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The influence of progestogen types on the risk of venous thrombosis An up-date jvind Lidegaard European Congress on Menopuse and Andropause. Athens March 2012 Gynaecological Clinic, Rigshospitalet University of Copenhagen OC generations

  1. The influence of progestogen types on the risk of venous thrombosis An up-date Øjvind Lidegaard European Congress on Menopuse and Andropause. Athens March 2012 Gynaecological Clinic, Rigshospitalet University of Copenhagen

  2. OC generations according to oestrogen dose and progestogen type Progestogen generation ”2” 3 1 2 3 4 Estrans Levonor- Norges- Deso- Gesto- Dros- NETA gestrel timate gestrel dene pirenone 50 high High dose EVRA NuvaRing - - 30-40 mid 1st + 2nd + + + +4th 20 low - 3rd + + - - E2/DNG + - - - - POP + + + Li/12

  3. Venous thrombosis in DK 2001-2009* Pregnant and puerperal women excluded Incidence per 100,000 years ( including users of hormonal contraception) 70 60 3/4 Deep venous Venous thrombosis 46 50 thrombosis alone 1/4 Pulmonary embolism 37 40 with or without DVT 28 30 Increase in incidence rate 20 of 5% per year 20 14 And 6.8 fold by age from 9 7 10 15 to 45 years. 0 Lidegaard et al BMJ 2011 Li/11

  4. CT, AMI and VT in DK 2001-2009* Pregnant and puerperal women excluded Incidence per 100,000 years ( including users of hormonal contraception) 70 64 60 CT Arterial Venous thrombosis 46 50 diseases 39 38 37 40 28 30 25 23 20 AMI 20 15 14 11 12 9 7 6 10 5 3 2 0,7 0,4 0 Lidegaard et al 2012 (submitted) and BMJ 2011 Li/12

  5. VT: Genetic risk factors Risk factor Prevalence RR Leiden fact V hetero 6% 8 Leiden fact V homoz 0.2% 64 Protein C insufficiency 0.2% 15 Protein S insufficiency <0.1% >10 Antithrombin III insuff. 0.02% 50 Prothrombin 20210A 2% 3 Hyperhomocysteinaemia 3% 3 Li/12

  6. VT: Acquired risk factors Prevalence RR Age ≥ 30 vs <30 50% 2.5 Pregnancy 4% 8 Adiposity (BMI>25) 30% 2 Varicose veins 8% 2 Immobilisation/trauma ? 2-10 Oral contraceptives 30% 3-6 Medical diseases 5%? 2-5 Li/12

  7. VT: Acquired risk factors Prevalence RR Age ≥ 30 vs <30 50% 2.5 Pregnancy 4% 8 Adiposity (BMI>25) 30% 2 Varicose veins 8% 2 Immobilisation/trauma ? 2-10 Oral contraceptives 30% 3-6 Medical diseases 5%? 2-5 Li/12

  8. Venous thrombosis in pregnant and puerperal women, DK 1995-2005. N=709 80 Incidence of VT per 10,000 exposure years 59 60 60 Puerperium Pregnancy (n=218) 48 (n=491) 39 Delivery 37 40 31 23 12 16 17 16 20 11 11 6 5 4 2 Gestational week Weeks after delivery 0 1-11 12- 24- 28- 32- 36 37 38 39 40+ 1 2 3 4 5-6 7-8 9-12 23 27 31 35 Li/12 Virkus et al. Thromb Haemost 2011; 106: 304-9

  9. VT: Acquired risk factors Prevalence RR Age ≥ 30 vs <30 50% 2.5 Pregnancy 4% 8 Adiposity (BMI>25) 30% 2 Varicose veins 8% 2 Immobilisation/trauma ? 2-10 Oral contraceptives 30% 3-6 Medical diseases 5%? 2-5 Li/12

  10. Adiposity in Danish women and men in 1994 and 2010 70 94 women 2010 women 94 men 2010 men 60 Adiposity: BMI >25 50 40 64 61 30 52 46 41 20 37 37 25 21 20 10 13 12 0 16-24 25-44 45-66 Li/12 www.si-folkesundhed.dk

  11. VT: Acquired risk factors Prevalence RR Age ≥ 30 vs <30 50% 2.5 Pregnancy 4% 8 Adiposity (BMI>25) 30% 2 Varicose veins 8% 2 Immobilisation/trauma ? 2-10 Oral contraceptives 30% 3-6 Medical diseases 5%? 2-5 Li/12

