Implants

Contraceptive Subdermal Implants

1. Contraceptive Subdermal Implants Presented by: Anvita Jadhav M. Pharm (IP) 1

2. Contraception Contraception include various methods or devices used to Prevent pregnancy 2

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4. Contraceptive Subdermal Implants This is excellent method of contraception. The implants are small and rod shaped. Contraceptive implants provide long-acting, highly effective reversible contraception. Nonbiodegradable & Progestines only Provides controlled release of progestin over years The rods are implanted surgically into upper nondominant arm. 4

5. Types of Contraceptive Implants 5

6. Levonorgestrel (LNG) Levonorgestrel is a totally synthetic and biologically active progestin. Mechanism of action Production of viscous cervical mucus that impairs sperm penetration. Inhibition of ovulation by action on the hypothalamus and pituitary to suppress or reduce the surge of Luteinising Hormone (LH) that triggers ovulation. 6

7. Norplant Levonorgestrel Crystals Thin walled silicone tubing Silicon Adhesive It is a type of Polymer membrane permeation-controlled drug delivery system. It is fabricated from a silicone elastomer tubing, by sealing both ends with silicone adhesive to encapsulate levonorgestrel crystals The thickness of the wall controls the rate of the drug release 7

8. It consisted of six flexible rods each containing 36 mg of levonorgestrel . Each capsule was 34 mm long with a diameter of 2.4 mm. It can prevent pregnancy for 5 years 8

9. Silicon Elastomer Suitable for long-term implanted devices Biocompatible Consistent from batch to batch Sterilizable 9

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11. Jadelle Jadelle is manufactured by Bayer HealthCare. This system consists of two implantable rods (2.5 mm in diameater & 43 mm in length), each consisting of a drug-releasing core encased in thin-walled silicone rubber tubing sealed at both ends. The core of each rod consists of 50% by weight of levonorgestrel (75mg) and 50% of elastomer . Prevention of pregnancy for the long-term (up to 5years) reversible method of contraception. 11

12. Jadelle Kit 12 Needle

13. The two rods are placed in the shape of a ‘V’ opening toward the shoulder. Levonorgestrel released per rod at a rate of 80 mcg/day in the first month, 50 mcg/day by 9 months, and then 25 to 30 mcg/day. 13

14. After placement of Jadelle implants, maximum levonorgestrel concentrations are reached in about 2 to 3 days. The mean levonorgestrel concentrations slowly decline to approximately 435 ± 172 pg/ mL at 1 month 357 ± 155 pg/ mL at 6 months, and 280 ± 123 pg/ mL at 3 years. Concentrations at 4 and at 5 years are similar to those at 3 years. 14

15. Sino-implant (II) Sino-implant (II), manufactured in China by Shanghai Dahua Pharmaceutical Co Ltd. Sino-implant (II) lasts four years. 15

16. Insertion The LNG implant should be inserted within 1 - 5 days of menses. When switching from LNG-IUD implant can be inserted after 7 days. Implants may be inserted within 5 days of a first trimester abortion & second trimester abortion. 16

17. Etonogestrel (ENG) Etonogestrel is a synthetic and biologically active progestin. Mechanism of action: (a) thickening cervical mucus which prevents sperm penetration (b) preventing ovulation 17

18. Implanon I t is a single rod implant that releases etonogestrel w hich prevents pregnancy for 3 years. It measures 4-cm long and 2mm in diameter. It is a made up of core containing an 40% ethylene vinyl acetate copolymer & 60% ENG (68 mg), surrounded by a 60- μ m skin of EVA copolymer. Etonogestrel released at a rate of 60 to 70 mcg/day initially, 35 to 45 mcg/day at the end of the first year, 30 to 40 mcg/day at the end of the second year, and finally 25 to 30 mcg/day at the end of the third year. 18

19. Initially, serum levels of ENG rapidly rise to a mean serum concentration of 265.9±80.9 pg/ mL by 8 hours, a level that exceeds the 90 pg/ mL needed to prevent ovulation. Maximum serum concentrations are usually seen by day 4 after implant insertion. ENG levels decrease slightly to a mean serum concentration of 196 pg/ mL at 1 year of use and 156 pg/ mL by 3 years. After removal, serum levels are undetectable (less than 20 pg/ mL ) by 1 week in the majority of users, with most women demonstrating ovulation within 6 weeks of implant removal. 19

