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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Etonogestrel implant: Drug information

Etonogestrel implant: Drug information
(For additional information see "Etonogestrel implant: Patient drug information" and see "Etonogestrel implant: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Nexplanon
Brand Names: Canada
  • Nexplanon
Pharmacologic Category
  • Contraceptive;
  • Progestin
Dosing: Adult
Contraception

Contraception: Subdermal: Insert 1 implant in the inner side of the upper, nondominant arm. Remove no later than 3 years after the date of insertion; may be replaced with a new implant at the time of removal if continued contraceptive protection is desired. After ruling out pregnancy, timing of insertion is based on the patient's contraceptive history:

Patients not currently using a hormonal contraceptive: Insert between days 1 through 5 of menstruation, even if the patient is still bleeding. A barrier method of contraception should be used for the first 7 days after insertion if deviating from the recommended timing of insertion. If intercourse has already occurred, pregnancy should be excluded.

Patients Switching to Etonogestrel from Another Contraceptive Methoda

Current method

Instructions for switching to etonogestrel

a A barrier method of contraception should be used for the first 7 days after insertion if deviating from the recommended timing of insertion. If intercourse has already occurred, pregnancy should be excluded.

b COC = Combined oral contraceptive

c IUS = intrauterine system

COCb

Insert etonogestrel on the day after the last active tablet was taken. At the latest, insert on the day following the usual tablet-free or placebo interval.

Progestin-only implant

Insert etonogestrel on same day as removal of implant.

Progestin-only injection

Insert etonogestrel on day next injection is due.

Progestin-only IUSc

Insert etonogestrel on same day as removal of IUS.

Progestin-only pill

Insert etonogestrel any day during the month within 24 hours of taking the last tablet.

Transdermal patch

Insert etonogestrel on the day when the transdermal patch is removed. At the latest, insert on the day following the transdermal-free interval.

Vaginal ring

Insert etonogestrel on the day the vaginal ring is removed. At the latest, insert on the day following the ring-free interval.

Use after childbirth (breastfeeding)

Insert etonogestrel after the fourth postpartum week and use a barrier method of contraception for the first 7 days of insertion. If intercourse has already occurred, pregnancy should be excluded.

Use after childbirth (not breastfeeding)

Insert etonogestrel between 21 to 28 days postpartum.a

Use after first trimester abortion or miscarriage

Insert etonogestrel within first 5 days following first trimester abortion or miscarriage.a

Use after second trimester abortion or miscarriage

Insert etonogestrel between 21 and 28 days following second trimester abortion or miscarriage.a

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Dosing: Hepatic Impairment: Adult

Use is contraindicated.

Dosing: Pediatric

(For additional information see "Etonogestrel implant: Pediatric drug information")

Contraception

Contraception: Postmenarche females: Subdermal: Insert 1 implant in the inner side of the upper, nondominant arm. Remove no later than 3 years after the date of insertion; may be replaced with a new implant at the time of removal if continued contraceptive protection is desired. After ruling out pregnancy, timing of insertion is based on the patient's recent contraceptive history:

No hormonal contraceptives within the past month: Insert between days 1 through 5 of menstruation, even if woman is still bleeding.

Switching from combination hormonal contraceptive:

Oral tablet: Insert on the day after the last active tablet (at the latest, insert on the day following the usual tablet-free or placebo interval).

Transdermal system or vaginal ring: Insert on the day of the removal of the transdermal system or vaginal ring (at the latest, insert on the day following the transdermal-free or ring-free interval).

Switching from a progestin-only contraceptive:

Oral tablet: Any day during the month; do not skip days between the last tablet and implant insertion.

Implant or intrauterine device (IUD): Insert on same day as removal of implant or IUD.

Injection: Insert on day next injection is due.

First trimester abortion or miscarriage: Insert within first 5 days following first trimester abortion or miscarriage.

Second trimester abortion or miscarriage: Insert between 21 and 28 days following second trimester abortion or miscarriage.

Postpartum: If not breastfeeding, insert between 21 to 28 days postpartum. If breastfeeding, insert after the fourth postpartum week and use a second nonhormonal form of contraception for the first 7 days of insertion.

Note: If following any of the above insertion schedules, no back-up contraception needed (except in postpartum women who are breastfeeding). If deviating, use a back-up nonhormonal contraceptive method for 7 days postinsertion. If intercourse has already occurred, pregnancy should be excluded.

Additional dosing considerations (Ref):

Initiation of therapy: May be started at any time in the menstrual cycle once it is determined that the woman is not pregnant. Back-up contraception is not needed if started within 5 days of onset of menstruation. If started >5 days after the onset of menstruation or at any time in a woman experiencing amenorrhea (not postpartum), back-up contraception should be used for 7 days.

Switching from a different contraceptive to an implant: May be started at any time if it is determined that the woman is not pregnant. Unless the woman abstains from sexual intercourse, a back-up method of contraception is needed if it has been >5 days since menstrual bleeding has begun. When an additional method of contraception is needed, consider continuing the woman's previous method for 7 days after inserting the implant.

