Trends in adherence to a revised risk management program designed to decrease or eliminate isotretinoin-exposed pregnancies: evaluation of the accutane SMART program

Prescription retinoid and contraception use in women in Australia: A population-based study

BACKGROUND/OBECTIVES

Oral retinoids are teratogenic, and pregnancy avoidance is an important part of retinoid prescribing. Australia does not have a standardised pregnancy prevention programme for women using oral retinoids, and the contraception strategies for women who use oral retinoids are not well understood. The objectives were to determine trends in the use of prescription retinoids among Australian reproductive-aged women and whether women dispensed oral retinoids used contraception concomitantly.

METHODS

This was a population-based study using Australian Pharmaceutical Benefits (PBS) dispensing claims for a random 10% sample of 15-44-year-old Australian women, 2013 - 2021. We described rates and annual trends in dispensing claims for PBS-listed retinoids and contraceptives. We also estimated concomitant oral retinoid and contraceptive use on the day of each retinoid dispensing and determined if there was a period of contraceptive treatment that overlapped. Estimates were then extrapolated to the national level.

RESULTS

There were 1,545,800 retinoid dispensings to reproductive-aged women; 57.1% were oral retinoids. The rate of retinoid dispensing to reproductive-aged women increased annually, from 28 dispensings per 1000 population in 2013 to 41 per 1000 in 2021. The rate of oral retinoid dispensing doubled over the study period, from 14 dispensings per 1000 population in 2013 to 28 per 1000 in 2021, while topical retinoid dispensing did not change. Only 25% of oral retinoid dispensings had evidence of concomitant contraceptive use in 2021.

CONCLUSIONS

Rates of oral retinoid dispensing have doubled among reproductive-aged women over the past decade. A large percentage of oral retinoid use does not appear to have concomitant contraception use, posing a risk of teratogenic effects in pregnancies.

Compliance with Pregnancy Prevention Recommendations for Isotretinoin Following the Amendment of the European Union Pregnancy Prevention Program: A Repeat Study in Estonia

BACKGROUND

Isotretinoin, indicated for severe acne, is a potent teratogen and therefore contraindicated in pregnancy. Thus, the pregnancy prevention program (PPP) for isotretinoin has been introduced.

OBJECTIVES

The aim of this study was to assess the concomitant use of isotretinoin and effective contraception and the rate of potential isotretinoin-exposed pregnancies in females of childbearing age in 2017-2020 in Estonia. In addition, we aimed to evaluate whether compliance with the PPP has improved compared with the previous study conducted in Estonia covering the period of 2012-2016.

METHODS

This retrospective, nationwide study using prescription and healthcare claims data included 2575 females aged 15-45 years who started using isotretinoin between 2017 and 2020.

RESULTS

For 64.7% of females of childbearing age, no concurrent use of an effective contraceptive was detected while using isotretinoin. A moderately higher contraceptive coverage (35.3%) was observed compared with the previous study (29.7%) (p < 0.001). Complete contraception coverage was highest in females aged 30-39 years with an adjusted OR of 12.8 (p < 0.001) compared with the age group 15-19 years and 2.47 (p < 0.001) compared with the age group 20-29 years. 17 pregnancies coincided with the isotretinoin treatment-related period. The risk for potential isotretinoin-exposed pregnancy was 6.6 (95% CI 3.9-10.5) per 1000 treated females of childbearing age over the 4-year observation period. The risk for potential isotretinoin-exposed pregnancies per 1000 treated females was 1.0 in females aged 15-19 years, 11.6 in females aged 20-29 years, 8.8 in females aged 30-39 years, and 7.4 in females aged 40-45 years (p = 0.009).

CONCLUSION

A slight improvement in complete contraceptive coverage during isotretinoin use has not resulted in a decrease in the risk of isotretinoin-exposed pregnancies. The contraceptive usage and risk for pregnancy vary greatly across age groups, suggesting the need for a more targeted approach to improve the effectiveness of the PPP.

An Assessment of the Knowledge of Oral Isotretinoin (Roaccutane) Treatment Among Pharmacy Students in Saudi Arabia

BACKGROUND

Oral isotretinoin (Roaccutane) is one of the most effective treatments for severe acne. However, it displays significant side effects such as teratogenicity and psychological adverse events. Previous studies have reported inadequate awareness of community pharmacists and the general population regarding the medication's potential risks and adverse effects. The aim of this study is to assess pharmacy students' awareness and knowledge about the appropriate use of oral isotretinoin (known as Roaccutane) and its associated side effects in Saudi Arabia.

