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| SSRi use during pregnancy |
What is Intensive Care?
Intensive care units (ICU), also called critical care or intensive therapy departments, are sections within a hospital that look after patients whose conditions are life-threatening and need constant, close monitoring and support from equipment and medication to keep normal body functions going. [1]
The British flagship programme Panorama is stirring the pot again, this time, it seems, it's siding with those who warn against the use of SSRi type medications in pregnant mothers.
Good for them.
I've highlighted SSRi birth defects on this blog many times, particularly paroxetine birth defects. It now seems a given that paroxetine, commonly known as Seroxat in the UK, Paxil in the states and Aropax in the Southern Hemisphere, can cause birth defects. But what about the other group of SSRis?
We, as consumers, constantly hear that the jury is out on their safety during pregancy and that doctors have to weigh up the risk/benefit ratio before prescribing.
This is classic pharmaceutical deflection and, dare I say it, medicine regulator deflection too.
Who is ultimately responsible here, the pharmaceutical company that make the product that can harm unborn children, the limp-wristed regulators who are supposed to regulate the drugs consumers take or the doctors who prescribe the drugs?
Personally, I believe it's the manufacturer who should be held accountable, there are many who take a different viewpoint, all valid views I might add.
Let's say you have fallen pregnant and you are feeling down. You go to your doctor and he, after apparently weighing up the risk/benefit offers you an antidepressant from the SSRi family. He tells you that untreated depression may harm your child and using an SSRi will therefore work to protect the child.
It's ridiculous when you think about that kind of statement. Its a statement that ignores the fact that 'depression' (sadness arising from negative life events or circumstances) can be treated by addressing the social factors causing it rather than by prescribing drugs that cause birth defects.
Let's say our subject is depressed because her employers have told her that there are going to be job cuts. She, like most, would worry. Because she is pregnant she'd probably worry more. How can I now afford to look after my child?
Pharmaceutical companies, regulators and doctors will have you believe that our subject is passing on her concerns to her unborn child. It's the selling point and one that is cruel and heartless. I don't think there is any doubt that having a mother who is scared, stressed, sad etc has a negative impact on a baby but surely that suggests doctors should be providing support to remove or cope with the stressors not prescribing drugs that they do not deny carry a risk. There are no risks associated with joining a new mothers coffee group, getting budget advice, seeking the support of friends, family or social service organisations and if the root causes of the distress are dealt with, huge benefits for both mother and baby. This approach surely has a better risk/benefit profile than prescribing antidepressants but of course doesn't come with the rewards to doctors from big pharma that prescribing does. Nor is it able to be provided in a 15 minute appointment which maximises profit for the doctor's business.
BBC Panorama spoke to eight mothers whose babies came into this world with serious heart defects. All eight mothers were taking SSRi medication during the course of their pregnancy. We are expected to believe that this is just a coincidence.
Babies are born with defects all the time and this really has nothing to do with what the mothers ingest... unless of course the mothers have been smoking, drinking alcohol or taking illegal substances during their term.
Yup, blame everything but the drug that is prescribed widely, right?
So, let's assume that our subject weighs up the risk/benefits herself and decides that taking an SSRi would increase the risk to her unborn child. But our subject is a smoker and want to quit... she has tried many times but just can't kick the habit.
Her doctor, once again, has a drug that can help her. Once again he has to weigh up the risk against the benefits. Chantix [also known as Champix] can, according to its manufacturer Pfizer, help anyone quit smoking. Zyban [also known as Wellbutrin] can, according to its manufacturers, GlaxoSmithKline, also help you quit smoking.
Your unborn child is, women are told, more at risk if you continue to smoke. This maybe true but both Chantix and Zyban, the latter being an antidepressant rebadged by GlaxoSmithKline, can also cause serious abnormalities in babies.
So, where do the regulators come in?
The UK medicines regulator, the MHRA, made recommendations back in early 2000 that SSRis should not be prescribed to children or teenagers. They did this because they had reviewed the evidence and found that there was no benefit in this population taking SSRis. In fact the evidence showed that there was an increased risk of suicidal thinking while this age group was taking an SSRi.
Now, I'm not suggesting that unborn children can have suicidal thoughts but if a drug can induce such chemical changes in the living then are we expected to believe that it will make no alterations to a child growing inside its mother?
The MHRA can and will tell us that they have played their part. They have issued the warnings to the prescribing physicians.
Analogy
"Hey kids, don't touch that fence, it has electricity running through it", the man on top of the grassy bank tells the children.
"Don't believe you", Simon tells the man.