Switching from an IUD to an implant: Continue the IUD for ≥7 days after the implant is inserted or advise the woman to abstain from sexual intercourse or use a barrier contraceptive for 7 days before removing the IUD. Alternately, an emergency contraceptive may be used at the time of IUD removal.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Dosing: Hepatic Impairment: Pediatric

Use is contraindicated in patients with hepatic impairment.

Adverse Reactions (Significant): Considerations
Gynecological bleeding

Etonogestrel is associated with changes in gynecological bleeding patterns (Ref). Reported bleeding patterns include infrequent, absent, prolonged, and frequent bleeding (Ref). While bleeding irregularities may affect quality of life, they are generally not harmful (Ref). However, they are the most common reason for discontinuation among users (Ref).

Mechanism: Not clearly established; hypotheses include estrogen changes and changes in molecular and/or cellular mechanisms within the endometrium (Ref).

Onset: Varied; changes in bleeding patterns during the first 3 months of therapy may be predictive of continued bleeding irregularities throughout therapy (Ref).

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for adults.

>10%:

Dermatologic: Acne vulgaris (14%)

Endocrine & metabolic: Weight gain (14%)

Gastrointestinal: Abdominal pain (11%)

Genitourinary: Gynecological bleeding (including amenorrhea [22%], frequent bleeding [7%], heavy menstrual bleeding, infrequent uterine bleeding [34%], prolonged menstrual bleeding [18%], spotty menstruation [12% to 37%]), mastalgia (13%), vaginitis (15%)

Nervous system: Headache (25%)

Respiratory: Pharyngitis (11%)

1% to 10%:

Gastrointestinal: Nausea (6%)

Genitourinary: Dysmenorrhea (7%), leukorrhea (10%)

Hypersensitivity: Hypersensitivity reaction (5%)

Local: Application-site reaction (implant site: 9%; including bruise [2%], hematoma [3%], localized erythema [3%], local pain [1% to 5%], local swelling [<1%])

Nervous system: Depression (6%), dizziness (7%), emotional lability (7%), nervousness (6%), pain (6%)

Neuromuscular & skeletal: Back pain (7%)

Respiratory: Flu-like symptoms (8%)

Postmarketing (postmenarche females and adults):

Cardiovascular: Acute myocardial infarction, deep vein thrombosis, edema, increased blood pressure, pulmonary embolism

Dermatologic: Alopecia (Lee 2006), chloasma, hypertrichosis, pruritus, seborrhea, skin rash, toxic epidermal necrolysis (Amin 2022), urticaria

Endocrine & metabolic: Decreased libido, hot flash, porphyria (cutaneous variegate) (Strome 2022), weight loss

Gastrointestinal: Constipation, diarrhea, flatulence, increased appetite, vomiting

Genitourinary: Breast hypertrophy, dysuria, ectopic pregnancy (Rodrigues 2021), genital pruritus, nipple discharge, ovarian cyst, urinary tract infection, vaginal discomfort

Hypersensitivity: Anaphylaxis, angioedema (including exacerbation of angioedema and exacerbation of hereditary angioedema)

Nervous system: Anxiety, cerebrovascular accident, drowsiness, fatigue, insomnia, intracranial hypertension (Tan 2019), migraine, seizure

Neuromuscular & skeletal: Arthralgia, lipoatrophy (application site) (Lindsay 2009), musculoskeletal pain, myalgia

Respiratory: Rhinitis

Miscellaneous: Fever

Contraindications

Hypersensitivity to etonogestrel or any component of the formulation; breast cancer (known, suspected, or personal history of); progestin-sensitive cancer (current or a history of); hepatic tumors (benign or malignant) or active hepatic disease; pregnancy (known or suspected); thrombosis or thromboembolic disorders (current or history of); undiagnosed abnormal genital bleeding.

Warnings/Precautions

Concerns related to adverse effects:

• Cervical cancer: The use of combination hormonal contraceptives has been associated with a slight increased risk of cervical cancer; however, studies are not consistent, and the risk may be related to the specific histologic type of cervical cancer, duration of contraceptive use, and other factors (Asthana 2020; Gadducci 2020). Theoretically, use may affect prognosis of existing disease. Patients awaiting treatment for cervical cancer may use progestin-only contraceptives (CDC [Curtis 2016b]).

• Ovarian cysts: Follicular development may occur and may continue to increase in size beyond what may occur in a normal cycle; generally, ovarian cysts resolve spontaneously without intervention; however, surgery may rarely be required.

• Retinal thrombosis: Discontinue if unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions occur and immediately evaluate for retinal thrombosis.

• Thromboembolism: Combination hormonal contraceptives may increase the risk of vascular and deep venous thrombotic events (eg, deep vein thrombosis [DVT], myocardial infarction, pulmonary embolism [PE], retinal vein thrombosis, stroke, venous thromboembolism [VTE]). The risk of DVT/PE is expected to be less with progestin only contraceptives than that observed with combination hormonal contraceptives (CDC [Curtis 2016b]). Use caution in patients with risk factors for thromboembolism; remove implant if an arterial or venous thromboembolic event occurs.

