Venlafaxine and breast-feeding

Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression

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.

Quality of Lactation Studies Investigating Antidepressants

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.

Use of Psychotropic Medications in Breastfeeding Women

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.

Antidepressants, anxiolytics, and hypnotics in pregnancy and lactation

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.

The safety of serotonin-noradrenaline reuptake inhibitors (SNRIs) in pregnancy and breastfeeding: a comprehensive review

OBJECTIVE

The present study provides a comprehensive review of the existing literature on the safety of serotonin-noradrenaline reuptake inhibitors (SNRIs) in pregnancy and lactation.

METHODS

Studies published in English, reporting the use of SNRIs in pregnant and/or breastfeeding women, were identified by searching MEDLINE/Pubmed, PsycINFO, and EMBASE.

RESULTS

Twenty-nine studies were included in the review. Altogether, the initial evidence coming from the reviewed studies suggests a lack of association between SNRIs and an increased risk of major congenital malformations. Conversely, exposure to SNRIs seems to be significantly associated with an increased risk of some perinatal complications. No neonatal adverse events emerged, so far, in the few studies concerning the safety of SNRIs during breastfeeding.

CONCLUSIONS

Available data suggest that venlafaxine is relatively safe during pregnancy, in particular as far as major malformations are concerned, whereas considering the small number of studies published, no definitive conclusions can be drawn on its safety during breastfeeding. Because of the few studies so far published, the safety of duloxetine during pregnancy and breastfeeding remains to be well established.

Serotonin reuptake inhibitors and breastfeeding: a systematic review

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.

Assessment of infant dose through milk in a lactating woman taking amisulpride and desvenlafaxine for treatment-resistant depression

This study presents the case of a 35-year-old breastfeeding mother who delivered her fourth child 5 months previously and was prescribed 100 mg amisulpride twice daily and 250 mg desvenlafaxine in the morning for treatment-resistant depression. Arriving at this regimen took approximately 2 months postbirth. Because she was keen to continue breastfeeding her infant, and published data on the use of amisulpride and desvenlafaxine were very limited, the clinical team sought assistance from the therapeutic drug monitoring laboratory to quantify infant dose-exposure to guide consideration of continuing breastfeeding. A sampling schedule for milk and plasma from mother and plasma from her infant was agreed and drug concentrations were measured by high-performance liquid chromatography. Absolute (theoretic) infant dose (μg/kg/d) was calculated as the product of the average concentration in milk and an assumed milk intake of 0.15 L/kg/day (294 mg/kg/day for desvenlafaxine and 183 mg/kg/day for amisulpride), and relative infant dose was estimated as absolute infant dose expressed as a percentage of the maternal dose in μg/kg/day (7.8% for desvenlafaxine and 6.1% for amisulpride). Consistent with the infant being partially breastfed, the ratio of drug in the infant's plasma to that in mother's plasma was lower at 1.7% for desvenlafaxine and 3.9% for amisulpride. A pediatric assessment of the infant found achievement of expected developmental progress for age and no detectable drug-related adverse effects. Assessing the safety of breastfeeding was difficult because it involved simultaneous use of two drugs for which there was limited previous experience. However, after discussion of the infant dose-exposure data and lack of adverse effects, the mother elected to continue partial breastfeeding for the next few months. The clinical team plans a reassessment of the infant's progress in 3 months.

Antidepressant Use During Breastfeeding

Background:

The treatment of breastfeeding mothers with depression raises several dilemmas, including the possible risk of drug exposure through breast milk for the infant. This article provides background information and presents practical advice and recommendations for the clinician dealing with the treatment of depression and related disorders in the postpartum period.

Methods:

An electronic search for relevant articles was performed. As the use of tricyclic antidepressants has considerably decreased during the last decade and no new information on breastfeeding has emerged for the tricyclics in this period, this review exclusively focuses on the newer, non-tricyclic compounds.

Results:

Most newer antidepressants produce very low or undetectable plasma concentrations in nursing infants. The highest infant plasma levels have been reported for fluoxetine, citalopram and venlafaxine. Suspected adverse effects have been reported in a few infants, particularly for fluoxetine and citalopram.

Conclusions:

Infant exposure of antidepressants through breast milk is generally low to very low. We consider that when antidepressant treatment is indicated in women with postpartum depression, they should not be advised to discontinue breastfeeding. Paroxetine and sertraline are most likely suitable first-line agents. Although some concern has been expressed for fluoxetine, citalopram and venlafaxine, we nevertheless consider that if the mother has been treated with one of these drugs during pregnancy, breast-feeding could also be allowed during continued treatment with these drugs in the postpartum period. However, an individual risk-benefit assessment should always be performed.

