Emergency Contracep/on & Post Exposure Prophylaxis. Dr Catherine White FMERSA 19 th January 2016

Transcription

1 Emergency Contracep/on & Post Exposure Prophylaxis Dr Catherine White FMERSA 19 th January 2016

2 There are two main methods of emergency contracep/on (E.C) Hormonal (Morning amer pill) Levonorgestrel (LNG) Levonelle 1.5mg Ulipristal Acetate ellaone 30mg Intra- uterine device (IUCD or copper coil ) Dr Cath White FMERSA

3 Methods of emergency contracep/on in the UK Method Class Products Recommended dose / use Copper- bearing intrauterine device Intrauterine contracep/ve method Various IUD retained un/l pregnancy excluded (e.g. onset of period) or for licensed dura/on of IUD (5-10 years) Indica6ons Within first 5 days (120 hours) following first UPSI in a cycle or within 5 days from earliest es/mated date of ovula/on Levonorgestrel (LNG) Progestogen hormone Levonelle One Step Levonelle 1500 Upostelle 1.5mg single oral dose 72 hours of UPSI Ulipristal acetate (UPA) Progesterone receptor modulator ellaone 30mg single oral dose 120 hours of UPSI Dr Cath White FMERSA

4 Menstrual cycle Name of phase Days menstrual phase 1 4 follicular phase (also known as prolifera6ve phase) Variable ovula6on (not a phase, but an event dividing phases) luteal phase (also known as secretory phase) Rela/vely constant at 14 days ischemic phase (some sources group this with secretory phase) Dr Cath White FMERSA

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6 When does pregnancy begin? Dr Cath White FMERSA

7 When does pregnancy begin? A Judicial review in 2002 ruled that pregnancy begins at implanta/on, not fer/lisa/on. DoH R v Secretary of State for Health (Defendant) & (1) Schering Health Care (2) Family Planning Associa/on (Interested Par/es), Ex Parte John Smeaton (on behalf of The Society for the Protec/on of Unborn Children) (Claimant) EWCH 610 Crim LR hdp://webarchives.gov.uk/+/ DH_ [Accessed 13 August 2011] Dr Cath White FMERSA

8 How does emergency contracep6on work? Levonorgestrel LNG Precise mode incompletely understood Inhibi/on of ovula/on Appears to prevent follicular rupture or cause luteal dysfunc/on LNG taken prior to LH surge ovulatory dysfunc/on 5 days. There inhibit ovula/on for 5-7 days. If given too close to ovula/on is no beder than placebo at suppressing ovula/on. Dr Cath White FMERSA

9 Ulipristal acetate UPA Inhibi/on or delay of ovula/on If given immediately before ovula/on UPA shown to suppress growth of lead follicles. Some evidence that UPA can prevent ovula/on amer LH surge has started, delaying follicular rupture un/l up to 5 days later. Has an endometrial effect but the contribu/on of this to efficacy is as yet unknown. Effect on inadvertent pregnancies is unknown Dr Cath White FMERSA

10 Cu- IUD Effec/ve immediately amer inser/on Copper is toxic to the ovum and sperm Inhibits fer/lisa/on Also an an/- implanta/on effect Mean /me of implanta/on is 9 (range 6-18) days Therefore to ensure inserted prior to implanta/on First 5 days following first UPSI in a cycle Within 5 days from earliest es/mated date of ovula/on Dr Cath White FMERSA

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12 How effec/ve are they? Hours ager UPSI Effec6veness IUD LNG Ulipristal % 69% 85% % 60% >60% Exact data unavailable Dr Cath White FMERSA

13 LNG- IUS not suitable for EC (Mirena coil) Dr Cath White FMERSA

14 Weight CEU supports use of all EC methods in obese women and does not recommend increasing the dose of oral EC. Obese = BMI>30 Dr Cath White FMERSA

15 IUD LNG Ulipristal Breast feeding OK OK X (for 36 hours amer taking) Pregnancy or suspected pregnancy X Contraindicated No evidence that LNG will interrupt an exis/ng X pregnancy or have adverse effects on a fetus. Good Contraindicated prac/ce would be to exclude a pregnancy prior to administra/on. Severe Liver Impairment OK other than Wilson s disease Cau/on, manufacturers say not recommended. X Contraindicated Severe Asthma uncontrolled by oral glucocor6coids OK OK X Contraindicated Galactose intolerance, Lapp lactase deficiency Glucose- galactose malabsorp6on OK X Contraindicated X Contraindicated Mul6ple use in same cycle N/a as IUD to remain in situ un/l at least next period OK but may cause cycle disturbance No Women taking Enzyme inducing drugs or who havepreferred op/on unless otherwise contra- indicated. Take total of 3mg as a single dose as soon as stopped them within last 28 days. possible. (this dose is outside product licence) No Drugs that affect gastric ph OK OK No Antacids Proton pump inhibitors Histamine H2 antagonists Dr Cath White FMERSA

16 IUD LNG UPA Breast feeding (Express and discard breastmilk for 1 week) Pregnancy or suspected pregnancy Contraindicated No evidence LNG will interrupt exis/ng pregnancy or harm adverse effect on foetus. Good prac/ce would be to exclude pregnancy prior to administra/on Contraindicated Severe liver impairment Ok other than Wilson s disease Cau/on, manufacturers say not recommended Contraindicated Severe asthma uncontrolled by oral glucocor/coids Contraindicated Galactose intolerance, Lapp lactase deficiency, Glucose- galactose malabsorp/on Contraindicated Contraindicated Mul/ple use in same cycle On enzyme inducing drugs or have stopped them within last 28/7 Drugs that effect gastric ph Antacids Proton pump inhibitors Histamine H2 antagonists N/a as IUD to remain in situ un/l at least next period Preferred op/on unless CI Ok but may cause cycle disturbance Take 3mg as single dose (Outside product licence) No No No Dr Cath White FMERSA