• Weight gain: Use commonly results in an average weight gain of ~2.8 pounds after 1 year and ~3.7 pounds after 2 years of treatment.

Disease-related concerns:

• Bariatric surgery: Fertility is increased following bariatric surgery. All available forms of contraception can be considered following bariatric surgery, considering the patient's body weight and time since surgery; however, long-acting reversible nonoral contraceptives (eg, implants, IUDs) may be preferred. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy both have the potential to expedite transit through the small bowel. RYGB may not significantly alter the absorption of oral estrogen or progestins (limited evidence following a single dose); however, gastric and small bowel transit is not well studied following chronic oral dosing, therefore contraceptive efficacy cannot be guaranteed. Oral contraceptives may be used in patients having adjustable gastric banding unless there is diarrhea or vomiting. Reliable contraception using oral contraceptives cannot be guaranteed following jejunoileal bypass, biliopancreatic diversion, single anastomosis duodeno-ilial bypass, or omega-loop gastric bypass. Estrogen-containing birth control should be stopped at least 4 weeks prior to bariatric surgery and resumed no earlier than 4 weeks after surgery to minimize risk of VTE (Ciangura 2019; Mechanick 2020; Moreira de Brito 2021; Shawe 2019).

• Cardiovascular disease: Use with caution in patients with risk factors for cardiovascular disease (eg, hypertension, hypercholesterolemia, morbid obesity, diabetes, patients who smoke) (CDC [Curtis 2016b])

• Depression: Use with caution in patients with a history of depression; consider removing implant if serious depression occurs.

• Diabetes: May impair glucose tolerance; use caution in patients with diabetes or prediabetes.

• Diseases exacerbated by fluid retention: Use with caution in patients with diseases that may be exacerbated by fluid retention.

• Gallbladder disease: Use of combination hormonal contraceptives may have an increased risk of developing gallbladder disease; it is not known if this risk increases with progestin only products.

• Hepatic adenomas or carcinomas: Use of combination hormonal contraceptives is associated with hepatic adenomas (rare). The risk with progestin only contraceptives is not known.

• Hepatic impairment: Etonogestrel may be poorly metabolized in patients with hepatic impairment. Discontinue if jaundice develops during therapy or if liver function becomes abnormal.

• Hyperlipidemia: Use caution in patients treated for hyperlipidemia; progestins may increase low-density lipoprotein concentrations.

• Hypertension: According to the manufacturer, patients with a history of hypertension-related diseases should be encouraged to use a nonhormonal form of contraception. In patients with hypertension that is well-controlled, use may be considered; monitor BP closely. If sustained hypertension develops during use, or if a significant increase in BP does not respond adequately to antihypertensive therapy, remove the implant. Patients with adequately controlled hypertension may use progestin-only implants; other risk factors for cardiovascular disease (such as older age, smoking, diabetes) should be considered when prescribing (CDC [Curtis 2016b]).

• Renal impairment: Patients with renal disease should be encouraged to use a nonhormonal form of contraception.

Special populations:

• Body weight: Lower etonogestrel serum concentrations are associated with increased BMI (Lazorwitz 2019). Use with caution in patients who are overweight (may be less effective, especially in the presence of other risk factors such as concomitant enzyme inducers that may influence serum concentrations). Women >130% of ideal body weight were not included in clinical studies; however, contraceptive failure was not observed in patients who were obese in a prospective study (Xu 2012). Progestin-only implants may be used in patients with a BMI ≥30 kg/m2 (CDC [Curtis 2016b]).

• Contact lens wearers: Any changes with lens tolerance or vision should be evaluated by an ophthalmologist.

• Surgical patients: Consider removal during periods of prolonged immobilization due to surgery or illness.

Dosage form specific issues:

• Implant: Broken or bent implants while in the patient's arm have been reported (may be related to manipulation of the implant or contact sports); migration of broken implant fragments within the arm have also been reported. The release rate of etonogestrel may be slightly increased with broken or bent implants. Ensure implant is removed in its entirety.

Other warnings/precautions:

• Appropriate use: Improper insertion may lead to unintended pregnancy. Insertion/removal should be done by a trained health care provider and implant must be palpable after insertion. Complications may occur from insertion and removal procedures including bleeding, hematoma, infection, pain, scarring, paraesthesia (due to neural injury), migration of the implant (due to IM or fascial insertion), and intravascular insertion. Cases in which the implant migrated within the pulmonary artery have been asymptomatic or associated with chest pain and/or respiratory disorders (eg, cough, dyspnea, hemoptysis). Deeply placed implants (deeper than subdermally) should be localized and removed as soon as possible to prevent migration. Treatment should be instituted for infection at the insertion site; if infection persists, the implant should be removed. Expulsion may occur following incomplete insertion or infection. The implant must be removed by the end of the third year.

