See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/288021460

Safety and Pharmacokinetics of Pravastatin Used for the Prevention of

Preeclampsia in High-Risk Pregnant Women: A Pilot Randomized Controlled
Trial

Article  in  American Journal of Obstetrics and Gynecology · December 2015

DOI: 10.1016/j.ajog.2015.12.038

CITATIONS READS

133 386

14 authors, including:

Mary F Hebert Mahmoud S. Ahmed

University of Washington Seattle University of Texas Medical Branch at Galveston
135 PUBLICATIONS   6,133 CITATIONS    159 PUBLICATIONS   2,704 CITATIONS   

SEE PROFILE SEE PROFILE

Zhaoxia Ren David M Haas

U.S. Department of Health and Human Services Indiana University-Purdue University Indianapolis
8 PUBLICATIONS   244 CITATIONS    242 PUBLICATIONS   3,931 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

A Randomized Controlled Trial of Dilapan-S versus Foley Balloon for Pre-induction Cervical Ripening (DILAFOL Trial) View project

Optoacoustic measurement of blood oxygenation in human placenta View project

All content following this page was uploaded by Mahmoud S. Ahmed on 23 December 2019.

The user has requested enhancement of the downloaded file.

 HHS Public Access
Author manuscript
Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.
Author Manuscript

Published in final edited form as:

Am J Obstet Gynecol. 2016 June ; 214(6): 720.e1–720.e17. doi:10.1016/j.ajog.2015.12.038.

Safety and Pharmacokinetics of Pravastatin Used for the

Prevention of Preeclampsia in High-Risk Pregnant Women: A
Pilot Randomized Controlled Trial
Maged M. Costantine, MD, Kirsten Cleary, MD, Mary F. Hebert, PharmD, FCCP, Mahmoud S.
Ahmed, PhD, Linda M. Brown, DrPH, Zhaoxia Ren, MD, PhD, Thomas R. Easterling, MD,
David M. Haas, MD, MS, Laura S. Haneline, MD, Steve N. Caritis, MD, Raman
Author Manuscript

Venkataramanan, PhD, Holly West, DHEd, Mary D’Alton, MD, Gary Hankins, MD, and for the
Eunice Kennedy Shriver National Institute of Child Health and Human Development
Obstetric-Fetal Pharmacology Research Units Network (OPRU)
Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX
(MMC, MA, HW, GH); Columbia University, New York, NY (KC, MD); Departments of Pharmacy
and Obstetrics & Gynecology, University of Washington, Seattle, WA (MFH, TRE); University of
Pittsburgh, Pittsburgh, PA (SNC, RV); Departments of Obstetrics & Gynecology and Pediatrics,
Indiana University, Indianapolis, IN (DMH, LH); RTI international, Rockville, MD (LB); and the
Eunice Kennedy Shriver National Institute of Child Health and Human Development (ZR)

Abstract
Background—Preeclampsia complicates approximately 3% to 5% of pregnancies and remains a
Author Manuscript

major cause of maternal and neonatal morbidity and mortality. It shares pathogenic similarities
with adult cardiovascular disease as well as many risk factors. Pravastatin, a hydrophilic, 3-
hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor, has been shown in preclinical studies
to reverse various pathophysiological pathways associated with preeclampsia, providing biological
plausibility for its use for preeclampsia prevention. However, human trials are lacking.

Objective—As an initial step in evaluating the utility of pravastatin in preventing preeclampsia,

and after consultation with the U.S. Food and Drug Administration, we undertook a pilot
randomized controlled trial with the objective to determine pravastatin safety and pharmacokinetic
parameters when used in pregnant women at high risk of preeclampsia.

Study Design—We conducted a pilot, multicenter, double-blind, placebo-controlled,

randomized trial of women with singleton, non-anomalous pregnancies at high risk for
Author Manuscript

preeclampsia. Women between 120/7 and 166/7 weeks gestation were assigned to daily pravastatin
10 mg or placebo orally until delivery. Primary outcomes were maternal-fetal safety and

Corresponding author, Maged Costantine MD, 301 University Blvd., Galveston, TX 77555-0587, Phone: 409-772-1571 Fax:
409-772-5297, ; Email: [email protected]
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of
the resulting proof before it is published in its final citable form. Please note that during the production process errors may be
discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Conflicts of Interest: None
Financial Disclosures: None to disclose
 Costantine et al. Page 2

pharmacokinetic parameters of pravastatin during pregnancy. Secondary outcomes included rates

Author Manuscript

of preeclampsia and preterm delivery, gestational age at delivery, birthweight, and maternal and
cord blood lipid profile (Clinicaltrials.gov Identifier NCT01717586).

Results—Ten women assigned to pravastatin and ten to placebo completed the trial. There were
no differences between the two groups in rates of study drug side effects, congenital anomalies, or
other adverse or serious adverse events. There was no maternal, fetal, or neonatal death.
Pravastatin renal clearance was significantly higher in pregnancy compared to postpartum. Four
subjects in the placebo group developed preeclampsia compared to none in the pravastatin group.
Although pravastatin reduced maternal cholesterol concentrations, umbilical cord cholesterol
concentrations and infant birthweight were not different between the groups. The majority of
umbilical cord and maternal pravastatin plasma concentrations at time of delivery were below the
lower limit of quantification of the assay.

Conclusions—This study provides preliminary safety and pharmacokinetic data regarding the
Author Manuscript

use of pravastatin for preventing preeclampsia in high-risk pregnant women. Although the data are
preliminary, no identifiable safety risks were associated with pravastatin use in this cohort. This
favorable risk-benefit analysis justifies using pravastatin in a larger clinical trial with dose
escalation.

