utorak, 24. ožujka 2015.

LIJEKOVI U TRUDNOĆI !!! DRUGS IN PREGNANCY !!!



Oprez s lijekovima u trudnoći!!!

Istraživanja u SAD-u pokazuju da trudnica,uprkos rizicima, prosječno uzima tri lijeka, neke iz slobodne prodaje, neke propisane

Trudnoća je period u kojem posebno treba biti oprezan s lijekovima, jer za trudnicu lijek može biti dvostruko opasan. Može joj ugroziti zdravlje i utjecati na sposobnost da trudnoću iznese do kraja. Uz to, uvijek treba imati na umu mogućnost štetna učinka lijeka na plod, jer preko posteljice može dospjeti do još nerođena djeteta i utjecati na tok njegova razvoja.
Budući da više od 50% trudnoća nije planirano, postoji mogućnost izlaganja štetnom djelovanju lijeka i u razdoblju kad žena još ne zna da je u drugom stanju. Od 10. do 15. dana nakon oplodnje, u stadiju intenzivna dijeljenja oplođene jajne stanica prije ugnježđivanja u maternicu, embrion reagira po načelu "sve ili ništa", što znači da postoji vrlo velika mogućnost njegova propadanja. Najopasnije razdoblje za nepovoljan utjecaj lijekova je prvi trimestar trudnoće (od 3. do 10. sedmice), tj. u razdoblju organogeneze, kad se stvaraju razvojne osnove organa. Djelovanje lijekova tada može izmijeniti način oblikovanja, djeljenja i migracije neurona, njihovu sposobnost prepoznavanja svojih pravih odredišta u mozgu koji raste ili njihovo povezivanja s drugim neuronima.

Tipične posljedice teratogeneze (pogrešaka u razvoju) mogu se u krajnjoj mjeri manifestirati smrću fetusa ili zastojem rasta, nepravilnim razvojem organa, kao i razvojem karcinoma poslije u životu. Mehanizam teratogenog učinka nije potpuno jasan i vjerojatno je uzrokovan brojnim faktorima. Lijekovi mogu imati i posredan utjecaj na fetus, tj. ometati prenos kisika i hranjivih tvari u fetus, ali i izravno uticati na procese diferencijacije u fetalnom krvotoku.
Opasnost uzimanja lijekova ne prestaje ni nakon prvog trimestra trudnoće. Primjerice, neki antibiotici mogu oštetiti stanice unutarnjeg uha (a s njima sluh i ravnotežu), koje su se u prvom trimestru savršeno oblikovale. Jedna je od čestih komplikacija i povećanje mogućnosti preranog poroda (čak i do šest sedmica prije predviđenoga termina). Ako se zna da je majka tokom trudnoće uzimala (uzima) potencijalno štetne lijekove, razvoj ploda mora se pratiti češćim kontrolama i ultrazvukom.
Lijekovi u trudnoći, dakle, mogu izazvati ozbiljan problem, pa u pravilu treba izbjegavati njihovo svako suvišno i nekritično uzimanje zbog mogućeg, nedovoljno istraženoga, nepovoljnog uticaja na plod.

SPOZNAJE NE SEŽU DALEKO U PROŠLOST

Da lijekovi mogu biti izrazito štetni u trudnoći, doznalo se početkom 60-ih godina prošlog stoljeća, kad je trudnicama vrlo često bio propisivan lijek talidomid za smirenje i spriječavanje jutarnje mučnine. Zbog njegove upotrebe veliki broj djece rodio se s nerazvijenim ekstremitetima ili oštećenjima drugih organa. Od tada se lijekovi trudnicama propisuju uz veliki oprez i mnogo se pozornije pristupa praćenju nuspojava do kojih mogu dovesti. Za mnoge lijekove nema sigurnih podataka o njihovu djelovanju u trudnoći, s obzirom na to da klinički pokusi nisu dopušteni na trudnicama. S toga možemo samo nagađati kako lijekovi djeluju na trudnice, ali ne i pouzdano tvrditi. No, stavovi liječnika o tom pitanju nisu usuglašeni. Dok neki praktički izbjegavaju propisivanje bilo kakva lijeka trudnici, drugi se drže principa "da se lijek može propisati trudnici ako je korist veća od potencijalnog rizika".

