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

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

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

Reliable Pregnancy Testing Before Intravenous Cyclophosphamide: A Quality Improvement Study

BACKGROUND AND OBJECTIVE

Cyclophosphamide is a teratogenic medication used in the treatment of adolescents with autoimmune disorders. This adolescent population is sexually active, does not receive adequate contraceptive care, and is at risk for unintended pregnancy. We undertook a quality improvement initiative to improve rates of pregnancy screening before intravenous cyclophosphamide administration in our adolescent girl patients.

METHODS

Data were collected from the electronic medical record. The primary outcome was completion of a urine pregnancy test before intravenous cyclophosphamide infusion in girls aged 12 to 21 years between July 2011 and June 2015. Data were reviewed quarterly and an iterative quality improvement approach was used. Interventions included staff education, electronic order set updates, and a Maintenance of Certification project. Interrupted time series analysis and multivariable mixed effects logistic regression were used to evaluate trends over time and to adjust for potential confounders.

RESULTS

Thirty girls received 153 cyclophosphamide infusions during the study. Pregnancy testing before medication administration increased from 25% to 100% by study completion. Infusions in the last time period were significantly more likely to be accompanied by a pregnancy test versus those in the first time period (odds ratio: 17.7; 95% confidence interval [CI]: 3.1-101.6) after adjustment for patient age, managing service, infusion setting, and insurance type.

CONCLUSIONS

Our institution achieved a significant increase in standard pregnancy screening in adolescent girls receiving intravenous cyclophosphamide. The interventions most valuable in increasing screening rates were updating electronic order sets, educating staff, and physician engagement in the Maintenance of Certification program.

Congenital microtia in a neonate due to maternal isotretinoin exposure 1 month before pregnancy: Case Report

Isotretinoin is a drug used for treating severe cystic/nodular acne. Severe malformations have been documented in neonates whose mothers had taken isotretinoin during pregnancy. Women who became pregnant one cycle after completing therapy are believed to be at teratogenic risk not higher than baseline. We describe the case of a newborn whose mother had taken the drug for 4 weeks. The woman then had contraception for 4 weeks (after the drug treatment had finished), and became pregnant after that period. The newborn had isolated bilateral microtia due to suspected isotretinoin exposure. His mother also had a history of urine tract infection in the second week of pregnancy that was treated with cephalexin. The parents were not from a consanguineous marriage and had no family history of congenital malformations. To reduce the risk, effective contraception should be continued in fertile women more than 1 month after completing therapy.

Concomitant use of isotretinoin and contraceptives before and after iPledge in the United States

PURPOSE

The major concern associated with isotretinoin treatment is its high teratogenic potential. Therefore, ensuring use of contraception while on therapy is an important strategy for at-risk patients and has been emphasized in all risk management programs. iPledge, the latest and most rigorous isotretinoin program, requires, among other stipulations, monthly assessments of contraceptive use for patients undergoing isotretinoin treatment. The purpose of this study is to evaluate isotretinoin usage patterns and assess concomitant use of isotretinoin and contraceptives before and after iPledge.

METHODS

Female patients aged 13-45 years with a new prescription for isotretinoin products during 2004-2008 were identified in the IMS Health longitudinal prescription claims database. Monthly concomitant use of isotretinoin and contraceptives was estimated. Segmented regression analysis of interrupted time series data was used to assess changes in monthly proportion of concomitant use in the 24 months preceding versus following iPledge implementation.

RESULTS

The number of isotretinoin prescriptions decreased after iPledge implementation. A small but significant increase in monthly proportion of patients concomitantly using isotretinoin and contraceptive therapies was observed immediately after iPledge implementation (1.3%, p-value = 0.02), particularly among younger patients (2.5%, p-value < 0.01). No changes in the proportion of concomitancy over time (i.e. slope) between the periods before and after iPledge implementation were observed.

CONCLUSION

The findings of this pharmacy prescription claims-based study suggest a small increase in concomitant use of isotretinoin and contraceptives coincident with the time of implementation of iPledge, particularly among younger women. Published 2013. This article is a U. S. Government work and is in the public domain in the USA.

Providing contraception for women taking potentially teratogenic medications: a survey of internal medicine physicians' knowledge, attitudes and barriers

BACKGROUND

The majority of women prescribed category D or X medications may not receive adequate contraceptive counseling or a reliable contraceptive method. Physicians who prescribe potentially teratogenic medications have a responsibility to provide women with contraceptive counseling, a method of highly-effective contraception, or both.

OBJECTIVE

Investigate the knowledge, beliefs and barriers of primary care physicians toward providing adequate contraception to women taking potential teratogens.

DESIGN & PARTICIPANTS

Self-administered confidential survey of primary care internal medicine physicians at an urban, academic medical center.

MEASUREMENTS

Knowledge of potential teratogenic medications and contraceptive failure rates was assessed. Participants' beliefs about adequacy of their medical education, practice limitations and attitudes toward improving provision of contraception to women on potential teratogens were assessed.

