etonogestrel (Rx)

Brand and Other Names:Implanon, Nexplanon
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

implant

  • 68mg
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Contraception

Insert 1 implant subdermally

No preceding hormonal contraceptive use in past month: Insert between Days 1 through 5

Switch from combination other contraceptive

  • OCP: Within 7 days after last active pill
  • Vaginal ring: During 7-day ring-free period etonogestrel/ethinylestradiol
  • Transdermal patch: During 7-day patch-free period of a transdermal contraceptive system

Switch from progestin-only contraceptive

  • Any day of the month when switching from pill; do not skip any days between last pill and insertion
  • On the same day as contraceptive implant removal
  • On the same day as removal of a progestin-containing IUD
  • On the day when next contraceptive injection would be due

Administration

For detailed info regarding use following delivery/abortion/miscarriage, see manufacturer's package insert

May be used for up to 3 years and then requires replacement

Insertion procedure and technique differs between brands

Nexplanon: Radiopaque; may use X-ray, CT, ultrasound, or MRI to locate once implanted

Implanon: Nonradiopaque; may use ultrasound or MRI to locate once implanted

Confirm that the entire implant, which is 4 cm long, has been removed by measuring its length

When an implant is broken or bent, in situ, the release rate of etonogestrel may be slightly increased; important to remove in its entirety

Not recommended

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Interactions

Interaction Checker

and etonogestrel

No Results

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    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Oligomenorrhea (34%)

            Headache (25%)

            Vaginitis (24.5%)

            Amenorrhea (22%)

            Menorrhagia (18%)

            Weight gain (14%)

            Acne (13.5%)

            Breast pain (13%)

            Upper resp tract infection (13%)

            Pharyngitis (11%)

            Leucorrhea (10.5%)

            1-10%

            Back pain (7%)

            Depression (6%)

            Dizziness (7%)

            Dysmenorrhea (7%)

            Emotional lability (7%)

            Flu-like symptoms (8%)

            Insertion-site pain (9%)

            Nausea (6%)

            Nervousness (6%)

            Pain (6%)

            Postmarketing Reports

            Gastrointestinal disorders: Constipation, diarrhea, flatulence, vomiting

            General disorders and administration site conditions: Edema, fatigue, implant site reaction, pyrexia

            Immune system disorders: Anaphylactic reactions

            Infections and infestations: rhinitis, urinary tract infection

            Investigations: Clinically relevant rise in blood pressure, weight decreased

            Metabolism and nutrition disorders: Increased appetite

            Musculoskeletal and connective tissue disorders: Arthralgia, musculoskeletal pain, myalgia

            Nervous system disorders: Convulsions, migraine, somnolence

            Pregnancy, puerperium and perinatal conditions: Ectopic pregnancy

            Psychiatric disorders: Anxiety, insomnia, libido decreased

            Renal and urinary disorders: Dysuria

            Reproductive system and breast disorders: Breast discharge, breast enlargement, ovarian cyst, pruritus genital, vulvovaginal discomfort

            Skin and subcutaneous tissue disorders: Angioedema, aggravation of angioedema and/or aggravation of hereditary angioedema, alopecia, chloasma, hypertrichosis, pruritus, rash, seborrhea, urticaria

            Vascular disorders: Hot flush

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            Warnings

            Contraindications

            Documented hypersensitivity

            Active or history of breast cancer

            Arterial thromboembolic disease (stroke, MI), thrombophlebitis, DVT/PE, thrombogenic valvular disease

            Estrogen-dependent neoplasia, liver disease, liver tumors

            Undiagnosed abnormal vaginal bleeding

            Uncontrolled hypertension

            Diabetes mellitus with vascular involvement

            Jaundice with prior oral contraceptive use

            Hypersensitivity to etonogestrel or component of the formulation

            Current/history of thrombophlebitis, thromboembolic disorders

            Missed abortion

            Cautions

            Caution in family history of breast cancer and or DVT/PE, current/history of depression, endometriosis, DM, HTN, bone mineral density changes, renal/hepatic impairment, bone metabolic disease, SLE; conditions exacerbated by fluid retention (eg, migraine, asthma, epilepsy).

