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Chen X, Yang Y, Chen L, Wang K. Pregnancy outcomes and birth defects in offspring following Non-steroidal anti-inflammatory drugs exposure during pregnancy: A systematic review and meta-analysis. Reprod Toxicol 2024; 125:108561. [PMID: 38423229 DOI: 10.1016/j.reprotox.2024.108561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/03/2024] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
There is a high global prevalence of NSAIDs during pregnancy. However, current evidence is largely conflicting regarding the safety of gestational NSAIDs use both for the pregnancy and offspring health. The aim of this study is to systematically review the relationship between NSAIDs use during pregnancy and the risk of adverse pregnancy outcomes and congenital abnormalities. Cohort studies and case control studies on congenital malformations, miscarriage and preterm birth in infants born to mothers who were exposed to NSAIDs during pregnancy were identified via PubMed, Medline, Embase, the Cochrane Library databases and the Reprotox® database from inception to 26 March 2021, and updated on 6 April 2023. On the whole, compared with the unexposed group, infants exposed to NSAIDs during early pregnancy showed a 28% increased risk of overall congenital anomalies (OR 1.28, 95%CI 1.16-1.40), and 19% for major birth defects (OR 1.19, 95%CI 1.08-1.30). Contrary to previous beliefs, there appeared to be a trend towards a higher risk of miscarriage among women who were exposed to NSAIDs during pregnancy, but the association was not statistically significant (OR 1.20, 95%CI 0.93-1.55). According to our study findings, the use of NSAIDs by pregnant women has been linked to a higher risk of congenital anomalies and a negative impact on preterm birth. Therefore, we advise pregnant women to carefully consider the potential benefits and risks before using NSAIDs during pregnancy.
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Affiliation(s)
- Xiaohong Chen
- Department of pharmacy, Women and Children's Hospital of Chongqing Medical University, Chongqing, China; Department of pharmacy, Chongqing Health Center for Women and Children, Chongqing, China
| | - Yang Yang
- Department of pharmacy, Women and Children's Hospital of Chongqing Medical University, Chongqing, China; Department of pharmacy, Chongqing Health Center for Women and Children, Chongqing, China
| | - Lin Chen
- Department of pharmacy, Women and Children's Hospital of Chongqing Medical University, Chongqing, China; Department of pharmacy, Chongqing Health Center for Women and Children, Chongqing, China.
| | - Kejing Wang
- Department of pharmacy, Women and Children's Hospital of Chongqing Medical University, Chongqing, China; Department of pharmacy, Chongqing Health Center for Women and Children, Chongqing, China.
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2
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Delker E, Kelly A, Chambers C, Johnson D, Bandoli G. Associations of prenatal exposure to non-steroidal anti-inflammatory drugs with preterm birth and small for gestational age infants among women with autoimmune disorders. Pharmacoepidemiol Drug Saf 2023; 32:225-237. [PMID: 36377036 DOI: 10.1002/pds.5570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/12/2022] [Accepted: 11/07/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Estimate associations between prenatal non-steroidal anti-inflammatory (NSAID) exposure and preterm birth and small for gestational age among women with autoimmune conditions. METHODS Participants were enrolled in the MotherToBaby cohort and had an autoimmune disorder and singleton live birth >20 weeks gestation (n = 2007). We characterized self-reported NSAID exposure over gestation for timing, duration, and average daily dose. Outcomes were preterm birth (i.e., <37 weeks' gestation) and small for gestational age infants (SGA; <10th percentile birthweight). We used Poisson regression to estimate associations between NSAID exposure and study outcomes adjusting for demographics, co-use of other medications (Model 1), and disease severity at baseline (Model 2). Secondarily, we considered the role of acetaminophen use by individually matching NSAID users to controls on cumulative dose of acetaminophen exposure. RESULTS Overall, 15% of women reported NSAID use in pregnancy, with most use in the first trimester. No NSAID use exposure variables were associated with risk of preterm birth. Any NSAID use was associated with 1.7 (95% CI 1.2, 2.5) times greater risk of SGA and this estimate was attenuated to 1.5 (95% CI 1.0, 2.3) after adjustment for baseline disease severity. NSAID exposure in the first trimester was most strongly associated with SGA. After matching on acetaminophen exposure, associations between any NSAID use and preterm birth and SGA were 0.9 (95% CI 0.6, 1.4) and 1.8 (95% CI 1.1, 2.9). CONCLUSIONS NSAID use in pregnancy is associated with SGA but not preterm birth. Future research should explore mechanisms that may explain these findings. Future research must also consider alternative explanations for these associations.