RESULTS

One hundred and ten physicians responded (57.3%). Nearly two-thirds (62.3%) of participants had cared for reproductive aged women taking category D or X medications in the past year. The mean percent of correctly identified category D or X medications was 58.4% (SD 22.1%). The mean percent correct for knowledge of published contraceptive failure rates was 64.6% (SD 23.1%). Most respondents (87.6%) felt it is the responsibility of primary care physicians to provide contraception. Time constraints were reported to be somewhat or very limiting by 61.3% and over half felt medical school (63.2%) or residency (58.1%) inadequately prepared them to prescribe or counsel about contraceptives.

CONCLUSIONS

Primary care physicians commonly encounter reproductive age women taking category D or X medications, but may lack sufficient knowledge and time to counsel about potential teratogens and contraception to prevent fetal exposure to these drugs.

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

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

Chiral toxicology: it's the same thing...only different

Chiral substances possess a unique architecture such that, despite sharing identical molecular formulas, atom-to-atom linkages, and bonding distances, they cannot be superimposed. Thus, in the environment of living systems, where specific structure-activity relationships may be required for effect (e.g., enzymes, receptors, transporters, and DNA), the physiochemical and biochemical properties of racemic mixtures and individual stereoisomers can differ significantly. In drug development, enantiomeric selection to maximize clinical effects or mitigate drug toxicity has yielded both success and failure. Further complicating genetic polymorphisms in drug disposition, stereoselective metabolism of chiral compounds can additionally influence pharmacokinetics, pharmacodynamics, and toxicity. Optically pure pharmaceuticals may undergo racemization in vivo, negating single enantiomer benefits or inducing unexpected effects. Appropriate chiral antidotes must be selected for therapeutic benefit and to minimize adverse events. Enantiomers may possess different carcinogenicity and teratogenicity. Environmental toxicology provides several examples in which compound bioaccumulation, persistence, and toxicity show chiral dependence. In forensic toxicology, chiral analysis has been applied to illicit drug preparations and biological specimens, with the potential to assist in determination of cause of death and aid in the correct interpretation of substance abuse and "doping" screens. Adrenergic agonists and antagonist, nonsteroidal anti-inflammatory agents, SSRIs, opioids, warfarin, valproate, thalidomide, retinoic acid, N-acetylcysteine, carnitine, penicillamine, leucovorin, glucarpidase, pesticides, polychlorinated biphenyls, phenylethylamines, and additional compounds will be discussed to illustrate important concepts in "chiral toxicology."

RevAssist: a comprehensive risk minimization programme for preventing fetal exposure to lenalidomide

Lenalidomide (Revlimid) is an immunomodulatory drug and an analogue of thalidomide, a known teratogen. To prevent fetal exposure, in the US lenalidomide is available only under a special restricted distribution programme called RevAssist. Under this risk minimization programme, only prescribers and contract pharmacies registered with the programme are able to prescribe and dispense the product. Patients must be advised of, agree to and comply with the requirements of the RevAssist programme in order to receive lenalidomide through a registered prescriber. A total of 15 584 patients were registered in the RevAssist programme during the first year lenalidomide was on the market. There were four reports of false-positive beta-human chorionic gonadotrophin measurements in patients aged 43-57 years. Mandatory patient and prescriber surveys have shown discrepant responses that were resolved by risk management intervention specialists 99% of the time. The voluntary patient surveys have shown understanding of the risks of lenalidomide use and of behaviours necessary to minimize risks in >95% of females of childbearing potential and adult males. To date, there have been no reports of pregnancy in female patients or female partners of male patients. The pharmacy audit findings showed compliance with RevAssist was high. Although RevAssist is labour-intensive, time-consuming and costly, it continues to be effective in preventing fetal exposure to lenalidomide.

Medication errors in obstetrics

The findings highlighted in this article suggest that obstetricians and perinatologists face several challenges for safe medication use during pregnancy. Furthermore, evidence of in-hospital medication errors from obstetric services has been provided by national medication error data voluntarily submitted from many hospitals. The data provide fresh insight into the nature of medication errors in obstetrics, especially regarding the medication use process, the most common types of errors reported, the most commonly reported products overall, as well as those that resulted in patient harm. Providers and staff working within health care organizations should be well aware that a substantial number of patients experience medication errors which can result in serious injuries.

Utility of family history reports of major birth defects as a public health strategy

A major birth defect is an abnormality that can affect the structure or function of an organ. In the United States, major birth defects are the leading cause of infant mortality and contribute substantially to childhood disability and morbidity. Globally, these conditions lead to the death of millions of infants and children annually. Patients with 1 or more affected family members may be at increased risk for having a child with a major birth defect; thus, accurate knowledge of these conditions among family members of their patients gives the clinician the ability to provide improved risk assessment and reproductive planning. Such knowledge can also serve as motivation for patients to adhere to healthy behaviors such as folic acid use or smoking cessation. To evaluate the utility of collecting family history reports of major birth defects as a public health strategy, 6 key criteria were examined by reviewing the relevant published literature. Overall, the review showed that major birth defects satisfied several of the criteria. Additional research is needed, however, regarding the awareness of parent reports of the occurrence of these conditions among relatives and how knowledge of birth defect diagnoses and related risk factors are transmitted among relatives. Such research needs to encompass not only immediate family members but also other first-degree and second-degree relatives. In summary, routine collection of family history reports of birth defects in pediatric practice holds promise as a public health strategy to reduce the burden of morbidity, mortality, and disability associated with major birth defects.