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Chan AYL, Gao L, Hsieh MHC, Kjerpeseth LJ, Avelar R, Banaschewski T, Chan AHY, Coghill D, Cohen JM, Gissler M, Harrison J, Ip P, Karlstad Ø, Lau WCY, Leinonen MK, Leung WC, Liao TC, Reutfors J, Shao SC, Simonoff E, Tan KCB, Taxis K, Tomlin A, Cesta CE, Lai ECC, Zoega H, Man KKC, Wong ICK. Maternal diabetes and risk of attention-deficit/hyperactivity disorder in offspring in a multinational cohort of 3.6 million mother-child pairs. Nat Med 2024; 30:1416-1423. [PMID: 38589601 PMCID: PMC11108779 DOI: 10.1038/s41591-024-02917-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/08/2024] [Indexed: 04/10/2024]
Abstract
Previous studies report an association between maternal diabetes mellitus (MDM) and attention-deficit/hyperactivity disorder (ADHD), often overlooking unmeasured confounders such as shared genetics and environmental factors. We therefore conducted a multinational cohort study with linked mother-child pairs data in Hong Kong, New Zealand, Taiwan, Finland, Iceland, Norway and Sweden to evaluate associations between different MDM (any MDM, gestational diabetes mellitus (GDM) and pregestational diabetes mellitus (PGDM)) and ADHD using Cox proportional hazards regression. We included over 3.6 million mother-child pairs between 2001 and 2014 with follow-up until 2020. Children who were born to mothers with any type of diabetes during pregnancy had a higher risk of ADHD than unexposed children (pooled hazard ratio (HR) = 1.16, 95% confidence interval (CI) = 1.08-1.24). Higher risks of ADHD were also observed for both GDM (pooled HR = 1.10, 95% CI = 1.04-1.17) and PGDM (pooled HR = 1.39, 95% CI = 1.25-1.55). However, siblings with discordant exposure to GDM in pregnancy had similar risks of ADHD (pooled HR = 1.05, 95% CI = 0.94-1.17), suggesting potential confounding by unmeasured, shared familial factors. Our findings indicate that there is a small-to-moderate association between MDM and ADHD, whereas the association between GDM and ADHD is unlikely to be causal. This finding contrast with previous studies, which reported substantially higher risk estimates, and underscores the need to reevaluate the precise roles of hyperglycemia and genetic factors in the relationship between MDM and ADHD.
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Affiliation(s)
- Adrienne Y L Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology and Economics, University of Groningen, Groningen, The Netherlands
| | - Le Gao
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Miyuki Hsing-Chun Hsieh
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Lars J Kjerpeseth
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Raquel Avelar
- Institute of Biological Psychiatry, Mental Health Centre Sct Hans, Mental Health Services, Copenhagen, Denmark
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Amy Hai Yan Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - David Coghill
- Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jacqueline M Cohen
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Mika Gissler
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Research Centre for Child Psychiatry, University of Turku, Turku, Finland
| | - Jeff Harrison
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Patrick Ip
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Øystein Karlstad
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Wallis C Y Lau
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Maarit K Leinonen
- Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Wing Cheong Leung
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
| | - Tzu-Chi Liao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Johan Reutfors
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Shih-Chieh Shao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Emily Simonoff
- Department of Child and Adolescent Psychiatry, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Kathryn Choon Beng Tan
- Department of Medicine, School of Clinical Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Katja Taxis
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology and Economics, University of Groningen, Groningen, The Netherlands
| | - Andrew Tomlin
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Carolyn E Cesta
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden.
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Helga Zoega
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland.
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
| | - Kenneth K C Man
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, Hong Kong.
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong.
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK.
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, Hong Kong.
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong.
- School of Pharmacy, Medical Sciences Division, Macau University of Science and Technology, Taipa, Macau.
- Advance Data Analytics for Medical Science Limited, Hong Kong, Hong Kong.
- School of Pharmacy, Aston University, Birmingham, UK.
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Liu C, Pace S, Bromley R, Dobson R. Exposure to medication for neurological disease in pregnancy - time to consider the long-term implications? EClinicalMedicine 2023; 63:102157. [PMID: 37662523 PMCID: PMC10474373 DOI: 10.1016/j.eclinm.2023.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
A range of long-term neurological conditions may be diagnosed in young adulthood. These conditions are generally not curable, and most people need to take ongoing treatment for symptom control and/or disease modification. When chronic diseases are diagnosed before people have completed their families, there is a need to balance the potential benefits of treatment for the mother against potential risk(s) to the fetus from exposure to medications during pregnancy. Whilst available data regarding short-term fetal outcomes following treatment exposures during pregnancy is rapidly increasing, information regarding longer-term outcomes is more limited. The association of fetal exposure to valproate with serious long-term neurodevelopmental outcomes has highlighted the importance of capturing and evaluating long-term data. In this review we examine available evidence around the long-term effects of treatments used for the most common long-term neurological conditions diagnosed in early adulthood, namely epilepsy, migraine and neuroinflammatory disorders. We draw from existing literature across a range of diseases and discuss strategies to improve future knowledge.
