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Salmeterol inhaled — (Serevent; Serevent Diskus)

International Brand Names

Aeromax (Germany); Salmeter (India); Seretide (Philippines); Serevent (Hong Kong, Indonesia, Japan, Malaysia, New Zealand, Philippines, Taiwan, Thailand); Serevent Inhaler and Disks (Australia); Serobid (India); Zamitrel (Mexico)

Drug Class Adrenergic agonists; β-Agonists; Bronchodilators
Indications Asthma prophylaxis, exercise-induced asthma, COPD
Mechanism Selective β 2 -adrenergic agonist
Dosage With Qualifiers Asthma prophylaxis—2 puffs INH q12h
Exercise-induced asthma—2 puffs INH × 1
COPD—2 puffs INH q12h
NOTE: 21 mcg/spray MDI.

  • Contraindications —hypersensitivity to drug or class, acute asthma, arrhythmia

  • Caution —hypertension, CV disease, diabetes mellitus, seizures, hyperthyroidism, hypokalemia

Maternal Considerations Asthma affects up to 4% of pregnancies. Inhaled cromolyn is generally considered first-line therapy for pregnant women with persistent asthma, followed by inhaled budesonide if symptoms worsen. When that fails to provide control, salmeterol is a long-acting β-adrenergic agonist that is also a potent inhibitor of mast cell release of histamine, leukotrienes, and prostaglandin D 2 . Systemic levels of salmeterol are low to undetectable after inhalation. It has also been used to treat altitude sickness. There are no published trials of its use during pregnancy, and recommendations are based on “expert” opinion.
Side effects include angioedema, paradoxical bronchospasm, laryngospasm, arrhythmia, hypertension, headache, nasal congestion, rhinitis, pharyngitis, urticaria, palpitations, tachycardia, tremor, and nervousness.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. It is unknown whether salmeterol crosses the human placenta. Transfer across the rat placenta is low. Considering the low systemic levels achieved and the poor placental transport, it is unlikely the fetus is exposed to a clinically relevant concentration. When given orally at doses 50–100 × greater than those inhaled, salmeterol is associated with cleft palate and abnormal ossification. These studies do not seem relevant to clinical practice.
Breastfeeding Safety There is no published experience with salmeterol in breastfeeding women. However, considering the dose and route, it is unlikely the breastfed neonate would ingest clinically relevant amounts. Transfer into rodent milk is limited.
Drug Interactions MAOIs or TCAs may potentiate the CV actions of salmeterol; use with extreme caution if the patient is being treated with or within 2 w of these agents.
β-Adrenergic receptor blocking agents not only block the pulmonary effect of β-agonists, but they may also produce severe bronchospasm in asthmatic patients. Patients with asthma should not normally be treated with β-blockers. Under certain circumstances (e.g., as prophylaxis after MI), there may be no acceptable alternative to the β-adrenergic blocker. In this setting, cardioselective β-blockers can be considered, although they should be administered with caution.
ECG changes and/or hypokalemia secondary to non–potassium-sparing diuretics (such as loop or thiazide diuretics) can be acutely worsened by β-agonists, especially when the recommended dose of the β-agonist is exceeded.
Inducers and inhibitors of CYP3A4 may alter serum concentrations of salmeterol.
References Blaiss MS; National Institute of Health. Allergy Asthma Proc 2004; 25:375-9.
Manchee GR, Barrow A, Kulkarni S, et al. Drug Metab Dispos 1993; 21:1022-8.
Summary Pregnancy Category: C
Lactation Category: S (probably)

  • Salmeterol should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • It seems unlikely that it poses any significant risk to fetus or neonate when used as directed.

Salsalate — (Amigesic; Anaflex 750; Artha-G; Carsalate; Diagen; Disalcid; Marthritic; Mono-Gesic; Nobegyl; Ro-Salcid; Salflex; Salgesic; Salicylsalicylic acid; Salsitab)

International Brand Names

Atisuril (Spain); Disal (Korea, Taiwan); Disalgesic (Germany); Salina (Japan); Saril (Korea); Umbradol (Spain)

Drug Class Analgesics, non-narcotic; Salicylates
Indications Arthritis
Mechanism Unknown; prostaglandin synthesis inhibitor
Dosage With Qualifiers Arthritis—1000 mg PO tid

  • Contraindications —hypersensitivity to drug or class, NSAID/ASA-induced asthma history, flulike symptoms or varicella, peptic ulcer disease

  • Caution —renal dysfunction

Maternal Considerations Salsalate is a dimer of salicylic acid and absorbed in the intestine. Unlike aspirin, salsalate does not inhibit platelet aggregation, and there is no increase in GI bleeding over placebo. There is no published experience during pregnancy.
Side effects include hepatic toxicity or nephrotoxicity, Reye’s syndrome, N/V, epigastric pain, fatigue, rash, and dizziness.
Fetal Considerations There is no published experience in human fetuses. It is unknown whether salsalate crosses the human placenta. Salsalate and salicylic acid are teratogenic and embryocidal in rats when given in doses 4–5 × the usual human dose; teratogenicity is not seen when given at twice the usual human dose.
Breastfeeding Safety There is no published experience in nursing women. Salicylic acid, the primary metabolite, reaches an M:P ratio approximating unity. Avoid salsalate while breastfeeding because of the potential risk of Reye’s syndrome in the neonate.
Drug Interactions Salicylates antagonize the uricosuric action of drugs used to treat gout.
Aspirin and other salicylates will be additive to salsalate and may lead to salicylate toxicity.
Drugs and foods that raise urine pH will increase renal clearance and urinary excretion of salicylic acid, thus lowering plasma levels; acidifying drugs or foods will decrease urinary excretion and increase plasma levels.
Use with anticoagulant drugs may predispose to systemic bleeding.
May enhance the hypoglycemic effect of sulfonylurea oral antidiabetic drugs.
Salicylate competes with a number of drugs for protein binding sites, notably methotrexate, naproxen, penicillin, phenytoin, sulfinpyrazone, thiopental, thyroxine, triiodothyronine, warfarin, and possibly corticosteroids.
References There is no published experience in pregnancy or during lactation.
Summary Pregnancy Category: C
Lactation Category: NS (possibly)

  • Salsalate should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • There are alternative agents for which there is more experience regarding use during pregnancy and lactation.