            Discontinue if the following develop jaundice, visual problems (may cause contact lens intolerance), any signs of VTE, migraine with unusual severity, severe depression, increased risk of thromboembolic complications after surgery.

            May cause retinal vascular thrombosis; discontinue if loss of vision, migraine proptosis, diplopia or other visual disturbances occur

            Discontinue 4 week before major surgery or prolonged immobilization

            Use caution in patients on warfarin, oral anticoagulants (increase in anticoagulant dose may be warranted)

            Some studies link OCP use with increased risk of breast cancer, whereas other studies have not shown a change in risk; woman's risk depends on conditions where naturally high hormone levels persist for long periods of time including early onset menstruation before age 12, late onset menopause, after age 55, first child after age 30, nulliparity

            Increased risk of cervical cancer with OCP use, however HPV remains as main risk factor for this cancer; evidence suggests long-term use of OCPs, 5 or more years, may be associated with increased risk

            Increased risk of liver cancer with OCP use; risk increases with longer duration of OCP use

            Be alert to the possibility of an ectopic pregnancy in women receiving therapy who become pregnant or complain of lower abdominal pain

            Counsel women regarding changes in bleeding frequency, intensity, or duration

            Implant should be removed in the event of a thrombosis

            Implant should be removed if blood pressure rises significantly and becomes uncontrolled

            When implant broken or bent, may increase release rate of etonogestrel; when implant removed, remove it in its entirety

            Monitor prediabetic and diabetic women receiving therapy

            Complications of Insertion

            • Implant removal may be difficult or impossible if implant not inserted correctly, inserted too deeply, not palpable, encased in fibrous tissue, or has migrated
            • Exploratory surgery without knowledge of exact location of implant is strongly discouraged
            • Migration of implant within arm from insertion site, which may be related to deep insertion, reported; in cases where implant has migrated to pulmonary artery, endovascular or surgical procedures may be needed for removal
            • If at any time implant cannot be palpated, it should be localized; removal is recommended
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            Pregnancy & Lactation

            Pregnancy

            Contraindicated during pregnancy because there is no need for pregnancy prevention in woman who is already pregnant; epidemiologic studies and meta-analyses have not shown an increased risk of genital or non-genital birth defects (including cardiac anomalies and limb-reduction defects) following maternal exposure to low dose CHCs prior to conception or during early pregnancy

            Lactation

            Small amounts of contraceptive steroids and/or metabolites, including etonogestrel are present in human milk; no significant adverse effects observed in production or quality of breast milk, or on physical and psychomotor development of breastfed infants

            Hormonal contraceptives, including etonogestrel, can reduce milk production in breastfeeding mothers; this is less likely to occur once breastfeeding is well-established; however, it can occur at any time in some women; when possible, advise nursing mother about both hormonal and non-hormonal contraceptive options, as steroids may not be initial choice for these patients; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for hormonal contraceptive and any potential adverse effects on breastfed child from hormonal contraceptive or from underlying maternal condition

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Progestin; inhibits secretion of gonadotropins from pituitary gland; prevents follicular maturation and ovulation, increases viscosity of cervical mucous, and stimulates growth of mammary tissues

            Absorption

            Bioavailability: 100%

            Release Rate

            • Week 5-6: 60-70 mcg/day
            • After 1 yr: 35-45 mcg/day
            • After 2 yr: 30-40 mcg/day
            • After 3 yr: 25-30 mcg/day

            Distribution

            Protein Bound: 98% (32% SHBG; 66% albumin)

            Vd: 201 L

            Metabolism

            Hepatic CYP3A4

            Elimination

            Half-Life: 25 hr

            Excretion: Urine (primarily), feces

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            Formulary

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
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