20. Implanon Kit 20

21. Failure Rate (%) Return to Fertility Effectiveness DMPA ( DepoProvera ) 0.3 6-month delay At least 3 month Copper-T IUD (ParaGard T 380A) 0.6 Immediate Up to 10 y LNG-IUD ( Mirena ) 0.1 Immediate Up to 5 y Single-Rod ENG implant (Implanon) 0.1 Immediate Up to 3 y 21

22. Nexplanon Nexplanon is manufactured by Merck/MSD. Nexplanon and Implanon are bioequivalent The only difference is the addition of barium sulfate which makes Nexplanon radio-opaque. This means that it can be seen on X-ray, computed tomography (CT) and magnetic resonance imaging (MRI). Therefore easier to locate. 22

23. Insertion For women without preceding hormone use, the ENG implant should be inserted within 5 days from the start of menses. When switching from a oral contraceptive pills, insertion should occur within 7 days of the last active pill. Implants may be inserted within 5 days of a first trimester abortion, within 6 weeks of a second trimester abortion, or within 6 weeks of childbirth. 23

24. Difference between LNG & ENG 24

25. Insertion of Implant 25

26. Removal of Implant 26

27. It was developed in Brazil, its active ingredient is nestorone . Discontinued due to endometriosis It contains 55 mg of nomegestrol acetate that offers contraceptive efficacy for 1 year. It is currently under clinical trials. Elcometrine Uniplant 27

28. Advantages 28

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30. Disadvantages 30

31. Contraindications 31

32. Contraceptive implants for men MENT ® is created from a synthetic steroid that resembles testosterone (7α-methyl-19-nortestosterone). It is one-year implant that is placed under the skin of the upper arm. MENT ® under development at the Population Council. 32

33. Conclusion 33

34. References Contraceptive Methods in Focus: IUDs, Implants, and Oral Contraceptives, Outlook, Path, Vol. 21, No. 1, Pg. No. 1 – 8, 2004. Frost and Reich, Chapter 6 Norplant: Access to Contraceptives, Pg. No. 115 – 140, 2009. Ione Cristina Barbosa , Hugo Maia Jr., Elsimar Coutinho , Renata Lopes, Antonio C.V. Lopes, Cristina Noronha and Adelmo Botto , Effects of a single Silastic contraceptive implant containing nomegestrol acetate ( Uniplant ) on endometrial morphology and ovarian function for 1 year, Contraception, Pg. No.492 – 497, 2006. Irving Sivin , Harold Nash and Sandra Waldman, Jadelle Levonorgestrel Rod Implants: A Summary of Scientific Data and Lessons Learned from Programmatic Experience, The Population Council, Pg. No. 1 – 58, 2002. Heather Hohmann and Mitchell D. Creinin , The Contraceptive Implant, Clinical Obstetrics and Gynecology, Vol. 50, No. 4, Pg. No. 907–917, 2007. Population Reports: New Contraceptive Choices, The Info Project, Series M, No.19, Pg. No. 1 – 25, 2005. Power J, French R and Cowan F, Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods for preventing pregnancy (Review), The Cochrane Library, Issue 4, Pg. No. 1 – 38, 2008. 34

35. References Robin M. Zavod , Chapter 41 Women’s Health, Foye’s Principles of Medicinal Chemistry, Ed. 7 th , Pg. No. 1386 – 1410, 2013. Rebecca L. Callahan, Douglas Taylor, David W. Jenkins, Derek H. Owen, Linan Cheng, Aida M. Cancel, Laneta J. Dorflinger and Markus J. Steiner, In vivo release of levonorgestrel from Sino-implant (II) — an innovative comparison of explant data, Contraception, Pg. No. 1 – 6, 2015. Thuong-Thuong Nguyen and Paul D. Blumenthal, Contraceptive Procedures: Subdermal Contraceptive Implants, A Practical Guide to Office Gynecologic Procedures, Pg. No. 145 – 154, 2013. Woraprapa Laphikanont and Surasak Taneepanichskul , Effects of Jadelle Used in Thai Women Aged between 20 and 45 Years in King Chulalongkorn Memorial Hospital, J Med Assoc Thai, Vol. 89 No. 6, Pg. No. 761 – 766, 2006. Yie W. Chien and Senshang Lin, Drug Delivery: Controlled Release, Encyclopedia of Pharmaceutical Technology, Pg. No. 1082 – 1086, 2007. http://www.popcouncil.org/research/ment-subdermal-implants-for-men http://adisinsight.springer.com/drugs/800008022 http://www.medicinenet.com/script/main/art.asp?articlekey=53351 35

36. Thank U 36