Saquinavir — (Fortovase; Invirase)

International Brand Names

Fortovase (Argentina, Australia, Brazil, Canada, Chile, Colombia, Ecuador, Hong Kong, Israel, Mexico, Peru, Philippines, Taiwan, Thailand, Uruguay, Venezuela)

Drug Class Antivirals; Protease inhibitors
Indications HIV adjunct treatment
Mechanism HIV protease inhibitor
Dosage With Qualifiers HIV adjunct treatment—600 mg PO tid (Invirase) or 1200 mg tid PO (Fortovase) within 2 h of eating

  • Contraindications—hypersensitivity to drug or class; astemizole, cisapride, ergot, midazolam, terfenadine, or triazolam use

  • Caution—hepatic dysfunction, use of lovastatin or simvastatin

Maternal Considerations Saquinavir is well tolerated during pregnancy and is part of several treatment regimens. Its clearance is increased by pregnancy, and the usually recommended dose may be inadequate. Ritonavir significantly increases saquinavir concentration, and the combination during pregnancy may have some advantage.
Side effects include N/V, diarrhea, diabetes mellitus, hyperglycemia, peripheral neuropathy, headache, buccal ulceration, rash, dyspepsia, abdominal pain, and eczema.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. Saquinavir, like many protease inhibitors, does not significantly cross the human placenta probably because of reverse placental P-glycoprotein transport. Unbound concentrations of saquinavir are likely to be substantially lower in umbilical cord than maternal plasma. It is unlikely to pose a significant risk to the fetus, nor is it likely to provide the fetus any protection. In follow-up studies, saquinavir exposure was associated with late language emergence at 1 y, but not at 2 y of age. Rodent studies are reassuring, revealing no evidence of teratogenicity or IUGR.
Breastfeeding Safety There is no published experience in nursing women. It is unknown whether saquinavir enters human breast milk. Breastfeeding is contraindicated in HIV-infected nursing women where formula is available to reduce the risk of neonatal transmission.
Drug Interactions The metabolism of saquinavir is mediated by CYP3A4 (90% of the hepatic metabolism), and it is a substrate for P-glycoprotein (Pgp). Drugs that affect CYP3A4 and/or Pgp may modify the pharmacokinetics of saquinavir. Similarly, saquinavir might also modify the pharmacokinetics of other drugs that are substrates for CYP3A4 or Pgp.
Drugs that should not be used with saquinavir include the following:
Antiarrhythmics (e.g., amiodarone, bepridil, flecainide, propafenone, quinidine ) and antihistamines (e.g., astemizole, terfenadine ), which may cause serious and/or life-threatening reactions.
Ergot derivatives (e.g., dihydroergotamine, ergonovine, ergotamine, methylergonovine ), which may cause serious and life-threatening acute ergot toxicity characterized by peripheral vasospasm and ischemia of the extremities and other tissues.
Garlic capsules decrease saquinavir plasma levels and should not be used while taking saquinavir as the sole protease inhibitor.
Cisapride is contraindicated due to the potential for serious and/or life-threatening reactions such as cardiac arrhythmias.
Rifampin decreases the concentration of saquinavir and should be avoided if possible.
Herbal products such as St. John’s wort (Hypericum perforatum) may lead to the loss of virologic response and possible resistance to saquinavir or to this class of protease inhibitors.
Sedative-hypnotic agents (e.g., midazolam, triazolam ) may prolong or increase sedation or respiratory depression.
An alteration in the dose or regimen may be necessary when used with the following:
NNRTIs (e.g., delavirdine, efavirenz, nevirapine ), which may decrease saquinavir levels. Saquinavir should not be given as the sole protease inhibitor.
HIV protease inhibitors (e.g., indinavir, nelfinavir, ritonavir ), which can increase saquinavir concentrations. Saquinavir 1200 mg bid with nelfinavir 1250 mg bid results in adequate drug concentrations of both protease inhibitors. The lopinavir/ritonavir coformulated capsule increases saquinavir.
Increases the antiarrhythmic effects of lidocaine; monitor the levels.
May increase the anticoagulant effect of warfarin; monitor the INR.
Anticonvulsant drugs (e.g., carbamazepine, phenobarbital, phenytoin ) decrease the concentration of saquinavir. Use with caution.
Clarithromycin increases saquinavir and clarithromycin levels. No dose adjustment is required when the two drugs are co-administered for < 7–10 d and there is normal renal function. However, the clarithromycin dose should be reduced by 50% in patients with CrCl 30–60 mL/min and by 75% if < 30 mL/min.
Ketoconazole and potentially itraconazole increase the saquinavir level with no change in the ketoconazole concentration.
Rifabutin and rifampin decrease the saquinavir level while increasing the rifabutin level.
Increases the levels of benzodiazepines (e.g., alprazolam, clorazepate, diazepam, flurazepam ), perhaps necessitating a decrease in the benzodiazepine dose.
Increases the levels of calcium channel blockers (e.g., amlodipine, diltiazem, felodipine, isradipine, nicardipine, nifedipine, nimodipine, nisoldipine, verapamil ), perhaps necessitating a decrease in the dose of the calcium channel blocker.
Dexamethasone decreases the saquinavir level, perhaps decreasing efficacy.
Increases the level and effect of some HMG-CoA reductase inhibitors (e.g., atorvastatin, lovastatin, simvastatin ). Use the lowest possible dose with careful monitoring or consider other HMG-CoA reductase inhibitors (e.g., fluvastatin, pravastatin, rosuvastatin ).
Increases the levels of some immunosuppressants (e.g., cyclosporine, rapamycin, tacrolimus ).
The dose of methadone may need to be increased.
Alternative or additional contraceptive measures should be used when estrogen-based oral contraceptives and saquinavir are co-administered.
Increases levels of PDE5 inhibitors (e.g., sildenafil, tadalafil, vardenafil ). Use with caution at reduced doses ( sildenafil: 25 mg q48h; tadalafil: ≤ 10 mg q72h; vardenafil: ≤ 2.5 mg q72h) with increased monitoring of adverse events.
Increases the levels of TCAs such as amitriptyline and imipramine . Therapeutic concentration monitoring is recommended.
A high-fat meal maximizes bioavailability. Saquinavir levels may increase if taken with grapefruit juice
References Acosta EP, Zorrilla C, Van Dyke R, et al. HIV Clin Trials 2001; 2:460-5.
Huisman MT, Smit JW, Wiltshire HR, et al. Mol Pharmacol 2001; 59:806-13.
Lopez-Cortes LF, Ruiz-Valderas R, Rivero A, et al. Ther Drug Monit 2007; 29:171-6.
Mirochnick M, Dorenbaum A, Holland D, et al. Pediatr Infect Dis J 2002; 21:835-8.
Mölsä M, Heikkinen T, Hakkola J, et al. Clin Pharmacol Ther 2005; 78:123-31.
Parry S, Zhang J. Am J Obstet Gynecol 2007; 196:476.e1-6.
Sudhakaran S, Rayner CR, Li J, et al. Br J Clin Pharmacol 2007; 63:315-21.
Van Dyke RB, Chadwick EG, Hazra R, Williams PL, Seage GR 3rd. Front Immunol 2016; 7:199.
Vithayasai V, Moyle GJ, Supajatura V, et al. J Acquir Immune Defic Syndr 2002; 30:410-2.
Summary Pregnancy Category: B
Lactation Category: NS