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Affiliation(s)
- Erin Delker
- Department of Pediatrics, Division of Environmental Science and Health, University of California San Diego, San Diego, California, USA
| | - Ann Kelly
- Department of Pediatrics, Division of Environmental Science and Health, University of California San Diego, San Diego, California, USA
| | - Christina Chambers
- Department of Pediatrics, Division of Environmental Science and Health, University of California San Diego, San Diego, California, USA
| | - Diana Johnson
- Department of Pediatrics, Division of Environmental Science and Health, University of California San Diego, San Diego, California, USA
| | - Gretchen Bandoli
- Department of Pediatrics, Division of Environmental Science and Health, University of California San Diego, San Diego, California, USA
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3
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Brien ME, Gaudreault V, Hughes K, Hayes DJL, Heazell AEP, Girard S. A Systematic Review of the Safety of Blocking the IL-1 System in Human Pregnancy. J Clin Med 2021; 11:jcm11010225. [PMID: 35011965 PMCID: PMC8745599 DOI: 10.3390/jcm11010225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022] Open
Abstract
Blockade of the interleukin-1 (IL-1) pathway has been used therapeutically in several inflammatory diseases including arthritis and cryopyrin-associated periodic syndrome (CAPS). These conditions frequently affect women of childbearing age and continued usage of IL-1 specific treatments throughout pregnancy has been reported. IL-1 is involved in pregnancy complications and its blockade could have therapeutic potential. We systematically reviewed all reported cases of IL-1 blockade in human pregnancy to assess safety and perinatal outcomes. We searched several databases to find reports of specific blockade of the IL-1 pathway at any stage of pregnancy, excluding broad spectrum or non-specific anti-inflammatory intervention. Our literature search generated 2439 references of which 22 studies included, following extensive review. From these, 88 different pregnancies were assessed. Most (64.8%) resulted in healthy term deliveries without any obstetrical/neonatal complications. Including pregnancy exposed to Anakinra or Canakinumab, 12 (15.0%) resulted in preterm birth and one stillbirth occurred. Regarding neonatal complications, 2 cases of renal agenesis (2.5%) were observed, and 6 infants were diagnosed with CAPS (7.5%). In conclusion, this systematic review describes that IL-1 blockade during pregnancy is not associated with increased adverse perinatal outcomes, considering that treated women all presented an inflammatory disease associated with elevated risk of pregnancy complications.
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Affiliation(s)
- Marie-Eve Brien
- Ste-Justine Hospital Research Center, Montreal, QC H3T 1C5, Canada; (M.-E.B.); (V.G.); (K.H.)
| | - Virginie Gaudreault
- Ste-Justine Hospital Research Center, Montreal, QC H3T 1C5, Canada; (M.-E.B.); (V.G.); (K.H.)
| | - Katia Hughes
- Ste-Justine Hospital Research Center, Montreal, QC H3T 1C5, Canada; (M.-E.B.); (V.G.); (K.H.)
| | - Dexter J. L. Hayes
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK; (D.J.L.H.); (A.E.P.H.)
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK; (D.J.L.H.); (A.E.P.H.)
