Trileptal and breastfeeding?

[Mom621]

I take trileptal 300 mg once daily for epilepsy. Is it safe for me to breastfeed? If it is, what side effects may occur to the baby? Thanks so much!! I really hope you tell me I can breastfeed my baby!

[admin]

Mom621:

Note the data we have below and their dose was three times higher. Sounds like it would be probably OK to breastfeed with this dose, and even perhaps with the higher dose as well.

Tom Hale Ph.D.




In a brief and somewhat incomplete study of a pregnant patient who received 300 mg three times daily while pregnant, plasma levels were studied in her infant for the first 5 days postpartum while the infant was breastfeeding. While no breastmilk levels were reported, plasma levels of MHD in the infant were essentially the same as the mother's immediately after delivery, suggesting complete transfer transplacentally of the drug. However, while breastfeeding for the next 5 days, plasma levels of MHD in the infant declined significantly from approximately 7 µg/mL to 0.2 µg/mL on the fifth day. The decay of MHD concentrations in neonatal plasma during the first 4 days postpartum indicated first order elimination. The plasma MHD levels on day 5 amounted to 7% of those one day postpartum (93% drop in 5 days). The authors estimated the milk/plasma ratio to be 0.5. No neonatal side effects were reported by the authors.

Bulau P, Paar WD, von Unruh GE. Pharmacokinetics of oxcarbazepine and 10-hydroxy-carbazepine in the newborn child of an oxcarbazepine-treated mother. Eur J Clin Pharmacol 1988; 34(3):311-313.

[danielle]

HI,
So i am doing research on a mood stabilizer to use while breast feeding.
Prior to being pregnant, i was on depakote & klonopin (as needed, but rarely used) for bipolar (mainly manic, but some significant depression episodes), anxiety & ocd. It worked way better than any anti-depressants i was ever on (prior to knowing i was bipolar), but it was the only mood stabilizer i've ever used.

I am 33weeks pregnant. I came off the depokate (250mg 2x/day) before being pregnant, started 400mg seroquel, 150 wellbutrin, hydroxoyzine (to use in place of klonopin).

I've stopped the hodroxoyzine & wellbutrin a few weeks ago 1.) because they were not working 2.) i couldn't afford to pay for meds that dont help. So i'm on the seroquel currently. my prescription is for 400mg/pm. However, the seroquel is not working as desired, especially for my anxious & "brittle" mood issues.

Long story short - as i'm approaching my due date, i am determined to breastfeed. So i need to find a proper mood stabilizer, that would be conducive to breastfeeding. Also need to know at what point i could start them.
I've seen references that suggest (such as depakote) cannot be started during pregnancy, or not the first 2 months postpartum for like liver/jaundice issues in the newborn. However i'm nervous to ween off of seroquel and have nothing to replace it with. I've also read research saying seroquel has problems with lactation & nursing (sedating the infant, milk letting down). so i really dont think i want to be on it come my baby's birth time - i do not want it to affect her ability to feed/my milk.
I've done some research and have found many non-negative references to depakote. Although most suggest lamictal. However what i've found on lamictal seems quite a bit more harmful than depakote? I've just recently found studies regarding spine bifida with depakote, but would that still come in to play if i only take it while breastfeeding, say a month or 2 months out? I've seen suggestions on Trileptal & Tegretol & verapamil - that seem promising, would those be good alternatives?

Any help would be appreciated. I'm trying to find information to present to my doctors. I've posed these questions with my pediatrician, psychiatrist, ob & lactation consultant. My ob, really does not seem interested in promoting breastfeeding with any kind of bipolar medication, which i do not accept. i think the benefits to breastfeeding far outweigh what i've seen on these meds, hence i'm looking for information to bring back. I haven't heard from the pediatrician or psychiatrist, yet.
thank you in advance.

[admin-james]

Hi, thanks for your post.

It is very difficult to predict what medications will be effective at treating a person's bipolar or OCD; each person seems to be a little different. We can certainly help you with the breastfeeding safety part of your question and hopefully open up some new options for you.

The good news is that nearly all of the antidepressants, antipsychotics, mood stabilizers, and anti-anxiety medications on the market are compatible with breastfeeding. Unfortunately, the one that stands out as being particularly dangerous is Depakote (valproic acid). Several studies have shown that exposure to valproic acid during pregnancy significantly increases the risk of autism spectrum and other mental disorders. This effect could presumably continue on during lactation as well. A study published just this year associated valproic acid exposure in infants with a drop in IQ slightly larger than the IQ boost from breastfeeding.

Lithium also causes some problems in babies due to the very large portion of the mother's dose that ends up in the milk. There are ways around this problem if lithium turns out to be your best option.

Lamictal (lamotrigine) is one of the safer drugs on the market when it comes to breastfeeding. A significant amount gets to the baby via the milk, but this does not seem to cause enough of a problem to warrant a cessation of breastfeeding.

Nearly all of the bipolar drugs are FDA pregnancy category "C," again with the exception of lithium and valproic acid. The “C” drugs are those that have no good studies out there, or have a few worrisome studies in animals but no good evidence in people one way or the other. Most drugs start out as a “C” while basic research is still going on. The theoretical risks for these drugs are greater in the first trimester than they are in the third.

Some women complain that these drugs sedate their babies a little more than they find acceptable. If you find this to be the case, call us and we can discuss strategies for minimizing the baby's exposure to the medications. If you notice no change in your baby's behavior, you can consider your meds to be safe for your situation.

I hope that this gives you and your medical team room to experiment a little and see what works best for you. A healthy mom makes a healthy baby.

I have included citations below for the studies I mentioned. If your doctors routinely struggle with questions about medications in breastfeeding women, I recommend that they invest in our world-renowned reference text, "Medications in Mothers' Milk" by Dr. Thomas Hale. The essentials are also contained in our Android/iPhone apps "InfantRisk" and "MommyMeds." The "MommyMeds" app is free for the next week or so while we're promoting its launch. Check it out!

Please call us at the InfantRisk Center if this has not completely answered your question.*(806)352-2519

-James Abbey, MD

Veiby G, Engelsen BA, Gilhus NE. Early child development and exposure to antiepileptic drugs prenatally and through breastfeeding A prospective cohort study on children of women with epilepsy. JAMA Neurol 2013:E1-E8.

Meador KJ, Baker GA, Browning N et al. Breastfeeding in children of women taking antiepileptic drugs cognitive outcomes at age 6. JAMA Pediatr 2014;168(8):729-36.

Meador KJ, Baker GA, Browning N, Clayton-Smith J, Combs-Cantrell DT, Cohen M, Kalayjian LA, Kanner A, Liporace JD, Pennell PB, Pivitera M, Loring DW. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs. N Eng J Med. 2009 Apr 16; 360 (16): 1597-1605.

Pennell PB, Peng L, Newport DJ, et al. Lamotrigine in pregnancy: clearance, therapeutic drug monitoring, and seizure frequency. Neurology. May 27 2008;70(22 Pt 2):2130-2136.