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Monfort A, Cardoso E, Eap CB, Ansermot N, Crettol S, Fischer Fumeaux CJ, Graz MB, Harari MM, Weisskopf E, Gandia P, Allegaert K, Annaert P, Nordeng H, Hascoët JM, Claris O, Epiney M, Ferreira E, Leclair G, Csajka C, Panchaud A, Guidi M. A population pharmacokinetic model for sertraline in women during the perinatal period-A contribution from the ConcePTION project. Br J Clin Pharmacol 2024. [PMID: 39030897 DOI: 10.1111/bcp.16177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/17/2024] [Accepted: 06/17/2024] [Indexed: 07/22/2024] Open
Abstract
AIMS Sertraline is frequently prescribed for mental health conditions in both pregnant and breastfeeding women. According to the limited available data, only small amounts of sertraline are transferred into human milk, yet with a large amount of unexplained interindividual variability. This study aimed to develop a population pharmacokinetic (popPK) model to describe the pharmacokinetics of sertraline during the perinatal period and explain interindividual variability. METHODS Pregnant women treated with sertraline were enrolled in the multicenter prospective cohort SSRI-Breast Milk study. A popPK model for sertraline maternal plasma and breast milk concentrations was developed and allowed estimating the milk-to-plasma ratio (MPR). An additional fetal compartment allowed cord blood concentrations to be described. Several covariates were tested for significance. Ultimately, model-based simulations allowed infant drug exposure through placenta and breast milk under various conditions to be predicted. RESULTS Thirty-eight women treated with sertraline were included in the study and provided 89 maternal plasma, 29 cord blood and 107 breast milk samples. Sertraline clearance was reduced by 42% in CYP2C19 poor metabolizers compared to other phenotypes. Doubling milk fat content increased the MPR by 95%. Simulations suggested a median daily infant dosage of 6.9 μg kg-1 after a 50 mg maternal daily dose, representing 0.95% of the weight-adjusted maternal dose. Median cord blood concentrations could range from 3.29 to 33.23 ng mL-1 after maternal daily doses between 25 and 150 mg. CONCLUSIONS Infant exposure to sertraline, influenced by CYP2C19 phenotype and breast milk fat content, remains low, providing reassurance regarding the use of sertraline during pregnancy and breastfeeding.
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Affiliation(s)
- Anaëlle Monfort
- CHU Sainte-Justine, Montréal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - Evelina Cardoso
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Chin B Eap
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva and University of Lausanne, Lausanne and Geneva, Switzerland
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Ansermot
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Severine Crettol
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Céline J Fischer Fumeaux
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Myriam Bickle Graz
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Mathilde Morisod Harari
- Division of Child and Adolescent Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Etienne Weisskopf
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Peggy Gandia
- Laboratory of Pharmacokinetics and Toxicology, Purpan Hospital, University Hospital of Toulouse, Toulouse, France
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Pieter Annaert
- Drug Delivery and Disposition Lab, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Jean-Michel Hascoët
- Department of Neonatology, Maternité Régionale, Université de Lorraine, Nancy, France
| | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Lyon, France
- Claude Bernard University, Lyon, France
| | - Manuella Epiney
- Department of Women, Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| | - Ema Ferreira
- CHU Sainte-Justine, Montréal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - Grégoire Leclair
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva and University of Lausanne, Lausanne and Geneva, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Monia Guidi
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva and University of Lausanne, Lausanne and Geneva, Switzerland
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Lanzi C, Davanzo R, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Mannaioni G, Salvatori G, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:551. [PMID: 38791766 PMCID: PMC11121006 DOI: 10.3390/ijerph21050551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Our consensus statement aims to clarify the use of antidepressants and anxiolytics during breastfeeding amidst clinical uncertainty. Despite recent studies, potential harm to breastfed newborns from these medications remains a concern, leading to abrupt discontinuation of necessary treatments or exclusive formula feeding, depriving newborns of benefits from mother's milk. METHODS A panel of 16 experts, representing eight scientific societies with a keen interest in postpartum depression, was convened. Utilizing the Nominal Group Technique and following a comprehensive literature review, a consensus statement on the pharmacological treatment of breastfeeding women with depressive disorders was achieved. RESULTS Four key research areas were delineated: (1) The imperative to address depressive and anxiety disorders during lactation, pinpointing the risks linked to untreated maternal depression during this period. (2) The evaluation of the cumulative risk of unfavorable infant outcomes associated with exposure to antidepressants or anxiolytics. (3) The long-term impact on infants' cognitive development or behavior due to exposure to these medications during breastfeeding. (4) The assessment of pharmacological interventions for opioid abuse in lactating women diagnosed with depressive disorders. CONCLUSIONS The ensuing recommendations were as follows: Recommendation 1: Depressive and anxiety disorders, as well as their pharmacological treatment, are not contraindications for breastfeeding. Recommendation 2: The Panel advocates for the continuation of medication that has demonstrated efficacy during pregnancy. If initiating an antidepressant during breastfeeding is necessary, drugs with a superior safety profile and substantial epidemiological data, such as SSRIs, should be favored and prescribed at the lowest effective dose. Recommendation 3: For the short-term alleviation of anxiety symptoms and sleep disturbances, the Panel determined that benzodiazepines can be administered during breastfeeding. Recommendation 4: The Panel advises against discontinuing opioid abuse treatment during breastfeeding. Recommendation 5: The Panel endorses collaboration among specialists (e.g., psychiatrists, pediatricians, toxicologists), promoting multidisciplinary care whenever feasible. Coordination with the general practitioner is also recommended.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Addiction Centre, Ser.D, Local Health Unit, 28100 Novara, Italy
| | - Cecilia Lanzi
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Riccardo Davanzo
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Maternal and Child Health Institute IRCCS “Burlo Garofolo”, 34137 Trieste, Italy
- Task Force on Breastfeeding, Ministry of Health, 00144 Rome, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella, Drug Addiction Service, 13875 Biella, Italy;
- Italian Society of Addiction Diseases (S.I.Pa.D), Via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
- Italian Society for Drug Addiction (SITD), Via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
| | - Guido Mannaioni
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
- Italian Society of Pharmacology, Via Giovanni Pascoli, 3, 20129 Milan, Italy
| | - Guglielmo Salvatori
- Italian Society of Pediatrics, Via Gioberti 60, 00185 Rome, Italy;
- Department of Medical and Surgical Neonatology Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
