IMPORTANT - query about antidepresant and bf - any bfcs on line?

[susanmt]

I saw a psychiatrist today about my pnd and she wants to change my drugs from Lustral which is OK for bf to Effexor (ventafexine???), and I dont know if its ok? She said she'd trust what a bfc said over the product literature ( which, as always, says no). Can anyone help? Thanks.

There are a couple of papers in Pubmed, this one is the most relevant:

Distribution of venlafaxine and its O-desmethyl metabolite in human milk and their effects in breastfed infants.

Ilett KF, Kristensen JH, Hackett LP, Paech M, Kohan R, Rampono J.

Department of Pharmacology, University of Western Australia, Nedlands 6009 Western Australia. [email protected]

AIMS: To characterize milk/plasma (M/P) ratio and infant dose, for venlafaxine (V) and its O-desmethyl metabolite (ODV), in breastfeeding women taking venlafaxine for the treatment of depression, and to determine the plasma concentration and effects of these drugs in their infants. METHODS: Six women (mean age 34.5 years, mean weight 84.3 kg) taking venlafaxine (median dose 244 mg day(-1), range 225-300 mg day(-1)) and their seven infants (mean age 7.0 months, mean weight 7.3 kg) were studied. V and ODV in plasma and milk were measured by high-performance liquid chromatography over a 12 h dose interval at steady-state. Infant exposure was estimated as the product of estimated milk production rate (0.15 l kg(-1)day(-1)) and average drug concentration in milk, normalized to body weight and expressed as a percentage of the weight-adjusted maternal dose. RESULTS: Mean M/PAUC values of 2.5 (range 2.0-3.2) and 2.7 (range 2.3-3.2) were calculated for V and ODV, respectively. The mean maximum concentrations (95% CI) of V and ODV in milk were 1161 (95% CI, 588, 1734) microg l(-1) and 796 (362, 1230) microg l(-1). Mean infant exposure was 3.2% (1.7, 4.7%) for V and 3.2% (1.9, 4.9%) for ODV (as V equivalents). V was detected in the plasma of one out of seven infants studied (5 microg l(-1)), while ODV was detected in four of the infants, at concentrations ranging from 3 to 38 microg l(-1). All of the infants in the study were healthy, as reported by their mothers and/or by clinical examination on the study day. CONCLUSIONS: The concentrations of V and ODV in breast milk were 2.5 and 2.7 times those in maternal plasma. The mean total drug exposure (as venlafaxine equivalents) of the breastfed infants was 6.4% (5.5-7.3%), which is below the 10% notional level of concern. There were no adverse effects in any of the infants. The data support the use of V in breastfeeding. Nevertheless, since low concentrations of ODV were detected in the plasma of four out of the seven infants studied, we recommend breastfed infants should be monitored closely. Each decision to breast feed should be made as an individual risk:benefit analysis.

Not very cut-and-dried though, sorry!

Hi Susan - Why does she think Effexor would be better?
I know this is so difficult because I faced it myself but if it turns out that the medication you need isnt compatable with breastfeeding then it may be better in the long run for all of you to swap to bottle.
The most important thing is for you to feel better. I really beat myself up over the fact that I only breast fed my twins for a few weeks but I know now it was much more important for them for me to get the treatment I needed.
I hope things start to look a bit straighter soon.
Kizziex

susanmt, you've been in such a bad way that I also think (and this is just my thought so say Butt OUT if you want to ) that if the medication gets the PND under control but prevents you breastfeeding safely, I think getting the PND under control is more important for you AND your baby. But that IS just my opinion.

I've been looking around and it seems to be a case of IF the benefits outweigh the risks .... a hard decision. The thing is, the breastfeeding is the one thing that I KNOW I am doing well for Rachel, and the only part of baby care that makes me feel good at all. I wondered if anyone had the Hale book (tiktok?) Medecine and Mother's Milk, to see what he said about it.

