The non-dominant arm is where the flexible, ultra-thin Nexplanon (Etonogestrel implant) is inserted. It is recommended for long-term pregnancy prevention. Up to three years are allowed for the Nexplanon Etonogestrel implant before it needs to be removed.

Nexplanon (Etonogestrel implant) Uses:

• Contraception:

  • It is indicated for the long-term prevention of pregnancy.

Nexplanon (Etonogestrel implant) Use for Contraception in females:

• Subdermal:
  • One implant should be placed on the interior of the upper, non-dominant arm.
  • Remove no later than three years from the date of implantation; if continued contraceptive protection is wanted, a replacement implant may be inserted in its place at that time.
  • After ruling out pregnancy, the patient's history of using contraception is used to determine when to put the device:
    • No hormonal contraceptives within the past month:
      • Even if the woman is still bleeding, place between days 1 through 5 of the period.

• Switching from combination hormonal contraceptive:

  • Oral tablet:
    • The day following the last active tablet should be used (at the latest, insert on the day following the usual tablet-free or placebo interval)
  • Transdermal system or vaginal ring:
    • Place it the day before the transdermal system or vaginal ring is removed (at the latest, Put it on the day following the transdermal-free or ring-free interval)

  • Switching from a progestin-only contraceptive:

    • Oral tablet:
      • Do not forget or miss days between taking the final medication and inserting the implant; choose any day during the month.
    • Implant or intrauterine device (IUD):
      • Put it on the same day as the implant or IUD is removed.
    • Injection:
      • Set it for the day of the subsequent injection.
  • First-trimester abortion or miscarriage:
    • Put within the first five days after an abortion or miscarriage in the first trimester.
  • Second-trimester abortion or miscarriage:
    • Put it between 21 and 28 days after an abortion or miscarriage in the second trimester.
  • Postpartum:
    • If not breastfeeding, place it between 21 and 28 days after delivery.
    • If you plan to nurse, wait until the fourth postpartum week to conceive and use a second non-hormonal method of contraception for the first few days.
  • Note:
    • There is no need for backup contraception while using any of the insertion regimens listed above (except in postpartum women who are breastfeeding).
    • Use a backup non-hormonal contraceptive strategy in case of deviation to prevent a weak postinsertion. If there has already been sexual activity, pregnancy should be ruled out.

• Additional dosing considerations:

  • Initiation of therapy:
    • It can begin at any point during the menstrual cycle if it has been established that the lady is not pregnant.
    • If used within five days of the first menstrual period, further contraception is not required.
    • Back-up contraception should be used for a weak pill if begun more than 5 days after the start of menstruation or at any time in a woman having amenorrhea (not postpartum) (7 days).
  • Switching from a different contraceptive to an implant:
    • It can begin whenever it is decided that the lady is not pregnant.
    • If it has been more than 5 days since the start of menstrual flow, a backup form of contraception is necessary unless the woman abstains from sexual activity.
    • Consider using the woman's prior method as a weak substitute when a new contraceptive method is needed.
  • Switching from an IUD to an implant:
    • After the implant is placed, keep the IUD in place for at least 7 days(weak), or suggest that the lady abstain from sexual activity or use a barrier contraceptive for a week before removing the IUD.
    • When removing an IUD, another option is to utilize emergency contraception.

Note: In the US, Implanon has been withdrawn for more than a year.

Nexplanon (Etonogestrel implant) Pregnancy Risk Category: X

• Pregnant women should not use it.
• Combination hormonal contraceptives used inadvertently early in pregnancy have not been shown to cause teratogenic effects.
• Before prescribing, it is important to evaluate your pregnancy status. If you are pregnant, the implant should be removed.
• There is no evidence to suggest that etonogestrel has a higher risk.
• The manufacturer recommends that you wait at least 21 days after delivery to avoid the risk of thromboembolism.
• According to available guidelines, the progestin-only implants may be placed at any time provided that the woman is not pregnant. This includes immediately after birth or after an abortion.
• The administration immediately postpartum (prior hospital discharge) can be provided regardless of breastfeeding status. This may help to prevent unintended or rapid pregnancies.
• The serum concentrations of Etonogestrel decrease 7 days after the implant is removed. Pregnancies can be reported as soon as 7 to 14 business days after the implant has been removed.
• If you wish to continue contraception, it is important that you immediately start contraception after the removal.