  • Saquinavir is an effective protease inhibitor when used in conjunction with other retroviral agents.

  • It should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • Breastfeeding is contraindicated in HIV-infected nursing women where formula is available to reduce the risk of neonatal transmission.

  • Physicians are encouraged to register pregnant women under the Antiretroviral Pregnancy Registry (1-800-258-4263) for a better follow-up of the outcome while under treatment with saquinavir.

Sargramostim — (GM-CSF; Granulocyte Macrophage-Colony Stimulating Factor; Leukine; Prokine)

International Brand Names

Leucogen (Korea)

Drug Class Hematopoietic agents
Indications Neutropenia post bone marrow transplant, post-AML chemotherapy, progenitor mobilization, bone marrow transplant failure
Mechanism Stimulates granulocyte and macrophage proliferation and differentiation
Dosage With Qualifiers Neutropenia post bone marrow transplant—250 mcg/m 2 IV qd over 2 h beginning 2–4 h after transplant and > 24 h post chemotherapy
Neutropenia post-AML chemotherapy—250 mcg/m 2 IV qd over 4 h beginning day 11 post chemotherapy; continue until ANC > 1500 × 3 d, max 42 d
Progenitor mobilization—250 mcg/m 2 IV qd over 24 h
Bone marrow transplant failure—250 mcg/m 2 IV qd over 2 h × 14 d; may repeat in 7 d

  • Contraindications —hypersensitivity to drug or class, leukemic myeloid blast cells > 10%, current chemotherapy, current radiation therapy

  • Caution —arrhythmia, CHF, pericardial effusion, pleural effusion

Maternal Considerations Sargramostim is a recombinant human granulocyte-macrophage colony-stimulating factor. There is no published experience with sargramostim during pregnancy.
Side effects include arrhythmias, anaphylaxis, pleural or pericardial effusion, capillary leak syndrome, RDS, fever, chills, headache, N/V, diarrhea, myalgias, asthenia, bone pain, edema, rash, pruritus, dyspnea, flushing, hypotension, tachycardia, and syncope.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. It is unknown whether sargramostim crosses the human placenta. Rodent teratogenicity studies have not been conducted.
Breastfeeding Safety There is no reported experience in nursing women. It is unknown whether sargramostim enters human breast milk.
Drug Interactions Drugs that may potentiate the myeloproliferative effects of sargramostim, such as lithium and corticosteroids, should be used with caution.
References There is no published experience in pregnancy or during lactation.
Summary Pregnancy Category: C
Lactation Category: U

  • Sargramostim should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

Saxagliptin — (Onglyza)

International Brand Names

Drug Class Antidiabetic agents
Indications Diabetes mellitus, type 2
Mechanism Inhibits dipeptidyl peptidase 4 (DPP-4); slows the inactivation of the incretin hormones or incretins
Dosage With Qualifiers Diabetes mellitus, type 2—2.5–5 mg PO qd
Note: Use lowest dose when administered with CYP3A4/5 inhibitors.
Note: Renal dosing.

  • Contraindications —type 1 DM, diabetic ketoacidosis, hypersensitivity to drug

  • Caution —if patient has an increased risk of heart failure, pancreatitis

Maternal Considerations Saxagliptin is an adjunct to diet and exercise for glycemic control in patients with type 2 diabetes. There is no published experience with saxagliptin during pregnancy.
Side effects include upper respiratory tract infection, urinary tract infection, and headache, hypoglycemia, hypersensitivity.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. It is unknown whether saxagliptin crosses the human placenta. It does cross the placenta of rodents. Rodent studies are generally reassuring, revealing no evidence of teratogenicity or IUGR despite the use of doses higher than those used clinically. Incomplete ossification of the pelvis, a form of developmental delay, occurs in rats at higher doses. Maternal toxicity and reduced fetal body weights were observed at > 300 × the MRHD.
Breastfeeding Safety There is no reported experience in nursing women. It is unknown whether saxagliptin enters human breast milk. It is secreted in the milk of lactating rats at a M/P ratio of 1:1.
Drug Interactions A substrate for both CYP3A4 and P-glycoprotein (Pgp).
Co-administration with strong CYP3A4/5 inhibitors (e.g., ketoconazole, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, ritonavir, saquinavir, and telithromycin ) significantly increases saxagliptin concentrations.
Rifampin significantly decreased saxagliptin exposure with no change in the AUC of its active metabolite, 5-hydroxy saxagliptin.
Diltiazem increased the exposure of saxagliptin .
Pgp inhibitors may alter the placental transfer of saxagliptin.
References There is no published experience in pregnancy or during lactation.
Summary Pregnancy Category: B
Lactation Category: U

  • Sargramostim should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • There are alternative agents for which there is more experience regarding use during pregnancy and lactation.