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Affiliation(s)
- Chen Liu
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
| | - Samuel Pace
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Rebecca Bromley
- Division of Neuroscience, School of Biological Sciences, Faculty of Medicine, Biology and Health, University of Manchester, UK
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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Spiteri JA, Camilleri G, Piccinni C, Sultana J. Safety of drugs used for the treatment of migraine during pregnancy: a narrative review. Expert Rev Clin Pharmacol 2023; 16:207-217. [PMID: 36803196 DOI: 10.1080/17512433.2023.2181157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION Migraine is common in females of childbearing age and negatively impacts quality of life. The majority of those with migraine who become pregnant see an improvement in their condition but not all do. Providing evidence-based recommendations for the pharmacological management of migraine in pregnancy is challenging. AREAS COVERED This narrative review provides an update on the safety of drugs used for migraine in pregnancy. National and international guidelines on the management of episodic migraine in adults were used to select the drugs of relevance to pregnant women. The final list of drugs was chosen by a pain specialist who categorized them according to drug class and use in acute management or prevention. PubMed was searched from inception to 31st July 2022 for evidence on drug safety. EXPERT OPINION Obtaining high-quality drug safety data in pregnant migraineurs is difficult not least because exposing a fetus to research-related risks is often considered unethical. There is reliance on observational studies which often group drugs together and lack specificities pertinent to drug prescribing like timing, dosing and duration. Improved statistical tools, study designs and the creation of international collaborative frameworks are ways to advance knowledge on drug safety in pregnancy.
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Affiliation(s)
- Jessica A Spiteri
- Department of Anaesthesia, Intensive Care and Pain Medicine, Mater Dei Hospital, Triq Dun Karm, Malta
| | - Gabrielle Camilleri
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida MSD, Malta
| | - Carlo Piccinni
- Fondazione Ricerca e Salute (ReS)-Research and Health Foundation, Casalecchio di Reno, Italy
| | - Janet Sultana
- Exeter College of Medicine and Health, University of Exeter, Exeter, UK
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Harris GM, Wood M, Ystrom E, Nordeng H. Association of Maternal Use of Triptans During Pregnancy With Risk of Attention-Deficit/Hyperactivity Disorder in Offspring. JAMA Netw Open 2022; 5:e2215333. [PMID: 35657626 PMCID: PMC9166221 DOI: 10.1001/jamanetworkopen.2022.15333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/15/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Triptans are commonly used in the treatment of migraine. Prenatal exposure to triptans may be associated with adverse fetal neurodevelopment; however, there is limited information about the long-term safety of triptan use during pregnancy. Objective To examine the association between maternal use of triptans during pregnancy and diagnosis and symptoms of attention-deficit/hyperactivity disorder (ADHD) among offspring. Design, Setting, and Participants This study used data from the Norwegian Mother, Father and Child Cohort Study (recruitment 1999-2008), linked to national health registries. Live-born singleton children born to women with migraine before or during pregnancy were included. Two analytic samples were defined: one to assess ADHD diagnosis and one to assess ADHD symptoms. Data were analyzed from May 1 to November 30, 2021. Exposure Maternal self-report of triptan use during pregnancy. Exposed children were compared with 2 groups of unexposed children whose mothers reported migraine (1) during pregnancy and (2) before pregnancy only. Main Outcomes and Measures An ADHD diagnosis was defined as diagnosis of hyperkinetic disorder or receipt of dispensed ADHD medication. Symptoms of ADHD at 5 years were measured by the Conners' Parent Rating Scale, where a higher score indicates more symptoms of ADHD. Cox proportional hazards regression models and generalized linear models with inverse probability weights were used to estimate weighted hazard ratios (HRs) and standardized mean differences, respectively, with 95% CIs. Results The ADHD diagnosis sample comprised 10 167 children (mean [SD] maternal age, 30.2 [4.6] years; 5231 boys [51.5%]), and the ADHD symptoms sample comprised 4367 children (mean [SD] maternal age, 30.6 [4.4] years; 2191 boys [50.2%]). Children were followed up for a mean (SD) of 10.6 (2.2) years. Children with prenatal triptan exposure had no increased risk of ADHD diagnosis compared with unexposed children whose mothers had migraine during pregnancy (weighted HR, 1.16; 95% CI, 0.78-1.74) and compared with unexposed children whose mothers had migraine only before pregnancy (weighted HR, 1.28; 95% CI, 0.84-1.94). There were no differences in ADHD symptom scores between exposed and unexposed children. Conclusions and Relevance The findings of this study suggest that there is no increased risk of ADHD among offspring associated with prenatal exposure to triptans.