Na osnovu do sad stečenih spoznaja, lijekovi su po FDA klasifikaciji (American Food and Drug Association - Američka uprava za hranu i lijekove) svrstani u pet kategorija rizika, počevši od kategorije A koja se smatra najmanje štetnom, do kategorije X koja je potpuno kontraindicirana u trudnoći.

FDA TABLICA RIZIKA

kategorija A: kontrolirana ispitivanja na životinjama nisu pokazala štetne učinke na plod - lijekovi se smiju upotrebljavati u trudnoći

kategorija B: nema pouzdanih podataka o štetnosti - ne preporučuje se primjena u trudnoći

kategorija C: ispitivanja na životinjama pokazala su štetne učinke - primjenjuju se u trudnoći jedino ako je procijenjena korist za majku veća od rizika za plod

kategorija D: postoje podaci o štetnim učincima na plod - primjenjuju se samo u akutnim, hitnim slučajevima kad je ugrožen život majke

kategorija X: ispitivanja su pokazala štetne učinke - takvi lijekovi su kontraindicirani u trudnoći.

LIJEKOVI S UTICAJEM NA RAZVOJ DJETETA U TRUDNOĆI

Lijekovi za liječenje epilepsije (od kojih većina spada u kategoriju rizika D) - Trudnice s epilepsijom čine 0,5 posto svih trudnica i uz odgovarajuću liječničku skrb njih više od 95% bilježi povoljan ishod trudnoće.
Antipsihotici, antidepresivi, litij - Najčešće spadaju u C i B kategoriju rizika, zbog čega je potrebno češće praćenje ultrazvukom trudnica koje su uzimale te lijekove.
Lijekovi za liječenje povišenoga krvnog pritiska - Iz ove grupe lijekova apsolutno su kontraindicirani ACE inhibitori i antagonisti AT1 receptora, a vrlo je upitan i učinak beta-blokatora, kalcij antagonista i diuretika.
Lijekovi za liječenje akni (retinoidi) - Apsolutno su kontraindicirani u trudnoći. Liječenje njima počinje nakon menstruacije, uz negativan test na trudnoću i dvije vrste kontracepcije, te uz mjesečno ponavljanje testa na trudnoću.
Lijekovi za liječenje poremećaja štitnjače - Iako spadaju u kategoriju D, moraju se primjenjivati jer sama hipertiroza (pojačana funkcija štitnjače) ima veću učestalost malformacija nego navedeni lijekovi.
Antimikotici - Grizeofulvin je, primjerice, apsolutno kontraindiciran u trudnoći. U slučaju gljivičnog oboljenja, preporučuje se lokalna terapija i sve češće lokalni antiseptik na bazi oktenidina (koji se ne resorbira preko kože ili sluznice).
Analgetici - Neki nesteroidni antireumatici (diklofenak, ibuprofen, ketoprofen, piroksikam) imaju kategoriju B u prvom i drugom trimestru trudnoće, a u trećem spadaju u kategoriju rizika D i nikako se ne smiju upotrebljavati. U trudnoći se preporučuje upotreba paracetamola koji spada u grupu rizika B.
Antibiotici:
- Tetraciklini i aminoglikozidi spadaju u kategoriju rizika D i ne smiju se upotrebljavati u trudnoći.
- Kloramfenikol, ciprofloksacin, klaritromicin, trimetoprim, kotrimoksazol i vankomicin u kategoriji su rizika C i smiju se davati samo ako potencijalna korist opravdava mogući rizik za fetus.
- Penicilini, klindamicin, metronidazol, eritromicin i azitromicin spadaju u kategoriju rizika B, što znači da se mogu upotrebljavati tijekom trudnoće.
Citostatici - Kontraindicirani su u tudnoći.

