What medications are contraindicated in pregnant and pediatric patients?

Contraindicated Medications in Pregnant and Pediatric Patients

ACE inhibitors, ARBs, and isotretinoin are absolutely contraindicated in pregnant women, while several medications including tetracyclines, fluoroquinolones, and high-dose aspirin are contraindicated in pediatric patients due to significant risks to development and safety. 1, 2

Medications Contraindicated in Pregnancy

Cardiovascular Medications

• ACE inhibitors (benazepril, captopril, fosinopril, lisinopril, quinapril)

  • Contraindicated in all trimesters of pregnancy
  • Can cause renal dysgenesis, oligohydramnios, neonatal anuric renal failure, intrauterine growth retardation, pulmonary hypoplasia, and fetal death 1
  • Women of childbearing age using ACE inhibitors should use reliable contraception 1

• Angiotensin Receptor Blockers (ARBs) (irbesartan, losartan, valsartan)

  • Contraindicated in all trimesters of pregnancy
  • Similar risks as ACE inhibitors
  • Women of childbearing age using ARBs should use reliable contraception 1

• Direct renin inhibitors and angiotensin receptor-neprilysin inhibitors

  • Contraindicated due to similar risks as ACE inhibitors 1

• Aldosterone antagonists

  • Contraindicated due to anti-androgen effects and potential teratogenesis 1

• Warfarin

  • Pregnancy Category X
  • Associated with fetal malformations 3

Dermatologic Medications

• Isotretinoin
  • Pregnancy Category X
  • Highly teratogenic with risk of birth defects up to 30% 2, 4
  • Requires two forms of effective contraception for one month before, during, and one month after therapy
  • Any suspected fetal exposure must be reported immediately 2

Weight Management Medications

• All FDA-approved weight loss medications
  • Contraindicated in women who are or may become pregnant
  • Women of reproductive potential must use reliable contraception 1
  • Includes phentermine, orlistat, phentermine/topiramate, naltrexone/bupropion, liraglutide, and semaglutide

Antirheumatic Drugs

• Medications with insufficient safety data to be avoided in pregnancy 1:
  • Apremilast
  • Avacopan
  • Baricitinib
  • Bosentan
  • Filgotinib
  • Leflunomide
  • Mepacrine
  • Tofacitinib
  • Upadacitinib
  • Voclosporin

Neurological Medications

• Sodium valproate

  • Known to be teratogenic
  • Must not be used in pregnancy 1

• Topiramate and candesartan

  • Contraindicated due to adverse effects on the fetus 1

Medications Contraindicated in Pediatric Patients

Cardiovascular Medications

• Noncardioselective beta-blockers (e.g., propranolol)

  • Contraindicated in pediatric patients with asthma and heart failure 1

• Beta-blockers in general

  • Contraindicated in insulin-dependent diabetic pediatric patients 1

Calcium Channel Blockers

• Immediate-release nifedipine
  • Contraindicated for children under 1 year of age 1

Respiratory Medications

• Certain antihistamines
  • First-generation antihistamines should be used with caution due to sedating properties 5
  • Oral decongestants should be avoided during pregnancy, especially in first trimester 5

Special Considerations for Both Populations

Medication Administration Principles

1. For pregnant women:

   • Use lowest effective dose for shortest duration
   • Greatest caution during first trimester (organogenesis)
   • Consider non-pharmacological approaches first

2. For pediatric patients:

   • Dose based on weight or body surface area
   • Consider developmental stage and organ maturity
   • Monitor for unique pediatric adverse effects

Common Pitfalls to Avoid

• Assuming adult medications are safe in children

  • Many medications lack pediatric safety data or have different risk profiles
  • Pediatric patients may have different pharmacokinetics and pharmacodynamics

• Assuming all medications in a class have the same contraindications

  • Within drug classes, individual agents may have different safety profiles
  • Example: While all ACE inhibitors are contraindicated in pregnancy, some beta-blockers may be used if benefits outweigh risks

• Overlooking potential drug interactions

  • Both pregnant women and children may be more susceptible to certain drug interactions
  • Consider all medications, including OTC products and supplements

• Ignoring patient education

  • Pregnant women need clear information about medication risks
  • Parents/guardians of pediatric patients need proper dosing instructions

By understanding these contraindications and following appropriate prescribing practices, clinicians can help minimize risks while effectively treating both pregnant women and pediatric patients.