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Affiliation(s)
- Gerd Marie Harris
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Mollie Wood
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Eivind Ystrom
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
- PROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Wood ME, Lupattelli A, Palmsten K, Bandoli G, Hurault-Delarue C, Damase-Michel C, Chambers CD, Nordeng HME, van Gelder MMHJ. Longitudinal Methods for Modeling Exposures in Pharmacoepidemiologic Studies in Pregnancy. Epidemiol Rev 2022; 43:130-146. [PMID: 34100086 PMCID: PMC8763114 DOI: 10.1093/epirev/mxab002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 12/17/2022] Open
Abstract
In many perinatal pharmacoepidemiologic studies, exposure to a medication is classified as "ever exposed" versus "never exposed" within each trimester or even over the entire pregnancy. This approach is often far from real-world exposure patterns, may lead to exposure misclassification, and does not to incorporate important aspects such as dosage, timing of exposure, and treatment duration. Alternative exposure modeling methods can better summarize complex, individual-level medication use trajectories or time-varying exposures from information on medication dosage, gestational timing of use, and frequency of use. We provide an overview of commonly used methods for more refined definitions of real-world exposure to medication use during pregnancy, focusing on the major strengths and limitations of the techniques, including the potential for method-specific biases. Unsupervised clustering methods, including k-means clustering, group-based trajectory models, and hierarchical cluster analysis, are of interest because they enable visual examination of medication use trajectories over time in pregnancy and complex individual-level exposures, as well as providing insight into comedication and drug-switching patterns. Analytical techniques for time-varying exposure methods, such as extended Cox models and Robins' generalized methods, are useful tools when medication exposure is not static during pregnancy. We propose that where appropriate, combining unsupervised clustering techniques with causal modeling approaches may be a powerful approach to understanding medication safety in pregnancy, and this framework can also be applied in other areas of epidemiology.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Marleen M H J van Gelder
- Correspondence to Dr. Marleen van Gelder, Department for Health Evidence, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands (e-mail: )
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Tauqeer F, Wood M, Hjorth S, Lupattelli A, Nordeng H. Perinatal use of triptans and other drugs for migraine-A nationwide drug utilization study. PLoS One 2021; 16:e0256214. [PMID: 34424941 PMCID: PMC8382165 DOI: 10.1371/journal.pone.0256214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 08/02/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To characterize nationwide utilization patterns of migraine pharmacotherapy before, during, and after pregnancy in women with triptan use. METHODS Population-based data were obtained by linking the Medical Birth Registry of Norway and the Norwegian Prescription Database from 2006 to 2017. We included 22,940 pregnancies among 19,669 women with at least one filled triptan prescription, a proxy for migraine, in the year before pregnancy or during pregnancy. The population was classified into four groups: i) continuers; ii) discontinuers; iii) initiators, and vi) post-partum re-initiators. Participant characteristics and prescription fills for other drugs such as analgesics, antinauseants, and preventive drugs among the groups were examined, along with an array of triptan utilization parameters. RESULTS In total, 20.0% of the women were classified as triptan continuers, 54.1% as discontinuers, 8.0% as initiators, and 17.6% as re-initiators. Extended use of triptans (≥15 daily drug doses/month) occurred among 6.9% of the continuers in the first trimester. The top 10% of triptan continuers and initiators accounted for 41% (95% CI: 39.2% - 42.5%) and 33% (95% CI: 30.3% - 35.8%) of the triptan volume, respectively. Triptan continuers and initiators had similar patterns of acute co-medication during pregnancy, but use of preventive drugs was more common among the continuers before, during, and after pregnancy. CONCLUSION Among women using triptans before and during pregnancy, one in four continued triptan treatment during pregnancy, and extended triptan use was relatively low. Triptan discontinuation during and in the year after pregnancy was common. Use of other acute migraine treatments was higher among both continuers and initiators of triptans. Women using preventive migraine treatment were most commonly triptan continuers and re-initiators after pregnancy. Prescribing to and counseling of women with migraine should be tailored to the condition severity and their information needs to promote optimal migraine management in pregnancy.