METHODS

 This is a cross-sectional study that uses a validated online questionnaire adopted from the literature distributed among pharmacy students between September 2021 and November 2021.

RESULTS

This study includes 1044 pharmacy students from multiple regions of Saudi Arabia. Among the total number of students included, 47.5% of the participants had used oral isotretinoin before or had a close family member who had used it previously. The most well-known side effect reported is skin dryness (87.7%), followed by teratogenicity (45.2%) and depression (37.9%). Most of the students (90.6%) know that isotretinoin's use is contraindicated in pregnancy. Despite this, only 39.6% of the participants state that married women of childbearing age using isotretinoin must utilize two types of contraception. There was a significant difference between genders in their knowledge about the side effects of the medication (P=0.01), as well as the safety precautions that women of childbearing age should take while taking the medication, as females had better knowledge and understanding of the required measures.

CONCLUSION

The total awareness level of pharmacy students about the most common side effects of isotretinoin is generally high. However, the students' knowledge about teratogenicity and depression is inadequate. We recommend paying attention to providing better education on the potential risks and precautionary measures related to the use of this medication, especially for women of childbearing age.

Teratogenic effect of isotretinoin in both fertile females and males (Review)

Isotretinoin is an oral derivate of vitamin A that has been used since 1982 for the treatment of multiple dermatologic conditions such as severe acne, rosacea, scarring alopecia, ichthyosis or non-melanoma skin cancer prophylaxis. The recommended dose is 0.5-1 mg/kg/day for a period of 4-6 months in sebaceous gland pathologies. There are many adverse effects caused by isotretinoin but by far the most important is the teratogenicity induced by this drug which is estimated to have a 20-35% risk to infants that are exposed to isotretinoin in utero and includes numerous congenital defects such as craniofacial defects, cardiovascular and neurological malformations or thymic disorders. Isotretinoin induces apoptosis and cell cycle arrest in human sebocytes, emphasizing these as processes associated with its teratogenic effect. The aim of this review is to analyze the latest literature data regarding the teratogenic effect of isotretinoin for both fertile females and males and its biological effects underlying the occurrence of congenital malformations under the influence of isotretinoin.

Washout Period for Pregnancy Post Isotretinoin Therapy

Introduction and Background:

Isotretinoin is an oral medication used for the treatment of severe acne unresponsive to other medications. This drug is teratogenic and should be prescribed with appropriate caution in selected group of patients. The washout period for pregnancy post isotrenoin therapy has always been a topic of controversy. Several guidelines have recommended a wash out period of one month if pregnancy is planned in a patient being administered with the drug.

Objective:

This article discusses the available evidence for different recommended wash out periods and addresses important clinical questions that arise.

Methods:

Pubmed research was carried out to collect relevant data using the keywords isotretinoin, pregnancy, contraception, pharmacokinetics and guidelines.

Conclusion:

Our research based on the published data concludes that a wash out period of 35 days post isotretinoin therapy is adequate in routine clinical practice.

'Engagement' of patients and healthcare professionals in regulatory pharmacovigilance: establishing a conceptual and methodological framework

BACKGROUND

Engagement of patients and healthcare professionals is increasingly considered as fundamental to pharmacovigilance and risk minimisation activities. Few empirical studies of engagement exist and a lack of explicit conceptualisations impedes effective measurement, research and the development of evidence-based engagement interventions.

AIMS

This article (1) develops a widely applicable conceptualisation, (2) considers various methodological challenges to researching engagement, proposing some solutions, and (3) outlines a basis for converting the conceptualisation into specific measures and indicators of engagement among stakeholders.

METHOD

We synthesise social science work on risk governance and public understandings of science with insights from studies in the pharmacovigilance field.

FINDINGS

This leads us to define engagement as an ongoing process of knowledge exchange among stakeholders, with the adoption of this knowledge as the outcome which may feed back into engagement processes over time. We conceptualise this process via three dimensions; breadth, depth and texture. In addressing challenges to capturing each dimension, we emphasise the importance of combining survey approaches with qualitative studies and secondary data on medicines use, prescribing, adverse reaction reporting and health outcomes. A framework for evaluating engagement intervention processes and outcomes is proposed. Alongside measuring engagement via breadth and depth, we highlight the need to research the engagement process through attentiveness to texture-what engagement feels like, what it means to people, and how this shapes motivations based on values, emotions, trust and rationales.

