Every Friday, starting this morning 08/16/2013, I will be a guest on “The Morning Zone” with Dave Chaffin. The current general topic is “Assisting Youth in Need”, and today we discussed the problem of increasing alcohol use amongst teens, especially in Wyoming. You can listen on the radio or online for free, and please call in during the show if you have the time or inclination. Dr. Wylie
Maternal use of SSRI, SNRI and NaSSA (AKA Newer Generation) antidepressant medications during pregnancy and lactation is a common and usually quite safe practice. However, there is a void in the otherwise broad-based empirical research on these medications when it comes to differences in the safety of individual drugs during pregnancy and lactation. There are two common misconceptions regarding “newer” antidepressants and pregnancy/lactation: 1) Newer antidepressants, despite being simply classified (as above), show significant differences in pharmacodynamics (effects of a drug on a biological system) and pharmacokinetics (effects of a biological system on a drug), and pharmacogenomics (Gene-related phenotypes & polymorphisms) which predict an individual’s specific dynamics and kinetics for a drug; and 2) Despite common belief, there are many differences between the state of pregnancy and the lactation period. New research has begun to shed some light on the relative risks of different “new” antidepressants, and how these risks differ from pregnancy to lactation.
The Archives of Disease in Childhood, Fetal and Neonatal Edition published an article in 2012 titled “Maternal use of SSRIs, SNRIs and NaSSAs: practical recommendations during pregnancy and lactation”. This article, even though it is quite brief, provided some very practical and important data regarding the risks of individual drugs during pregnancy and lactation. The article referenced 67 prior studies, and produced some much needed, interesting, and surprising results. They suggested that the safest medications for treating depression during pregnancy were sertraline, paroxetine, citalopram and fluoxetine. They also produced convincing data that the safest medications during lactation were sertraline and paroxetine, but discouraged the use of fluoxetine due to its significantly longer half-life (t ½) of approximately 4-16 days, and the elevated risk of accumulation in the young child. However, what one finds when reading the article is that the relative data available on the effects of sertraline, fluoxetine and paroxetine exceeded that of all the other “new” antidepressants by approximately ten-fold, with the exception of citalopram which was only exceed by a two-fold margin. So, in fact the newer drugs such as escitalopram and mirtazapine where not validly compared to the older medications which had much more directly applicable data; Overall, a positive correlation between the number of years a drug had been on the market and its positive recommendation status was present and significant; more research on the newer medications is needed.
Action: Within the top three medications, paroxetine is recommended in both pregnancy and lactation, but following this guideline is a bad idea! Paroxetine is rarely used anymore, in any population, due to its wide array of side-effects, widely varied receptor binding properties (dirty drug), and research showing that it may be carcinogenic. Sertraline, which also received a dual recommendation, is not a dirty drug, has a wide dosing range, relatively few, if any, side-effects in most people, and is quite effective and not cost prohibitive. At this time the data strongly supports using sertraline as a first line medication for mood and anxiety disorders in women who are pregnant, may become pregnant, or are nursing. Fluoxetine is a good option in pregnancy, but not during lactation, and paroxetine should be avoided completely. The fetal risks associated with untreated psychiatric disorders far exceed those of utilizing certain medications, at certain times, to treat these conditions.