Psychomotor developmental effects of prenatal exposure to psychotropic drugs: a study in EFEMERIS database

Signal Detection in EUROmediCAT: Identification and Evaluation of Medication-Congenital Anomaly Associations and Use of VigiBase as a Complementary Source of Reference

INTRODUCTION

Knowledge on the safety of medication use during pregnancy is often sparse. Pregnant women are generally excluded from clinical trials, and there is a dependence on post-marketing surveillance to identify teratogenic medications.

AIMS

This study aimed to identify signals of potentially teratogenic medications using EUROmediCAT registry data on medication exposure in pregnancies with a congenital anomaly, and to investigate the use of VigiBase reports of adverse events of medications in the evaluation of these signals.

METHODS

Signals of medication-congenital anomaly associations were identified in EUROmediCAT (21,636 congenital anomaly cases with 32,619 medication exposures), then investigated in a subset of VigiBase (45,749 cases and 165,121 exposures), by reviewing statistical reporting patterns and VigiBase case reports. Evidence from the literature and quantitative and qualitative aspects of both datasets were considered before recommending signals as warranting further independent investigation.

RESULTS

EUROmediCAT analysis identified 49 signals of medication-congenital anomaly associations. Incorporating investigation in VigiBase and the literature, these were categorised as follows: four non-specific medications; 11 likely due to maternal disease; 11 well-established teratogens; two reviewed in previous EUROmediCAT studies with limited additional evidence; and 13 with insufficient basis for recommending follow-up. Independent investigations are recommended for eight signals: pregnen (4) derivatives with limb reduction; nitrofuran derivatives with cleft palate and patent ductus arteriosus; salicylic acid and derivatives with atresia or stenosis of other parts of the small intestine and tetralogy of Fallot; carbamazepine with atrioventricular septal defect and severe congenital heart defect; and selective beta-2-adrenoreceptor agonists with posterior urethral valve and/or prune belly.

CONCLUSION

EUROmediCAT data should continue to be used for signal detection, accompanied by information from VigiBase and review of the existing literature to prioritise signals for further independent evaluation.

Prenatal antidepressant exposure and child development at kindergarten age: a population-based study

BACKGROUND

Though prenatal antidepressant exposure has been associated with adverse developmental outcomes, the extent to which the effects are due to prenatal drug exposure or underlying maternal mood disturbances is unclear.

METHODS

This was a population-based retrospective cohort study using administrative data from British Columbia, Canada (n = 94,712). Analyses were designed to remove confounding effects of prenatal antidepressant exposure from maternal mood. First, children prenatally exposed to antidepressants were matched to unexposed children using high-dimensional propensity scores (HDPS). Second, children whose mothers had used antidepressants throughout pregnancy were compared against those whose mothers discontinued treatment.

RESULTS

In all, 3.87% (n = 3661) of children in the overall study population were prenatally exposed to antidepressants. In both analyses, we report increased odds for lower levels of physical independence (HDPS: OR, 1.14; 95% CI, 1.00-1.30; continuers/discontinuers: OR, 1.14; 95% CI, 0.99-1.32), and higher levels of anxious behaviors (HDPS: OR, 1.30; 95% CI, 1.01-1.66; continuers/discontinuers: OR, 1.32; 95% CI, 1.01-1.72) associated with antidepressant use in pregnancy. All other relationships were not significant using these methods.

CONCLUSIONS

Prenatal antidepressant exposure was selectively associated with worse anxious behaviors and physical independence at kindergarten age, with no effects on other developmental domains. Effects are also likely attributable to maternal mental illness severity or other unmeasured confounding factors.

IMPACT

Selective associations between prenatal antidepressant exposure and children's anxiety and physical independence at kindergarten were identified, with no impact on other developmental domains. Contradictory reports have emerged regarding the association of adverse child outcomes with prenatal antidepressant exposure. These inconsistencies may be due to differences in control for confounding. Effects of prenatal antidepressant exposure on anxious behaviors and physical independence are likely also attributable to severity of underlying maternal mood disorders, highlighting the importance of maternal mental health for developmental health.

[Antipsychotics during pregnancy: a systematic review]

BACKGROUND

The benefits and risks of treatment with antipsychotics during pregnancy must be weighed up carefully and individually because antipsychotics can penetrate the placental barrier and prescription is off-label.