CONCLUSION

Capturing all three dimensions of engagement is vital to develop valid understandings of what works and why, thus informing engagement interventions of patients and healthcare professionals to given regulatory pharmacovigilance scenarios.

Isotretinoin; A review on the Utilization Pattern in Pregnancy

Purpose: Isotretinoin is the most effective anti-acne drug with a long-term remission. However; it contains severe teratogenic effects with serious adverse drug reactions, which limits the use of medication.

Methods: To review the use of isotretinoin during pregnancy, we carried out a comprehensive search of literature in Google Scholar, Scopus and PubMed/Medline from their inception until April 2015.

Results: Database searching identified 277 records, of which, 38 articles were retrieved according to abstract and title assessment. After full-text review, 17 articles were excluded and finally, a total of 21 studies met the inclusion criteria. Data showed an increased pattern in the use of isotretinoin. In some studies, health care providers were not fully adhered to the risk reduction programs in pregnancy. Exposing to isotretinoin among pregnant women has still occurred due to detrimental adherence to risk reduction programs which resulted in live-born infants with different kinds of abnormalities.

Conclusion: Despite the known serious adverse effect of isotretinoin, the use of drug was not based on the guidelines in some cases, which needs more attentions to prevent the severe drug related problems.

Compliance with Pregnancy Prevention Recommendations for Isotretinoin in Estonia in 2012-2016

Background

Isotretinoin is an effective treatment for severe acne; no alternative treatment has an equal therapeutic effect. The teratogenic effects of isotretinoin can be avoided, and numerous recommendations and regulations are in force to minimize the risk of pregnancy during treatment.

Objectives

To describe isotretinoin prescription patterns for women aged 15–45 years, assess the concomitancy of isotretinoin and contraceptive use, and determine the rate of potential isotretinoin-exposed pregnancies in Estonia.

Methods

This retrospective, nationwide, population-based, cohort study derived data from national health insurance databases and included female patients aged 15–45 years in Estonia for whom one or more prescriptions for isotretinoin were dispensed between 2012 and 2016. The main outcome was the proportion of women who used systemic isotretinoin and had a concomitant record of (hormonal or intrauterine) contraception use covering the isotretinoin treatment period when pregnancy is contraindicated.

Results

Of the 2792 women aged 15–45 years filling an isotretinoin prescription, 15.7% (95% CI 14.4–17.1) had full and 13.9% (95% CI 12.7–15.3) partial (not covering the whole period during which pregnancy is contraindicated) contraceptive coverage. The risk for potential isotretinoin-exposed pregnancy was 3.6 (95% CI 2.0–7.0) per 1000 treated women over the 5-year observation period. The odds for full coverage with effective contraception increased with the age of the patient, with the duration of isotretinoin treatment and over the period of observation.

Conclusion

Our study adds to the existing literature documenting limited compliance with pregnancy prevention programs for isotretinoin-containing products, and calls for program assessment to identify whether new measures should be taken or whether weaknesses in policy or implementation can be corrected.

Measuring the impact of medicines regulatory interventions - Systematic review and methodological considerations

AIMS

Evaluating the public health impact of regulatory interventions is important but there is currently no common methodological approach to guide this evaluation. This systematic review provides a descriptive overview of the analytical methods for impact research.

METHODS

We searched MEDLINE and EMBASE for articles with an empirical analysis evaluating the impact of European Union or non-European Union regulatory actions to safeguard public health published until March 2017. References from systematic reviews and articles from other known sources were added. Regulatory interventions, data sources, outcomes of interest, methodology and key findings were extracted.

RESULTS

From 1246 screened articles, 229 were eligible for full-text review and 153 articles in English language were included in the descriptive analysis. Over a third of articles studied analgesics and antidepressants. Interventions most frequently evaluated are regulatory safety communications (28.8%), black box warnings (23.5%) and direct healthcare professional communications (10.5%); 55% of studies measured changes in drug utilization patterns, 27% evaluated health outcomes, and 18% targeted knowledge, behaviour or changes in clinical practice. Unintended consequences like switching therapies or spill-over effects were rarely evaluated. Two-thirds used before-after time series and 15.7% before-after cross-sectional study designs. Various analytical approaches were applied including interrupted time series regression (31.4%), simple descriptive analysis (28.8%) and descriptive analysis with significance tests (23.5%).