Scopolamine — (Isopto Hyoscine; Minims Hyoscine Hydrobromide; Scopoderm; Transderm Scop)

International Brand Names

Kimite-patch (Korea); Scopoderm Depotplast (Norway); Scopoderm TTS (Austria, Bulgaria, China, England, France, Germany, Netherlands, New Zealand, Switzerland, Taiwan); Transcop (Italy); Transderm-V (Canada)

Drug Class Anesthetics, adjunct; Anticholinergics; Antiemetics; Cycloplegics; Gastrointestinals; Motion sickness agents; Mydriatics; Ophthalmics; Vertigo agents
Indications Motion sickness, obstetric amnesia, preoperative sedation, intraoperative amnesia
Mechanism Anticholinergic
Dosage With Qualifiers Motion sickness—1 patch behind the ear 4 h prior to need; may replace in 3 d
Obstetric amnesia or preoperative sedation—0.32–0.65 mg SC/IM
Intraoperative amnesia—0.4 mg IV

  • Contraindications —hypersensitivity to drug or class, narrow-angle glaucoma

  • Caution —intestinal obstruction, history of seizures or psychosis, impaired metabolic function, hepatic or renal dysfunction

Maternal Considerations Scopolamine differs only quantitatively in antimuscarinic actions from atropine. It is ineffective for the prevention of postoperative N/V. At one time popular for “twilight sleep” during labor, scopolamine has appropriately fallen out of favor. One study suggested it was effective reducing the duration of the first stage of labor and was not associated with any obvious adverse outcomes. It may reduce the post–cesarean section N/V associated with epidural morphine but with an increase in drowsiness and dry mouth. Scopolamine is rapidly cleared, but there is no significant relationship between HR changes, sedative effects, and antisialagogue effects and serum concentration.
Side effects include narrow-angle glaucoma, drowsiness, blurred vision, disorientation, dizziness, dilated pupils, hallucinations, confusion, psychosis, bronchospasm, respiratory depression, rash, muscle weakness, and red eyes.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. Scopolamine rapidly crosses the human placenta and may cause tachycardia and decreased beat-to-beat and long-term variability. Rodent studies are reassuring, revealing no evidence of teratogenicity or IUGR despite the use of doses higher than those used clinically.
Breastfeeding Safety There are no adequate reports or well-controlled studies in nursing women. Scopolamine enters human breast milk, but because of its poor oral availability it is unlikely to reach a relevant level in the breastfed infant.
Drug Interactions Other drugs that have weak antimuscarinic activity (e.g., certain antihistamines, meperidine, phenothiazines, TCAs) may intensify the effects of antimuscarinic drugs.
Aluminum- and magnesium trisilicate–containing antacids decrease the absorption of some antimuscarinic drugs and may do so with all of them.
Scopolamine should be used with care in patients taking drugs, including ethanol, capable of causing CNS effects. Special attention should be given to drugs having anticholinergic properties, such as belladonna alkaloids, antihistamines (including meclizine ), and antidepressants.
Scopolamine may decrease the absorption of oral medications because of decreased gastric motility and delayed gastric emptying.
References Ayromlooi J, Tobias M, Berg P. J Reprod Med 1980; 25:323-6.
Harnett MJ, O’Rourke N, Walsh M, et al. Anesth Analg 2007; 105:764-9.
Kanto J, Kentala E, Kaila T, Pihlajamaki K. Acta Anaesthesiol Scand 1989; 33:482-6.
Koski EM, Mattila MA, Knapik D, et al. Br J Anaesth 1990; 64:16-20.
Kotelko DM, Rottman RL, Wright WC, et al. Anesthesiology 1989; 71:675-8.
Samuels LA, Christie L, Roberts-Gittens B, et al. BJOG 2007; 114:1542-6.
Summary Pregnancy Category: C
Lactation Category: S (likely)

  • Scopolamine should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

Secobarbital — (Immenoctal; Novosecobarb; Secanal; Seconal)

International Brand Names

Quinalbarbitone (United Kingdom)

Drug Class Anesthetics, adjunct; Anxiolytics; Barbiturates; Hypnotics
Indications Short-term insomnia
Mechanism Nonselective CNS depressant
Dosage With Qualifiers Short-term insomnia—100 mg PO qd

  • Contraindications —hypersensitivity to drug or class, respiratory depression, porphyria

  • Caution —unknown

Maternal Considerations Barbiturates are dangerous drugs, with a narrow therapeutic index between the level required for sedation and that causing coma and death. Secobarbital is used by patients to self-treat the unpleasant effects of illicit stimulants, to reduce anxiety, and to get “high.” It is physiologically addicting if taken in high doses for 1 mo or more, and the abstinence syndrome can be life threatening. There are no adequate reports or well-controlled studies of secobarbital in pregnant women. As a short-acting agent, secobarbital was used for decades as a short-term sleeping aid for pregnant women. Unfortunately, the sleep produced is not restful and is characterized by a low percentage of REM stage. Hypnotic doses of barbiturates do not impair uterine activity significantly during labor. Anesthetic doses of barbiturates decrease the force and frequency of uterine contractions.
Side effects include respiratory depression, dependency, hepatotoxicity, Stevens-Johnson syndrome, angioedema, lethargy, and drowsiness.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. Barbiturates can be detected in the placenta, fetal liver, and fetal brain, and it is likely secobarbital rapidly crosses the human placenta. There is no substantive evidence secobarbital is a human teratogen. Administration during labor may cause respiratory depression in the newborn. Premature infants are particularly susceptible to the depressant effects of barbiturates. Withdrawal symptoms occur in infants of women who receive secobarbital throughout the third trimester.
Breastfeeding Safety There is no published experience in nursing women. Secobarbital is excreted into human breast milk and may be detected for 24 h or more. Its occasional use is generally considered compatible with breastfeeding, but it may be best to delay feeding 3-4 h absent the availability of detailed information.
Drug Interactions Most reports of significant drug interactions with the barbiturates have involved phenobarbital. The application of these data to other barbiturates appears valid.
Barbiturates induce hepatic microsomal enzymes, resulting in increased metabolism and decreased anticoagulant response to oral anticoagulants (e.g., acenocoumarol, dicumarol, phenprocoumon, warfarin ). Patients on anticoagulant therapy may require a dose adjustment if barbiturates are added or withdrawn.
Barbiturates may enhance the metabolism of exogenous corticosteroids. Patients on corticosteroid therapy may require a dose adjustment if barbiturates are added or withdrawn.
Phenobarbital appears to interfere with the absorption of oral griseofulvin. It is preferable to avoid concomitant administration.
Shortens the t/2 of doxycycline for as long as 2 w after barbiturate therapy is discontinued.
The effect of barbiturates on the metabolism of phenytoin appears to be variable.
Sodium valproate and valproic acid increase secobarbital blood levels; thus secobarbital levels should be monitored closely and appropriate dose adjustments made.
Use of other CNS depressants, including other sedatives or hypnotics, antihistamines, tranquilizers, or ethanol, may produce additive depressant effects.
MAOIs prolong the effects of barbiturates, probably because metabolism of the barbiturate is inhibited.
May decrease the effect of estradiol by increasing its metabolism. There have been reports of patients treated with AEDs (e.g., phenobarbital ) who become pregnant while taking oral contraceptives. An alternate contraceptive method might be suggested to women taking barbiturates.
References There are no current relevant references.
Summary Pregnancy Category: D
Lactation Category: NS (possibly)

  • Secobarbital should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • There are alternative agents with greater safety and efficacy for the same indications that can be taken during pregnancy and lactation.

