Clozapine and pregnancy

A review of the safety of clozapine during pregnancy and lactation

Clozapine is an antipsychotic used in the management of treatment-resistant schizophrenia. However, little is known about clozapine use during pregnancy and lactation, or its impact on the mother, foetus, and infant. This review aims to summarize the available literature on the safety of clozapine use during the perinatal period. EMBASE, PsycINFO, and MEDLINE were searched from their inceptions through June 2016. The review encompasses 21 studies that have examined clozapine use during pregnancy and lactation. The limited available data do not support an increased risk of congenital malformations in foetuses exposed to clozapine during pregnancy, though rates of gestational diabetes are twice as high in pregnant women using clozapine. Clozapine accumulation in foetal serum possibly contributes to increased rates of floppy infant syndrome at delivery, decreased foetal heart rate variability, and seizures in infancy. Clozapine crosses the placenta and also accumulates in breast milk, which may increase the risk of agranulocytosis in infants and may necessitate infant testing. The majority of these data come from case reports and case series, making it unclear if the published risks associated with clozapine are due to mental illness, lifestyle factors, or co-treatment with other psychotropic medications. While the available literature on clozapine use during the perinatal period is very limited, the risks of clozapine use during pregnancy and the postpartum period should be discussed with women and weighed against those associated with other treatments and partially or untreated schizophrenia.

Mood stabilizers in pregnancy and lactation

Management of bipolar during pregnancy and postpartum is very challenging. The treating clinicians have to take into account various factors like current mental state, longitudinal history of the patient, past history of relapse while off medication, response to medication, time of pregnancy at which patient presents to the clinician, etc. The choice of drug should depend on the balance between safety and efficacy profile. Whenever patient is on psychotropic medication, close and intensive monitoring should be done. Among the various mood stabilizers, use of lithium during the second and third trimester appears to be safe. Use of valproate during first trimester is associated with major malformation and long-term sequalae in the form of developmental delay, lower intelligence quotient, and higher risk of development of autism spectrum disorder. Similarly use of carbamazepine in first trimester is associated with higher risk of major congenital malformation and its use in first trimester is contraindicated. Data for lamotrigine (LTG) appears to be more favorable than other antiepileptics. During lactation, use of valproate and LTG is reported to be safe. Use of typical and/atypical antipsychotic is a good option during pregnancy in women with bipolar disorder.

Psychopharmacological treatment of mood and anxiety disorders during pregnancy

Many women with psychiatric disorders want to become mothers and only a minority seek advise prior to becoming pregnant. In those women, in whom pregnancy can be planned, the decision, if a medication is required for stabilisation and which one to choose if this is the case, is easier to make than in women in whom pregnancy occurs unplanned. The physician has to weigh the risk that a relapse of the psychiatric disorder during pregnancy poses to the foetus against the reproductive risk of psychotropic drugs. This presentation is intended to assist in understanding the general principles of pharmacotherapy during pregnancy as well as the morphological, perinatal and neurobehavioural toxicity of antidepressants, antipsychotics, benzodiazepines and mood stabilisers.

Antipsychotic therapy during early and late pregnancy. A systematic review

OBJECTIVE

Both first- (FGAs) and second-generation antipsychotics (SGAs) are routinely used in treating severe and persistent psychiatric disorders. However, until now no articles have analyzed systematically the safety of both classes of psychotropics during pregnancy. DATA SOURCES AND SEARCH STRATEGY: Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, TOXNET, EMBASE, and The Cochrane Library. Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from companies developing drugs. Search terms were pregnancy, psychotropic drugs, (a)typical-first-second-generation antipsychotics, and neuroleptics. A separate search was also conducted to complete the safety profile of each reviewed medication. Searches were last updated on July 2008.

DATA SELECTION

All articles reporting primary data on the outcome of pregnancies exposed to antipsychotics were acquired, without methodological limitations.