17 Ulipristal and breasveeding hdp:// Dr Cath White FMERSA

18 CI for IUD As for rou/ne IUD inser/on Undiagnosed genital tract bleeding Post sep/c abor/on Etc etc hdp:// Dr Cath White FMERSA

19 Hormonal EC Repeat if vomit within 3 hours for UPA, 2 hours LNG Take as soon as possible Won t provide effec/ve contracep/on for remainder of cycle May cause menstrual disturbance Pregnancy test If next period delayed for more than 5 days Lighter than usual Consider ectopic Dr Cath White FMERSA

20 UPA and hormonal contracep/on In the absence of evidence regarding other POP formula/ons and other hormonal contracep/ve methods, the CEU would recommend that amer taking UPA for EC, a woman should not start a hormonal contracep/ve method for at least 5 days and be advised to use barrier methods or to abstain from sex un/l effec/ve hormonal contracep/ve cover has been achieved. Dr Cath White FMERSA

21 hdp:// Dr Cath White FMERSA

22 Liver enzyme inducers An/epilep/cs An/bio/cs Herbal St John s Wort An/retrovirals If commencing HIV PEP* at same /me, give double dose LNG ie 3mg. Dr Cath White FMERSA

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24 Copper IUD An/bio/c prophylaxis Insert up to 5 days amer ovula/on Dr Cath White FMERSA

25 Assessing the need for EC Nature of assault Time from assault to examina/on Other episodes of unprotected sexual intercourse (with assailant or a third party) in the current cycle. Menstrual status Cycle including LMP Current method of contracep/on Dr Cath White FMERSA

26 Things to remember when giving EC The failure rate for hormonal EC is higher than for an IUD and this should be discussed with the pa/ent. Take as soon as possible. Warn that it will not provide effec/ve contracep/on cover for the remainder of the cycle. It may cause menstrual disturbance. A pregnancy test is recommended if the next period is delayed for more than 5 days or is lighter than usual. Consider an ectopic pregnancy in these women. Dr Cath White FMERSA

27 Hep B prophylaxis Has an incuba/on period of days May lead to liver failure and liver cancer Is cleared naturally by the majority of adults (90-95%), but the minority of babies (10%) Can be prevented by vaccina/on Is treatable if acquired Dr Cath White FMERSA

28 When to consider Hep B Dr Cath White FMERSA

29 Hep B course A super- accelerated course Three doses at 0, 7 and 21 days respec/vely, and a booster at 1 year. An intramuscular 20mcg dose Engerix B is appropriate for over 16s, a 10mcg dose for under 16s*). Dr Cath White FMERSA

30 United Kingdom Na/onal Guideline on the Management of the Viral Hepa//des A, B & C 2015 Clinical Effec/veness Group The ultra- rapid vaccination schedule (0,1,3 weeks) leads to an anti- HBs antibody response in only 80% of recipients 4-12weeks after the third dose Dr Cath White FMERSA

31 HIV PEP BASHH CHIVA 5 day starter pack GU follow up Dr Cath White FMERSA

32 HIV PEP Window of opportunity to prevent HIV infec/on by inhibi/ng viral replica/on following an exposure 72 hours 28 days Risk assessment Dr Cath White FMERSA

33 RISK Risk of HIV transmission = Dr Cath White FMERSA

34 RISK Risk of HIV transmission = Risk assailant is HIV posi3ve x Risk of exposure Dr Cath White FMERSA

35 RISK Risk of HIV transmission = Risk assailant is HIV posi3ve x Risk of exposure 0 x 6 = 0 Dr Cath White FMERSA

36 RISK Risk of HIV transmission = Risk assailant is HIV posi3ve x Risk of exposure 0 x 6 = 0 0 x 60 = 0 Dr Cath White FMERSA

37 RISK Risk of HIV transmission = Risk assailant is HIV posi3ve x Risk of exposure 0 x 6 = 0 0 x 60 = 0 0 x 600 =? Dr Cath White FMERSA

38 RISK Risk of HIV transmission = Risk assailant is HIV posi3ve x Risk of exposure 0 x 6 = 0 0 x 60 = 0 0 x 600 =? We (BASHH) recommend the use of PEPSE where there is a significant risk of HIV transmission (risk >1/1000) Dr Cath White FMERSA

39 HIV PEPSE hdp:// Dr Cath White FMERSA

40 BASHH 2015 Dr Cath White FMERSA

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42 BASHH 2015 Dr Cath White FMERSA

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45 PEPSE Drug Interactions Specialist HIV Pharmacist and/or use Liverpool Drug Interaction website Dr Cath White FMERSA

46 Cost of PEPSE 28 day course of PEP (Truvada + raltegravir) = 800 Life/me cost of treatment for an HIV + individual = 360,000 BNF price May 2015 (Nakagawa F, Miners A, Smith CJ, Simmons R, Lodwick RK, Cambiano V, et al. Projected Life/me Healthcare Costs Associated with HIV Infec/on. PloS one. 2015;10(4):e ) Dr Cath White FMERSA

47 Documenta/on Ini/al advice stage (e.g. phone calls from police/ poten/al self referrals) In notes Follow up Dr Cath White FMERSA

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