Association between CYP2D6 Genotypes and the Risk of Antidepressant Discontinuation, Dosage Modification and the Occurrence of Maternal Depression during Pregnancy

Importance: Polymorphic expression of drug metabolizing enzymes affects the metabolism of antidepressants, and thus can contribute to drug response and/or adverse events. Pregnancy itself can affect CYP2D6 activity with profound variations determined by CYP2D6 genotype.

Objective: To investigate the association between CYP2D6 genotype and the risk of antidepressant discontinuation, dosage modification, and the occurrence of maternal CYP2D6, Antidepressants, Depression during pregnancy.

Setting: Data from the Organization of Teratology Information Specialists (OTIS) Antidepressants in Pregnancy Cohort, 2006–2010, were used. Women were eligible if they were within 14 completed weeks of pregnancy at recruitment and exposed to an antidepressant or having any exposures considered non-teratogenic.

Main Outcomes and Measures: Gestational antidepressant usage was self-reported and defined as continuous/discontinued use, and non-use; dosage modification was further documented. Maternal depression and anxiety were measured every trimester using the telephone interviewer-administered Edinburgh Postnatal Depression Scale and the Beck Anxiety Inventory, respectively. Saliva samples were collected and used for CYP2D6 genotype analyses. Logistic regression models were used to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals.

Results: A total of 246 pregnant women were included in the study. The majority were normal metabolizers (NM, n = 204, 83%); 3.3% (n = 8) were ultrarapid metabolizers (UM), 5.7% (n = 14) poor metabolizers (PM), and 8.1% (n = 20) intermediate metabolizers (IM). Among study subjects, 139 women were treated with antidepressants at the beginning of pregnancy, and 21 antidepressant users (15%) discontinued therapy during pregnancy. Adjusting for depressive symptoms, and other potential confounders, the risk of discontinuing antidepressants during pregnancy was nearly four times higher in slow metabolizers (poor or intermediate metabolizers) compared to those with a faster metabolism rate (normal or ultrarapid metabolizers), aOR = 3.57 (95% CI: 1.15-11.11). Predicted CYP2D6 metabolizer status did not impact dosage modifications. Compared with slow metabolizers, significantly higher proportion of women in the fast metabolizer group had depressive symptom in the first trimester (19.81 vs. 5.88%, P = 0.049). Almost 21% of treated women remained depressed during pregnancy (14.4% NM-UM; 6.1% PM-IM).

Conclusions and Relevance: Prior knowledge of CYP2D6 genotype may help to identify pregnant women at greater risk of antidepressant discontinuation. Twenty percent of women exposed to antidepressants during pregnancy remained depressed, indicating an urgent need for personalized treatment of depression during pregnancy.

Methylphenidate in Pregnancy: A Multicenter, Prospective, Comparative, Observational Study

INTRODUCTION

Methylphenidate is a central nervous system stimulant medicinally used in the treatment of attention-deficit disorder with or without hyperactivity (ADD/ADHD). Data on its use in human pregnancy are limited. The primary objective of the study was to evaluate the risk of major congenital anomalies after pregnancy exposure to methylphenidate for medical indications.

METHODS

In a prospective, comparative, multicenter observational study performed in 4 participating Teratology Information Services (in Jerusalem, Berlin, Newcastle upon Tyne, and Toronto) between 1996 and 2013, methylphenidate-exposed pregnancies were compared with pregnancies counseled for nonteratogenic exposure (NTE) after matching by maternal age, gestational age, and year at initial contact.

RESULTS

382 methylphenidate-exposed pregnancies (89.5% in the first trimester) were followed up. The overall rate of major congenital anomalies was similar between the groups (10/309 = 3.2% [methylphenidate] vs 13/358 = 3.6% [NTE], P = .780). The rates of major congenital anomalies (6/247 = 2.4% [methylphenidate] vs 12/358 = 3.4% [NTE], P = .511) and cardiovascular anomalies (2/247 = 0.8% [methylphenidate] vs 3/358 = 0.8% [NTE], P = .970) were also similar after exclusion of genetic or cytogenetic anomalies and limiting methylphenidate exposure to the period of organogenesis (weeks 4-13 after the last menstrual period). There was a higher rate of miscarriages and elective terminations of pregnancy in the methylphenidate group. Significant predictors for the miscarriages using Cox proportional hazards model were methylphenidate exposure (adjusted hazard ratio [HR] = 1.98; 95% CI, 1.23-3.20; P = .005) and past miscarriage (adjusted HR = 1.35; 95% CI, 1.18-1.55; P < .001).

CONCLUSIONS

The present study suggests that methylphenidate does not seem to increase the risk for major malformations. Further studies are required to establish its pregnancy safety and its possible association with miscarriages.

