University:
West Coast University
Course:
PHAR 837 | IPC Infectious Diseases I
Academic year:

2024
Views:

417

Pages:

45
Author:

Asal A.

Contraception Pharmacotherapy Ani Avoundjian, PharmD Clinical Assistant Professor, Pharmacy Practice West Coast University School of Pharmacy Starting a Contraceptive Method pathpill • Starting grins CHCs on different days of the cycle does not affect bleeding or other side effects • “Quick start” may increase continuation of combined oral contraceptives (COCs) and patch in the short term; this difference disappears over time • No increased risk for adverse outcomes (congenital anomalies, neonatal death, infant death) among infants exposed in utero to COCs • Brahmi, Contraception, 2013. • Bracken, Obstet Gynecol. 1990;76:552-7. Slide adapted from CDC 2016 SPR Eon How to Start Hormonal Contraception Sunday start • Protection after 7 days of active pills/patch/ring • Cycle begins on Sunday always First day of bleeding start “Any time” start (Quick start) • Protection immediate (no back up required) • Cycle begins on same day each month (e.g., Wednesday) • Starts pills today (or tomorrow if EC used today) • Protection requires 7 days of active pills/patch/ring Evidence: Pregnancy Test Limitations • Pregnancy detection rates can vary based on sensitivity of test and timing with respect to missed menses • Pregnancy test not able to detect pregnancy resulting from recent intercourse • Pregnancy test may remain positive several weeks after pregnancy ends • Cervinski, Clin Chem Lab Med. 2010;48:935-42. • Cole LA, Expert Rev Mol Diagn. 2009;9:721-47. • Wilcox, JAMA. 2001;286:1759-61. • Korhonen, Clin Chem. 1997;43:2155-63. • Reyes, Am J Obstet Gynecol. 1985;153:486-9. • Steier, Obstet Gynecol. 1984;64:391-4.` Slide adapted from CDC 2016 SPR Furnishing Contraception in CA HC Protocol Requirements • A self-screening questionnaire with specific questions must be used • Assessments required by the pharmacist • Review of self-assessment questionnaire and application of the Medical Eligibility Criteria (MEC) • BP measurement for estrogen-containing products • Patient Education required of the pharmacist • For the method selected including administration instructions • Written patient education ( a “Fact Sheet”) Slide adapted from materials developed by K. Besinque, PharmD HC Protocol Requirements cont. • Documentation of services and notification to primary care provider • Medication profile • Patient to provide PCP contact info or may decline • Referral as needed • for preventative care & screenings • for ineligible patients • for long-acting reversible contraceptives • Training before implementation • complete one hour of continuing education program from a board-approved provider regarding HC and application of US MEC (recent graduates excepted) Slide adapted from materials developed by K. Besinque, PharmD CA HC Protocol He DMPA • Includes: pills, patch, ring, depot injection pop • Required counseling points: • Dosage • Effectiveness • Potential SE • Safety • Importance of recommended health screenings • Self-administered contraception does not prevent STIs Amy estrogen progestra Coc CHI more… Amy more… Amy A medicalHistory Bp self Review the selfscreening questionnaire What do you need to do before furnishing HC? Is she eligible to receive HC from the pharmacist? screeningform Coco combined orated Condition Cu-IUD LNG-IUD Implant DMPA POP CHC Age Menarche – <20 yr: 2 Menarche – <20 yr: 2 Menarche – <18 yr: 1 Menarche – <18 yr: 2 Menarche – <18 yr: 1 Menarche – <40 yr: 1 ≥ 20 yr: 1 ≥ 20 yr: 1 18-45 yr: 1 18-45 yr: 1 18-45 yr: 1 ≥ 40 yr: 1 ≥ 45 yr: 1 ≥ 45 yr: 2 ≥ 45 yr: 1 Cu-IUD: copper-containing intrauterine device LNG – IUD: levonorgestrel-releasing intrauterine device DMPA: depot medroxyprogesterone acetate POP: progestin-only pill CHC: combined hormonal contraceptives Documentation • Document blood pressure. Amy is requesting an estrogen containing product. • Document who will receive notification of product/services provided. • Complete prescription. • Counsel Amy regarding how to use product. • Provide Fact Sheet (can use PPI) selfscreen Barbara BPmedal estrogen Discontinue more… Barbara • Review the selfscreening questionnaire • What do you need to do before furnishing HC? • Does Barbara meet eligibility for pharmacist furnishing HC? • You measure her BP at 154/88 • You check it again 10 minutes later…same reading pt LNG-IUD Implant DMPA POP O CHC Sub-condition Cu-IUD Condition 1 1 1 2 1 3 Systolic 140-159 or Diastolic 90 - 99 1 1 1 2 1 3 Systolic ≥ 160 or Diastolic ≥ 100 1 2 2 3 2 4 Vascular disease 1 2 2 3 2 4 15488 HTN Adequately controlled BP Elevated BP (proper measurement) Documentation • Document blood pressure. Barbara has been taking an estrogen containing product. Documentation • Document who will receive notification of product/services provided. • Complete prescription. • Counsel Barbara regarding how to use product. • Provide Fact Sheet (PPI ok) Leslie To Late/Missed Combined Pills combined estrogenand progestge LATE Pill: MISSED Pill: Should have been taken < 24 hours ago Should have been taken 24 – 48 hours ago -Take the late pill ASAP -Continue taking pills daily, one each day, at the same time each day, even if it means taking two pills on