On-call scenario 6: Resolution
What an on-call pharmacist could advise...
This is a difficult problem with no ideal solution and you’ll need to discuss with the nurse which is the ‘least worst option’. Gabapentin does not interact with sertraline but has limited and conflicting information about its safety in pregnancy. There is more information about using amitriptyline in pregnancy but it might interact with sertraline. In trying to make the decision, it can help to think through the consequences of each course of action and what you can do to manage any risks.In this scenario there is not a great deal you can do to plug the knowledge gap around gabapentin use in pregnancy. However, what you can do is to manage the risk of an interaction between amitriptyline and sertraline by recommending a lower amitriptyline dose, and making sure the patient and the professionals looking after them are aware of the potential side effects.
Finally, you might ask the specialist pain nurse if, in her opinion, the patient might be suitable for a non-drug treatment like manipulation or percutaneous electrical nerve stimulation. This is not your area of expertise, but always consider non-drug options during pregnancy.
Sometimes when you are on-call you may feel pressurised to try and find the perfect answer, but there may not always be one. It’s important to reflect on this. Pharmacists want to be helpful, and when you’re the only one on duty you may feel this responsibility even more strongly, yet you also have to be honest about the limitations of the data available.
Follow up
At the earliest opportunity, find out if the patient has been admitted to your hospital or discharged. If she has been admitted then speak to the pharmacist caring for her and explain the clinical advice you have given and the reasoning behind your decision. Can you document your input in your hospital's e-prescribing system or the patient's health records? If she has been discharged, then you should check the patient’s discharge summary to make sure that the GP and community midwife are aware of the risks of using amitriptyline and sertraline together, and any monitoring that is required.If the amitriptyline (and sertraline) continue for the remainder of the pregnancy then the healthcare team also need to remember the risk of a neonatal withdrawal syndrome and think about the potential safety of these medicines in breastfeeding.
Perhaps this scenario has made you doubt your ability to handle a clinical problem involving the use of medicines on pregnancy. If so, check out the core learning in our Pregnancy tutorial.