Prenatal Vitamins Therapeutic Class Review (TCR)

Prenatal Vitamins Therapeutic Class Review (TCR) February 10, 2020 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected].

FDA-APPROVED INDICATIONS Prenatal vitamins are approved for nutritional supplementation of females of childbearing potential during pre-conception, pregnancy, or lactation.1 Current products are listed in Appendix A. OVERVIEW Prenatal vitamins provide supplementation for both the mother and fetus. While prenatal supplements contain numerous vitamins and minerals, the folic acid, iron, and calcium content are particularly important.2 When folic acid stores are replenished before pregnancy, a 50% reduction in neural tube defects has been observed.3 The 2017 American College of Obstetricians and Gynecologists (ACOG) Neural Tube Defect Practice Bulletin recommends periconceptional folic acid supplementation as it has shown to reduce the occurrence and recurrence of neural tube defects.4 All women of child-bearing potential should take folic acid supplementation daily. For women at low-risk of neural tube defect, folic acid supplementation of 400 mcg per day is recommended. Supplementation should be initiated at least 1 month prior to pregnancy and continued through the first 12 weeks of pregnancy. For females at high- risk, defined as those who have had a prior neural tube defect pregnancy, who have a neural tube defect themselves, or who have a partner who has a neural tube defect or a child with a neural tube defect, folic acid supplementation of 4 mg/day is recommended. Supplementation in high-risk patients should be initiated ≥ 3 months prior to pregnancy and continued until 12 weeks of gestational age. Higher levels of folic acid supplementation (> 400 mcg/day) should be achieved by taking an additional folic acid supplement and not by taking excess multivitamins, since they may contain vitamin A, which is potentially teratogenic at high doses. In 2017, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its 2009 statement on folic acid for neural tube defect prevention.5 The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement 400 mcg to 800 mcg of folic acid (Grade A recommendation). This recommendation does not apply to women who have had a prior pregnancy affected by neural tube defects or women taking certain anti-epileptic medicines. Most organizations recommend that these women take higher doses of folic acid.6 The task force found that most women in the U.S. are not ingesting fortified foods at a level thought to provide optimal benefit. In a setting in which food is fortified with folic acid, the effective amount of additional folic acid supplementation is unclear. The Centers for Disease Control (CDC) and March of Dimes actively recommend folic acid as one of the nutrients needed in prenatal vitamins.7,8 Iron is recommended to prevent maternal anemia, preterm labor, low birth weight, and aid in maternal/fetal muscle development. Calcium, along with vitamin D, is important for skeletal development, as well as preventing future maternal osteoporosis.9 For pregnant and lactating women ages 14 to 18 years old, the Institute of Medicine (IOM) recommended daily allowance (RDA) is 1,300 mg/day and 600 IU/day of calcium and vitamin D, respectively.10 For pregnant and lactating women ages 19 to 50 years old, the RDA is 1,000 mg and 600 IU daily calcium and vitamin D supplementation, respectively. Some vitamins contain omega-3 fatty acids, such as docosahexaenoic acid (DHA), in their products to support neural and ophthalmic development. The March of Dimes actively recommends at least 200 mg of DHA/day for women.11

