Introduction: Domperidone is frequently prescribed postnatally to enhance lactation, however its use for this indication remains controversial owing to mixed efficacy and safety data, with particular concerns about QT prolongation. No Australian studies have examined patterns of domperidone prescribing in the general practice setting.

Aims: To describe longitudinal trends in postpartum domperidone prescribing, and to characterise dosing practices, electrocardiogram (ECG) monitoring rates, and between-practice variation across prescribing quality indicators.

Methods: Retrospective cohort study of women aged 18–49 years with one or more general practice encounters within six months of a live birth between 2011–2021, using the large general practice research dataset MedicineInsight. Individual patient prescription records were examined with data extracted on daily dose and treatment duration. Data on ECG monitoring was extracted from encounter notes, pathology tests and billing data. We examined differences in likelihood of domperidone prescribing according to patient characteristics using generalised linear modelling. Between-practice variation was quantified using two-level logistic regression with intraclass correlation coefficients (ICC), which included adjustments for differences in patient case mix across practices.

Results: Of 188,874 eligible live births, 16,645 (8.8%) received domperidone, increasing from 5.7% in 2011 to 11.4% in 2021. Most women (84.5%) were prescribed a dose of 30 mg/day or lower, with more than half (53.1%) having a treatment duration exceeding 28 days. Documentation of ECGs was infrequent occurring in less than 2%. Substantial between-practice variation was evident across dose, treatment duration, and ECG monitoring (ICCs ranging from 14% to 33%, all p-values <0.001).

Conclusions: Despite ongoing safety concerns, domperidone prescribing postpartum appears to be substantially increasing over time, with significant variation in prescribing practices and safety monitoring rates. Targeted quality improvement interventions at the practice level appear warranted, alongside updated prescriber guidance that addresses the gap between recommended and observed clinical practice.

Keywords: domperidone; galactagogue; lactation

Introduction: General practice is the primary setting for contraceptive care in Australia; however, no studies have examined the extent to which contraceptive prescribing varies across individual general practices.

Aims: This study aimed to assess variations in the prescribing of long-acting reversible contraceptives.

Methods: A retrospective cohort study of >1.6 million females aged 15-49 years attending 423 general practices between 2011 and 2021 was conducted, using a national research dataset, MedicineInsight. For each calendar year, we calculated the proportion of general practices that prescribed levonorgestrel intrauterine devices (LNG-IUDs), copper IUD and implants among practices that delivered any care to females of reproductive age and stratified results by practice remoteness. Variation in contraceptive prescribing across general practices was assessed using intraclass correlation coefficients (ICCs) derived from two-level logistic regression models adjusted for differences in patient case-mix between practices.

Results: Significant increases in the proportion of practices prescribing were observed for LNG-IUDs (from 83.1% in 2011 to 93.4% in 2021), implant (87.2% to 98.1%) and Copper IUD (3.0% to 37.8%). In 2011, IUD and implant prescribing was greater among sites located in regional/remote areas, however these differences were no longer evident in 2021. Using ICC, the highest level of variation in prescribing attributable to differences between general practices was evident for copper IUD (40%; 95%CI; 30-50%), LNG-IUD (21%; 95%CI; 17-23%) and implant (7%; 95%CI; 5-8%).

Conclusions: The proportion of Australian general practices prescribing long-acting reversible contraceptives increased over time. Observed differences in contraceptive prescribing were largely explained by patient demographic characteristics rather than differences between general practices.
Keywords: Contraception; drug utilisation; Long-acting reversible contraceptive

Introduction: Mental illness is common perinatally, and psychotropic medicines are recommended when clinically indicated, yet fetal and infant safety concerns often prompt treatment changes during these high-risk periods.
Aims: To describe patterns of psychotropic medicine utilisation across the perinatal period.
Methods: We conducted a retrospective population-based cross-sectional study using linked administrative data from the Early Life Course platform in New South Wales, Australia, including pregnancies with conception and childbirth between July 2013 and December 2018. We calculated monthly dispensing rates, prevalence, and incidence of psychotropic medicine use (antidepressants, antipsychotics, anxiolytics/hypnotics/sedatives, and attention-deficit/hyperactivity disorder [ADHD] medicines) from 12 months pre-conception to 12 months post-birth.
Results: The cohort included 453,923 pregnancies resulting in a birth, with 749,697 psychotropic medicines dispensed to 76,547 women (11.1%) across the pre-conception, pregnancy, and post-birth periods. Antidepressants were most commonly used across all periods (pre-conception prevalence 8.8%; pregnancy 4.8%; post-birth 10.0%), followed by anxiolytics/hypnotics/sedatives (3.4%; 0.9%; 2.4%), antipsychotics (0.8%; 0.5%; 0.8%), and ADHD medicines (0.2%; 0.1%; 0.1%). Monthly exposure declined from pre-conception through pregnancy, with the largest reductions in early pregnancy across all classes, and a further decline in late gestation for antidepressants and antipsychotics, alongside a relative increase in anxiolytic/hypnotic/sedative use. Postpartum use returned to pre-conception levels for most classes; however, antidepressant use exceeded pre-conception levels and showed a transient rise in initiation in the first two months postpartum before returning to baseline.
Conclusions: Psychotropic use declined substantially in early pregnancy and before childbirth, indicating discontinuation and low initiation despite guidelines against routine cessation. Although antidepressant use rose postpartum, overall prevalence (10%) fell below estimated perinatal depression and anxiety prevalence (12–17%), suggesting undertreatment. These findings highlight the need for better education, clearer safety guidance, and ongoing surveillance.

Keywords: perinatal, pharmacoepidemiology, psychotropics

Introduction: While the safety of antipsychotic use during pregnancy has been established in previous literature, discontinuation of antipsychotics in pregnant women remains common. Evidence regarding the risks of relapse after discontinuing antipsychotics during pregnancy remains limited.