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Krauskopf V, Valenzuela P. Depresión perinatal: detección, diagnóstico y estrategias de tratamiento. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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den Besten-Bertholee D, van der Meer DH, Ter Horst PGJ. Quality of Lactation Studies Investigating Antidepressants. Breastfeed Med 2019; 14:359-365. [PMID: 31013435 DOI: 10.1089/bfm.2019.0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: The aim of this study was to determine the quality of lactation studies investigating antidepressants in breast milk according to the Food and Drug Administration (FDA) draft guidelines and the article by Begg et al., 2002, published in the official journal of the International Lactation Consultant Association (ILCA). Materials and Methods: We used PubMed and LactMed® for the literature search. Furthermore, cross references were searched for additional studies. Results: A total number of 60 articles were included for review. For selective serotonin reuptake inhibitors and venlafaxine, only two studies correctly assessed the absolute infant dose and milk to plasma ratio; one sertraline and one fluoxetine study. Of all tricyclic antidepressants, one study for amitriptyline and one for nortriptyline assessed these endpoints correctly. We found a lack of information on breast milk sampling methods in many studies. Concentrations needed for the calculations were based on single measurements instead of at least five measurements during one dose interval, and the relative infant dose was not normalized by maternal weight, or an average maternal weight of 70 kg was used as a standard. Discussion: We conclude that the quality of the current literature on this topic does not meet the standards of the FDA. Studies of higher quality are needed to determine the extent of drug transfer to breast milk for antidepressants, so an adequate recommendation about use of these drugs during lactation can be given.
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Kronenfeld N, ziv Baran T, Berlin M, Karra N, Dinavitser N, Cohen R, Wiener Y, Schwartzberg E, Bercovitch M. Chronic use of psychotropic medications in breastfeeding women: Is it safe? PLoS One 2018; 13:e0197196. [PMID: 29782546 PMCID: PMC5962050 DOI: 10.1371/journal.pone.0197196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/27/2018] [Indexed: 01/16/2023] Open
Abstract
Background Current knowledge regarding chronic use of psychotropic medications during breastfeeding is limited. The objective of this study was to evaluate the long-term effects of psychotropic monotherapy use during lactation on the breastfed infant. Materials and methods In this prospective study, we followed 280 infants whose mothers contacted the Drug Consultation Center (DCC) at Assaf Harofeh Medical Center between January 2011 and December 2015, seeking information regarding the chronic use of psychotropic medications during lactation. This group was compared with a group of 152 callers, who inquired evidence regarding the use of antibiotics compatible with breastfeeding. Information on adverse effects, physical measures and gross motor developmental milestone achievements of the breastfed infants was obtained during a follow-up telephone interview. At follow up, the median age of the infants in the Psychotropic-drug group was 20 (11–33) months versus 36 (20–48) months in the Antibiotic group (p < 0.001). The outcomes were compared between the groups followed by a propensity score matching to control for difference in baseline characteristics. Results At follow-up, no significant differences between infants in the two groups were observed with regard to height, weight, head circumference and weight-length ratio percentile (p = 0.339, p = 0.223, p = 0.738, p = 0.926, respectively). Children in both groups were, according to their parents, within the normal developmental range for all milestones, according to the Denver Developmental Scale. Use of psychotropic medications during breastfeeding was not significantly associated with adverse reactions. After propensity score matching (n = 120 pairs) to control for differences in baseline characteristics and the length of lactation, only one significant difference was reported, sleepiness in infants in the study group (7/120) and none in the comparison group (p = 0.008). Conclusions Chronic use of psychotropic monotherapy during lactation is associated with normal growth and gross motor developmental as by milestone achievements reported by parents. Sleepiness was reported, it seemed self-limited with no developmental effect.
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Affiliation(s)
- Nirit Kronenfeld
- Department of Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tomer ziv Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Berlin
- Department of Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nour Karra
- Department of Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Natalie Dinavitser
- Department of Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rana Cohen
- Department of Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yifat Wiener
- Department of Obstetric and Gynecology, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Schwartzberg
- Department of Pharmacy, Ben Gurion University of the Negev, Beer-Sheba, Israel
| | - Matitiahu Bercovitch
- Department of Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- * E-mail:
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Kronenfeld N, Berlin M, Shaniv D, Berkovitch M. Use of Psychotropic Medications in Breastfeeding Women. Birth Defects Res 2018; 109:957-997. [PMID: 28714610 DOI: 10.1002/bdr2.1077] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Breastfeeding women who are prescribed with psychotropic medications on a regular basis are often concerned, regarding the possible implications of such treatment on the breastfed infant. A mother's well-being has a direct influence on the well-being of the baby. However, the notorious reputation of psychotropic medications may lead to suboptimal prescribing by the physician and poor adherence by the mother. METHODS A PubMed search (from 1976 through February 2017) was conducted for commonly used psychotropic drug classes, as well as individual medications commonly prescribed in these classes, along with the MeSH terms "breastfeeding"/"lactation". In each case, we chose studies that describe the pharmacokinetics of passage into breast milk and/or adverse effects in breastfed infants. RESULTS No large-scale controlled studies regarding the safety of psychotropic medications in breastfeeding mothers were reported. Based on case reports and small studies, most psychotropic medications produce low milk levels and low plasma levels in the infant, while serious adverse effects in the breastfed infant are rarely reported. Safety data for some psychotropic medications are still unavailable. CONCLUSION According to the data available in the literature to date, most psychotropic medications are expected to produce low levels in breast milk with no clinical importance. Nevertheless, an individual risk-benefit assessment of a proposed treatment should always be performed, as inter-individual differences may have a substantial effect on the breastfeeding infant's response to the treatment. Further studies and additional objective data are needed to consolidate and improve our current knowledge of psychopharmacotherapy in breastfeeding women. Birth Defects Research 109:957-997, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Nirit Kronenfeld
- School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem.,Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Maya Berlin
- Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dotan Shaniv
- Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Edwards JG. Newer v. older antidepressants in long-term pharmacotherapy: Revisiting… Prevention of relapse and recurrence of depression. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.11.3.184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
There is much evidence from clinical trials that antidepressants help prevent relapse and recurrence of major depression. However, this is unlikely to hold true for all patients with depression, particularly those treated in primary care. Individual antidepressants are equally efficacious, so choice (as first-line treatment in general or for individual patients) is largely determined by differences in side-effects, even though many of these disappear during long-term treatment, owing to adaptation. Specific effects that are considered in choosing a drug include those on cognition, psychomotor performance and sexual function; drug interactions, lethality in overdose and the potential for teratogenicity are also considered. There are insufficient entirely objective and generally accepted data on pharmaco-economics to allow for confident recommendations on drug choice for long-term treatment. Drug acquisition costs must be considered by those with restricted budgets, and especially patients in developing countries where difference in cost between newer and older drugs can be translated into more food for a hungry family.
