Sertraline use while Breastfeeding

Drugs containing Sertraline: Zoloft

Sertraline Levels and Effects while Breastfeeding

Summary of Use during Lactation

Because of the low levels of sertraline in breastmilk, amounts ingested by the infant are small and is usually not detected in the serum of the infant, although the weakly active metabolite desmethylsertraline is often detectable in low levels in infant serum. Rarely, preterm infants with impaired metabolic activity might accumulate the drug and demonstrate symptoms similar to neonatal abstinence. Most authoritative reviewers consider sertraline one of the preferred antidepressants during breastfeeding.[1][2][3][4] Mothers taking an SSRI during pregnancy and postpartum may have more difficulty breastfeeding and may need additional breastfeeding support.

Drug Levels

Sertraline is metabolized to norsertraline that has antidepressant activity considered to be 10% that of sertraline.[2]

Maternal Levels In a pooled analysis of serum levels from published studies and 4 unpublished cases, the authors found that 15 mothers taking an average daily dosage of 83 mg (range 25 to 200 mg) had an average breastmilk sertraline level of 45 mcg/L (range 7 to 207 mcg/L).[2] Using the average dosage and milk level data from this paper, an exclusively breastfed infant would receive an estimated 0.5% of the maternal weight-adjusted dosage of sertraline.

Twenty-six women who were an average of 15.8 weeks postpartum (range 5 to 36 weeks) and receiving an average of 124 mg sertraline daily for at least 14 days for severe depression were studied while breastfeeding with extensive milk and serum sampling over a 24-hour period. All milk samples had detectable sertraline (average 129 mcg/L; range 11 to 938 mcg/L) and desmethylsertraline (average 258 mcg/L; range 20 to 1498 mcg/L). Drug concentrations were higher in the hindmilk than the foremilk. Analysis of milk sertraline data from 15 mothers who submitted complete sets of milk samples indicated that the peak concentration of the drug and metabolite occurred 8 to 9 hours after a dose. In these women, the concentration in milk correlated with serum concentration, but not daily dosage. The authors estimated that an exclusively breastfed infant would receive an average of 0.54% of the maternal weight-adjusted dosage and that pumping and discarding milk 8 to 9 hours after the mother's dose would decrease the infant's daily dosage by 17%.[5]

From data in 6 mothers who were 5 to 34 weeks postpartum and taking sertraline in an average daily dosage of 64 mg (range 50 to 100 mg), the authors estimated that an exclusively breastfed infant would receive 0.9% of the maternal weight-adjusted dosage.[1]

At 2 months postpartum, 4 mothers taking an average of 87.5 mg of sertraline daily had average milk levels of 26.4 mcg/L of sertraline and 29 mcg/L of desmethylsertraline at random times after the previous dose. The authors estimated that an exclusively breastfed infant would receive 0.04 mg/kg of sertraline daily.[6]

The mother of a preterm infant was taking sertraline 150 mg daily during pregnancy and postpartum. Her breastmilk levels of sertraline and desmethylsertraline on 3 days at random times averaged 201 and 358 mcg/L, respectively.[7]

Infant Levels Of 30 breastfed infants (19 exclusively, 11 breastfed 50% or more) aged 6 to 13 weeks, 22 had undetectable (<1 mcg/L) sertraline serum levels during maternal therapy with sertraline dosages of 25 to 200 mg daily. Of the 8 infants who had detectable serum levels, their average sertraline serum level was 7.9 mcg/L. Their mothers, who were taking an average of 109 mg daily, had an average serum level of 52.8 mcg/L.[8]

In a pooled analysis of 53 mother-infant pairs from published and unpublished cases, the authors found that infants had an average of 2% (range 0 to 15%) of the sertraline plasma levels of the mothers'; 3 of the infants had a plasma level greater than 10% of the mothers' which was defined by the authors as being elevated.[2]

Twenty-two breastfed (20 exclusively) infants with an average age of 16.6 weeks (range 4 to 28 weeks) whose mothers were receiving an average of 124 mg sertraline daily for at least 14 days for severe depression were studied. Infant serum levels were measured 2.2 hours (range 0.5 to 5 hours) after nursing. Four infants had detectable sertraline (>2 mcg/L) and 11 infants had detectable desmethylsertraline in their serum with an average concentration of 22 mcg/L. One 11-week-old infant who was being treated for acute asthma with albuterol, inhaled corticosteroids and hydroxyzine had serum levels higher than its mother's, even though 4 other infants received higher doses of sertraline and desmethylsertraline through milk.[5]

In 6 breastfed (extent not stated) infants aged 5 to 34 weeks whose mothers were taking sertraline in an average daily dosage of 15 mg (range 5 to 34 mg), sertraline and desmethylsertraline were undetectable (<3.4 mcg/L).[1]