Selegiline — (Alzene; Carbex; Deprenyl; Eldeprine; Eldepryl; Selgene)

International Brand Names

Apo-Selegiline (New Zealand); Elegelin (Thailand); Julab (Hong Kong, Thailand); Julegil (Malaysia); Jumex (Austria, China, Hong Kong, Hungary, Indonesia, Israel, Italy, Korea, Malaysia, Philippines, Thailand); Jumexal (Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Switzerland, Taiwan); Kinline (Thailand); MAO-B (Korea); MAOtil (Germany); Movergan (Germany); Niar (Mexico); Otrasel (France); Plurimen (Spain); Procythol (Greece); Sedicel (Colombia); Sefmex (Hong Kong); Selegil (Colombia, Peru); Selegos (Hong Kong, Singapore); Selgene (Thailand); Selgin (India); Xilopar (Germany); Zelapar (Philippines)

Drug Class Antiparkinson agents
Indications Parkinsonism
Mechanism Selective MAO-B antagonist
Dosage With Qualifiers Parkinsonism—5 mg PO qam and qnoon
NOTE: Death may occur if combined with meperidine. Also available as disintegrating table and a transdermal system (~ 30% absorbed over a 24-h period).

  • Contraindications —hypersensitivity to drug or class, opiate use

  • Caution —unknown

Maternal Considerations Selegiline is a derivative of phenethylamine. It has also been used to treat depression and Alzheimer’s dementia and narcolepsy. There are no adequate reports or well-controlled studies of selegiline in pregnant women. The literature consists mostly of case reports involving 30–40 women in total with Parkinson’s disease.
In hopes of circumventing the need for dietary restrictions (see Drug Interactions), the transdermal selegiline patch was developed to bypass the gastrointestinal tract and avoid interaction with the intestinal mucosa monoamine oxidase-A (MAO-A). Avoiding intestinal MAO-A interaction decreases the risk of dietary tyramine accumulation and hypertensive crisis. Motivation to more readily use MAOIs stems from the positive reputation that this class garners and the specific role MAOIs have in treatment of atypical and treatment-resistant depression where they have been found more effective than the tricyclic antidepressants in the outpatient setting. There is one case report of such therapy being used throughout most of the subject’s pregnancy with an acceptable outcome.
Side effects include ventricular arrhythmia, N/V, diarrhea, dizziness, confusion, hallucinations, vivid dreams, headache, anxiety, anemia, hair loss, fatigue, and low back pain.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. It is unknown whether selegiline crosses the human placenta. Monoamine neurotransmitters are important for the development of the immature brain. Their endogenous levels are highly regulated by MAO, and any change in enzyme activity could have a profound effect on brain development. Some recommend discontinuing MAOIs before conception. Unfortunately, there is little scientific information on which to base such decisions. Rodent studies are generally reassuring, revealing no evidence of teratogenicity at doses higher than those used clinically. There was evidence of embryotoxicity at high doses.
Breastfeeding Safety There are no adequate reports or well-controlled studies in nursing women. It is unknown whether selegiline enters human breast milk. A case report of transdermal selegiline use during pregnancy and lactation in a mother with chronic depression reported undetectable levels of selegiline in the infant after 12 d of breastfeeding, suggesting a minimal transfer into breast milk; no adverse maternal effects or congenital malformations were observed.
Drug Interactions Carbamazepine slightly increases levels of selegiline and its metabolites. Changes in plasma concentrations are nearly twofold but variable across the subject population. Carbamazepine is contraindicated with MAOIs, including selegiline.
Use with phenylpropanolamine was associated with a higher incidence of significant BP elevations than with phenylpropanolamine alone, suggesting a possible pharmacodynamic interaction. There were no clinically significant changes in BP with pseudoephedrine use, but hypertension has been reported with ephedrine. It is prudent to avoid the concomitant use of sympathomimetic agents with selegiline.
Has greater affinity for MAO-B; this selectivity is lost as its concentration increases. In addition to their role in the catabolism of CNS monoamines, MAOs are also important in the catabolism of exogenous amines found in foods and drugs. MAO in the GI tract (primarily type A) protects from exogenous amines with vasopressor actions, such as tyramine, which if absorbed intact can cause a hypertensive crisis (the so-called cheese reaction). If a large amount of tyramine is absorbed, it is taken up by adrenergic neurons and
causes hypertension secondary to NE release from neuronal storage sites. Although most foods contain negligible amounts or no tyramine, a few food products may contain large amounts that represent a potential risk for patients with significant inhibition of GI MAO-A. Studies suggest selegiline 6 mg/24 h does not require a modified diet. Due to the more limited data available for 9 mg/24 h and 12 mg/24 h, patients taking these doses should follow a modified diet.
Stupor, muscular rigidity, severe agitation, and elevated temperature have been reported when used with meperidine. Symptoms usually resolve over days when the combination is discontinued. This is typical of the interaction of meperidine and MAOIs. Other serious reactions (including severe agitation, hallucinations, and death) have been reported in patients receiving this combination. Severe toxicity has also been reported when used with TCAs and SSRIs.
Use with dextromethorphan has been reported to cause brief episodes of psychosis or bizarre behavior. Therefore dextromethorphan should not be used with selegiline.
References Bauer RL, Orfei J, Wichman CL. Psychosomatics 2017; 58:450-2.
Golbe LI. Neurol Clin 1994; 12:497-508.
Hagell P, Odin P, Vinge E. Mov Disord 1998; 13:34-8.
Summary Pregnancy Category: C
Lactation Category: U

  • Selegiline should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • MAOIs have many food-drug and drug-drug interactions, which require careful monitoring.