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Affiliation(s)
- Fatima Tauqeer
- Pharmaco Epidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Mollie Wood
- Pharmaco Epidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Epidemiology, T.H. Chan School of Public Health, Harvard University, Boston, MA, United States of America
| | - Sarah Hjorth
- Pharmaco Epidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Angela Lupattelli
- Pharmaco Epidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- Pharmaco Epidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Hjorth S, Lupattelli A, Handal M, Spigset O, Ystrom E, Nordeng H. Prenatal exposure to non-steroidal anti-inflammatory drugs and risk of attention-deficit/hyperactivity disorder: A follow-up study in the Norwegian mother, father and child cohort. Pharmacoepidemiol Drug Saf 2021; 30:1380-1390. [PMID: 33866622 DOI: 10.1002/pds.5250] [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] [Received: 08/19/2020] [Revised: 02/01/2021] [Accepted: 04/15/2021] [Indexed: 11/08/2022]
Abstract
PURPOSE To estimate the association between Attention-Deficit/Hyperactivity Disorder (ADHD) in children in preschool and primary school, and prenatal exposure to non-steroidal anti-inflammatory drugs (NSAIDs) by timing and duration. METHODS This study was based on the Norwegian Mother, Father and Child Cohort Study linked to the Medical Birth Registry of Norway, the Norwegian Patient Registry (NPR) and the Norwegian Prescription Database (NorPD). NSAID exposure was identified by maternal self-report in pregnancy. Child diagnosis of ADHD was obtained from NPR and NorPD. Symptoms of ADHD at age 5 years were measured using Conners' Parent Rating Scale-Revised, where higher scores correspond to more symptoms. To account for time-varying exposure and confounders, marginal structural models were fitted to estimate hazard ratios and mean difference in z-scores. RESULTS The analyses on ADHD diagnosis and ADHD symptoms included 56 340 and 34 961 children respectively. Children exposed to NSAIDs prenatally had no increased risk of ADHD diagnosis (first trimester: HR 1.12, 95% CI 0.86;1.45, second trimester: HR 0.98, 95% CI 0.69;1.38, third trimester: HR 0.68, 95% CI 0.31; 1.46) or ADHD symptoms (first trimester: standardized mean difference 0.03, 95% CI -0.03;0.09, second trimester: standardized mean difference 0.03, 95% CI -0.04;0.11, third trimester: standardized mean difference 0.11, 95% CI -0.03; 0.25). There was no duration-response relationship for either outcome. CONCLUSION Though non-differential misclassification of the exposure may have attenuated results, these findings are reassuring and suggest no substantially increased risk of ADHD diagnosis or symptoms in children prenatally exposed to NSAIDs, regardless of timing or duration.
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Affiliation(s)
- Sarah Hjorth
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Marte Handal
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav's University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Eivind Ystrom
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.,Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway.,PROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.,Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Petersen JM, Ranker LR, Barnard-Mayers R, MacLehose RF, Fox MP. A systematic review of quantitative bias analysis applied to epidemiological research. Int J Epidemiol 2021; 50:1708-1730. [PMID: 33880532 DOI: 10.1093/ije/dyab061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19. METHODS We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility. RESULTS Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale. CONCLUSIONS QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.
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Affiliation(s)
- Julie M Petersen
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lynsie R Ranker
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ruby Barnard-Mayers
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Saldanha IJ, Cao W, Bhuma MR, Konnyu KJ, Adam GP, Mehta S, Zullo AR, Chen KK, Roth JL, Balk EM. Management of primary headaches during pregnancy, postpartum, and breastfeeding: A systematic review. Headache 2021; 61:11-43. [PMID: 33433020 DOI: 10.1111/head.14041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/28/2020] [Accepted: 11/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to best and most safely manage them. OBJECTIVE We conducted a systematic review (SR) of interventions to prevent or treat primary headaches in women who are pregnant, attempting to become pregnant, postpartum, or breastfeeding. METHODS We searched Medline, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Database of SRs, and Epistemonikos for primary studies of pregnant women with primary headache and existing SRs of harms in pregnant women regardless of indication. No date or language restrictions were applied. We assessed strength of evidence (SoE) using standard methods. RESULTS We screened 8549 citations for studies and 2788 citations for SRs. Sixteen studies (mostly high risk of bias) comprising 14,185 patients (total) and 26 SRs met the criteria. For prevention, we found no evidence addressing effectiveness. Antiepileptics, venlafaxine, tricyclic antidepressants, benzodiazepines, β-blockers, prednisolone, and oral magnesium may be associated with fetal/child adverse effects, but calcium channel blockers and antihistamines may not be (1 single-group study and 11 SRs; low-to-moderate SoE). For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache (1 randomized controlled trial; low SoE). Triptans may not be associated with fetal/child adverse effects (8 nonrandomized comparative studies; low SoE). Acetaminophen, prednisolone, indomethacin, ondansetron, antipsychotics, and intravenous magnesium may be associated with fetal/child adverse effects, but low-dose aspirin may not be (indirect evidence; low-to-moderate SoE). We found insufficient evidence regarding non-pharmacologic treatments. CONCLUSIONS For prevention of primary headache, calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects. For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine. Triptans and low-dose aspirin may not be associated with fetal/child adverse effects. Future research should identify effective and safe interventions in pregnancy and postpartum.