According to the Academy of Nutrition and Dietetics (formerly the American Dietetic Association), daily vitamin supplementation is not a substitute for a healthy diet.12 Prenatal vitamins should be used along with balanced meals to ensure adequate levels of vitamins and minerals and ensure a healthy pregnancy outcome. PHARMACOLOGY13 Calcium is used to maintain calcium balance. Adult pregnant and lactating females require 1,000 mg elemental calcium per day. Calcium supplementation decreases the risk of preeclampsia and hypertensive disease in pregnancy. Folic acid is necessary for formation of a number of coenzymes in many metabolic systems, especially for purine and pyrimidine synthesis. Folic acid is essential for neural tube development occurring within 28 days of conception. Iron replaces iron found in hemoglobin, myoglobin, and enzymes. Iron allows for the transportation of oxygen via hemoglobin. Iron stores are vital for maternal safety. Maternal iron stores at conception are a strong indicator of maternal iron status and risk of iron deficiency and anemia in later pregnancy. The recommendation for pregnant females within the first trimester is 15 mg of elemental iron per day; and 27 mg of elemental iron per day during the second and third trimesters. Lactating females require 9 mg to 10 mg of elemental iron per day. PHARMACOKINETICS14 Prenatal supplements are available as over-the-counter (OTC) and prescription. They differ in their consistency, quality level, and relative bioavailability for fat-soluble and water-soluble vitamins and important minerals. Most OTC supplements now contain higher levels of folic acid. CONTRAINDICATIONS/WARNINGS15 Hypersensitivity to any component of the formulation and pre-existing hypervitaminosis are considered contraindications. Iron toxicity is a boxed warning. Severe iron toxicity may occur in overdose, particularly if ingested by children. It should be stored out of reach of children and in child resistant bottles. Iron supplementation should be avoided in patients with hemochromatosis and hemosiderosis. Prenatal vitamin formulations containing omega-3 fatty acids, such as ALA (alpha-linolenic acid, EPA (eicosapentaenoic acid), and DHA (docosahexaenoic acid), from fish oils may potentially have antithrombotic activities; thereby, increased bleeding times may be noticed. The administration of DHA should be avoided in patients with inherited or acquired bleeding diatheses, including patients taking anticoagulants. Prenatal vitamins should be used with caution in patients with severe hepatic and renal impairment. Use caution in patients with kidney stones due to the calcium content. DRUG INTERACTIONS16 The absorption of iron can be inhibited by eggs and milk. Some products may contain phenylalanine. Pyridoxine supplements should not be taken with levodopa alone. The actions of levodopa may be antagonized with concomitant use.