OBJECTIVE

Evaluation of the risks and benefits of administering antipsychotics during pregnancy or for women who wish to become pregnant regarding teratogenic effects, risk of fetal death and stillbirths, perinatal complications, persisting postnatal impairments or disorders and gestational diabetes.

METHODS

A systematic review of the literature is provided to aid the selection of psychotropic drugs during pregnancy and in determining whether to begin, continue or switch an antipsychotic treatment during pregnancy.

RESULTS

Large, well-designed and controlled studies are missing; however, most studies suggest that the group of antipsychotics seem to be safe in terms of teratogenicity during pregnancy, at least in monotherapy.

CONCLUSION

Treating mental illnesses during pregnancy requires an individual assessment of the benefits and risks. The risk of an untreated mental illness versus the benefit of a suitable treatment with antipsychotics and the potential harm to the infant must be evaluated. If certain rules are observed and a suitable antipsychotic is selected the risk to the newborn child and/or mother during pregnancy can be minimized, however, a decision about subsequent medication can only be indirectly made from the results of this study.

Prescription patterns of benzodiazepine and benzodiazepine-related drugs in the peripartum period: A population-based study

Using prescription drugs during pregnancy is challenging and approached with caution. In this study, we present population-based information on prescription patterns of benzodiazepines and benzodiazepine-related drugs in the peripartum period. A population-based study of 1,154,817 pregnancies between 1997 and 2015 in Denmark, of which 205,406 (17.8%) pregnancies in women with a psychiatric history. Prescription drugs starting with Anatomical Therapeutic Chemical codes N05BA, N05CD, and N05CF from 12 months before pregnancy to 12 months following pregnancy were identified. We used generalised estimating equations to estimate the adjusted 5 year risk difference in the proportion of women redeeming benzodiazepines from 1 year to 5 years after. Logistic regression was used to analyze the association between characteristics and discontinuation of benzodiazepines during pregnancy. The prevalence of benzodiazepine prescriptions was 1.9% before pregnancy, 0.6% during pregnancy, and 1.3% after pregnancy. In women with a psychiatric history, the prevalence was 5-6 times higher. A significant decrease in prescriptions to women with a psychiatric history was observed, which was less profound among women with no psychiatric history. Approximately 90% of women discontinue benzodiazepines during pregnancy, with a higher percentage of women discontinuing from 1997 to 2015. The observed decrease is likely explained by changing treatment guidelines.

Prevalence of benzodiazepines and benzodiazepine-related drugs exposure before, during and after pregnancy: A systematic review and meta-analysis

BACKGROUND

Maternal use of benzodiazepines during pregnancy is common and has increased over the last decades. In this systematic review and meta-analysis, we studied the literature to estimate the worldwide use of benzodiazepines before, during and after pregnancy, which could help to estimate benzodiazepine exposure and to prioritize and guide future investigations.

METHODS

We systematically searched Embase, Medline Ovid, Web of Science and Cochrane Central up until July 2019 for studies reporting on benzodiazepine use before (12 months), during and after pregnancy (12 months). Random effects meta-analysis was conducted to calculate pooled prevalence estimates, as well as stratified according to substantive variables.

RESULTS

We identified 32 studies reporting on 28 countries, together reporting on 7,343,571 pregnancies. The worldwide prevalence of benzodiazepine use/prescriptions during pregnancy was 1.9% (95%CI 1.6%-2.2%; I² 97.48%). Highest prevalence was found in the third trimester (3.1%; 95%CI 1.8%-4.5%; I² 99.83%). Lorazepam was the most frequently used/prescribed benzodiazepine (1.5%; 95%CI 0.5%-2.5%; I² 99.87%). Highest prevalence was found in Eastern Europe (14.0%; 95%CI 12.1%-15.9%; I² 0.00%).

LIMITATIONS

All analyses revealed considerable heterogeneity.

CONCLUSIONS

Our meta-analysis confirmed that benzodiazepine use before, during and after pregnancy is prevalent. The relatively common use of benzodiazepines with possible risks for both mother and (unborn) child is worrying and calls for prescription guidelines for women, starting in the preconception period. Given the substantial proportion of children exposed to benzodiazepines in utero, future research should continue to study the short- and long-term safety of maternal benzodiazepine use during pregnancy and to explore non-pharmacological alternative treatments.