In a study of mothers given sertraline prophylactically for recurrent postpartum depression, 7 opted to breastfeed. Infant serum was tested at 4 weeks of age with a maternal dosage of 50 mg daily. Sertraline (<2 mcg/L) and desmethylsertraline (<12 mcg/L) were undetectable in the serum of any infant.[9]

In a study comparing sertraline to nortriptyline for postpartum depression, 13 infants were breastfed by mothers taking sertraline (dosage and extent of nursing were not stated). After a constant maternal sertraline dosage for at least 14 days, infants had their serum concentrations measured. The infants were an average of 5.9 weeks old at the time of serum sampling. Sertraline was not detectable (<2 mcg/L) in any of the infants' serum; desmethylsertraline serum levels ranged from undetectable (<2 mcg/L) to 6 mcg/L.[4][10]

At 2 months postpartum, the breastfed infants of 4 mothers taking an average of 87.5 mg of sertraline daily had undetectable (<0.1 mcg/L) serum levels of sertraline and desmethylsertraline.[6]

A 33-week preterm infant was exclusively breastfed by a mother who was taking sertraline 150 mg daily during gestation, at delivery and postpartum. Because of symptoms similar to neonatal abstinence syndrome, the infant's serum concentrations of sertraline and desmethylsertraline were measured on day 5 postpartum. Levels were 13 and 52 mcg/L, respectively. Because of ongoing symptoms, breastfeeding was stopped on day 9 and the infant's serum levels reportedly dropped, although specific values were not presented in the paper. The infant was later found to have genetically intermediate metabolism of two of the CYP450 enzymes involved in sertraline metabolism.[7]

Effects in Breastfed Infants

Two side effects possibly related to sertraline in breastmilk have been reported to the Australian Adverse Drug Reaction Advisory Committee. Benign neonatal sleep myoclonus occurred in one 4-month-old infant[11] and agitation that spontaneously resolved was reported in another infant.[12]

None of 26 infants with an average age of 16.6 weeks (range 4 to 28 weeks) whose mothers were receiving an average of 124 mg sertraline daily had any detectable acute adverse reactions to sertraline in breastmilk. All had been breastfeeding for at least 3 weeks.[5]

Whole blood serotonin levels were measured in 14 mothers and their breastfed infants after 6 to 16 weeks of sertraline therapy. Maternal dosages ranged from 25 to 200 mg daily. Although maternal serotonin levels were decreased from 159 mcg/L to 19 mcg/L by sertraline therapy, infant serotonin levels averaged 227 mcg/L before and 224 mcg/L after maternal therapy. The authors concluded that these findings indicate that the amount of sertraline ingested by the infants was not sufficient to affect platelet serotonin uptake in breastfed infants. Platelets and neurons both have the same serotonin transporter, so this lack of effect was seen as indirect evidence of safety of sertraline use during breastfeeding. None of the infants experienced any adverse effects from sertraline in breastmilk, including 6 exclusively breastfed infants under 3 months of age.[13]

Twenty-five mothers who took an average sertraline dosage of 82.4 mg daily breastfed their infants exclusively for 4 months and breastfed at least 50% during months 5 and 6. Their infants had 6-month weight gains that were normal according to national growth standards and the mothers reported no abnormal effects in their infants.[14]

In 6 infants aged 5 to 34 weeks whose mothers were taking sertraline 50 to 100 mg daily, no adverse reactions were noted clinically at the time of the study.[1]

No adverse effects were seen in 7 infants who were 4 weeks old and whose mothers had been taking sertraline 50 mg daily since day 4 postpartum.[9]

One study of side effects of SSRI antidepressants in nursing mothers found no adverse reactions that required medical attention among 2 infants whose mother was taking sertraline. No specific information on maternal sertraline dosage, extent of breastfeeding or infant age was reported.[15]

A small study compared the reaction to pain in infants of depressed mothers who had taken an SSRI during pregnancy alone or during pregnancy and nursing, to a control group of unexposed infants of nondepressed mothers. Infants exposed to an SSRI either prenatally alone or prenatally and postnatally via breastmilk had blunted responses to pain compared to control infants. Four of the 30 infants were exposed to sertraline. Because there was no control group of depressed, nonmedicated mothers, an effect due to maternal behavior caused by depression could not be ruled out. The authors stressed that these findings did not warrant avoiding drug treatment of depression during pregnancy or avoiding breastfeeding during SSRI treatment.[6]

