RESP: L8 Treatment of Asthma in Pregnancy & Lactation

Asthma is the most common … medical condition in pregnancy

chronic

It is difficult to predict if asthma symptoms will improve, worsen, or remain stable during pregnancy

• If symptoms are poorly controlled at time of … may increase likelihood of symptoms worsening in pregnancy

conception

Poorling controlled asthma in pregnancy is associated with

• … birth

• … birth weight

• Pre-eclampsia

• … complications

Preterm, low, Placenta

Those with … controlled asthma are not expected to have more pregnancy … than those without the condition

well, complications

Risk of complications due to … asthma is higher than risk posed by asthma …

uncontrolled, medication

… has no known effect on the severity of asthma

Lactation

If pregnant, you don’t want to increase the risk of asthma …, so … asthma treatment is not considered even if there is improvement

• Whereas in normal populations, you would consider decreasing treatment if patient symptoms improve

asthma, decreasing

Comprehensive approach

• Identify and avoid precipitating factors

• Encourage smoking …

  • Nicotine replacement therapy (NRT) is … in pregnancy

    • Patch, lozenge, gum, inhaler

    • … are not recommended

• Treat conditions that may impact asthma symptoms/control

  • …

    • Chewable calcium carbonate, H2 antagonists (e.g. famotidine) and … (e.g. pantoprazole) are suitable in pregnancy

• … caution with medications that can exacerbate symptoms

  • E.g. beta blockers used for hypertension in pregnancy

• … monitoring of asthma is recommended

  • Pharmacist-clinician collaboration

cessation, suitable, E-cigarettes, GERD, PPIs, Exercise, Monthly

Clinical factors

• Assess need for medication

  • What would happen if patient does not take medication?

    • … of asthma

    • …

    • Additional … drug therapy

    • … in pregnancy

Exacerbations, Hospitalization, rescue, Complications

Medication factors

• … toxicity

• Determinants of drug toxicity

  • Exposure at a … period

  • Does the medication cross the …

• What outcome data is available in the literature

  • Benefits/risk for pregnant person and fetus

  • Animal toxicity

    • Usually the last line

Developmental, critical, placenta

Treatments suitable in pregnancy

• Beta agonists

• ICS

  • Most data on …

• Long acting beta agonists

  • Most data on …

• Leukotriene receptor antagonists

  • 6 cases of … anomalies reported

  • Most studies have found no increased risk

• Oral corticosteroids

  • …

  • … birth weight

  • Historically increased risk cleft … ± cleft …

  • A number of other human studies have not shown this increased risk for birth defects

budesonide, salmeterol, limb, Prematurity, Low, lip, palate

Asthma biologics

• Data related to the use of … antibodies for severe treatment of severe asthma during pregnancy are limited

• The option to start or continue treatment in pregnant patients should be part of a … decision-making discussion

• Neonatal outcomes

  • Some biologic exposures in utero have been linked to … abnormalities in neonates

  • However, use in pregnancy is not expected to increase the risk of neonatal …

• Infant immunization

  • Special considerations are given to immunizing infants exposed to biologics in …

    • Some monoclonal antibodies in pregnancy (e.g. rituximab) can cause temporary … in the infant

      • For these biologic exposures in utero assessment of the infants’ immune function is required prior to administration of … vaccines (e.g. rotavirus)

      • Routine non-live infant immunizations in BC do not require modification

    • Thus far, biologics used for asthma (e.g. omalizumab, dupilumab) are not considered to be broadly immunosuppressive

monoclonal, shared, hematologic, infections, utero, immunosuppression, live

Best recommendations for asthma treatment are … measures and … prn for fever

non-drug, acetaminophen

Non-drug recommendations

• Good … washing

• Soup, … beverages, …

• Rest

• … head of bed at night

hand, warm, lozenges, Elevate

Other recommendations for asthma treatment

• … nasal spray ii sprays in each nostril qid prn

• Medications

  • Anti-…

  • …

    • Can cause birth defects

  • Guaifenasen or dextromethorphan

    • Not really …, so better to just not recommend

Saline, histamine, Decongestants, effective

Pregnant and lactating people should receive the … influenza vaccine and the … vaccine

inactivated, COVID-19

The flu vaccine is recommended and provided … for pregnant people during the influenza season

free

For best …, pregnant and lactating people should get immunized as soon as possible during … season

protection, influenza

There are data with infant outcomes after exposure to … (e.g. omalizumab) in milk and one case with limitations regarding milk concentrations

anti-IgE

There is no lactation data on …, anti-IL-5 receptor alpha (e.g. mepolizumab, benralizumab), and anti-thymic stromal lymphopoietin (Anti-TSLP)

• Presumed suitable based on … and poor … absorption

Anti-IL-5 kinetics, oral

There are data with infant outcomes after exposure to … (e.g. dupilumab) in milk and milk concentration data

• This is suitable in lacatation

Anti-IL-4 receptor alpha

Asthma biologics can be initiated or continued while …

• Due to large protein molecule & size ~ … Da, the amount in milk is likely to be very low

• Drug is expected to be partially … in the infant’s stomach and … by the infant is likely minimal

• Patient should be counselled about potential risks and benefits due to lack of or limited short term data in lactation

• Waiting for at least … weeks postpartum to resume therapy may minimize transfer into milk

150,000, destroyed, absorption, 2

Medication Safety in Lactation

• Key points

  • Choose … therapy

  • Evaluate … of lactation

  • Does medication enter milk?

    • What is … & oral bioavailability?

• Review typical side effects in adults & pediatrics

• Monitor infant

  • Changes in …, feeding or sleeping patterns

  • Inform health care providers of medication(s) infant is exposed to via milk

effective, stage, RID, growth

Can it Cross the Placenta?

• Plasma … (systemic bioavailability)

• Molecular weight (<… Daltons)

• …

• … solubility (cross membrane easier)

• … at physiologic pH

• Plasma … binding

• Placental … enzymes

concentration, 600, Half-life, Lipid, Ionization, protein, metabolizing

Does it enter milk?

• Plasma concentration

• Molecular weight (<… Da)

• Half-life

• Protein binding

• .Volume of distribution (Vd < … L/kg)

• pH (pKa > …)

• Lipid solubility

800, 1, 7.2

Oral bioavailability (F)

• Drug exposure via milk depends on bioavailability of drug in infant

  • … molecular weight = … absorbed orally (e.g. heparin)

• … in GI tract of infant is important

Large, poorly, Stability

Relative infant dose (RID)

• Relative infant dose via milk divided by lactating persons’ dose

• Calculated using

  • Lactating person’s …

    • Commonly adjusted to a … kg female in literature

  • Daily infant milk …

    • Typically … mL/kg/day

  • < …% of lactating person’s daily dose is acceptable

• RID = daily infant dose (mg/kg/day) / daily lactating person’s dose (mg/kg/day) x 100

weight, 70, intake, 150, 10