She thinks Effexor would be better as I am on the highest dose of Lustral and I still took a big overdose and ended up in hospital earier this week. Effexor is the second line of treatment, and should work better.

hi Susanmt, according to Hale effexor is used frequently in bf mothers in Australia but less so in the US. When I searched on it it came up as preferable to Prozac, which is used quite a lot round these parts in bf mothers. It also says that side effects are most common in the first 3 months postpartum - don't know how old your baby is though. I took Lustral while bf last time and will do so again no doubt when this baby is born. Have to say that after an inital boost it wasn't working so well but then I got pg and so am off everything at the moment. Huge hugs, can really appreciate how you are feeling esp the bit about feeling that bf is the one thing you can do right. I felt just the same.

Only a personal opinion but maybe you would get more upset at having to stop Bf.BF has been shown to ipmprove maternal/infant attachment in mums with pnd so i hope you can carry on and take the drugs.Your dr should really have discussed all the risks ect with you.Have you tried contacting the nct-perhaps someone can give you some tel nos to try.I know the nct have a telephone support line just for drug compatability-does anyone have it ??? If not get back to me and Ill root it out for you. Hope you start too feel better soon.

Susan - why don't you ask Kath at the ABM????

Pupuce - you're a star, what a great idea. I'm just not thinking straight, durrrr.

Posted on Thursday, May 15, 2003 - 03:23 pm:

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A patient I am working with is concerned about switching from Zoloft 50 mg to Effexor XR (starting dosage 75mg). Her complaint regarding Zoloft was the side effects of weight gain and sexual dysfunction. Her GP insists that Effexor is fine while breastfeeding. I understand that Medications & Mothers' Milk states that Effexor is compatible with breastfeeding.

However, a colleague of mine contacted The Breastfeeding and Human Lactation Study Center at the University of Rochester School of Medicine. They informed her that Effexor was NOT compatible with breastfeeding; that there was too little data; and that the AAP says the risks outweigh the benefits.

Naturally we are confused as to how we advise this patient (and any in the future). Our patient reports that the Zoloft is controlling her depression and she could tolerate the side effects until she weans.

I am thinking that my recomendation should be: to stay on the 50mg of Zoloft; increase the dosage to 100mg if needed; and switch to Effexor when she weans. However, we would like to have the most accurate information available on Effexor.

I appreciate any input you have.

THANK YOU VERY MUCH!!! Your information and research has helped us help mothers.

Regards,
Teresa Vilensky, R.N.
Lactation Consultant

Tom Hale Ph.D.
Member
Username: Tom

Post Number: 44
Registered: 04-2003
Posted on Thursday, May 15, 2003 - 04:37 pm:

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Teresa:

The data on Effexor is reasonably good. Ilett's group showed that the Relative Infant Dose of venlafaxine was about 3.2% and of the active metabolite about 3.2%. We don't generally get concerned about a drug until it approaches 10% of the maternal dose and then it depends on the drug and its toxicity.

As for not being compatible and not being approved by the AAP...sorry again, none of the infants in the above study had any untoward side effects, and lastly, the AAP in 2001 did not even review venlafaxine, its not in their publication.

The choice of antidepressant always depends on how well the patient responds. Some love Zoloft, others hate it. So I would suggest that if this mom likes Effexor, its probably a better choice for her.

All this data is in my 2002 MMM.

Tom Hale, PH.D.
Professor of Pediatrics

1. Illett KF, Kristensen JH, Hackett LP, Paech M, et.al. Distribution of venlafaxine and its O-desmethyl metabolite in human milk and their effects in breastfed infants. Br J Clin Pharmacol 53:17-22, 2002.

