{"id":742,"date":"2015-06-23T12:55:54","date_gmt":"2015-06-23T12:55:54","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=742"},"modified":"2017-08-21T11:45:01","modified_gmt":"2017-08-21T11:45:01","slug":"primary-care-corner-with-geoffrey-modest-md-new-vs-old-ocps-and-thromboembolism","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/06\/23\/primary-care-corner-with-geoffrey-modest-md-new-vs-old-ocps-and-thromboembolism\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: New vs old OCPs and thromboembolism"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

The BMJ just published a large analysis of\u00a0the relationship between combined oral contraceptives OCPs\u00a0and the risk of venous thromboembolism VTE\u00a0<\/span>(see\u00a0BMJ 2015;350:h2135). They analyzed\u00a02 nested case-control studies from 2 different UK\u00a0<\/span>databases, with a combined input\u00a0from 1340 general practices, assessing the first diagnosis of VTE in women aged 15-49 from 2001-2013, and comparing this group to\u00a05 controls matched for age, practice, and calendar year. <\/span><\/p>\n

Results:<\/span><\/p>\n

–10562 cases of VTE. mean age 38, 27% smokers in the VTE cases and 21% in\u00a0controls, obesity in 27% vs 16% in controls. established risk factors for VTE were 47% vs 26% in controls<\/span><\/p>\n

–odds ratio for incident VTE\u00a0and use of OCPs in the previous year, adjusted for smoking, alcohol, ethnic group, BMI, comorbidities, and other contraceptives:<\/span><\/p>\n

–current exposure to any OCP was associated with increased risk of VTE [odds ratio\u00a0OR 2.97 (2.78-3.17)]\u00a0vs no OCP\u00a0exposure over the previous year, with breakdown as follows.<\/span><\/p>\n

–newer OCPs:<\/span><\/p>\n

–desogestrel \u00a0 \u00a0 \u00a0 \u00a0\u00a0OR 4.28\u00a0\u00a0(3.66-5.01)<\/span><\/p>\n

–gestodene \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0OR\u00a03.64\u00a0\u00a0(3.00-4.43) \u00a0–not available in the US<\/span><\/p>\n

–drospirenone\u00a0 \u00a0 \u00a0\u00a0OR\u00a04.12(3.43-4.96)<\/span><\/p>\n

–cyproterone\u00a0 \u00a0 \u00a0 \u00a0\u00a0OR\u00a04.27\u00a0 (3.57-5.11) \u00a0–not available in the US<\/span><\/p>\n

–older OCPs (second generation)<\/span><\/p>\n

–levonorgestrel \u00a0 \u00a0\u00a0OR 2.38 (2.18-2.59)<\/span><\/p>\n

\u200b–norethisterone \u00a0 \u00a0OR\u00a02.56 (2.15-3.06) \u00a0 \u00a0–not available in the US<\/span><\/p>\n

–norgestimate \u00a0 \u00a0 \u00a0\u00a0OR 2.53 ( 2.17-2.96) \u00a0–actually a third generation OCP\u00a0which is partly metabolized to levonorgestrel, but is less androgenic than levonorgestrel and is actually\u00a0considered a second generation one in Denmark.<\/span><\/p>\n

–this translates to: the number of extra cases of VTE per year per women<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0–levonorgestrel was lowest at 6 (5-7), along with norgestimate at 6 (5-8)<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u200b–desogestrel was highest at 14 (11-17), along with\u00a0cyproterone\u00a0at 14 (11-17)<\/span><\/p>\n

–overall, the risk associated with gestodene was 1.5x higher than levonorgestrel (the most commonly used in the UK), and those of desogestrel, drospirenone, and cyproterone was about 1.8x higher<\/span><\/p>\n

–desogestrel had a slightly higher odds ratio for VTE with higher doses of estrogen. norethisterone and gestodene actually had slightly higher VTE rates at the lower estrogen dosages (these were not significant, which\u00a0seems to support the primary association being with the progestin in these women already on lowish doses of estrogen)
\n\u200b<\/span><\/p>\n

So,\u00a0most,\u00a0but not all,\u00a0studies over the past 2 decades\u00a0have often shown increased VTE risk in the 3rd and\u00a04th generation OCPs. The current very large UK groups, given the high quality of reporting, provides more information, though it is retrospective and observational. In terms of bias,\u00a0one might think that since there have been older studies showing increased VTE risk with the newer agents,\u00a0there might have been preselection bias to avoiding these agents in women surmised to be at somewhat increased risk, leading to understating the actual\u00a0risk. \u00a0Although I do not prescribe OCPs so often these past years, I must admit that I have been largely avoiding the newer agents because of the issue of increased VTE found in several of the earlier studies, and now confirmed here.\u200b<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

By: Dr. Geoffrey Modest The BMJ just published a large analysis of\u00a0the relationship between combined oral contraceptives OCPs\u00a0and the risk of venous thromboembolism VTE\u00a0(see\u00a0BMJ 2015;350:h2135). They analyzed\u00a02 nested case-control studies from 2 different UK\u00a0databases, with a combined input\u00a0from 1340 general practices, assessing the first diagnosis of VTE in women aged 15-49 from 2001-2013, and comparing […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-742","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/742","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=742"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/742\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=742"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=742"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=742"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}