On-call scenario 6: Sources

Last updated: Tuesday, November 26, 2019

Here are some information resources you might have thought about:

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  • UK Teratology Info Service monographs – these assessments of the safety of medicines in pregnancy are found on the Toxbase website. You’ll need your Trust password and login to see the detailed healthcare professional versions, but there are good summaries for patients available without a password. 
  • SmPCs via eMC – 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’ and ‘Schaefer’.
  • 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 quickly establish that the data on pregabalin are so limited that it is not possible to undertake an informed assessment of the risks posed by the drug during pregnancy. For gabapentin, you run into the problem that most pregnancy exposures have occurred in women 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: some resources advise to avoid its use completely, and others are less conservative. Data specifically on problems encountered when the drug is used during the third trimester are lacking. 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?
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.