Photo Credit: iStock.com/Natali_Mis

Research showed that many anesthesia providers lack knowledge of sugammadex and aprepitant contraceptive interactions and offer suboptimal related counseling.

A recent study published in Anesthesia & Analgesia revealed gaps in anesthesia providers’ knowledge of sugammadex’s and aprepitant’s interactions with various hormonal contraceptives (HCs), as well as suboptimal patient counseling and shared decision‐making.

Although drug interactions are routinely reviewed with patients before surgery, studies have indicated that counseling on certain perioperative medications’ potential to compromise HCs remains insufficient. In particular, sugammadex—which increases the speed of neuromuscular blockade reversal—and aprepitant, used to mitigate postoperative nausea and vomiting, are infrequently discussed in relation to HC efficacy. This communication shortfall can precipitate unintended pregnancies and preventable health complications.

Gauging Awareness

To illuminate this protocol gap, study author Molly B. Kraus, MD, Mayo Clinic, and colleagues developed an online survey to determine anesthesia providers’ theoretical understanding of sugammadex-HC and aprepitant-HC interactions and to gauge the frequency of provider-patient pre-surgery discussions relating to these interactions. The study solicited participation from 1,092 anesthesia healthcare providers; 337 completed the survey, comprising 98 attending anesthesiologists, 34 anesthesiology residents/fellows, 179 certified registered nurse anesthetists (CRNAs), and 26 student registered nurse anesthetists (SRNAs).

Sugammadex Use

Current practice reflects broad uptake of sugammadex, with 88% of respondents preferring it for neuromuscular blockade reversal. Awareness that sugammadex interferes with oral contraceptives was nearly universal (96%), but recognition of its impact on other HC methods was lower: 61% acknowledged interaction with levonorgestrel intrauterine devices (IUDs; Mirena), 70% with etonogestrel implants (Nexplanon), and 66% with medroxyprogesterone injections (Depo-Provera).

Labeling stipulates that patients should use alternative contraception for 7 days after sugammadex administration; only 52% of providers cited this correct interval. The remainder recommended 10 days (5.4%), 14 days (20.9%), or 30 days (14%). Only 49% reported being satisfied with their training on sugammadex’s contraceptive implications.

Aprepitant Use

Aprepitant’s perioperative use was less frequent: 48% of respondents reported never or rarely administering it in the past year. Knowledge of its interaction with oral contraceptive pills was acknowledged by 46.8% of respondents, yet only 32% knew of its interference with levonorgestrel IUDs, 36% with etonogestrel implants, and 34%, with medroxyprogesterone injections.

Clinical guidance recommends alternative contraception for 28 to 31 days after aprepitant administration; 38.5% of providers identified this timeframe correctly, whereas others cited 0 days (6.5%), 7 days (24.9%), 10 days (3.2%), or 14 days (16.8%). A mere 11% deemed training on aprepitant’s contraceptive interactions adequate, according to the study.

Discussions & Shared Decision-Making

Although 83% of respondents agreed that sugammadex’s interference with HCs merits preoperative discussion—and 76% concurred that aprepitant’s effects should likewise be addressed—routine practice falls short, according to survey results:

• For aprepitant, 73% rarely or never discussed contraception use with patients before an operation.
• For sugammadex, 36% rarely or never discussed contraception use with patients before an operation.

In addition, although support for patient involvement in the decision-making process was strong [practitioners in training (92%), residents (85%), SRNAs (100%), attendings (59%)], most respondents reported rarely engaging in such shared decision-making. Specifically:

• Seventy-nine percent of all providers reported that they had rarely or never provided a choice between perioperative use of neostigmine and sugammadex for patients using HCs, although 72% responded that this should be a shared provider-patient decision.
• Seventy-eight percent said that the choice between aprepitant and an alternative antiemetic should be a shared decision in the perioperative setting, yet 82% responded that they had never or rarely provided this option to patients using HCs.

Lastly, many providers believed that the interactions between sugammadex and HCs and between aprepitant and HCs were poorly taught during training, according to survey findings.

The Path Forward

“This survey illuminates critical deficiencies in both provider knowledge and patient counseling regarding perioperative medications that may compromise hormonal contraceptives,” the authors concluded. “To mitigate unintended pregnancies and safeguard patient health, it is imperative to standardize education, integrate explicit counseling protocols into perioperative workflows, and foster shared decision-making between clinicians and HC users.”