Selenium sulfide topical — (Abbottselsun; Exsel; Glo-Sel; Lenium; Micalon; Sebo-Lenium; Sel-Pen; Selsum; Selsun; Selukos; Versel)

International Brand Names

Abbottselsun (Spain); Sebo-Lenium (Switzerland); Sebosel (Thailand); Selson (Korea); Selsun 1.0 (Hong Kong); Selsun 2.5 (Hong Kong); Selsun Blue (Finland, Hong Kong, Indonesia, Israel, Norway, Sweden, Switzerland); Selsun R (Netherlands); Selukos (Austria, Finland, Germany, Norway, Sweden); Versel (Canada)

Drug Class Antidermatophytes; Antifungals; Dermatologics
Indications Dandruff, seborrhea, tinea versicolor
Mechanism Reduces epidermal and follicular epithelial corneocyte production
Dosage With Qualifiers Dandruff, seborrhea—massage 5–10 mL on wet scalp 2 ×/w, rinse after 2–3 min
Tinea versicolor—apply 2.5% lotion qd × 7 d, then monthly × 3 mo
NOTE: Wash hands and avoid contact with jewelry.

  • Contraindications —hypersensitivity to drug or class, inflamed skin

  • Caution —unknown

Maternal Considerations There is no published experience with selenium sulfide during pregnancy. Systemic absorption is scant whether measured after shampooing or after lotion application.
Side effects include skin irritation, hair loss, hair discoloration, and oily or dry scalp.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. It is unknown whether selenium sulfide crosses the human placenta. Elemental selenium does cross passively. Considering the dose and route, it is unlikely the maternal systemic concentration will reach a clinically relevant level.
Breastfeeding Safety There is no published experience in nursing women. It is unknown whether selenium sulfide enters human breast milk. However, the concentration of elemental selenium in milk is the same as maternal plasma. Considering the indication and dosing, selenium sulfide use is unlikely to pose a clinically significant risk to the breastfeeding neonate.
Drug Interactions No clinically relevant interactions identified.
References Nandakumaran M, Dashti HM, Al-Saleh E, Al-Zaid NS. Mol Cell Biochem 2003; 252:91-6.
Ozdemir HS, Karadas F, Pappas AC, et al. Biol Trace Elem Res 2008; 122:206-15.
Summary Pregnancy Category: C
Lactation Category: S (likely)

  • Selenium sulfide is unlikely to pose a risk when used as indicated.

Senna — (Ex-lax; Senna-Gen; Sennokot)

International Brand Names

None identified.

Drug Class Laxatives
Indications Constipation
Mechanism Cathartic; increases peristalsis
Dosage With Qualifiers Constipation—2–4 tabs PO qd or bid

  • Contraindications —hypersensitivity to drug or class, bowel obstruction, undiagnosed abdominal pain

  • Caution —unknown

Maternal Considerations Despite a long clinical experience, there are no adequate reports or well-controlled studies of senna in pregnant women. Senna is absorbed across the GI tract only to a limited degree. Some believe senna is the purgative of choice during pregnancy and lactation. It effectively relieves postpartum constipation. It does not affect the myometrial activity of the pregnant ewe.
Side effects include laxative abuse, nausea, bloating, cramps, flatulence, diarrhea, melanosis coli, and discolored urine.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. It is unknown whether senna crosses the human placenta.
Breastfeeding Safety Less than 1% of the maternal dose of senna enters human breast milk. This amount is inadequate for a clinical effect.
Drug Interactions No clinically relevant interactions identified.
References Faber P, Strenge-Hesse A. Pharmacology 1988; 36(Suppl 1):212-20.
Garcia-Villar R. Pharmacology 1988; 36(Suppl 1):203-11.
[No authors]. Pharmacology 1992; 44(Suppl 1):20-2.
[No authors]. Pharmacology 1992; 44(Suppl 1):23-5.
Shelton MG. S Afr Med J 1980; 57:78-80.
Summary Pregnancy Category: C
Lactation Category: S

  • Senna should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • Occasional use for the relief of constipation should be safe during pregnancy and lactation.

Sertraline — (Lustral; Zoloft)

International Brand Names

Altruline (Mexico); Aremis (Spain); Atruline (Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama); Besitran (Spain); Deprax (Chile); Dominum (Colombia, Peru); Doxime (Paraguay); Fatral (Indonesia); Fridep (Indonesia); Gladem (Austria, Germany); Lesefer (Colombia); Lustral (England, Ireland, Israel); Nudep (Indonesia); Seltra (Korea); Sercerin (Brazil); Serlain (Belgium); Serlift (Malaysia); Sertranex (Colombia); Sertranquil (Colombia); Sosser (Colombia); Traline (Korea); Zolof (Colombia); Zoloft (Argentina, Brazil, Bulgaria, Canada, China, Czech Republic, Denmark, Finland, France, Germany, Hong Kong, Hungary, Indonesia, Italy, Korea, Malaysia, Netherlands, Peru, Philippines, Poland, Sweden, Switzerland, Taiwan, Thailand, Uruguay, Venezuela); Zosert (India)

Drug Class Antidepressants; SSRIs, type 1
Indications Depression, postpartum depression, OCD, premenopausal dysphoric disorder, posttraumatic stress disorder, panic disorder
Mechanism Selective serotonin reuptake inhibitor
Dosage With Qualifiers Depression—begin 50 mg PO qd; max 200 mg PO qd
OCD—begin 50 mg PO qd; max 200 mg PO qd
Premenopausal dysphoric disorder—begin either 50 mg PO qd or cycle days 15–28, may increase 50 mg/d per cycle, max 150 mg/d
Posttraumatic stress disorder—begin 25 mg PO qd × 7 d before increasing 25–50 mg/d; max 200 mg/d
Panic disorder—begin 25 mg PO qd; max 200 mg PO qd
NOTE: Discontinue slowly.