ADVERSE EFFECTS17 Common reactions to prenatal supplements are gastrointestinal including abdominal pain, constipation, dark stools, diarrhea, nausea, and vomiting. Allergic reactions can occur. SPECIAL POPULATIONS18 Pediatrics Prenatal vitamins are approved in adolescents and adult females. Pregnancy All products are generally recognized as safe (Pregnancy Category A). Hepatic Impairment Prenatal vitamins should be used in caution in patients with severe hepatic impairment. Renal Impairment Prenatal vitamins should be used with caution in patients with severe renal impairment. Use caution in patients with kidney stones due to the calcium content. DOSAGES19 Prenatal vitamins are available as oral dosage forms, including tablet, caplets, capsules, softgel capsules, chewable tablets, liquid, powder, and bars. They should be taken once daily with food, unless otherwise specified. If patients cannot tolerate prenatal vitamins, time of dosing can be changed; taking the vitamin prior to sleep or changing the dosage form may help. CLINICAL TRIALS Search Strategy Articles were identified through searches performed on PubMed, and review of information sent by manufacturers. Search strategy included the agents in this class. Randomized, controlled, comparative trials are considered the most relevant in this category. Studies included for analysis in the review were published in English, performed with human participants, and randomly allocated participants to comparison groups. In addition, studies must contain clearly stated, predetermined outcome measure(s) of known or probable clinical importance, use data analysis techniques consistent with the study question, and include follow-up (endpoint assessment) of at least 80% of participants entering the investigation. Despite some inherent bias found in all studies, including those sponsored and/or funded by pharmaceutical manufacturers, the studies in this therapeutic class review were determined to have results or conclusions that do not suggest systematic error in their experimental study design. While the potential influence of manufacturer sponsorship and/or funding must be considered, the studies in this review have also been evaluated for validity and importance. A randomized, double-blind, multicenter prevention trial with a factorial design tried to determine whether supplementation with folic acid or a combination of seven other vitamins (A, D, B1, B2 , B6, C, and nicotinamide) around the time of conception can prevent neural tube defects, particularly

anencephaly, spina bifida, and encephalocele.20 A total of 1,817 women at high risk of having a pregnancy with a neural tube defect, due to a prior affected pregnancy, were randomized to 1 of 4 groups (folic acid, other vitamins, both, or neither). A total of 1,195 had a completed pregnancy where the fetus or infant was known to have or not have a neural tube defect; 27 had a known neural tube defect, 6 in the folic acid groups, and 21 in the 2 other groups, a 72% protective effect (relative risk [RR], 0.28; 95% confidence interval [CI], 0.12 to 0.71). The other vitamins showed no significant protective effect (RR, 0.8; 95% Cl, 0.32 to 1.72). No adverse events for folic acid were seen. SUMMARY A prenatal vitamin with folic acid, iron, calcium, and vitamin D satisfies the requirements of most pregnant women. REFERENCES

