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

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. https://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.