Medication for Narcolepsy during pregnancy

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I've recently been diagnosed with narcolepsy, which means I will soon be on a cocktail of medications. I'm going to get my symptoms under control before trying to get pregnant, but ideally I would pick medications now that I could stay on through a pregnancy (and through breastfeeding if at all possible). Can you tell me which of these would be better choices for pregnancy and breastfeeding? Or which are not permitted at all?

Thanks in advance. My doctors seem to want me to either be entirely unmedicated (not possible), or not have a child.

The categories are:

1. A tricyclic antidepressant to initiate sleep. A small dose (12.5 -25 mg) of Amitriptyline is what I'm on now, but a similarly small dose of Trazadone is sometimes used.

2. An SSRI or SNRI to suppress REM sleep. The recommended ones are Effexor, Zoloft, Prozac, or Cymbalta. I've used Cymbalta in the past and would prefer that one, but it seems there might be less info available on its use during pregnancy?

3. A stimulant to keep me awake during the day. Ideally Provigil or Nuvigil, but Ritalin or Adderoll are sometimes used, too. I have not yet tried any of them and so don't have any preferences yet.

4. A "serious" sleep medication: Xyrem. I know xyrem was category B and then was recently changed to category C but I can't find any more information on the medication in pregnancy (or breastfeeding).

Thanks in advance.

[admin-james]

Hi, thanks for your post. You asked a lot of questions, so this answer is kind of long. We use the forum to help point out deficiencies in our existing reference materials, so we really appreciate the opportunity to explore this topic with you. Please post again or call us at the InfantRisk Center if this has not completely answered your question.*(806)352-2519

Amitriptylineregnancy - FDA pregnancy category "C" - Some animal studies have shown no increase in birth defects when this drug was used in pregnancy. Other studies, using proportional doses equal to 10-20x the maximum human doses, demonstrated a significant increase in skeletal abnormalities. The risk of defects from this drug appears to be dose-dependent. Sporadic reports of similar defects in human babies exposed in utero to amitriptyline have been published. In these cases, there was not enough information to draw a firm conclusion that the drug caused the defects; there is a "background" birth defect rate of around 2-4% in the USA that has nothing to do with drug exposure.

Amitriptyline:breastfeeding - InfantRisk safety rating "L2" - Direct laboratory examination of breastmilk samples suggests that only 2-3% of the mother's dose is transmitted to an exclusively breastfeeding baby. At a maternal dose of 100mg/day, amitriptyline and its metabolites were frequently undetectable in the baby's blood and no side effects were reported. Observe the baby for changes in wakefulness.

Trazodoneregnancy - FDA pregnancy category "C" - Animal studies indicate an increased rate of birth defects at doses well in excess of the maximum human dose. Similar defects and risks have not been observed in humans.

Trazodone:breastfeeding - InfantRisk safety rating "L2" - Approximately 0.5% of the mother's dose is transmitted to the baby. This is likely to be too low to be clinically relevant. Observe the baby for changes in wakefulness.

SSRIs in pregnancy and breastfeeding are addressed at the link below. SNRIs are not mentioned in this article, but they are similar when it comes to safety considerations.
http://mommymeds.com/content/antidepressant-use-during-pregnancy-and-breastfeeding

Ritalin/Adderallregnancy - FDA pregnancy category "C" - Similar to the other drugs discussed here, animal studies with very large doses show an increased risk of birth defects on these drugs, but the same effect has not yet been documented in humans.

Ritalin/Adderall:breastfeeding - Addressed here:
http://mommymeds.com/content/adhd

Provigil/Nuvigilregnancy - FDA pregnancy category "C" - Unlike the other drugs, animal studies of these medications have established an increase in the risk of adverse fetal events at doses SIMILAR to the maximum prescribed dose in humans. Sporadic cases of birth anomalies and growth restriction have been reported in humans taking these drugs. In these cases, the evidence was insufficient to conclude that the drug caused the adverse event.

Provigil/Nuvigil:breastfeeding - InfantRisk safety rating "L4" - No information is available concerning how much of these drugs transfer into milk, but it is predicted to be substantial based on their chemical properties. These medications are not approved for use in children and it is unclear what effect incidental drug exposure would have on a baby. These drugs have been associated with serious allergic reactions. The way that these drugs interact with neurotransmitters in the brain suggests a substantial risk of reduced milk supply as a side effect. This latter statement is our primary reason for giving them both the L4 ("possibly hazardous") rating.

Xyremregnancy - FDA pregnancy category "C" - Animal studies showed increased stillbirths and decreased body weights at doses similar to the maximum recommended human dose. These effects have not been demonstrated in humans. In countries where this drug is used as part of the pain control during labor, Xyrem appears to cause short-term sedation in the infants, and decreases in uterine contraction strength in the mother.

Xyrem:breastfeeding - Not rated - There are no specific studies on Xyrem or GHB in breastfeeding women. However, drugs with similar chemical properties are very likely to end up in the milk. Animal studies with Xyrem have found it to cause significant toxicity in offspring exposed during lactation to doses proportional to typical human doses. Half-life of elimination is short, 30-60 minutes, with elimination virtually complete in 4 hours. Using previously pumped milk or formula for night-time feedings will essentially eliminate all risk from this product. There is no need to discard your milk in the morning; the drug is reabsorbed into the blood during the night.

-James Abbey, MD