Estimation of desvenlafaxine transfer into milk and infant exposure during its use in lactating women with postnatal depression

This study characterises the extent of desvenlafaxine transfer into milk and provides data on infant exposure to desvenlafaxine via breast milk in ten women with postnatal depression and their breastfed infants. Desvenlafaxine concentration in milk and plasma was measured chromatographically in milk and in maternal and infant plasma collected at steady state. Theoretic and relative infant doses via milk were estimated and the per cent drug in infant versus mother's plasma was calculated. Theoretic infant dose via milk was 85 (53-117) μg kg(-1) day(-1) (mean and 95% confidence interval) and relative infant dose was 6.8% (5.5-8.1%). The ratio of drug in infant/maternal plasma also gave an infant exposure estimate of 4.8% (3.5-6.2%) for all ten infants and 5.3% (4.2-5.7%) in the eight infants who were exclusively breastfed. No adverse effects were seen in the infants. The relative infant dose was similar to that for previous studies using venlafaxine and was supported by a separate exposure measure using the ratio of drug in the infant's plasma relative to that in the mother's plasma. The theoretic infant dose of desvenlafaxine was 41-45% of that for venlafaxine and its metabolite desvenlafaxine in previous studies, reflecting the lower recommended maternal dose for desvenlafaxine. Although our data for desvenlafaxine use in lactation are encouraging and there are supporting data from venlafaxine studies, more patients and their infants need to be studied before the safety of desvenlafaxine as a single therapeutic agent can be fully assessed.

Pharmacokinetics of duloxetine in breast milk and plasma of healthy postpartum women

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.

Treatment of perinatal mood and anxiety disorders: a review

OBJECTIVES

To review the nonpharmacologic and pharmacologic treatment modalities for perinatal mood and anxiety disorders and to discuss the importance of weighing the risks and the benefits of exposing the fetus or baby to maternal mental illness as opposed to exposure to antidepressant medications.

METHODS

We conducted a literature search of the PubMed and MEDLINE databases. Key words included the following: perinatal, pregnancy, postpartum, depression, anxiety, pharmacologic, nonpharmacologic, psychotherapy, and treatment.

RESULTS

Recent literature reflects that both pharmacologic and nonpharmacologic treatments for perinatal women are associated with positive and negative outcomes. No treatment decision was found to be risk-free. The detrimental effects of untreated mental illness on the mother, as well as on the baby, highlight the need for treatment intervention. The long-term effects of exposure to either medications or maternal mental illness are unknown, as yet.

CONCLUSION

Women with perinatal depression and anxiety disorders require timely and efficient management with a goal of providing symptom relief for the suffering mother while simultaneously ensuring the baby's safety. Although knowledge in the area of appropriate intervention is constantly evolving, rigorous and scientifically sound research in the future is critical.

Use of contemporary antidepressants during breastfeeding: a proposal for a specific safety index

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.

Use of psychotropic medications in treating mood disorders during lactation : practical recommendations

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.

The Safety of Newer Antidepressants in Pregnancy and Breastfeeding

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.

Benefits and risks to mother and infant of drug treatment for postnatal depression

The postnatal period presents a special problem to healthcare providers treating psychiatric disorders in women. Many new mothers who need antidepressant treatment may wish to breastfeed their infants, but are hesitant to do so for fear of passing on possible harmful effects of the medication through their milk. The focus of this article will be on highlighting and interpreting the existing literature on the benefits and risks to mother and infant of drug treatment for postnatal depression, as well as outlining treatment guidelines for the use of antidepressants in breastfeeding mothers. The article will specifically focus on the use of fluoxetine, sertraline, paroxetine, fluvoxamine and citalopram, which are more commonly used and belong to the selective serotonin reuptake inhibitor group of antidepressants. The tricyclic and other newer antidepressant medications will also be discussed. As there are no published controlled studies on the use of antidepressants by breastfeeding women, publications of individual case reports, case series, and pharmacokinetic investigations serve as the basis for the development of treatment guidelines. Results from this growing body of literature are promising in that, with the exception of a few cases, no serious adverse events have been reported in infants exposed to antidepressant medications through breast milk. In addition nonpharmacological treatments consisting of different types of psychotherapies will be discussed. It is critical that healthcare providers evaluate each mother-infant dyad on an individual basis when faced with the decision to prescribe antidepressant medications during the postnatal period.