1 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 2 Rakel. Preconception counseling. Textbook of Family Medicine. 2007. 7th ed. Chapter 29. 3 Milunsky A, Jick H, Jick SS, et al: Multivitamin/folic acid supplementation in early pregnancy reduces the prevalence of neural tube defects. JAMA. 1988; 262:2847-2852. 4 ACOG Practice Bulletin No. 187: Neural Tube Defects. Obstet Gynecol. 2017; 130(6): e279-e290. DOI: 10.1097/AOG.0000000000002412. 5 U.S. Preventive Services Task Force. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force recommendation statement. JAMA, 2017; 317(92):183- DOI:10.1001/jama.2016.1943. Available at: http://jamanetwork.com/journals/jama/fullarticle/2596300. Accessed February 10, 2020. 6 Folic Acid. CDC. Available at: https://www.cdc.gov/ncbddd/folicacid/recommendations.html. Accessed February 10, 2020. 7 Centers for Disease Control. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992; 41(No. RR-14). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00019479.htm. Accessed February 10, 2020. 8 March of Dimes: Vitamins and minerals during pregnancy. Last updated February 2018. Available at: http://www.marchofdimes.org/pregnancy/vitamins- and-other-nutrients-during-pregnancy.aspx. Accessed February 10, 2020. 9 Salari P, Abdollahi M. The influence of pregnancy and lactation on maternal bone health: a systematic review. J Fam Reprod Health. 2014; 8(4): 135-148. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266784/. Accessed February 10, 2020. 10 Dietary reference intakes for calcium and vitamin D. Institute of Medicine of National Academies. November 2010. Available at: http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin- D/calciumvitd_lg.jpg?la=en. Accessed February 10, 2020. 11 March of Dimes: Vitamins and minerals during pregnancy. Last updated February 2018. Available at: http://www.marchofdimes.org/pregnancy/vitamins- and-other-nutrients-during-pregnancy.aspx. Accessed February 10, 2020. 12 Kaiser L, Allen LH. American Dietetic Association. Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc. 2008; 108(3):553-561. 13 Lowensohn RI, Stadler DD, Naze C. Current Concepts of Maternal Nutrition. Obstetrical & Gynecological Survey. 2016; 71(7): 413-426. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949006/. Accessed February 10, 2020. 14 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 15 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 16 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 17 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 18 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 19 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 20 Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet. 1991; 338: 131.

PRENATAL VITAMINS, Appendix A; Current Product Listing

LABEL NAME MANUFACTURER DRUG TYPE PROVIDER SYNERGIES BRAND NAME ROUTE PROVIDER SYNERGIES MARKET BASKET CITRANATAL 90 DHA COMBO PACK MISSION PHARM. SSB CITRANATAL 90 DHA (ORAL) PRENATAL VITAMINS CITRANATAL ASSURE COMBO PACK MISSION PHARM. SSB CITRANATAL ASSURE (ORAL) PRENATAL VITAMINS CITRANATAL B-CALM COMBO PACK MISSION PHARM. SSB CITRANATAL B-CALM (ORAL) PRENATAL VITAMINS CITRANATAL DHA PACK MISSION PHARM. SSB CITRANATAL DHA (ORAL) PRENATAL VITAMINS CITRANATAL HARMONY CAPSULE MISSION PHARM. SSB CITRANATAL HARMONY (ORAL) PRENATAL VITAMINS CITRANATAL RX TABLET MISSION PHARM. SSB CITRANATAL RX (ORAL) PRENATAL VITAMINS COMPLETENATE TABLET CHEW TRIGEN LABORATO SSB