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Koldeweij C, Dibbets C, Franklin BD, Scheepers HCJ, de Wildt SN. A User-Driven Framework for Dose Selection in Pregnancy: Proof of Concept for Sertraline. Clin Pharmacol Ther 2024. [PMID: 39248386 DOI: 10.1002/cpt.3429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/07/2024] [Indexed: 09/10/2024]
Abstract
Despite growing knowledge of pregnancy-induced changes in physiology that may alter maternal and fetal pharmacokinetics, evidence-based antenatal doses are lacking for most drugs. Pharmacokinetic modeling and expanding clinical data in pregnancy may support antenatal doses. We aimed to develop and pilot a comprehensive and user-driven Framework for Dose Selection in Pregnancy to support the clinical implementation of a best-evidence antenatal dose for sertraline. After initial development and evaluation by experts, the framework prototype was piloted to formulate an antenatal dosing strategy for sertraline in depression and anxiety disorders. Next, the framework was reviewed and assessed for usability by a multidisciplinary working committee of end-users comprising healthcare practitioners, experts from other disciplines including pharmacometrics, reproductive toxicology and medical ethics, alongside pregnant women and a partner. The resulting framework encompasses the following: rationale for drug selection, a comprehensive analysis of pharmacokinetic and dose-related efficacy and safety data, and implementation aspects including feasibility and desirability of the recommended antenatal dose based on a structured maternal and fetal benefit-risk assessment. An antenatal dose recommendation for sertraline, as a case study, was formulated using this approach and endorsed for clinical use by the working committee. Future applications of the framework for other drugs can further demonstrate its suitability for developing best evidence, acceptable and clinically feasible antenatal doses.
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Affiliation(s)
- Charlotte Koldeweij
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Caroline Dibbets
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bryony D Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Grow, School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Saskia N de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pediatric and Neonatal Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Pistelli A, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Pregnant Women with Depressive Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6565. [PMID: 37623151 PMCID: PMC10454549 DOI: 10.3390/ijerph20166565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION The initiative of a consensus on the topic of antidepressant and anxiolytic drug use in pregnancy is developing in an area of clinical uncertainty. Although many studies have been published in recent years, there is still a paucity of authoritative evidence-based indications useful for guiding the prescription of these drugs during pregnancy, and the data from the literature are complex and require expert judgment to draw clear conclusions. METHODS For the elaboration of the consensus, we have involved the scientific societies of the sector, namely, the Italian Society of Toxicology, the Italian Society of Neuropsychopharmacology, the Italian Society of Psychiatry, the Italian Society of Obstetrics and Gynecology, the Italian Society of Drug Addiction and the Italian Society of Addiction Pathology. An interdisciplinary team of experts from different medical specialties (toxicologists, pharmacologists, psychiatrists, gynecologists, neonatologists) was first established to identify the needs underlying the consensus. The team, in its definitive structure, includes all the representatives of the aforementioned scientific societies; the task of the team was the evaluation of the most accredited international literature as well as using the methodology of the "Nominal Group Technique" with the help of a systematic review of the literature and with various discussion meetings, to arrive at the drafting and final approval of the document. RESULTS The following five areas of investigation were identified: (1) The importance of management of anxiety and depressive disorders in pregnancy, identifying the risks associated with untreated maternal depression in pregnancy. (2) The assessment of the overall risk of malformations with the antidepressant and anxiolytic drugs used in pregnancy. (3) The evaluation of neonatal adaptation disorders in the offspring of pregnant antidepressant/anxiolytic-treated women. (4) The long-term outcome of infants' cognitive development or behavior after in utero exposure to antidepressant/anxiolytic medicines. (5) The evaluation of pharmacological treatment of opioid-abusing pregnant women with depressive disorders. CONCLUSIONS Considering the state of the art, it is therefore necessary in the first instance to frame the issue of pharmacological choices in pregnant women who need treatment with antidepressant and anxiolytic drugs on the basis of data currently available in the literature. Particular attention must be paid to the evaluation of the risk/benefit ratio, understood both in terms of therapeutic benefit with respect to the potential risks of the treatment on the pregnancy and on the fetal outcome, and of the comparative risk between the treatment and the absence of treatment; in the choice prescription, the specialist needs to be aware of both the potential risks of pharmacological treatment and the equally important risks of an untreated or undertreated disorder.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), via di Porta Pinciana 6, 00187 Rome, Italy
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), via di Porta Pinciana 6, 00187 Rome, Italy
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Ser.D Biella—Drug Addiction Service, 13875 Biella, Italy