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Uguz F. Gastrointestinal Side Effects in the Baby of a Breastfeeding Woman Treated with Low-Dose Fluvoxamine. J Hum Lact 2015; 31:371-3. [PMID: 25896469 DOI: 10.1177/0890334415582207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 03/24/2015] [Indexed: 11/15/2022]
Abstract
Depression and anxiety disorders are frequently seen in the postpartum period. Primary pharmacological agents for these disorders are antidepressants, especially selective serotonin reuptake inhibitors. Despite no adverse reports, data on safety for the maternal use of fluvoxamine on breastfed infants are limited. This case report presents diarrhea and vomiting in the breastfed baby of a woman using fluvoxamine at 50 mg/d.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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Abstract
AIMS Untreated perinatal depression and anxiety disorders are known to have significant negative impact on both maternal and fetal health. Dilemmas still remain regarding the use and safety of psychotropics in pregnant and lactating women suffering from perinatal depression and anxiety disorders. The aim of the current paper was to review the existing evidence base on the exposure and consequences of antidepressants, anxiolytics, and hypnotics in women during pregnancy and lactation and to make recommendations for clinical decision making in management of these cases. MATERIALS AND METHODS We undertook a bibliographic search of Medline/PubMed (1972 through 2014), Science Direct (1972 through 2014), Archives of Indian Journal of Psychiatry databases was done. References of retrieved articles, reference books, and dedicated websites were also checked. RESULTS AND CONCLUSIONS The existing evidence base is extensive in studying multiple outcomes of the antidepressant or anxiolytic exposure in neonates, and some of the findings appear conflicting. Selective serotonin reuptake inhibitors are the most researched antidepressants in pregnancy and lactation. The available literature is criticized mostly on the lack of rigorous well designed controlled studies as well as lacunae in the methodologies, interpretation of statistical information, knowledge transfer, and translation of information. Research in this area in the Indian context is strikingly scarce. Appropriate risk-benefit analysis of untreated mental illness versus medication exposure, tailor-made to each patient's past response and preference within in the context of the available evidence should guide clinical decision making.
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Affiliation(s)
- Daya Ram
- Director, Central Institute of Psychiatry, Ranchi, Jharkhand, India
| | - S. Gandotra
- Department of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
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Sriraman NK, Melvin K, Meltzer-Brody S. ABM Clinical Protocol #18: Use of Antidepressants in Breastfeeding Mothers. Breastfeed Med 2015. [PMID: 26204124 PMCID: PMC4523038 DOI: 10.1089/bfm.2015.29002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
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Affiliation(s)
- Natasha K Sriraman
- 1 Department of Pediatrics, Children's Hospital of The King's Daughters/Eastern Virginia Medical School , Norfolk, Virginia
| | - Kathryn Melvin
- 2 Department of Psychiatry, University of North Carolina Chapel Hill School of Medicine , Chapel Hill, North Carolina
| | - Samantha Meltzer-Brody
- 2 Department of Psychiatry, University of North Carolina Chapel Hill School of Medicine , Chapel Hill, North Carolina.,3 Perinatal Psychiatry Program, University of North Carolina Chapel Hill Center for Women's Mood Disorders , Chapel Hill, North Carolina
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Pinheiro E, Bogen DL, Hoxha D, Ciolino JD, Wisner KL. Sertraline and breastfeeding: review and meta-analysis. Arch Womens Ment Health 2015; 18:139-146. [PMID: 25589155 PMCID: PMC4366287 DOI: 10.1007/s00737-015-0499-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 01/04/2015] [Indexed: 01/16/2023]
Abstract
We examined the risk-benefit profile of sertraline treatment during breastfeeding, summarized the available literature on sertraline use, presented previously unpublished data, and performed a correlation-based meta-analysis of sertraline serum levels in mother-infant pairs. We conducted a search of PubMed and the National Library of Medicine LactMed database. We performed a meta-analysis to examine correlations between maternal and infant serum sertraline levels in the existing literature and in previously unpublished data. Of 167 available infant sertraline levels, 146 (87.4 %) were below the limit of detection, and the meta-analysis found no significant relationship between maternal and infant sertraline concentrations. Of 150 infant desmethylsertraline levels, 105 (70.0 %) were below the limit of detection. The correlation analysis revealed a significant relationship between maternal and infant desmethylsertraline concentrations, but this metabolite has only a fraction of the activity of sertraline. A significant relationship was also found for the sum of sertraline and desmethylsertraline, which stems primarily from the contribution of desmethylsertraline. Sertraline is a first-line drug for breastfeeding women due to documented low levels of exposure in breastfeeding infants and very few adverse events described in case reports. Based on the current literature, neither routine serum sampling nor genotyping is warranted for breastfeeding mothers taking sertraline and/or their infants. Routine pediatric care is appropriate monitoring for breastfed infants of women who take sertraline monotherapy.
