not just antidepressants, but other drugs too
TRANSCRIPT
Not Just Antidepressants, but other drugs too.
Chris Johnson
Antidepressant Specialist Pharmacist NHSGGC
From conception to birth and beyond...
Chris Johnson
Antidepressant Specialist Pharmacist NHSGGC
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. Drugs in Pregancy
4. Drugs in Pregnancy
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