Fluconazole use during breastfeeding

QUESTION

I have a patient with persistent breast and nipple thrush. Other therapies have failed, so I have decided to treat her with a loading dose of 400 mg of oral fluconazole followed by 100 mg twice daily for at least 2 weeks. Is there any need for her to interrupt breastfeeding during this treatment?

ANSWER

Available data regarding fluconazole use during breastfeeding are reassuring. Fluconazole is also used in the treatment of fungal diseases in infants and has a good safety profile. Therefore, there is no need to interrupt breastfeeding when a mother is treated with fluconazole.

Is it safe to breastfeed while taking methylphenidate?

QUESTION

My patient has narcolepsy and is currently breastfeeding her 3-month-old infant. Lately she has had difficulties adjusting to caring for her baby, especially staying alert with the demands of breastfeeding. If she starts taking methylphenidate again, should I advise her to switch to formula?

ANSWER

Methylphenidate is excreted in breast milk only in small amounts, and to date there have been no reports of breastfed infants demonstrating any adverse effects. Based on the available data, methylphenidate appears to be compatible with breastfeeding; however, the long-term neurodevelopmental effects have not been adequately studied.

Fluconazole exposure during pregnancy

QUESTION

One of my patients has just learned that she is 8 weeks pregnant. She took a 150-mg dose of fluconazole 2 weeks ago for the treatment of vaginal candidiasis and she is worried about the effect on her child and pregnancy. Can I reassure her?

ANSWER

Short-term and low-dose fluconazole exposure, such as that indicated in the treatment of vaginal candidiasis, is not expected to increase the overall risk of major congenital malformations.

Sugar substitutes during pregnancy

QUESTION

I have a pregnant patient who regularly consumes sugar substitutes and she asked me if continuing their use would affect her pregnancy or child. What should I tell her, and are there certain options that are better for use during pregnancy?

ANSWER

Although more research is required to fully determine the effects of in utero exposure to sugar substitutes, the available data do not suggest adverse effects in pregnancy. However, it is recommended that sugar substitutes be consumed in moderate amounts, adhering to the acceptable daily intake standards set by regulatory agencies.

Safety of tacrolimus in pregnancy

QUESTION

I have a 30-year-old patient who had a kidney transplant 2 years ago. She is now planning a pregnancy. She has been treated with tacrolimus since her transplant. Will it be safe for the fetus if she continues to take it during the pregnancy or should she switch to a different antirejection medication?

ANSWER

If your patient is stable while taking tacrolimus, there is no reason to switch. The current available information does not suggest that tacrolimus increases the risk of major congenital malformations above the baseline risk in the general population. Premature birth and low birth weight are often reported in this population; however, these effects are frequently reported in pregnant transplant patients treated with other immunosuppressant agents and probably reflect the effects of the maternal condition. As there are some reports of hyperkalemia and renal impairment in infants exposed to tacrolimus in utero, kidney function and electrolytes should be monitored in exposed neonates.

Is it safe to use inhaled corticosteroids in pregnancy?

QUESTION

A healthy woman with mild to moderate asthma came to my clinic today after learning that she was pregnant. She inquired about continuing her inhaled corticosteroid (ICS) medication and whether there would be any risks to her unborn child if she were to do so. What would you advise?

ANSWER

Given the published evidence, ICSs should be continued throughout pregnancy at low to moderate doses sufficient to control asthma symptoms and prevent exacerbations. However, caution must be taken with doses greater than 1000 µg/d (chlorofluorocarbon beclomethasone equivalent), although whether such doses cause adverse effects is currently still questionable. Patient education on proper ICS administration and adherence, including during the first trimester, must be ongoing. Well controlled asthma will reduce the need for higher ICS doses and possible exposure to systemic corticosteroids, and might decrease the risk of adverse pregnancy or perinatal outcomes.

Consuming non-alcoholic beer and other beverages during pregnancy and breastfeeding

QUESTION

An increasing number of my patients are asking about the safety of consuming non-alcoholic beer and other alcohol-free versions of alcoholic beverages during pregnancy and breastfeeding, as they believe that these drinks might be a "safer" alternative to regular alcoholic beverages. What are Motherisk's recommendations regarding these products?

ANSWER

Such drinks might contain higher ethanol levels than what is indicated on their labels. As there is no known safe level of alcohol intake in pregnancy, abstinence from non-alcoholic beverages would eliminate any risk of fetal alcohol spectrum disorder. Although it is likely that moderate intake of non-alcoholic beverages would pose no harm to breastfed infants, briefly delaying breastfeeding after consumption of such drinks would ensure that the infant is not exposed to alcohol.

Cost effectiveness of teratology counseling - the Motherisk experience

BACKGROUND

While the benefits of evidence-based counseling to large numbers of women and physicians are intuitively evident, there is an urgent need to document that teratology counseling, in addition to improving the quality of life of women and families, also leads to cost saving. The objective of the present study was to calculate the cost effectiveness of the Motherisk Program, a large teratology information and counseling service at The Hospital for Sick Children and the University of Toronto.