| | - Sylvie Girard
- Department of Obstetrics and Gynecology, Universite de Montreal, Montreal, QC H3T 1J4, Canada
- Department of Obstetrics and Gynecology, Department of Immunology, Mayo Clinic, Rochester, MN 55902, USA
- Correspondence: ; Tel.: +1-507-284-0545
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Castro CT, Gama RS, Pereira M, Oliveira MG, Dal-Pizzol TS, Barreto ML, Santos DB. Effect of acetaminophen use during pregnancy on adverse pregnancy outcomes: a systematic review and meta-analysis. Expert Opin Drug Saf 2021; 21:241-251. [PMID: 34964403 DOI: 10.1080/14740338.2022.2020246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION A high number of women are exposed to acetaminophen during pregnancy worldwide. This drug safety during pregnancy regarding preterm birth, birth weight, and fetal development has not been well described. This study investigated the effect of acetaminophen use during pregnancy on selected adverse pregnancy outcomes. AREAS COVERED Databases were searched to identify studies reporting the effects of acetaminophen use during pregnancy on preterm birth, low birth weight, and small for gestational age. The studies' quality was assessed by the Newcastle-Ottawa Scale and the Methodological Index for Non-Randomized Studies. Relative risk with 95% confidence intervals of each outcome was estimated using a fixed or random-effects model. Six studies were included for final review, four cohort and two case-control studies. We found no increased risk of preterm birth (RR 0.97; 95% CI 0.59-1.58), and decreased risks of low birth weight (RR 0.65; 95% CI 0.59-0.72) and small for gestational age (RR 0.69; 95% CI 0.50-0.97). Acetaminophen exposure during the third trimester revealed non-significantly in the outcomes. EXPERT OPINION Exposure to acetaminophen during pregnancy appears to not increase the risk of the outcomes analyzed. However, there is a lack of information regarding the exposure dose and frequency of acetaminophen use.
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Affiliation(s)
- Caroline T Castro
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Romana S Gama
- Program of Pos-Graduation in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Marcos Pereira
- Program of Post-Graduation in Collective Health, Institute of Collective Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Marcio G Oliveira
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Tatiane S Dal-Pizzol
- Post-Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Mauricio L Barreto
- Program of Post-Graduation in Collective Health, Institute of Collective Health, Federal University of Bahia, Salvador, Bahia, Brazil.,Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | - Djanilson B Santos
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil.,Center for Health Sciences, Federal University of Recôncavo da Bahia, Santo Antônio de Jesus, Bahia, Brazil
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Zhao JP, Berthod C, Sheehy O, Kassaï B, Gorgui J, Bérard A. Prevalence and duration of prescribed opioid use during pregnancy: a cohort study from the Quebec Pregnancy Cohort. BMC Pregnancy Childbirth 2021; 21:800. [PMID: 34847870 PMCID: PMC8638412 DOI: 10.1186/s12884-021-04270-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background Recent studies show a rapid growth among pregnant women using high potency opioids for common pain management during their pregnancy. No study has examined the duration of treatment among strong opioid users and weak opioid users during pregnancy. We aimed to investigate the prevalence of prescribed opioid use during pregnancy, in Quebec; and to compare the duration of opioid treatment between strong opioid users and weak opioid users. Methods Using the Quebec Pregnancy Cohort (1998–2015), we included all pregnancies covered by the Quebec Public Prescription Drug Insurance Program. Opioid exposure was defined as filled at least one prescription for any opioid during pregnancy or before pregnancy but with a duration that overlapped the beginning of pregnancy. Prevalence of opioids use was calculated for all pregnancies, according to pregnancy outcome, trimester of exposure, and individual opioids. The duration of opioid use during pregnancy was analyzed according to 8 categories based on cumulative duration (< 90 days vs. ≥90 days), duration of action (short-acting vs. long-acting) and strength of the opioid (weak vs. strong). Results Of 442,079 eligible pregnancies, 20,921 (4.7%) were exposed to opioids. Among pregnancies ending with deliveries (n = 249,234), 5.4% were exposed to opioids; the prevalence increased by 40.3% from 3.9% in 1998 to 5.5% in 2015, more specifically a significant increase in the second and third trimesters of pregnancy. Weak opioid, codeine was the most commonly dispensed opioid (70% of all dispensed opioids), followed by strong opioid, hydromorphone (11%), morphine (10%), and oxycodone (5%). The prevalence of codeine use decreased by 47% from 4.3% in 2005 to 2.3% in 2015, accompanied by an increased use of strong opioid, morphine (0.029 to 1.41%), hydromorphone (0.115 to 1.08%) and oxycodone (0.022 to 0.44%), from 1998 to 2015. The average durations of opioid exposure were significantly longer among pregnancies exposed to strong opioid as compared to weak opioid regardless of the cumulative duration or duration of action (P < 0.05). Conclusions Given the differences in the safety profile between strong opioids and the major weak opioid codeine, the increased use of strong opioids during pregnancy with longer treatment duration raises public health concerns. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04270-x.