Keywords
pravastatin; preeclampsia; pharmacokinetics; safety; angiogenic

Introduction
Preeclampsia is a multisystem disorder that complicates 3%–5% of pregnancies and remains
Author Manuscript

a major cause of maternal, fetal, and neonatal morbidity and mortality (1). It is characterized
by angiogenic imbalance, exaggerated inflammation, and endothelial dysfunction, which
ultimately lead to the clinical manifestations of hypertension, proteinuria, and end organ
damage (1,2). Preeclampsia is associated with serious short- and long-term maternal and
neonatal morbidities (1,3), and its recurrence in subsequent pregnancies depends on the
presence of risk factors (e.g., diabetes, hypertension, and multifetal gestation) and the
severity and time of onset of preeclampsia in a prior pregnancy (4, 5).

Despite being unique to pregnancy, preeclampsia shares pathogenic similarities and many
risk factors with adult cardiovascular disease (4). Endothelial dysfunction and inflammation
are fundamental for the initiation and progression of both atherosclerosis and preeclampsia
(2,6,7,8). Numerous attempts at primary and secondary prevention of preeclampsia, using
various supplements and medications, have had limited success. (4) Only low-dose aspirin
Author Manuscript

was found to have a modest benefit in reducing the rate of preeclampsia in an individual
patient meta-analysis, (9) and that benefit was only achieved if the drug was started before
16 weeks gestational age. On the contrary, inhibitors of 3-hydroxy-3-methylglutaryl-
coenzyme-A (HMG-CoA) reductase (statins) are effective in primary and secondary
prevention of cardiovascular mortality and morbidity (10,11). Moreover, statins have been in
animal models of preeclampsia to revert the angiogenic imbalance, a hallmark of

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 3

preeclampsia, and restore endothelial dysfunction. This biological plausibility and data from
Author Manuscript

preclinical animal studies support a role for statins in preeclampsia prevention (12–19).

Our long-term goal is to evaluate the utility of pravastatin (a hydrophilic statin) to reduce the
recurrence of preeclampsia in high-risk pregnant women. As an initial step in this process,
and after consultation with the U.S. Food and Drug Administration (FDA), we undertook a
pilot randomized controlled trial (RCT) with an objective to evaluate the maternal-fetal
safety and pharmacokinetic (PK) parameters of pravastatin when used in pregnant women at
high risk for preeclampsia (19). In this publication, we are reporting the first phase of a
series of planned studies using a low dose (10 mg) of pravastatin.

Materials and Methods

Study population
Author Manuscript

We conducted a multicenter, double-blind, placebo-controlled randomized trial involving

pregnant women at high risk for preeclampsia. Eligible women were 18 years or older, with
singleton, non-anomalous pregnancy between 120/7 weeks and 166/7 weeks gestation
(confirmed with an ultrasound examination), and with a history of severe preeclampsia in a
prior pregnancy that required delivery prior to 34 weeks gestation (documented by chart
review). We excluded women with known fetal genetic or major malformations; fetal
demise; multifetal gestation; contraindications for statin therapy (e.g., hypersensitivity to
pravastatin, recent or active liver disease); concomitant therapy with fibrates, niacin,
cyclosporine, clarithromycin, or erythromycin; pre-gestational diabetes mellitus; HIV
infection; history of solid organ transplant; chronic renal disease; epilepsy; uterine
malformations; cancer; familial hypercholesterolemia; or inability to tolerate oral
medications secondary to severe nausea and vomiting of pregnancy.
Author Manuscript

The trial was conducted from August 2012 through February 2014 by the Eunice Kennedy
Shriver National Institute of Child Health and Human Development (NICHD) Obstetric-
Fetal Pharmacology Research Units (OPRU) Network at five clinical center sites as an FDA-
approved investigational new drug study (IND #114205) (19). The institutional review
boards at all the participating sites approved the study protocol. All women provided written
informed consent. The study was registered on Clinicaltrials.gov (Identifier NCT01717586).

Study Design and Intervention

Before randomization, all participants were documented to have normal liver transaminases
(AST and ALT). Women were randomized to pravastatin 10 mg or placebo and were
assigned a prepackaged supply of study medication corresponding to the appropriate study
Author Manuscript

drug code. Randomization was performed through a central process that was prepared and
maintained by the data coordinating center (DCC; RTI International, Research Triangle
Park, NC). Initial stratification was by clinical site. Pravastatin and placebo capsules were
manufactured by University of Iowa Pharmaceuticals and packaged in identical capsules.
Subjects were asked to take 1 capsule orally daily, and treatment continued until delivery or
until a condition developed that required discontinuation of the study drug.

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 4

After randomization, research personnel followed subjects at scheduled intervals. Subjects’

Author Manuscript

care and that of their infants was according to standard practice. At each study visit,
medication’s side effects were assessed using a checklist, adverse events (AEs) were
determined and assessed, and pill count performed. Subjects’ pregnancy management
(including antenatal testing, ultrasounds, management of preeclampsia, use of low dose
aspirin, and others) was left to the discretion of the treating physician and performed as
recommended by standard prenatal care as defined by the respective participating institution.
All data were collected or abstracted by research coordinators at the clinical centers and
uploaded to a central database that was managed by the DCC, which was responsible for
data analysis.

