114 Risk communication prior to pharmacotherapeutic choice

Drug administration during pregnancy means that both the mother and unborn child are exposed. The drug or metabolite concentration may be even higher in the embryonic or fetal compartment than it is in the mother. The fetus as an "additional" patient therefore demands a strict pharmacotherapeutic approach, as it is imperative to try to restore maternal health without endangering the development of the child. In severe conditions, such as bronchial asthma, diabetes melli-tus, epilepsy or particular communicable diseases, treatment is obligatory regardless of pregnancy. In contrast, inessential products such as antitussive preparations, "pregnancy-supporting" substances, and high doses of vitamins and minerals should not be prescribed or used, as their potential risks outweigh their unproven benefits.

The following rules of thumb are applicable when prescribing drugs:

■ Women of reproductive age must be asked, prior to drug prescription, whether an as-yet undetected pregnancy is possible, or whether they are planning a pregnancy. By the time a woman learns that she is pregnant, organogenesis has already progressed substantially.

m In chronic treatment of women of reproductive age, the possibility of pregnancy must be considered. In the case of drugs with teratogenic potential, effective contraceptive measures must be discussed and implemented. Products proven to be safe in pregnancy are the drugs of first choice for long-term treatment during the reproductive years.

■ Some medicinal products (e.g. anticonvulsants) rcduce the effectiveness of hormonal contraception.

■ In general, drugs that have already been in use for several years should be the preferred choice during pregnancy, provided that they have not been substantially suspected of carrying risk. These products usually involve greater safety in their therapeutic efficacy in the mother and tolerability by the fetus. On the contrary, recently introduced agents must be considered to be an unap-praised risk; in many instances these products are also "pseudoinnovations" without any proven therapeutic advantage.

■ If possible, monotherapy is preferred.

■ The lowest effective dose should be prescribed.

■ Non-drug treatment should be considered.

■ The disease itself may be a greater fetotoxic risk than the appropriate drug therapy, as in diabetes mellitus. The same applies to severe psychic stress. An individual risk evaluation related to condition and treatment is neccssary in these cases.

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