When your doctor prescribed you Lipitor, he or she probably told you not to take it with grapefruit juice. But did he or she tell you not to get pregnant? According to a new study, your chances of hearing the latter are approximately 50/50. Which is a problem, given that Lipitor — or, more to the point, the class of drugs it belongs to — carries a risk of causing birth defects.
The report, published in the current Annals of Internal Medicine, studied nearly 500,000 women of childbearing age who filled about 1 million prescriptions through Kaiser Permanente of Northern California. One in six got at least one prescription for a class D or X drug, those that may carry birth defect risks. (According to Food and Drug Administration categories, classes A and B carry no evidence of harm to pregnancies, class C has insufficient evidence either way, class D — e.g., antidepressants and cancer drugs — may be taken if the benefits outweigh the risks, and class X, including thalidomide and cholesterol-lowering drugs, is out of the question.)
But according to the study, the women prescribed class D and class X drugs were no more likely than the others to receive pregnancy counseling or use contraception. Among women taking high-risk drugs, 48 percent appeared to get no guidance from their doctors, compared with 47 percent for those taking drugs considered safe. (It’s not clear what sort of pregnancy counseling that group should be getting.) Forty-eight percent is a lot, especially considering that half of pregnancies are unplanned.
There is one caveat: The data comes from health plan billing codes, which are not as detailed as medical charts. In other words, a doctor could have said, “By the way, are you on the Pill?” but not coded it in his or her records. The actual results here, therefore, may overestimate the problem. Still, the results do echo earlier findings, which concluded, alarmingly, “Physician awareness of the teratogenic risk associated with class D or X medications seems low.”
It’s interesting to note that when it comes to prescribing drugs to women of childbearing age, there seems to be no Accutane effect across the board. Women taking Accutane (isotretinoin, or a generic version of same) for acne are required to use birth control and “pass” a pregnancy test before each refill, as well as enroll in a national registry. Of course, such measures may be extreme for drugs with lower risks — many women and their doctors, for example, decide that the risks of depression during pregnancy outweigh those of taking antidepressants — but it’s curious to observe the gulf between such stringent precautions and, well, none at all. Especially considering that patients receiving class X statins had the lowest rate of contraceptive counseling.
(It’s also interesting to note that, in a perversely refreshing sense, the medical community as depicted here seems to be out of step with the paternalistic/fetus-first attitudes toward women we’ve seen elsewhere.)
Of course, these apparent lapses likely have little to do with women themselves and much to do with the current wham-bam-thank-you (“That’ll be $350″) healthcare climate. “My concern is that primary-care health-care providers are under such pressure to move patients through their offices, that contraception counseling related to this prescribing is being overlooked or not considered,” Robert Welch, chairman of obstetrics and gynecology at St. John Providence Hospital in Southfield, Mich., told ABC. “This is a highly significant problem.” Which also means, of course, that there may be a whole lot of things doctors aren’t telling a whole lot of people. Sure, we should (ideally) know what to ask, and there’s always Dr. Google, but still.
The study’s authors make clear that they’re not demonizing drugs, just saying “talk to your doctor.” As Eleanor Schwarz, M.D., said, “There isn’t a right or a wrong answer here.” Schwarz added, “What is an acceptable risk to one woman might be unacceptable to another woman. [Doctors] should get a sense of what the goals are.”