***The following perspective is of HG Pharmacist and not of any organization or association in which she is affiliated or employed.
How do doctors decide what medication to prescribe to pregnant women for nausea and vomiting?
After working with hundreds of women around the world suffering from Hyperemesis Gravidarum (HG), extreme nausea and vomiting during pregnancy, I have seen the standard of care vary greatly. The differences could even be among providers in the same practice! Other disease states have guidelines based on clinical studies compiled by overarching associations, yet there are only limited studies in HG comparing one medication against another, and while these medications may work or may have a better safety profile, there are no FDA approved medications for HG, and the ones that are used either are not effective or may have adverse effects that outweigh the benefits. So how do doctors* decide what medications to prescribe to women suffering from hyperemesis gravidarum?
In the United States, obstetricians follow the guidelines written by American College of Obstetricians and Gynecologists (ACOG). The algorithm, from what I can tell, is done by safest medications, which are not necessarily the most effective, and some of their information is flat out false. For example, their site says, “Safe and effective treatments are available for more severe cases, and mild cases of nausea and vomiting of pregnancy may be resolved with lifestyle and dietary changes. The woman’s perception of the severity of her symptoms plays a critical role in the decision of whether, when, and how to treat nausea and vomiting of pregnancy.”
- https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/01/nausea-and-vomiting-of-pregnancy
I do not know any treatments that are safe AND effective for severe cases, and to say a woman’s perception of her severity plays a critical role…Show me the data to back this please! To some degree, all treatment depends on the patient’s perception of the severity of the disease, but that’s not written into any guidelines by experts. I couldn’t imagine saying this about any other disease state.
With expert information like this, it’s no wonder that treatments vary and are, for the most part, completely lacking appropriate therapy.
What should happen?
In an ideal world, medications are prescribed:
- Based on DNA using pharmacogenetics
- A complete medication reconciliation is done to determine the best route, dose and duration of each medication for the patient
- On clinically tested and peer reviewed guidelines that are updated as new medications become available
- Considering the patient’s finances, to include what costs insurances will cover and what will be paid out of pocket.
- Doctors would be willing to prescribe home health early on in the pregnancy, so that the mom with HG would have easy access to IV therapy and potentially keep her job and her ability to take care of other children, opposed to leaving her at the mercy of repeat visits to emergency rooms, being cared for by practitioners trained in acute, not chronic malnutrition, who do not treat pregnancy sickness as a life altering disease state, and who often limit or completely miss sending the patient home with outpatient medications
- A woman would be believed about the severity of her disease, and she would not have to take a patient advocate to each visit
What really happens?
- Insurance formularies dictate prescribing and medication limits.
- Meager guidelines
- Practitioner education, training and personal experiences determine which medications are prescribed
***There are problems with this reality:
- Many effective medications are not on insurance’s lower tier formularies. For example, granistetron (Sancuso) patch
- The current ACOG guidelines are based on safety not effectiveness and do not cover the depth of disease state, and for the most part, only obstetricians, not all the other practitioners I mentioned above, would have access to ACOG’s journals which publish the guidelines
- Few practitioners are thoroughly training in treating Hyperemesis Gravidarum
- Many prescribers are withholding medications based on outdated information
- Many effective medications are not available in different areas
Until HG gets funding for researchers and have guidelines based on peer revised clinical trials, the best algorithm available is that written by the HER Foundation. (In full disclosure, I was part of this creation.).
If you are suffering with HG:
- Please follow these guidelines until you find a combination where the benefits outweigh the risks
- Be aware of what adverse effects may happen and proactive treating preventative ones. For example, doxylamine causes drowsiness, ondansetron causes constipation and compazine depletes scopolamine
- Note the medications missing from the algorithm. For example, while scopolamine works great for someone going on a cruise ship, and may help with ptyalism, it dries out the body and often causes more harm than good. Others, like gabapentin and cannabis, are waiting for more studies to prove their safety.
- Discuss with your providers the third line and experimental medications including steroids and mirtazapine. Often these are more effective but less common.
- Be comfortable asking your pharmacist about interactions and possible adverse effects. If you have headaches, pain behind your eyes, blinking eyelids, shaking or rocking that you can’t control, then it might be time to take a look at your mediation algorithm and nutrient depletion.
- If a medication is not working, ask your provider how to stop it. I often see women prescribed Diclegis in the beginning of a pregnancy, and although they continue to get worse, they stay on the combination the entire nine months. Before you discontinue a medication, however, ask if you are on the maximum daily dose. I have seen many women say that ondansetron did not work for them, only to find out they were taking 4 mg three times daily.
- If you cannot afford a medication, ask about alternate ways to have access to it. For example:
- Some medications require a doctor’s office to complete a prior authorization to prove the patient failed the cheaper alternative
- Some pharmaceutical companies have patient assistance programs
- Some medications have cheaper generic options
- Medication prices may vary depending on how the pharmacy has priced the medication or which pharmacy is preferred on an insurance formulary
Final thoughts:
- Call your insurance to see how to arrange home health. Often, the insurance company will then contact your doctor’s office to set it up.
- If you are told that there is nothing more that can be done to help you, know this is not true. If you have truly gone down every medication option on the HER Foundation algorithm, you should be getting IV nutrition.
- If you are getting total parenteral nutrition (TPN) outpatient, ask if a hospital pharmacist can look over the formula. I have seen too many situations where the patient’s TPN given through home health caused more harm than good due to incorrect formulas.
- If you feel your disease is not being taken seriously, educate your provider on HG and how to treat it. Resources are available at www.hyperemesis.org/tools. If your provider will not listen, look into getting a new provider.
- Continue to speak up and reach out for help until your quality of life has resumed. Never suffer alone!
Note that in today’s medical world, the term “Doctor” is a catch all for a variety of health care professionals. It’s often incorrectly used to refer to anyone an HG sufferer may see for medical advice. These practitioners include a midwife, physician assistant (PA), nurse practitioner (NP), advanced practice registered nurse (APRN), if in a military environment then a corpsman or independent duty corpsman (IDC), or any other of the many types of of licensed healthcare professionals (HCP). All of these HCPs have been trained differently and their understanding of NVP, from morning sickness to HG, varies dramatically. Even when the HCP has a doctorate in medicine, to include obstetricians, Medical Fetal Management specialists, emergency room doctors… their degree and specialty determines their view on treating nausea and vomiting during pregnancy and method of practice, therefore impacting which medications they may prescribe to the pregnant patient.
