not just antidepressants, but other drugs too
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Not Just Antidepressants, but other drugs too.
Chris Johnson
Antidepressant Specialist Pharmacist NHSGGC
c.johnson2@nhs.net
From conception to birth and beyond...
Chris Johnson
Antidepressant Specialist Pharmacist NHSGGC
c.johnson2@nhs.net
Outline
1. Which drugs?
2. What are the risks?
3. When should we think about the risks?
4. Information sources
5. Pharmacovigilence
6. Potential research
1. Which drugs?• Herbal
– Raspberry tea – miscarriage
• Antibiotics
– Trimethoprim – teratogenic 1st trimester
• Antiepileptics
• Cardiac drugs
– Warfarin, angiotensin inhibitors, beta-blockers
• Rheumatic disease modifying drugs
• etc, etc
1. When?• Pre-conception - amiodarone
• Conception – anti-inflammatories
• Pregnancy
– Start – anti-inflammatories
– Middle – ACE-Inhibitors
– End – opioids, benzodiazepines
• Birth – baby has withdrawals
• Breastfeeding – benzos, z-hypnotics
• Developmental - antiepileptics
2. What are the risks?
• SSRI antidepressants (fluoxetine/paroxetine):
– ↓ oxygenation due to pulmonary hypertension
– Risk ↑ from 2 in 1000 to 5 in 1000 pregnancies
– ↑ risk later in pregnancy vs <20 weeks
– Siblings exposed vs unexposed – no difference
NICE Eyes on Evidence: use of selective serotonin reuptake inhibitors or
venlafaxine in early preganancy Sept 2015
2. What are the risks?• Valproate exposure during pregnancy:
– Congenial malformations 1 in 10 pregnancies• Valproate + other antiepileptic further ↑ risks
– 30-40% exposed preschoolers • Delayed development: talking, walking, low intellectual
abilities, poor language skills and memory problems
– Autistic disorders ↑ 3-5x in exposed children
– Dose related risk: bigger dose bigger risk
– ▼MHRA Drug Safety Update. Medicines related to valproate: risk of
abnormal pregnancy outcomes 22nd Jan 2015
3. Think advice: How, when, where, who?
• Child, adolescent, adult – chemotherapy
– Harvest eggs?
• Which conditions: Rheumatology, UTIs?
• When starting treatment?
• Who is responsible?
– The Healthcare Team = Everyone
• Balancing the risk: treat vs don’t treat
4. Information sources
• British National Formulary paper/apps etc
• Medicines Information Services
– 17 Main centres UK
• Telephone numbers inside front page BNF
– Other local ones: general hospitals,
psychiatric hospitals.
4. Breastfeeding
www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
4. Information sourcesDatabases, National guideline and other
• Scottish Intercollegiate Guideline Network www.sign.ac.uk– SIGN 60 Postnatal Depression and Puerperal
Psychosis
– British Assoc Psychopharmacology – new guidance due: Antidepressants - pregnancy and the postnatal period www.bap.ac.uk
• NICE Clinical Knowledge Summaries: Depression www.cks.nice.org.uk
4. Information sources
Local guidelines and others
• NHSGGC: Depression treatment in
primary care
– Telephone: Perinatal Mental Health Service
– Links to above
• Maudsley prescribing guidelines – via
NHS Knowledge Network or buy one!!
4. Patient Information• Patient Information Leaflets in drug packaging
NHS Choices:
• Medicines in pregnancy http://www.nhs.uk/conditions/pregnancy-and-baby/pages/medicines-in-pregnancy.aspx
But
• Pre-conception – nothing
• Breastfeeding – nothing
• BUMPS: http://www.medicinesinpregnancy.org/Medicine--pregnancy/
4. Conflicting Advice
• One healthcare professional vs another!
– Challenge to provide balanced continuity of care
• Natural/herbals safer than modern drugs!
– Challenge to provide a balance informed view
5. Pharmacovigilence
• UK Epilepsy in Pregnancy Register
Outcome monitoring
http://epilepsyandpregnancy.co.uk/
• FARR Institute Data-linkage:
– Drugs in pregnancy to child’s educational
attainment.
• Yellow Cards – Report ADEs
www.yccscotland.scot.nhs.uk
5. PharmacovigilencePotential Research
• SafeHaven patient-level data linkage: Prescribing-Primary Care-Secondary Care-Social Care
• Awareness: Info access, used and not used
• Novel Psychoactive Substances (NPS) – legal highs
Compulsory drug monitoring?
• Easy – prescribed medicines
• Hard – non-prescribed herbal/hoemopathicmedicines
References• Joint Formulary Committee. British National Formulary.
69th ed. London: BMJ Group and Pharmaceutical Press;
March 2015.
• MHRA Drug Safety Update. SSRIs and SNRIs: risk of
persistent pulmonary hypertension in the newborn. 1st May
2010. https://www.gov.uk/drug-safety-update/ssris-and-
snris-risk-of-persistent-pulmonary-hypertension-in-the-
newborn
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