CONCLUSION

Whilst impact evaluation of pharmacovigilance and product-specific regulatory interventions is increasing, the marked heterogeneity in study conduct and reporting highlights the need for scientific guidance to ensure robust methodologies are applied and systematic dissemination of results occurs.

Post-approval evaluation of effectiveness of risk minimisation: methods, challenges and interpretation

Evaluation of the effectiveness of drug risk-minimisation measures is mandatory for both risk evaluation and mitigation strategies (REMS) in the United States and risk management plans in the European Union (EU-RMPs). Such evaluations aim to assess the impact of risk-minimisation measures on the knowledge, attitudes or behaviours of healthcare professionals or patients, the incidence of safety concerns, and their impact on the overall benefit-risk balance. Although many effectiveness evaluation models and methods are available, regulatory guidance and policy are still evolving. This paper considers evaluation strategies, challenges in evaluating risk minimisation post-authorisation, possible outcome measures and their interpretation, and potential emerging regulatory policy issues. Particular challenges include appropriate data collection, perceived and real burdens of performing evaluation on clinical practice, lack of comparators and benchmarking, and uncertainty about the best outcome measures.

Methodological gaps in the assessment of risk minimization interventions: a systematic review

INTRODUCTION

Since the introduction of therapeutic risk management regulatory guidance, an increase in the number of risk minimization interventions (RMIs) published in the literature has been observed. Methods used to evaluate their effectiveness remain, however, poorly examined.

OBJECTIVE

This paper aimed to conduct a literature review on the methods of evaluation of effectiveness of RMIs and to identify methodological gaps.

METHODS

The search was conducted using MEDLINE and Embase between 1 January 2000 and 31 December 2010, and updated on 1 April 2013. The following characteristics were extracted from each study: target population for the RMI, target population for the assessment of effectiveness, study design, data sources, and effectiveness outcome(s).

RESULTS

A total of 188 unique RMIs were identified in the literature, of which effectiveness was evaluated in only 65 (34.6%) at the time of publication. The largest proportion of studies reviewed (n = 49, 75.4%) attempted to evaluate changes in behavior through prescribing or laboratory test practices. One quarter of studies evaluated the effect of RMIs on the occurrence of adverse events. Only a minority of studies used robust designs, such as randomized controlled trials (n = 6, 9.2%) or a quasi-experimental design with a parallel comparison group (n = 8, 12.3%).

CONCLUSION

Lack of robust methodological design used in published studies on RMI effectiveness evaluation is an important methodological gap in the evaluation of RMI effectiveness. © 2014 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd.

Additional risk minimisation measures in the EU - are they eligible for assessment?

PURPOSE

"Additional" risk minimisation measures (aRMMs) can be necessary to optimise the benefit-risk balance of a drug. Evaluation of effectiveness of these measures has become mandatory with the new European Union (EU) pharmacovigilance legislation in force since July 2012. The aim of this study was to classify the aRMMs in the EU with a special emphasis on the possibilities to analyse the effectiveness of these aRMMs in existing electronic healthcare databases (EHDs).

METHODS

European Public Assessment Reports were reviewed to identify key elements of the aRMMs. Researchers categorised the key elements based on the objectives, i.e. knowledge change or behavioural change and sub-categorised the behavioural changes. They assessed for each key element if it would be eligible for analysis in existing EHDs.

RESULTS

68 drugs with aRMMs contained 801 key elements of which 57% aimed at behavioural changes. 22% of all key elements, all aimed behavioural changes, were assessed eligible for analysis in existing EHDs. These mainly concerned recommendations targeted at healthcare professionals regarding drug prescription, e.g. dose recommendations, contraindications or the need to perform laboratory tests for patient monitoring.

CONCLUSIONS

Only a limited proportion of key elements of the aRMMs could potentially be monitored in existing EHDs as these data sources cannot capture all the required data. Due to difference between existing EHDs, not necessarily all available EHDs are appropriate for every drug or aRMM. To facilitate rapid evaluation of aRMM implementation and timely adjustments, industry and regulatory authorities should agree well-defined key elements of aRMMs leading to unambiguous actions of the target group.