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Affiliation(s)
- Emily Pinheiro
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 1000, Chicago, IL, 60611, USA.
| | - Debra L Bogen
- Department of Pediatrics, University of Pittsburgh School of Medicine, 3420 Fifth Ave., Pittsburgh, PA, 15213, USA
| | - Denada Hoxha
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 1000, Chicago, IL, 60611, USA
| | - Jody D Ciolino
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Katherine L Wisner
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 1000, Chicago, IL, 60611, USA
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Altamura AC, Caldiroli A, Buoli M. Pharmacokinetic evaluation of fluvoxamine for the treatment of anxiety disorders. Expert Opin Drug Metab Toxicol 2015; 11:649-60. [DOI: 10.1517/17425255.2015.1021331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Orsolini L, Bellantuono C. Serotonin reuptake inhibitors and breastfeeding: a systematic review. Hum Psychopharmacol 2015; 30:4-20. [PMID: 25572308 DOI: 10.1002/hup.2451] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 10/15/2014] [Accepted: 10/30/2014] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The postnatal period represents a critical phase for mothers because of physiological hormonal changes, the increase of emotional reactions and a greater susceptibility for the onset/recrudescence of psychiatric disorders. Despite the evidence of an increasing utilization of antidepressant drugs during breastfeeding, there is still few reliable information on the neonatal safety of the selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs) [serotonin reuptake inhibitors (SRIs)] in nursing mothers. The aim of this study is to provide a systematic review on the neonatal safety profile of these drugs during breastfeeding, also assessing the limits of available tools. METHODS MEDLINE and PubMed databases were searched without any language restrictions by using the following set of keywords: ((SSRIs OR selective serotonin inhibitor reuptake OR SNRIs OR selective serotonin noradrenaline inhibitor reuptake) AND (breastfeeding OR lactation OR breast milk)). A separate search was also performed for each SSRIs (paroxetine, fluvoxamine, fluoxetine, sertraline, citalopram and escitalopram) and SNRIs (venlafaxine and duloxetine). RESULTS Sertraline and paroxetine show a better neonatal safety profile during breastfeeding as compared with other SRIs. Less data are available for fluvoxamine, escitalopram and duloxetine. Few studies followed up infants breastfeed for assessing the neurodevelopmental outcomes. CONCLUSIONS Literature review clearly indicates paroxetine and sertraline as the drugs that should be preferred as first line choice in nursing women who need an antidepressant treatment.
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Affiliation(s)
- Laura Orsolini
- Psychiatric Unit and DEGRA Center, United Hospital of Ancona and Academic Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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Abstract
Many mothers are inappropriately advised to discontinue breastfeeding or avoid taking essential medications because of fears of adverse effects on their infants. This cautious approach may be unnecessary in many cases, because only a small proportion of medications are contraindicated in breastfeeding mothers or associated with adverse effects on their infants. Information to inform physicians about the extent of excretion for a particular drug into human milk is needed but may not be available. Previous statements on this topic from the American Academy of Pediatrics provided physicians with data concerning the known excretion of specific medications into breast milk. More current and comprehensive information is now available on the Internet, as well as an application for mobile devices, at LactMed (http://toxnet.nlm.nih.gov). Therefore, with the exception of radioactive compounds requiring temporary cessation of breastfeeding, the reader will be referred to LactMed to obtain the most current data on an individual medication. This report discusses several topics of interest surrounding lactation, such as the use of psychotropic therapies, drugs to treat substance abuse, narcotics, galactagogues, and herbal products, as well as immunization of breastfeeding women. A discussion regarding the global implications of maternal medications and lactation in the developing world is beyond the scope of this report. The World Health Organization offers several programs and resources that address the importance of breastfeeding (see http://www.who.int/topics/breastfeeding/en/).
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Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry 2013; 14:334-85. [PMID: 23879318 DOI: 10.3109/15622975.2013.804195] [Citation(s) in RCA: 382] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions. METHODS The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force. RESULTS This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults. CONCLUSIONS To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.
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Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany.
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19
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Abstract
UNLABELLED Perinatal depression is an increasingly common comorbidity of pregnancy and is associated with adverse birth outcomes. Newer classes of antidepressants have been developed with a variety of mechanisms and improved side effect profiles. There is increasing use of these medications in reproductive-aged women. Medical providers have to balance the need to prevent relapse of maternal depressive symptoms with the need to minimize fetal exposure to medications. We review the literature on 10 of the most commonly used antidepressant medications: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, duloxetine, bupropion, and mirtazapine. The pharmacokinetic properties of the medications are detailed, as well as practical considerations for their use in pregnant and lactating women. Guidance on counseling and management of pregnancies complicated by perinatal depression is discussed. TARGET AUDIENCE Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES After completing this CME activity, physicians should be better able to differentiate the current classes of medications utilized commonly for perinatal depression, evaluate the reported adverse effects of antidepressant medications on the patient and developing fetus and choose the appropriate antidepressant medications for a depressed patient who is breast-feeding.