the same day -Emergency not usually needed but may be considered if hormonal pills were missed earlier in the cycle or in the last week of the previous cycle. Eton progestrinonly Late/Missed Norethindrone Pills LATE Pill: MISSED Pill: Should have been taken < 3 hours ago Should have been taken > 3 hours ago 9 Theylooks -Take the late pill ASAP -Take the late pill ASAP -Continue taking the rest of the pills as usual -Continue taking pills daily, one each day, at the same time each day, even if it means taking two pills on the same day -No additional contraception is needed -Use back-up contraception (e.g., condoms) or avoid sexual intercourse until pills have been taken correctly, on time, for 2 consecutive days -Emergency contraception should be considered if the woman has had unprotected sexual intercourse. progestinonly Late/Missed Drosperinone Pills LATE Pill: MISSED Pill: Should have been taken < 24 hours ago Should have been taken > 24 hours ago -Take the late pill ASAP -Take the late pill ASAP -Continue taking the rest of the pills as usual -Continue taking pills daily, one each day, at the same time each day, even if it means taking two pills on the same day -No additional contraception is needed -Use back-up contraception (e.g., condoms) or avoid sexual intercourse until pills have been taken correctly, on time, for 7 consecutive days -Emergency contraception should be considered if the woman has had unprotected sexual intercourse. Suzanne • Review the self-screening questionnaire Suzanne • Does Suzanne meet eligibility for pharmacist furnishing HC? Emergency Contraception Emergency Contraception 3 • The use of medication for prevention of unintended pregnancy 72songs 120 hours after unprotected intercourse • Mechanism of action: • Prevents ovulation • Alters tubal transport of sperm and/or egg • Alters endometrium which inhibits implantation • Does NOT cause abortion, birth defects, or ectopic pregnancy if implantation has already occurred When to give EC: •Anytime it is asked for BUT needs to be used within 120h (5d) of unprotected intercourse •Products available: • Copper IUD (MD only) • Rx only • Ulipristal acetate (ella) • OTC Progestin-only pills (levonorgestrel (LNG)) • Examples: Plan B One-Step, Next Choice, My Way • Yuzpe method Counseling Points on EC • OTC – more effective if used earlier (95% if taken within 24 hours, 88% if taken within 72 hours) • If no menses in 3 weeks, take pregnancy test or see clinician • Consider: Is this a good time to talk about SAHC? • No protection against STIs (get tested) • Refer to MD if pt experiences severe lower abdominal cramping (possible ectopic pregnancy) • NAUSEA! • Repeat dose if vomiting within 2h of taking • Anitemetic may be used (i.e. meclizine) Levonorgestrel EC (Plan B) • Dose: 1.5 mg • Should be taken as soon as possible • OTC for ALL ages Ups we Ella (ulipristal acetate 30 mg) • Rx only • 95% effective even after 120 hours of unprotected intercourse • More effective than progestin only options for obese/overweight women • Side effects: HA, nausea, abdominal pain, dysmenorrhea, fatigue, dizziness Yuzpe Method • Using Rx oral CHC pills as EC • (Must include estrogen and progesterone) • Most effective if within 72 hours of unprotected sex • Taken in 2 doses, 12 hours apart • 75% effective in preventing pregnancy • N/V common • Dose dependent: only effective with certain brands of CHC Levonorgestil orplants Resuming contraception: resumright angand Backup Iday • If CHC/progestin only EC method used -> resume right away and use backup for 7 days • If Ella was used -> wait 5 days before restarting hormonal contraception and use barrier method until next menstrual period Barrier Methods Male Condoms • Types: • Latex – protect against STI, most effective • Polyurethane – protect against STI, alt for latex allergy • Natural skin – does NOT protect against STI, alt for latex allergy • Check expiration date (latex degrades over time; susceptible to breakage) • Cannot be used with oil-based lubricants (weakens latex), waterbased okay • Simultaneous use with female condom not recommended • Can use with spermicide Female Condoms • Only FDA approved brand of internal condom available in the U.S. is the FC2® Internal Condom • Provides protection against STIs • Contains 2 polyurethane rings • Can insert up to 8 hours before intercourse • Pre-lubricated • May not be as effective as male condom Spermicide • Available as creams, gels, film, foam, and suppositories • Used alone or with a barrier method (though high failure rate when used alone) • Does not protect against STI • Side effects: increased risk of vaginal irritation, yeast infection, bacterial vaginosis, UTI Diaphragm and Cervical Cap • MOA: • Device blocks from opening of uterus • Spermicide stops sperm from moving • Must be fitted • Reusable (diaphragm replaced every 2 years, cervical cap replaced every year) • Both used with spermicide • Both Rx only Diaphragm Cervical Cap Contraceptive Sponge • Plastic foam sponge with spermicide • Can be inserted up to 24h before intercourse and must be left in for 6h after intercourse • Works by: • Covering cervix and blocking sperm from entering • Releasing spermicide stopping action of sperm

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