• HIV infection protection: Use does not protect against HIV infection or other sexually transmitted diseases (CDC [Curtis 2016a]; CDC [Curtis 2016b]).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Implant, Subcutaneous:

Nexplanon: 68 mg (1 ea) [latex free]

Generic Equivalent Available: US

No

Pricing: US

Implant (Nexplanon Subcutaneous)

68 mg (per each): $1,387.54

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Implant, Subcutaneous:

Nexplanon: 68 mg (1 ea)

Administration: Adult

Subdermal: For subdermal insertion by health care providers trained in the insertion and removal procedure. Insert implant subdermally just under the skin at the inner side of the nondominant upper arm overlying the triceps muscle ~8 to 10 cm (3 to 4 inches) from the medial epicondyle of the humerus and 3 to 5 cm (1.25 to 2 inches) posterior to the sulcus between the biceps and triceps muscles. This location is intended to avoid the large blood vessels and nerves lying within and surrounding the sulcus. If it is not possible to insert at this location (eg, in patients with thin arms), insert as far posterior from the sulcus as possible. To ensure proper placement just under the skin, view advancement of the needle from the side, not from above the patient. Implant must be palpable after insertion. X-ray, CT scan, ultrasound scanning, or MRI may also be used to confirm the location of the implant if it is not palpable. Deeply placed implants (deeper than subdermally) should be localized and removed as soon as possible. Removal of deeply placed implants, implants that are not palpable, or implants that cannot be grasped during removal should be performed by health care providers trained in complex removal procedures. Inspect packaging prior to use; do not use if damaged (eg, torn, punctured). Use of a nonhormonal contraceptive (eg, condom) is required until the presence of the implant can be verified.

Perform removal under aseptic conditions. Inject local anesthetic under (not over) the implant. Confirm that the entire implant has been removed by measuring its length (4 cm). Remove all pieces if implant has broken. A new implant may be inserted in the same arm through the same incision as long as the site is in the correct location.

Refer to the manufacturer's product labeling for complete insertion, removal, and reinsertion instructions. Materials related to the insertion and removal of etonogestrel implant (including videos demonstrating insertion and removal) are available from the manufacturer (1-844-674-3200); www.nexplanontraining.com.

Administration: Pediatric

Subdermal: For insertion under local anesthesia by health care providers trained in the insertion and removal procedure. Insert implant subdermally just under the skin at the inner side of the nondominant arm overlying the triceps muscle ~8 to 10 cm (3 to 4 inches) from the medial epicondyle of the humerus and 3 to 5 cm (1.25 to 2 inches) posterior to the sulcus between the biceps and triceps muscles. To ensure proper placement just under the skin, view advancement of the needle from the side, not from above the patient. Implant must be palpable after insertion. X-ray, CT scan, ultrasound scanning, or MRI may also be used to confirm the location of the implant if it is not palpable. Deeply-placed implants should be localized and removed as soon as possible. Removal of deeply-placed implants, implants that are not palpable, or implants that cannot be grasped during removal should be performed by health care providers trained in complex removal procedures. Use of a nonhormonal contraceptive (eg, condom) is required until the presence of the implant can be verified.

Perform removal under aseptic conditions. Inject local anesthetic under (not over) the implant. When removing the implant, confirm that the entire implant has been removed by measuring its length (4 cm). Remove all pieces if implant has broken. A new implant may be inserted in the same arm through the same incision as long as the site is in the correct location.

Refer to the manufacturer's product labeling for complete insertion, removal, and reinsertion instructions. A User Card (to give to the patient), consent form (to keep on file), and patient product information are provided with the device. Materials related to the insertion and removal of etonogestrel implant (including videos demonstrating insertion and removal) are available from the manufacturer.

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2016 [group 2]).

Use appropriate precautions for receiving, handling, administration, and disposal. Gloves (single) should be worn during receiving, unpacking, and placing in storage.

NIOSH recommends double gloving and a protective gown during administration (NIOSH 2016).

Use: Labeled Indications

Contraception: For the prevention of pregnancy

Limitations of use: For use in patients who may become pregnant; not for use prior to menarche or post menopause.

Use: Off-Label: Adult

Dysmenorrhea (primary and secondary to endometriosis)

Medication Safety Issues
High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs that have a heightened risk of causing significant patient harm when used in error.

Metabolism/Transport Effects

Substrate of CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Adalimumab: May decrease the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Risk C: Monitor therapy

Aprepitant: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration with aprepitant, and to continue back-up contraception for 28 days after discontinuing aprepitant to ensure contraceptive reliability. Risk D: Consider therapy modification

Asparaginase Products: Hormonal Contraceptives may enhance the thrombogenic effect of Asparaginase Products. Management: Consider discontinuing hormonal contraceptives and using an alternative contraceptive method in patients treated with asparaginase products. Risk D: Consider therapy modification

Asunaprevir: May decrease the serum concentration of Hormonal Contraceptives. Management: Use of a high-dose oral contraceptive (at least 30 mcg of ethinyl estradiol combined with norethindrone) is recommended when combined with asunaprevir. Consider an additional barrier method when other forms of contraception are used with asunaprevir. Risk D: Consider therapy modification