  • Contraindications —hypersensitivity to drug or class, MAOI < 14 d

  • Caution —renal dysfunction

Maternal Considerations Depression is common during and after pregnancy, but it typically goes unrecognized. Pregnancy is not a reason a priori to discontinue psychotropic drugs. There are no adequate reports or well-controlled studies of sertraline in pregnant women, though there is growing experience with its use for the treatment of postpartum depression. However, sertraline is not recommended for prophylactic use. And although women taking SSRIs during pregnancy commonly require an increased dose to maintain euthymia, longitudinal study of sertraline suggests its clearance declines in the third trimester.
Side effects include serotonin withdrawal syndrome, withdrawal syndrome, N/V, diarrhea, insomnia, headache, dry mouth, somnolence, dizziness, fatigue, tremor, dyspepsia, constipation, decreased libido, sweating, anorexia, nervousness, agitation, anxiety, and visual disturbances.
Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. Sertraline crosses the human placenta and enters the AF. Maternal doses predict the umbilical cord concentration and are correlated with AF concentrations. Though controversy remains, epidemiologic analyses reveal a significant association with omphalocele (OR, 5.7; 95% CI, 1.6–20.7; 3 exposed subjects) and septal defects (OR, 2; 95% CI, 1.2–4; 13 exposed subjects). An increased prevalence of IUGR cannot be excluded. Neonatal abstinence syndrome may occur in up to one-third of exposed neonates. There is some concern that the impact of antenatal exposure continues for at least a few months. Newborns chronically exposed to SSRIs have reduced responses to pain. A systematic meta-analysis compared the risk of congenital malformations of individual SSRIs and found no association linked to sertraline or citalopram . Rodent studies are generally reassuring, though a delay in ossification was noted in rabbits. Further, the fetal loss rate is increased by late pregnancy exposure. The mechanism and significance are unclear. The exposure of mouse embryos in culture to sertraline at a high concentration (10 μM) causes craniofacial malformations without evidence of general embryotoxicity, consistent with a direct action at 5-HT uptake sites.
Breastfeeding Safety There is extensive information on sertraline and breastfeeding. Sertraline and desmethylsertraline both enter human breast milk. The concentrations are affected by the fraction of milk sampled, the time after maternal dose (max 7–10 h), and daily dose. The relative infant dose ranges from 0.4%–2.2%. Neonatal serum concentrations are usually below the detection limit of most commercial laboratories.
Drug Interactions Tightly bound to plasma protein; its use with other drugs tightly bound to protein (e.g., digitoxin, warfarin ) may cause a shift in plasma levels. Conversely, adverse effects may result from displacement of protein-bound sertraline by other tightly bound drugs.
Cimetidine significantly increased the sertraline mean AUC (50%), C max (24%), and t/2 (26%) compared with placebo. The clinical significance is unknown.
Sertraline decreases diazepam clearance by one-third; the clinical significance is unknown.
Increases the pimozide AUC and C max by about 40% but is not associated with any changes in ECG. Because the highest recommended pimozide dose (10 mg) has not been evaluated in combination with sertraline, the effect on QT interval and pharmacokinetic parameters at doses higher than 2 mg are not known. Although the mechanism of this interaction is unknown, concomitant administration of sertraline and pimozide is contraindicated due to the narrow therapeutic index of pimozide.
The duration of an appropriate washout period that should intervene before switching from one SSRI to another has not been established.
Many drugs effective in the treatment of major depressive disorder (e.g., the SSRIs, including sertraline, and most TCAs) inhibit the biochemical activity of CYP2D6 (debrisoquin hydroxylase) and thus may increase the plasma concentrations of co-administered drugs that are metabolized by CYP2D6. The drugs for which this potential interaction is of greatest concern are those metabolized primarily by 2D6 and that have a narrow therapeutic index (e.g., the TCAs and the class 1C antiarrhythmics flecainide and propafenone ). There is variability among the drugs effective in the treatment of major depressive disorder in the extent of clinically important 2D6 inhibition, and in fact sertraline at lower doses has a less prominent inhibitory effect on 2D6 than some others in the class. Nevertheless, even sertraline has the potential for clinically important 2D6 inhibition, and use with a drug metabolized by CYP2D6 may require lower doses than usual. Furthermore, an increased dose of the co-administered drug may be required whenever sertraline is withdrawn.
There are rare postmarketing reports describing patients with weakness, hyperreflexia, and incoordination following the use of an SSRI and sumatriptan. If concomitant treatment with sumatriptan and an SSRI (e.g., citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline ) is warranted, appropriate patient observation is advised.
The extent to which SSRI-TCA interactions may pose clinical problems will depend on the degree of inhibition and the pharmacokinetics of the SSRI involved. Nevertheless, caution is indicated as sertraline may inhibit TCA metabolism. Plasma TCA concentrations may need to be monitored and the dose of TCA reduced.
Serotonin release by platelets plays an important role in hemostasis. Studies reveal an association between the use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper GI bleeding when used with nonselective NSAIDs. Patients should be cautioned about the use of such drugs with sertraline.
References Bellantuono C, Migliarese G, Gentile S. Hum Psychopharmacol 2007; 22:121-8.
Freeman MP, Nolan PE, Davis MF, et al. J Clin Psychopharmacol 2008; 28:646-53.
Hendrick V, Smith LM, Suri R, et al. Am J Obstet Gynecol 2003; 188:812-5.
Hendrick V, Stowe ZN, Altshuler LL, et al. Am J Psychiatry 2003; 160:993-6.
Hostetter A, Ritchie JC, Stowe ZN. Biol Psychiatry 2000; 48:1032-4.
Hostetter A, Stowe ZN, Strader JR Jr, et al. Depress Anxiety 2000; 11:51-7.
Howard LM, Hoffbrand S, Henshaw C, et al. Cochrane Database Syst Rev 2005; (2):CD004363.
Kulin NA, Pastuszak A, Sage SR, et al. JAMA 1998; 279:609-10.
Levinson-Castiel R, Merlob P, Linder N, et al. Arch Pediatr Adolesc Med 2006; 160:173-6.
Louik C, Lin AE, Werler MM, et al. N Engl J Med 2007; 356:2675-83.
Myles N, Newall H, Ward H, et al. Aust N Z J Psychiatry 2013; 47:1002-12.
Oberlander TF, Eckstein Grunau R, et al. Pediatr Res 2002; 51:443-53.
Paulzen M, Goecke TW, Stickeler E, et al. J Affect Disord 2017; 212:1-6.
Rampono J, Proud S, Hackett LP, et al. Int J Neuropsychopharmacol 2004; 7:329-34.
Shuey DL, Sadler TW, Lauder JM. Teratology 1992; 46:367-78.
Stowe ZN, Hostetter AL, Owens MJ, et al. J Clin Psychiatry 2003; 64:73-80.
Stowe ZN, Owens MJ, Landry JC, et al. Am J Psychiatry 1997; 154:1255-60.
Westin AA, Brekke M, Molden E, et al. PLoS One 2017; 12:e0181082.
Womersley K, Ripullone K, Agius M. Psychiatr Danub 2017; 29 (Suppl 3):629-44.
Summary Pregnancy Category: C
Lactation Category: S

  • Depression is common during pregnancy and the puerperium and should not be ignored if treatment is otherwise indicated.

