zusammenfassung

In der Adoleszenz melden sich Probleme, die mit der Geschlechtsreifung zusammenhängen. Von den Folgeerscheinungen einer juvenilen idiopathischen Arthritis (JIA) können die sexuelle Aktivität und die Beziehung zum anderen Geschlecht betroffen sein, doch trifft dies meist nur auf Patienten zu, die körperlich stark behindert sind, weiterhin aktive Krankheit haben oder ein reduziertes Selbstwertgefühl aufweisen. Die Fertilität ist bei JIA meist normal, doch kann aktuelle oder frühere medikamentöse Therapie die Fruchtbarkeit herabsetzen. Bei Therapie mit Chlorambucil oder Cyclophosphamid im Jugendalter sind Maßnahmen zum Gonadenschutz zu ergreifen. Bei vorbestehender Thrombophilie ist die Wahl einer hormonellen Antikonzeption eingeschränkt. Ansonsten ist die Verhütung bei der JIA unproblematisch. Eine Schwangerschaft beeinflusst die poly- und oligoartikuläre Form der JIA meist positiv, wogegen die systemische Form häufig aktiv bleibt. Etwa 60 % der Patientinnen mit JIA erleben eine Verschlechterung der Krankheit innerhalb der ersten sechs Monate nach einer Schwangerschaft. Medikamentöse Therapie während der Schwangerschaft verlangt sorgfältiges Abwägen möglicher Risiken für Mutter und Kind, ist aber möglich mit Kortikosteroiden, Salazopyrin, Antimalarika, Azathioprin und Cyclosporin. Früher abgeschlossene Therapie mit Zytostatika hat keine negativen Langzeitwirkungen auf den Nachwuchs von Eltern mit JIA.

Abstract

Sexual dysfunction can arise in female and male patients with JIA and is most often related to pain, fatigue, and physical impairment as well as to reduced self esteem. Antirheumatic drugs can interfere with fertility because of gonadotoxicity. The role of NSAID in delaying ovulation has not been sufficiently clarified. Gonadotoxic effects of immunosuppressive drugs depend on their mechanism of action, dose and duration of treatment. Alkylating agents can induce amenorrhea in women, and oligo- or azoospermia in men, but recovery of the gonadal function is possible. Preservation of fertility during cyclophosphamide therapy can be achieved by gonadotropin releasing hormone (GnRH) agonists in women and by sperm banking before commencement of the therapy in men. Pregnancy does not reactivate a JIA in remission, but a flare occurs in 58 % of women with JIA post partum regardless of disease activity at conception. The polyarticular and oligoarticular forms of JIA benefit mostly from pregnancy whereas the systemic form does not. As a rule, JIA does not impair fetal outcome. Drug treatment during pregnancy may be necessary in women with active JIA. The classic non-selective nonsteroidal anti-inflammatory drugs are not teratogenic, but given in late pregnancy they can induce renal and cardiac side effects in the fetus. NSAID should therefore be stopped by gestational week 32. Corticosteroids are frequently necessary to control rheumatic disease flares, but high doses (1 - 2 mg/kg) should be avoided in the first trimester because of an increased risk of oral clefts. Among disease modifying drugs, sulfasalazine and antimalarials have the safest record. Cyclosporine and azathioprine can be given throughout pregnancy if disease control requires it. Insufficient data exist for treatment of pregnant patients with TNF-inhibitors. Prophylactic withdrawal of drugs before pregnancy is mandatory for the cytotoxic agents methotrexate and cyclophosphamide. Previous treatment with cytotoxic drugs does not imply negative effects on future offspring of patients with JIA.

Schlüsselwörter

Juvenile idiopathische Arthritis - Adoleszenz - Sexualität - Fertilität - Schwangerschaft

Key words

Juvenile idiopathic arthritis - adolescence - sexuality - fertility - pregnancy

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