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Lebetkin E, Steiner MJ, Sonneveldt E, Selim A, Feyisetan B, Ndugga BM, Munthali AW, Malkin M, Jallow F. Couple-Years of Protection Indicator: New Global Guidance for Updating Existing Methods and Adding New Methods. GLOBAL HEALTH, SCIENCE AND PRACTICE 2024; 12:e2300388. [PMID: 38589048 PMCID: PMC11057804 DOI: 10.9745/ghsp-d-23-00388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Couple-years of protection (CYP) is an indicator that allows for monitoring and evaluating of family planning (FP) program performance through simple calculations. The CYP for each contraceptive method is calculated by multiplying the number of contraceptive commodity units distributed to clients over a 1-year period by a conversion factor that quantifies the duration of contraceptive protection provided per unit distributed. CYP calculations across methods were previously updated in 2000 and 2011, resulting in changes in methodology, factor inclusion, and specific methods. Since the 2011 update, changes and additions to the modern contraceptive method mix required new CYP conversion factors for 4 methods of contraception: Levoplant implant, progestin-only pills (POPs), Caya diaphragm, and the hormonal intrauterine device. METHODS We conducted literature reviews of both published and gray literature and consulted with experts to identify updated data on continuation rates, duration of efficacy, and method effectiveness for the 4 methods. New CYP conversion factors were calculated for the 4 methods either by using the same calculation used previously for the method considering new data or, for new methods, using calculations for similar methods. RESULTS New CYP conversion factors were assigned to the 4 methods of contraception covered in this update: Levoplant, 2.5 CYP per implant inserted; POPs, 0.0833 CYP per pack (i.e., 12 cycles per CYP); Caya diaphragm, 1 CYP per device, and hormonal intrauterine device, 4.8 CYP per device inserted. CONCLUSIONS CYP is an important indicator for FP programs. As new methods of contraception are developed and new evidence is generated for current methods, the indicator may need to be updated. A standard process for updating and documenting future CYP updates is recommended.
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Affiliation(s)
| | | | | | - Amani Selim
- Public Health Institute Contractors with USAID Global Health Training, Advisory and Support Contract, Washington, DC, USA
| | - Bamikale Feyisetan
- Public Health Institute Contractors with USAID Global Health Training, Advisory and Support Contract, Washington, DC, USA
| | - Baker Maggwa Ndugga
- Public Health Institute Contractors with USAID Global Health Training, Advisory and Support Contract, Washington, DC, USA
| | - A Wezi Munthali
- Public Health Institute Contractors with USAID Global Health Training, Advisory and Support Contract, Washington, DC, USA
| | | | - Fatou Jallow
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Kim S, Cicali B, Pressly M, Da Silva L, Wendl T, Vozmediano V, Schmidt S, Cristofoletti R. Model-Based Analysis of In Vivo Release Data of Levonorgestrel Implants: Projecting Long-Term Systemic Exposure. Pharmaceutics 2023; 15:pharmaceutics15051393. [PMID: 37242635 DOI: 10.3390/pharmaceutics15051393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
Levonorgestrel (LNG) is a progestin used in many contraceptive formulations, including subcutaneous implants. There is an unmet need for developing long-acting formulations for LNG. To develop long-acting formulations, release functions need to be investigated for LNG implant. Therefore, a release model was developed and integrated into an LNG physiologically-based pharmacokinetic (PBPK) model. Utilizing a previously developed LNG PBPK model, subcutaneous administration of 150 mg LNG was implemented into the modeling framework. To mimic LNG release, ten functions incorporating formulation-specific mechanisms were explored. Release kinetic parameters and bioavailability were optimized using Jadelle® clinical trial data (n = 321) and verified using two additional clinical trials (n = 216). The First-order release and Biexponential release models showed the best fit with observed data, the adjusted R-squared (R2) value is 0.9170. The maximum released amount is approximately 50% of the loaded dose and the release rate is 0.0009 per day. The Biexponential model also showed good agreement with the data (adjusted R2 = 0.9113). Both models could recapitulate observed plasma concentrations after integration into the PBPK simulations. First-order and Biexponential release functionality may be useful in modeling subcutaneous LNG implants. The developed model captures central tendency of the observed data as well as variability of release kinetics. Future work focuses on incorporating various clinical scenarios into model simulations, including drug-drug interactions and a range of BMIs.