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Affiliation(s)
- Jin-Ping Zhao
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Christelle Berthod
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada.,Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada.,University of Lyon 1, 69008, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, University of Lyon 1; CNRS, UMR 5558, 69622, Villeurbanne, France
| | - Odile Sheehy
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Behrouz Kassaï
- EPICIME-CIC 1407 Lyon, Inserm, Pharmacotoxicology Department, CHU-Lyon, 69677, Bron, France.,University of Lyon 1, 69008, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, University of Lyon 1; CNRS, UMR 5558, 69622, Villeurbanne, France
| | - Jessica Gorgui
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada.,Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Anick Bérard
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada. .,Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada. .,EPICIME-CIC 1407 Lyon, Inserm, Pharmacotoxicology Department, CHU-Lyon, 69677, Bron, France. .,University of Lyon 1, 69008, Lyon, France. .,Laboratoire de Biométrie et Biologie Evolutive, University of Lyon 1; CNRS, UMR 5558, 69622, Villeurbanne, France.
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Meißner Y, Strangfeld A. [Insights into pregnancy and breastfeeding in inflammatory rheumatic diseases through observational data]. Z Rheumatol 2021; 80:733-742. [PMID: 34535821 DOI: 10.1007/s00393-021-01082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
Information on pregnancy and breastfeeding in women with chronic inflammatory rheumatic diseases is relevant for a successful pregnancy and also for maternal and child health. In general, pregnant and breastfeeding women are excluded from randomized clinical trials and therefore evidence for clinical care and counselling has to be generated from observational studies. In the past decades, various data collections have been established for this purpose in addition to the existing spontaneous reporting systems initiated by drug authorities, with the aim of monitoring the teratogenic risk of a drug. Health insurance claims data, electronic health records and Scandinavian registers are also increasingly being used for research on pregnancy-associated events; however, all these data sources lack the inclusion of the maternal disease, especially with respect to its inflammatory component. Established cohort studies, biologics and disease registries record disease activity but are not designed for pregnancy-specific questions. Pregnancy registries and studies in rheumatology close this gap. In order to be able to make a better assessment of the possibilities and limitations of existing data sources on pregnancy and lactation, they are presented in detail in the following review including their respective advantages and disadvantages and examples from rheumatology are given. In addition, existing collaborations as well as studies for investigating the influence of paternal rheumatic disease are highlighted.
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Affiliation(s)
- Yvette Meißner
- Programmbereich Epidemiologie und Versorgungsforschung, Deutsches Rheuma-Forschungszentrum Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Anja Strangfeld
- Programmbereich Epidemiologie und Versorgungsforschung, Deutsches Rheuma-Forschungszentrum Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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7
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Quantin C, Yamdjieu Ngadeu C, Cottenet J, Escolano S, Bechraoui‐Quantin S, Rozenberg P, Tubert‐Bitter P, Gouyon J. Early exposure of pregnant women to non-steroidal anti-inflammatory drugs delivered outside hospitals and preterm birth risk: nationwide cohort study. BJOG 2021; 128:1575-1584. [PMID: 33590634 PMCID: PMC8451913 DOI: 10.1111/1471-0528.16670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the risk of preterm birth associated with nonsteroidal anti-inflammatory drugs (NSAIDs), focusing on early exposure in the period from conception to 22 weeks of gestation (WG). DESIGN National population-based retrospective cohort study. SETTING The French National Health Insurance Database that includes hospital discharge data and health claims data. POPULATION Singleton pregnancies (2012-2014) with a live birth occurring after 22WG from women between 15 and 45 years old and insured the year before the first day of gestation and during pregnancy were included. We excluded pregnancies for which anti-inflammatory medications were dispensed after 22WG. METHODS The association between exposure and risk of preterm birth was evaluated with GEE models, adjusting on a large number of covariables, socio-demographic variables, maternal comorbidities, prescription drugs and pregnancy complications. MAIN OUTCOME MEASURES Prematurity, defined as a birth that occurred before 37WG. RESULTS Among our 1 598 330 singleton