Approaches to Patient Counseling Regarding Effectiveness of Oral Contraceptives

DeAndrade, Diana S.; Berman, Julie R.; Boisen, Michael L.

doi:10.1213/ane.0000000000002856

Cited by 4 publications

(6 citation statements)

References 1 publication

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“…Given this potential for hormone sequestration, professional society guidelines and the manufacturer recommend that all women of fertile age who take any form of hormonal contraception and who receive sugammadex should be informed of this potential risk [ 1 , 7 ]. They advise anaesthetists to warn patients to take extra contraceptive precautions equivalent to a missed dose of the pill [ 4 , 7 , 8 , 9 , 10 , 11 ].…”

Section: Introductionmentioning

confidence: 99%

A prospective observational study of the effects of sugammadex on peri‐operative oestrogen and progesterone levels in women who take hormonal contraception

2022

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Pharmacokinetic modelling suggests that sugammadex may interact with endogenous progesterone and reduce levels by 34% in patients taking hormonal contraception. Due to this potential interaction that may be equivalent to missing one dose of an oral contraceptive pill, both the manufacturer and professional anaesthesia organisations recommend counselling patients to use additional non-hormonal contraception after administration of sugammadex. We performed a prospective observational study examining the changes in serum oestrogen and progesterone concentrations in premenopausal adult women undergoing an operative procedure. Sixty participants who were on hormonal contraception received sugammadex. Two additional control groups were recruited, consisting of 30 participants who were not on hormonal contraception and did not receive sugammadex, and 32 who were not on hormonal contraception and did receive sugammadex. Three blood samples were taken: before sugammadex; 15 min post-sugammadex; and 240 min post-sugammadex or end of operating theatre time. Median oestrogen levels decreased from baseline by around 40% at 240 min in all three groups (p ≤ 0.001). Progesterone levels rose significantly at 15 min (p = 0.002) in patients on contraception then decreased non-significantly to 20% below baseline at 240 min. The decrease in oestrogen and the rise in progesterone could both act to minimise the risk of ovulation and thus protect contraception in this population. We found no evidence of a change in hormone levels that might threaten contraceptive efficacy in women on hormonal contraception receiving sugammadex.

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Section: Introductionmentioning

confidence: 99%

A prospective observational study of the effects of sugammadex on peri‐operative oestrogen and progesterone levels in women who take hormonal contraception

2022

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“…Instead, most reports describe informing patients of sugammadex exposure and contraceptive counseling ex post facto. 5–8…”

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confidence: 99%

“…1 This warning and recommendation have been promulgated by the Society for Obstetric Anesthesia and Perinatology 2 and embraced by numerous medical centers. [3][4][5][6][7][8] Some authors have recommended considering intentional avoidance of this interaction by using the alternative neuromuscular blockade (NMB) antagonist, neostigmine. 3,4 Ethical considerations of administering sugammadex to women using HC without prior discussion vis-à-vis paternalism have been reviewed, 3 but reports describing preoperative discussion with at-risk women of implications of the sugammadex/HC drug interaction are lacking.…”

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confidence: 99%

“…Instead, most reports describe informing patients of sugammadex exposure and contraceptive counseling ex post facto. [5][6][7][8] Considering clinical and financial implications of complications from postoperative residual NMB, such as tracheal reintubation, our institution decided that enhanced safety of ensuring complete NMB reversal was worth the added cost of routine sugammadex use instead of neostigmine. Beginning February 2017, sugammadex was officially designated as the NMB antagonist of choice.…”

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confidence: 99%

“…Sugammadex was readily available in operating room carts, while the number of neostigmine vials in carts was limited to 1. As reported by other institutions, [5][6][7][8] women using HC and exposed to sugammadex were to be counseled postoperatively in the postanesthesia care unit (PACU), including provision of an informational document that describes the sugammadex/HC interaction, potential risk of HC failure, and recommendations for alternative contraceptive measures (see Supplemental Digital Content 1, Appendix 1, http://links.lww.com/AA/ D413, for discharge instructions for patients exposed to sugammadex).…”

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confidence: 99%

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Unanticipated Consequences of Switching to Sugammadex: Anesthesia Provider Survey on the Hormone Contraceptive Drug Interaction

Dwan

Raymond

Richardson

2021

Anesthesia &Amp; Analgesia

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BACKGROUND: Sugammadex binds progesterone with high affinity and may interfere with hormonal contraceptive effectiveness. The clinical, economical, and ethical implications of unintended pregnancy should prompt anesthesiologists to actively consider and manage this pharmacologic interaction. We surveyed anesthesiology providers at our institution about knowledge of this potential adverse drug interaction, how they manage it clinically, and the extent to which they involve patients in shared decision-making regarding choice of neuromuscular blocker antagonist. METHODS: A survey instrument was distributed to anesthesiology providers at a large, tertiary-care medical center. The survey explored prior experience using neostigmine and sugammadex, knowledge about potential sugammadex interference with hormonal contraception, pre-/postoperative counseling practices, clinical management, and shared decision-making regarding potential use of neostigmine in lieu of sugammadex to avoid this drug-drug interaction. RESULTS: Of 259 surveys distributed, 155 were fully completed, and 10 were partially completed. Overall response rate was 60% (residents 85%, student nurse anesthetists 53%, certified registered nurse anesthetists 58%, attendings 48%). All but 1 respondent recognized the potential for sugammadex interference with oral hormonal contraception. Far fewer accurately identified potential interference with hormonal intrauterine devices (44%) and hormonal contraceptive implants (55%). The manufacturer’s recommended 7-day duration of alternative contraception was correctly identified by 72% of respondents; others (22%) reported longer durations (range 10–30 days). Most (78% overall) agreed/strongly agreed that potential interference with contraceptive effectiveness should be discussed with patients preoperatively. Despite the majority (86% overall) that endorsed shared decision-making and inviting patient input regarding choice between sugammadex and neostigmine, many respondents reported “rarely/never” having discussed this drug interaction with patients in actual clinical practice, either preoperatively (67%) or postoperatively (80%). Furthermore, most respondents (79%) reported “rarely/never” administering neostigmine to intentionally avoid this drug interaction. CONCLUSIONS: Two years after designating sugammadex as antagonist of choice, physician and nurse anesthesia providers reported seldom inquiring about contraceptive use among women of childbearing potential and rarely discussing potential risk of contraceptive failure from sugammadex exposure. Most lack accurate knowledge of sugammadex interference with hormonal intrauterine and subcutaneous contraceptive devices. Although most endorse preoperative counseling and support patient autonomy or shared decision-making regarding choice of reversal agent, the same respondents report rarely, if ever, actualizing these positions in clinical practice. These conflicting findings highlight the need for education regarding residual neuromuscular block versus adverse drug interactions, collaboration among providers involved in patient counseling, and intentional mindfulness of reproductive justice when caring for women of childbearing potential.

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