In this episode, I’ll discuss whether the sugammadex-contraceptive interaction is being adequately considered in practice.
Sugammadex is a γ-cyclodextrin that was designed to bind rocuronium and vecuronium for the purpose of reversing paralysis from these neuromuscular blocking medications. The prescribing information includes information that sugammadex may interfere with the effectiveness of hormonal contraceptives. In vitro studies suggest that sugammadex may bind to progesterone, and therefore lower the free plasma concentrations.
Both rocuronium and vecuronium are steroid-based neuromuscular blockers, and progesterone is a steroid-based molecule. Therefore it makes sense that sugammadex would bind progesterone the same way it binds rocuronium or vecuronium and cause this interaction.
A recent survey, published in Anaesthesia and Analgesia was distributed to anesthesiology providers at a large, tertiary-care medical center.
155 surveys were completed and while all but one respondent recognized the potential for sugammadex interference with oral hormonal contraception, only about half recognized that the issue could also occur with other hormonal contraceptives like intrauterine devices and contraceptive implants. Furthermore, the survey found that:
…many respondents reported “rarely/never” having discussed this drug interaction with patients in actual clinical practice, either preoperatively (67%) or postoperatively (80%). Furthermore, most respondents (79%) reported “rarely/never” administering neostigmine to intentionally avoid this drug interaction.
This is a single-center survey and the result may not be generalizable to all institutions. However, it does raise the possibility that the extent of the sugammadex-contraceptive interaction is not fully known by anesthesia providers and that education and systems may need to be put into place to mitigate this interaction. Pharmacists may wish to investigate the extent of their local anesthesia provider’s knowledge and processes regarding this interaction and assist as needed.
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