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Affiliation(s)
- Ian J Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Wangnan Cao
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Monika Reddy Bhuma
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kristin J Konnyu
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Gaelen P Adam
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Shivani Mehta
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kenneth K Chen
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA.,Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Julie L Roth
- Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Ethan M Balk
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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10
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Intrauterine Exposure to Acetaminophen and Adverse Developmental Outcomes: Epidemiological Findings and Methodological Issues. Curr Environ Health Rep 2021; 8:23-33. [PMID: 33398668 DOI: 10.1007/s40572-020-00301-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Acetaminophen (or paracetamol) is one of the most commonly used medications during pregnancy. We reviewed recent epidemiological evidence regarding intrauterine exposure to acetaminophen and risk for asthma, neurodevelopment disorders, and reproductive health in childhood. RECENT FINDINGS An increasing number of cohort studies have suggested that maternal use of acetaminophen during pregnancy was associated with increased risk for asthma; neurodevelopmental disorders, especially ADHD and behavioral problems; and genital malformations in the offspring. Oxidative stress and inflammation or endocrine effects are plausible shared biological mechanisms for the exposure to influence multiple developmental outcomes. We discussed methodological challenges that can threaten the validity of these observational data, including confounding and measurement errors. Novel statistical methods and research designs that can be used to mitigate these issues were introduced. Given the high prevalence of use, findings regarding intrauterine exposure to acetaminophen on multiple child health outcomes raise concerns. Research on causal and non-causal mechanisms that might explain these associations should be a priority.
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11
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Nab L, Groenwold RHH, van Smeden M, Keogh RH. Quantitative Bias Analysis for a Misclassified Confounder: A Comparison Between Marginal Structural Models and Conditional Models for Point Treatments. Epidemiology 2020; 31:796-805. [PMID: 32826524 PMCID: PMC7523582 DOI: 10.1097/ede.0000000000001239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/17/2020] [Indexed: 11/25/2022]
Abstract
Observational data are increasingly used with the aim of estimating causal effects of treatments, through careful control for confounding. Marginal structural models estimated using inverse probability weighting (MSMs-IPW), like other methods to control for confounding, assume that confounding variables are measured without error. The average treatment effect in an MSM-IPW may however be biased when a confounding variable is error prone. Using the potential outcome framework, we derive expressions for the bias due to confounder misclassification in analyses that aim to estimate the average treatment effect using an marginal structural model estimated using inverse probability weighting (MSM-IPW). We compare this bias with the bias due to confounder misclassification in analyses based on a conditional regression model. Focus is on a point-treatment study with a continuous outcome. Compared with bias in the average treatment effect in a conditional model, the bias in an MSM-IPW can be different in magnitude but is equal in sign. Also, we use a simulation study to investigate the finite sample performance of MSM-IPW and conditional models when a confounding variable is misclassified. Simulation results indicate that confidence intervals of the treatment effect obtained from MSM-IPW are generally wider, and coverage of the true treatment effect is higher compared with a conditional model, ranging from overcoverage if there is no confounder misclassification to undercoverage when there is confounder misclassification. Further, we illustrate in a study of blood pressure-lowering therapy, how the bias expressions can be used to inform a quantitative bias analysis to study the impact of confounder misclassification, supported by an online tool.
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Affiliation(s)
- Linda Nab
- From the Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf H H Groenwold
- From the Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten van Smeden
- From the Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
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12
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Hanswijk SI, Spoelder M, Shan L, Verheij MMM, Muilwijk OG, Li W, Liu C, Kolk SM, Homberg JR. Gestational Factors throughout Fetal Neurodevelopment: The Serotonin Link. Int J Mol Sci 2020; 21:E5850. [PMID: 32824000 PMCID: PMC7461571 DOI: 10.3390/ijms21165850] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/24/2020] [Accepted: 08/11/2020] [Indexed: 12/21/2022] Open
Abstract
Serotonin (5-HT) is a critical player in brain development and neuropsychiatric disorders. Fetal 5-HT levels can be influenced by several gestational factors, such as maternal genotype, diet, stress, medication, and immune activation. In this review, addressing both human and animal studies, we discuss how these gestational factors affect placental and fetal brain 5-HT levels, leading to changes in brain structure and function and behavior. We conclude that gestational factors are able to interact and thereby amplify or counteract each other's impact on the fetal 5-HT-ergic system. We, therefore, argue that beyond the understanding of how single gestational factors affect 5-HT-ergic brain development and behavior in offspring, it is critical to elucidate the consequences of interacting factors. Moreover, we describe how each gestational factor is able to alter the 5-HT-ergic influence on the thalamocortical- and prefrontal-limbic circuitry and the hypothalamo-pituitary-adrenocortical-axis. These alterations have been associated with risks to develop attention deficit hyperactivity disorder, autism spectrum disorders, depression, and/or anxiety. Consequently, the manipulation of gestational factors may be used to combat pregnancy-related risks for neuropsychiatric disorders.