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Affiliation(s)
- Soyoung Kim
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA
| | - Brian Cicali
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA
| | - Michelle Pressly
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA
| | - Lais Da Silva
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA
| | - Thomas Wendl
- Bayer AG Pharmaceuticals, 51377 Leverkusen, Germany
| | - Valvanera Vozmediano
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA
| | - Rodrigo Cristofoletti
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA
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Application of exposure bracketing to streamline the development of contraceptive products. Contracept X 2022; 4:100072. [PMID: 35243326 PMCID: PMC8857469 DOI: 10.1016/j.conx.2022.100072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 01/05/2022] [Accepted: 01/20/2022] [Indexed: 11/20/2022] Open
Abstract
Developing new long-acting products of well-characterized contraceptive drugs is one way to address some of the reasons for unmet need for modern methods of family planning among women in low- and middle-income countries. Development and approval of such products traditionally follow a conventional paradigm that includes large Phase 3 clinical trials to evaluate efficacy (pregnancy prevention) and safety of the investigational product. Exposure-bracketing is a concept that applies known pharmacokinetics and pharmacodynamics of a drug substance to inform its safe and efficacious use in humans. Several therapeutic areas have applied this concept by leveraging established drug concentration-response relationships for approved products to expedite development and shorten the timeline for the approval of an investigational product containing the same drug substance. Based on discussions at a workshop hosted by the Bill & Melinda Gates Foundation in December 2020, it appears feasible to apply exposure-bracketing to develop novel contraceptive products using well-characterized drugs.
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Contraceptive Technology: Present and Future. Obstet Gynecol Clin North Am 2021; 48:723-735. [PMID: 34756292 DOI: 10.1016/j.ogc.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Many sexually active, reproductive-aged persons capable of becoming pregnant use some method of contraception. To expand options for those desiring birth control, new choices include a vaginal ring, transdermal patch, progestin-only pill, and spermicide. Compared with currently available methods, additional technologies that are highly effective, easy to use, cost efficient, and well-tolerated lay on the horizon. During contraceptive counseling, patient choice, and reproductive autonomy should remain paramount.
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Fuchs R, Taylor D, Jenkins DW, Brache V, Luo D, Dorflinger LJ, Steiner MJ. Levonorgestrel release rates measured through analysis of two-rod contraceptive explants. Contracept X 2020; 2:100039. [PMID: 32995746 PMCID: PMC7509190 DOI: 10.1016/j.conx.2020.100039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 11/15/2022] Open
Abstract
Objective The objective was to characterize and compare in vivo rates of levonorgestrel (LNG) release from Sino-implant (II) and Jadelle® contraceptive implants. Study design We sampled 48 Sino-implant (II) and 49 Jadelle® explant sets for residual LNG content from participants treated for up to 51 months in a randomized contraceptive efficacy trial in the Dominican Republic (DR). Additional Sino-implant (II) explants were obtained from 8 women who became pregnant in the DR trial and 10 who contributed 3 to 5 years of use in a cohort study in China. Baseline LNG loads were estimated from five unused implant sets per device type. Release profiles were estimated using mixture models that captured initial burst fractions and compared with efficacy and pharmacokinetics data from the DR trial. Results Estimated baseline LNG loads for Sino-implant (II) and Jadelle® were 142.8 mg and 150.5 mg, respectively (vs. the labeled 150 mg). There was an initial burst release of drug (5.6% and 7.9%, respectively) followed by an exponential decrease in LNG content evident for each device. Release rates were significantly lower for Sino-implant (II) throughout the treatment period, with estimated rates after 3 years of 24.2 mcg/day and 29.0 mcg/day for Sino-implant (II) and Jadelle®, respectively. The estimated Sino-implant (II) rate after 3 years was similar to the predicted rate after 5 years (23.6 mcg/day) for Jadelle® (rate ratio: 1.03; 95% confidence interval: 0.92-1.13). Conclusions Sino-implant (II) LNG release rates were significantly lower than Jadelle® with Sino-implant (II) rates through year 3 comparable to Jadelle® rates through year 5. These results reinforce the 3-year duration of action for which Sino-implant (II) was prequalified by the World Health Organization. Implications This analysis confirms the WHO prequalification of Sino-implant (II) for 3 years of use and supports different durations of action for Jadelle® and Sino-implant (II). It provides additional evidence that this approach can complement efficacy trials in determining duration of action of hormonal contraceptives in general.