Pharmacokinetic studies
Steady-state pravastatin PK studies were conducted in the second trimester (18–24 weeks
Author Manuscript

gestation) and third trimester (30–34 weeks gestation) of pregnancy as well as postpartum
(4–6 months post-delivery). Each subject served as her own control. Subjects recorded the
time of pravastatin dosing for the 4 days prior to each study day and pill counts were
conducted to determine adherence. Women were asked to fast (except for water) for 5 hours
prior to each study visit until 1 hour after dosing. Serial blood samples (6 mL each) were
collected for measurement of pravastatin and 3’α-isopravastatin (a major metabolite of
pravastatin, that is only 1/10th to 1/40th as potent as parent drug in inhibiting HMG-CoA
reductase) concentrations in plasma at times: pre-dose, and at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12
and 24 hours after the dose on each pharmacokinetic study day. Urine was collected pre-
dose and then all urine over one dosing interval was collected as follows: 0–4, 4–8, 8–12 and
12–24 hours following dosing on each study day. Urine from each interval was combined,
mixed and total volume measured. An aliquot from each interval was assayed for pravastatin
Author Manuscript

and 3’α-isopravastatin concentrations. Maternal, umbilical cord venous and umbilical cord
arterial blood samples were collected at the time of delivery for measurement of pravastatin
and 3’α-isopravastatin concentrations in plasma. All samples were stored at −70° C until
analysis (More details on PK studies and analysis will be found in the supplementary
materials).

Outcome variables
The primary outcomes were (1) maternal-fetal safety and (2) pravastatin PK parameters
during pregnancy.

Safety outcomes included evaluation of medication side effects (checklist), maternal AEs
and serious AEs, as well as fetal or perinatal death, and congenital malformations.
Pravastatin PK parameters included maximum concentration (Cmax) and time to maximum
Author Manuscript

concentration (Tmax), area under the concentration time curve (AUC), apparent oral
clearance (CL/F), half-life, renal clearance, and others (supplementary material).

In addition, the study collected secondary maternal and fetal/neonatal outcomes including
rate and severity of preeclampsia, gestational age at delivery, rate of preterm delivery,
maternal lipid profile, and the concentrations of angiogenic (placental growth factor, PlGF)
and anti-angiogenic factors (soluble fms-like tyrosine kinase-1, sFlt-1; and soluble endoglin,

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 5

sEng) in the maternal circulation. Preeclampsia was diagnosed according to criteria set by
Author Manuscript

the American College of Obstetricians and Gynecologists (20) (see supplementary material),
and the diagnosis (or absence) was confirmed by a panel of three maternal-fetal medicine
physicians, blinded to treatment assignment, who reviewed the de-identified medical records
of all enrolled subjects.

Fetal and neonatal secondary outcomes included birthweight, rates of small for gestational
age, failure of auditory brainstem response evoked potential, admission to the neonatal
intensive care unit (NICU) and other neonatal complications, and cord blood analytes
(concentrations of pravastatin and 3’α-isopravastatin, liver enzymes, lipid profile, creatine
kinase, angiogenic and anti-angiogenic markers, steroidogenic hormones (TSH, FSH, LH,
estradiol, and total testosterone), and S100B and neuron specific enolase, two non-specific
markers of neurologic injury).
Author Manuscript

Statistical Analysis
Statistical analyses were performed using SAS statistical software (SAS Institute, Cary, NC).
Maternal and neonatal continuous variables were compared using Wilcoxon rank-sum and
categorical variables with the chi-square or Fisher’s exact test as appropriate. Biomarker
concentrations were analyzed as continuous variables. Steady-state pravastatin PK
parameters were estimated using standard non-compartmental techniques and normalized
using actual body weights (see supplementary material). PK parameters during pregnancy
were compared to those postpartum using paired Wilcoxon signed-rank test.

Our sample size was 20 subjects (10 assigned to pravastatin and 10 to placebo) for which the
primary outcomes were available. This was determined a priori by FDA as part of the IND
approval process (19) and was not intended to achieve power to detect hypothetical
Author Manuscript

differences in primary or secondary clinical outcomes or other laboratory values. P-value

less than 0.05 was considered statistically significant.

Results
Of 22 subjects who consented for the study, 21 were randomized, with 11 assigned to the
pravastatin group and 10 to the placebo group. One subject from the pravastatin group
withdrew from the study after randomization for social reasons (Supplementary Figure 1).
Ten subjects in each group completed the trial, as requested by the FDA. No subjects were
lost to follow-up. There was no significant difference in estimated adherence to study
medication between the pravastatin group and placebo group (94.6 percent vs. 95.9 percent).
At study entry, there were no differences in baseline characteristics such as gestational age at
Author Manuscript

delivery in prior qualifying pregnancy and the percent of subjects receiving low dose aspirin.
Although statistically non significant, more subjects in the pravastatin group were obese
(Table 1, Supplementary Figure 2).

The rates and types of side effects and AEs, irrespective of relation to study medication,
were not different between the 2 groups (Table 2). The most common side effects reported
by subjects who received pravastatin were musculoskeletal pain and heartburn. There were
no reports of myopathy/rhabdomyolysis or liver injury (data on maternal concentrations of

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 6

creatine kinase, AST, and ALT are in Supplementary Table 1). None of the participants
Author Manuscript

discontinued their study medication. In addition, there were no maternal, fetal, or infant
deaths in either group. One fetus in the pravastatin group had hypospadias and another had
coarctation of the aorta (diagnosed postnatally), whereas in the placebo group one fetus had
polydactyly and another had ventriculomegaly. One subject in the placebo group underwent
postpartum hysterectomy secondary to hemorrhage from placenta previa and uterine atony.