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Affiliation(s)
- Sabrina I. Hanswijk
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Centre, 6525 EN Nijmegen, The Netherlands; (S.I.H.); (M.S.); (M.M.M.V.); (O.G.M.)
| | - Marcia Spoelder
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Centre, 6525 EN Nijmegen, The Netherlands; (S.I.H.); (M.S.); (M.M.M.V.); (O.G.M.)
| | - Ling Shan
- Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, 1105 BA Amsterdam, The Netherlands;
| | - Michel M. M. Verheij
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Centre, 6525 EN Nijmegen, The Netherlands; (S.I.H.); (M.S.); (M.M.M.V.); (O.G.M.)
| | - Otto G. Muilwijk
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Centre, 6525 EN Nijmegen, The Netherlands; (S.I.H.); (M.S.); (M.M.M.V.); (O.G.M.)
| | - Weizhuo Li
- College of Medical Laboratory, Dalian Medical University, Dalian 116044, China; (W.L.); (C.L.)
| | - Chunqing Liu
- College of Medical Laboratory, Dalian Medical University, Dalian 116044, China; (W.L.); (C.L.)
| | - Sharon M. Kolk
- Department of Molecular Neurobiology, Donders Institute for Brain, Cognition and Behavior, Radboud University, 6525 AJ Nijmegen, The Netherlands;
| | - Judith R. Homberg
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Centre, 6525 EN Nijmegen, The Netherlands; (S.I.H.); (M.S.); (M.M.M.V.); (O.G.M.)
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13
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Wood ME, Andrade SE, Toh S. Safe Expectations: Current State and Future Directions for Medication Safety in Pregnancy Research. Clin Ther 2019; 41:2467-2476. [PMID: 31563392 PMCID: PMC6917855 DOI: 10.1016/j.clinthera.2019.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/30/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022]
Abstract
Medication use in pregnancy is common, but information about the safety of most medications in pregnant women or their infants is limited. In the absence of data from randomized clinical trials to guide decisions made by regulators, clinicians, and patients, we often have to rely on well-designed observational studies to generate valid evidence about the benefits and risks of medications in pregnancy. Spontaneous reporting, primary case-control and cohort studies, pregnancy exposure registries, and electronic health data have been used extensively for studying medication safety in pregnancy. This article discusses these data sources, their strengths and limitations, and possible strategies and approaches to mitigating limitations when planning studies or interpreting findings from the literature. Strategies discussed include combining data sources across institutional or national borders, developing and using more sophisticated study designs, and taking advantage of existing analytic methods for more complex data structures, such as time-varying exposure or unmeasured confounding. Finally, we make recommendations for study designs that aid in better risk-related communication.
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Affiliation(s)
- Mollie E Wood
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Susan E Andrade
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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14
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Hjorth S, Bromley R, Ystrom E, Lupattelli A, Spigset O, Nordeng H. Use and validity of child neurodevelopment outcome measures in studies on prenatal exposure to psychotropic and analgesic medications - A systematic review. PLoS One 2019; 14:e0219778. [PMID: 31295318 PMCID: PMC6622545 DOI: 10.1371/journal.pone.0219778] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 07/01/2019] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Sarah Hjorth
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Rebecca Bromley
- Division of Evolution and Genomic Science, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Eivind Ystrom
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
- PROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav's University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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15
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Affiliation(s)
- Samantha E Parker
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sarah A Keim
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
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16
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Harris GME, Wood M, Ystrom E, Nordeng H. Prenatal triptan exposure and neurodevelopmental outcomes in 5-year-old children: Follow-up from the Norwegian Mother and Child Cohort Study. Paediatr Perinat Epidemiol 2018; 32:247-255. [PMID: 29569251 DOI: 10.1111/ppe.12461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Triptans are commonly used to treat migraine headaches, but data on the long-term safety of these medications during pregnancy are sparse. Triptans have a biologically plausible mechanism for effects on the fetal brain through binding to 5-HT1 -receptors, and previous studies show increased risks of externalising behaviour problems in toddlers exposed to triptans during pregnancy. METHODS We included 3784 children in the Norwegian Mother and Child Cohort Study, whose mothers returned the 5-year-questionnaire and reported a history of migraine or triptan use; 353 (9.3%) mothers reported use of triptans during pregnancy, 1509 (39.9%) reported migraine during pregnancy but no triptan use, and 1922 (50.8%) had migraine prior to pregnancy only. We used linear and log-binomial models with inverse probability weights to examine the association between prenatal triptan exposure and internalising and externalising behaviour, communication, and temperament in 5-year-old children. RESULTS Triptan-exposed children scored higher on the sociability trait than unexposed children of mothers with migraine (β 1.66, 95% confidence interval [0.30, 3.02]). We found no other differences in temperament, or increased risk of behaviour or communication problems. CONCLUSIONS Contrary to results from previous studies in younger children, we found no increased risk of externalising behaviour problems in 5-year-old children exposed to triptans in fetal life. Triptan-exposed children did have slightly more sociable temperaments, but the clinical meaning of this finding is uncertain.