The neurobehavioral teratology of retinoids: a 50-year history

This review of the central nervous system (CNS) and behavioral teratology of the retinoids over the last 50 years is a commemorative retrospective organized by decade to show the prominent research focus within each period and the most salient findings. In the 1960s, research focused on the gross CNS malformations associated with exposure and the delineation of dose-response and stage-specific responses in rodent models. Relevant scientific events before and during the 1960s are also discussed to provide the zeitgeist in which the field of neurobehavioral teratology emerged in the 1970s. During this period, studies demonstrated that adverse effects on postnatal behavior could be produced in animals exposed to doses of vitamin A lower than those that were teratogenic or impacted growth. Work during the 1980s showed an overrepresentation of behavioral studies focused on the reliability of screening methods, while the marked effects of human exposure were illustrated in children born to women treated with isotretinoin during pregnancy. The human catastrophe invigorated research during the 1990s, a period when technological advances allowed more elegant examinations of the developing CNS, of biochemical, cellular, and molecular developmental events and regulatory actions, and of the effects of direct genetic manipulations. Likewise, research in the 1990s reflected a reinvigoration of research in neurobehavioral teratology evinced in studies that used animal models to try to better understand human vulnerability. These foci continued in the 2000-2010 period while examinations of the role of retinoids in brain development and lifelong functioning became increasingly sophisticated and broader in scope. This review of the work on retinoids also provides a lens on the more general ontogeny of the field of neurobehavioral teratology. Birth Defects Research (Part A), 2010. © 2010 Wiley-Liss, Inc.

Risk management in dermatology: an analysis of data available from several British-based reporting systems

BACKGROUND

The elimination or reduction of risk is a prime requirement of all healthcare workers. The matter has come to the fore in dermatological practice recently with the widespread use of effective drugs that have significant side-effects (e.g. retinoids, cytotoxic drugs, biologics), the increase in skin surgery, especially for skin cancer, and the extensive use of phototherapies.

OBJECTIVES

To examine the available database from different agencies to which adverse events may be reported over at least a 5-year time frame, categorize the risks, look forward to where as yet unidentified risks might exist, and draw conclusions to improve the safety of dermatological practice. This work came about through a request from the National Patient Safety Agency [to the Joint Specialty Committee of the British Association of Dermatologists (BAD) and Royal College of Physicians] for information on risks to patients receiving treatment or investigation for skin disease.

METHODS

Organizations in the U.K. that receive information about adverse events, whether caused by drugs or procedures in dermatological treatments, were approached for information about reported events over a 5-year (or, in one case, 10-year) time frame up to 2009. Data were received from the National Patient Safety Agency, the Medicines and Healthcare Products Regulatory Agency, the National Health Service Litigation Authority, the Medical Protection Society and the Medical Defence Union. In addition, the results of a survey conducted in 2010 by the BAD of its members concerning potential critical incident reporting were included. The received information was analysed according to category of event and conclusions drawn about how best to manage the risks that were identified.

RESULTS

Adverse events were divided into the following categories, listed in order of the number of reports received: drug side-effects (biologics and retinoids), phototherapy dosage, drug monitoring (including initial screening), pregnancy prevention programmes, skin cancer follow-up (including acting on reports), dermatopathological reporting and conduct of dermatological surgery (including management of complications, equipment problems, use of lasers, cosmetic procedures and cryotherapy). Critical incidents reported by BAD members often concerned follow-up failures, e.g. of patients receiving systemic drugs or of those with skin cancer.

CONCLUSIONS

Several of the reported adverse events concern systemic failures. Recommendations for risk reduction include the following points: better systems for drug monitoring (including regularity of attendance, provision of sufficient follow-up appointments, acting on results and adequacy of pregnancy prevention programmes); staff training and record keeping for phototherapy; acting on skin cancer multidisciplinary team meeting outcomes (including provision of sufficient follow-up appointments); and adequate training of staff in dermatological surgery including cryotherapy. Regular monitoring of the occurrence of such reports is needed to ensure safe practice and to identify early areas of new risk.