| | - Alessandra Pistelli
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella—Drug Addiction Service, 13875 Biella, Italy
- Italian Society of Addiction Diseases (SIPAD), via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
- Italian Society for Drug Addiction (SITD), via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
- Italian Society of Neuropsychopharmacology (SINPF), via Cernaia 35, 00158 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Italian Society of Neuropsychopharmacology (SINPF), via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
- Division of Clinic Psychiatry, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
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Robakis TK, Miyares S, Bergink V. Risks and benefits of pre-delivery taper in pregnant women taking antidepressants. Acta Psychiatr Scand 2023:10.1111/acps.13593. [PMID: 37421329 PMCID: PMC11166172 DOI: 10.1111/acps.13593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/19/2023] [Accepted: 06/23/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Serotonin reuptake inhibitors are commonly used for treatment of mental health problems in pregnancy but may cause neonatal adaptation syndrome. It is unknown whether reduction or discontinuation of medication prior to delivery may mitigate this effect. METHODS We present a case series of 38 women who either tapered their medication prior to delivery or maintained or increased their dose. RESULTS Greater reductions in maternal antidepressant dose just prior to delivery were associated with fewer admissions to the neonatal intensive care unit (NICU) for infants. There was a slightly greater increase in depressive symptoms across delivery for women who tapered, which was not statistically significant. CONCLUSIONS NICU admissions may be less frequent among neonates whose mothers tapered their medication prior to delivery. Large prospective randomized trials are needed to further study this practice.
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Affiliation(s)
- Thalia K Robakis
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samantha Miyares
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Veerle Bergink
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Trinh NTH, Munk-Olsen T, Wray NR, Bergink V, Nordeng HME, Lupattelli A, Liu X. Timing of Antidepressant Discontinuation During Pregnancy and Postpartum Psychiatric Outcomes in Denmark and Norway. JAMA Psychiatry 2023; 80:441-450. [PMID: 36884236 PMCID: PMC9996461 DOI: 10.1001/jamapsychiatry.2023.0041] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Importance Approximately one-half of women treated for affective disorders discontinue antidepressant use during pregnancy, yet this discontinuation could lead to relapse post partum. Objective To investigate the associations between longitudinal antidepressant fill trajectories during pregnancy and postpartum psychiatric outcomes. Design, Setting, and Participants This cohort study used nationwide registers in Denmark and Norway. The sample included 41 475 live-born singleton pregnancies in Denmark (1997-2016) and 16 459 in Norway (2009-2018) for women who filled at least 1 antidepressant prescription within 6 months before pregnancy. Exposures Antidepressant prescription fills were obtained from the prescription registers. Antidepressant treatment during pregnancy was modeled using the k-means longitudinal method. Main Outcomes and Measures Initiation of psycholeptics, psychiatric emergencies, or records of self-harm within 1 year post partum. Between April 1 and October 30, 2022, hazard ratios (HRs) for each psychiatric outcome were estimated using Cox proportional hazards regression models. Inverse probability of treatment weighting was used to control for confounding. Country-specific HRs were pooled using random-effects meta-analytic models. Results Among 57 934 pregnancies (mean [SD] maternal age, 30.7 [5.3] years in Denmark and 29.9 [5.5] years in Norway), 4 antidepressant fill trajectories were identified: early discontinuers (31.3% and 30.4% of the included pregnancies in Denmark and Norway, respectively), late discontinuers (previously stable users) (21.5% and 27.8%), late discontinuers (short-term users) (15.9% and 18.4%), and continuers (31.3% and 23.4%). Early discontinuers and late discontinuers (short-term users) had a lower probability of initiating psycholeptics and having postpartum psychiatric emergencies vs continuers. A moderately increased probability of initiation of psycholeptics was found among late discontinuers (previously stable users) vs continuers (HR, 1.13; 95% CI, 1.03-1.24). This increase in late discontinuers (previously stable users) was more pronounced among women with previous affective disorders (HR, 1.28; 95% CI, 1.12-1.46). No association between antidepressant fill trajectories and postpartum self-harm risk was found. Conclusions and Relevance Based on pooled data from Denmark and Norway, a moderately elevated probability of initiation of psycholeptics in late discontinuers (previously stable users) vs continuers was found. These findings suggest that women with severe mental illness who are currently on stable treatment may benefit from continuing antidepressant treatment and personalized treatment counseling during pregnancy.
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Affiliation(s)
- Nhung T H Trinh
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Trine Munk-Olsen
- NCRR-The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Naomi R Wray
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
- Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Veerle Bergink
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hedvig M E Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Xiaoqin Liu
- NCRR-The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
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