USE OF VORTIOXETINE IN PREGNANCY

Vortioxetine is a novel multimodal antidepressant of the bisarylsulfonyl amine class. Vortioxetine acts as a serotonin reuptake inhibitor as well as being active at a number of serotonergic receptors. In addition, vortioxetine administration has been reported to increase the efflux of norepinephrine, dopamine and acetylcholine. Vortioxetine is used in the treatment of major depressive episodes.

Data regarding gestational exposure to vortioxetine are limited, and although there is currently no good evidence of an association between gestational exposure to vortioxetine and miscarriage, congenital malformation, intrauterine death, low birth weight or preterm delivery, an increased risk cannot be excluded. There are no data regarding neurodevelopment following gestational vortioxetine exposure.

There are no data regarding neonatal complications following gestational exposure to vortioxetine. Due to the mechanism of action, neonatal complications may theoretically be similar to those observed following exposure to selective serotonin reuptake inhibitors (SSRIs), which include respiratory problems, low Apgar score and convulsions. Use of centrally acting drugs throughout pregnancy or around the time of delivery is associated with an increased risk of poor neonatal adaptation syndrome (PNAS).

Gestational SSRI exposure is associated with a small increased risk (<0.4% vs. 0.1 to 0.2%) of persistent pulmonary hypertension of the newborn (PPHN). Vortioxetine has a similar mechanism of action to the SSRIs and there are theoretical concerns that gestational vortioxetine exposure could also increase the risk of PPHN. Although there are no published data which identify an association between gestational exposure to vortioxetine and PPHN, the available data are insufficient to disprove this theory and an increased risk of PPHN cannot be excluded, although the absolute risk is likely to be low. As PPHN is potentially serious, this should be discussed with women considering vortioxetine use in pregnancy.

The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that there is a small overall increased risk of postpartum haemorrhage (PPH) attributable to SSRI/selective noradrenaline reuptake inhibitor (SNRI) use in the month prior to delivery, but this risk may be higher in women with other risk factors for abnormal bleeding. Although no studies have investigated an association between vortioxetine and PPH, as vortioxetine has a similar mechanism of action to the SSRIs, there are theoretical concerns that gestational vortioxetine exposure could increase the risk of PPH. Careful assessment of the risk of PPH versus the risk of maternal relapse should the medication be discontinued is advised when considering continued use in late pregnancy. Prescribers are also encouraged to ensure maternal compliance with heparin self-administration in all pregnant women with risk factors for venous thromboembolism.

It is important to ensure that mental health conditions are treated appropriately. As such, vortioxetine may be suitable for use in pregnancy following an individualised assessment of the risks and benefits. Where clinically appropriate, non-pharmaceutical management of depression and/or anxiety could be considered during pregnancy. However, where a patient is stabilised on vortioxetine, either prior to conception or during pregnancy, the risk of discontinuing treatment, changing the medication, or reducing the dose should be carefully weighed against the risk of maternal relapse. In cases where treatment with vortioxetine is continued in pregnancy, the lowest effective dose should be used.