Atazanavir: May decrease the serum concentration of Hormonal Contraceptives. Specifically, atazanavir/ritonavir may decrease concentrations of estrogens. Atazanavir may increase the serum concentration of Hormonal Contraceptives. Specifically, atazanavir alone may increase concentrations of estrogens and atazanavir alone or boosted may increase concentrations of progestins. Management: Dose adjustment of hormonal contraceptives or use of alternative or additional nonhormonal contraceptive may be needed when combined with atazanavir. See full interact monograph for details. Atazanavir/cobicistat with drospirenone is contraindicated. Risk D: Consider therapy modification

Bimekizumab: May decrease the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Brigatinib: May decrease the serum concentration of Hormonal Contraceptives. Management: Use a non-hormonal contraceptive during brigatinib use and for at least 4 months after the last brigatinib dose. Males with partners of reproductive potential should use contraception during treatment with brigatinib and for 3 months after brigatinib use. Risk D: Consider therapy modification

Carfilzomib: Hormonal Contraceptives may enhance the thrombogenic effect of Carfilzomib. Management: Consider alternative, non-hormonal methods of contraception in patients requiring therapy with carfilzomib, especially patients using carfilzomib in combination with dexamethasone, lenalidomide plus dexamethasone, or daratumumab plus dexamethasone. Risk D: Consider therapy modification

Chlorprothixene: Progestins may enhance the adverse/toxic effect of Chlorprothixene. Progestins may enhance the therapeutic effect of Chlorprothixene. Risk C: Monitor therapy

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Cobicistat: May decrease the serum concentration of Hormonal Contraceptives. Specifically, cobicistat may decrease serum concentrations of estrogens. Cobicistat may increase the serum concentration of Hormonal Contraceptives. Specifically, cobicistat may increase serum concentrations of progestins. Management: Use alternative or additional nonhormonal forms of contraception when estrogen-containing hormonal contraceptives are combined with cobicistat. Progestin-only contraceptives can be used without back up, but monitor for progestin toxicities. Risk D: Consider therapy modification

Colchicine: May enhance the adverse/toxic effect of Hormonal Contraceptives. Risk C: Monitor therapy

CYP3A4 Inducers (Moderate): May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing a moderate CYP3A4 inducer to ensure contraceptive reliability. Risk D: Consider therapy modification

CYP3A4 Inducers (Strong): May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing a strong CYP3A4 inducer to ensure contraceptive reliability. Risk D: Consider therapy modification

CYP3A4 Inducers (Weak): May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing a weak CYP3A4 inducer to ensure contraceptive reliability. Risk D: Consider therapy modification

CYP3A4 Inhibitors (Strong): May increase the serum concentration of Hormonal Contraceptives. Risk C: Monitor therapy

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Efavirenz: May decrease the serum concentration of Hormonal Contraceptives. Management: Use a back-up method during coadministration, and to continue back-up contraception for 12 weeks after stopping efavirenz to ensure contraceptive reliability. Injected depot medroxyprogesterone acetate does not appear to participate in this interaction. Risk D: Consider therapy modification

Elagolix: Hormonal Contraceptives may diminish the therapeutic effect of Elagolix. Specifically, estrogen-containing hormonal contraceptives may diminish the therapeutic effects of elagolix. Elagolix may decrease the serum concentration of Hormonal Contraceptives. Specifically, concentrations of progestins may be decreased with elagolix therapy. Elagolix may increase the serum concentration of Hormonal Contraceptives. Specifically, concentrations of ethinyl estradiol may be increased with elagolix therapy. Management: Use an alternative, nonhormonal contraceptive during treatment with elagolix and for at least 28 days following discontinuation of elagolix treatment. Use of elagolix 200 mg twice daily with an estrogen-containing hormonal contraceptive is not recommended Risk D: Consider therapy modification

Elexacaftor, Tezacaftor, and Ivacaftor: Hormonal Contraceptives may enhance the adverse/toxic effect of Elexacaftor, Tezacaftor, and Ivacaftor. Specifically, the risk for rash may be increased. Risk C: Monitor therapy

Encorafenib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Erdafitinib: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk X: Avoid combination

Etravirine: May decrease the serum concentration of Hormonal Contraceptives. Specifically, progestin concentrations may decrease. Etravirine may increase the serum concentration of Hormonal Contraceptives. Specifically, estrogen concentrations may increase. Risk C: Monitor therapy

Exenatide: Hormonal Contraceptives may diminish the therapeutic effect of Exenatide. Exenatide may decrease the serum concentration of Hormonal Contraceptives. Management: Administer oral hormonal contraceptives at least one hour prior to exenatide. Monitor blood glucose more frequently when patients treated with exenatide initiate therapy with a hormonal contraceptive. Increases in exenatide doses may be needed. Risk D: Consider therapy modification

Felbamate: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing felbamate to ensure contraceptive reliability. Risk D: Consider therapy modification

Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Flibanserin: Hormonal Contraceptives may increase the serum concentration of Flibanserin. Risk C: Monitor therapy