Roadmap to risk evaluation and mitigation strategies (REMS) success

Medical safety-related risk management is a rapidly evolving and increasingly important aspect of drug approval and market longevity. To effectively meet the challenges of this new era, we describe a risk management roadmap that proactively yet practically anticipates risk-management requirements, provides the foundation for enduring yet appropriately flexible risk-management practices, and leverages these techniques to efficiently and effectively utilize risk evaluation and mitigation strategies (REMS)/risk minimization programs as market access enablers. This fully integrated risk-management paradigm creates exciting opportunities for newer tools, techniques, and approaches to more successfully optimize product development, approval, and commercialization, with patients as the ultimate beneficiaries.

Isotretinoin use and compliance with the Dutch Pregnancy Prevention Programme: a retrospective cohort study in females of reproductive age using pharmacy dispensing data

BACKGROUND

Isotretinoin is very effective in the treatment of severe acne. However, because of the teratogenic properties of this agent an isotretinoin Pregnancy Prevention Programme (PPP) was implemented in the Netherlands to guarantee that treatment is contraindicated in women of reproductive age unless at least one effective method of contraception is used. Furthermore, the PPP stipulates that isotretinoin treatment should be managed by physicians or specialists experienced in treatment with this drug and that only monthly prescriptions are issued.

OBJECTIVE

To assess compliance with the Dutch isotretinoin PPP in women of reproductive age during the study period of 1 January 2005 to 31 December 2008.

METHODS

Detailed information on dispensed medication and co-medication was available from the Dutch Foundation of Pharmaceutical Statistics. Four types of outcome were studied: concomitant dispensing of hormonal contraceptive with isotretinoin; the proportion of specialist prescribing of isotretinoin; prescribing of conventional acne therapy prior to isotretinoin initiation; and isotretinoin dispensing exceeding the maximum amount. The use of contraceptives in women aged between 15 and 45 years was defined as concomitant if the period of systemic contraceptive use overlapped the period of isotretinoin dispensing for at least 10 days, or if any dispensing of an intrauterine or intravaginal contraceptive was recorded since the year 2000. Dispensings were separated into those prescribed by either specialists or general practitioners (GPs). The use of antibacterials, antiandrogens or topical agents against acne was checked 4 months prior to an isotretinoin dispensing, and a possible excess of the maximum amount of isotretinoin was defined as prescriptions of more than 100 defined daily doses.

RESULTS

During the study period, data were available for 442 Dutch pharmacies encompassing 4881 women of reproductive age using isotretinoin at least once during study period. Among women of reproductive age, the use of isotretinoin increased during the study period. The proportion of isotretinoin initiation with concomitant oral hormonal or intrauterine contraceptives was low (59.3% [95% CI 57.6, 61.0]). Initiation of isotretinoin by a specialist increased the chance for concomitant contraception by 26% (95% CI 6.0, 49.0); in 78.2% (95% CI 76.8, 79.6) of women, isotretinoin was initiated by a specialist. Conventional acne therapy up to 16 months prior to isotretinoin initiation was found in 70% of the women (70.3% [95% CI 66.0, 74.6]). In 1.4% (95% CI 1.0, 1.8) of cases of treatment initiation, the amount of isotretinoin dispensed on one prescription seemed too high.

CONCLUSION

Attention should be paid to improving the implementation of the isotretinoin PPP. Despite clear guidelines and warnings in the product information, our study strongly suggests that concomitant use of isotretinoin and contraceptives is too low. Even though we will have missed non-pharmacological forms of contraception, these results raise doubts about the safe use of isotretinoin in women of reproductive age in the Netherlands. Furthermore, isotretinoin does not seem to be used in cases of severe acne only. Reserving isotretinoin prescribing to specialists may improve adherence to the PPP.

A case of suspected isotretinoin-induced malformation in a baby of a mother who became pregnant one month after discontinuation of the drug

Isotretinoin is a known human teratogen that can cause multiple malformations. At present, women who conceive one cycle after discontinuing isotretinoin are told that their teratogenic risk is not higher than baseline. We present a case of both-ear malformation in a newborn whose mother had taken isotretinoin for 2 years until one month prior to the time when she became pregnant. We suggest that further studies of pharmacokinetics and malformation of isotretinoin are needed.

