Prescribing patterns of antiretroviral treatments during pregnancy for women living with HIV in Canada 2004-2020: A surveillance study.

BACKGROUND: While treatment guidelines for HIV in adults have evolved rapidly with the advent of new antiretroviral (ARV) treatment, those for the prevention of vertical HIV transmission in pregnancy have evolved more slowly due to safety and efficacy concerns. Here we describe Canadian prescribing patterns for ARV treatments during pregnancy and compare them to perinatal HIV prescribing guidelines of the United States Department of Health and Human Services (HHS), that are commonly used in Canada and include recommendations for newly commercialized therapies. METHODS: The Canadian Perinatal HIV Surveillance Program (CPHSP) captures annual medical data on mothers living with HIV and their infants from 23 sites across Canada. Women from this cohort who received an ARV treatment during pregnancy and who gave birth between 2004 and 2020 were included in the study. ARV treatments were designated as 'preferred/alternative' as per HHS HIV perinatal guidelines, or 'other than preferred/alternative'. RESULTS: We identified 3673 pregnancies from 2720 women. The proportion of women that conceived while on ARV treatment increased from 29% in 2003 to 90% in 2020. Other than preferred/alternative ARV treatments were received in 1112 (30%) of pregnancies and this was significantly associated with having initiated ARV treatment before conception. CONCLUSION: In Canada during the study period, a high number of women were prescribed an other than preferred/alternative ARV treatment during pregnancy. Further optimization of ARV treatment in women of childbearing age living with HIV is warranted.

Is Cabergoline Safe and Effective for Postpartum Lactation Inhibition? A Systematic Review.

BACKGROUND: Despite its benefits, there are some situations where breastfeeding is impossible or not recommended. Breast milk secretion and engorgement can be distressing to these non-breastfeeding women. There is currently no universal guideline on the most appropriate management for these women. Our objective is to evaluate the effectiveness and safety of cabergoline, a dopamine agonist, in lactation inhibition in postpartum women. METHODS: Studies were identified through electronic database searching (Cochrane library, EMBASE, Medline, IPA and Scopus) to identify all relevant studies that evaluated the use of cabergoline as a lactation inhibitor in postpartum women. Citations were screened and a narrative synthesis was undertaken given the heterogeneity of study designs. RESULTS: A total of six randomized trials met the inclusion criteria. Majority of the studies recruited healthy postpartum women electing for lactation inhibition for personal reasons. A range of 0.4 mg to 1 mg of cabergoline was given within 0 to 50 hrs of delivery. Dose-response relationship is established, and the highest rate of complete success was achieved with 1 mg of cabergoline, with time to cessation between 0 and 1 day. Cabergoline is non-inferior to bromocriptine for lactation inhibition while also associated with fewer rebound symptoms and adverse effects. Commonly reported adverse effects of cabergoline (eg, dizziness, headache and nausea) are self-limited. CONCLUSION: Cabergoline is simple, effective and generally safe when given to postpartum women either wishing or needing to suppress lactation. Further research is needed to improve postpartum care of these women.

Cabergoline: a review of its use in the inhibition of lactation for women living with HIV.

INTRODUCTION: In developed countries, breastfeeding is not recommended for women living with human immunodeficiency virus (WLWH). However, lactation symptoms can be distressing for women who choose not to breastfeed. There is currently no universal guideline on the most appropriate options for prevention or reduction of lactation symptoms amongst WLWH. This review describes the evidence base for using cabergoline, a dopaminergic agonist, for the post-partum inhibition of lactation for WLWH. METHODS: A scoping review of post-partum pharmaceutical lactation inhibition specific for WLWH was conducted using searches in PubMed, Medline Ovid, EBM Reviews Ovid, Embase, Web of Science and Scopus until 2019. A narrative review of cabergoline pharmacologic properties, therapeutic efficacy, tolerability data and drug interaction data relevant to lactation inhibition was then conducted. RESULTS AND DISCUSSION: Among 1366 articles, the scoping review identified 13 relevant publications. Eight guidelines providing guidance regarding lactation inhibition for WLWH and two surveys of medical practice on this topic in UK have been published. Three studies have evaluated the use of pharmaceutical agents in WLWH. Two of these studies evaluated cabergoline and reported it to be an effective method of lactation inhibition in this population. The third study evaluated ethinyl estradiol and bromocriptine use and showed poor efficacy. Cabergoline is a long-acting dopamine D2 agonist and ergot derivative that inhibits prolactin secretion and suppresses physiologic lactation when given as a single oral dose of 1 mg after delivery. Cabergoline is at least as effective as bromocriptine for lactation inhibition with success rates between 78% and 100%. Transient, mild to moderate adverse events to cabergoline are described in clinical trials. Few drug interactions exist as cabergoline is neither a substrate nor an inducer/inhibitor of hepatic cytochrome P450 isoenzymes. There are no reported clinically significant drug-drug interactions between cabergoline and any antiretroviral medications including protease inhibitors. CONCLUSIONS: Cabergoline is a safe and effective pharmacologic option for the prevention of physiological lactation and associated physical symptoms in non-breastfeeding women. Future studies should focus on its safety, efficacy and acceptability among WLWH.

Intramuscular olanzapine in the management of acute agitation.

OBJECTIVE: To review the current efficacy and safety evidence for the use of intramuscular olanzapine in the management of acute agitation. DATA SOURCES: MEDLINE, EMBASE, and PubMed (all to March 2004) were searched for full-text, English-language publications in humans. Search terms included olanzapine, psychosis, agitation, psychiatric emergency, and intramuscular. STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized, controlled trials that evaluated efficacy or safety endpoints of intramuscular olanzapine in the management of acute agitation were included. All studies were evaluated independently by both authors. For clinical outcomes (efficacy, safety), the definitions as specified by each study were used. DATA SYNTHESIS: Four prospective trials were included in this review. Intramuscular olanzapine is comparable to haloperidol or lorazepam monotherapy in managing acute agitation associated with schizophrenia and dementia. Intramuscular olanzapine is superior to lorazepam monotherapy in the management of agitation associated with bipolar affective disorder. Preliminary evidence demonstrates that intramuscular olanzapine is associated with fewer adverse movement disorders than monotherapy with intramuscular haloperidol. Interpretation of published evidence is limited by confounding factors of comparator regimens and the patient populations studied. CONCLUSIONS: Additional studies comparing intramuscular olanzapine with combination antipsychotic/benzodiazepine therapy in more severely ill patients and patients with concomitant medical illnesses are needed to determine the most effective dosing regimen, use of adjunctive medications, and to obtain a comprehensive safety profile.