Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy

The Impact of Hormonal Contraceptive Use on Serotonergic Neurotransmission and Antidepressant Treatment Response: Results From the NeuroPharm 1 Study

BACKGROUND

Hormonal contraceptive (HC) use has been associated with an increased risk of developing a depressive episode. This might be related to HC's effect on the serotonergic brain system as suggested by recent cross-sectional data from our group, which show that healthy oral contraceptive (OC) users relative to non-users have lower cerebral serotonin 4 receptor (5-HT4R) levels. Here, we determine if cerebral 5-HT4R binding differs between HC non-users, OC users, and hormonal intrauterine device (HIUD) users among women with an untreated depressive episode. Also, we test if antidepressant drug treatment response and its association with pre-treatment 5-HT4R binding depends on HC status.

METHODS

[¹¹C]-SB207145 Positron Emission Tomography imaging data from the NeuroPharm-NP1 Study (NCT02869035) were available from 59 depressed premenopausal women, of which 26 used OCs and 10 used HIUDs. The participants were treated with escitalopram. Treatment response was measured as the relative change in the Hamilton Depression Rating Scale 6 items (rΔHAMD₆) from baseline to week eight. Latent variable models were used to evaluate the association between global 5-HT4R binding and OC and HIUD use as well as rΔHAMD₆.

RESULTS

We found no evidence of a difference in global 5-HT4R binding between depressed HC users and non-users (p≥0.51). A significant crossover interaction (p=0.02) was observed between non-users and OC users in the association between baseline global 5-HT4R binding and week eight rΔHAMD₆; OC users had 3-4% lower binding compared to non-users for every 10% percent less improvement in HAMD₆. Within the groups, we observed a trend towards a positive association in non-users (p_adj=0.10) and a negative association in OC users (p_adj=0.07). We found no strong evidence of a difference in treatment response between the groups (p=0.13).

CONCLUSIONS

We found no difference in 5-HT4R binding between HC users vs. non-users in depressed women, however, it seemed that 5-HT4R settings differed qualitatively in their relation to antidepressant drug treatment response between OC users and non-users. From this we speculate that depressed OC users constitutes a special serotonin subtype of depression, which might have implications for antidepressant drug treatment response.

Contraception for Women With Psychiatric Disorders

OBJECTIVE

Mental health care for women includes decision support to prepare for major life events, including preconception planning for treatment during pregnancy and the postpartum period. The authors discuss contraceptive choices and their effectiveness, side effects, and impact on psychiatric symptoms. The Centers for Disease Control and Prevention's recommendations, Medical Eligibility Criteria for Contraceptive Use, provided the structure for review of contraceptive choices.

METHODS

A search of PsycINFO, PubMed, Embase, and Scopus was conducted for publications on the management of contraception for women with mental illness. Publications were selected if they included, based on the authors' consensus, data supporting evidence-based care important for psychiatrists who treat women desiring contraceptives.

RESULTS

The majority of women choose combined oral contraceptives. Although long-acting reversible contraceptives (implants, intrauterine devices) are associated with low failure rates, favorable safety profiles, rapid return to fertility after removal, and few contraindications, they are chosen by only 14% of women. All methods are acceptable for women with depression, although medical comorbidities may dictate a specific type. The impact of hormonal contraceptives on the risk for depression is controversial; however, clinical studies and randomized placebo-controlled trials of women with psychiatric disorders have generally reported similar or lower rates of mood symptoms in hormonal contraceptive users compared with nonusers. Although interactions between psychotropic drugs and contraceptives are rare, clozapine, anticonvulsants, and St. John's Wort are exceptions.

CONCLUSIONS

Proactive management of mental illness, contraception, and pregnancy improves a woman's capacity to function and optimizes her mental and reproductive health.

ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions

Although numerous studies have addressed the safety and effectiveness of hormonal contraceptive use in healthy women, data regarding women with underlying medical conditions or other special circumstances are limited. The U.S. Medical Eligibility Criteria (USMEC) for Contraceptive Use, 2016 (), which has been endorsed by the American College of Obstetricians and Gynecologists, is a published guideline based on the best available evidence and expert opinion to help health care providers better care for women with chronic medical problems who need contraception. The goal of this Practice Bulletin is to explain how to use the USMEC rating system in clinical practice and to specifically discuss the rationale behind the ratings for various medical conditions. Contraception for women with human immunodeficiency virus (HIV) (); the use of emergency contraception in women with medical coexisting medical conditions, including obesity, (); and the effect of depot medroxyprogesterone acetate (DMPA) on bone health () are addressed in other documents from the American College of Obstetricians and Gynecologists.

Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review

BACKGROUND

Women with depressive or bipolar disorders are at an increased risk for unintended pregnancy.

OBJECTIVE

To examine the safety of hormonal contraception among women with depressive and bipolar disorders.

METHODS

We searched for articles published through January 2016 on the safety of using any hormonal contraceptive method among women with depressive or bipolar disorders, including those who had been diagnosed clinically or scored above threshold levels on a validated screening instrument. Outcomes included changes in symptoms, hospitalization, suicide and modifications in medication regimens such as increase or decrease in dosage or changes in type of drug.

RESULTS

Of 2376 articles, 6 met the inclusion criteria. Of three studies that examined women clinically diagnosed with depressive or bipolar disorder, one found that oral contraceptives (OCs) did not significantly change mood across the menstrual cycle among women with bipolar disorder, whereas mood did significantly change across the menstrual cycle among women not using OCs; one found no significant differences in the frequency of psychiatric hospitalizations among women with bipolar disorder who used depot medroxyprogesterone acetate (DMPA), intrauterine devices (IUDs) or sterilization; and one found no increase in depression scale scores among women with depression using and not using OCs, for both those treated with fluoxetine and those receiving placebo. Of three studies that examined women who met a threshold for depression on a screening instrument, one found that adolescent girls using combined OCs (COCs) had significantly improved depression scores after 3 months compared with placebo, one found that OC users had similar odds of no longer being depressed at follow-up compared with nonusers, and one found that COC users were less frequently classified as depressed over 11 months than IUD users.

CONCLUSIONS

Limited evidence from six studies found that OC, levonorgestrel-releasing IUD and DMPA use among women with depressive or bipolar disorders was not associated with worse clinical course of disease compared with no hormonal method use.

Drug interactions between hormonal contraceptives and psychotropic drugs: a systematic review

OBJECTIVE

To examine whether the co-administration of hormonal contraceptives (HC) and psychotropic drugs commonly used to treat anxiety and/or depression results in safety or efficacy concerns for either drug.

METHODS

We searched PubMed and Cochrane libraries for clinical or pharmacokinetic (PK) studies that examined co-administration of any HC with psychotropic drugs [selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), oral benzodiazepines, bupropion, mirtazapine, trazadone, buspirone, hydroxyzine, monoamine oxidase inhibitors (MAOIs), or atypical antipsychotics] in reproductive aged women.

RESULTS

Of 555 articles identified, 22 articles (18 studies) met inclusion criteria. We identified 5 studies on SSRIs, four on TCAs, one on bupropion, three on atypical antipsychotics and five on oral benzodiazepines. No articles met inclusion criteria for SNRIs, mirtazapine, trazadone, buspirone, hydroxyzine or MAOIs. Overall, clinical studies did not demonstrate differences in unintended pregnancy rates when HCs were administered with and without psychotropic drugs or in psychotropic drug treatment outcomes when psychotropic drugs were administered with and without HCs. PK studies did not demonstrate changes in drug exposure related to contraceptive safety, contraceptive effectiveness or psychotropic drug effectiveness for most classes of psychotropic drugs. However, limited PK data raise concern for HCs increasing systemic exposure of amitriptyline and imipramine (both TCAs), theoretically posing safety concerns.