Pravastatin Cmax, Tmax, AUC, T1/2, percent of the dose excreted unchanged as parent drug,
and CL/F were not significantly different between the three time periods (Table 3). The
average steady-state concentration-time profiles are depicted graphically in Supplementary
Figure 3. For subjects in whom we were able to quantify the 24-hour post-dose
concentration, pravastatin appears to exhibit a 2-compartment PK model. The apparent half-
life of pravastatin based on concentration data till 12 hours was estimated to be 2.1±0.9
hours in the second trimester (n=11), 3.0±1.6 hours in the third trimester (n=10), and
Author Manuscript

2.4±1.3 hours postpartum (n=9). However, in the small subset of subjects (n=1–3 per PK
study day) in whom we were able to quantify the 24-hour post-dose concentration, the
estimated terminal half-life was much longer. Renal clearance and net renal secretion
clearance of pravastatin were significantly higher during pregnancy compared with
postpartum (Table 3). We had adequate sample to assay for pravastatin concentrations in 6
umbilical cord arterial and 7 umbilical cord venous samples. In the majority of umbilical
cord and maternal samples at time of delivery, pravastatin concentrations were below the
limit of quantification of the assay (Supplementary Table 2).

Four subjects in the placebo group developed preeclampsia (with 3 of 4 having severe
disease) compared to none in the pravastatin group. There were five indicated preterm
deliveries before 37 weeks in the placebo group compared with one in the pravastatin group.
Author Manuscript

(Table 4) Other obstetric outcomes were similar between the two groups. The concentrations
of PlGF were increased in subjects receiving pravastatin, and those of sFlt-1 and sEng were
decreased; however the differences for these markers did not reach statistical significance.
Of note, the four women in the placebo arm who developed preeclampsia had the highest
sFlt-1 concentrations near term (Figure 1, Supplementary Table 1).

Birthweight was similar between the 2 groups. One infant in the placebo group was
diagnosed as small for gestational age. Five infants born to women in the placebo group
were admitted either to an intermediate nursery (n=2) or NICU (n=3) compared with two in
the pravastatin group (intermediate nursery [n=1] and NICU [n=1]; Table 4). None of the
newborns in either group failed their auditory brainstem response evoked potential or similar
hearing screening tests. Of note, eight of 10 women in both groups breast fed or provided
Author Manuscript

breast milk to their newborns.

Maternal total cholesterol (TC) and low density lipoproteins (LDL) were similar at baseline,
but lower in subjects receiving pravastatin compared with placebo in the second trimester
(TC 188.6±31 vs 230±48.3 mg/dL and LDL 81.1±20.9 vs 124.1±42 mg/dL) and in the third
trimester (TC 201.7±33.5 vs 250±25.3 mg/dL, P=0.02, and LDL 85.6±25.7 vs 126.1±44.4
mg/dL; Supplementary Table 1). Despite the decrease in maternal TC and LDL, cord blood
concentrations of TC and LDL were similar between the pravastatin- and placebo-exposed

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 7

fetuses (TC: 56.2±11.5 vs 63.9±18.8 mg/dL and LDL 28.2±10.2 vs 31.8±13.3 mg/dL).
Author Manuscript

There were no differences in other cord blood parameters assayed (Supplementary Table 3).

Comment
This pilot RCT provides preliminary safety and PK data regarding the use of pravastatin, a
drug traditionally avoided in pregnancy, for preventing preeclampsia, a pregnancy
complication with serious morbidity. Initiation and completion of this trial was a direct
result of collaboration between the NICHD–OPRU network and FDA. Although the data are
preliminary, no identifiable safety risks were associated with the use of pravastatin at a dose
of 10 mg in this cohort of high-risk pregnant women, with strong signals for possible
efficacy (lower rates of preeclampsia and indicated preterm delivery and a maternal pro-
angiogenic profile). The lack of a reduction in cholesterol concentration in the fetuses
exposed to pravastatin is reassuring. This favorable risk-benefit analysis justifies continued
Author Manuscript

research using pravastatin in a larger clinical trial with dose escalation.

Pravastatin classification as a Category X medication was due to a lack of indications that

warranted its use during pregnancy rather than for observed risk. An increased risk of
congenital malformations has not been demonstrated in multiple cohorts of subjects exposed
to pravastatin during pregnancy (21–26). In this trial, pravastatin was started in the second
trimester (i.e., after completion of organ formation), and the rate of anomalies was similar
between subjects receiving pravastatin or placebo. Additionally, despite maternal
concentrations of TC and LDL being reduced in the second and third trimesters with
pravastatin use, neither cord blood TC and LDL concentrations nor infant birthweight
differed between the 2 groups. These findings support prior studies that showed
independence of fetal cholesterol concentrations from maternal cholesterol levels or diet (27,
Author Manuscript

28). The pattern and rates of AEs and serious AEs in our study are consistent with data from
prior large pravastatin trials in nonpregnant women and men (29), suggesting that pregnancy
does not adversely affect the occurrence of these AEs.