Etonogestrel implant use during breastfeeding:

• Breast milk contains Etonogestrel.
• According to the manufacturer, the relative infant dose for etonogestrel is 2.2 percent of its weight-adjusted maternal dosage.
• When the RID of medication falls below 10 percent, breastfeeding is generally acceptable.
• According to the manufacturer, the RID of etonogestrel was calculated from the milk concentrations of 38 women who were breastfeeding at 4-8 weeks after the start date for treatment.
• A 4-month study showed that milk concentrations increased after the implant was inserted and decreased when the maternal serum concentrations dropped.
• However, etonogestrel did not affect the quantity or quality of breast milk.
• The theory is that progestin implants could prevent lactogenesis from arising.
• Breastfed babies of mothers who used an etonogestrel intrauterine device were found not to show differences in growth (body length and biparietal head circumference), or adverse physical or psychological development, as compared to infants who received a nonhormonal contraceptive intrauterine implant (mean breastfeeding duration was 421 months). Infants evaluated over 36 month.
• The manufacturer advises that you weigh the hazards to babies, the advantages for the baby, and the advantages for the mother while selecting whether or not to breastfeed.
• The implant's placement is not advised by the manufacturer until four weeks following birth, although according to recommendations, progestin-only implants may be inserted whenever it is reasonable to believe the patient is not pregnant. mothers who are breast-feeding are included.

Dose in Kidney Disease:

Manufacturer's labeling doesn't provide any dose adjustments (has not been studied

Dose in Liver disease:

Its use is contraindicated.

Common Side Effects of Nexplanon (Etonogestrel implant):

• Central Nervous System:

  • Headache

• Dermatologic:

  • Acne Vulgaris

• Endocrine & Metabolic:

  • Amenorrhea
  • Weight Gain
  • Menstrual Disease

• Gastrointestinal:

  • Abdominal Pain

• Genitourinary:

  • Mastalgia
  • Vaginitis

• Respiratory:

  • Pharyngitis

Less Common Side Effects Of Nexplanon (Etonogestrel implant):

• Central Nervous System:

  • Nervousness
  • Pain
  • Dizziness
  • Emotional Lability
  • Depression

• Dermatologic:

  • Localized Erythema

• Endocrine & Metabolic:

  • Dysmenorrhea

• Gastrointestinal:

  • Nausea

• Genitourinary:

  • Leukorrhea

• Hypersensitivity:

  • Hypersensitivity Reaction

• Local:

  • Hematoma At Injection Site
  • Bruising At Injection Site
  • Application Site Reaction
  • Local Pain

• Neuromuscular & Skeletal:

  • Back Pain

• Respiratory:

  • Flu-Like Symptoms

Contraindications to Nexplanon (Etonogestrel implant):

• Hypersensitivity to etonogestrel 
• Breast cancer 
• Progestin-sensitive cancer 
• Hpatic tumors 
• Pregnancy 
• thrombosis and thromboembolic conditions 
• Undiagnosed abnormal Genital Bleeding.

Warnings and precautions

• Breast cancer

  • Women with breast cancer history or who have had it are advised not to use it.
  • Breast cancer is a hormone sensitive tumor. Women with a history of breast cancer or current symptoms may have a worse prognosis if they use progestin-only contraceptives.

• Ectopic pregnancy

  • Ectopic pregnancies may, in rare cases, be more frequent among women who utilise no form of contraception.

• Ovarian cysts

  • Follicular growth can take place and may enlarge beyond what might be anticipated in a typical cycle.
  • Usually, ovarian cysts go away on their own without treatment. Surgery is a possibility, though.

• Retinal vascular embolism:

  • Stop using right away and get tested for a retinal vein embolism if you develop an undetected loss of vision, diplopia, papilledema, or lesions on the retinal vessels.

• Thromboembolism

  • Progestin-only contraceptives are expected to have a lower risk of DVT/PE than those using combination hormonal contraceptives.
  • Women with thrombosis (current or past) or thromboembolic conditions (current or past) are not advised to use etonogestrel.
  • In addition to other vascular problems, combining hormonal contraceptives can raise the risk of thromboembolism (eg deep vein thrombosis [DVT], infarction, or pulmonary embolism [PE]).
  • Combination hormonal contraceptives can increase the risk of venous embolism in women with inherited thrombophilias, such as protein C or S deficiencies.

• Vaginal bleeding

  • It is possible for bleeding patterns to change.
  • To exclude cancer, persistent, undetected, or recurrent abnormal vaginal bleeding must be diagnosed.

• Weight loss

  • After a year of regular use, there is an average weight gain of 2.8 pounds, and after two years, it rises to 3.7 pounds.

• Cardiovascular disease

  • Use with caution in people who have cardiovascular disease risk factors (eg, morbid obesity, diabetes, hypertension, hypercholesterolemia, women who smoke).

• Diabetes:

  • This may cause impaired glucose tolerance. Be cautious with prediabetes and diabetes cases in women.

• Fluid retention can lead to more severe diseases

  • Patients with fluid retention-related diseases should be cautious.

