Savvy Psychopharmacology

What to tell your bipolar disorder patient who wants to breast-feed

Current Psychiatry. 2015 April;14(4):30-33

References

1. Sach HC; Committee on Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3);e796-e809.
2. Moretti ME, Koren G, Verjee Z, et al. Monitoring lithium in breast milk: an individualized approach for breast-feeding mothers. Ther Drug Monit. 2003;25(3):364-366.
3. Viguera AC, Newport DJ, Ritchie J, et al. Lithium in breast milk and nursing infants: clinical implications. Am J Psychiatry. 2007;164(2):342-345.
4. Xyprexa [package insert]. Indianapolis, IN: Eli Lilly and Company; 2014.
5. Brunner E, Falk DM, Jones M, et al. Olanzapine in pregnancy and breastfeeding: a review of data from global safety surveillance. BMC Pharmacol Toxicol. 2013;14:38.
6. Schlotterbeck P, Leube D, Kircher T, et al. Aripiprazole in human milk. Int J Neuropsychopharmacol. 2007;10(3):433.
7. Saphris [package insert]. St. Louis, MO: Forest Pharmaceuticals; 2014.
8. Latuda [package insert]. Marlborough, MA: Sunovion Pharmaceuticals; 2013.
9. Lee A, Giesbrecht E, Dunn E, et al. Excretion of quetiapine in breast milk. Am J Psychiatry. 2004;161(9):1715-1716.
10. Rampono J, Kristensen JH, Ilett KF, et al. Quetiapine and breastfeeding. Ann Pharmacother. 2007;41(4):711-714.
11. Misri S, Corral M, Wardrop AA, et al. Quetiapine augmentation in lactation: a series of case reports. J Clin Psychopharmacol. 2006;26(5):508-511.
12. Hill RC, McIvor RJ, Wojnar-Horton RE, et al. Risperidone distribution and excretion into human milk: case report and estimated infant exposure during breast-feeding. J Clin Psychopharmacol. 2000;20(2):285-286.
13. Ilett KF, Hackett LP, Kristensen JH, et al. Transfer of risperidone and 9-hydroxyrisperidone into human milk. Ann Pharmacother. 2004;38(2):273-276.
14. Aichhorn W, Stuppaek C, Whitworth AB. Risperidone and breast-feeding. J Psychopharmacol. 2005;19(2):211-213.
15. Geodon [package insert]. New York, NY: Pfizer; 2014.
16. Davanzo R, Dal Bo S, Bua J, et al. Antiepileptic drugs and breastfeeding. Ital J Pediatr. 2013;39:50.
17. Newport DJ, Pennell PB, Calamaras MR, et al. Lamotrigine in breast milk and nursing infants: determination of exposure. Pediatrics. 2008;122(1):e223-e231.
18. Nordmo E, Aronsen L, Wasland K, et al. Severe apnea in an infant exposed to lamotrigine in breast milk. Ann Pharmacother. 2009;43(11):1893-1897.
19. Stahl MM, Neiderud J, Vinge E. Thrombocytopenic purpura and anemia in a breast-fed infant whose mother was treated with valproic acid. J Pediatr. 1997;130(6):1001-1003.
20. Kelly LE, Poon S, Madadi P, et al. Neonatal benzodiazepines exposure during breastfeeding. J Pediatr. 2012;161(3):448-451.
21. U.S. Food and Drug Administration. FDA issues final rule on changes to pregnancy and lactation labeling information for prescription drug and biological products. http://www. fda.gov/NewsEvents/Newsroom/PressAnnouncements/ ucm425317.htm. Published December 3. 2014. Accessed March 4, 2015.

Risperidone. A 2000 study¹² of risperidone in lactation reported that 0.84% weight-adjusted maternal risperidone dosage and 3.46% of its metabolite 9-hydroxyrisperidone is transferred to the infant. A later study showed 2.3% to 4.7% of the maternal dosage is transferred, with no adverse events reported in infants.¹³ A case study reported no adverse events and normal neurodevelopment in a the child of a mother taking risperidone.¹⁴

Ziprasidone. According to the ziprasidone prescribing information¹⁵ and a literature search, is not known whether ziprasidone is excreted in human breast milk.

See the Table^{4,6-10,12,13,15} for a summary of the evidence levels of second-generation antipsychotics that are excreted in breast milk.

Other mood stabilizers
Carbamazepine has been measured in breast milk at 3.8% to 5.9% of the maternal dosage.¹⁶

Lamotrigine. In a study of 30 lactating women, the breast milk contained an average of 9.2% of the maternal dosage of lamotrigine.¹⁷ Mild thrombocytosis was detected in 7 of 8 infants; no other adverse effects were reported. A case study describes a woman who breast-fed while taking lamotrigine, 850 mg/d, and who experienced dizziness and visual disturbances. The infant had apnea episodes followed by a cyanotic crisis, which required resuscitation. The infant’s plasma lamotrigine level was 4.87 μg/mL. Symptoms disappeared when the mother stopped breast-feeding.¹⁸ Lamotrigine is considered to be moderately safe in breast-feeding patients with proper monitoring. The drug also has a known safety profile because of its use in children with epilepsy.

Valproic acid. Because of its high plasma protein binding, valproic acid does not pass readily into the breast milk. Newborns receive approximately 1.4% to 1.7% of the maternal dosage.¹⁶ Caution is advised, however, because of some reported adverse events. One case reported thrombocytopenic purpura and anemia in an infant.¹⁹ Valproic acid is considered to be compatible with breast-feeding with proper monitoring.

Benzodiazepines
Benzodiazepines can be helpful adjunctive medications to aid sleep, which is essential for the mother’s and infant’s health. In a prospectively recruited, retrospectively assessed cohort study that evaluated 124 women taking benzodiazepines while breast-feeding, adverse effects, specifically sedation, were noted in 1.6% of infants.²⁰

Future developments in prescribing information
Under a 2008 FDA recommendation, the “Nursing Mothers” section of prescribing information would be replaced with a section entitled “Lactation.” This new heading would include the sub-headings Risk Summary, Clinical Considerations, and Data.¹ It is expected that this new format will be more practical and will help clinicians and patients make informed decisions. The prescribing changes will be in effect on June 30, 2015.²¹

Related Resources
• Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org.
• LactMed. http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm.
• MOTHERISK. www.motherisk.org/women/ breastfeeding.jsp.

Drug Brand Names
Aripiprazole • Abilify Olanzapine • Zyprexa
Asenapine • Saphris Quetiapine • Seroquel
Carbamazepine • Tegretol Risperidone • Risperdal
Lamotrigine • Lamictal Valproic acid • Depakene
Lithium • Eskalith, Lithobid Ziprasidone • Geodon
Lurasidone • Latuda

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

What to tell your bipolar disorder patient who wants to breast-feed

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