METHODS

We analyzed data from the Motherisk Program on its 2012 activities in two domains: 1) Calculation of cost-saving in preventing unjustified pregnancy terminations; and 2) prevention of major birth defects. Cost of pregnancy termination and lifelong cost of specific birth defects were identified from primary literature and prorated for cost of living for the year 2013.

RESULTS

Prevention of 255 pregnancy terminations per year led to cost savings of $516,630. The total estimated number of major malformations prevented by Motherisk counseling in 2012 was 8.41 cases at a total estimated cost of $9,032,492.

CONCLUSIONS

With an estimated minimum annual prevention of 8 major malformations, and numerous unnecessary terminations of otherwise- wanted pregnancies, a cost saving of $10 million can be calculated. In 2013 the operating budget of Motherisk counseling totaled $640,000. Even based on the narrow range of activities for which we calculated cost, this service is highly cost- effective. Because most teratology counseling services are operating in a very similar method to Motherisk, it is fair to assume that these results, although dependent on the size of the service, are generalizable to other countries.

Safety of the newer class of opioid antagonists in pregnancy

QUESTION

I have a patient recently confirmed to be 6 weeks pregnant. For the past 6 months she has been treated for an opioid addiction with buprenorphine-naloxone combination. Should I be concerned about her exposure to this drug combination up to this point of the pregnancy? Should I switch her medication to methadone now that she is pregnant?

ANSWER

The limited data on buprenorphine exposure during pregnancy show no increased risk of adverse outcomes in the newborn. There are limited data on naloxone exposure during pregnancy; however, oral use is not expected to be associated with an increased risk of adverse pregnancy outcomes. Physicians treating pregnant women or women who become pregnant while they are stable taking buprenorphine-naloxone treatment are advised to continue this treatment but to consider transition to buprenorphine monotherapy.

Using nitrofurantoin while breastfeeding a newborn

QUESTION

My patient has a urinary tract infection and is currently breastfeeding. Her son is only 3 weeks old. Is nitrofurantoin a safe antibiotic for treatment?

ANSWER

The use of nitrofurantoin in breastfeeding mothers is generally safe, as only small amounts transfer into the breast milk. Despite the lack of documented reports, there is a risk of hemolytic anemia in all newborns exposed to nitrofurantoin owing to their glutathione instability, especially in infants with glucose-6-phosphate dehydrogenase deficiency. Although some suggest that nitrofurantoin be avoided in infants younger than 1 month, studies have noted that glutathione stability might be established by the eighth day of life. In infants younger than 1 month, an alternative antibiotic might be preferred; however, if an alternative were not available, the use of nitrofurantoin would not be a reason to avoid breastfeeding. In any such case the suckling infant should be monitored by his or her physician.

Botulinum toxin type A in pregnancy

QUESTION

My patient received 62 units of botulinum toxin type A (BTX-A) for facial lines. Two weeks later, she found out that she was pregnant. Will this cause any harm to her fetus?

ANSWER

Botulinum toxin is not expected to be present in systemic circulation following proper intramuscular or intradermal injection. Moreover, BTX-A, which has a high molecular weight, does not appear to cross the placenta. From the 38 pregnancies reported in the literature, including women who had botulism poisoning during pregnancy, exposure to BTX-A does not appear to increase the risk of adverse outcome in the fetus.

Update on antidepressant use during breastfeeding

QUESTION

Many of my patients who are diagnosed with postpartum depression want to continue breastfeeding. How safe are the newer antidepressant medications during breastfeeding?

ANSWER

The newer antidepressants transfer into breast milk in low amounts and have not been associated with serious adverse events. Therefore, the antidepressant most effective for the woman should be considered.

Tdap vaccination during pregnancy to reduce pertussis infection in young infants

QUESTION

What is the basis for the new recommendations to vaccinate pregnant women against pertussis after the first trimester?

ANSWER

There have been outbreaks of epidemic proportions of pertussis, mostly among young infants who have not received sufficient passive immunity from their mothers. This strategy of vaccination during pregnancy aims at stopping these life-threatening epidemics.

Is caffeine consumption safe during pregnancy?

QUESTION

I have a pregnant patient who experienced a miscarriage in the past and who has asked me whether her consumption of 2 cups of coffee per day could have caused it. What should I tell her?

ANSWER

There are conflicting data on the fetal safety of dietary caffeine consumption during pregnancy, particularly at levels of 300 mg/d or greater. Although it is difficult to assess the risk of spontaneous abortion with caffeine consumption, most of the data do not suggest an increased risk of adverse pregnancy, fertility, or neurodevelopmental outcomes with caffeine consumption of 300 mg/d or less from all sources. Therefore, consumption of 1 to 2 cups of coffee a day is not expected to be a concern.