OPREZA NIKAD DOSTA

Istraživanja provedena u SAD-u pokazuju da, uprkos rizicima, trudnica prosječno uzima tri lijeka, neke iz slobodne prodaje, neke propisane, koji imaju potencijal da izmijene ćelije i njihovo funkcioniranje u fetusu te dovedu do usporenog rasta, malformacija ili oštećenja. Zanimljivo je još jedno zapažanje - da trudnice češće uzimaju lijekove iz slobodne prodaje nego propisane?! Opće je prihvaćeno da su sigurniji preparati prirodnog porijekla pa se biljni pripravci uzimaju nekritički. No, i u tom slučaju korisno je potražiti savjet liječnika. Slučaj iz SAD-a govori o uporabi Caullophyllum thallictroiides (engl. Blue cohosh), biljke koja raste u Sjevernoj Americi i tradicionalno se propisuje ženama u trudnoći. Potkraj devedesetih godina opisan je slučaj žene čije je dijete netom nakon rođenja imalo ozbiljne probleme u radu kardiovaskularnog sistema, a koji su bili izravna posljedica majčina uzimanja tradicionalnog biljnog pripravka za trudnice.

S toga tokom trudnoće treba uzimati samo lijekove koji su se pokazali neškodljivima, i to u najmanjoj djelotvornoj dozi. U svakom slučaju, nemojte pribjegavati samoliječenju i obavezno se posavjetujte s ginekologom koji prati vašu trudnoću o problemima koji vas muče i o tome što vam je u određenom slučaju dopušteno, a što nije. Uvijek imajte na umu da više niste sami, i da morate misliti ne samo na sebe nego i na svoju još nerođenu bebu.






Caution with drugs in pregnancy !!!

Studies in the US have shown that pregnant women, despite the risks, on average takes three drugs, some of the free sale, some prescribed

Pregnancy is a period in which especially should be careful with drugs, because drug for a pregnant woman can be doubly dangerous. He may endanger health and affect the ability to present by the end of pregnancy. In addition, you should always bear in mind the possibility of harmful effects of the drug on the fetus because the placenta can reach the unborn child and affect the course of its development.
Since more than 50% of pregnancies are not planned, there is a possibility of exposure to damaging effects of the drug in the period when a woman does not know that she was pregnant. From 10 to 15 days after fertilization, at the stage of intensive sharing of fertilized egg cells before implantation in the uterus, the embryo reacts according to the principle "all or nothing", which means that there is a very high possibility of its deterioration. The most dangerous period for the adverse effect of drugs for the first trimester of pregnancy (from 3 to 10 weeks), ie. the period of organogenesis, when creating developmental basis organs. Effects of drugs can then change the way we design, sharing and migration of neurons, their ability to recognize their real destination in the brain that grows or their connections with other neurons.

Typical consequences of teratogenicity (errors in development) can they ultimately manifest fetal death or growth retardation, abnormal development of organs, as well as the development of cancer later in life. The mechanism of teratogenic activity is not completely clear and is probably caused by a number of factors. Medications can also have an indirect effect on the fetus, ie. interfere with the transfer of oxygen and nutrients to the fetus, but also directly affect the processes of differentiation in the fetal bloodstream.
Risk taking medication does not stop even after the first trimester of pregnancy. For example, some antibiotics can damage the cells of the inner ear (and with them hearing and balance), which were in the first trimester perfectly shaped. One of the frequent complications and increase the likelihood of premature birth (up to six weeks before the due date). If it is known that the mother during pregnancy took (take) potentially harmful drugs, fetal development must be monitored more frequent controls and ultrasound.
Drugs in pregnancy, therefore, can cause a serious problem, but as a rule should avoid any excessive and their indiscriminate use because of the potential, under-researched, adverse effects on the fetus.

Knowledge does not existed for years

That drugs can be extremely harmful in pregnancy, it was learned early 60s of last century, when the pregnant women often been prescribed the drug thalidomide to calm and prevent morning sickness. Due to its use of a large number of children born with underdeveloped limbs or damage other organs. Since then, the drugs prescribed to pregnant women with great caution and much more attentive approach to monitoring the side effects they can lead. For many drugs can not be sure about their activities during pregnancy, due to the fact that clinical trials are not allowed in pregnant women. Thus, we can only guess how drugs work in pregnant women, but not say for certain. But the attitudes of doctors on this issue have not been harmonized. While some practically avoid prescribing any medication pregnant woman, another held the principle "that the drug may be prescribed by a pregnant woman if the benefit outweighs the potential risk."