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Davanzo R, Copertino M, De Cunto A, Minen F, Amaddeo A. Antidepressant drugs and breastfeeding: a review of the literature. Breastfeed Med 2011; 6:89-98. [PMID: 20958101 DOI: 10.1089/bfm.2010.0019] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The use of antidepressants in breastfeeding mothers is controversial: Manufacters often routinely discourage breastfeeding for the nursing mother despite the well-known positive impact that breastfeeding carries on the health of the nursing infant and on his or her family and society. We conducted a systematic review of drugs commonly used in the treatment of postpartum depression. For every single drug two sets of data were provided: (1) selected pharmacokinetic characteristics such as half-life, milk-to-plasma ratio, protein binding, and oral bioavailability and (2) information about lactational risk, according to some authoritative sources of the literature: Drugs in Pregnancy and Lactation edited by Briggs et al. (Lippincott Williams, Philadelphia, 2008), Medications and Mothers' Milk by Hale (Hale Publishing, Amarillo, TX, 2010), and the LactMed database of TOXNET ( www.pubmed.gov ; accessed June 2010). Notwithstanding a certain variability of advice, we found that (1) knowledge of pharmacokinetic characteristics are scarcely useful to assess safety and (2) the majority of antidepressants are not usually contraindicated: (a) Selective serotinin reuptake inhibitors and nortryptiline have a better safety profile during lactation, (b) fluoxetine must be used carefully, (c) the tricyclic doxepine and the atypical nefazodone should better be avoided, and (d) lithium, usually considered as contraindicated, has been recently rehabilitated.
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Affiliation(s)
- Riccardo Davanzo
- Division of Neonatology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.
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21
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Abstract
One of the least-developed areas of clinical pharmacology and drug research is the use of medication during pregnancy and lactation. This article is the first in a two-part series designed to familiarize physicians with many aspects of the drugs they commonly prescribe for pregnant and breast-feeding women. Almost every pregnant woman is exposed to some type of medication during pregnancy. Although the majority of pregnant and breast-feeding women consume clinically indicated or over-the-counter drug preparation regularly, only few medications have specifically been tested for safety and efficacy during pregnancy. There is scant information on the effect of common pregnancy complications on drug clearance and efficacy. Often, the safety of a drug for mothers, their fetuses, and nursing infants cannot be determined until it has been widely used. Absent this crucial information, many women are either refused medically important agents or experience potentially harmful delays in receiving drug treatment. Conversely, many drugs deemed "safe" are prescribed despite evidence of possible teratogenicity. Novel research and diagnostic applications evolving from the opportunities presented by the advances in genomics and proteomics are now beginning to affect clinical diagnosis, vaccine development, drug discovery, and unique therapies in a modern diagnostic-therapeutic framework-part of the new scientific field of theranostics. This review critically explores a number of recently raised issues in regard to the use of several classes of medications during gestation and seeks to provide a general and concise resource on drugs commonly used during pregnancy and lactation. It also seeks to make clinicians more aware of the controversies surrounding some drugs in an effort to encourage safer prescribing practices through consultation with a maternal-fetal medicine specialist and through references and Web sites that list up-to-date information.
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22
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Fleschler R, Peskin MF. Selective Serotonin Reuptake Inhibitors (SSRIs) in Pregnancy. MCN Am J Matern Child Nurs 2008; 33:355-61; quiz 362-3. [DOI: 10.1097/01.nmc.0000341255.80426.7b] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Lobo ED, Loghin C, Knadler MP, Quinlan T, Zhang L, Chappell J, Lucas R, Bergstrom RF. Pharmacokinetics of duloxetine in breast milk and plasma of healthy postpartum women. Clin Pharmacokinet 2008; 47:103-9. [PMID: 18193916 DOI: 10.2165/00003088-200847020-00003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE The purpose of this study was to characterize duloxetine pharmacokinetics in the breast milk and plasma of lactating women and to estimate the duloxetine dose that an infant might consume if breastfed. METHODS This open-label study included six healthy women aged 22-35 years who stopped nursing during and after the study. Duloxetine 40 mg was given orally every 12 hours for 3.5 days; seven plasma and milk samples over 12 hours were obtained after the seventh dose. Plasma and milk samples were analysed using validated liquid chromatography-tandem mass spectrometry methods. Safety measures included vital signs, ECGs, laboratory tests, adverse event monitoring and depression rating scales. RESULTS The mean steady-state milk-to-plasma duloxetine exposure ratio was 0.25 (90% CI 0.18, 0.35). The amount of duloxetine in the breast milk was 7 microg/day (range 4-15 microg/day). The estimated infant dose was 2 microg/kg/day (range 0.6-3 microg/kg/day), which is 0.14% of the maternal dose. Dizziness, nausea and fatigue were commonly reported adverse events. No clinically important changes in safety measures occurred. CONCLUSION Duloxetine is detected in breast milk, and steady-state concentrations in breast milk are about one-fourth of those in maternal plasma. As the safety of duloxetine in infants is unknown, prescribers should carefully assess, on an individual basis, the potential risks of duloxetine exposure to infants and the benefits of nursing an infant when the mother is on duloxetine therapy.
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Affiliation(s)
- Evelyn D Lobo
- Eli Lilly and Company, Indianapolis, Indiana 46285-0724, USA.
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25
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Field T. Breastfeeding and antidepressants. Infant Behav Dev 2008; 31:481-7. [PMID: 18272227 DOI: 10.1016/j.infbeh.2007.12.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Revised: 06/13/2007] [Accepted: 12/30/2007] [Indexed: 11/16/2022]
Abstract
Although a large literature supports the benefits of breastfeeding, this review suggests that breastfeeding is less common among postpartum depressed women, even though their infants benefit from the breastfeeding. Depressed mothers, in part, do not breastfeed because of their concern about potentially negative effects of antidepressants on their infants. Although sertraline (Zoloft) and paroxetine (Paxol) concentrations are not detectable in infants' sera, fluoxetine (Prozac) and citalopram (Celexa) do have detectable levels. Unfortunately these findings are not definitive because they are based on very small sample, uncontrolled studies. As in the literature on prenatal antidepressant effects, the question still remains whether the antidepressants or the untreated depression itself has more negative effects on the infant. It is possible that the positive effects of breastfeeding may outweigh the positive effects of the antidepressants for both the mother and the infant. In addition, some alternative therapies may substitute or attenuate the effects of antidepressants, such as vagal stimulation or massage therapy, both therapies being noted to reduce depression. Further studies of this kind are needed to determine the optimal course of therapy for the benefit of the depressed, breastfeeding mother and the breastfed infant.