COMPLETENATE CHEW TABLET (ORAL) PRENATAL VITAMINS ENBRACE HR SOFTGEL JAYMAC PHARMA SSB ENBRACE HR (ORAL) PRENATAL VITAMINS EXPECTA PRENATAL COMBO PACK MJ NUTRITIONAL SSB EXPECTA PRENATAL OTC (ORAL) PRENATAL VITAMINS ELITE-OB CAPLET TRIGEN LABORATO GEN FE C/FA (ORAL) PRENATAL VITAMINS IRON 100 PLUS TABLET CYPRESS PHARM. GEN FE C/VIT C/VIT B12/FA OTC (ORAL) PRENATAL VITAMINS MARNATAL-F CAPSULE MARNEL/ALLEGIS SSB MARNATAL-F (ORAL) PRENATAL VITAMINS NESTABS ABC PRENATAL COMBO PK WOMEN'S CHOICE SSB NESTABS ABC (ORAL) PRENATAL VITAMINS NESTABS ONE SOFTGEL WOMEN'S CHOICE SSB NESTABS ONE (ORAL) PRENATAL VITAMINS OB COMPLETE ONE SOFTGEL VERTICAL PHARM SSB OB COMPLETE ONE (ORAL) PRENATAL VITAMINS OB COMPLETE PETITE SOFTGEL VERTICAL PHARM SSB OB COMPLETE PETITE (ORAL) PRENATAL VITAMINS OB COMPLETE PREMIER TABLET VERTICAL PHARM SSB OB COMPLETE PREMIER (ORAL) PRENATAL VITAMINS OB COMPLETE WITH DHA SOFTGEL VERTICAL PHARM SSB OB COMPLETE WITH DHA (ORAL) PRENATAL VITAMINS O-CAL FA TABLET PHARMICS SSB O-CAL FA (ORAL) PRENATAL VITAMINS C-NATE DHA SOFTGEL CENTURION LABS GEN PNV 11-IRON FUM-FOLIC ACID-OM3 (ORAL) PRENATAL VITAMINS VIRT-NATE DHA SOFTGEL VIRTUS PHARMACE GEN PNV 11-IRON FUM-FOLIC ACID-OM3 (ORAL) PRENATAL VITAMINS PNV-DHA SOFTGEL ACELLA PHARMACE GEN PNV COMBO#47/IRON/FA #1/DHA (ORAL) PRENATAL VITAMINS VIRT-PN DHA SOFTGEL VIRTUS PHARMACE GEN PNV COMBO#47/IRON/FA #1/DHA (ORAL) PRENATAL VITAMINS ZATEAN-PN DHA CAPSULE TRIGEN LABORATO GEN PNV COMBO#47/IRON/FA #1/DHA (ORAL) PRENATAL VITAMINS SE-NATAL 19 CHEWABLE TABLET SETON PHARMACEU GEN PNV NO.118/IRON FUMARATE/FA CHEW TABLET (ORAL) PRENATAL VITAMINS FOLIVANE-OB CAPSULE TRIGEN LABORATO GEN PNV NO.15/IRON FUM & PS CMP/FA (ORAL) PRENATAL VITAMINS PNV-SELECT TABLET ACELLA PHARMACE GEN PNV W-CA NO.40/IRON FUM/FA CMB NO.1 (ORAL) PRENATAL VITAMINS PNV-OMEGA SOFTGEL ACELLA PHARMACE GEN PNV WITH CA NO.68/IRON/FA NO.1/DHA (ORAL) PRENATAL VITAMINS VIRT-PN PLUS SOFTGEL VIRTUS PHARMACE GEN PNV WITH CA NO.68/IRON/FA NO.1/DHA (ORAL) PRENATAL VITAMINS ZATEAN-PN PLUS SOFTGEL TRIGEN LABORATO GEN PNV WITH CA NO.68/IRON/FA NO.1/DHA (ORAL) PRENATAL VITAMINS M-NATAL PLUS TABLET METHOD PHARMACE GEN PNV WITH CA,NO.72/IRON/FA (ORAL) PRENATAL VITAMINS PRENATAL VITAMIN PLUS LOW IRON generic GEN PNV WITH CA,NO.72/IRON/FA (ORAL) PRENATAL VITAMINS PREPLUS CA-FE 27 MG-FA 1 MG TB VIRTUS PHARMACE GEN PNV WITH CA,NO.72/IRON/FA (ORAL) PRENATAL VITAMINS NIVA-PLUS TABLET NIVAGEN PHARMAC GEN PNV WITH CA,NO.74/IRON/FA OTC (ORAL) PRENATAL VITAMINS TARON-C DHA CAPSULE TRIGEN LABORATO GEN PNV#16/IRON FUM & PS/FA/OM-3 (ORAL) PRENATAL VITAMINS VIRT-C DHA SOFTGEL VIRTUS PHARMACE GEN PNV#16/IRON FUM & PS/FA/OM-3 (ORAL) PRENATAL VITAMINS SE-NATAL-19 TABLET SETON PHARMACEU GEN PNV119/IRON FUMARATE/FA/DSS TABLET (ORAL) PRENATAL VITAMINS THRIVITE 19 TABLET METHOD PHARMACE GEN PNV119/IRON FUMARATE/FA/DSS TABLET (ORAL) PRENATAL VITAMINS COMPLETE NATAL DHA TRIGEN LABORATO GEN PNV2/IRON B-G SUC-P/FA/OMEGA-3 (ORAL) PRENATAL VITAMINS TRUST NATAL DHA VERTICAL PHARM GEN PNV2/IRON B-G SUC-P/FA/OMEGA-3 (ORAL) PRENATAL VITAMINS TRIVEEN-DUO DHA COMBO PACK TRIGEN LABORATO GEN PNV53/IRON B-G HCL-P/FA/OMEGA3 (ORAL) PRENATAL VITAMINS PNV-DHA + DOCUSATE SOFTGEL ACELLA PHARMACE GEN PNV66/IRON FUMARATE/FA/DSS/DHA (ORAL) PRENATAL VITAMINS PRENAISSANCE PLUS SOFTGEL ACELLA PHARMACE GEN PNV69/IRON,CARBONYL/FA/DSS/DHA (ORAL) PRENATAL