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Affiliation(s)
- Gerd-Marie Eskerud Harris
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Mollie Wood
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Eivind Ystrom
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.,Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.,Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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17
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Afridi SK. Current concepts in migraine and their relevance to pregnancy. Obstet Med 2018; 11:154-159. [PMID: 30574176 DOI: 10.1177/1753495x18769170] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/01/2018] [Indexed: 12/12/2022] Open
Abstract
The prevalence of migraine in women of childbearing age is high, estimated at 24%. Migraine management during pregnancy and lactation can be challenging. Our understanding of the way in which medications affect the unborn fetus is still incomplete and the evidence is constantly changing with more recent emphasis on longitudinal studies and childhood development. The aim of this article is to describe the relationship between migraine and pregnancy and review the current evidence on treatment options in pregnancy and lactation.
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Affiliation(s)
- Shazia K Afridi
- Department of Neurology, Guy's and St Thomas' NHS Trust, London, UK
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18
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Ray-Griffith SL, Wendel MP, Stowe ZN, Magann EF. Chronic pain during pregnancy: a review of the literature. Int J Womens Health 2018; 10:153-164. [PMID: 29692634 PMCID: PMC5901203 DOI: 10.2147/ijwh.s151845] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery. METHODS A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016. RESULTS The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain. CONCLUSION The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.
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Affiliation(s)
- Shona L Ray-Griffith
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael P Wendel
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
| | - Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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19
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Salvatore S, Domanska D, Wood M, Nordeng H, Sandve GK. Complex patterns of concomitant medication use: A study among Norwegian women using paracetamol during pregnancy. PLoS One 2017; 12:e0190101. [PMID: 29284043 PMCID: PMC5746239 DOI: 10.1371/journal.pone.0190101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/10/2017] [Indexed: 12/16/2022] Open
Abstract
Background Studies on medication safety in pregnancy often rely on an oversimplification of medication use into exposed or non-exposed, without considering intensity and timing of use in pregnancy, or concomitant medication use. This study uses paracetamol in pregnancy as the motivating example to introduce a method of clustering medication exposures longitudinally throughout pregnancy. The aim of this study was to use hierarchical cluster analysis (HCA) to better identify clusters of medication exposure throughout pregnancy. Methods Data from the Norwegian Mother and Child Cohort Study was used to identify subclasses of women using paracetamol during pregnancy. HCA with customized distance measure was used to identify clusters of medication exposures in pregnancy among children at 18 months. Results The pregnancies in the study (N = 9 778) were grouped in 5 different clusters depending on their medication exposure profile throughout pregnancy. Conclusion Using HCA, we identified and described profiles of women exposed to different medications in combination with paracetamol during pregnancy. Identifying these clusters allows researchers to define exposure in ways that better reflects real-world medication usage patterns. This method could be extended to other medications and used as pre-analysis for identifying risks associated with different profiles of exposure.
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Affiliation(s)
- Stefania Salvatore
- Department of Informatics, University of Oslo, Oslo, Norway
- PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- * E-mail:
| | - Diana Domanska
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Mollie Wood
- PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- PharmacoEpidemiology and Drug Safety Research Group, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- PharmacoEpidemiology and Drug Safety Research Group, School of Pharmacy, University of Oslo, Oslo, Norway
- Department of Child Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Geir Kjetil Sandve
- Department of Informatics, University of Oslo, Oslo, Norway
- Department of Child Health, Norwegian Institute of Public Health, Oslo, Norway
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20
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Negro A, Delaruelle Z, Ivanova TA, Khan S, Ornello R, Raffaelli B, Terrin A, Reuter U, Mitsikostas DD. Headache and pregnancy: a systematic review. J Headache Pain 2017; 18:106. [PMID: 29052046 PMCID: PMC5648730 DOI: 10.1186/s10194-017-0816-0] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 10/11/2017] [Indexed: 02/06/2023] Open
Abstract
This systematic review summarizes the existing data on headache and pregnancy with a scope on clinical headache phenotypes, treatment of headaches in pregnancy and effects of headache medications on the child during pregnancy and breastfeeding, headache related complications, and diagnostics of headache in pregnancy. Headache during pregnancy can be both primary and secondary, and in the last case can be a symptom of a life-threatening condition. The most common secondary headaches are stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome. Migraine is a risk factor for pregnancy complications, particularly vascular events. Data regarding other primary headache conditions are still scarce. Early diagnostics of the disease manifested by headache is important for mother and fetus life. It is especially important to identify “red flag symptoms” suggesting that headache is a symptom of a serious disease. In order to exclude a secondary headache additional studies can be necessary: electroencephalography, ultrasound of the vessels of the head and neck, brain MRI and MR angiography with contrast ophthalmoscopy and lumbar puncture. During pregnancy and breastfeeding the preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one. Treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby. Therefore, if non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks.
