Comparative safety & effectiveness of antihypertensive medications in pregnancy

描述（由申请人提供）：高血压疾病的复杂性估计占所有妊娠的6-8%，是胎儿和母亲发病率和死亡率的重要来源。大约3-4%的孕妇在怀孕期间会接触到抗高血压药物。在美国，妊娠期最常用的抗高血压药物是甲基多巴;然而，它是一种较老的，通常耐受性较差的药物。与其他类型的药物（包括α-β受体阻滞剂、β受体阻滞剂和钙通道阻滞剂）相比，在重要的妊娠结局方面，它可能是一种较差的治疗。然而，对于这些其他类别中的每一个，都提出了重要的胎儿安全问题。因此，拟议项目的主要目标是评估这些常用药物相对于甲基多巴的安全性和有效性。本研究旨在解决的临床问题是：“如果患者在妊娠期间因既存或妊娠期高血压而需要门诊抗高血压药物，对胎儿最安全的药物是什么，最有可能确保良好的妊娠结局？“我们还将检查妊娠早期暴露于噻嗪类利尿剂和血管紧张素转换酶抑制剂的安全性，这是妊娠期外育龄妇女最常见的抗高血压药物类型，因此是妊娠早期暴露的常见药物。该分析将解决临床问题：“对于计划怀孕或可能怀孕的女性，考虑到胎儿早期暴露于药物的可能性，哪些药物可以安全使用？“这项研究将使用从Medicaid Analytic Extract（MAX）获得的妊娠队列进行，这是一个基于人口的大型索赔数据库。使用这个数据集，我们开发了一个超过110万例妊娠的队列，其纵向数据涵盖了从孕前到产后的各个时期。这个队列与门诊药房索赔和胎儿记录有关，使其成为我们提出的研究的非常合适的数据源。本人将在Brigham and Women's Hospital药物流行病学和药物经济学部门（“该部门”）的完善基础设施内开展拟定研究。该司在利用观察数据来源进行出色的药物安全性和有效性研究方面有着悠久的记录。我将与来自哈佛大学各机构的导师和合作者组成的跨学科团队合作，这些机构在流行病学和统计方法，围产期药物流行病学，高危产科，高血压疾病和药物政策方面具有深厚的专业知识和国内/国际声誉。这项研究工作将由哈佛公共卫生学院的正式课程和该司经常举行的研讨会和实验室会议加以补充。这种密集的研究，指导和正规教育的结合将为我成为一个成功的，独立的产科药物流行病学研究人员提供必要的背景。

DESCRIPTION (provided by applicant): Hypertensive disorders complicate an estimated 6-8% of all pregnancies and are a significant source of fetal and maternal morbidity and mortality. Approximately 3-4% of all pregnant women will be exposed to antihypertensive medications during pregnancy. The antihypertensive most commonly used in pregnancy in the United States is methyldopa; however, it is an older, often poorly tolerated medication. It may be an inferior therapy with respect to important pregnancy outcomes compared to other classes of agents including alpha-beta blockers, beta blockers, and calcium channel blockers. Yet, for each of these other classes, important fetal safety concerns have been raised. The primary goal of the proposed project is therefore to evaluate the comparative safety and effectiveness of each of these commonly used agents relative to methyldopa. The clinical question this study aims to address is: "If a patient requires an outpatient antihypertensive during pregnancy for pre-existing or gestational hypertension, what is the safest agent for the fetus, and the one most likely to assure a good pregnancy outcome?" We will also examine the safety of first trimester exposure to thiazide diuretics and angiotensin converting enzyme inhibitors, which are the most common types of antihypertensives used in women of reproductive age outside of pregnancy and thus common first trimester exposures. This analysis will address the clinical question: "For a woman in whom pregnancy is planned or possible, which agents can be safely used given the potential for early fetal exposure to the medication?" The study will be performed using a pregnancy cohort obtained from the Medicaid Analytic Extract (MAX), a large population-based claims database. Using this dataset, we have developed a cohort of over 1.1 million pregnancies with longitudinal data that span from the pre-pregnancy to the postpartum periods. This cohort is linked to outpatient pharmacy claims and fetal records making it an exceptionally well-suited data source for the kind of study we propose. I will perform the proposed research within the well developed infrastructure of the Division of Pharmacoepidemiology and Pharmacoeconomics ("The Division") at the Brigham and Women's Hospital. The Division has a long track record of producing outstanding drug safety and effectiveness research using observational data sources. I will work with an interdisciplinary team of mentors and collaborators drawn from across institutions at Harvard University that have deep expertise and national/international reputations in epidemiological and statistical methods, perinatal pharmacoepidemiology, high-risk obstetrics, hypertensive diseases, and drug policy. This research work will be complemented by formal coursework at the Harvard School of Public Health and frequent seminars and lab meetings at the Division. This combination of intensive research, mentoring, and formal education will provide the necessary background for me to become a successful, independent researcher in obstetric pharmacoepidemiology.