Simon touches the fence. Many volts of electricity are passed through his body. Simon dies as a result of his injuries.
8 days later...
"Hey kids, don't touch that fence, it has electricity running through it", the same man on top of the grassy bank tells the children.
"Don't believe you", Julie tells the man.
Julie touches the fence. Many volts of electricity are passed through her body. Julie dies as a result of her injuries.
The man stands from his sitting position. He's satisfied and has no conscience, he did, after all, warn of the dangers.
Would a humanistic more active approach to protecting the lives of these children have been called for here?
Should the man have raised alarm, been more vocal, called the relevant authorities or maybe erected warning signs in clear bold text, "THIS FENCE IS ELECTRIC". Might warning parents that the fence was dangerous and urging them to monitor their children closely when in proximity to it have been warranted?
The man had been sitting on the grassy bank for many months. In total he had witnessed 5 children touch the fence. Only two of those 5 had died as a result of their injuries. The other three suffered burns but lived as a result.
Because of this the man decided that more people who touched the fence survived than those who died and the fence was therefore not a risk to children.
Bizarre way of thinking, right?
But this is the exact logic that regulators are using when it comes to mothers taking antidepressants during pregnancy. Moreover, they are passing the buck and allowing doctors to make the call.
Let's just take a look at a recent birth defect trial in the United States. The decision of which found GlaxoSmithKline guilty.
When the verdict was announced I contacted the MHRA and asked if they were going to change the labelling on Seroxat now that evidence had emerged that it was a clear teratogen [2]. They told me they were not. I wrote a whole chapter about this in my book where I produce the email correspondence between myself and MHRA CEO, Kent Woods [3]
Here's an extract from court documents [Kilker Vs GlaxoSmithKline]
September 15, 2009
13 Courtroom 253, City Hall
Philadelphia, Pennsylvania
Sean Tracey of the Tracey Law Firm [Attorney for Kilker]
Glaxo were represented, as usual, by King & Spalding
MR. TRACEY: May it please the Court, good morning.
JURORS: Good morning.
MR. TRACEY: I am going to reintroduce myself. My name is Sean Tracey. I represent Michelle David and Lyam Kilker. Before I begin, I want to reintroduce to you Jamie Sheller here, and there are a couple young lawyers up front here. Scott Love and Adam Peavy you are going to see wandering around and probably hearing from during this trial. Who you haven't met are my clients. This is Michelle David. Michelle, will you stand up. This is Michelle David. Over here with Michelle's mother is Lyam Kilker. Lyam is here with his grandmother. Lyam is going to stay a few minutes, then I think his grandmother is going to take him out of the courtroom.
Next we see Tracey explain to the jury the injuries caused to Lyam Kilker.
MR. TRACEY: This is the time for me to talk to you about what I believe the facts are going to be, what I think the evidence that comes in during this trial is going to be through the witness stand starting this afternoon, and through the documents that I have obtained as a result of this lawsuit. And so I want to start that by, this is the name of the case, as you have heard, Kilker versus GlaxoSmithKline. And Lyam Kilker, this is going to be undisputed, Lyam Kilker was born October 24, 2005. And shortly after he was born, Michelle found out he had been born with a series of congenital heart defects. During the time Michelle was pregnant, before she was pregnant, she was taking Paxil. She was on Paxil for her first trimester. Now, Lyam, after he was born, was at the hospital and he was diagnosed and his heart defects, there really are three. One is called the ventricular septal defect. One is called an atrial septal defect. Those are holes on the inside of the heart in the walls that separate the four chambers of the heart. The other heart defect he had is something called an interrupted aortic arch. The aorta, where it is supposed to curve, doesn't fully develop. And so what he has is three different, distinct heart defects, each of them related to the failure of his heart to fully develop.
Tracey then goes on to explain to the jurors about the FDA pregnancy categories.
MR. TRACEY: The first one is pregnancy Category A. Are there adequate and well-controlled studies? Are there human studies that demonstrate there is no risk to the fetus? If it is Category A, you can take this drug with impunity and you don't have to worry about children, you don't have to worry about if she gets pregnant. You will learn during this trial that, I think, over 50 percent of pregnancies in the United States are unplanned. Women aren't planning on getting pregnant. That's why these categories can be so important. You don't just consider these categories when you have a woman who is planning a pregnancy. It is any woman of childbearing years who may become pregnant. The evidence in this case is going to be that GlaxoSmithKline knew that over 50 percent of the women in the United States became pregnant without trying to, they were unplanned pregnancies. They knew this back in the 1990s. So Category A, no problems.