CONCLUSIONS

Reviewed information was too limited to draw definite conclusions on structural teratogenicity of FGAs and SGAs. Both classes of drugs seem to be associated with an increased risk of neonatal complications. However, most SGAs appear to increase risk of gestational metabolic complications and babies large for gestational age and with mean birth weight significantly heavier as compared with those exposed to FGAs. These risks have been reported rarely with FGAs. Hence, the choice of the less harmful option in pregnancy should be limited to FGAs in drug-naive patients. When pregnancy occurs during antipsychotic treatment, the choice to continue the previous therapy should be preferred.

Indian research: Focus on clozapine

Clozapine has been used in the treatment of schizophrenia for about two decades and extensive data have been accumulated with regard to its use in various parts of the world. However, in contrast to Western countries, there are few studies which have evaluated the usefulness of clozapine in Indian patients. This article attempts to review the available data on clozapine originating from India. This review reflects the fact that there are few studies from the Indian subcontinent and most of these are case reports. In view of the same, there is a need for further research to evaluate the effectiveness of clozapine in India.

Clozapine use in two women with schizophrenia during pregnancy

Stabilized patients who receive clozapine may wish to have children; but studies on pregnant women receiving clozapine treatment are limited. In this study, we report on clozapine use during pregnancy in two women. The first woman (Case 1) had two deliveries while she was receiving clozapine treatment for schizophrenia. Both her deliveries were term, uncomplicated vaginal deliveries, and the clozapine dose was reduced throughout pregnancy. The second woman (Case 2) developed schizophrenia after her first child was born. She became pregnant after clozapine initiation. She delivered twins by term, uncomplicated vaginal delivery. In our cases, no specific risks for the mothers and their children can be attributed to the use of clozapine. Physicians must be aware of the changes in fertility induced by prolactin-sparing drugs. Mothers who receive clozapine treatment should not be advised to breastfeed their children.

Clozapine in pregnancy

This report describes the case of a woman with treatment-resistant schizophrenia who became pregnant while being treated successfully with clozapine. Possible risks associated with continuation of clozapine during pregnancy are discussed.

Clinical utilization of atypical antipsychotics in pregnancy and lactation

OBJECTIVE

To analyze the available literature regarding the safety of atypical antipsychotics in pregnancy and lactation in order to recommend evidence-based strategies for pharmacologic management of psychosis in these conditions.

DATA SOURCES

We summarized the results from articles identified via MEDLINE/PubMed/TOXNET (1993-January 31, 2004), using the key terms pregnancy, lactation, breast-feeding, human milk, psychotropic drugs, atypical antipsychotics, olanzapine, quetiapine, risperidone, clozapine, ziprasidone, and aripiprazole.

STUDY SELECTION AND DATA EXTRACTION

Retrospective studies, clinical observations, and case reports regarding the 6 atypical antipsychotics mentioned above were selected and analyzed. Extensive manual review of pertinent journals and textbooks was also performed.

DATA SYNTHESIS

Reviewed studies show that olanzapine and clozapine apparently do not increase the teratogenic risk if administered to pregnant women, while evidence on quetiapine, risperidone, aripiprazole, and ziprasidone is still limited. In contrast, available information is not able to exclude unwanted serious effects associated with the use of all atypical antipsychotics on mother-infant dyads. Furthermore, more than a few studies suggest increased hyperglycemic risk for pregnant women related to atypical antipsychotic therapy during gestation. Finally, published evidence about the effects on long-term infant neurodevelopment of drug exposure through both placenta and breast milk is represented only by sporadic case reports.

CONCLUSIONS

It is well known that potential consequences of an untreated psychotic episode may be severe and may lead to the mother attempting suicide and/or infanticide. For these reasons, clinicians need to help mothers weigh both fetal and neonatal risks of exposure to drugs against the potential risk they and their infant may incur if the psychiatric illness is not treated. On the other hand, atypical antipsychotics in pregnancy and breast-feeding do not show evident advantages in safety when compared with typical neuroleptic agents. Therefore, we suggest that the most relevant parameters for selecting the best clinical option for pregnant and breast-feeding women with schizophrenia and related disorders remain strongly related to 3 main points: (1). cautious evaluation of the risk/benefit ratio of fetal and neonatal drug exposure, (2). degree of severity of maternal psychiatric illness, and (3). careful preliminary choice of drugs characterized by a balanced safety/efficacy profile.