• Gallbladder disease

  • The risk of gallbladder disease can be increased by using combination hormonal contraceptives. It is unknown if progestin-only products carry a higher risk for this condition.

• Hepatic adenomas and carcinomas

  • Preexisting hepatic cancers are contraindicated by Etonogestrel.
  • Rarely, combination hormonal contraceptives can cause hepatic tumors.
  • It is unknown what the risk of progestin-only contraceptives.

• Hepatic impairment

  • Hepatic disease is a contraindication to its use.
  • Women with impaired hepatic function may not be able to properly metabolize the drug.
  • If jaundice occurs during treatment or if the liver function is abnormal, discontinue use.

• Hyperlipidemia:

  • Patients with hyperlipidemia should be cautious. Progestins can increase low-density lipoprotein LDL levels.

• Hypertension:

  • Progestin-only implants are safe for use in women with hypertension. When prescribing, it's important to take into account additional heart disease risk factors including diabetes and smoking.
  • According to the manufacturer, it is recommended that women who have a history of hypertension-related conditions should use non-hormonal contraceptives.
  • Women with well-controlled hypertension may consider using it. Keep an eye on your blood pressure.
  • If you suffer chronic hypertension or a significant rise in blood pressure that does not go away with treatment, remove the implant.

• Renal impairment

  • Encouragement should be given to women with renal disease to refrain from using hormonal contraception.

Etonogestrel implant: Drug Interaction

Monitoring parameters:

• Assessment of pregnancy status 
• weight 
• body mass index 
• health changes 
• vision changes;
• blood pressure;
• thromboembolic disorders;
• depression
• glycemic control in patients with diabetes;
• lipid profiles
• Bleeding irregularities including amenorrhea

How to Insert and remove Nexplanon (Etonogestrel implant)?

Subdermal:

• For subcutaneous insertion by medical professionals skilled in the insertion and removal technique.
• Approximately 8 to 10 cm (3 to 4 inches) from the medial epicondyle of the humerus and 3 to 5 cm (1.25 to 2 inches) posterior to the sulcus between the biceps and triceps muscles, place the implant subdermally, just under the skin, at the inner side of the non-dominant upper arm overlying the triceps muscle.
• Insert as far posterior from the sulcus as you can if this position cannot be used (for instance, in ladies with slender arms).
• To ensure proper placement just under the skin, view the advancement of the needle from the side, not from above the patient.

The implant must be palpable after insertion.

• If the implant cannot be felt, it may be confirmed by X-ray, CT scan, ultrasonic scanning, or MRI.
• Deep implants should be located and eliminated as soon as possible.
• Removal of deeply placed implants, implants that are not palpable, or implants that cannot be grasped during removal should be performed by health care providers trained in complex removal procedures.
• It is necessary to use a non-hormonal contraceptive, such as a condom, up until the implant's presence can be confirmed.
• Removal should be done in an aseptic environment. inject a local anaesthetic underneath the implant, not over it.
• Measure the implant's 4 cm length to make sure the entire thing has been taken out. If the implant has broken, take it apart completely.
• As long as the site is in the right place, a new implant may be placed through the same incision in the same arm.
• For comprehensive insertion, removal, and reinsertion instructions, refer to the product labelling provided by the manufacturer.
• The gadget comes with a User Card (to present to the patient), a Consent Form (to maintain on file), and patient product information.
• The manufacturer has materials (including films demonstrating insertion and removal) relating to inserting and removing the etonogestrel implant.(877-888-4231); www.nexplanontraining.com.

Mechanism of action of Nexplanon (Etonogestrel implant):

•  The active metabolite of desogestrel is etonogestrel. It inhibits endometrial growth and suppresses ovulation.

Duration:

• Each implant keeps etonogestrel levels high enough to prevent ovulation for three years.

Protein binding:

• Albumin (66%) and sex hormone-binding globulin (~32%)

Metabolism:

• Hepatic via CYP3A4; forms metabolites (activity not known)

Bioavailability:

• Implant: 100%

Half-life, elimination:

• ~25 hours

Excretion:

• Urine (primarily);
• feces

Pharmacokinetics note:

• Etonogestrel is released from the rod at a rate of 60 to 70 mcg/day in weeks 5 to 6, then drops to 35 to 45 mcg/day, 30 to 40 mcg/day, and 25 to 30 mcg/day by the end of the first year, second year, and third year.
• Levels drop quickly once the rod is removed and are no longer detectable after a week.

International Brand Names of Etonogestrel Implant:

• Implanon NKST
• Implanon NXT
• Nexplanon
• Implanon

Etonogestrel Implant Brand Names in Pakistan:

No Brands are Available in Pakistan.

Read: Nexplanon for PCOS