Aripiprazole use while Breastfeeding
Drugs containing Aripiprazole: Abilify, Abilify Maintena, Aristada, Abilify Discmelt, Abilify MyCite
Aripiprazole Levels and Effects while Breastfeeding
Summary of Use during Lactation
Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk, but until more data become available, an alternate drug may be preferred, especially while nursing a newborn or preterm infant. Aripiprazole can lower serum prolactin in a dose-related manner and can affect the milk supply variably.
Maternal Levels. A women who was 6 months postpartum was taking aripiprazole 15 mg by mouth daily. Milk levels after 11 and 12 days of therapy (times not stated) at that dose were 13 and 14 mcg/L.
A woman took aripiprazole 15 mg daily by mouth during pregnancy and postpartum. At 3 days postpartum, aripiprazole was not detectable in colostrum because of an unknown substance that interfered with the assay. On day 27 postpartum, 3 additional milk samples were collected at 30 minutes before the dose (24 hours after the last dose), and 4 and 10 hours after the dose. The drug and its metabolite were undetectable (<10 mcg/L) in all samples. The authors estimated that a fully breastfed infant would receive less than 0.7% of the maternal weight-adjusted dosage.
A woman was taking aripiprazole 18 mg daily. On day 6 postpartum, a breastmilk sample (time not reported) contained a concentration of aripiprazole of 38.7 mcg/L.
A woman took aripiprazole 10 mg daily by mouth beginning in week 9 of pregnancy and continuing postpartum. Mid-nursing milk samples were obtained at 8 and 10 weeks postpartum over a 24-hour period after the dose. Aripiprazole and dehydroaripiprazole were measured in the milk. On the first sampling day, mean milk concentrations were 52.6 mcg/L of aripiprazole and 8.8 mcg/L for the metabolite. On the second day, mean milk concentrations were 53.6 and 6.3 mcg/L, respectively. The authors calculated that a 5 kg infant would receive a daily dose of 47 mcg daily and the weight-adjusted dosage would be 8.3% of the maternal dosage.
Infant Levels. A woman was taking aripiprazole 18 mg daily during pregnancy and postpartum. On day 6 her breastfed infant had a serum concentration of 7.6 mcg/L, although some portion of the concentration could have been residual from transplacental transmission because of the drug's on half-life.
Effects in Breastfed Infants
A woman took aripiprazole 15 mg daily by mouth during pregnancy and postpartum. She breastfed her infant (amount not stated) and at 3 months of age, the infant was growing normally.
A woman took aripiprazole 10 mg daily by mouth beginning in week 9 of pregnancy and continuing postpartum. She exclusively breastfed her infant for 6 weeks, then was partially breastfed. At 4 months of age the infant was still breastfeeding and had normal psychomotor and behavioral development and had reached the expected milestones for her age.
A 12-day-old exclusively breastfed male infant presented with severe weight loss and hypernatremic dehydration because of inadequate milk intake and a 30% weight loss since birth. The infant's mother was being treated for bipolar disorder with lamotrigine 250 mg orally once daily, aripiprazole 15 mg orally once daily, and sertraline 100 mg orally once daily. She was also taking levothyroxine 50 mcg once daily, a prenatal multivitamin, and folic acid. On initial evaluation in the emergency department, he was pale, with marbled skin, dry mucous membranes, decreased skin turgor, and bluish feet with prolonged capillary refill. The right foot eventually became darker with blackened toes and he developed gangrene of the right lower limb, which did not respond to medical therapy and required amputation of all five toes and surgical debridement of the metatarsals. Necrosis was attributed to arterial microthrombi caused by disseminated intravascular coagulation after severe dehydration. The authors considered the mother's medications as a possible cause of the dehydration and related problems.
Effects on Lactation and Breastmilk
Unlike the phenothiazines, aripiprazole has a minimal effect on serum prolactin levels and it has been used to reverse hyperprolactinemia in nonlactating patients taking other antipsychotics. The maternal prolactin level in a mother with established lactation may not affect her ability to breastfeed. However, cases of galactorrhea apparently caused by aripiprazole have been reported.
One woman began taking aripiprazole 10 mg daily at week 20 of pregnancy. She underwent a cesarean section delivery at term, but was unable to establish lactation. The authors suggested that more data are needed to determine if aripiprazole adversely affects lactation.
A woman took aripiprazole 10 mg daily by mouth beginning in week 9 of pregnancy and continuing postpartum. She exclusively breastfed her infant for 6 weeks, but then began supplementation because of insufficient milk production. Her serum prolactin was 35 to 40 mcg/L, which is lower than expected for a nursing mother. The authors speculated that the aripiprazole might have been the cause of her low serum prolactin and diminished her milk supply.