On the basis of so far acquired knowledge, drugs are FDA classification (American Food and Drug Association - The US Food and Drug Administration) classified into five risk categories, ranging from category A, which is considered the least damaging to the category X, which is totally contraindicated in pregnancy.

FDA TABLE OF RISK

Category A: Controlled studies in animals have revealed adverse effects on the fetus - drugs may be used in pregnancy

Category B: there is no reliable data on the harmful effects - not recommended for use during pregnancy

category C: studies in animals have shown adverse effects - are used in pregnancy only if the estimated benefit to the mother outweighs the risk to the fetus

Category D: There are no data on the harmful effects on the fetus - apply only in acute, urgent cases when the mother's life is threatened

Category X: studies have shown adverse effects - such drugs are contraindicated in pregnancy.

DRUGS WITH THE INFLUENCE ON THE DEVELOPMENT OF A CHILD IN PREGNANCY

Drugs for treatment of epilepsy (most of which falls into the category of risk D) - Pregnant women with epilepsy accounted for 0.5 percent of all pregnant women and the appropriate medical care of them more than 95% reported favorable outcomes.
Antipsychotics, antidepressants, lithium - Most belong to the C and B risk category, indicating a need for more frequent ultrasound monitoring of pregnant women who were taking these drugs.
Drugs for the treatment of high blood pressure - from this group of drugs are absolutely contraindicated ACE inhibitors and AT1 receptor antagonists and it is questionable and the effect of beta-blockers, calcium antagonists and diuretics.
Drugs for treatment of acne (retinoids) - They are absolutely contraindicated in pregnancy. Treating them begins after menstruation, with negative pregnancy test and two types of contraception, and with monthly repeat pregnancy test.
Drugs for the treatment of thyroid disorders - Although falling in category D, must be administered alone as hyperthyroidism (increased thyroid function) has a higher frequency than said drugs malformations.
Antifungals - Griseofulvin is, for example, is absolutely contraindicated in pregnancy. In the case of fungal diseases, recommended local therapy and increasingly local antiseptic based on octenidine (which is not absorbed through the skin or mucous membranes).
Analgesics - Some non-steroidal antirheumatic drugs (diclofenac, ibuprofen, ketoprofen, piroxicam) have category B in the first and second trimester of pregnancy, and in the third fall into the category D risk and can not be used. In pregnancy the recommended use of paracetamol which belongs to the group of risk B.
Antibiotics:
- Tetracyclines and aminoglycosides fall into the category D risk and may not be used in pregnancy.
- Chloramphenicol, ciprofloxacin, clarithromycin, trimethoprim, cotrimoxazole and vancomycin in the category of risk C and not be given only if the potential benefit justifies the potential risk to the fetus.
- Penicillin, clindamycin, metronidazole, erythromycin and azithromycin are in risk category B, which means that it can be used during pregnancy.
Cytostatics - are contraindicated in getting pregnant.

Never be too careful

Studies conducted in the US show that, despite the risks, pregnant women take an average of three drugs, some of the free sale, some prescribed, which have the potential to alter the cells and their function in the fetus and lead to slow growth, malformation or damage. Interestingly, another observation - that pregnant women more frequently take drugs from the free sales than prescribed ?! It is generally accepted that they are safer preparations of natural origin and the herbal preparations taken uncritically. But in this case it is useful to consult a doctor. The case of the United States discusses the use Caullophyllum thallictroiides (Eng. Blue cohosh), a plant that grows in North America and is traditionally prescribed to women during pregnancy. At the end of the nineties described the case of a woman whose child just after birth have serious problems in the work of the cardiovascular system, which were a direct result of the mother's intake of traditional herbal preparation for pregnant women.

Therefore, during pregnancy should be taken only medicines that have proved harmless, and that the lowest effective dose. In any case, do not resort to self-treatment and sure to consult with a gynecologist who follows your pregnancy about the problems that you struggle and how you in a particular case is allowed and what is not. Always remember that you are not alone, and that you have to think not only of themselves but also to their unborn baby.