CONCLUSION

Limited quality and quantity evidence on use of psychotropic drugs and HCs suggests low concern for clinically significant interactions, though no data exist specifically for non-oral formulations of HC. Given the high frequency of use for both HCs and psychotropic drugs among reproductive-age women in the US, this review highlights a need for further research in this area.

Sex differences in the pharmacokinetics of antidepressants: influence of female sex hormones and oral contraceptives

Women are twice as likely to develop depression as men. Moreover, the symptoms they experience also show sex differences: women tend to develop depression at an earlier age and show more severe symptoms than men. Likewise, the response to antidepressant pharmacotherapy appears to have sex differences. These differences can partially be explained by differences in pharmacokinetic properties (i.e., absorption, distribution, metabolism, and excretion) of drugs in males and females. More recent research has shown that sex hormones may influence all these previously named pharmacokinetic processes. As concentrations of sex hormones vary throughout the female lifespan, these hormonal variations can have effects on therapeutic responses to antidepressants as well as the occurrence of adverse events. The purpose of this paper is therefore to review the literature reporting on the effects of female sex hormones on the pharmacokinetics of antidepressants and to discuss and evaluate the implications of changes in levels of sex hormones throughout life for the treatment of depression.

Reproductive and contraceptive issues in chronically ill adolescents

OBJECTIVES

To address reproductive and contraceptive issues in adolescent girls with chronic medical conditions in order to assist health-care providers when they counsel teenagers about contraceptive methods.

METHODS

The review is based on a literature search in Medline (1973-2010) about specific contraceptive use by adolescents with obesity, endocrine, cardiovascular, haematologic, oncologic, neurological, psychiatric, gastrointestinal, hepatobiliary, autoimmune, renal, pulmonary conditions and disabilities. The latest recommendations from the World Health Organisation for adolescents are also added. Contraceptive methods studied were combined hormonal contraceptives, progestogen-only contraceptives, and intrauterine contraceptives.

RESULTS

Adolescents are eligible to use any method of contraception. Contraceptive choices of chronically ill adolescents have changed over time. Given new developments in the field of adolescent sexual and reproductive health care, safe and effective forms of contraception are available for almost every adolescent with a chronic condition. When selecting a method, the nature of the medical illness and the expressed desires of the teenager must be taken into account.

CONCLUSIONS

Adolescents, including those with chronic conditions, are sexual beings; they are entitled to sexual and reproductive health care. Decisions on appropriate contraception must be based upon informed choice, after adequate sexual health education.

Concepts of contraception for adolescent and young adult women with chronic illness and disability

Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.

Safety and side effect profile of fluoxetine

Fluoxetine was the first selective serotonin re-uptake inhibitor to be widely available for treatment of depression and numerous other neuropsychiatric disorders. Its attributes have been described in numerous scientific papers, and it has been the subject of a considerable volume of lay press. Fluoxetine is generally safe and well-tolerated. Common adverse events reported with the recommended dose of 20 mg/day are referable to the gastrointestinal system and the nervous system. The approved dose range is up to 80 mg/day, and when higher doses are used, adverse events are more common. The long half-life of fluoxetine and its active metabolite essentially preclude a withdrawal phenomenon. It is an inhibitor of cytochrome P450 (CYP) 2D6 and other CYP enzymes, which increases the potential for drug interactions. However, most of these are not clinically important. The purpose of this review is to provide an overview of some of the most important information related to safety and side effects of this drug.

Treatment of premenstrual dysphoria with selective serotonin re-uptake inhibitors: focus on safety

Many women experience physical or mood symptoms associated with the menstrual cycle. For approximately 3 - 8% of women, the symptoms are severe enough to significantly affect social, domestic and occupational functioning. This cluster of primarily emotional and behavioural symptoms is now labelled premenstrual dysphoric disorder (PMDD). Women who meet criteria for PMDD do not usually respond to conservative interventions; selective serotonin re-uptake inhibitors (SSRIs) taken either daily or intermittently are considered to be an effective first-line therapy for this population. In this paper, the authors report on the efficacy and tolerability of SSRIs that are currently recognised as the treatment of choice for PMDD.