Answer
A: Atorvastatin
Educational Objective
Adjust medications in a woman who may become pregnant.
Critique
Discontinuation of atorvastatin is indicated in this patient who is planning pregnancy. Statin medications should be avoided in pregnancy due to the potential risk for congenital abnormalities. In patients actively planning pregnancy, dyslipidemia is best managed with diet and lifestyle modification for the duration of the pregnancy. Because the effects of statin use during breastfeeding are not known, their use during nursing should be discouraged.
ACE inhibitors and angiotensin receptor blockers are also contraindicated due to potential risk of teratogenicity and should be discontinued in women who are planning pregnancy, as was done in this patient. Her hypertension should be followed and treated, if needed, with another agent known to be safe in pregnancy, such as β-blockers, calcium channel blockers, or methyldopa.
Oral antidiabetic agents should be continued in women contemplating pregnancy to maintain control of diabetes mellitus. Metformin is an FDA pregnancy category B medication (no definitive studies in pregnant women but no animal studies showing risk to the fetus) and is a reasonable option for controlling this patient's hyperglycemia before pregnancy. Evidence suggests that metformin and sulfonylureas are acceptable during pregnancy; however, further management decisions are best made through co-management of medical and obstetric issues with a high-risk obstetrician.
In the treatment of depression, medication discontinuation may not be appropriate in women with a history of major or recurrent depression. Some selective serotonin reuptake inhibitors (SSRIs), including sertraline and fluoxetine, are FDA pregnancy category C (no definitive studies in pregnant women but evidence of potential harm in animal reproduction studies, although potential benefits may warrant use despite potential risks), and their use must be determined on an individual basis. Such agents may be continued if needed, but the risks and benefits of treatment, taking into account severity of depressive symptoms, stage of gestation, and associated circumstances, should be evaluated by a psychiatrist or high-risk obstetrician. SSRIs should not be stopped precipitously.
Because this patient is on a known medication classified as FDA pregnancy category X (atorvastatin), continued treatment with this agent would be inappropriate.
Key Point
Statins, ACE inhibitors, and angiotensin receptor blockers are teratogenic and should be discontinued in women planning pregnancy.
Bibliogrpahy
Callegari LS, Ma EW, Schwarz EB. Preconception care and reproductive planning in primary care. Med Clin North Am. 2015 May;99(3):663-82. [PMID: 25841606]