pregnancies, early exposure to non-selective NSAIDs was associated with a significantly increased risk of preterm birth, regardless of the severity of prematurity: adjusted odds ratio (aOR) = 1.76 (95% CI 1.54-2.00) for extreme prematurity (95% CI 22-27WG), 1.28 (95% CI 1.17-1.40) for moderate prematurity (28-31WG) and 1.08 (95% CI 1.05-1.11) for late prematurity (32-36WG), with non-overlapping confidence intervals. We identified five NSAIDs for which the risk of premature birth was significantly increased: ketoprofen, flurbiprofen, nabumetone, etodolac and indomethacin: for the latter, aOR = 1.92 (95% CI 1.37-2.70) with aOR = 9.33 (95% CI 3.75-23.22) for extreme prematurity. CONCLUSION Overall, non-selective NSAID use (delivered outside hospitals) during the first 22WG was found to be associated with an increased risk of prematurity. However, the association differs among NSAIDs. TWEETABLE ABSTRACT French study for which early exposure to non-selective NSAIDs was associated with increased risk of prematurity.
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Affiliation(s)
- C Quantin
- High‐Dimensional Biostatistics for Drug Safety and GenomicsUniversité Paris‐SaclayUVSQUniv. Paris‐SudInsermCESPVillejuifFrance
- Biostatistics and Bioinformatics (DIM)University HospitalDijonFrance
- Bourgogne Franche‐Comté UniversityDijonFrance
- InsermCIC 1432DijonFrance
- Clinical Investigation CentreClinical Epidemiology/Clinical Trials UnitDijon University HospitalDijonFrance
| | - C Yamdjieu Ngadeu
- Biostatistics and Bioinformatics (DIM)University HospitalDijonFrance
- Bourgogne Franche‐Comté UniversityDijonFrance
| | - J Cottenet
- Biostatistics and Bioinformatics (DIM)University HospitalDijonFrance
- Bourgogne Franche‐Comté UniversityDijonFrance
| | - S Escolano
- High‐Dimensional Biostatistics for Drug Safety and GenomicsUniversité Paris‐SaclayUVSQUniv. Paris‐SudInsermCESPVillejuifFrance
| | - S Bechraoui‐Quantin
- Biostatistics and Bioinformatics (DIM)University HospitalDijonFrance
- Bourgogne Franche‐Comté UniversityDijonFrance
| | - P Rozenberg
- Department of Obstetrics and GynaecologyPoissy‐Saint Germain HospitalPoissyFrance
- Paris Saclay University, UVSQ, Inserm, Team U1018, Clinical Epidemiology, CESPMontigny‐le‐BretonneuxFrance
| | - P Tubert‐Bitter
- High‐Dimensional Biostatistics for Drug Safety and GenomicsUniversité Paris‐SaclayUVSQUniv. Paris‐SudInsermCESPVillejuifFrance
| | - J‐B Gouyon
- Centre d’Etudes Périnatales Océan Indien (EA 7388)Centre Hospitalier Universitaire Sud RéunionLa RéunionSaint PierreFrance
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Machado GC, Abdel-Shaheed C, Underwood M, Day RO. Non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain. BMJ 2021; 372:n104. [PMID: 33514562 DOI: 10.1136/bmj.n104] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gustavo C Machado
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Christina Abdel-Shaheed
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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Ghalandari N, Dolhain RJEM, Hazes JMW, van Puijenbroek EP, Kapur M, Crijns HJMJ. Intrauterine Exposure to Biologics in Inflammatory Autoimmune Diseases: A Systematic Review. Drugs 2020; 80:1699-1722. [PMID: 32852745 PMCID: PMC7568712 DOI: 10.1007/s40265-020-01376-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory autoimmune diseases are chronic diseases that often affect women of childbearing age. Therefore, detailed knowledge of the safety profile of medications used for management of inflammatory autoimmune diseases during pregnancy is important. However, in many cases the potential harmful effects of medications (especially biologics) during pregnancy (and lactation) on mother and child have not been fully identified. OBJECTIVE Our aim was to update the data on the occurrence of miscarriages and (major) congenital malformations when using biologics during pregnancy based on newly published articles. Additionally, we selected several different secondary outcomes that may be of interest for clinicians, especially information on adverse events in the use of a specific biologic during pregnancy. MATERIAL AND METHODS A search was conducted from 1 January 2015 until 4 July 2019 in Embase.com, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar with specific search terms for each database. Selection of publications was based on title/abstract and followed by full text (double blinded, two researchers). An overview was made based on outcomes of interest. References of the included publications were reviewed to include and minimize the missing publications. RESULTS A total of 143 publications were included. The total number of cases ranged from nine for canakinumab to 4276 for infliximab. The rates of miscarriages and major congenital malformations did not show relevant differences from those rates in the general population. CONCLUSION Despite limitations to our study, no major safety issues were reported and no trend could be identified in the reported malformations.