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Affiliation(s)
- A Negro
- Department of Clinical and Molecular Medicine, Regional Referral Headache Centre, Sapienza University of Rome, Sant'Andrea Hospital, 00189, Rome, Italy.
| | - Z Delaruelle
- Department of Neurology, Ghent University Hospital, 9000, Ghent, Belgium
| | - T A Ivanova
- Institute of Professional Education, Chair of Neurology. I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - S Khan
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, -2600, Glostrup, DK, Denmark
| | - R Ornello
- Department of Neurology, University of L'Aquila, 67100, L'Aquila, Italy
| | - B Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - A Terrin
- Department of Neurosciences, Headache Centre, University of Padua, 35128, Padua, Italy
| | - U Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - D D Mitsikostas
- Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, 11528, Athens, Greece
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Wood ME, Lapane KL, van Gelder MM, Rai D, Nordeng HM. Making fair comparisons in pregnancy medication safety studies: An overview of advanced methods for confounding control. Pharmacoepidemiol Drug Saf 2017; 27:140-147. [PMID: 29044735 PMCID: PMC6646901 DOI: 10.1002/pds.4336] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/29/2017] [Accepted: 09/18/2017] [Indexed: 12/12/2022]
Abstract
Understanding the safety of medication use during pregnancy relies on observational studies: However, confounding in observational studies poses a threat to the validity of estimates obtained from observational data. Newer methods, such as marginal structural models and propensity calibration, have emerged to deal with complex confounding problems, but these methods have seen limited uptake in the pregnancy medication literature. In this article, we provide an overview of newer advanced methods for confounding control and show how these methods are relevant for pregnancy medication safety studies.
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Affiliation(s)
- Mollie E. Wood
- PharmacoEpidemiology and Drug Safety Research Group, School of PharmacyUniversity of OsloNorway
| | - Kate L. Lapane
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMAUSA
| | - Marleen M.H.J. van Gelder
- Department for Health Evidence, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
- Radboud REshape Innovation CenterRadboud University Medical CenterNijmegenThe Netherlands
| | - Dheeraj Rai
- School of Social and Community MedicineUniversity of BristolUK
| | - Hedvig M.E. Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, School of PharmacyUniversity of OsloNorway
- Department of Child Mental and Physical HealthNorwegian Institute of Public HealthOsloNorway
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Wood ME, Frazier JA, Nordeng HME, Lapane KL. Longitudinal changes in neurodevelopmental outcomes between 18 and 36 months in children with prenatal triptan exposure: findings from the Norwegian Mother and Child Cohort Study. BMJ Open 2016; 6:e011971. [PMID: 27625061 PMCID: PMC5030558 DOI: 10.1136/bmjopen-2016-011971] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE This study sought to determine whether changes in neurodevelopmental outcomes between 18 and 36 months of age were associated with prenatal exposure to triptan medications, a class of 5-HT receptor agonists used in the treatment of migraine. METHOD Using data from the Norwegian Mother and Child Cohort Study, a prospective birth cohort that includes nearly 40% of all pregnancies in Norway from 1999 to 2008, we identified 50 469 mother-child dyads who met inclusion criteria and were present for at least one follow-up assessment at 18 or 36 months postpartum. Neurodevelopment was assessed using the Child Behaviour Checklist, the Emotionality, Activity, and Shyness Questionnaire, and the Ages and Stages Questionnaire. We used generalised estimating equations to evaluate change from 18 to 36 months for children prenatally exposed to triptans, relative to contrast groups, and used marginal structural models with inverse probability of treatment and censoring weights to address time-varying exposure and confounding as well as loss to follow-up. RESULTS Among eligible participants (n=50 469), 1.0% used a triptan during pregnancy, 2.0% used triptans prior to pregnancy only, 8.0% reported migraine without triptan use and 89.0% had no history of migraine. Children with prenatal triptan exposure had greater increases in emotionality (r-RR 2.18, 95% CI 1.03 to 4.53) and activity problems (r-RR 1.70, 95% CI 1.02 to 2.8) compared to children born to mothers who discontinued triptan use prior to pregnancy. CONCLUSION Prenatal triptan exposure was associated with changes over time in externalising-type behaviours such as emotionality and activity, but not with internalising-type behaviours.
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Affiliation(s)
- Mollie E Wood
- The University of Oslo School of Pharmacy, Oslo, Norway
- The University of Massachusetts Medical School, Worcester, Massachusetts, USA
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Jean A Frazier
- The University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Hedvig M E Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
- The University of Oslo School of Pharmacy and the Norwegian Institute of Public Health, Oslo, Norway
| | - Kate L Lapane
- The University of Massachusetts Medical School, Worcester, Massachusetts, USA
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