Time to review the risk benefit ratio of using NSAID in pregnancy should we use in pregnancy associated with inflammatory bowel or chronic rheumatic diseases? Any adverse effect on growing foetus?

Time to review the risk benefit ratio  of using NSAID in pregnancy should we use in pregnancy associated with inflammatory bowel or chronic rheumatic diseases? Any adverse effect on growing foetus?

Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn.

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed in pregnancy to treat fever, pain and inflammation. Indications for chronic use of these agents during pregnancy are inflammatory bowel or chronic rheumatic diseases. Since the seventies, NSAIDs have been used as effective tocolytic agents: indomethacin has been the reference drug, delaying delivery for at least 48 hours and up to 7-10 days. Additionally, self-medication with NSAIDs is practiced by pregnant women. NSAIDs given to pregnant women cross the placenta and may cause embryo-fetal and neonatal adverse effects, depending on the type of agent, the dose and duration of therapy, the period of gestation, and the time elapsed between maternal NSAID administration and delivery. These effects derive from the action mechanisms of NSAIDs (mainly inhibition of prostanoid activity) and from the physiological changes in drug pharmacokinetics occurring during pregnancy. Increased risks of miscarriage and malformations are associated with NSAID use in early pregnancy. Conversely, exposure to NSAIDs after 30 weeks' gestation is associated with an increased risk of premature closure of the fetal ductus arteriosus and oligohydramnios. Fetal and neonatal adverse effects affecting the brain, kidney, lung, skeleton, gastrointestinal tract and cardiovascular system have also been reported after prenatal exposure to NSAIDs. NSAIDs should be given in pregnancy only if the maternal benefits outweigh the potential fetal risks, at the lowest effective dose and for the shortest duration possible. This article discusses in detail the placental transfer and metabolism of NSAIDs, and the adverse impact of prenatal NSAID exposure on the offspring.

PMID: 22299823

NSAIDs: maternal and fetal considerations.

Nonsteroidal anti-inflammatory drugs (NSAIDs) gained popularity in the late 1970s. Inhibition of prostaglandin synthesis with indomethacin has been reported to be effective for prevention of labor and for treatment for symptomatic polyhydramnios. Concern about its possible constrictive effect on the fetal ductus arteriosus has limited its use in pregnancy. Maternal indomethacin therapy has also been associated with reduction in urine production in the fetus and with oligohydramnios. Obstetricians have discouraged pregnant women from taking analgesic doses of aspirin, mainly because of the availability of paracetamol (acetaminophen), which causes less gastric irritation, but also because of fear of maternal and fetal hemorrhage and of possible premature closure of the ductus. These fears largely derive from studies on patients taking large doses and from extrapolation from other NSAIDs. The likelihood that treatment with 60-75 mg/day of aspirin markedly reduces the incidence of preeclampsia and fetal intrauterine growth retardation makes it important to reexamine its use. This review describes the pharmacology and pharmacokinetics of aspirin with particular reference to pregnancy and considers teratogenesis, prolongation of pregnancy and labor, maternal bleeding, fetal and neonatal bleeding, possible effects on the ductus arteriosus and pulmonary circulation, and possible nonspecific effects on intelligence and breast feeding and acute toxicity in the neonate.

PMID: 1285865

Pattern of Self Prescribed Analgesic Use in a Rural Area of Delhi: Exploring the Potential Role of Internet.

Kochhar A¹, Gupta T².

Author information

Abstract

INTRODUCTION:

Analgesics are the most common self prescribed drugs. Although considered to be relatively safe, side effects are often seen when these drugs are used for prolonged period, in high doses or used where contraindicated. Majority of the consumers are not aware of the side effects. These days ample amount of information is available on web, it is important to explore its role in educating the population regarding the safe use of self prescribed analgesics.

AIM:

To explore pattern of analgesic use, to identify population at risk of developing side effects related to analgesic use, awareness of side effects and potential role of internet to bring awareness about safe use of self prescribed analgesic drugs in a rural area of Delhi.

MATERIALS AND METHODS:

A cross-sectional survey based study was done on 500 adults in the age group of 18-65 years of Madanpur Khadar area of South Delhi, India. Data collection was done by conducting visits to pharmacy shops from the people who were buying drugs without prescription and taking face to face interviews using a semi-structured questionnaire. Statistical analysis was performed using descriptive tests with Microsoft office excel 2007.

RESULTS:

Results of our study showed that among all the self prescribed analgesics paracetamol (57%) was used most frequently followed by aspirin and other NSAIDs. It was found that 9.6% of the consumers were having associated co-morbid illness, 11.4% were simultaneously taking other drugs and 15.2% were alcoholics. Majority (65.4%) of the buyers were not aware about any kind of side effects of the analgesics. Internet friendly consumers were found to be 44%. Ability to use internet and education level were found to be directly related (r=0.802).

