Journal Article

Exposure to candesartan during the first trimester of pregnancy in type 1 diabetes: experience from the placebo-controlled diabetic retinopathy candesartan trials

Malm, A., Hainer, J. W., Fuller, J. H., Jansson, S.-O., Parving, H.-H., Klein, R., Sjølie, A.-K., Orchard, T., Bilous, R., Porta, M., Chaturvedi, N.

2011

Overview

Aims/hypothesis The teratogenic consequences of angiotensin-converting enzyme inhibitors angiotensin receptor blockers (ARBs) during the second and third trimesters of pregnancy are well described. However, the consequences of exposure during the first trimester are unclear, especially in diabetes. We report the experience from DIRECT (DIabetic REtinopathy and Candesartan Trials), three placebo-controlled studies designed to examine the effects of an ARB, candesartan, on diabetic retinopathy. Methods Over 4 years or longer, 178 normotensive women with type 1 diabetes (86 randomised to candesartan, 32 mg once daily, and 92 assigned to placebo) became pregnant (total of 208 pregnancies). Results More than half of patients were exposed to candesartan or placebo prior to or in early pregnancy, but all discontinued it at an estimated 8 weeks from the last menstrual period. Full-term pregnancies (51 vs 50), premature deliveries (21 vs 27), spontaneous miscarriages (12 vs 15), elective terminations (15 vs 14) and other outcomes (1 vs 2) were similar in the candesartan and placebo groups. There were two stillbirths and two ‘sick babies’ in the candesartan group, and one stillbirth, eight ‘sick babies’ and one cardiac malformation in the placebo group. Conclusions/interpretation The risk for fetal consequences of ARBs in type 1 diabetes may not be high if exposure is clearly limited to the first trimester. Long-term studies in fertile women can be conducted with ARBs during pregnancy, provided investigators diligently stop their administration upon planning or detection of pregnancy. Trial registration ClinicalTrials.gov DIRECT-Prevent 1 NCT00252733; DIRECT-Protect 1 NCT00252720; DIRECT-Protect 2 NCT00252694. Funding The study was funded jointly by AstraZeneca and Takeda.

• Publisher: Springer-Verlag,Springer,Springer Nature B.V,Springer Verlag
• Subject: Abnormalities, Drug-Induced / Abnormalities, Drug-Induced - epidemiology / Adolescent / Adult / Angiotensin Receptor Antagonists / Angiotensin Receptor Antagonists - adverse effects / Angiotensin Receptor Antagonists - therapeutic use / Antihypertensives / Benzimidazoles / Benzimidazoles - adverse effects / Benzimidazoles - therapeutic use / Biological and medical sciences / Diabetes / Diabetes Mellitus, Type 1 / Diabetes Mellitus, Type 1 - complications / Diabetes. Impaired glucose tolerance / Diabetic Retinopathy / Diabetic Retinopathy - drug therapy / Diabetic Retinopathy - etiology / Endocrine pancreas. Apud cells (diseases) / Endocrinopathies / Enzymes / Epidemiology / Etiopathogenesis. Screening. Investigations. Target tissue resistance / Female / Hospitals / Human Physiology / Humans / Hypertension / Hypertension - drug therapy / Hypertension - physiopathology / Internal Medicine / Life Sciences / Medical sciences / Medicine / Medicine & Public Health / Metabolic Diseases / Ophthalmology / Pregnancy / Pregnancy Complications, Cardiovascular / Pregnancy Complications, Cardiovascular - drug therapy / Pregnancy Complications, Cardiovascular - physiopathology / Pregnancy Outcome / Pregnancy Trimester, First / Retinopathies / Risk Factors / Tetrazoles / Tetrazoles - adverse effects / Tetrazoles - therapeutic use / Womens health / Young Adult