On-call scenario 10: Sources
Here are some information resources you might have thought about: |
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- UK Teratology Information Service monographs. You’ll need to log in to see the full versions: summaries are available without logging in. Their patient-facing content is available on the Bumps site.
- SmPCs via the emc or MHRA – they don’t commonly have practical advice on medicine use in pregnancy but some do. SmPCs are good for interactions though, such as between sertraline and pregabalin or gabapentin.
- You may have local access to books about prescribing in pregnancy such as 'Briggs’.
- Does the Royal College of Obstetrics & Gynaecology have guidelines on managing this kind of pain in pregnancy?
- Stockley’s Drug Interactions offers practical advice on many interactions.
- NICE Clinical Knowledge Summaries can help you with alternative treatment options.
Using these resources, you find that the data on pregabalin do not currently suggest that its use is associated with increased risks in pregnancy. However, information is limited.
For gabapentin, you run into the problem that most pregnancy exposures have occurred in patients with epilepsy. This makes it difficult to tease apart any effect of the drug over the disease. In addition, opinion as to whether gabapentin may be used during pregnancy for pain is conflicting. The SmPC doesn't mention any interaction between gabapentin and sertraline.
Faced with a lack of information or conflicting information, one way forward is to explore whether there are any other adjuvant analgesics that the team might consider. You might find that there is more experience during pregnancy with older drugs, for example.
You review the NICE Clinical Knowledge Summaries and find that amitriptyline is an alternative agent for neuropathic pain. You check your specialist pregnancy resources, and these advise that amitriptyline may be used as an adjuvant analgesic if clearly indicated.
You think you have a solution to the problem, but you then remember that the patient is taking sertraline. A check of the SmPC and Stockley’s Drug Interactions reveals that there is the potential for sertraline to increase the levels of tricyclic antidepressants unpredictably; the combination might also cause serotonin syndrome too.
What would you do now in terms of advice?
Faced with a lack of information or conflicting information, one way forward is to explore whether there are any other adjuvant analgesics that the team might consider. You might find that there is more experience during pregnancy with older drugs, for example.
You review the NICE Clinical Knowledge Summaries and find that amitriptyline is an alternative agent for neuropathic pain. You check your specialist pregnancy resources, and these advise that amitriptyline may be used as an adjuvant analgesic if clearly indicated.
You think you have a solution to the problem, but you then remember that the patient is taking sertraline. A check of the SmPC and Stockley’s Drug Interactions reveals that there is the potential for sertraline to increase the levels of tricyclic antidepressants unpredictably; the combination might also cause serotonin syndrome too.
Think about what you'd do yourself in this situation, and then click through to the Next Page where you can read some of our suggestions.