Aims: To compare the risk of psychiatric disease relapse during pregnancy and within 90 days postpartum between those who discontinued antipsychotics within the first trimester and those who remained on treatment.

Methods: Target trial emulation using territory-wide electronic medical records in Hong Kong. Pregnant women with live births between 2001-2023 who received antipsychotics for a consecutive ≥90 days immediately before start of pregnancy were included. They were followed up from start of pregnancy (i.e. last menstrual period) till earliest of outcome occurrence, 90 days postpartum, death, or 31-Dec-2023. Primary outcome was psychiatric disease relapse, defined as psychiatric hospitalisation. Clone-censor-weight approach was used to minimize immortal time bias. Weighted pooled logistic regression adjusted for baseline covariates (age, index year, parity, socioeconomic status, psychiatric diagnoses, psychotropic medications) were used to estimate the risks of outcomes.

Results: 1,455 eligible pregnant episodes were included. 237 psychiatric hospitalisations were observed during a median (interquartile range) follow-up of 349 [195-363] days. Discontinuation of antipsychotics during first trimester was associated with increased risk of psychiatric hospitalisations compared to remaining on treatment (hazard ratio [95% CI]: 1.355 [1.023, 1.793], risk difference at 90-days postpartum [95% CI]: 7.74% [1.73, 14.46]), especially in those aged <35 years, with schizophrenia, received first-generation antipsychotics, or received ≥1 defined-daily-dose of antipsychotics.

Conclusions: Discontinuation of antipsychotics during the first trimester was associated with increased risks of psychiatric disease relapse during pregnancy and within 90 days postpartum. Considering the maternal and neonatal safety of antipsychotic use during pregnancy reported in previous literature, remaining on antipsychotic treatment may be preferred over discontinuation during pregnancy.

Keywords: Antipsychotic discontinuation, pregnancy, disease relapse

Introduction: Menopausal hormone therapy (MHT) prescribing has increased substantially in the United Kingdom (UK). Although MHT increases the risk of some cardiovascular diseases (CVD) in the general population, it is not contraindicated in women with diabetes. Therefore, evaluating the cardiovascular safety of MHT in this high-risk population is important.

Aims: We aimed to compare the risk of CVD between MHT initiators and non-initiators among women aged 48-55 years with type 2 diabetes in England.

Methods: We used data from the UK Clinical Practice Research Datalink (CPRD) linked to hospital and death records from January 2004 to June 2024. Women with prior CVD outcomes, breast or ovarian cancer, primary ovarian insufficiency, or surgical menopause were excluded. Sequential monthly trials were emulated from the date women reached the minimum eligible age, with inverse probability of treatment weighting (IPTW) to emulate randomisation. Pooled logistic regression estimated one-year risk ratios (RRs) for major adverse cardiovascular events (MACE), defined as cardiovascular death, myocardial infarction (MI), or stroke.

Results: A total of 85 trials were emulated, including 9,389 and 492,236 person-trials in initiator and non-initiator group, respectively. No significant differences in MACE were observed between groups in either intention-to-treat (ITT) or per-protocol (PP) analyses (ITT: RR 1.07 [95% CI 0.71-1.42]; PP: RR 1.16 [95% CI 0.71-1.58]). Analyses by individual outcomes showed similar results, with no significant differences observed. ITT analyses by route of administration showed no significant differences (oral: RR 1.36 [95% CI 0.62-2.26]; transdermal: RR 0.55 [95% CI 0.18-1.19].

Conclusions: In this emulated target trial, we did not observe an increased risk of MACE with MHT among women with type 2 diabetes aged 48–55 years. Route-specific analyses suggested a potentially lower risk with transdermal versus oral MHT, although wide confidence intervals may indicate limited power to detect differences.

Keywords: cardiovascular, diabetes, menopausal hormone therapy

Introduction: The use of antipsychotic medications during pregnancy requires careful risk-benefit consideration. Thus, managing maternal psychiatric conditions is critical. However, long-term epidemiological data in Asian populations remain limited.

Aims: This study aimed to investigate the prevalence and trends of antipsychotic use among pregnant women in Taiwan from 2004 to 2020.

Methods: This population-based cohort study utilized Taiwan's National Health Insurance Research Database and the National Birth Certificate Application database. A total of 3,261,859 pregnancies between 2004 and 2020 were identified. Women with at least 1 dispensed antipsychotic prescription during pregnancy were classified and further stratified into first-generation (FGAs) and second-generation antipsychotics (SGAs). Annual prevalence in the use of antipsychotics was assessed. We also conducted sensitivity analysis by excluding antipsychotic agents that were commonly prescribed for emesis and peptic ulcer (prochlorperazine, droperidol, and sulpiride).

Results: The overall prevalence of antipsychotic use was 8.40% during pregnancy. The prevalence of FGA use decreased from 2004 (10.14%) to 2014 (6.89%), before rising slightly to 8.19% in 2020. In contrast, SGA use remained stable between 2004 (0.45%) and 2008 (0.41%), halved in 2009 (0.17%), and increased slowly to 0.25% in 2020. In the sensitivity analysis, the overall prevalence dropped remarkably to 0.11%, and the prevalence of FGA use demonstrated a nearly threefold steady decrease from 2004 (0.14%) to 2020 (0.05%), whereas the SGA use increased from 2004 (0.01%) to 2020 (0.09%).

Conclusions: The overall prevalence of antipsychotics was a U-shaped trend with the lowest point in 2014. A distinct shift pattern in generation was observed over the 17 years, highlighting the changes in clinical practice. A more sophisticated definition of the use of antipsychotic agents was needed.

Keywords: Antipsychotics, Prevalence, Pregnancy