Maternal cocaine use during breastfeeding

QUESTION

In my practice several patients have struggled with cocaine abuse during their pregnancies. One woman, now postpartum, wants to breastfeed her infant. Despite being abstinent for the final few months of her pregnancy, I am concerned about the potential adverse effects on her child if she happens to relapse. What is the current evidence about the risks of cocaine exposure during breastfeeding?

ANSWER

Given the substantial benefits of breastfeeding for infant health and development, there is no reason for mothers who previously abused cocaine to avoid breastfeeding. It is important for the health care team to counsel patients both on the serious potential risks of cocaine exposure for babies and on the benefits of breastfeeding, to allow for an informed choice. Additionally, attempts should be made to estimate maternal commitment to breastfeeding and discontinuation of cocaine use, and to offer addiction counseling to mitigate the potential risks of infant cocaine exposure. It is paramount to minimize the risk to the infant, which would certainly include mothers ceasing use of cocaine while breastfeeding. For mothers who elect to breastfeed and use cocaine intermittently, breastfeeding should be delayed sufficiently after cocaine use to allow for drug elimination (approximately 24 hours).

Health Canada advisory on domperidone should I avoid prescribing domperidone to women to increase milk production [corrected]?

QUESTION

I often prescribe domperidone to women as a galactagogue starting at a dose of 30 mg and increasing the dose as needed. In March of this year, Health Canada released an advisory warning of domperidone use and abnormal heart rhythms and sudden cardiac death. Should I cap doses at 30 mg or stop prescribing domperidone all together to these women?

ANSWER

The Health Canada warning is based on 2 studies. The results of the studies are not directly applicable to breastfeeding and should not change the way you normally manage otherwise healthy breastfeeding women.

Treating constipation during pregnancy

QUESTION

Many of my patients experience constipation during pregnancy, even after increasing dietary fibre and fluids. Are there any safe treatments I can recommend to them?

ANSWER

Although the recommended first-line therapy for constipation includes increasing fibre, fluids, and exercise, these are sometimes ineffective. Therefore, laxatives such as bulk-forming agents, lubricant laxatives, stool softeners, osmotic laxatives, and stimulant laxatives might be considered. Although few of the various types of laxatives have been assessed for safety in pregnancy, they have minimal systemic absorption. Therefore, they are not expected to be associated with an increased risk of congenital anomalies. However, it is recommended that osmotic and stimulant laxatives be used only in the short term or occasionally to avoid dehydration or electrolyte imbalances in pregnant women.

Smoking cessation therapy during pregnancy

QUESTION

Despite being highly motivated to quit, many of my patients struggle with smoking cessation during pregnancy. Can you comment on the current treatment options and discuss their safety and efficacy during pregnancy?

ANSWER

Given the considerable and well-documented adverse effects of antenatal smoking on mother and fetus, pharmacotherapy for smoking cessation should be considered. Available medications include nicotine replacement therapy, sustained-release bupropion, and varenicline. Nicotine replacement therapy and bupropion do not appear to increase the risk of major malformations; however, there is currently limited evidence on the use of varenicline during pregnancy. Given that these agents are only marginally successful in smoking cessation, their use should always be accompanied by behavioural counseling and education to maximize quit rates.

Human papillomavirus vaccine and pregnancy

QUESTION A: patient of mine who recently learned she was 6 weeks pregnant had received the recombinant human papillomavirus (HPV) quadrivalent vaccine at 4 weeks of gestation. She is quite worried about how this will affect her baby. What is known about the safety of the HPV vaccine during pregnancy?

ANSWER

The HPV vaccine is generally not recommended for use in pregnant women. However, theoretically, because it is not a live vaccine, it is not expected to be associated with an increased risk. Also, information from the manufacturer's pregnancy registry and phase 3 clinical trials does not indicate an increased risk of fetal malformations or other adverse effects due to the vaccine.

Safety of azathioprine use during pregnancy

QUESTION

Quite a few of my female patients with rheumatic diseases and inflammatory bowel disease are using azathioprine. They are afraid to take a "cancer drug" during pregnancy. What is known about the risks?

ANSWER

An increasing body of evidence from prospective cohort studies suggests that azathioprine is safe for the fetus during pregnancy.

Prophylactic use of antimalarials during pregnancy

QUESTION

Some of my pregnant patients wish to travel to malaria-endemic regions. Are there medications that can be used safely during pregnancy for malaria prophylaxis?

ANSWER

Pregnant women should avoid travel to malaria-endemic areas if possible. However, if travel cannot be avoided, measures to prevent mosquito bites, along with an effective chemoprophylaxis regimen, should be implemented. Chloroquine or hydroxychloroquine are considered safe to use in all trimesters of pregnancy. Mefloquine is the agent of choice for chloroquine-resistant areas, and evidence suggests it is not associated with an increased risk to the fetus. Although the atovaquone-proguanil drug combination is not currently recommended for use during pregnancy, limited data suggest that it is not harmful to the fetus. Doxycycline and primaquine are not recommended during pregnancy.