  12. 0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0 3 rd versus 2 nd generation COC Rate ratio Blomen- 126 2,3 kamp 88-92 WHO 433 2,1 1989-93 Jick 1,8 80 1991-94 Spitzer 471 1,5 1991-95 Lewis 502 0,8 1993-95 Farmer 1,6 85 1991-95 Todd 1,4 99 1992-97 Bloemen- 185 1,9 kamp 94-98 Parkin 2,9 26 1990-1998 Lidegaard 987 1,4 1994-98 Dinger 118 1,3 2000-04

  13. VT and COC drospirenone (4 th ) VT Risk Rate ratio no / 10,000 DRSP/2nd gen Dinger 07 118 9.1 1.0 (0.6-1.8) 4th/2nd Seeger 07 57 13.0 * 0.9 (0.5-1.6) 4th/???

  14. VT and COC drospirenone (4 th ) VT Risk Rate ratio no / 10,000 DRSP/2nd gen Dinger 07 118 9.1 1.0 (0.6-1.8) 4th/2nd Seeger 07 57 13.0 * 0.9 (0.5-1.6) 4th/???

  16. VT and drospirenone VT Risk Rate ratio no / 10,000 DRSP/2nd gen Dinger 07 118 9.1 1.0 (0.6-1.8) 4th/2nd Seeger 07 57 13.0 * 0.9 (0.5-1.6) 4th/??? 09 Vlieg 1,524 na 1.7 (0.7-3.9) 4th/2nd Lidegaard 09 4.213 7.8 1.6 (1.3-2.1) 4th/2nd

  17. OC and VT: Methods National Registry of National Registry of Patients (>1977) Medicinal products (>1995): OC use VT diagnoses, Medication against Previous CaVD/canc. BP , DM, Hyperchol. Pregnancies, surgery 1995 2005 Cause of Deaths Statistics of Denmark Registry (>1977) PIN-codes, education Lethal VT vital status, emigration Lidegaard et al. BMJ 2009

  18. OC and VT: Progestagen type adjusted for duration of use ug EE Neta Lng NGM Deso Gest Drsp CPA 50 1.4 1.2 na na na na na 1.0-2.1 0.9-1.7 30-40 1.0 1 1.2 1.8 1.9 1.64 1.9 0.7-1.4 Ref 1.0-1.5 1.5-2.2 1.6-2.2 1.3-2.1 1.5-2.4 20 na na na 1.5 1.5 na na 1.3-1.8 1.2-1.9 POP na 0.3 0.2-0.5 0.5 0.2-1.7 Mirena na 0.4 0.3-0.6 Lidegaard et al. BMJ 2009; 339; b2890 Li/09

  19. VT and drospirenone VT Risk Rate ratio no / 10,000 DRSP/2nd gen Dinger 07 118 9.1 1.0 (0.6-1.8) 4th/2nd Seeger 07 57 13.0 * 0.9 (0.5-1.6) 4th/??? 09 Vlieg 1,524 na 1.7 (0.7-3.9) 4th/2nd Lidegaard 09 4.213 7.8 1.6 (1.3-2.1) 4th/2nd

  20. Research story • 2010, Jan: Shapiro-Dinger critique*

  21. OC and VT: Methods National Registry of National Registry of Patients (>1977) Medicinal products (>1995): OC use VT diagnoses, Medication against Previous CaVD/canc. BP , DM, Hyperchol. Pregnancies, surgery 1995 2005 Cause of Deaths Statistics Denmark Registry (>1977) PIN-codes, education Lethal VT vital status, emigration Lidegaard et al. BMJ 2009

  22. Research story • 2010, Jan: Shapiro-Dinger critique* • 2010, Jan: EMA request • 2010, March: Agreement PI, EMA, and MH • 2010, June: Steering Committee established • 2010, Oct: Protocol agreement • 2010, New case-control study by Dinger

  23. VT and drospirenone VT Risk Rate ratio no / 10,000 DRSP/2nd gen Dinger 07 118 9.1 1.0 (0.6-1.8) 4th/2nd Seeger 07 57 13.0 * 0.9 (0.5-1.6) 4th/??? 09 Vlieg 1,524 na 1.7 (0.7-3.9) 4th/2nd Lidegaard 09 4.213 7.8 1.6 (1.3-2.1) 4th/2nd Dinger 10 680 na 1.0 (0.5-1.8) 4th/2nd