A woman with bipolar disorder was taking lithium during pregnancy and postpartum. At 10 days postpartum, her infant's serum lithium level was 0.26 mmol/L, so lithium was discontinued. Quetiapine was begun, but discontinued because of maternal sedation. Aripiprazole 2.5 mg daily was begun and within 24 hours, the mother noted a marked decrease in milk supply. After 2 weeks of working with a lactation consultant, she continued to have lactation difficulties and she switched back to lithium. Within 48 hours, her milk supply improved markedly.
A retrospective study of outpatients receiving an average aripiprazole dose of 17.3 mg daily (n = 20) or another antipsychotic (n = 141) found that those receiving such high-dose aripiprazole had an 81% chance of having hypoprolactinemia. Patients not treated with aripiprazole had only a 2.9% chance of having hypoprolactinemia.
Alternate Drugs to Consider
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2. Schlotterbeck P, Leube D, Kircher T, Hiemke C, Grunder G. Aripiprazole in human milk. Int J Neuropsychopharmacol. 2007;10:433. PMID: 17291382
3. Lutz UC, Hiemke C, Wiatr G et al. Aripiprazole in pregnancy and lactation a case report. J Clin Psychopharmacol. 2010;30:204-5. Letter. PMID: 20520299
4. Watanabe N, Kasahara M, Sugibayashi R et al. Perinatal use of aripiprazole: a case report. J Clin Psychopharmacol. 2011;31:377-9. PMID: 21532364
5. Nordeng H, Gjerdalen G, Brede WR et al. Transfer of aripiprazole to breast milk: A case report. J Clin Psychopharmacol. 2014;34:272-5. PMID: 24525645
6. Morin C, Chevalier I. Severe hypernatremic dehydration and lower limb gangrene in an infant exposed to lamotrigine, aripiprazole, and sertraline in breast milk. Breastfeed Med. 2017;12:377-80. PMID: 28481632
7. Goodnick PJ, Rodriguez L, Santana O. Antipsychotics: impact on prolactin levels. Expert Opin Pharmacother. 2002;3:1381-91. PMID: 12387684
8. Kane JM, Carson WH, Saha AR et al. Efficacy and safety of aripiprazole and haloperidol versus placebo in patients with schizophrenia and schizoaffective disorder. J Clin Psychiatry. 2002;63:763-71. PMID: 12363115
9. Byerly MJ, Marcus RN, Tran QV et al. Effects of aripiprazole on prolactin levels in subjects with schizophrenia during cross-titration with risperidone or olanzapine: analysis of a randomized, open-label study. Schizophr Res. 2009;107:218-22. PMID: 19038534
10. Boggs AA, Bihday C, Boggs DL. Aripiprazole's effects on risperidone consta induced hyperprolactinemia: A case report. J Pharm Pract. 2012;25:298. Abstract. DOI: doi:10.1177/0897190012441353
11. Lorenz RA, Weinstein B. Resolution of haloperidol-induced hyperprolactinemia with aripiprazole. J Clin Psychopharmacol. 2007;27:524-5. PMID: 17873694
12. Rocha FL, Hara C, Ramos MG. Using aripiprazole to attenuate paliperidone-induced hyperprolactinemia. Prog Neuropsychopharmacol Biol Psychiatry. 2010;34:1153-4. PMID: 20547197
13. van Kooten M, Arends J, Cohen D. Preliminary report: a naturalistic study of the effect of aripiprazole addition on risperidone-related hyperprolactinemia in patients treated with risperidone long-acting injection. J Clin Psychopharmacol. 2011;31:126-8. PMID: 21192158
14. Wahl R, Ostroff R. Reversal of symptomatic hyperprolactinemia by aripiprazole. Am J Psychiatry. 2005;162:1542-3. PMID: 16055781
15. Wolf J, Fiedler U. Hyperprolactinemia and amenorrhea associated with olanzapine normalized after addition of aripiprazole. J Clin Pharm Ther. 2007;32:197-8. PMID: 17381670
16. Mendhekar DN, Andrade C. Galactorrhea with aripiprazole. Can J Psychiatry. 2005;50:243. Letter. PMID: 15898468
17. Ruffatti A, Minervini L, Romano M, Sonino N. Galactorrhea with aripiprazole. Psychother Psychosom. 2005;74:391-2. PMID: 16244518
18. Mendhekar D, Sunder KR, Andrade C. Aripiprazole use in a pregnant schizoaffective woman. Bipolar Disord. 2006;8:299-300. PMID: 16696834
19. Frew JR. Psychopharmacology of bipolar I disorder during lactation: a case report of the use of lithium and aripiprazole in a nursing mother. Arch Womens Ment Health. 2015;18:135-6. PMID: 25352315
20. Lozano R, Marin R, Santacruz MJ. Prolactin deficiency by aripiprazole. J Clin Psychopharmacol. 2014;34:539-40. PMID: 24911440
21. Morin C, Chevalier I. Severe hypernatremic dehydration and lower limb gangrene in an infant exposed to lamotrigine, aripiprazole, and sertraline in breast milk. Breastfeed Med. 2017;12:377-80. PMID: 28481632
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