Herpes zoster during pregnancy

QUESTION

One of my pregnant patients, a 32-year-old woman (gravida 2, para 1), has a flare up of herpes zoster (HZ) at the T11 to T12 dermatomes. This virus, the varicella-zoster virus, causes chickenpox, which can be teratogenic. Is this also true for HZ?

ANSWER

Herpes zoster, unlike chickenpox, is not associated with increased fetal risk. In contrast, a nonimmune woman exposed to HZ by contact might contract chickenpox.

Nausea and vomiting of pregnancy (NVP) and depression: cause or effect?

Background: Both nausea and vomiting and depression are common conditions affecting women during pregnancy. Several studies have linked depression with nausea and vomiting of pregnancy (NVP); however, researchers were unable to determine whether depression was caused by NVP or by a pre-existing condition. Objective: To determine whether NVP is associated with depression in women with no history of depression prior to pregnancy. Study design and methods: This was a prospective, observational, longitudinal study. Women with no diagnosis of depression who contacted The Motherisk Program prior to becoming pregnant or were at < 6 weeks gestation were enrolled in the study. Each woman was interviewed at 8, 11, 18, 30 weeks gestation and at 6-18 weeks post-partum. At each interview, we administered the EDPS, Wellbeing and PUQE questionnaires and analyzed the data for correlation between depression and NVP. Results: Data were analyzed obtained from 57 women. There were five EPDS scores ≥13 (one at baseline and two each at weeks 8 and 11) considered indicative of depression and 11 cases with PUQE scores ≥7, indicative of moderate-high severity of NVP. We did not find an association between high PUQE scores and high EPDS scores and conversely, there was no relationship between high EPDS scores and high PUQE scores. Conclusion: No association between depressive symptoms and NVP was observed; however, our sample size was very small and further studies could be done with a larger population of pregnant women.

Safety of skin care products during pregnancy

QUESTION

Many of my female patients complain about acne, unwanted hair growth, and other skin problems that have only developed since they became pregnant. Are products used for these types of benign skin conditions safe to use in pregnancy, as it is understandable that women want to look their best at this important time in their lives?

ANSWER

With the exception of hydroquinone, which has a relatively high systemic absorption rate, and tretinoin, for which the evidence is controversial, these products act locally and therefore produce minimal systemic levels. Consequently, in most cases women can deal with these cosmetically unappealing skin conditions without compromising the safety of their unborn children.

Vaccination during pregnancy

QUESTION

One of my patients is studying to become a dental hygienist. Owing to the program requirements, she received several vaccinations last week, including measles-mumps-rubella, varicella, and hepatitis B (HB) vaccines, as well as a tetanus booster. However, today a blood test confirmed that she is currently 6 weeks pregnant. What is known about the safety of these vaccines during pregnancy, and are there any general recommendations for vaccines for women who are planning to become pregnant or who are currently pregnant?

ANSWER

The combination measles-mumps-rubella vaccine and the varicella vaccine are live attenuated vaccines, and are contraindicated during pregnancy owing to theoretical concerns. However, there is no evidence that there are increased risks of malformations, congenital rubella syndrome, or varicella syndrome attributable to these vaccines. The HB and tetanus vaccines are composed of noninfectious particles or toxoids, and theoretically should cause no increased risk to the developing fetus. In addition, limited observational data also support no increased risk of any adverse pregnancy outcomes; consequently, administration of the HB and tetanus vaccines might be, if indicated, considered during pregnancy.

Safety of antiviral medication for the treatment of herpes during pregnancy

QUESTION

One of my patients is a pregnant woman in her first trimester with a history of recurrent genital herpes. She is concerned about whether use of her antiviral medication will adversely affect her baby. What should I tell her?

ANSWER

Studies have shown that the use of acyclovir or valacyclovir is not associated with an increase in birth defects. Limited data exist for famciclovir and therefore it would not be considered a first-line choice for treatment of herpes during pregnancy.

Are probiotics safe for use during pregnancy and lactation?

QUESTION

There has been a great deal of discussion in both the medical and lay literature about the use of probiotics to improve general health. Subsequently, pregnant women have been asking me if probiotics used for treating conditions such as bacterial vaginosis and diarrhea are safe to use during pregnancy and lactation.

ANSWER

Current data suggest that probiotic supplementation is rarely systemically absorbed when used by healthy individuals. One meta-analysis and several randomized controlled trials conducted with women during the third trimester of pregnancy did not report an increase in adverse fetal outcomes. There have been no published studies addressing Saccharomyces species use in pregnancy. Probiotics are unlikely to be transferred into breast milk.

Safety of triptans for migraine headaches during pregnancy and breastfeeding

QUESTION

A patient who just found out that she is pregnant and suffers from migraine headaches informs me that she has been taking naratriptan. She indicates that she is planning on breastfeeding her baby and might need to continue treatment. How safe are the medications from this class of drugs during pregnancy and breastfeeding?

