|Systematic (IUPAC) name|
|Trade names||Cytotec, Misodel|
|Oral, vaginal, sublingual|
|Protein binding||80-90% (active metabolite, misoprostol acid)|
|Metabolism||Hepatic (extensive to misoprostic acid)|
|Biological half-life||20–40 minutes|
|CAS Registry Number|
|ATC code||A02 G02|
|Molecular mass||382.534 g/mol|
Misoprostol is a medication used to health system. Misoprostol was invented and marketed by G.D. Searle & Company (now Pfizer) under the trade name Cytotec, but other trade names and generic formulations are available.
Medical uses 1
- Ulcer prevention 1.1
- Labor induction 1.2
- Abortion 1.3
- Missed miscarriage 1.4
- Postpartum bleeding 1.5
- Adverse effects 2
- Usage 3
- Society and culture 4
- Pharmacology 5
- Veterinary medicine 6
- References 7
- External links 8
Misoprostol is approved for use in the prevention of NSAID-induced gastric ulcers. It acts upon gastric parietal cells, inhibiting the secretion of gastric acid by G-protein coupled receptor-mediated inhibition of adenylate cyclase, which leads to decreased intracellular cyclic AMP levels and decreased proton pump activity at the apical surface of the parietal cell. Because other classes of drugs, especially H2-receptor antagonists and proton pump inhibitors, are more effective for the treatment of acute peptic ulcers, misoprostol is only indicated for use by people who are both taking NSAIDs and are at high risk for NSAID-induced ulcers, including the elderly and people with ulcer complications. Misoprostol is sometimes coprescribed with NSAIDs to prevent their common adverse effect of gastric ulceration (e.g. with diclofenac in Arthrotec).
Misoprostol has other protective actions, but is only clinically effective at doses high enough to reduce gastric acid secretion. For instance, at lower doses, misoprostol may stimulate increased secretion of the protective mucus that lines the gastrointestinal tract and increase mucosal blood flow, thereby increasing mucosal integrity. However, these effects are not pronounced enough to warrant prescription of misoprostol at doses lower than those needed to achieve gastric acid suppression.
However, even in the treatment of NSAID-induced ulcers, omeprazole proved to be at least as effective as misoprostol, but was significantly better tolerated, so misoprostol should not be considered a first-line treatment. Misoprostol-induced diarrhea and the need for multiple daily doses (typically four) are the main issues impairing compliance with therapy.
Misoprostol is commonly used for labor induction. It causes uterine contractions and the ripening (effacement or thinning) of the cervix. It can be significantly less expensive than the other commonly used ripening agent, dinoprostone (trade names Cervidil and Prepidil).
Oxytocin (trade names Pitocin and Syntocinon) has long been used as the standard agent for labor induction, but does not work well when the cervix is not yet ripe. Misoprostol also may be used in conjunction with oxytocin.
Between 2002 and 2012, extensive safety testing of a controlled-delivery formulation of misoprostol was performed, and misoprostol was approved in the EU under the trade names "Misodel" or "Mysodelle". The US FDA, though, refused to grant approval to this formulation, and it remains unapproved for labor induction in the US.
Misoprostol is used for
- Misoprostol.org an independent website containing dosage guidelines and advice on misoprostol use.
- The Mechanism of Action and Pharmacology of Mifepristone, Misoprostol, and Methotrexate
- "Misoprostol". The American Society of Health-System Pharmacists. Retrieved Feb 20, 2015.
- "WHO Model List of EssentialMedicines" (PDF). World Health Organization. October 2013. Retrieved 22 April 2014.
- Hawkey CJ, Karrasch JA, Szczepañski L, et al. (March 1998). "Omeprazole compared with misoprostol for ulcers associated with nonsteroidal antiinflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management (OMNIUM) Study Group". N. Engl. J. Med. 338 (11): 727–34.
- Wood, Alastair J. J.; Goldberg, Alisa B.; Greenberg, Mara B.; Darney, Philip D. (2001). "Misoprostol and Pregnancy". New England Journal of Medicine 344 (1): 38–47.
- Summers, L (1997). "Methods of cervical ripening and labor induction". Journal of Nurse-Midwifery 42 (2): 71–85.
- "Ferring's removable misoprostol vaginal delivery system, approved for labour induction in European Decentralised Procedure". Ferring. 17 October 2013. Retrieved 26 November 2013.
- Wing, Deborah. "Misoprostol Vaginal Insert and Time to Vaginal Delivery: A Randomized Controlled Trial". Obstetrics and gynaecology. Wolters Kluwer Health. Retrieved 2014-05-26.
- "Medical methods for first trimester abortion". The WHO Medical Reproductive Library. Retrieved 2014-06-22.
- Safe abortion: technical and policy guidance for health systems World Health Organization, 2012
- What is the "Mexican abortion pill" and how safe is it? Jen Gunter, July 27, 2013
- "Annotated Bibliography on Misoprostol Alone for Early Abortion" (PDF). Gynuity Health Projects. Retrieved 2006-08-22.