A comparative, single-blind, randomized study on quetiapine and aripiperazole augmentation in treatment of selective serotonin reuptake inhibitor refractory obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a chronic psychiatric disorder, of unknown etiology, that affects 2.5% of the population. An appropriate therapeutic response to conventional treatment is seen. Some studies use augmentative treatment by antipsychotics, glutamatergic, lithium, buspirone, and others agents to improve the therapeutic response. In this study, we aimed to evaluate the efficacy and tolerability of aripiprazole and quetiapine as augmentative treatments in patients with selective serotonin reuptake inhibitor (SSRI) refractory OCD. The OCD patients were initially treated for 12 weeks with a SSRI. If after 12 weeks their Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score was more than 16, they were randomly assigned to either the aripiprazole or the quetiapine augmentation group for an additional 12 weeks. There were no significant differences in age, sex, education, marital status, or score of Y-BOCS and Clinical Global Impression-Severity Scale (CGI-S) between groups (p > 0.05) at the outset of the study. Significant differences were noted after 1 month when compared with results at 2, 3, and 4 months in both groups (p < 0.001). Both quetiapine and aripiprazole may be effective and well-tolerated augmentative agents in the treatment of SSRI-refractory OCD. Because of positive results, aripiprazole may be considered more effective and may have a more rapid onset in terms of therapeutic response.

Antidepressants during pregnancy: a French drug utilisation study in EFEMERIS cohort

BACKGROUND

Previous studies have suggested that exposure to some antidepressants (AD) during pregnancy could be associated with an increased risk of congenital malformations and neurodevelopment disorders for the child. We conducted a study to describe the use of AD during pregnancy in France.

METHODS

We performed a drug utilisation study in EFEMERIS, a French cohort of pregnant women. At the time of the present study, 89,170 pregnant women, who were pregnant from 2005 to 2014 in Haute-Garonne were included. Prevalence and incidence of AD prescriptions during pregnancy, characteristics of AD users, and trends in AD use over the 10-year period were studied.

RESULTS

During the 10-year study period, 1620 women registered in EFEMERIS (1.8%) received at least one prescription and dispensation for AD during pregnancy: 1363 during the first (1.5%), 591 during the second (0.7%), and 412 during the third (0.5%) trimester. A total of 2874 women (3.2%) got a prescription for an AD during the 3 months before and/or during pregnancy; 2187 of them (76.1%) stopped AD before pregnancy or during the first trimester. Selective serotonin reuptake inhibitors represented the most prescribed class during pregnancy (1.3%). A very slight decrease in the prevalence of AD prescriptions in pregnant women over time (1.7% in 2014 vs 2% in 2005) and some variations within classes were observed.

CONCLUSIONS

Nearly, 2% of women received antidepressant drugs during pregnancy. This assessment encourages following research on these drugs including the potential risk of neurodevelopmental disorders in children after an exposure to antidepressants during pregnancy.

Use and validity of child neurodevelopment outcome measures in studies on prenatal exposure to psychotropic and analgesic medications - A systematic review

In recent years there has been increased attention to child neurodevelopment in studies on medication safety in pregnancy. Neurodevelopment is a multifactorial outcome that can be assessed by various assessors, using different measures. This has given rise to a debate on the validity of various measures of neurodevelopment. The aim of this review was twofold. Firstly we aimed to give an overview of studies on child neurodevelopment after prenatal exposure to central nervous system acting medications using psychotropics and analgesics as examples, giving special focus on the use and validity of outcome measures. Secondly, we aimed to give guidance on how to conduct and interpret medication safety studies with neurodevelopment outcomes. We conducted a systematic review in the MEDLINE, Embase, PsycINFO, Web of Science, Scopus, and Cochrane databases from inception to April 2019, including controlled studies on prenatal exposure to psychotropics or analgesics and child neurodevelopment, measured with standardised psychometric instruments or by diagnosis of neurodevelopmental disorder. The review management tool Covidence was used for data-extraction. Outcomes were grouped as motor skills, cognition, behaviour, emotionality, or "other". We identified 110 eligible papers (psychotropics, 82 papers, analgesics, 29 papers). A variety of neurodevelopmental outcome measures were used, including 27 different psychometric instruments administered by health care professionals, 15 different instruments completed by parents, and 13 different diagnostic categories. In 23 papers, no comments were made on the validity of the outcome measure. In conclusion, establishing neurodevelopmental safety includes assessing a wide variety of outcomes important for the child's daily functioning including motor skills, cognition, behaviour, and emotionality, with valid and reliable measures from infancy through to adolescence. Consensus is needed in the scientific community on how neurodevelopment should be assessed in medication safety in pregnancy studies. Review registration number: CRD42018086101 in the PROSPERO database.