ANSWER

Accumulated data suggest that exposure to sumatriptan during pregnancy does not increase the risk of birth defects above the baseline rate. There are currently insufficient data to confirm the safety of other triptans; however, evidence to date is reassuring. Information regarding safety of triptans while breastfeeding is limited but also reassuring, as the minimal amounts excreted into the milk are insufficient to cause any adverse effects on the breastfeeding infant.

Safety of antihistamines during pregnancy and lactation

QUESTION

Many of my pregnant and breastfeeding patients suffer from allergies and frequently ask me about the safety of antihistamines during pregnancy and breastfeeding. Should I advise them to use the older sedating medications? I have heard that they might be safer than the newer nonsedating class of drugs. Or have the newer ones been studied as well?

ANSWER

First-generation antihistamines are considered safe to use during pregnancy. There are relatively fewer data on the nonsedating second-generation antihistamines; however, published studies are reassuring. All antihistamines are considered safe to use during breastfeeding, as minimal amounts are excreted in the breast milk and would not cause any adverse effects on a breastfeeding infant.

FDA pregnancy risk categories and the CPS: do they help or are they a hindrance?

QUESTION

My patient is taking a medication for a chronic condition and has just found out that she is 6 weeks pregnant. The US Food and Drug Administration (FDA) has assigned this medication to pregnancy risk category D, and the Compendium of Pharmaceuticals and Specialties provides no additional data. How should I interpret this information, and how does the Motherisk Program evaluate the safety or risks of drug use in pregnancy?

ANSWER

Pregnancy safety data provided by the FDA pregnancy risk categories and the Compendium of Pharmaceuticals and Specialties are insufficient to guide clinical decisions on how to proceed with a pregnancy following exposure to a category D medication. The Motherisk Program creates peer-reviewed statements derived from the primary literature, and we examine fetal outcomes as well as the risk-benefit profile of maternal treatment when evaluating the safety of medication use in pregnancy. The FDA announced in May 2008 that it is dropping its pregnancy risk categories and adopting a method similar to the one we use at Motherisk.

Treatment of heartburn and acid reflux associated with nausea and vomiting during pregnancy

QUESTION

In addition to suffering from nausea and vomiting of pregnancy, which is being treated with antiemetics, some of my pregnant patients complain of heartburn and acid reflux. Should these symptoms also be treated and, if so, which acid-reducing medications are safe for use during pregnancy?

ANSWER

Increased severity of nausea and vomiting of pregnancy is associated with the presence of heartburn and acid reflux. Antacids, histamine-2 receptor antagonists, and proton pump inhibitors can be used safely during pregnancy, as large studies have been published with no evidence of adverse fetal effects.

Guidelines for maternal codeine use during breastfeeding

QUESTION

In light of the recent evidence of adverse events in infants whose mothers use codeine medication, we have been struggling with the issue of how to manage codeine analgesia in our postpartum patients. What are some guidelines for the safe use of codeine during breastfeeding?

ANSWER

Motherisk has summarized recent scientific evidence into suggested guidelines for the safe use of codeine during breastfeeding.

Use of diuretics during pregnancy

QUESTION

Several of my pregnant patients use diuretics for hypertension. I have heard that diuretics cannot be used in pregnancy because of the reduction of plasma volume and the potential for decreasing placental perfusion, as well as a possible diabetogenic effect.

ANSWER

Many studies--including a meta-analysis of almost 7000 neonates exposed to diuretics during pregnancy--did not find an increased risk of adverse effects, such as birth defects, fetal growth restriction, thrombocytopenia, or diabetes, among neonates exposed to diuretics in utero.

Safety of hair products during pregnancy: personal use and occupational exposure

QUESTION

Several of my pregnant patients who are hairdressers have asked me if exposure to products they use is harmful to their unborn babies. They also want to know if their pregnant clients' personal use of hair products should be of concern.

ANSWER

There is no evidence of teratogenic effects for pregnant women exposed to these products from occupational use (ie, hairdressing); however, it is recommended that pregnant hairdressers wear gloves to minimize exposure, work for no more than 35 hours per week, avoid standing for prolonged periods of time, and ensure that the salons where they work have adequate ventilation. Evidence suggests there is minimal systemic absorption of hair products, so personal use by pregnant women 3 to 4 times throughout pregnancy is not considered to be of concern.

Urinary tract infections in pregnancy

QUESTION

My pregnant patients often present with urinary tract infections. Are the medications commonly used for the management of urinary tract infections safe to use during pregnancy?

ANSWER

Existing data indicate that exposure to penicillins, cephalosporins, fluoroquinolones, nitrofurantoin, or phenazopyridine during pregnancy is not associated with increased risk of fetal malformations. Trimethoprim-sulfamethoxazole should be avoided, if possible, during the first trimester of pregnancy because of the antifolate effect associated with neural tube defects.