Fosaprepitant: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration with fosaprepitant, and to continue back-up contraception for 28 days after discontinuing fosaprepitant to ensure contraceptive reliability. Risk D: Consider therapy modification

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Griseofulvin: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing griseofulvin to ensure contraceptive reliability. Risk D: Consider therapy modification

Interleukin-6 (IL-6) Inhibiting Therapies: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Ivosidenib: May decrease the serum concentration of Hormonal Contraceptives. Management: Consider alternative methods of contraception (ie, non-hormonal) in patients receiving ivosidenib. Risk D: Consider therapy modification

Ixazomib: May decrease the serum concentration of Hormonal Contraceptives. More specifically, use of ixazomib with dexamethasone may decrease the serum concentrations of hormonal contraceptives. Management: Patients of reproductive potential should use a non-hormonal contraceptive method during treatment with ixazomib and for at least 90 days after the last ixazomib dose. Risk D: Consider therapy modification

Lixisenatide: Hormonal Contraceptives may diminish the therapeutic effect of Lixisenatide. Lixisenatide may decrease the serum concentration of Hormonal Contraceptives. Management: Administer oral hormonal contraceptives 1 hour before or at least 11 hours after administration of lixisenatide. Additionally, monitor blood glucose more frequently when patients treated with lixisenatide initiate therapy with a hormonal contraceptive. Risk D: Consider therapy modification

Mavacamten: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative contraceptive that is not sensitive to CYP3A4 induction or a back-up method during coadministration, and to continue back-up contraception for 4 months after stopping mavacamten to ensure contraceptive reliability. Risk D: Consider therapy modification

MetyraPONE: Progestins may diminish the diagnostic effect of MetyraPONE. Management: Consider alternatives to the use of the metyrapone test in patients taking progestins. Risk D: Consider therapy modification

MiFEPRIStone: May diminish the therapeutic effect of Hormonal Contraceptives. Management: Nonhormonal contraception should be used during, and for 4 weeks following, mifepristone treatment for hyperglycemia due to Cushing syndrome. If used for pregnancy termination, hormonal contraceptives can be used after pregnancy expulsion is confirmed. Risk D: Consider therapy modification

Mitotane: May decrease the serum concentration of Hormonal Contraceptives. Management: Effective nonhormonal contraception is recommended for those of reproductive potential during treatment with mitotane as well as after discontinuation of mitotane for as long as mitotane plasma levels are detectable. Risk X: Avoid combination

Mobocertinib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Mycophenolate: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients of childbearing potential who are taking hormonal contraceptives should use an additional form of barrier contraception during treatment with mycophenolate and for 6 weeks after mycophenolate discontinuation. Risk D: Consider therapy modification

Nirmatrelvir and Ritonavir: May decrease the serum concentration of Hormonal Contraceptives. Specifically, nirmatrelvir and ritonavir may decrease concentrations of estrogens. Nirmatrelvir and Ritonavir may increase the serum concentration of Hormonal Contraceptives. Specifically, nirmatrelvir and ritonavir may increase concentrations of progestins. Management: Use additional nonhormonal forms of contraception (back-up method) when estrogen-containing hormonal contraceptives are combined with nirmatrelvir/ritonavir. Progestin-only contraceptives can be used without back-up, but monitor for progestin toxicities. Risk D: Consider therapy modification

Octreotide: May decrease the serum concentration of Hormonal Contraceptives. Management: Women should use an alternative non-hormonal method of contraception or a back-up method when octreotide is combined with hormonal contraceptives. Risk D: Consider therapy modification

Olutasidenib: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Management: Avoid use of olutasidenib with sensitive or narrow therapeutic index CYP3A4 substrates when possible. If concurrent use with olutasidenib is unavoidable, monitor closely for evidence of decreased concentrations of the CYP3A4 substrates. Risk D: Consider therapy modification

Omaveloxolone: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

OXcarbazepine: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing oxcarbazepine to ensure contraceptive reliability. Risk D: Consider therapy modification

Perampanel: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients should use an alternative, nonhormonal-based form of contraception during the concurrent use of perampanel and for 1 month after discontinuing perampanel. Risk D: Consider therapy modification

Pexidartinib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Pitolisant: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients using hormonal contraception should be advised to use an alternative non-hormonal contraceptive method during treatment with pitolisant and for at least 21 days after discontinuation of pitolisant treatment. Risk D: Consider therapy modification

Protease Inhibitors: May decrease the serum concentration of Hormonal Contraceptives. Specifically, protease inhibitors may decrease concentrations of estrogens. Protease Inhibitors may increase the serum concentration of Hormonal Contraceptives. Specifically, protease inhibitors may increase concentrations of progestins. Management: Use alternative or additional nonhormonal forms of contraception when estrogen-containing hormonal contraceptives are combined with protease inhibitors. Progestin-only contraceptives can be used without back up, but monitor for progestin toxicities. Risk D: Consider therapy modification

Repotrectinib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Sugammadex: May diminish the therapeutic effect of Hormonal Contraceptives. Management: Patients receiving any hormonal contraceptive (oral or non-oral) should use an additional, nonhormonal contraceptive method during and for 7 days following sugammadex treatment. Risk D: Consider therapy modification