Medications in pregnancy and lactation: part 1. Teratology

One of the least-developed areas of clinical pharmacology and drug research is the use of medication during pregnancy and lactation. This article is the first in a two-part series designed to familiarize physicians with many aspects of the drugs they commonly prescribe for pregnant and breast-feeding women. Almost every pregnant woman is exposed to some type of medication during pregnancy. Although the majority of pregnant and breast-feeding women consume clinically indicated or over-the-counter drug preparation regularly, only few medications have specifically been tested for safety and efficacy during pregnancy. There is scant information on the effect of common pregnancy complications on drug clearance and efficacy. Often, the safety of a drug for mothers, their fetuses, and nursing infants cannot be determined until it has been widely used. Absent this crucial information, many women are either refused medically important agents or experience potentially harmful delays in receiving drug treatment. Conversely, many drugs deemed "safe" are prescribed despite evidence of possible teratogenicity. Novel research and diagnostic applications evolving from the opportunities presented by the advances in genomics and proteomics are now beginning to affect clinical diagnosis, vaccine development, drug discovery, and unique therapies in a modern diagnostic-therapeutic framework-part of the new scientific field of theranostics. This review critically explores a number of recently raised issues in regard to the use of several classes of medications during gestation and seeks to provide a general and concise resource on drugs commonly used during pregnancy and lactation. It also seeks to make clinicians more aware of the controversies surrounding some drugs in an effort to encourage safer prescribing practices through consultation with a maternal-fetal medicine specialist and through references and Web sites that list up-to-date information.

iPLEDGE allegiance to the pill: evaluation of year 1 of a birth defect prevention and monitoring system

The United States Food and Drug Administration (FDA), in collaboration with pharmaceutical manufacturers, have recently implemented a heavily revised risk-management program for patients on isotretinoin (Accutane), a drug with known and pronounced teratogenic effects. This revised risk management plan places significant burdens on both providers and patients in the hopes of achieving its goal of reducing fetal exposure to isotretinoin. The main focus of this paper is to discuss the burdens of various aspects of the program in relationship to potential corresponding benefits. In particular, we evaluate the pregnancy rates of women on isotretinoin therapy compared with that of the general population and the rate changes based on the risk management programs. Additionally, we investigate whether the benefits of the program for women have increased as the benefits have risen. We devote special attention to the ethical implications of the intent of the program and to an analysis of the ethical justification of the restrictions placed on women of childbearing potential (WCP) as it compares to the risk-benefit relationship of using isotretinoin.

The effect of drug consultation center guidance on contraceptive use among women using isotretinoin: a randomized, controlled study

BACKGROUND

Women of reproductive age treated with isotretinoin are required to use two forms of contraceptives, yet adherence to the recommendations is limited. Our objective was to determine if an active intervention by a drug consultation center (DCC) will increase contraceptive use among women taking isotretinoin.

METHODS

In a randomized, controlled study, women of reproductive age who called the DCC seeking advice regarding isotretinoin were randomly assigned to an intervention group (information by phone during initial interview, by mailed written form, and by text messages sent to their cellular phones) and a control group (information given once). A follow-up call was made to all women 3 months after the first interview.

RESULTS

One hundred eight women (50 in the intervention group and 58 control) were enrolled. Most women do not adhere to the recommended contraceptive use. After 3 months, 50% of the study group and 40% of the control group were using a contraceptive (p = 0.41), and only 2 women in each group used two methods of contraception.

CONCLUSIONS

Strategies to increase adherence to contraceptive use among women treated with isotretinoin are needed.

Can we ensure the safe use of known human teratogens?: The iPLEDGE test case

Minimising the public health burden of isotretinoin-induced teratogenicity has been a challenge for 24 years, the duration of availability of isotretinoin in the US for the treatment of severe, recalcitrant nodular acne. Although the teratogenicity of this drug is well known and risk-management programmes had been implemented, preventable fetal exposures continued to occur, largely as a result of the lack of sufficient controls within the programmes themselves. The manufacturers of isotretinoin implemented a new risk-management programme, iPLEDGE, in March 2006. iPLEDGE is a comprehensive distribution system that includes mandatory registration of patients, healthcare providers, pharmacies, and wholesalers. It allows real-time linkage of pregnancy-test results for verification prior to the dispensing of isotretinoin. Although the challenges of implementing a closed distribution system for a very widely used medication have been extensive, the potential public health benefits from preventing fetal exposure to isotretinoin are substantial.

Patient receipt and understanding of written information provided with isotretinoin and estrogen prescriptions

BACKGROUND

Medication guides (MG) and mandatory patient package inserts (MPPI) are required with some prescription medications.

OBJECTIVE

We sought to determine how many patients receive, read, and understand these mandated materials.