Although not statistically significant, a 10-mg dose of pravastatin was associated with
favorable pregnancy outcomes including lower rates of preeclampsia, indicated preterm
delivery, and neonatal admissions to intermediate nurseries or NICU, as well as improved
pro-angiogenic profile (lower sFlt-1, sEng, and higher PlGF). The high rate of preeclampsia
recurrence in the placebo group is consistent with prior studies (4,5). The exact mechanism
of how pravastatin may prevent preeclampsia is unknown but is thought to be associated
with pravastatin’s ability to reverse the pregnancy-specific angiogenic imbalance and
oxidative and inflammatory stress and to restore global endothelial health (19). The ability
of pravastatin to restore the angiogenic balance is also being tested in a proof of concept
Author Manuscript

“StAmP trial” in the UK (Statins to Ameliorate early onset Preeclampsia; www.controlled-

trials.com; ISRCTN23410175)

Pravastatin’s reassuring data with its use in human pregnancy and in animal models were not
unexpected. Pravastatin is one of the most hydrophilic statins and is a substrate for the efflux
transporters P-glycoprotein and multidrug resistance-associated protein 2 (MRP2), which
would potentially limit its transplacental transfer (30–32). Consistent with these

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 8

characteristics, recent transplacental studies have shown that the clearance of pravastatin in
Author Manuscript

third-trimester placentas was higher in the fetal-to-maternal than the maternal-to-fetal

direction (32). In this study, the majority of umbilical cord and maternal pravastatin
concentrations at delivery were below the lower limit of quantification of the assay (<0.1 ng/
mL). Only 2 subjects had measurable concentrations in the umbilical cord plasma
(Supplementary Table 2), which may also be related to the low dose of pravastatin used in
this study and its short apparent half-life.

Postpartum values for pravastatin CL/F, renal clearance, AUC, half-lifeinitial, Cmax, Tmax,
and fraction of dose excreted unchanged in the urine are consistent with those previously
reported in nonpregnant subjects (33,34). Although significance was not reached because of
the small sample size, there is a strong trend toward an increase in CL/F and a decrease in
pravastatin AUC in pregnancy compared with postpartum. As expected, the renal clearance
of pravastatin was significantly increased during pregnancy consistent with the increased
Author Manuscript

glomerular filtration as measured by creatinine clearance, accounting for some of the

variability. In addition, the net renal secretion clearance was also increased in pregnancy,
likely because of changes in active transport by renal excretory transporters such as P-
glycoprotein, MRP2, BCRP or renal uptake transporters such as OAT3 and OAT1 (31, 32,
35). The PK parameters of 3’α-isopravastatin, a major metabolite of pravastatin with only
1/10th to 1/40th of its HMG-CoA reductase inhibition (30), are reported in Supplementary
Table 4.

Because to our knowledge this is the first preeclampsia prevention trial using statins, it was
designed to have multiple layers of safety including being conducted under an IND, use of
an independent medical monitor who reviewed all serious AEs in real time, oversight by a
data safety monitoring board that reviewed all AEs and serious AEs quarterly, and use of
Author Manuscript

well-defined criteria to withdraw subjects or stop the study. Maternal, fetal, and neonatal
safety was determined using clinical and laboratory outcomes at multiple time points. An
independent panel, blinded to study drug allocation, reviewed the preeclampsia outcomes.
At the recommendation of FDA, we were limited by our sample size, which prevented us
from conducting subgroup and other more detailed analyses. In addition, our study does not
have the power to detect differences in individual outcomes such as congenital anomalies or
other clinical or safety outcomes of low prevalence. Other limitations include the use of a
low dose of pravastatin (10 mg/day) and the short-term follow-up for subjects and infants
included in this report. Infant follow-up is planned at 5 years of age, and subjects’ contact
information is updated regularly to facilitate long-term follow-up.

Conclusion
Author Manuscript

This study provides preliminary safety and pharmacokinetic data regarding the use of
pravastatin for preventing preeclampsia in high-risk pregnant women. Although the data are
preliminary, no identifiable safety risks were associated with pravastatin use in this cohort.
This favorable risk-benefit analysis justifies continued research with dose escalation in a
future larger clinical trial to evaluate pravastatin’s effectiveness in preventing preeclampsia.
Finally, collaboration between NICHD and FDA was essential for the success of this trial.

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 9

Supplementary Material
Author Manuscript

Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
The authors wish to thank Ms. Charlene Williamson and members of the FDA Division of Reproductive and
Urologic Products who reviewed our Investigational New Drug (IND) application for their thoughtful study design
comments.

In addition, the authors wish to thank the following members who participated in protocol development, oversight,
data management, and coordination between clinical research centers: Katrina Burson, RN, and Julie Croxford, RN,
MPH. They also thank the following collaborators and study research personnel:

University of Texas Medical Branch, Galveston, TX —George Saade, MD; Shannon Clark MD; Wayne Snodgrass,
MD; Xing Zhang, PhD; Svetlana Patrikeeva, MS; Tatiana Nanovskaya, PhD; Angela Jones, RN; Sonia Jordan, RN;
Carly Oliver, RN; Margaret Zimmerle, RN; Maria Garza
Author Manuscript

Columbia University, New York, NY—Mary Talucci, MSN, CCRP

Indiana University, Indianapolis, IN—David Flockhart, MD; Janie Klank, RN, MSN

University of Washington, Seattle, WA—Michael Z. Liao, BS; Yvonne Lin, PhD; Kenneth Thummel, PhD; Karan
Hays, DNP, CNM, ARNP; Erin Michelson; Claudine Hernandez; Anna Lemchen, RN

University of Pittsburgh, Pittsburgh, PA—Dawn Fischer, RN; Donna DeAngeles, BS

RTI International, Research Triangle Park, NC—Lei Li, PhD; Matthew Westlake, MS; Kelly Rooney, PhD