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Affiliation(s)
- Tiffany Field
- Touch Research Institutes, University of Miami School of Medicine, P.O. Box 016820, Miami, FL 33101, United
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Bauer M, Bschor T, Pfennig A, Whybrow PC, Angst J, Versiani M, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care. World J Biol Psychiatry 2007; 8:67-104. [PMID: 17455102 DOI: 10.1080/15622970701227829] [Citation(s) in RCA: 238] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).
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Affiliation(s)
- Michael Bauer
- University Hospital Carl Gustav Carus, Department of Psychiatry and Psychotherapy, Technische Universität Dresden, Dresden, Germany.
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27
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Abstract
Despite the well known severe repercussions of maternal depression on infants' well being, women are often reluctant to seek pharmacological treatment for postnatal depression. The fear of adverse events for the suckling infant plays an important role in such maternal considerations. However, the pharmacological approach to mood disorders at postpartum onset often represents one of the most realistic options in a number of clinical conditions. Therefore, the necessity exists to establish the safety of antidepressant treatment in the breastfed infant. For this reason, the aim of this article is to propose a specific safety index that assesses the frequency and degree of severity of adverse events in infants associated with maternal treatment with second-generation antidepressants during puerperium. The index is derived from a simple formula that uses the number of reports of adverse events in infants exposed to antidepressants as the numerator and the combined total of reports of healthy outcomes and reports of adverse events as the denominator. The sum is then multiplied by 100. A value of < or =2 indicates that the drug should be relatively safe for use during breastfeeding, a value of 2.1-10 indicates that the drug should be used with great caution and a value >10 indicates that the drug should be contraindicated in breastfeeding mothers. In addition to the figure created by this calculation, each drug will also be assigned a letter or the combination of a letter and a subscripted number to symbolise, respectively, the type and clinical management of the most serious recorded event. At this early developmental stage of the index, a complete classification of contemporary antidepressants regarding their safety in infants nursed to the breast is unfeasible. Indeed, because of the lack of suitable published data, so far the index has been limited to the evaluation of four antidepressants. In accordance with the index classification for these four antidepressants, sertraline and paroxetine should be considered as first-line medications in women who need to start antidepressant treatment during the postpartum period and wish to continue breastfeeding. The utilisation of fluoxetine and citalopram seems conversely to be associated with a relatively higher risk of adverse events (with a low degree of severity, however). For the other newer antidepressant drugs, the index is still of no assistance to the patient or physician in deciding on the safety of their use in lactation.
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Affiliation(s)
- Salvatore Gentile
- Department of Mental Health ASL Salerno 1, Mental Health Center n. 4, Cava de' Tirreni, Salerno, Italy.
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Eberhard-Gran M, Eskild A, Opjordsmoen S. Use of psychotropic medications in treating mood disorders during lactation : practical recommendations. CNS Drugs 2006; 20:187-98. [PMID: 16529525 DOI: 10.2165/00023210-200620030-00002] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Many new mothers who need antidepressant or mood-stabilising drug treatment may wish to breastfeed their infants, but are hesitant to do so because of possible harmful effects of the medication on the infant. This article reviews current data on drug excretion into breast milk and the effects on the breast-fed child, and provides recommendations for the use of the different psychotropic drugs in lactating women. Relevant literature was identified through systematic searches of MEDLINE, EMBASE and the Science Citation Index Expanded (ISI) from 1966 to February 2005. The present knowledge is based on the accumulation of case studies. No randomised controlled trials in breast-fed infants have been performed and there is a lack of long-term follow-up studies. Use of SSRIs and TCAs (except doxepin) is compatible with breastfeeding. However, if treatment with an SSRI is started in the postpartum period, fluoxetine and citalopram may not be drugs of first choice. With regard to other antidepressants, such as venlafaxine, trazodone, mirtazapine, reboxetine, moclobemide and other MAOIs, very little knowledge exists. Breastfeeding should be avoided while using lithium. Carbamazepine and sodium valproate (valproic acid) are generally better tolerated by the breast-fed infant than lithium. Data on lamotrigine are still sparse. Knowledge is also scarce on the novel antipsychotics and thus recommendations in lactating women cannot be made for these agents. It is unwise to expose infants unnecessarily to drugs that may have severe adverse effects. As such, clozapine should probably be avoided because of the risk of agranulocytosis. Our knowledge of the impact of drug exposure through breast milk is still limited. Infant drug exposure is, however, generally higher during pregnancy through placental passage than through breast milk. Despite the low dosage transferred to the infant through breast milk, premature infants and infants with neonatal diseases or inherited disturbances in metabolism may be vulnerable to such exposure.
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Affiliation(s)
- Malin Eberhard-Gran
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
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Abstract
OBJECTIVES The aim of this review is to assess and summarize the existing literature data about the efficacy of estrogen replacement therapy (ERT) in preventing and treating postpartum psychiatric disorders. METHODS An extensive and unrestrictive computerized search (from 1970 to June 2005) on MEDLINE/PubMed, TOXNET, EMBASE, and Cochrane Databases was conducted with the following search terms: estradiol, estrogen-treatment, hormonal treatment, therapy, postpartum depression, postnatal depression, puerperal depression, postpartum blues, postpartum psychosis, lactation, and breastfeeding. RESULTS In assessing available literature information about the role of ERT in preventing and treating puerperal psychiatric diseases, all reviewed studies were found to suffer from severe methodological limitations. CONCLUSION Well-designed and strictly focused multicenter trials are warranted in order to firmly establish the effectiveness of ERT in puerperal psychiatric disorders.
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Affiliation(s)
- Salvatore Gentile
- Mental Health Center, Azienda Sanitaria Locale Salerno Number 1, Nocera Inferiore, Italy.