  24. Research story • 2010, Jan: Shapiro-Dinger critique* • 2010, Jan: EMA request • 2010, March: Agreement PI, EMA, Bayer • 2010, June: Steering Committee established • 2010, Oct: Protocol agreement • 2010, New case-control study by Dinger • 2011, March: Submission BMJ

  25. OC and VT: Methods National Registry of Registry of Medicinal Patients (>1977) products (>1995): OC use (>1995) VT diagnoses, Anticoagulation therapy Previous CaVD/canc. BP , DM, Hyperchol. Pregnancies, surgery 1995 2001 2005 2009 1.3 million women Cause of Deaths Statistics Denmark Registry (>1977) PIN-codes, education Lethal VT vital status, emigration Lidegaard et al. BMJ 2011

  27. Results 2001-2009 • Identified 15-49 years: 1,436,130 women • Excluded: 140,010 women • Included in analysis: 1,296,120 women • Observation years: 8,010,290 womenyrs • First time VT (all): 4,307 events First time DVT: 2,738 (64%) First time PE: 1,130 (26%) First time other VT: 357 (10%) Lidegaard et al. BMJ 2011; 343: d6423

  28. OC and VT: Progestogen type Confirmed versus non-use ug EE Neta Lng NGM Deso Gest Drsp Cypr 50 6.2 4.5 Patch na na na na 3.0-13.2 2.9-6.9 30-40 2.2 3.0 3.5 6.6 6.2 6.4 6.4 1.1-4.5 2.4-4.0 2.9-4.3 5.6-7.8 5.6-7.0 5.4-7.5 5.4-7.5 20 na na na 4.8 5.1 6.9 na 4.1-5.6 4.4-5.9 4.2-11.5 Vg. Ring POP 0.7 0.3-1.5 0.6 0.2-1.9 Mirena 0.7 0.5-1.1 Lidegaard et al. BMJ 2011; 343: d6423

  29. OC and VT: Progestogen type Confirmed versus non-use ug EE Neta Lng NGM Deso Gest Drsp Cypr 50 6.2 4.5 7.9 Patch na na na 3.0-13.2 2.9-6.9 3.5-17.7 30-40 2.2 3.0 3.5 6.6 6.2 6.4 6.4 1.1-4.5 2.4-4.0 2.9-4.3 5.6-7.8 5.6-7.0 5.4-7.5 5.4-7.5 20 na na na 4.8 5.1 6.9 na 4.1-5.6 4.4-5.9 4.2-11.5 6.5 4.5-8.9 Vaginal Ring POP 0.7 0.3-1.5 0.6 0.2-1.9 Lng-IUS 0.7 0.5-1.1 Lidegaard et al. In press

  30. Relative risk versus non-use Confirmed events only 10 Rate ratio 8 6 4 7,9 6,6 6,5 6,4 6,4 6,2 2 3,5 3 0 Lidegaard et al. BMJ 2011; 343: d6423 + new in press

  31. Relative risk versus non-use 10 Rate ratio Vs non use 8 6 4 7,3 6,8 6,3 5,9 5,6 2 3,6 0 Vlieg et al. BMJ 2009; 339; b2921

  32. VT and drospirenone VT Risk Rate ratio no / 10,000 DRSP/2nd gen Dinger 07 118 9.1 1.0 (0.6-1.8) 4th/2nd Seeger 07 57 13.0 * 0.9 (0.5-1.6) 4th/??? 09 Vlieg 1,524 na 1.7 (0.7-3.9) 4th/2nd Lidegaard 09 4.213 7.8 1.6 (1.3-2.1) 4th/2nd Dinger 10 680 na 1.0 (0.5-1.8) 4th/2nd Lidegaard 11 4,246 2.1 (1.6-2.8) 4th/2nd 9.3 IR = incidence per 10,000 women years

  33. VT and drospirenone VT Risk Rate ratio no / 10,000 DRSP/2nd gen Dinger 07 118 9.1 1.0 (0.6-1.8) 4th/2nd 09 Vlieg 1,524 na 1.7 (0.7-3.9) 4th/2nd Lidegaard 09 4.213 7.8 1.6 (1.3-2.1) 4th/2nd Dinger 10 680 na 1.0 (0.5-1.8) 4th/2nd Parkin 11 61 2.3 2.7 (1.5-4-7) 4th/2nd Jick 11 186 3.1 2.8 (2.1-3.8) 4th/2nd Lidegaard 11 4,246 9.3 2.1 (1.6-2.8) 4th/2nd IR = incidence per 10,000 women years

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