Long-acting injectable antipsychotic treatment during pregnancy: Outcomes for women at a tertiary maternity hospital

Use of Long-Acting Injectables for Severe Mental Illness in the Peripartum Period: A Case Report and a Scoping Review

The management of acute mania during pregnancy poses a complex clinical task, necessitating careful consideration of treatment options and demanding a delicate balance between the risks associated with medication use and the adverse impacts of untreated severe mental illness on the fetus. Medication nonadherence stands out as a significant factor contributing to relapse, with rates potentially reaching 40%. The pharmacokinetic profile of long-acting injectable (LAI) risperidone contrasts with that of oral risperidone, characterized by a gradual and consistent release from the depot, mitigating fluctuations between peak and trough concentrations. Clinically, this sustained plasma profile of LAI risperidone has been linked to a reduction in adverse events, such as extrapyramidal side effects, metabolic syndrome, and hyperprolactinemia. Numerous studies have indicated that LAI antipsychotic therapy correlates with reduced mortality rates and decreased number of hospitalizations. This case report illustrates the effective management of acute mania in a pregnant 32-year-old through the utilization of LAI risperidone. This case underscores the significance of individualized treatment strategies and emphasizes the potential utility of LAI antipsychotics as a viable therapeutic option for managing acute mania in pregnancy. Further research is warranted to delineate the long-term outcomes and safety profile of LAI antipsychotics in this population.

Outcomes of long-acting injectable antipsychotics use in pregnancy: A literature review

BACKGROUND

Women with a history of serious psychotic disorders are at increased risk of disease relapse during pregnancy. Long-acting injectable (LAI) antipsychotics have been widely used to improve adherence and prevent relapse in patients with various severe psychotic disorders, but there is a lack of high-quality data from previous research on the safety of LAI antipsychotics during pregnancy.

AIM

To summarize relevant data on maternal, pregnancy, neonatal, and developmental outcomes from published cases of LAI antipsychotic use in pregnancy.

METHODS

A literature search was performed through November 11, 2023, using three online databases: PubMed/MEDLINE, Scopus, and Web of Science. Case reports or case series that reported information about the outcomes of pregnancy in women who used LAI antipsychotics at any point in pregnancy, with available full texts, were included. Descriptive statistics, narrative summation, and tabulation of the extracted data were performed.

RESULTS

A total of 19 publications satisfied the inclusion criteria: 3 case series, 15 case reports, and 1 conference abstract. They reported the outcomes of LAI antipsychotic use in 74 women and 77 pregnancies. The use of second-generation LAI antipsychotics was reported in the majority (n = 47; 61.0%) of pregnancies. First-generation LAI antipsychotics were administered during 30 pregnancies (39.0%). Most of the women (approximately 64%) had either satisfactory control of symptoms or no information about relapse, while approximately 12% of them had developed gestational diabetes mellitus. A minority of cases reported adverse outcomes such as stillbirth, spontaneous abortion, preterm birth, low birth weight, congenital anomalies, and neurological manifestations in newborns. However, there were no reports of negative long-term developmental outcomes.

CONCLUSION

Currently available data seem reassuring, but further well-designed studies are required to properly evaluate the risks and benefits of LAI antipsychotic use during pregnancy.

Physiologically-based pharmacokinetic modelling of long-acting injectable cabotegravir and rilpivirine in pregnancy

AIMS

Long-acting cabotegravir and rilpivirine have been approved to manage HIV in adults, but data regarding safe use in pregnancy are limited. Physiologically-based pharmacokinetic (PBPK) modelling was used to simulate the approved dosing regimens in pregnancy and explore if Ctrough was maintained above cabotegravir and rilpivirine target concentrations (664 and 50 ng/mL, respectively).

METHODS

An adult PBPK model was validated using clinical data of cabotegravir and rilpivirine in nonpregnant adults. This was modified by incorporating pregnancy-induced metabolic and physiological changes. The pregnancy PBPK model was validated with data on oral rilpivirine and raltegravir (UGT1A1 probe substrate) in pregnancy. Twelve weeks' disposition of monthly and bimonthly dosing of long-acting cabotegravir and rilpivirine was simulated at different trimesters and foetal exposure was also estimated.

RESULTS

Predicted Ctrough at week 12 for monthly long-acting cabotegravir was above 664 ng/mL throughout pregnancy, but below the target in 0.5% of the pregnant population in the third trimester with bimonthly long-acting cabotegravir. Predicted Ctrough at week 12 for monthly and bimonthly long-acting rilpivirine was below 50 ng/mL in at least 40% and over 90% of the pregnant population, respectively, throughout pregnancy. Predicted medians (range) of cord-to-maternal blood ratios were 1.71 (range, 1.55-1.79) for cabotegravir and 0.88 (0.78-0.93) for rilpivirine between weeks 38 and 40.

CONCLUSIONS

Model predictions suggest that monthly long-acting cabotegravir could maintain antiviral efficacy throughout pregnancy, but that bimonthly administration may require careful clinical evaluation. Both monthly and bimonthly long-acting rilpivirine may not adequately maintain antiviral efficacy in pregnancy.

Concepts for selection and utilization of psychiatric medications in pregnancy

Psychiatric illness may develop or relapse during pregnancy, and understanding best practices is paramount. In 2017, the British Association for Psychopharmacology (BAP) consensus guidance on the use of psychotropic medication preconception, in pregnancy, and postpartum was released. The BAP guidelines provide concise evidence and additional insight and flexibility for use of psychiatric medication. Key takeaways of these guidelines are highlighted serving as a concise reference for practitioners. Additionally, practice points, such as recommendations for rapid tranquilization and the role of long-acting injectable antipsychotic medications as well as additional insights to the growing body of literature associated with psychiatric medications in pregnancy since 2017 are summarized. Providers are strongly encouraged to stay up to date to provide optimal care for pregnant patients and their babies.

Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors

ABSTRACT

Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.

Schizophrenia in Women: Clinical Considerations

Men and women, for biologic and sociocultural reasons, differ in the nature of their risks for schizophrenia and also in their care needs. Women with schizophrenia have several reproduction-associated risks and care needs that require special clinical consideration. They also have several specific risks related to antipsychotics and gender-associated needs not necessarily related to biology. These require clinicians' diagnostic acumen, treatment skills, cultural sensitivity, and advocacy know-how. Although this does not pertain to everyone, awareness on the part of clinicians is essential. This article addresses the current evidence for difference.

Long-Acting Injectable Antipsychotic Treatment during Pregnancy: A Case Series

INTRODUCTION

Data from the literature show that prolonged-release injectable antipsychotics (LAIs) ensure constant blood drug levels better patient compliance and offer a simpler treatment regimen for both patients and caregivers. This observational-descriptive study aims to detect the possible complications found in newborns of women with bipolar or psychotic disorders and LAI therapy during pregnancy.

METHODS

This study involved women with psychotic disorders during pregnancy who contacted the Teratology Information Center of Bergamo, Italy between 2016 and 2021 to receive counseling on the possible risks of exposure to LAI therapy. The follow-up procedure was carried out by telephone interview or direct contact with the patient and/or her physician.

RESULTS

In this study, LAI treatment in pregnancy was not associated with an increased risk of malformations. All but one of the children in the sample were born healthy and the mothers maintained psychopathological compensation during pregnancy.

CONCLUSIONS

This study showed that, despite the small size of the sample under examination, the administration of LAIs do not compromise the normal intrauterine development of the unborn child and there were no evident major malformations.