Use of Antipsychotic Drugs During Pregnancy

Purpose of review

Antipsychotics are frequently prescribed to women of childbearing age and are increasingly prescribed during pregnancy. A small, but growing, body of research on implications for pregnancy and infant outcomes is available to inform the risks and benefits of in utero exposure to antipsychotics. This review examines the existing published research on the use of common typical and atypical antipsychotics in pregnancy and the implications for pregnancy and infant outcomes.

Recent findings

The majority of studies do not show associations with major malformations and antipsychotic use in pregnancy, with the possible exception of risperidone. There is concern that atypical antipsychotics may be associated with gestational diabetes. Metabolic changes during pregnancy may necessitate dose adjustments.

Summary

In general, it is recommended that women who need to take an antipsychotic during pregnancy continue the antipsychotic that has been most effective for symptom remission. Further study on risperidone is needed to better understand its association with malformations and it is not considered a first-line agent for use during pregnancy.

Long-term neurodevelopmental consequences of intrauterine exposure to lithium and antipsychotics: a systematic review and meta-analysis

Lithium and antipsychotics are often prescribed to treat bipolar disorder or psychotic disorders in women of childbearing age. Little is known about the consequences of these medications during pregnancy for the developing child. The objective of this article is to systematically review findings from preclinical and clinical studies that have examined the neurodevelopmental consequences of intrauterine exposure to lithium and antipsychotics. A systematic search was performed in Embase, Medline, Web of Science, PsychINFO, Cochrane, and Google Scholar. Clinical and experimental studies were selected if they investigated neurodevelopment of offspring exposed to lithium or antipsychotics during gestation. Quality of clinical and preclinical studies was assessed by the Newcastle-Ottawa Scale and the SYRCLE's risk of Bias tool, respectively. In total, 73 studies were selected for qualitative synthesis and three studies were selected for quantitative synthesis. Of preclinical studies, 93% found one or more adverse effects of prenatal exposure to antipsychotics or lithium on neurodevelopment or behaviour. Only three clinical cohort studies have investigated the consequences of lithium exposure, all of which reported normal development. In 66% of clinical studies regarding antipsychotic exposure, a transient delay in neurodevelopment was observed. The relative risk for neuromotor deficits after in utero exposure to antipsychotics was estimated to be 1.63 (95% CI 1.22-2.19; I2 = 0%). Preclinical studies suggest long-term adverse neurodevelopmental consequences of intrauterine exposure to either lithium or antipsychotics. However, there is a lack of high-quality clinical studies. Interpretation is difficult, since most studies have compared exposed children with their peers from the unaffected population, which did not allow correction for potential influences regarding genetic predisposition or parental psychiatric illness.

Prenatal Antidepressant Exposure and Child Motor Development: A Meta-analysis

CONTEXT

There is increasing use of antidepressants in pregnancy and hence children exposed in utero. Contradictory studies exist in the literature in which researchers report on the potential impact of antenatal antidepressant exposure on subsequent child motor development.

OBJECTIVE

Our objective in this systematic review and meta-analysis was to determine whether antenatal antidepressant exposure increases the risk of impaired motor development in children.

DATA SOURCES

We searched PsychINFO, Embase, Medline, PubMed, and Scopus up to July 24, 2017.

STUDY SELECTION

English-language cohort and case control studies in which researchers report primary data from a motor assessment of infants or children after any antidepressant exposure in pregnancy were included.

DATA EXTRACTION

Of the 329 studies identified, there were 160 articles screened, 24 were included in the systematic review, and 18 met inclusion criteria for the meta-analysis.

RESULTS

The total pooled results were based on random effects models and revealed a significant association between exposure to antidepressants during pregnancy and overall occurrence of poorer motor outcomes in children (effect size = 0.22; 95% confidence interval = 0.07 to 0.37) with a moderate degree of heterogeneity (I² = 56.6%).

LIMITATIONS

There was variation in the measurement both of exposure and motor development across the identified study, and few followed up to later childhood or beyond.

CONCLUSIONS

A small increased risk of poorer motor development may exist for children who are exposed to antidepressant medications during pregnancy. However, the marked methodological variation among studies and the limited control for possible confounds warrants cautious interpretation of these findings.