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30
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Abstract
Section 1 describes the benefits of breastfeeding to both mother and infant as well as the potential risks to the infant from maternal drug use. The extent of adverse drug-related events and the need for quality information on drug transfer is stated. Section 2 describes the physiology of lactation and the effects of drugs that stimulate or decrease milk production. Section 3 deals with transport mechanisms for drug passage into milk and factors that may modify the infant's exposure to drugs. The critical descriptors of 'absolute' and 'relative' infant dose are defined to give an objective measure of infant exposure to drugs in milk. Section 4 reviews new or commonly used drugs under the headings of analgesics and anti-inflammatory agents, neurological, endocrine, psychotropic and antihypertensive drugs. Section 5 concludes with an expert opinion of the drug industry and drug use in lactation, herbal preparations, the process of 'risk-benefit' analysis, minimising infant exposure, understanding drug-related adverse events and fostering good experimental design for drugs in lactation studies.
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Affiliation(s)
- Kenneth F Ilett
- University of Western Australia, School of Medicine and Pharmacology, Crawley, 6009, Australia.
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Whitby DH, Smith KM. The Use of Tricyclic Antidepressants and Selective Serotonin Reuptake Inhibitors in Women Who Are Breastfeeding. Pharmacotherapy 2005; 25:411-25. [PMID: 15843288 DOI: 10.1592/phco.25.3.411.61597] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Postpartum depression is a well-recognized psychiatric condition that has gained increased attention over the past decade due to several nationally publicized tragedies. Medical management of this condition in women who are breastfeeding provides a unique challenge to health care professionals who may seek to maintain a fine balance between limiting the infant's exposure to hormone-altering drugs and maintaining the benefits of breastfeeding. No controlled trials have examined antidepressant therapy in nursing women; however, numerous case reports and case series have been published. Relatively few serious adverse effects have been reported. Although tricyclic antidepressants have been the treatment of choice in the past, selective serotonin reuptake inhibitors are gaining popularity due to their superior safety profiles. Of all the agents reviewed in the literature, sertraline was the most prescribed, and no adverse effects were reported. Therefore, this agent would be a good first choice for treatment-naive women. For treatment of postpartum depression in women with a history of successfully treated depression, the most practical approach may be to continue therapy with the previously effective agent. Treatment should be maintained at the lowest effective dosage to minimize infant exposure. Both mother and child should be closely monitored; in addition, collaboration between the prescribing physician and the child's pediatrician is essential.
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Affiliation(s)
- Dale H Whitby
- Department of Pharmacy Services, Shands Hospital at the University of Florida, Gainesville, Florida, USA
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33
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Abstract
Postpartum depression affects 10% to 20% of women in the United States and negatively influences maternal, infant, and family health. Assessment of risk factors and depression symptoms is needed to identify women at risk for postpartum depression for early referral and treatment. Individual and group psychotherapy have demonstrated efficacy as treatments, and some complementary/alternative therapies show promise. Treatment considerations include severity of depression, whether a mother is breastfeeding, and mother's preference. Nurses who work with childbearing women can advise depressed mothers regarding treatment options, make appropriate recommendations, provide timely and accessible referrals, and encourage engagement in treatment.
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Abstract
The pregnancy and postpartum periods are considered to be relatively high risk times for depressive episodes in women, particularly for those with pre-existing psychiatric illnesses. Therefore, it may be necessary to start or continue the pharmacological treatment of depression during these two timeframes. Hence, the aim of this review is to examine the effects on the fetus and infant of exposure, through the placenta and maternal milk, to the following drugs: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram, mirtazapine, venlafaxine, reboxetine and bupropion. The teratogenic risks, perinatal toxicity and effects on the neurobehavioural development of newborns associated with exposure through the placenta or maternal milk to these medications need to be carefully assessed before starting psychopharmacological treatment in pregnant or lactating women. In spite of the limitations of some of the studies reviewed, the older selective serotonin-reuptake inhibitors (SSRIs) [as we await further data regarding escitalopram] and venlafaxine seem to be devoid of teratogenic risks. By contrast, the data concerning possible consequences related to exposure to SSRIs via the placenta and breastmilk on neonatal adaptation and long-term neurocognitive infant's development are still controversial. Nevertheless, a number of reports have shown that an association between placental exposure to SSRIs and adverse but self-limiting effects on neonatal adaptation may exist. In addition, the information on both teratogenic and functional teratogenic risks associated with exposure to bupropion, mirtazapine and reboxetine is incomplete or absent; at present, these compounds should not be used as first-line agents in the pharmacological treatment of depression in pregnancy and breastfeeding. Untreated depression is not without its own risks since mothers affected by depression have a negative impact on the emotional development of their children and major depression, especially when complicated by a delusional component, may lead to the mother attempting suicide and infanticide. Consequently, clinicians need to help mothers weigh the risks of prenatal exposure to drugs for their babies against the potential risks of untreated depression and abrupt discontinuation of pharmacological treatment. Given these situations, we suggest that choosing to administer psychopharmacological treatment in pregnant or breastfeeding women with depression will result primarily from a careful evaluation of their psychopathological condition; currently, the degree of severity of maternal disease appears to represent the most relevant parameter to take this clinical decision.
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Affiliation(s)
- Salvatore Gentile
- Department of Mental Health, ASL Salerno 1, District n. 4, Cava de' Tirreni (Salerno), Italy.
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35
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Abstract
There are many benefits of breast-feeding both for the infant and for the mother. Nursing mothers who are also taking medications or exposed to environmental hazards may be confronted with a difficult choice to discontinue nursing or maternal medication or risk potential harm to the infant. Frequently, these decisions are made without sufficient information or understanding of the factors influencing exposure. The current review explores two indices of exposure, together with their pharmacokinetic determinants. Both of the indices include the milk to serum (M/S) concentration ratio for a given drug and the volume of milk consumed. The first exposure term, EI(Dose), expresses neonatal dose as a percentage of maternal dose and is inversely related to the maternal systemic clearance. By contrast, the second exposure term, EI(Conc), expresses infant concentration as a percentage of maternal concentration and is inversely related to the infant systemic clearance. Issues related to intersubject variation in M/S (e.g., colostrum vs. mature milk, fore vs. hind milk) and infant clearance (e.g., ontogeny of elimination pathways, pharmacogenetics) and their role in modulating exposure are also discussed.