Supported by grants U10HD047891, U10HD063094, U10HD047892, U10HD047905, and U10HD057753 from the
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and UL1TR000423
and UL1TR001439 from NIH, and National Center for Advancing Translational Sciences through the Clinical and
Translational Science Awards Program. The manuscript does not necessarily represent the official views of NICHD
or the National Institutes of Health.
Author Manuscript

References
1. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Report of the
American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy.
Obstet Gynecol. 2013; 122:1122–1131. [PubMed: 24150027]
2. Baumwell S, Karumanchi SA. Preeclampsia: clinical manifestations and molecular mechanisms.
Nephron Clin Pract. 2007; 106:c72–c81. [PubMed: 17570933]
3. Mongraw-Chaffin ML, Cirillo PM, Cohn BA. Preeclampsia and cardiovascular disease death:
prospective evidence from the child health and development studies cohort. Hypertension. 2010;
56:166–171. [PubMed: 20516394]
4. Barton JR, Sibai B. Prediction and prevention of recurrent preeclampsia. Obstet Gynecol. 2008;
112:359. [PubMed: 18669736]
5. Hernández-Dıaz S, Toh S, Cnattingius S. Risk of pre-eclampsia in first and subsequent pregnancies:
prospective cohort study. BMJ. 2009; 338:b2255. [PubMed: 19541696]
Author Manuscript

6. Young BC, Levine RJ, Karumanchi SA. Pathogenesis of preeclampsia. Annu Rev Pathol. 2010;
5:173–192. [PubMed: 20078220]
7. Ramma W, Ahmed A. Is inflammation the cause of preeclampsia? Biochem Soc Trans. 2011;
39:1619–1627. [PubMed: 22103497]
8. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005;
352:1685–1695. [PubMed: 15843671]
9. Askie LM, Duley L, Henderson-Smart DJ, Stewart LA. PARIS Collaborative Group. Antiplatelet
agents for prevention of pre-eclampsia: a meta-analysis of individual patient data. Lancet. 2007;
369:1791–1798. [PubMed: 17512048]

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 10

10. Mills EJ, Rachlis B, Wu P, Devereaux PJ, Arora P, Perri D. Primary prevention of cardiovascular
mortality and events with statin treatments: a network meta-analysis involving more than 65,000
Author Manuscript

patients. J Am Coll Cardiol. 2008; 52:1769–1781. [PubMed: 19022156]

11. Brugts JJ, Yetgin T, Hoeks SE, et al. The benefits of statins in people without established
cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled
trials. BMJ. 2009; 338:b2376. [PubMed: 19567909]
12. Cudmore M, Ahmad S, Al-Ani B, et al. Negative regulation of soluble Flt-1 and soluble endoglin
release by heme oxygenase-1. Circulation. 2007; 115:1789–1797. [PubMed: 17389265]
13. Costantine M, Tamayo E, Bytautiene E, et al. Using pravastatin to improve the vascular reactivity
in a mouse model of soluble Fms-like tyrosine kinase-1-induced preeclampsia. Obstet Gynecol.
2010; 116(116):114–120. [PubMed: 20567176]
14. Fox KA, Longo M, Tamayo E, et al. Effects of pravastatin on mediators of vascular function in a
mouse model of soluble Fms-like tyrosine kinase-1–induced preeclampsia. Am J Obstet Gynecol.
2011; 205(366):e1–366–e1-e365. [PubMed: 22083058]
15. Ahmed A, Singh J, Khan Y, Seshan SV, Girardi G. A new mouse model to explore therapies for
preeclampsia. PLoS ONE 5. 2010; 10:e13663.
Author Manuscript

16. Singh J, Ahmed A, Girardi G. Role of complement component C1q in the onset of preeclampsia in
mice. Hypertension. 2011; 58:716–724. [PubMed: 21859968]
17. Kumasawa K, Ikawa M, Kidoya H, et al. Pravastatin induces placental growth factor and
ameliorates preeclampsia in a mouse model. Proc Natl Acad Sci USA. 2011; 108:1451–1455.
[PubMed: 21187414]
18. Saad AF, Kechichian T, Yin H, et al. Effects of Pravastatin on Angiogenic and Placental Hypoxic
Imbalance in a Mouse Model of Preeclampsia. Rep Sci. 2014; 21:138–145.
19. Costantine MM, Cleary K. for the Eunice Kennedy Shriver National Institute of Child Health and
Human Development Obstetric-Fetal Pharmacology Research Units Network. Pravastatin for the
Prevention of Preeclampsia in High Risk Pregnant Women. Obstet Gynecol. 2013; 121:349–353.
[PubMed: 23344286]
20. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. Obstet
Gynecol. 2002; 99(33):159–167. [PubMed: 16175681]
21. Edison R, Muenke M. Mechanistic and epidemiologic considerations in the evaluation of adverse
Author Manuscript