An uncontrolled online survey compiled data on 930 mothers who nursed their infants while taking an antidepressant. Infant drug discontinuation symptoms (e.g., irritability, low body temperature, uncontrollable crying, eating and sleeping disorders) were reported in about 10% of infants. Mothers who took antidepressants only during breastfeeding were much less likely to notice symptoms of drug discontinuation in their infants than those who took the drug in pregnancy and lactation.[16]

In a telephone follow-up study, 124 mothers who took a benzodiazepine while nursing reported whether their infants had any signs of sedation. One mother who was taking sertraline 50 mg daily, zopiclone 2.5 mg about every 3 days as needed, and also took alprazolam 0.25 mg on 2 occasions, reported sedation in her breastfed infant.[17]

A mother was taking sertraline 150 mg daily during gestation, at delivery and postpartum while exclusively breastfeeding her infant. Her preterm infant born by cesarean section at 33 weeks gestation developed hyperthermia, muscle tone regulation disorders, and high-pitched crying during the first 24 hours after birth. The symptoms worsened on the 4th day of life, but breastfeeding was continued. On day 5, the infant had serum concentrations of sertraline and its metabolite that are in the reported therapeutic range in adults. Breastfeeding was discontinued on day 9 postpartum and the infant's symptoms dissipated, serum drug levels decreased and the infant thrived over several months. The infant was later found to have genetically intermediate metabolism of two of the CYP450 enzymes involved in sertraline metabolism. The authors attributed the infant's symptoms to serotonergic overstimulation caused by persistently high sertraline levels from breastfeeding and reduced metabolism.[7] The reaction was probably caused by sertraline.

An infant was being breastfed (extent not stated) by a mother who began taking sertraline 50 mg daily and methylphenidate after 5 weeks postpartum. Dosage was started at 10 mg daily with an immediate-release product and gradually increased to 72 mg daily of an extended-release product. At 14 weeks of age, the infant was developing normally no feeding difficulties. Examinations at 6 months and 1 year of age found no developmental problems in the child.[18]

Effects on Lactation and Breastmilk

Sertraline has caused galactorrhea in nonpregnant, nonnursing patients.[19][20][21] However, in a study of cases of hyperprolactinemia and its symptoms (e.g., gynecomastia) reported to a French pharmacovigilance center, sertraline was not found to have an increased risk of causing hyperprolactinemia compared to other drugs.[22] The prolactin level in a mother with established lactation may not affect her ability to breastfeed.

A midwife observed 6 patients who reported a decrease in milk supply after starting sertraline (dosages not reported). One of the mothers had been taking sertraline since the 6th month of pregnancy. She reported an increase in milk supply when she stopped sertraline for one week at 4 months postpartum. When she restarted sertraline, her milk supply reportedly decreased. In all of the women, the milk supply increased in 2 to 3 days after increasing fluid and the frequency of nursing.[23]

In a small prospective study, 8 primiparous women who were taking a serotonin reuptake inhibitor (SRI; 3 taking fluoxetine and 1 each taking citalopram, duloxetine, escitalopram, paroxetine or sertraline) were compared to 423 mothers who were not taking an SRI. Mothers taking an SRI had an onset of milk secretory activation (lactogenesis II) that was delayed by an average of 16.7 hours compared to controls (85.8 hours postpartum in the SRI-treated mothers and 69.1 h in the untreated mothers), which doubled the risk of delayed feeding behavior in the untreated group. However, the delay in lactogenesis II may not be clinically important, since there was no statistically significant difference between the groups in the percentage of mothers experiencing feeding difficulties after day 4 postpartum.[24]

A case control study compared the rate of predominant breastfeeding at 2 weeks postpartum in mothers who took an SSRI antidepressant throughout pregnancy and at delivery (n = 167) or an SSRI during pregnancy only (n = 117) to a control group of mothers who took no antidepressants (n = 182). Among the two groups who had taken an SSRI, 33 took citalopram, 18 took escitalopram, 63 took fluoxetine, 2 took fluvoxamine, 78 took paroxetine, and 87 took sertraline. Among the women who took an SSRI, the breastfeeding rate at 2 weeks postpartum was 27% to 33% lower than mother who did not take antidepressants, with no statistical difference in breastfeeding rates between the SSRI-exposed groups.[25]

Alternate Drugs to Consider

Nortriptyline, Paroxetine

References

1. Berle JO, Steen VM, Aamo TO et al. Breastfeeding during maternal antidepressant treatment with serotonin reuptake inhibitors: infant exposure, clinical symptoms, and cytochrome P450 genotypes. J Clin Psychiatry. 2004;65:1228-34. PMID: 15367050

2. Weissman AM, Levy BT, Hartz AJ et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry. 2004;161:1066-78. PMID: 15169695

3. The Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #18: use of antidepressants in nursing mothers. Breastfeed Med. 2008;3:44-52. PMID: 18333769