CONCLUSION:

The pattern of analgesic consumption in the rural population of Delhi shows that a large number of consumers may be at risk of developing side effects of self prescribed analgesics. The awareness about the side effects is limited. A significant number of consumers are internet friendly. Hence, we recommend use of website/mobile apps as potential source of information in educating the population regarding the use of self prescribed analgesics.

Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are available as "over-the counter" medications in most countries, are widely used by both pregnant and lactating women. They are popular non-opioid analgesics for the treatment of pain after vaginal and operative delivery. In addition, NSAIDs are used for tocolysis in premature labor, and low-dose aspirin has a role in the prevention of preeclampsia and recurrent miscarriage in antiphospholipid syndrome. NSAIDs and aspirin may affect fertility and increase the risk of early pregnancy loss. In the second trimester their use is considered reasonably safe, but has been associated with fetal cryptorchism. In the third trimester, NSAIDs and aspirin are usually avoided because of significant fetal risks such as renal injury, oligohydramnios, constriction of the ductus arteriosus (with potential for persistent pulmonary hypertension in the newborn), necrotizing enterocolitis, and intracranial hemorrhage. Maternal administration or ingestion of most NSAIDs results in low infant exposure via breastmilk, such that both cyclooxygenase-1 and cyclooxygenase-2 inhibitors are generally considered safe, and preferable to aspirin, when breastfeeding.

PMID: 23558845

NSAID Use During Pregnancy Linked to Pulmonary Hypertension In Newborns

NSAID use during pregnancy increases the risk of pulmonary hypertension in newborns, according to a recently published study. Yet, women commonly use the drugs while they are pregnant despite labels that warn against doing so.

In a case-control study published in the March issue of Pediatrics, meconium was collected from 101newborn infants and analyzed for the presence of ibuprofen (e.g., Advil -- Whitehall Robbins), naproxen (e.g., Aleve -- Bayer), indomethacin (e.g., Indocin -- Merck), and aspirin. Results from 40 infants with persistent pulmonary hypertension of the newborn (PPHN), an often fatal complication, were compared with those of 61 randomly selected, healthy, full-term infants.

 Putting the Fetus at Risk

Overall, 49.5% of the meconium samples were positive for NSAIDs: 22.8% were positive for ibuprofen, 18.8% for naproxen,7.9% for indomethacin, and 43.6% for aspirin. PPHN was significantly associated with both the presence of at least one NSAID in the meconium and, in particular, the presence of aspirin,ibuprofen, or naproxen.

NSAIDs block the synthesis of prostaglandins and thromboxane, which are needed to keep open the ductus arterious, the blood vessel that shunts blood past the lungs in the fetus. When the vessel closes early, pulmonary hypertension results. Since NSAIDs cross the placenta easily and have a prolonged half-life in the fetus, they should be avoided during pregnancy, especially in the last trimester

Although other studies have suggested a link between NSAIDs and PPHN, this is the first time an association has been clearly demonstrated, according to co-author Enrique M. Ostrea Jr, MD, professor of pediatrics at Wayne State University and chief of pediatrics at Detroit's Hutzel Hospital.

In the February 3 edition of BMJ, European researchers reported a tentative connection between NSAID use and an increased risk of miscarriage. The odds ratios of women receiving an NSAID prescription in the last week before a miscarriage was 6.99; the odds ratio dropped to 2.69 when an NSAID prescription had been taken 7 to 9 weeks before miscarriage.

The authors of the Pediatrics study were surprised by the widespread use of the drugs. Use was grossly underreported as well, a finding confirmed by other researchers.

Women are thought to forget taking such common, everyday products and may not recognize their presence in multi-ingredient OTC medications. The widespread, easy availability of NSAIDs may also lull pregnant women into a false sense of safety.

The Pediatrics authors called for a reevaluation of the easy access pregnant women have to OTC NSAIDs as well as effective promotion of the dangers the drugs pose to the fetus.

Ostrea thinks the solution lies in stricter labeling, similar to what already exists on tobacco and alcohol products. Labeling should state explicitly that use could cause potentially fatal lung damage in infants, Ostrea said. "Similar statements on alcohol and cigarette labels have significantly reduced use during pregnancy."

He does not think it is necessary to place NSAIDs in a third, pharmacist-only drug class because all patients, not just pregnant women, use the products. Pharmacists should, however, warn pregnant women of the risks involved if they see them buying NSAIDs.