- providing medical abortion in low-resource settings (PDF) (2 ed.). Gynuity Health Projects. 2009. p. 4.
- "Instructions for Use: Abortion Induction with Misoprostol in Pregnancies up to 9 Weeks LMP" (PDF). Gynuity Health Projects. 2003. Retrieved 2006-08-24.
- Neilson, James P; Hickey, Martha; Vazquez, Juan C (2006). Neilson, James P, ed. "Medical treatment for early fetal death (less than 24 weeks)". Cochrane Database of Systematic Reviews (3): CD002253.
- Villar, J; Gülmezoglu, AM; Hofmeyr, GJ; Forna, F (2002). "Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage". Obstetrics & Gynecology 100 (6): 1301–12.
- O'Brien, P; El-Refaey, H; Gordon, A; Geary, M; Rodeck, CH (1998). "Rectally administered misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: A descriptive study". Obstetrics & Gynecology 92 (2): 212–4.
- Lokugamage, Amali U.; Sullivan, Keith R.; Niculescu, Iosif; Tigere, Patrick; Onyangunga, Felix; Refaey, Hazem El; Moodley, Jagidesa; Rodeck, Charles H. (2001). "A randomized study comparing rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion for the cessation of primary post partum hemorrhage". Acta Obstetricia et Gynecologica Scandinavica 80 (9): 835–9.
- Bradley, S. E. K.; Prata, N.; Young-Lin, N.; Bishai, D.M. (2007). "Cost-effectiveness of misoprostol to control postpartum hemorrhage in low-resource settings". International Journal of Gynecology & Obstetrics 97 (1): 52–6.
- Derman, Richard J; Kodkany, Bhalchandra S; Goudar, Shivaprasad S; Geller, Stacie E; Naik, Vijaya A; Bellad, MB; Patted, Shobhana S; Patel, Ashlesha; et al. (2006). "Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: A randomised controlled trial". The Lancet 368 (9543): 1248–53.
- Sanghvi, Harshad; Zulkarnain, Mohammad; Chanpong, Gail Fraser (2009). Blouse, Ann; Lewison, Dana, eds. Prevention of Postpartum Hemorrhage at Home Birth: A Program Implementation Guide (PDF).
- Prata, Ndola; Passano, Paige; Bell, Suzanne; Rowen, Tami; Potts, Malcolm (2012). "New hope: community-based misoprostol use to prevent postpartum haemorrhage". Health Policy and Planning 368: 339–46.
- Briggs, G. G.; Wan, SR (2006). "Drug therapy during labor and delivery, part 2". American Journal of Health-System Pharmacy 63 (12): 1131–9.
- Wagner 2006
- Goldberg & Wing 2003, which cites:
- Costa, S. H.; Vessey, M. P. (1993). "Misoprostol and illegal abortion in Rio de Janeiro, Brazil". The Lancet 341 (8855): 1258–61.
- Coêlho, Helena Lutéscia; Teixeira, Ana Cláudia; De Fátima Cruz, Maria; Gonzaga, Sandra Luzia; Arrais, Paulo Sérgio; Luchini, Laura; La Vecchia, Carlo; Tognoni, Gianni (1994). "Misoprostol: The experience of women in Fortaleza, Brazil". Contraception 49 (2): 101–10.
- Barbosa, Regina Maria; Arilha, Margareth (1993). "The Brazilian Experience with Cytotec". Studies in Family Planning 24 (4): 236–40.
- Rocha, J. (1994). "Brazil investigates drug's possible link with birth defects". BMJ 309 (6957): 757–8.
- Gonzalez, Claudette Hajaj; Vargas, Fernando R.; Perez, Ana Beatriz Alvarez; Kim, Chong Ae; Brunoni, Decio; Marques-Dias, Maria Joaquina; Leone, Clea R.; Neto, Jordão Correa; et al. (1993). "Limb deficiency with or without Möbius sequence in seven Brazilian children associated with misoprostol use in the first trimester of pregnancy". American Journal of Medical Genetics 47 (1): 59–64.
- Erik Eckholm (July 13, 2013). "In Mexican Pill, a Texas Option for an Abortion". The New York Times. Retrieved July 14, 2013.
- Erica Hellenstein (June 27, 2014). "The Rise of the DIY Abortion in Texas". The Atlantic.
- Goldberg, A; Wing, D (2003). "Induction of laborthe misoprostol controversy". Journal of Midwifery & Women's Health 48 (4): 244–8.
- Goldberg & Wing 2003, which cites:
- WHO. "WHO Essential drug list 2005 section 22.1 website" (PDF). Retrieved 2006-12-06.
- "Denver attorney receives 'Case of the Year' honor".
Misoprostol is used in veterinary emergency services to treat some drug overdoses, such as with paracetamol, in dogs. It is also used to prevent gastric ulcers.