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Affiliation(s)
- N Ghalandari
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands.
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - R J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E P van Puijenbroek
- Netherlands Pharmacovigilance Centre Lareb, 's Hertogenbosch, The Netherlands
| | - M Kapur
- Utrecht University of Medical Sciences, Utrecht, The Netherlands
| | - H J M J Crijns
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
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10
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Urrego D, Liwa AC, Cole WC, Wood SL, Slater DM. Cyclooxygenase inhibitors for treating preterm labour: What is the molecular evidence? 1. Can J Physiol Pharmacol 2019; 97:222-231. [PMID: 30661374 DOI: 10.1139/cjpp-2018-0380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Preterm birth (<37 weeks of gestation) significantly increases the risk of neonatal mortality and morbidity. As many as half of all preterm births occur following spontaneous preterm labour. Since in such cases there are no known reasons for the initiation of labour, treatment of preterm labour (tocolysis) has sought to stop labour contractions and delay delivery. Despite some success, the use of cyclooxygenase (COX) inhibitors is associated with maternal/fetal side effects, and possibly increased risk of preterm birth. Clinical use of these drugs predates the collection of molecular and biochemical evidence in vitro, examining the expression and activity of COX enzymes in pregnant uterine tissues with and without labour. Such evidence is important to the rationale that COX enzymes are, or are not, appropriate targets for the tocolysis. The current study systematically searched existing scientific evidence to address the hypothesis that COX expression/activity is increased with the onset of human labour, in an effort to determine whether there is a rationale for the use of COX inhibitors as tocolytics. Our review identified 44 studies, but determined that there is insufficient evidence to support or refute a role of COX-1/-2 in the onset of preterm labour that supports COX-targeted tocolysis.
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Affiliation(s)
- Daniela Urrego
- a Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW Calgary, AB T2N 4N1, Canada
| | - Anthony C Liwa
- a Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW Calgary, AB T2N 4N1, Canada.,b Department of Clinical Pharmacology, Weill School of Medicine, Catholic University of Health and Allied Sciences, PO Box 1464, Mwanza, Tanzania
| | - William C Cole
- a Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW Calgary, AB T2N 4N1, Canada
| | - Stephen L Wood
- c Department of Obstetrics and Gynaecology, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW Calgary, AB T2N 1N4, Canada
| | - Donna M Slater
- a Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW Calgary, AB T2N 4N1, Canada.,c Department of Obstetrics and Gynaecology, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW Calgary, AB T2N 1N4, Canada
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Bérard A, Sheehy O, Zhao JP, Gorgui J, Bernatsky S, de Moura CS, Abrahamowicz M. Associations between low- and high-dose oral fluconazole and pregnancy outcomes: 3 nested case-control studies. CMAJ 2019; 191:E179-E187. [PMID: 30782643 PMCID: PMC6379167 DOI: 10.1503/cmaj.180963] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND While topical azoles are the first-line treatment for fungal infections, oral fluconazole is frequently used during pregnancy. We aimed to assess the effect of exposure to low and high doses of fluconazole during pregnancy on the occurrence of spontaneous abortions, major congenital malformations and stillbirths. METHODS Within the Quebec Pregnancy Cohort (1998-2015), we identified women exposed to low- (≤ 150 mg) and high-dose (> 150 mg) fluconazole, and women who were not exposed. For each case of spontaneous abortion or stillbirth, up to 5 controls were randomly selected using an incidence density sampling method matched on gestational age at diagnosis of spontaneous abortion or stillbirth (index date) and the year of the last menstrual period. For cases of major congenital malformation, we considered all liveborn babies as controls. Generalized estimation equation models were used to analyze the 3 main outcomes separately. RESULTS Within a cohort of 441 949 pregnancies, 320 868 pregnancies were included in the analyses of spontaneous abortions, 226 599 of major