Kathryn B. Held
New member
Username: Kheld

Post Number: 1
Registered: 10-2003
Posted on Friday, October 03, 2003 - 11:47 am:

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I am on the faculty at the Johns Hopkins School of Medicine and also the mother of a five day old. Throughout my pregnancy, I took Effexor XR. Effexor has been very effective in relieving my depression symptoms with few side effects. Although I would have preferred a higher dose, I took 37.5mg. Postpartem I had planned to increase the dose to 75mg. However, the day after I took the first higher dose, my milk came in but I did not seem to be able to letdown and was not able to nurse or express. The following day I skipped the medication altogether and had no trouble nursing. My concern is that Effexor increases availability of dopamine. As dopamine agonists have been used to suppress milk production and letdown and antagonists are used to increase supply, I am wondering whether Effexor is likely to have a detrimental effect on my ability to nurse. My initial problem may have been simply engorgement on the day of real milk production, but I hesitate to continue the medication if it may jeopardize my ability to nurse well.

Tom Hale Ph.D.
Member
Username: Tom

Post Number: 213
Registered: 04-2003
Posted on Friday, October 03, 2003 - 01:36 pm:

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Kathryn:

While it possible that increasing the dose of Venlafaxine could have suppressed your let-down, I do not know for sure that dopamine is at all the controlling mechanism in OXYTOCIN release. In fact, I don't think it is.

We do know for sure that dompamine significantly suppresses Prolactin release, but this would have taken much more time to have effected your milk supply, unless it totally shut off prolactin release and this is rare.

I would suggest that it could have been the rapid change in Effexor, but it doesn't really fit. Many many women have breastfed just fine using venlafaxine and we have not had reports of reduced milk synthesis or letdown.

But you may be different. I'd suggest you hold your dose at the present level, and increase it only after you have a good established milk supply, and then only slowly. Venlafaxine levels in milk are moderate, and the dose to the infant is moderate. Sertraline(Zoloft) may be a better choice...but then again, it may not work for you at all.

Tom Hale, Ph.D.

Emily Bailey
New member
Username: Ejbailey729

Post Number: 1
Registered: 10-2003
Posted on Tuesday, October 21, 2003 - 11:34 pm:

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I am an RN in a small hospital. One of the other nurses that I work with has a 6 week old infant. She was on Effexor before becoming pregnant and then went off of it during pregnancy. She said she is having "trouble" again and wants to go back on the Effexor. Her physician, and one of the physicians at our hospital has ssaid that the Effexor is OK to take while breastfeeding, but just to monitor the baby closely. What kind of things should she be monitoring the infant for and should she be worried about taking this medication or is it really OK???? Thanks!!

Tom Hale Ph.D.
Member
Username: Tom

Post Number: 238
Registered: 04-2003
Posted on Wednesday, October 22, 2003 - 09:44 am:

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Emily:

This is hard to answer. The current studies don't show any side effects in the small number of infants studied.

I'd suggest: severe colic, diarrhea, weight-loss or lack of weight gain, severe prolonged crying and perhaps tremors. But this is so remote that I wouldn't worry about these.

In medicine and with side effects, sometimes the "pot" does boil too rapidly, if you get my meaning. Sometimes if you tell a patient about a remote side effect, it always turns up.

Tom Hale, PH.D.

gina j m
New member
Username: Gmjrn92

Post Number: 3
Registered: 11-2003
Posted on Sunday, November 02, 2003 - 10:42 am:

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besides the effects on infants /children being breastfed on effexor or zoloft ,do you have any current information regarding zanax or ambien on a PRN basis???just wondering.i was given a presciption for ambien but told not to fill until i stopped breastfeeding.what are your thoughts

Tom Hale Ph.D.
Member
Username: Tom

Post Number: 258
Registered: 04-2003
Posted on Monday, November 03, 2003 - 09:12 am:

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Gina:

Again, check my book. Both of these drugs are included.

Tom Hale, Ph.D

Susanmt - didn't know how else to do the post below. I have copies and pasted the online info from the website. I will post the link next.

The link to the website is here

mears thanks so much - I can show all this to my GP tomorrow when I go to get the prescription and it should all be OK. SOunds like I am going to be able to take it, get better and keep on breastfeeding, thank goodness. You're a star!

Still not sure what is happening as GP was a bit funny about the prescription but got my CPN on side today so should get my new antidepressants tomorrow.
Thanks everyone for your help.