Category B, we have done animal studies, doesn't look like there is any problems. Animal studies have failed to demonstrate a risk to the fetus, but we don't have any human studies.
Category C is, we have done animal studies, we have done animal studies, and the animal studies have shown an adverse effect on the fetus, but we don't have any human studies at all.
Category D is, there is positive evidence, there is positive evidence of human fetal risk based on a number of different things, either adverse reaction data from investigations they do or adverse marketing data from women and doctors reporting problems with the drug or from studies. And in that case in a Category D drug you do not prescribe that drug to women of childbearing age with one exception. If the doctor decides that the benefit to the patient is worth the risk to the fetus, then the drug can be prescribed. Doctor Healy, who is a psychiatrist and neuropyschopharmacologist who is going to testify this afternoon, will explain that there may be times when the disease is so serious that it may be worth the risk to the doctor and the patient if there is a life-threatening illness. If somebody is capable of harming themselves or others, they may make the decision to prescribe the drug if, there is no alternatives.
Category X is, we don't care what the benefits are. You do not give this drug to a woman unless she has a pregnancy test that shows she is not pregnant.
Tracey adds:
MR. TRACEY: In 2004 when Michelle David was prescribed this drug, it was a pregnancy Category C, and GlaxoSmithKline says their animal studies have revealed no evidence of teratogenic effects.
Tracey then explains to the jury the process of human development.
MR. TRACEY: In human development when women get pregnant, what you are going to learn and understand is that the most vulnerable time to the human fetus is from weeks 3 to weeks. That is when the fetus is dividing and growing and is the most susceptible to something called a teratogen to a drug that can cause a birth defect. During weeks 3 through 8 the body is rapidly, rapidly expanding, rapidly developing. Cells are being signalled to go to where they are supposed to go. The heart is developing by week 8. By week 8 the heart, from a cellular perspective, is almost completely developed, and there is nothing you can do after that to prevent the heart, to prevent a heart defect if it has already occurred. The importance of this is that when women don't know or aren't planning on becoming pregnant, many times, most of the time, by the time the woman finds out she is pregnant, the damage has been done. This is when in this time frame, weeks 3 to 8, almost every congenital abnormality -- that is a fancy word for a birth defect -- almost every congenital abnormality happens during this time frame.
Tracey goes on to explain to the jury what a teratogen is. In a nutshell, a teratogen is any agent or factor that induces or increases the incidence of abnormal prenatal development.
Enter Dr Sloot
MR. TRACEY: So during the course of this trial you will hear about teratogens and teratogenicity and you will find out about whether Paxil is a teratogen. And one of the ways you are going to learn about this is through a study, an animal study, an animal study done by a doctor named Sloot. Doctor Sloot is a European doctor who works for another pharmaceutical company called Shearing Plough. Shearing Plough is a pretty big company. You may have heard of it. In May of this year, 2009, a study was published by Doctor Sloot. The study said this. What Doctor Sloot did is, he took Paxil and all the other reuptake inhibitors and he exposed rat fetuses to these 12 different drugs, including Paxil. And what Shearing Plough was trying to figure out, what they were trying to do was figure out whether one of the drugs that they were going to put on the market to compete with GSK's drug was capable of causing birth defects. And so they took the drug they were going to take to market, and before they took it to market, they did this test. And they compared it to all the other SSRIs. Because, as you will learn, GSK never did this test. What Doctor Sloot discovered in May of this year is that out of all the teratogen --out of all the SSRIs, the 12, only one was a clear teratogen, Paxil. He discovered that Paxil in May of this year was actually more powerful a teratogen than cocaine. It would be safer, according to Doctor Sloot's study, to take cocaine than it would be to take Paxil while you were pregnant.
The Evidence
MR. TRACEY: I told you earlier that the way you learn about this case is through evidence, through witnesses that take the stand, through documents. And you are going to see documents in this case that have never seen the light of day before. You will see internal GlaxoSmithKline documents that the FDA hasn't seen, that the United States Congress hasn't seen, and that no jury has ever laid their eyes on before. For the first time in this trial you will see these documents. They have been under seal for over three years. And that's the way, one of the ways, you are going to learn about what GSK knew and when they knew it.
Tracey then explains to the jury how Glaxo had purchased the compound [paroxetine] from a Danish company called Ferrosan. He continues...