Impact of pregnancy on psychoactive substance use among women with substance use disorders recruited in addiction specialized care centers in France

Pregnancy can be a motivation for decrease in drug abusing but may also represent a period of high vulnerability for relapse. We aimed to assess psychoactive substance use among women with substance use disorders followed in addiction care centers in France. We analyzed data from women aged 15-44 years included in the 'Observation of illegal drugs and misuse of psychotropic medication (OPPIDUM) survey', an annual cross-sectional survey collecting details on psychoactive substances used. Characteristics of women included in 2005-2012 yearly surveys were compared depending on their pregnant or not pregnant status. Factors, including pregnancy, associated with illicit substance use and medication misuse were investigated through logistic regression. The study included 518 pregnant and 6345 nonpregnant women; 85.3% pregnant women were on opioid maintenance therapy (OMT) (vs. 77.1% of nonpregnant). Pregnancy was associated with lower illicit substance use (adjusted OR 0.71 [0.58-0.88]) and with lower medication misuse (0.66 [0.49-0.89]), whereas financial insecurity and living as a couple were associated with increased risk. Raising children was significantly associated with less risk of substance use. Each substance taken separately, the part of women using illicit substance or misusing medication did not differ depending on whether they were pregnant or not, except for heroin (24.5% in pregnant vs. 17.9% nonpregnant; <0.001). This nationwide study provides new insights into psychoactive substance use in a large mixed population of women with drug use disorders. Results outline the challenge of preventing drug use and initiating care strategies with a specific approach on socio-economic environment.

Psychopharmacological treatment of schizophrenia during pregnancy and lactation

PURPOSE OF REVIEW

It is necessary, in every-day clinical life when treating pregnant women with mental diseases, to reach quick decisions derived from recent comprehensive information. The knowledge of the use of antipsychotics in pregnancy has increased considerably in the last years. This review tries to summarize important considerations and facilitate clinical decisions.

RECENT FINDINGS

This review will cover not only the effects of exposure during pregnancy on outcomes, postnatal adaption syndrome and lactation, but also pharmacokinetic considerations on the use of antipsychotics during pregnancy.

SUMMARY

The recent publications have found only minimally increased risks for certain malformations, after using ever more sophisticated statistical models of analysis and reassuring amounts of data. Taken together, the quality of the studies has greatly improved and the results are reassuring with respect to the safety of the use of antipsychotics during pregnancy. The rates of weight gain and gestational diabetes warrant closer attention in the clinical setting.

Interest of the trajectory method for the evaluation of outcomes after in utero drug exposure: example of anxiolytics and hypnotics

PURPOSE

The aim of this study was to examine the potential benefit to take into account duration and intensity of drug exposure using the recently published method based on individual drug trajectories. This approach was used to define profiles of exposure to anxiolytics/hypnotics during pregnancy and to evaluate the potential effect on newborn health.

METHODS

The study was performed in EFEMERIS database (54 918 mother-children pairs). An estimation of adaptation to extrauterine life was assessed using several criteria especially cardio-respiratory symptoms. A proxy variable called "neonatal pathology" was created. The occurrence of this event was studied using two approaches: The Standard Method comparing exposed and unexposed newborns, The Trajectory Method comparing the different profiles of exposure.

RESULTS

Around 5% of newborns (n = 2768) were identified to be exposed to anxiolytics or hypnotics during pregnancy. Using the Standard Method, 6.2% of exposed newborns developed a "neonatal pathology" against 4.8% of unexposed newborns (odds ratios [OR] = 0.9[0.8-1.2], p = 0.7). With the Trajectory Method taking into account evolution of exposure during pregnancy and treatment intensity, four profiles of pregnant women were identified. A significant difference in the rates of "neonatal pathologies" was observed between profiles (p = 0.0002). Newborns of the two profiles exposed in utero to high constant level of anxiolytics or hypnotics were more at risk of developing "neonatal pathology" than unexposed newborns (OR₁  = 2.0 [1.0-3.9] and OR₂  = 7.6 [2.8-20.5]).

CONCLUSIONS

The present study demonstrates the interest of this method based on individual drug trajectories for the evaluation of outcomes in pharmaco-epidemiological studies and more specifically during pregnancy. Copyright © 2017 John Wiley & Sons, Ltd.