  • Sertraline should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

  • Sertraline and citalopram are first-line drug treatments for anxiety and depression in the SSRI class during pregnancy.

Sevoflurane — (Sevorane; Ultane)

International Brand Names

Elidiur (Italy); Sevofrane (China, Japan); Sevorane (Austria, Czech Republic, Denmark, France, Hong Kong, Hungary, Indonesia, Ireland, Israel, Italy, Malaysia, Netherlands, Philippines, Poland, Singapore, Thailand); Ultane (South Africa)

Drug Class Anesthesia, general
Indications Induction and maintenance of anesthesia
Mechanism Unknown
Dosage With Qualifiers Induction of anesthesia—titrate inhalation to effect; a technique used mainly in children
Maintenance of anesthesia—titrate inhalation to anesthetic effect, typically inspired concentration of 0.5%–3%
NOTE: Consult an anesthesia specialty text.

  • Contraindications —hypersensitivity to drug or class, malignant hyperthermia

  • Caution —hepatitis, hepatic or renal dysfunction, aortic stenosis, mitral valve disease, head injury, myasthenia gravis, increased ICP

Maternal Considerations There are no adequate reports or well-controlled studies of sevoflurane in pregnant women. It is popular for cesarean delivery when general anesthesia is elected, producing an intraoperative course and neonatal outcome similar to that of either isoflurane or a subarachnoid block. The US FDA released in December 2016 a warning regarding impaired brain development in children after exposure to anesthetic agents including the inhalational anesthetics isoflurane, sevoflurane, and desflurane and the IV agents propofol and midazolam in the third trimester. They recommended physicians balance the benefits of appropriate anesthesia in young children and pregnant women against the potential risks, especially for procedures > 3 h. The short fetal exposure during cesarean delivery has not been associated with learning disabilities. However, the fetus may be exposed to both IV and inhalation anesthetics during nonobstetric or fetal surgery in the second or third trimesters, and few studies have examined the effect of second-trimester fetal anesthetic exposure when most nonobstetric and fetal surgical procedures are performed. It is also not clear how the plasticity of the second-trimester fetal brain may respond to anesthetic exposure. Olutoye and colleagues suggested that to help circumvent the possible adverse effects of anesthesia physicians should (1) use nonimplicated agents for sedation such as opioids (remifentanil, fentanyl) or
the alpha-2 agonist, dexmedetomidine if appropriate; (2) minimize the duration of exposure as much as possible; and (3) limit the interval from induction of anesthesia to surgery start time. Although the FDA warning was based on duration and repeated exposure and not the concentration of inhalational agents, IV tocolytics can be considered for intraoperative use, to provide uterine relaxation for fetal surgery, in lieu of high concentrations of inhalational anesthetic agents.
Like the other volatile anesthetics ( halothane and isoflurane ), sevoflurane reduces oxytocin-induced contraction of pregnant rat myometrium mediated, at least in part, by activation of Ca 2 + -activated K + channels. In vitro , it is a vasodilator of chorionic plate vessels. A limited number of case reports in the first trimester do not report adverse outcomes.
Side effects include malignant hyperthermia, arrhythmias, hepatitis, increased ICP, N/V, agitation, cough, hypotension, shivering, laryngospasm, breath holding, increased salivation, bradycardia, dizziness, tachycardia, hypertension, and apnea.
Fetal Considerations Sevoflurane rapidly crosses the human placenta. It has been used for fetal anesthesia during the EXIT procedure. Rodent studies are reassuring, revealing no evidence of teratogenicity or IUGR. However, some animal studies suggest that prolonged or multiple maternal exposures to sevoflurane may be associated with neurodevelopmental abnormalities (see Maternal Considerations). Neonatal adaptive capacity may be reduced during the first 24 h compared with desflurane .
Breastfeeding Safety There are no adequate reports or well-controlled studies in nursing women. It is unknown whether sevoflurane enters human breast milk. However, considering the indication, dosing, and rapid clearance, one-time sevoflurane use is unlikely to pose a clinically significant risk to the breastfeeding neonate.
Drug Interactions Benzodiazepines and opioids would be expected to decrease the MAC of sevoflurane in the same manner as do other inhalational anesthetics. Sevoflurane administration is compatible with benzodiazepines and opioids as commonly used in surgical practice.
The anesthetic requirement for sevoflurane is decreased when administered in combination with nitrous oxide. Using 50% N 2 O, the MAC equivalent dose requirement is reduced approximately 50% in adults.
Increases both the intensity and duration of neuromuscular blockade induced by nondepolarizing muscle relaxants. When used to supplement alfentanil -N 2 O anesthesia, sevoflurane and isoflurane equally potentiate neuromuscular block induced with atracurium, pancuronium, or vecuronium.
Potentiation of neuromuscular blocking agents requires equilibration of muscle with delivered partial pressure of sevoflurane. Reduced doses of neuromuscular blocking agents during induction of anesthesia may delay the onset of conditions suitable for endotracheal intubation or inadequate muscle relaxation.
References Aydin GB, Coskun F, Sahin A, Aypan U. Saudi Med J 2008; 29:841-6.
Farragher R, Maharaj CH, Higgins BD, et al. Anesth Analg 2008; 107:171-7.
Gambling DR, Sharma SK, White PF, et al. Anesth Analg 1995; 81:90-5.
Kanazawa M, Kinefuchi Y, Suzuki T, et al. Tokai J Exp Clin Med 1999; 24:53-5.
Olutoye OA, Baker BW, Belfort MA, Olutoye OO. Am J Obstet Gynecol. 2017. pii: S0002-9378(17)31094-3.
Yamakage M, Tsujiguchi N, Chen X, et al. Can J Anaesth 2002; 49:62-6.
Summary Pregnancy Category: B
Lactation Category: S

  • Sevoflurane should be used during pregnancy and lactation only if the benefit justifies the potential perinatal risk.

Sibutramine — (Meridia)

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