Taurursodiol: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk X: Avoid combination

Tazemetostat: May decrease the serum concentration of Hormonal Contraceptives. Management: Individuals of childbearing potential should use a non-hormonal contraceptive method during treatment with tazemetostat and for 6 months after. Males with partners of childbearing potential should use contraception during treatment and for 3 months after. Risk D: Consider therapy modification

Tetrahydrocannabinol and Cannabidiol: May decrease the serum concentration of Hormonal Contraceptives. Management: Product labeling recommends that patients taking hormonal contraceptives should use an additional, non-hormonal contraceptive or reliable barrier method during treatment with tetrahydrocannabinol and cannabidiol buccal spray. Risk D: Consider therapy modification

Thalidomide: Hormonal Contraceptives may enhance the thrombogenic effect of Thalidomide. Risk C: Monitor therapy

Tirzepatide: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients using oral hormonal contraceptives should switch to a non-oral contraceptive method, or add a barrier method of contraception, for 4 weeks after initiation of tirzepatide and for 4 weeks after each dose escalation of tirzepatide. Risk D: Consider therapy modification

Topiramate: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing topiramate to ensure contraceptive reliability. Risk D: Consider therapy modification

Tranexamic Acid: Hormonal Contraceptives may enhance the thrombogenic effect of Tranexamic Acid. Risk X: Avoid combination

Ulipristal: May diminish the therapeutic effect of Progestins. Progestins may diminish the therapeutic effect of Ulipristal. Risk X: Avoid combination

Ustekinumab: May decrease the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Vaborbactam: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing meropenem/vaborbactam to ensure contraceptive reliability. Risk D: Consider therapy modification

Vitamin K Antagonists (eg, warfarin): Hormonal Contraceptives may increase the serum concentration of Vitamin K Antagonists. Hormonal Contraceptives may decrease the serum concentration of Vitamin K Antagonists. Risk C: Monitor therapy

Voriconazole: Hormonal Contraceptives may increase the serum concentration of Voriconazole. Voriconazole may increase the serum concentration of Hormonal Contraceptives. Risk C: Monitor therapy

Reproductive Considerations

Evaluate pregnancy status prior to use.

Due to the risk of thromboembolism associated with pregnancy and the immediate postpartum period, the manufacturer does not recommend insertion <21 days' postpartum; however, available guidelines state that progestin-only implants may be inserted at any time if it is reasonably certain the patient is not pregnant, including immediately postpartum or post abortion (CDC [Curtis 2016a]). Administration immediately postpartum (prior to hospital discharge) may be offered regardless of breastfeeding status and may help prevent rapid repeat and unintended pregnancies (ACOG 2017).

Etonogestrel serum concentrations decrease by 1 week after removal of the implant; pregnancies have been reported as early as 7 to 14 days after removal. Restart contraception immediately after removal if continued contraception is desired.

All available forms of contraception, including etonogestrel, can be considered for patients on gender-affirming testosterone therapy after evaluating patient preferences and medical conditions (eg, risk for venous thromboembolism). Amenorrhea may be induced more rapidly when the implant is initiated with testosterone therapy (Bonnington 2020; Krempasky 2020).

Pregnancy Considerations

Use is contraindicated during pregnancy.

Etonogestrel is used to prevent pregnancy; the implant should be removed if pregnancy occurs. In general, the use of combination hormonal contraceptives, when inadvertently used early in pregnancy, have not been associated with teratogenic effects. There is no evidence that the risk is different with etonogestrel.

Ectopic pregnancy (rare) may occur more commonly than in patients using no contraception. The possibility of ectopic pregnancy should be considered in patients with lower abdominal pain.

Breastfeeding Considerations

Etonogestrel is present in breast milk.

Information related to the presence of etonogestrel in breast milk is available from 42 breastfeeding patients who initiated treatment 4 to 8 weeks postpartum. In a 4-month study, milk concentrations were highest 1 month after insertion of the implant and decreased as the dose released from the implant and maternal serum concentrations decreased (Reinprayoon 2000). The manufacturer reports the relative infant dose (RID) of etonogestrel to be 2.2% of the weight-adjusted maternal dose. In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000).

There are theoretical concerns that progestin implants may prevent the onset of lactogenesis (ACOG 2016); however, etonogestrel was not found to affect the quality or quantity of breast milk (Reinprayoon 2000). Breastfed infants of mothers with an etonogestrel implant were not found to have differences in growth (body length, biparietal head circumference, body weight) or adverse physical or psychomotor development in comparison to those infants of mothers using a nonhormonal contraceptive IUD (mean duration of breastfeeding was 421 days); infants were evaluated over 36 months (Taneepanichskul 2006). No difference in infant growth at 12 months of age was found with implant insertion within 48 hours of delivery compared to insertion 6 weeks after delivery; the majority of women in the study exclusively breastfed for 40 to 90 days postpartum (Carmo 2017).