4. Lanza di Scalea T, Wisner KL. Antidepressant medication use during breastfeeding. Clin Obstet Gynecol. 2009;52:483-97. PMID: 19661763

5. Stowe ZN, Stowe MD, Hostetter AL et al. The pharmacokinetics of sertraline excretion into human breast milk: determinants of infant serum concentrations. J Clin Psychiatry. 2003;64:73-80. PMID: 12590627

6. Oberlander TF, Grunau RE, Fitzgerald C et al. Pain reactivity in 2-month-old infants after prenatal and postnatal serotonin reuptake inhibitor medication exposure. Pediatrics. 2005;115:411-25. PMID: 15687451

7. Muller MJ, Preuss C, Paul T et al. Serotonergic overstimulation in a preterm infant after sertraline intake via breastmilk. Breastfeed Med. 2013;8:327-9. PMID: 23249132

8. Hendrick V, Fukuchi A, Altshuler L et al. Use of sertraline, paroxetine and fluvoxamine by nursing women. Br J Psychiatry. 2001;179:163-6. PMID: 11483479

9. Sunder KR, Wisner KL, Hanusa BH et al. Postpartum depression recurrence versus discontinuation syndrome: observations from a randomized controlled trial. J Clin Psychiatry. 2004;65:1266-8. PMID: 15367055

10. Wisner KL, Hanusa BH, Perel JM et al. Postpartum depression: a randomized trial of sertraline versus nortriptyline. J Clin Psychopharmacol. 2006;26:353-60. PMID: 16855451

11. Mammen OK, Perel JM, Rudolph G et al. Sertraline and norsertraline levels in three breastfed infants. J Clin Psychiatry. 1997;58:100-3. PMID: 9108810

12. Rohan A. Drug distribution in human milk. Aust Prescriber. 1997;20:84.

13. Epperson N, Czarkowski KA, Ward-O'Brien D et al. Maternal sertraline treatment and serotonin transport in breast-feeding mother-infant pairs. Am J Psychiatry. 2001;158:1631-7. PMID: 11578995

14. Hendrick V, Smith LM, Hwang S et al. Weight gain in breastfed infants of mothers taking antidepressant medications. J Clin Psychiatry. 2003;64:410-2. PMID: 12716242

15. Lee A, Woo J, Ito S. Frequency of infant adverse events that are associated with citalopram use during breast-feeding. Am J Obstet Gynecol. 2004;190:218-21. PMID: 14749663

16. Hale TW, Kendall-Tackett K, Cong Z et al. Discontinuation syndrome in newborns whose mothers took antidepressants while pregnant or breastfeeding. Breastfeed Med. 2010. PMID: 20807106

17. Kelly LE, Poon S, Madadi P, Koren G. Neonatal benzodiazepines exposure during breastfeeding. J Pediatr. 2012;161:448-51. PMID: 22504099

18. Bolea-Alamanac BM, Green A, Verma G et al. Methylphenidate use in pregnancy and lactation: a systematic review of evidence. Br J Clin Pharmacol. 2014;77:96-101. PMID: 23593966

19. Lesaca TG. Sertraline and galactorrhea. J Clin Psychopharmacol. 1996;16:333-4. Letter. PMID: 8835712

20. Bronzo MR, Stahl SM. Galactorrhea induced by sertraline. Am J Psychiatry. 1993;150:1269-70. Letter. PMID: 8093119

21. Nebhinani N. Sertraline-induced galactorrhea: case report and review of cases reported with other SSRIs. Gen Hosp Psychiatry. 2013;35:576.e3-5. PMID: 23260337

22. Trenque T, Herlem E, Auriche P, Drame M. Serotonin reuptake inhibitors and hyperprolactinaemia: a case/non-case study in the French pharmacovigilance database. Drug Saf. 2011;34:1161-6. PMID: 22077504

23. Holland D. An observation of the effect of sertraline on breast milk supply. Aust N Z J Psychiatry. 2000;34:1032. PMID: 11127615

24. Marshall AM, Nommsen-Rivers LA, Hernandez LL et al. Serotonin transport and metabolism in the mammary gland modulates secretory activation and involution. J Clin Endocrinol Metab. 2010;95:837-46. PMID: 19965920

25. Gorman JR, Kao K, Chambers CD. Breastfeeding among women exposed to antidepressants during pregnancy. J Hum Lact. 2012;28:181-8. PMID: 22344850

Sertraline Identification

Substance Name

Sertraline

CAS Registry Number

79617-96-2

Drug Class

Antidepressants

Serotonin Uptake Inhibitors

Administrative Information

LactMed Record Number

328

Last Revision Date

20140116

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