VITAMINS PRENAISSANCE CAPSULE ACELLA PHARMACE GEN PNV80/IRON FUMARATE/FA/DSS/DHA (ORAL) PRENATAL VITAMINS VINACAL B PRENATAL COMBO PACK BRECKENRIDGE GEN PRENATAL #48/IRON CB&GLU/FA/B6 OTC (ORAL) PRENATAL VITAMINS PNV 29-1 TABLET VIRTUS PHARMACE GEN PRENATAL VIT #76/IRON,CARB/FA (ORAL) PRENATAL VITAMINS THRIVITE RX TABLET METHOD PHARMACE GEN PRENATAL VIT #76/IRON,CARB/FA (ORAL) PRENATAL VITAMINS PRETAB 29 MG-1 MG TABLET VIRTUS PHARMACE GEN PRENATAL VIT NO.78/IRON/FA (ORAL) PRENATAL VITAMINS CLASSIC PRENATAL TABLET RUGBY GEN PRENATAL VIT/FE FUMARATE/FA OTC (ORAL) PRENATAL VITAMINS PRENATAL VITAMIN TABLET generic GEN PRENATAL VIT/FE FUMARATE/FA OTC (ORAL) PRENATAL VITAMINS PRENATAL VITAMINS TABLET generic GEN PRENATAL VIT/FE FUMARATE/FA OTC (ORAL) PRENATAL VITAMINS PRENATE AM TABLET AVION PHARMACEU SSB PRENATE AM (ORAL) PRENATAL VITAMINS PRENATE CHEWABLE TABLET AVION PHARMACEU SSB PRENATE CHEWABLE TABLET (ORAL) PRENATAL VITAMINS PRENATE DHA SOFTGEL AVION PHARMACEU SSB PRENATE DHA (ORAL) PRENATAL VITAMINS PRENATE ELITE TABLET AVION PHARMACEU SSB PRENATE ELITE (ORAL) PRENATAL VITAMINS PRENATE ENHANCE SOFTGEL AVION PHARMACEU SSB PRENATE ENHANCE (ORAL) PRENATAL VITAMINS PRENATE ESSENTIAL SOFTGEL AVION PHARMACEU SSB PRENATE ESSENTIAL (ORAL) PRENATAL VITAMINS PRENATE MINI SOFTGEL AVION PHARMACEU SSB PRENATE MINI (ORAL) PRENATAL VITAMINS PRENATE PIXIE SOFTGEL AVION PHARMACEU SSB PRENATE PIXIE (ORAL) PRENATAL VITAMINS PRENATE RESTORE SOFTGEL AVION PHARMACEU SSB PRENATE RESTORE (ORAL) PRENATAL VITAMINS PRENATE STAR TABLET AVION PHARMACEU SSB PRENATE STAR (ORAL) PRENATAL VITAMINS PRIMACARE SOFTGEL AVION PHARMACEU SSB PRIMACARE (ORAL) PRENATAL VITAMINS PROVIDA OB CAPSULE US PHARMACEUTIC SSB PROVIDA OB (ORAL) PRENATAL VITAMINS PUREFE OB PLUS CAPSULE PURETEK CORPORA SSB PUREFE OB PLUS (ORAL) PRENATAL VITAMINS PUREFE PLUS CAPSULE PURETEK CORPORA SSB PUREFE PLUS (ORAL) PRENATAL VITAMINS SELECT-OB + DHA PACK EXELTIS USA, IN SSB SELECT-OB + DHA (ORAL) PRENATAL VITAMINS SELECT-OB CHEWABLE CAPLET EXELTIS USA, IN SSB SELECT-OB TAB CHEW (ORAL) PRENATAL VITAMINS STUART ONE CAPSULE EXELTIS USA, IN SSB STUART ONE OTC (ORAL) PRENATAL VITAMINS TARON-PREX PRENATAL DHA CAP TRIGEN LABORATO SSB TARON-PREX PRENATAL (ORAL) PRENATAL VITAMINS TENDERA-OB SOFTGEL BONGEO PHARMACE SSB TENDERA-OB OTC (ORAL) PRENATAL VITAMINS TRICARE PRENATAL TABLET MEDECOR PHARMA SSB TRICARE (ORAL) PRENATAL VITAMINS TRINATAL RX 1 TABLET TRIGEN LABORATO SSB TRINATAL RX 1 (ORAL) PRENATAL VITAMINS TRISTART DHA SOFTGEL CARWIN ASSOCIAT SSB TRISTART DHA (ORAL) PRENATAL VITAMINS VINATE DHA RF GELCAP BRECKENRIDGE SSB VINATE DHA RF (ORAL) PRENATAL VITAMINS VITAFOL FE PLUS SOFTGEL EXELTIS USA, IN SSB VITAFOL FE+ (ORAL) PRENATAL VITAMINS VITAFOL FE+ DOCUSATE COMBO PCK EXELTIS USA, IN SSB VITAFOL FE+ (ORAL) PRENATAL VITAMINS VITAFOL NANO TABLET EXELTIS USA, IN SSB VITAFOL NANO (ORAL) PRENATAL VITAMINS VITAFOL GUMMIES EXELTIS USA, IN SSB VITAFOL TAB CHEW (ORAL) PRENATAL VITAMINS VITAFOL ULTRA SOFTGEL EXELTIS USA, IN SSB VITAFOL ULTRA (ORAL) PRENATAL VITAMINS VITAFOL-OB CAPLET EXELTIS USA, IN SSB VITAFOL-OB (ORAL) PRENATAL VITAMINS VITAFOL-OB+DHA COMBO PACK EXELTIS USA, IN SSB VITAFOL-OB+DHA (ORAL) PRENATAL VITAMINS VITAFOL-ONE CAPSULE EXELTIS USA, IN SSB VITAFOL-ONE (ORAL) PRENATAL VITAMINS VP-CH-PNV PRENATAL SOFTGEL VIRTUS PHARMACE GEN VP-CH-PNV (ORAL) PRENATAL VITAMINS