ondansetron use in pregnancy

I do not have any conflicts of interest to disclose.

I will be discussing
off-label use during this presentation.

Untitled Slide

objectives

• Overview of nausea and vomiting of pregnancy
• Review of literature
• Methodology
• Results
• Discussion of antiemetic use in pregnanc

objectives

• Overview of nausea and vomiting of pregnancy
• Review of literature
• Methodology
• Results
• Discussion of antiemetic use in pregnancy

objectives

• Overview of nausea and vomiting of pregnancy
• Review of literature
• Methodology
• Results
• Discussion of antiemetic use in pregnancy

nausea and vomiting in pregnancy (NVP)

• Affects 74% of pregnant women
• Decreases quality of life
• Hyperemesis gravidarum affects 1% of pregnant women
• Mechanism is unknown
• Decreases quality of life and productivity

Treatment options

• Pyridoxine, doxylamine, or Diclegis (delayed-release doxylamine and pyridoxine)
• Metoclopramide
• Diphenhydramine
• Ondansetron
• Promethazine
• Dimenhydrinate

treatment of nvp

review of literature

Use

• Madjunkova et al (2014) reviewed data from Motherisk Helpline in Toronto, Canada
• 42.3% prescribed a medication for NVP
• 55.9% tried ondansetron
• 57.7% tried doxylamine
• Ondansetron and doxylamine were most common combination therapy

Efficacy

• Koren et al (2010) compared effectiveness of a delayed-release doxylamine succinate-pyridoxine hcl tablet to placebo
• Demonstrated a significant increase in NVP symptoms and well-being based on questionnaire answers (P=0.006)

Efficacy

• Oliveira et al (2014) compared ondansetron to doxylamine and pyradoxine using a visual analog scale to rate symptoms
• Use of ondansetron had significantly greater reductions in nausea compared with use of doxylamine and pyridoxine (P=0.019)

safety

• Danish National Birth Registry
• Pasternak et al (2013) found no increased risk with ondansetron use
• Andersen et al (2013) found an increase in congenital heart defects in infants exposed to ondansetron

safety

• National Birth Defects Prevention Study
• Women exposed to ondansetron during pregnancy were 2.37 times more likely to have a baby born with a cleft palate (CI 1.18-7.76)
• Study limitations

RESEARCH QUESTION: How do the prescribing habits of practitioners at WHS reflect the content of the clinic protocol?

methodology

Methodology

• Retrospective chart review
• Women with a pregnancy episode and an antiemetic on med list
• January 1, 2013 - May 1, 2014
• 100 total records included

inclusion criteria

• Pregnancy during the study time period
• Use of ondansetron, doxylamine, pyridoxine, delayed-release doxylamine and pyridoxine (Diclegis), metoclopramide, promethazine, and diphenhydramine, dimenhydrinate, meclizine

exclusion criteria

• Antiemetic medication prescribed for a different indication than NVP
• Antiemetic medication prescribed by a provider at another clinic or in the emergency department

results

discussion

Indication

• Delayed-release doxylamine and pyridoxine indicated for NVP
• Ondansetron indicated for prophylaxis of nausea and vomiting due to chemotherapy, radiation and postoperatively, but prescribed off-label widely

safety

• Safety vs efficacy in a gravid population
• Bendectin/Diclectin
• Increased safety data with doxylamine and pyridoxine

efficacy

• High ondansetron use compared to doxylamine and pyridoxine
• 2 patients tried an additional medication after ondansetron

Influencers for increased use

• Provider experience and perception
• Patient experience and perception
• Ease of prescription-writing
• Patient experience and perception
• Self-limiting nature of NVP

convenience

• Ondansetron is easy to write for and obtain
• Pyridoxine comes in multiple strengths
• Unisom product confusion
• Prescription combination product is easier to use but more costly

references

conclusion

questions