birth outcomes following gestational exposure to statins. Am J Med Gen. 2004; 131A:287.
22. Ofori B, Rey E, Berard A. Risk of congenital anomalies in pregnant users of statin drugs. Br J Clin
Pharmacol. 2007; 64(4):496. [PubMed: 17506782]
23. Taguchi N, Rubin ET, Hosokawa A, et al. Prenatal exposure to HMG-CoA reductase inhibitor:
effects on fetal and neonatal outcomes. Repro Tox. 2008; 26(2):175.
24. Petersen EE, Mitchell AA, Carey JC, et al. Maternal Exposure to Statins and Risk for Birth
Defects. Am J Med Gen. 2008; 146A:2701–2705.
25. Winterfeld U, Allignol A, Panchaud A, et al. Pregnancy outcome following maternal exposure to
statins: a multicentre prospective study. Br J Obstet Gynaecol. 2013; 120:463–471.
26. Bateman BT, Hernandez-Diaz S, Fischer MA, et al. Statins and congenital malformations: Cohort
study. BMJ. 2015; 350:h1035. [PubMed: 25784688]
27. Woollett LA. Maternal cholesterol in fetal development: transport of cholesterol from the maternal
to the fetal circulation. Am J Clin Nutr. 2005; 82:1155–1161. [PubMed: 16332646]
28. Ethier-Chiasson M, Duchesne A, Forest JC, et al. Influence of maternal lipid profile on placental
protein expression of LDLr and SR-BI. Biochem Biophys Res Commun. 2007; 359:8–14.
Author Manuscript

[PubMed: 17531953]
29. Pfeffer MA1, Keech A, Sacks FM, et al. Safety and tolerability of pravastatin in long-term clinical
trials: prospective Pravastatin Pooling (PPP) Project. Circulation. 2002; 105(20):2341–2346.
[PubMed: 12021218]
30. Hatanaka T. Clinical pharmacokinetics of pravastatin: mechanisms of pharmacokinetic events. Clin
Pharmacokinet. 2000; 39:397–412. [PubMed: 11192473]
31. Zarek J, DeGorter MK, Lubetsky A, et al. The transfer of pravastatin in the dually perfused human
placenta. Placenta. 2013; 34:719–721. [PubMed: 23746925]

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 11

32. Nanovskaya TN, Patrikeeva SL, Paul J, Costantine M, Hankins GDV, Ahmed MS. Transplacental
transfer and distribution of pravastatin. Am J Obstet Gynecol. 2013; 209:373.e1–373.e5. [PubMed:
Author Manuscript

24070396]
33. Singhvi SM, Pan HY, Morrison RA, Willard DA. Disposition of pravastatin sodium, a tissue-
selective HMG-CoA reductase inhibitor, in healthy subjects. Br J Clin Pharmacol. 1990; 29:239–
243. [PubMed: 2106337]
34. Ogawa K, Hasegawa S, Udaka Y, Nara K, Iwai S, Oguchi K. Individual difference in the
pharmacokinetics of a drug, pravastatin, in healthy subjects. J Clin Pharmacol. 2003; 43:1268–
1273. [PubMed: 14551181]
35. Hasegawa M, Kusuhara H, Sugiyama D, et al. Functional involvement of rat organic anion
transporter 3 (rOAT3; Slc22a8) in the renal uptake of organic anions. J Pharmacol Exp Ther. 2002;
300:746–753. [PubMed: 11861777]
Author Manuscript
Author Manuscript
Author Manuscript

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 12
Author Manuscript
Author Manuscript
Author Manuscript

Figure 1.
Author Manuscript

Longitudinal plots of serum concentrations of soluble fms-like tyrosine kinase (Panel A;

sFlt-1), soluble endoglin (Panel B; sEng), and placental growth factor (Panel C; PlGF)
within individual subjects who received pravastatin (n=10, red) or placebo (n=10, blue)
according to the gestational age window at time of collection: 120/7–166/7 weeks (baseline
and before treatment), 240/7–276/7, and 340/7–366/7.
Δ designates the subjects who developed preeclampsia.

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 13

Table 1

Baseline characteristics of subjects who participated in the study. Data are reported as median [interquartile
Author Manuscript

range], or n (%).

Characteristic Placebo Group # Pravastatin Group#

(N= 10) (N=11)

aRace:

White 9 10
African American 1 0
Asian 0 0
American Indian 0 1

aEthnicity:

Hispanic 7 5
Author Manuscript

Non-Hispanic 3 6

Age—years 30 [27,34] 27 [21, 34]

Body mass index—Kg/m2 29.6 [27, 32.3] 36 [26, 38.2]

bObesity 4 (40) 8 (72.7)

cSystolic blood pressure at entry to care, mm Hg 115 [110, 122] 109 [107, 131]

cDiastolic blood pressure at entry to care, mm Hg 68 [64, 72] 64 [55, 77]

dParity 2 [2, 3] 1 [1, 2]

Gestational age at randomization—weeks 14.9 [13.4, 16.4] 13.9 [13.3, 16.1]

Author Manuscript

Gestational age at delivery in prior pregnancy—weeks 30.7 [29.4, 32.0] 32.0 [30.7, 33.0]

Chronic hypertension 3(30) 5(50)

Use of low-dose aspirin 3 (30) 2 (18)

#
None of the comparisons between the two groups is statistically significant (P > 0.05)
a
Race and ethnicity were self-reported by patients.
b
Obesity is defined as BMI≥30 Kg/m2 using pre-pregnancy weight.
c
Blood pressure at entry to care, measured in clinic after a 10-minute rest period, in seating position with the right arm in a roughly horizontal
position at heart level, supported on a desk.
d
Parity is any pregnancy that lasted >20 weeks.
Author Manuscript

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 14

Table 2

Adverse and serious adverse events experienced by subjects, irrespective of association with study
Author Manuscript

medications. Data are reported as n (%).

