Determining the Exposure Threshold for Levonorgestrel Efficacy Using an Integrated Model Based Meta-Analysis Approach

Karthik Lingineni, Ayyappa Chaturvedula, Brian Cicali, Rodrigo Cristofoletti, Thomas Wendl, Joachim Hoechel, Joshua D. Brown, Valvanera Vozmediano, Stephan Schmidt

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Combined oral contraceptive pills are the most commonly used hormonal contraceptives for the prevention of unintended pregnancies in United States. They consist of a progestin (e.g., levonorgestrel (LNG)) and an estrogen component, typically ethinyl estradiol (EE). In addition to adherence issues, drug-drug interactions (DDIs) and obesity (women with body mass index (BMI) ≥ 30 kg/m2) are prime suspects for decreased LNG efficacy. Therefore, we developed an integrated physiologically-based pharmacokinetic modeling and model-based meta-analysis approach to determine LNG’s efficacy threshold concentrations and to evaluate the impact of DDIs and obesity on the efficacy of LNG-containing hormonal contraceptives (HCs). Based on this approach, co-administration of strong CYP3A4 inducers and LNG-containing HCs (LNG150: LNG 150 µg + EE 30 µg and LNG100: LNG 100 µg + EE 20 µg) resulted in a predicted clinically relevant decrease of LNG plasma exposure (women with BMI < 25 kg/m2: 50–65%; obese women: 70–75%). Following administration of LNG150 or LNG100 in the presence of a CYP3A4 inducer, there was an increase in mean Pearl Index of 1.2–1.30 and 1.80–2.10, respectively, in women with BMI < 25 kg/m2 (incidence rate ratios (IRRs): 1.7–2.2), whereas it ranged from 1.6–1.80 and 2.40–2.85 in obese women (IRR: 2.2–3.0), respectively. Our results suggest that the use of backup or alternate methods of contraception is not necessarily required for oral LNG + EE formulations except within circumstances of both obesity and strong CYP3A4 inducer concomitance following administration of LNG100.

Original languageEnglish
Pages (from-to)509-518
Number of pages10
JournalClinical Pharmacology and Therapeutics
Issue number2
StatePublished - Feb 2022


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