DESIGN AND PARTICIPANTS

A total of 3,620 patients were identified as filling prescriptions for isotretinoin or selected estrogen products from February 2004 to January 2005. Patients were surveyed to gauge receipt and understanding of the MG for isotretinoin and the MPPI for estrogen.

MEASUREMENTS AND MAIN RESULTS

A total of 500 patients completed the survey, with 186 (93%) of the 200 isotretinoin patients and 258 (86%) of the 300 estrogen patients reporting receipt of the MG/MPPI with their most recent prescription. The majority of respondents reported confidence in their knowledge of their medication (86% for isotretinoin and 75% for estrogen). However, the mean score on 5 questions assessing recognition of medication risks was only slightly better than the score expected from guessing (3.1 vs 2.5, P < .01 for both isotretinoin and estrogen).

CONCLUSIONS

Despite receiving the information and reporting confidence in medication knowledge, patients' understanding of major risks with these medications was poor. This finding highlights the need to develop better risk communication strategies to improve the safe and effective use of prescription medications.

What is the best approach to reducing birth defects associated with isotretinoin?

Isotretinoin is an effective treatment for severe acne, a condition which can be physically, emotionally, and socially disabling. Because the drug is teratogenic, causing severe birth defects, women taking the drug are directed to avoid pregnancy. In the United States, a series of risk reduction programs have been implemented that aim to prevent pregnant women from taking the drug and to prevent women taking it from getting pregnant. The most recent, and most stringent, is an Internet-based, performance-linked system called iPLEDGE, which tries to ensure that the drug is dispensed only when there is documentary proof that the patient is not pregnant and is using two forms of birth control. Is iPLEDGE the best way to reduce isotretinoin birth defects, or is it an unproven and overly burdensome system?

Coping with the isotretinoin registry

The isotretinoin registry has arrived. It has a lofty goal of preventing all isotretinoin pregnancies. How we got to this point and what the registry means to prescribers and patients have many dermatologists confused and concerned. Will it be burdensome, will it preclude the use in most offices of this most important drug? Will it breed a new group of "isotretinologists" who are willing to take on the challenge? This article endeavors to answer these questions and to put most concerns at rest. The new system seems ultimately to have few changes compared to the risk management program we are already (technically) following. The difference is that compliance with all the rules will be monitored and mandatory. The system seems user friendly, is accessible to the computer-savvy as well as those of us still addicted to telephone, and may well turn out to be much fuss made over minimal hassle. What is clear is that this is likely our last chance to save this wonderful drug from oblivion. It is time for dermatologists to step to the plate and do what is in the best interest of their patients.

A risk management program aimed at preventing fetal exposure to isotretinoin: retrospective cohort study

BACKGROUND

Preventing fetal exposure to isotretinoin is an important public health goal. Since approval of isotretinoin (1982), the Food and Drug Administration has implemented several unsuccessful risk management programs aimed at preventing fetal exposure. The Kaiser Permanente isotretinoin risk management program included electronic capture of all isotretinoin prescriptions and the documentation of pregnancy testing with each dispense.

OBJECTIVE

Our aim was to analyze the success of Kaiser Permanente's program at improving pregnancy testing rates and reducing fetal exposure.

METHODS

This was a retrospective cohort study.

RESULTS

Pregnancy testing rates improved after implementation of the Kaiser Permanente program. However, the rate of fetal exposure to isotretinoin did not change (0.21% before vs 0.23% after, P = .85). LIMITATIONS/CONCLUSION: In this study, linking a negative pregnancy test to isotretinoin dispensing did not reduce fetal exposures. Patient failure to use two contraceptive methods was the most common reason for fetal exposure. These results have important implications for iPLEDGE, the new isotretinoin risk management program mandated by the Food and Drug Administration.

Do we have a knowledge transfer and translation plan at Teratogen Information Services?

Recently, a new field in science is emerging, which addresses the issue of ensuring that information that is generated from research, reaches the right people in the right format. This has been coined as knowledge transfer and translation and public health leaders worldwide are finding out ways to carry this out effectively. Ultimately, this should ensure greater investment in knowledge syntheses and transfer initiatives, that involve potential users of research to improve the quality of health for everyone. In this brief review/comment, an attempt will be made to help the readers understand the meaning of this new terminology and how it impacts Teratogen Information Services.