According to the manufacturer, the decision to breastfeed should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of use to the mother. Although the manufacturer does not recommend insertion of the implant prior to 4 weeks postpartum, guidelines affirm progestin-only implants may be inserted at any time if it is reasonably certain the woman is not pregnant, including immediately postpartum in breastfeeding women (CDC [Curtis 2016a]).

Monitoring Parameters

Assessment of pregnancy status (prior to therapy); weight (optional; body mass index [BMI] at baseline may be helpful to monitor changes during therapy); assess potential health status changes at routine visits (CDC [Curtis 2016a]).

Monitor patient for vision changes; BP; signs and symptoms of thromboembolic disorders; signs or symptoms of depression; glycemic control in patients with prediabetes or diabetes; lipid profiles in patients being treated for hyperlipidemias. Bleeding irregularities including amenorrhea; adequate diagnostic measures should be performed to rule out malignancy in all cases of undiagnosed abnormal vaginal bleeding.

Mechanism of Action

Etonogestrel is the active metabolite of desogestrel. It prevents pregnancy by suppressing ovulation, increasing the viscosity of cervical mucous, and inhibiting endometrial proliferation.

Pharmacokinetics (Adult Data Unless Noted)

Duration: Each implant maintains etonogestrel levels sufficient to inhibit ovulation for 3 years

Distribution: Vd: ~201 L

Protein binding: Albumin (66%) and sex hormone-binding globulin (~32%)

Metabolism: Hepatic via CYP3A4; forms metabolites (activity not known)

Bioavailability: Implant: 100%

Half-life, elimination: ~25 hours

Excretion: Urine (primarily); feces

Pharmacokinetics note: The rod releases etonogestrel at a rate of 60 to 70 mcg/day in week 5 to 6, decreasing to ~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 ~25 to 30 mcg/day at the end of the third year. Following removal of rod, levels decrease rapidly and are less than the level of detection within 1 week

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Implanon;
  • (AR) Argentina: Implanon nxt;
  • (AT) Austria: Implanon | Implanon nxt;
  • (AU) Australia: Implanon | Implanon nxt;
  • (BE) Belgium: Implanon | Implanon nxt;
  • (BF) Burkina Faso: Implanon nxt;
  • (BR) Brazil: Implanon | Implanon nxt;
  • (CH) Switzerland: Implanon | Implanon nxt;
  • (CI) Côte d'Ivoire: Implanon nxt;
  • (CL) Chile: Implanon;
  • (CO) Colombia: Implanon | Implanon nxt;
  • (CZ) Czech Republic: Implanon | Nexplanon;
  • (DE) Germany: Implanon | Implanon nxt | Nexplanon;
  • (EC) Ecuador: Implanon nxt;
  • (EE) Estonia: Nexplanon;
  • (EG) Egypt: Implanon;
  • (ES) Spain: Implanon;
  • (ET) Ethiopia: Implanon nxt;
  • (FI) Finland: Implanon | Nexplanon;
  • (FR) France: Implanon;
  • (GB) United Kingdom: Implanon | Nexplanon;
  • (HK) Hong Kong: Nexplanon;
  • (HU) Hungary: Implanon;
  • (ID) Indonesia: Implanon;
  • (IE) Ireland: Implanon | Implanon nxt;
  • (IT) Italy: Implanon | Nexplanon;
  • (JO) Jordan: Implanon nxt;
  • (KE) Kenya: Implanon nxt;
  • (KR) Korea, Republic of: Implanon | Implanon nxt;
  • (KW) Kuwait: Implanon;
  • (LB) Lebanon: Implanon;
  • (LT) Lithuania: Nexplanon;
  • (LU) Luxembourg: Implanon;
  • (LV) Latvia: Nexplanon;
  • (MA) Morocco: Implanon nxt;
  • (MX) Mexico: Implanon nxt;
  • (MY) Malaysia: Implanon;
  • (NL) Netherlands: Implanon | Implanon nxt;
  • (NO) Norway: Implanon | Nexplanon;
  • (PE) Peru: Implanon | Nexplanon;
  • (PH) Philippines: Implanon | Implanon nxt;
  • (PK) Pakistan: Implanon nxt;
  • (PL) Poland: Implanon;
  • (PR) Puerto Rico: Implanon | Nexplanon;
  • (PT) Portugal: Implanon;
  • (PY) Paraguay: Implanon nxt;
  • (QA) Qatar: Implanon NXT;
  • (RU) Russian Federation: Implanon | Implanon nxt;
  • (SA) Saudi Arabia: Implanon nxt;
  • (SE) Sweden: Nexplanon;
  • (SG) Singapore: Implanon;
  • (SK) Slovakia: Implanon;
  • (TH) Thailand: Etoplan | Implanon | Implanon nxt;
  • (TN) Tunisia: Nexplanon;
  • (TR) Turkey: Implanon;
  • (UY) Uruguay: Implanon;
  • (ZA) South Africa: Implanon nxt;
  • (ZM) Zambia: Implanon nxt;
  • (ZW) Zimbabwe: Implanon nxt
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