Condition Placebo Group# Pravastatin Group#

(N=10) (N=11)

Adverse events

Heartburn 3 (30) 4 (36)

Musculoskeletal pain 1 (10) 4 (36)

Dizziness 2 (20) 3 (27)

Chest Pain 0 2 (18)

Diarrhea 1 (10) 2 (18)

Author Manuscript

Headache 3 (30) 2 (18)

Cough 1 (10) 2 (18)

Swelling 0 2 (18)

Nausea 1 (10) 1 (9)

Fever 2 (20) 1 (9)

Flatulence 0 1 (9)

Fatigue 0 1 (9)

Wheezing 0 1 (9)
Author Manuscript

Vomiting 1 (10) 0

Influenza-like symptoms 2 (20) 0

Serious Adverse Events

Maternal, fetal, or infant death 0 0

aRhabdomyolysis 0 0

aLiver injury 0 0

Congenital anomalies Polydactylyb Hypospadiasb

Ventriculomegaly Coarctation of aorta
Author Manuscript

Hospitalization >24 hours:

HTN/BP exacerbation, 3 (30) 2 (18)
Preeclampsia workup 1 (10) 0
Vaginal bleeding 1 (10) 0

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 15

Condition Placebo Group# Pravastatin Group#

(N=10) (N=11)
Author Manuscript

Influenza infection 1 (10) 0

Migraine 1 (10) 0
Syncope 0 1 (9)

#
None of the comparisons between the two groups is statistically significant (P > 0.05)
a
Rhabdomyolysis was defined as muscle pain or muscle weakness in conjunction with increase in creatinine kinase (CK) values to greater than 10
times the upper limit of normal. Liver injury was diagnosed with elevation of transaminases (AST or ALT) values greater than three times the upper
limit of normal. Data on maternal AST, ALT and CK concentrations are in Supplementary Table 1.
b
Family history of polydactyly and hypospadias in the father of each child respectively.
Author Manuscript
Author Manuscript
Author Manuscript

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 16

Table 3

Estimated steady-state pravastatin pharmacokinetics in subjects during the 2nd and 3rd trimesters of pregnancy
Author Manuscript

compared with postpartum. Data are reported as mean±SD.

Parameter 18–24 weeks 30–34 weeks 4–6 months

Gestation Gestation Postpartum
(n=11) (n=10) (n=9)
Cmax (ng/mL) 14.9± 11.3 11.1± 6.2 17.2± 11.5

Tmax (hr) 1.6±0.6 1.5±0.4 1.6±1.0

Half-lifeapparent (hr) 2.1±0.9 3.0±1.6 2.4 ±1.3

CL/F (L/hr) 396±190 389±215 289± 142

CL/F (L/hr/kg) 4.6±2.4 4.2±2.0 3.2±1.5

AUC(0–24) (ng· hr/mL) 31±16 32±16 43±20

Amount excreted(0–24hr) (mg) 0.98±0.60 1.04±0.57 0.93±0.60

Author Manuscript

Percent excreted unchanged 10±6 10±6 9±6

CLRenal (L/hr) 34±16a 34±1 1a 23±4

CLSecretion (mL/min) 480±273a 471± 151a 325 ±65

a
P<0.05; second and third trimester compared with postpartum

Cmax=maximum concentration; Tmax=time to maximum concentration; CL/F=apparent oral clearance; AUC(0–24)=area under the concentration
time curve; CLRenal=renal clearance; CLSecretion=net renal secretion clearance
Author Manuscript
Author Manuscript

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

 Costantine et al. Page 17

Table 4

Maternal and neonatal outcomes of participants in the study. Data are reported as n (%) mean±SD, or median
Author Manuscript

[IQR].

Outcomes Placebo Group# Pravastatin Group#

(N=10) (N=10)
Maternal Outcomes
Preeclampsia 4 (40) 0 (0)
Severe features 3 0

Postpartum preeclampsia 1 (10)a 0 (0)

Gestational hypertension 1(10) 1 (10)

Gestational age at delivery, weeks 36.7±2.1 37.7±0.9

Indicated preterm delivery less than 37 weeks 5 (50)b 1 (10) c

Indicated preterm delivery less than 34 weeks 1(10) 0 (0)

Author Manuscript

Blood transfusion 1 (10) 1 (10)

dLength of hospital stay (days) 4 [3–7], range 2–43 3 [3–4], range 1–6

Neonatal Outcomes
Birth weight, grams 2,877±630 3,018± 260

Highest level of care 5 (50) 8 (80)

Well baby/routine 2 (20) 1 (10)
Intermediate (Level 2) 3 (30) 1 (10)
NICU

NICU length of stay ≥ 48 hours 3 (30) 0

Respiratory Distress Syndrome 2 (20) 1 (10)

#
None of the comparisons between the two groups is statistically significant (P > 0.05)
a
This subject developed preeclampsia and was delivered at 353/7 weeks because of spontaneous preterm labor and history of prior classical
Author Manuscript

cesarean delivery. She received magnesium sulfate and on discharge had normal blood pressure. She then presented 7 days after delivery with
elevated blood pressure and was diagnosed with postpartum preeclampsia.
b
Three patients were delivered at 336/7, 343/7, and 352/7 for preeclampsia with severe features, one patient was delivered at 361/7 for worsening
gestational hypertension and history of classical cesarean delivery, and one patient was delivered at 354/7 for placenta previa.
c
One patient was delivered at 355/7 weeks for worsening chronic hypertension
d
Length of hospital stay was for the hospitalization resulting in delivery.

NICU=neonatal intensive care unit

Author Manuscript

Am J Obstet Gynecol. Author manuscript; available in PMC 2017 June 01.

View publication stats