congenital malformations and 7832 of stillbirths. Most (69.5%) women exposed to fluconazole in pregnancy received the common single therapeutic dose of 150 mg (low dose); the remainder received a dose of > 150 mg (high dose). Use of oral fluconazole during early pregnancy was associated with an increased risk of spontaneous abortion compared with no exposure (adjusted odds ratio [OR] for 345 cases exposed to low-dose treatment 2.23, 95% confidence interval [CI] 1.96-2.54; adjusted OR for 249 cases exposed to high-dose treatment 3.20, 95% CI 2.73-3.75). Exposure to fluconazole during the first trimester did not increase the risk of overall major congenital malformations; however, exposure to a high dose during the first trimester was associated with an increased risk of cardiac septal closure anomalies (adjusted OR 1.81, 95% CI 1.04-3.14; 13 exposed cases) compared with no exposure. No association was found between exposure to fluconazole during pregnancy and the risk of stillbirth. INTERPRETATION Any maternal exposure to fluconazole during pregnancy may increase risk of spontaneous abortion and doses higher than 150 mg during the first trimester may increase risk of cardiac septal closure anomalies.
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Affiliation(s)
- Anick Bérard
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que.
| | - Odile Sheehy
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Jin-Ping Zhao
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Jessica Gorgui
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Sasha Bernatsky
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Cristiano Soares de Moura
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Michal Abrahamowicz
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
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Littauer EQ, Skountzou I. Hormonal Regulation of Physiology, Innate Immunity and Antibody Response to H1N1 Influenza Virus Infection During Pregnancy. Front Immunol 2018; 9:2455. [PMID: 30420854 PMCID: PMC6215819 DOI: 10.3389/fimmu.2018.02455] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/04/2018] [Indexed: 12/13/2022] Open
Abstract
In 2009, the H1N1 swine flu pandemic highlighted the vulnerability of pregnant women to influenza viral infection. Pregnant women infected with influenza A virus were at increased risk of hospitalization and severe acute respiratory distress syndrome (ARDS), which is associated with high mortality, while their newborns had an increased risk of pre-term birth or low birth weight. Pregnant women have a unique immunological profile modulated by the sex hormones required to maintain pregnancy, namely progesterone and estrogens. The role of these hormones in coordinating maternal immunotolerance in uterine tissue and cellular subsets has been well researched; however, these hormones have wide-ranging effects outside the uterus in modulating the immune response to disease. In this review, we compile research findings in the clinic and in animal models that elaborate on the unique features of H1N1 influenza A viral pathogenesis during pregnancy, the crosstalk between innate immune signaling and hormonal regulation during pregnancy, and the role of pregnancy hormones in modulating cellular responses to influenza A viral infection at mid-gestation. We highlight the ways in which lung architecture and function is stressed by pregnancy, increasing baseline inflammation prior to infection. We demonstrate that infection disrupts progesterone production and upregulates inflammatory mediators, such as cyclooxygenase-2 (COX-2) and prostaglandins, resulting in pre-term labor and spontaneous abortions. Lastly, we profile the ways in which pregnancy alters innate and adaptive cellular immune responses to H1N1 influenza viral infection, and the ways in which these protect fetal development at the expense of effective long-term immune memory. Thus, we highlight advancements in the field of reproductive immunology in response to viral infection and illustrate how that knowledge might be used to develop more effective post-infection therapies and vaccination strategies.
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Affiliation(s)
- Elizabeth Q Littauer
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA, United States.,Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ioanna Skountzou
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA, United States.,Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, United States
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