Canadian Pharmacists Journal - May/June 2019 - 161

PRACTiCeTOOL
Therefore, patients can complete a MA in the
comfort of their home, with the agreement of a
follow-up visit with their prescriber after 7 to 14
days to confirm the abortion was successful.1,5

Contraindications to medical
abortion

There are several conditions where MIFE/MISO
is contraindicated, although some are relative.1,5
Pharmacists should confirm that no contraindications exist before dispensing MA. The Canadian
Abortion Providers Support network provides
useful checklists for prescribers and pharmacists.6 Absolute contraindications include the following: the presence of an ectopic pregnancy, as
MIFE/MISO will not work and surgery is more
appropriate; chronic adrenal failure, as MIFE
is a potent antiglucocorticoid that can decrease
the action of cortisol replacement therapy; and
inherited porphyria, as MIFE can increase the
likelihood of an acute porphyria attack.1,5 Other
absolute contraindications include uncontrolled
asthma, a known allergy to the medications and
patient uncertainty about having an abortion.1,5
The presence of an intrauterine device (IUD)
is a relative contraindication, as the pregnancy has
an increased chance of being ectopic. If an ectopic
pregnancy is ruled out, the IUD must be removed
before taking the MA medications.1,5 The need for
long-term corticosteroid therapy is a relative contraindication, as effectiveness is reduced for 3 to 4
days after MIFE administration.1,5 Therefore, either
a SA can be offered or the steroid therapy can be
adjusted during MA, such as by increasing the dose
for a week, although this will require close monitoring.1,5 Blood loss is routine with MA, so patients
who have blood disorders, use anticoagulants or
have severe anemia should use MA with caution.1,5
Patients with severe anemia (<95 mg/L) were
excluded from studies in MA.1,5 Surgical abortion
is the preferred method in many of these cases.1,5

Drug interactions

Pharmacists play a significant role during MA
dispensing, as they can easily identify drug interactions. While the clinical significance of the
drug interactions is not clear, MIFE is metabolized by the CYP3A4 enzyme. CYP3A4 inducers
such as rifampicin, barbiturates, carbamazepine
and St. John's wort may decrease the effectiveness of mifepristone.5,7 CYP3A4 inhibitors like
ketoconazole, erythromycin and grapefruit juice
may increase the side effects of MIFE, such as
C P J / R P C  *  M ay / J u n e  2 0 1 9  *  V O L  1 5 2 ,  N O  3 

nausea.5,7 Buccal and vaginal MISO do not have
clinically significant drug interactions, although
the coadministration with antacids or food may
decrease its bioavailability if it is taken orally
instead of buccally.5,7

Preparing the patient

Many patients are often uneducated about what
to expect when they have a MA. Pharmacists can
fill this gap by counselling patients during dispensing. For example, most patients will not feel
anything after taking MIFE, but light bleeding
may begin.1,5 Some patients choose to take MISO
in the evening to allow the process to occur overnight, especially if they must care for children or
family members during the day. Heavier bleeding
than menses will start within 3 hours of taking
MISO and should only last a few hours.1,5 Patients
should expect to pass tissues ranging from the
size of a quarter up to a lemon.7 Light bleeding
usually lasts about 2 weeks, and patients should
only use sanitary pads and should avoid tampons.1,5 Some patients may wonder if they will
see a fetus. A fetus should not be obvious if the
patient is less than 56 days pregnant (8 weeks).1
Most patients will have painful cramps.
Pharmacists can recommend nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen.1,5 These are more effective than
acetaminophen, and some patients may also
wish to have a prescription for an opioid.1 MISO
can cause nausea, diarrhea, dizziness, fever and
headaches usually within 2 to 4 hours of administration.1,5 Over-the-counter loperamide and
dimenhydrinate can be helpful suggestions to
combat these side effects.
If patients vomit within 1 hour of taking
MIFE, the pharmacist can contact the prescriber
to request another dose to be taken with an
antinausea medication like dimenhydrinate or
ondansetron.1,5 By comparison, MISO is quickly
absorbed. If the patient vomits when the MISO
is still placed in the cheeks, she should be reassessed in 2 to 3 hours for onset of effect before
taking a second dose.1,5
Pharmacists should also inquire about the plan
for future contraception, as ovulation can occur
within 8 days of MA.1,5 Patients can use condoms
or barriers as soon as they feel ready to engage
in intercourse. Oral contraceptive pills and progestin-only pills can be started when MISO is
taken.1,5 An IUD can be inserted at the follow-up
visit with the MA prescriber.1,5
161
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