Treating the common cold during pregnancy

QUESTION

Many of my pregnant patients inquire as to what medication they can use when they experience symptoms of the common cold, such as cough, congestion, sneezing, and fever. I am hesitant to recommend over-the-counter cold remedies because I have heard conflicting information regarding the safety of these products. What is known about the safety of cold medications during pregnancy?

ANSWER

Although there are many over-the-counter brands of cold medications, most products are quite similar, with some containing up to 5 medicinal ingredients. The evidence-based information for all these ingredients suggests no increased risk with short-term use. However, pregnant women should read labels carefully and, when necessary, consult with pharmacists to ensure they are not taking medicine they do not require.

The incidence of nausea and vomiting of pregnancy (NVP): a comparison between depressed women treated with antidepressants and non-depressed women

BACKGROUND

Nausea and vomiting of pregnancy (NVP) affects up to 80% of pregnant women. In many cases NVP causes changes i n family, social, o roccupational functioning. Several studies have linked NVP with depression; however, whether depression preceded or resulted from NVP, has not been established.

OBJECTIVE

To examine whether pregnant women, diagnosed with depression pre-conceptionally, treated with an antidepressant, reported a higher incidence of NVP when compared with pregnant women without depression.

METHOD

In this pilot study, two groups of pregnant women who called the Motherisk Program in Toronto, Canada, were compared. Group 1 was comprised of 179 pregnant women who reported taking an antidepressant for the treatment of depression prior to pregnancy and in the first trimester. Group 2 was comprised of 179 pregnant women with no history of depression. The incidence of NVP in both groupswas recorded and compared.

RESULTS

In the depressed group 109/179 (61%) women reported suffering from NVP vs.121/179 (68%) in the non-depressed group (P = 0.1). The logistic regression analysis did not identify any independent variable as significantly explaining NVP.

CONCLUSION

Depression and treatment with antidepressants prior to and in early pregnancy, does not appear to affect the incidence of NVP.

Measurement of chemopreventive efficacy in skin biopsies

OBJECTIVE

To explore methods suitable for quantitative assessment of the efficacy of chemopreventive intervention.

STUDY DESIGN

High-resolution imagery of nuclei from the suprabasal and basal cell layers of sun-damaged skin were recorded. There were 10 cases. A shave biopsy was taken from an area of clearly evident solar keratosis before and after treatment with 2-difluoromethyl-dlornithine (DFMO) and from the colateral forearm, treated with a placebo. A number of karyometric variables were computed and combined to derive marker features that provided a numeric measure of the degree of nuclear deviation from normal.

RESULTS

DFMO treatment was effective overall in reducing the degree of nuclear abnormality seen in the biopsies; in 8 of the 10 cases there was a significant improvement. The placebo-treated arm did not show a statistically different abnormality from the untreated arm.

CONCLUSION

Karyometric analysis can provide numeric measures that allow documentation of statistically significant regression of actinic keratotic lesions following treatment with DFMO.

Relationship of p53 mutations to epidermal cell proliferation and apoptosis in human UV-induced skin carcinogenesis

Human skin is continually subjected to UV-irradiation with the p53 gene playing a pivotal role in repair of UV-induced DNA damage and apoptosis. Consequently, p53 alterations are early events in human UV-induced skin carcinogenesis. We studied 13 squamous cell carcinomas (SCC), 16 actinic keratoses (AK), 13 samples adjacent to an AK (chronically sun-damaged), and 14 normal-appearing skin samples for p53 mutation, p53 immunostaining (IHC), apoptosis (in situ TUNEL and morphology), and proliferation (PCNA). The frequency of p53 mutation increased from 14% in normal skin, to 38.5% in sun-damaged skin, 63% in AK, and 54% in SCC. p53 IHC increased similarly. Apoptosis (TUNEL) increased from 0.06 +/- 0.02%, to 0.1 +/- 0.2, 0.3 +/- 0.3, and 0.4 +/- 0.3 in normal skin, sun-damaged skin, AK, and SCC, respectively. Apoptosis was strongly correlated with proliferation (i.e., TUNEL and PCNA, r = 0.7, P < 0.0001), and proliferation was significantly increased in the progression from normal skin to SCC. Bax was significantly increased in SCC compared to AK. These data imply that apoptosis in samples with a high frequency of p53 mutation may not necessarily be p53-dependent. We suggest that there is a mechanism for apoptosis in response to increased cellular proliferation that is p53-independent.