Misoprostol, a prostaglandin, binds to myometrial cells to cause strong myometrial contractions leading to expulsion of tissue. This agent also causes cervical ripening with softening and dilation of the cervix.
The largest medical malpractice award of nearly $70 million was awarded due to the use of misoprostol to induce labor in a California hospital.
A letter from Searle generated some controversy over the use of misoprostol in labor inductions. The American College of Obstetricians and Gynecologists holds that substantial evidence supports the use of misoprostol for induction of labor, a position it reaffirmed in 2000 in response to the Searle letter. Misoprostol is also on the WHO essential drug list for labor induction.
Society and culture
Misoprostol is used for self-induced abortions in Brazil, where black market prices exceed US$100 per dose. Illegal medically unsupervised misoprostol abortions in Brazil are associated with a lower complication rate than other forms of illegal self-induced abortion, but are still associated with a higher complication rate than legal, medically supervised surgical and medical abortions. Failed misoprostol abortions are associated with birth defects in some cases. Poor immigrant populations in New York have also been observed to use self-administered misoprostol to induce abortions, as this method is much cheaper than a surgical abortion (about $2 per dose). The drug is readily available in Mexico. Use of misoprostol has also increased in Texas in response to increase regulation of abortion providers.
All cervical ripening and induction agents can cause uterine hyperstimulation, which can negatively affect the blood supply to the fetus and increases the risk of complications such as uterine rupture. Concern has been raised that uterine hyperstimulation that occurs during a misoprostol-induced labor is more difficult to treat than hyperstimulation during labors induced by other drugs. Because the complications are rare, it is difficult to determine if misoprostol causes a higher risk than do other cervical ripening agents. One estimate is that it would require around 61,000 people enrolled in randomized controlled trials to detect a clinically significant difference in serious fetal complications and about 155,000 patients to detect a clinically significant difference in serious maternal complications.
Misoprostol should not be taken by pregnant women to reduce the risk of NSAID-induced gastric ulcers because it increases uterine tone and contractions in pregnancy, which may cause partial or complete abortions, and because its use in pregnancy has been associated with birth defects.
The next most commonly reported adverse effects of taking misoprostol orally for the prevention of gastric ulcers are: abdominal pain, nausea, flatulence, headache, dyspepsia, vomiting, and constipation, but none of these adverse effects occurred significantly more often than when taking placebos. In practice, fever is almost universal when multiple doses are given every 4 to 6 hours.
The most commonly reported adverse effect of taking a misoprostol orally for the prevention of stomach ulcers is diarrhea. In clinical trials, an average 13% of patients reported diarrhea, which was dose-related and usually developed early in the course of therapy (after 13 days) and was usually self-limiting (often resolving within 8 days), but sometimes (in 2% of patients) required discontinuation of misoprostol.
Misoprostol is also used to prevent and treat post-partum bleeding. Orally administered misoprostol was marginally less effective than oxytocin. The use of rectally administered misoprostol is optimal in cases of bleeding; it was shown to be associated with lower rates of side effects compared to other routes. Rectally administered misoprostol was reported in a variety of case reports and randomised controlled trials. However, it is inexpensive and thermostable (thus does not require refrigeration like oxytocin), making it a cost-effective and valuable drug to use in the developing world. A randomised control trial of misoprostol use found a 38% reduction in maternal deaths due to post partum haemorrhage in resource-poor communities. Misoprostol is recommended due to its cost, effectiveness, stability, and low rate of side effects. Oxytocin must also be given by injection, while misprostol can be given orally or rectally for this use, making it much more useful in areas where nurses and physicians are less available.
Misoprostol is regularly used in some Canadian hospitals for labour induction for fetal deaths early in pregnancy, and for termination of pregnancy for fetal anomalies. A low dose is used initially, then doubled for the remaining doses until delivery. In the case of a previous Caesarian section, however, lower doses are used.
Misoprostol is sometimes used to treat early fetal death in the absence of spontaneous miscarriage, but further research is needed to establish a safe, effective protocol.
Misoprostol can also be used to dilate the cervix in preparation for a surgical abortion, particularly in the second trimester (either alone or in combination with laminaria stents).
Most large studies recommend a protocol for the use of misoprostol in combination with mifepristone. Together they are effective in around 95% for early pregnancies. Misoprostol alone may be more effective in earlier gestation. WHO guidelines recommend for pregnancies up to 12 weeks to use up to 4 doses of misoprostol under the tongue or in the vagina with at least 3 hour intervals between doses. It works in 90% after first attempt and, in case of failure, the attempt may be repeated after a minimum of 3 days.
Misoprostol is most effective when it is used with methotrexate or mifepristone (RU-486). Misoprostol alone is less effective (typically 88% up to eight-weeks gestation). It is not inherently unsafe if medically supervised, but 1% of women will have heavy bleeding requiring medical attention, some women may have ectopic pregnancy, and the 12% of pregnancies that continue after misoprostol failure are more likely to have birth defects and are usually followed up with a more effective method of abortion.