Misoprostol

Aka: Misoprostol, Cytotec, PGE1 Gel

1. Mechanism
   1. Prostaglandin E1 Analog
   2. Gastric Mucosa Protection by Prostaglandin replacement
   3. Cervical Ripening and uterine contractions
2. Indication
   1. Peptic Ulcer Disease Prevention
      1. See NSAID Gastrointestinal Adverse Effects
      2. Prevents ulcers in those on NSAIDs chronically
   2. Cervical Ripening agent in Pregnancy Labor Induction
   3. Early Pregnancy Loss (<84 days)
   4. Termination of Pregnancy (<77 days)
3. Preparations
   1. Misoprostol (Cytotec)
4. Dosing: Prevention of NSAID-induced Peptic Ulcer Disease
   1. See NSAID Gastrointestinal Adverse Effects
   2. Option 1: 100-200 mcg four times daily with food
   3. Option 2: 200 mcg orally twice daily with food
      1. Better tolerated than four times per day dosing
5. Dosing: Obstetrics and Gynecology
   1. Cervical Ripening
      1. See Cervical Ripening for pregnancy dosing
      2. Misoprostol 25-50 mcg per vagina every 6 hours
   2. Early Pregnancy Loss (<84 days) or Termination of Pregnancy (<77 days)
      1. See Early Pregnancy Loss (includes precautions and monitoring protocol)
      2. Misoprostol 800 mcg intravaginally at 24-48 hours after Mifepristone
         1. Efficacy improves if followed by second dose Misoprostol 800 mcg 4 hours after first
      3. Strong uterine cramping and heavier Vaginal Bleeding follows Misoprostol dose
         1. Onset within several hours
         2. Persists for 3-5 hours
         3. Lighter Vaginal Bleeding may persist for 9-16 days
      4. Adjunctive medications
         1. NSAIDs
         2. Heating pad
6. Technique
   1. Vagnial Dosing
      1. Place 4 of the 200 mcg tablets (total 800 mcg) inside the vagina and lie supine for 30 minutes
   2. Buccal Dosing may be used in place of vaginal dosing
      1. Place two of the 200 mcg Misoprostol tablets on each side of the mouth (total 800 mcg)
      2. Allow tablets to dissolve over 30 minutes
7. Adverse Effects
   1. When used orally
      1. Diarrhea
      2. Nausea
      3. Vomiting
      4. Poorly tolerated
   2. Gynecologic symptoms (800 mcg dosing)
      1. Strong uterine cramping
      2. Vaginal Bleeding heavier than typical Menses
8. Efficacy: Peptic Ulcer Disease reduction
   1. Dosing qid: 4% Peptic Ulcer Disease recurrence
   2. Dosing bid: 8% Peptic Ulcer Disease recurrence
   3. Placebo: 16% Peptic Ulcer Disease recurrence
   4. Reference
      1. Raskin (1995) Ann Intern Med 123:344-50 [PubMed]
9. References
   1. MacNaughton (2021) Am Fam Physician 103(8) 473-80 [PubMed]