MR. TRACEY: Ferrosan had done the preliminary animal studies to look at teratogenicity. And they were done, I believe, in 1979 and 1980. And one of the studies was called Study 295. This is a study where they give Paxil, paroxetine, to pregnant female rats. And what the evidence showed in Study 295 is that the rats that got no Paxil, 88 percent of them were alive or 12 percent were dead by the fourth day after they were born. The ones that were given 5 milligrams of Paxil, 65 percent were dead by day 4. The ones that were dosed with 15 milligrams of Paxil, 92 percent were dead by day 4. And in the ones that were given 50 milligrams of Paxil, 100 percent were dead by the fourth day after they were born.
Ferrosan's Dr Baldwin
MR. TRACEY: At the time a doctor by the name of Baldwin, who works for them, Doctor Baldwin looked at the studies. He looked at Study 295, another study called 296, another study called 297. And 12 years before they started selling this drug to women in the world, Doctor Baldwin had some comments about these studies. What he told them internally -- this is a document that nobody has ever seen before. What he told them internally was: There remains the possibility this compound could be teratogenic at higher dose levels. As he saw, as you just did, that the more Paxil you got, the more rats died. And these were not heavy doses of Paxil. What he was concerned about was whether or not Ferrosan or anybody else was going to conduct or intended to conduct peri and postnatal studies to answer the question to why the rats died. He wanted to know that. In 1980 he sent a memo to the powers-to-be at Beecham. He said this needs to be done. The rats died. He talked about embryolethality. That means the fetuses die.
FDA Revolving Door
MR. TRACEY: Because I saw the animal studies that you just saw and the evidence that you will see about the animal studies and the rat pups dying, and I wondered how they could market the drug and say in the beginning that there were no problems with the drug. What I found out is that the FDA investigator that signed off and said you can sell your drug to the public is a guy named Gary Evanuic (sp.?). And Gary Evanuic, who signed off on Paxil being a Category B drug, now works for GSK. He works for GSK in the very department that sells Paxil.
Japan
MR. TRACEY: And as we are rocking along, in 1994 we are selling in the United States, we are selling in Europe. Business is brisk. Business is going well. And they want to move into other countries. They want to sell their drug in other countries. And they have a company called SmithKline or Smith Beecham Japan. It is one of their companies that is in Japan that sells their drug, one of their 70, I think, companies. And the Japanese, they suspected, were not going to accept their dead rat pup studies because they suspected the Japanese, because of the historical things that have gone on in Japan with birth defects related to Hiroshima, Nagasaki, and another environmental disaster there called Minamata, the Japanese had a heightened sense of concern. GSK believed that's what would be going on. And so GSK began discussions internally. Internally among themselves they said: What are we going to do, what are we going to do if Japan makes us do the studies to find out why the rat pups died? What are we going to do? Because what the documents, the internal documents that the FDA has never seen, that nobody else has ever seen, is, their conclusions were, if the Japanese make us do the studies to prove why the rat pups died, we might lose the United States market. So GSK was looking at science and research, not from the aspect of whether or not their drug was going to induce birth defects in children, but the evidence will be their only concern was commercial. Their only concern was whether they would lose the American market. The quote from them is: GSK concludes this is the study, the type of study we wish to avoid. We simply don't want to know the answer to these questions. They say: If the Japanese do request a study, if they do it, there is a potential problem, they may insist on us doing a study to their preferred design. And so what they did in March of 1994, they got a woman or man, I'm not sure which, I haven't been able to find out, named Gwyn Morgan. They got Gwyn Morgan involved. They put Gwyn Morgan in charge of reviewing the study designs that they would give to the Japanese. And Gwyn Morgan was to ensure for the company that any potential negative outcome from the studies is minimized. They designed the study to fail. They wanted the study to fail.
GSK Sales Reps
MR. TRACEY: GlaxoSmithKline has 110,000 employees. I think 40,000 of them are salespeople. What these people do, you will learn, is, they go to doctors' offices. And they take literature and they take cookies and they take lunch and they take pens and they take samples of Paxil. And they tell the doctors why they should prescribe their drug. These are bright, sophisticated, educated salespeople. They are the backbone of this company. And what they were telling doctors in the mid-1990s is that no drug is safer than ours for pregnant women.
Japan Revisited
MR. TRACEY: So we are rocking along. Remember that Japanese study I told you about, Doctor Patrick Wier? Well, they designed a study -- they avoided the studies they wanted to avoid and they designed a study that they thought would satisfy the Japanese, and they were right. But even in the study that was designed to fail, something cropped up, something that was potentially a problem for them. In this study done by GSK, which, quite frankly, by the way, was not a study designed to find out why the rat pups died, it was not a study designed to find out the answer to the questions Doctor Baldwin had in 1980, but some of rat pups did die, and they autopsied one of the rats. And in one of the rats they autopsied, they found that the rat that was found dead had edema, swelling around the heart, and it had a ventricular septal defect. The very same defect Lyam Kilker has. The very same defect that they had started receiving reports of in 1997. But they blew this off. They minimized it. In their conclusions they didn't even mention it. It is buried in the back of the study in an appendix.