Treatment of acute respiratory failure secondary to pulmonary oedema with bi-level positive airway pressure by nasal mask

We report the successful outcome of first-line intervention of noninvasive positive pressure ventilation (NPPV) in four patients, three of whom had hypercapnic acute respiratory failure (ARF) and one hypoxaemic ARF, secondary to pulmonary oedema. The clinical condition showed rapid improvement and the NPPV, performed together with aggressive medical treatment, was effective in decreasing the respiratory frequency, and in correcting gas exchange abnormalities within the first 3 h. The average duration of nasal mask ventilation was 11 h (range 6-15 h). The patients were weaned, following ARF, by removing the ventilator whenever inspiratory positive airway pressure (IPAP) was 5 cmH2O. NPPV was applied, by nasal mask, using a bi-level positive airway pressure (BiPAP) delivering pressure support ventilation (PSV). We conclude that application of noninvasive positive pressure ventilation may be effective in correcting gas exchange abnormalities, in relieving respiratory distress and, perhaps, in avoiding endotracheal intubation in selected patients with acute respiratory failure secondary to reversible medical condition such as pulmonary oedema.

Expression of p53 protein in actinic keratosis, adjacent, normal-appearing, and non-sun-exposed human skin

Nonmelanoma skin cancer, including both squamous cell carcinoma and basal cell carcinoma, is a significant and increasing health problem in the United States. The precursor lesion of cutaneous squamous cell carcinoma, actinic keratosis (AK), is a major risk factor for nonmelanoma skin cancer, and it is also a marker of long-term sun exposure. AKs themselves can serve as biomarkers in chemopreventive studies, but in addition, they may contain phenotypic and genetic alterations that are related to the process of UV-induced skin carcinogenesis. One of these alterations, the tumor suppressor gene p53, is altered early in UV-induced skin carcinogenesis in humans. p53 protein expression was measured by immunohistochemistry in biopsies from AKs, tissue immediately adjacent to AKs (AK-adjacent), normal-appearing upper medial arm skin, and non-sun-exposed skin from 19 subjects. There was a significant difference and a progressively increasing mean p53 labeling index in total epidermis (basal and suprabasal layers) between upper medial arm skin (0.9 +/- 1.8%) and AK-adjacent (12.1 +/- 14.4%; P = 0.0004) and between AK (27.7 +/- 21.3%) and AK-adjacent skin (P = 0.04), whereas upper medial arm skin was marginally different from non-sun-exposed skin (0.1 +/- 0.2; P = 0.05). This pattern of p53 expression was also seen when epidermis was separated into basal and suprabasal layers. We conclude that epidermal p53 protein expression is associated with histological evidence of chronic sun damage.

Evaluation of proliferating cell nuclear antigen as a surrogate end point biomarker in actinic keratosis and adjacent, normal-appearing, and non-sun-exposed human skin samples

The incidence of nonmelanoma skin cancer, including both squamous cell carcinoma and basal cell carcinoma, is a significant health problem in the United States. Actinic keratosis (AK), the precursor of cutaneous squamous cell carcinoma, is a major risk factor for nonmelanoma skin cancer. In addition, AKs are tissue targets for the identification of biomarkers for use in chemopreventive studies. The biomarker addressed in this study is epidermal cell proliferation, as quantitated by proliferating cell nuclear antigen (PCNA). Shave biopsies were obtained from AKs, tissue immediately adjacent to AKs, normal-appearing, upper-medial arm skin, and non-sun-exposed skin from 19 subjects. When any degree of PCNA staining was considered positive (semiquantitative 1-4 scale), there was a significant difference and a progressively increasing mean PCNA labeling index (LI) in the total epidermis (basal and suprabasal layers), beginning with non-sun-exposed buttock skin, with the lowest LI (2.5 + or - 1.6%), followed by upper-medial arm skin (12.3 + or - 7.4%; P = 0.0015), skin adjacent to AKs (19.2 + or - 12.2%; P = 0.0218), and finally, AKs with the highest LI (34.6 + or - 20.1%; P = 0.0017). This same pattern was observed when the epidermis was separated into basal and suprabasal layers, with the exception of a nonsignificant result for upper-medial arm skin compared with adjacent skin in the basal layer (P = 0.3981). PCNA LIs were also analyzed separately by staining intensity (i.e., scores of 1-4). The PCNA LI in skin with varying degrees of sun damage and/or histological atypia is a candidate surrogate end point biomarker for skin cancer chemoprevention studies.

Metastasizing keratoacanthomas? The difficulties in differentiating keratoacanthomas from squamous cell carcinomas

The problem in diagnosis of keratoacanthoma versus squamous cell carcinoma has been reviewed, and 13 patients are presented to illustrate the difficulties in differentiating between these two lesions. If the pathologist is in doubt, the lesion should be called "probable keratoacanthoma, but squamous cell carcinoma cannot be ruled out." We should all be aware that even the most careful pathologist, using all the information and material available, may still erroneously diagnose a lesion as a benign keratoacanthoma--one which, if inadequately treated, may metastasize or recur as a squamous cell carcinoma. Therefore, it is important for the clinician to treat most keratoacanthomas by adequate removal and close follow-up.