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Affiliation(s)
- Patrick J McNamara
- College of Pharmacy, University of Kentucky, Lexington, Kentucky 40536, USA.
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36
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Abstract
This review focuses on current information about luteal phase administration (i.e. typically for the last 2 weeks of the menstrual cycle) of pharmacological agents for the treatment of premenstrual dysphoric disorder (PMDD). Compared with continuous administration, a luteal phase administration regimen reduces the exposure to medication and lowers the costs of treatment. Based on evidence from randomised clinical trials, SSRIs are the first-line treatment for PMDD at this time. Of these agents, sertraline, fluoxetine and paroxetine (as an extended-release formulation) are approved by the US FDA for luteal phase, as well as continuous, administration. Clinical trials of these agents and citalopram have demonstrated that symptom reduction is similar with both administration regimens. When used to treat PMDD, SSRI doses are consistent with those used for major depressive disorder. The medications are well tolerated; discontinuation symptoms with this intermittent administration regimen have not been reported. Other medications that have been examined in clinical trials for PMDD or severe premenstrual syndrome (PMS) using luteal phase administration include buspirone, alprazolam, tryptophan and progesterone. Buspirone and alprazolam show only modest efficacy in PMS (in some but not all studies), but there may be a lower incidence of sexual adverse effects with these medications than with SSRIs. Symptom reduction with tryptophan was significantly greater than with placebo, but the availability of this medication is strictly limited because of safety concerns. Progesterone has consistently failed to show efficacy for severe PMS/PMDD in large, randomised, placebo-controlled trials.
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Affiliation(s)
- Ellen W Freeman
- Departments of Obstetrics/Gynecology and Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Arbat A, Danés I. [Postpartum depression]. Med Clin (Barc) 2003; 121:673-5. [PMID: 14642231 DOI: 10.1016/s0025-7753(03)74055-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Agnès Arbat
- Fundació Institut Català de Farmacologia, Servicio de Farmacología Clínica, Hospital Universitari Vall d'Hebron, Barcelona, España
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Abstract
Medication use during breastfeeding shortens the duration of breastfeeding often because of overly cautious information given by healthcare providers. No comprehensive review of the literature on infant adverse reactions from drugs in breastmilk has been published. All published studies and case reports on adverse events in infants caused by medications (excluding drugs of abuse) in breastmilk were identified and analyzed. Of 100 case reports evaluated, none were considered to be "definite" using a standard ranking scale; 47% were "probable" and 53% were "possible." Drugs with central nervous system activity accounted for half of all reports. All 3 reported fatalities involved central nervous system depressants, but each had extenuating circumstances. At least 63% of reported cases were in neonates and 78% were in infants 2 months or younger; only 4% of adverse reactions occurred in infants older than 6 months of age. Published studies expand on and generally reinforce the analysis of case reports. By taking a few simple precautions in drug selection and considering the infant's age, breastfeeding rarely needs to be discouraged or discontinued when a mother needs drug therapy.
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Affiliation(s)
- Philip O Anderson
- Drug Information Service, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92019-8925, USA
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Abstract
This review of paroxetine is based on Medline and PsycLit searches and a manual search of the available research literature. It aims to cover the pharmacology of this frequently prescribed SSRI antidepressant in terms of its indications, efficacy and adverse effects. Overall, paroxetine is a well-tolerated and safe first-line SSRI antidepressant with anxiolytic qualities. It has been found useful in depression, anxiety and other conditions such as obsessive compulsive disorder and post-traumatic stress disorder. The antidepressant has some advantages over earlier tricyclic medication in terms of a lack of cardiovascular side-effects and relative safety in overdose. Cessation of use, however, is associated with withdrawal or discontinuation symptoms and patients should be counselled as to how these might be avoided. A 3- or 4-week graded withdrawal regimen, perhaps with concomitant fluoxetine to cover serotonergic discontinuation symptoms, may be advisable.
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Affiliation(s)
- Ben Green
- North Cheshire Hospitals NHS Trust, Halton, Cheshire, UK.
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Abstract
This article reviews the risk factors, pathogenesis, treatment, and prevention of postpartum depression. Postpartum depression is common and occurs in up to 18% of newly delivered mothers. Though the hormonal changes occurring after childbirth are believed to play a role in postpartum depression, no hormonal etiology has been identified. Estrogen appears somewhat helpful for postpartum depression, but its use is limited by problematic medical sequelae. Several antidepressants are effective for postpartum depression and appear safe for use by breastfeeding women. Psychosocial interventions and cultural rituals, which may prevent or ameliorate postpartum depression, have also been employed.
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Affiliation(s)
- Deborah Lynne Flores
- Department of Psychiatry and Behavioral Sciences, University of California, Los Angeles, Neuropsychiatric Institute and Hospital, 760 Westwood Boulevard, Los Angeles, CA 90024, USA.
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Affiliation(s)
- Katherine L Wisner
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY 40202, USA
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Current literature in. Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:79-94. [PMID: 11998557 DOI: 10.1002/pds.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Bauer M, Whybrow PC, Angst J, Versiani M, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder. World J Biol Psychiatry 2002; 3:5-43. [PMID: 12479086 DOI: 10.3109/15622970209150599] [Citation(s) in RCA: 262] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.
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Affiliation(s)
- Michael Bauer
- Neuropsychiatric Institute & Hospital, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles (ULCA), 300 UCLA Medical Plaza, Suite 2330, Los Angeles, CA 90095, USA.
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