Cannot Stop Taking Paxil
MR. TRACEY: Now, this case is primarily, primarily, about birth defects, primarily about what happened to Lyam Kilker and whether they knew about what would happen to him. But in the course of selling Paxil for the past 15 years other issues have come up. One of them is this. In the mid-1990s some studies came out, some literature came out, showing that Paxil had a significant problem with withdrawal. What that means is this. They were finding that women that took the drug and then want to the stop couldn't get off of it. So they would get sick. They would try to stop and they would get sick. And so they would be forced to keep taking the drug so they wouldn't be sick.
Glaxo Burying Data
MR. TRACEY: In the mid-1990s there had been some studies done, not by GSK but by others, and talking about withdrawal. This, you are going to learn from the evidence, caused them some concern. They were concerned about losing their market, losing their market to Prozac. And what they decided to do was, do their own study. And one of the documents you are going to see is this document, a document from a woman named Bonnie Rossello. Bonnie Rossello is the vice-president of GSK's marketing, Paxil marketing. And what Bonnie said in 1997 was: In response to this, let's do our own studies. Then we will own the data. If the results come back negative, we can bury it all. We can bury the evidence that our drug is a problem. In 1997 that's what she said.
The full opening statement can be downloaded HERE
After hearing evidence from both sides Jurors deliberated about seven hours over two days before finding Glaxo failed to properly warn doctors and pregnant users of Paxil's risk. The panel awarded $2.5 million in compensatory damages to the family of Lyam Kilker.
With the latest news coming from BBC's Panorama about other SSRi's causing birth defects it pays to do your homework on these types of drugs before taking them. The pharmaceutical companies won't be clear and concise about the risks because it would only serve to harm their profits. The regulators won't be clear and concise because they refuse to see the link, even when sent evidence from the above trial. Doctors will continue to prescribe because they have been told that untreated depression can harm the unborn - I have yet to see any clear evidence on this that has not been funded the the pharmaceutical industry.
Forget the doctor weighing up the risk/benefit - Weigh up the odds yourself. Don't be fooled by the stethoscope and BNF in your doctor's office. Look for the product placements, note pads, coffee cups, calanders - I'll guarantee they have the name of a drug on them. That's called good pharmaceutical repping.
Panorama will no doubt be accused of scaremongering. To me, at least, the biggest scaremongers are those that tow the line that untreated depression in pregnant mothers can harm the foetus and then prescribe an SSRi.
Whilst there may be evidence that depressed mothers should treat there depression there is no evidence that SSRi treatment can help protect the baby.
If you stop and think about clinical trials for SSRis it leaves you with a burning question.
Clinical trials for SSRis all have a protocol to follow. All stipulate that there can be no subjects allowed onto the clinical trials that are pregnant.
Women, when faced with the decision of taking antidepressants, should remember this. They should also ask their prescribing physician to provide them with evidence that SSRi treatment can prevent their foetus from developing depression.
There is no evidence. If evidence were needed pharmaceutical companies who carry out trials would include pregnant women in these very same trials. They don't because there is a risk.
SSRi birth defects include, but are not limited to:
Abdominal Birth Defects / Omphalocele
Anal atresia (complete or partial closure of the anus)
Autism Spectrum Disorders
Cardiac (heart) defects
Cleft lip and cleft palate
Clubfoot (one or both feet turn downward and inward)
Craniosynostosis (skull defect)
Limb Defects
Neural-tube defects (brain and spinal cord, spina bifida)
PPHN (Persistent Pulmonary Hypertension of the Newborn)
Even if you have taken antidepressants during pregnancy and your child is born defect-free you still have many hurdles to jump.
Breast feeding an infant whilst taking an SSRi carries risks too. Mothers could unknowingly be feeding the very same drug to their infants that the regulators have warned against giving to children and teenagers.
I've yet to see any Sir David Attenborough documentary that has showed me an animal eating toxic plants before allowing her young to suckle.
And we, as humans, claim to have the highest intelligence.
The Panorama story can be found HERE.
The following video contains images that some viewers may find disturbing.
Bob Fiddaman
[1] The Intensive Care Society
[2] "Teratotogen" - Medical Dictionary
[3] The Evidence, However, is Clear - The Seroxat Scandal
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