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Affiliation(s)
- Rachael Fuchs
- FHI 360, 359 Blackwell St. Suite 200, Durham, NC 27701, USA
| | - Douglas Taylor
- FHI 360, 359 Blackwell St. Suite 200, Durham, NC 27701, USA
| | | | - Vivian Brache
- Asociación Dominicana Pro Bienestar de la Familia, Inc. (PROFAMILIA), Santo Domingo, Dominican Republic
| | - Diane Luo
- FHI 360, 359 Blackwell St. Suite 200, Durham, NC 27701, USA
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Che Y, Taylor D, Luo D, Maldonado LY, Wang M, Wevill S, Vahdat H, Han X, Halpern V, Dorflinger L, Steiner MJ. Cohort study to evaluate efficacy, safety and acceptability of a two-rod contraceptive implant during third, fourth and fifth year of product use in China. Contracept X 2019; 1:100008. [PMID: 32494773 PMCID: PMC7252427 DOI: 10.1016/j.conx.2019.100008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/08/2019] [Accepted: 05/14/2019] [Indexed: 11/26/2022] Open
Abstract
Objective Sino-implant (II) is a contraceptive implant approved for 4 years of use in China. We evaluated the contraceptive efficacy during the third, fourth and fifth year, and assessed additional pharmacokinetics (PK), safety, and acceptability endpoints. Study design We enrolled a cohort of 255 current Sino-Implant (II) users entering their third year and a second cohort of 243 users entering their fourth year. We followed these two cohorts for 12 and 24 months, respectively. To characterize PK endpoints (i.e. levonorgestrel (LNG), sex hormone binding globulin and free LNG index) over 5 years, we collected blood samples in a subset of 50 participants we followed during the third, fourth and fifth year. We also enrolled small cohorts (n = 20) of Sino-implant (II) users entering their sixth month and second year and followed them each for up to 6 months. Our primary efficacy measures were the pregnancy Pearl Indices during Year 3 and 4. Secondary objectives included assessments of PK, safety, acceptability and efficacy in the fifth year. Results We recorded four pregnancies, with a higher pregnancy rate during Year 3 [1.34 (95% CI: 0.28–3.93)] than Year 4 [0.44 (95% CI: 0.01–2.47)] or Year 5 [0.00 (95% CI: 0.00–2.02)]. The overall pregnancy rate for the third, fourth and fifth years of product use was 0.63 per 100 WY; 95% CI: (0.17–1.62). Mean LNG concentrations remained well above 200 pg/mL (Year 3 = 280.9; Year 4 = 233.6; Year 5 = 270.6). Most participants (93.7%) described their bleeding pattern as acceptable. Conclusion Sino-implant (II) is a highly effective contraceptive method in this population of Chinese women over 5 years. Implications Sino-implant (II) is a highly effective contraceptive method with an estimated Pearl Index of less than 1% over the third, fourth and fifth years of use in a population of Chinese women of reproductive age.
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Affiliation(s)
- Y Che
- Key Laboratory of Reproduction Regulation of NPFPC (SIPPR, IRD, Fudan University), Shanghai 200032, China
| | - D Taylor
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - D Luo
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - L Y Maldonado
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - M Wang
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - S Wevill
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - H Vahdat
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - X Han
- Henan Provincial Research Institute for Population and Family Planning, Henan, 450002, China
| | - V Halpern
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - L Dorflinger
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
| | - M J Steiner
- Contraceptive Technology Innovation Division, FHI 360, 359 Blackwell Street, Durham, NC 27701, USA
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