AboutIvan Goldberg, M.D. Expertise I am a psychiatrist/psychopharmacologist with many years of expereince in treating individuals with depressions, manic-depression (Bipolar Disorder), other mood disorders,. I am especially interested in the psychopharmacologic treatment of individuals with so called "treatment-resistant" syndromes.
Experience I have been on the staff of the National Institute of Mental Health, Columbia's College of Physicians and Surgeons, and the Columbia-Presbyterian Medical Center. I am currently in full-time private practice in New York City.
A.B. Johns Hopkins University M.D. N.Y.U. College of Medicine
I am the creator of Depression Central:http://www.psycom.net/depression.central.html
Question Is it possible to take Lamictal and
continue breast feeding? I am BP I, and
have a 6 mon. old daughter. Moods have
been stable up until the last month. I would
really like to start back on Lamictal.
Am on no other psychiatric medication presently.
I exclusively pump for my daughter, so I could
pump and dump around the medication's peaks.
The other reason to continuing to breast feed
is my daughter has problems with milk/soy
based formulas and probably would have to
drink Neocate ($$$).
Thank you
Nan and Sarah 3/26/04
Answer Hi . . .
Lamictal (LTG)is a drug that remains in the body for at least 24-hours after it is taken . . . that is why it is suitable for once-a-day administration. Infants do not metabolize or excrete LTG very well, so when it is present in breast milk, there is a chance that it will accumulate to therapeutic levels in the infant. I do not suggest that my patients taking LTG breastfeed. Below you will find some abstracts from medical journals on this topic.
Best regards . . .
Ivan
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1: Epilepsy Behav. 2004 Feb;5(1):102-5.
Concerns regarding lamotrigine and breast-feeding.
Liporace J, Kao A, D'Abreu A.
Department of Neurology, Jefferson Medical College, Philadelphia, PA, USA.
Joyce.Liporace@jefferson.edu
PURPOSE: Many women with epilepsy who are planning a pregnancy are treated with
lamotrigine (LTG), resulting in greater fetal exposure to the drug. Current care
guidelines suggest that mothers with epilepsy breast-feed their children. These
recommendations are made without regard to how nursing newborns metabolize
medication. Lamotrigine is extensively metabolized by glucuronidation, which is
immature in neonates and may lead to accumulation of medication. This article
reports LTG levels in full-term nursing newborns born to mothers with epilepsy
on lamotrigine monotherapy. METHODS: Serum LTG levels were obtained in nursing
mothers and their neonates on Day 10 of life. Maternal LTG clearance during
pregnancy and postpartum was determined and correlated with levels. RESULTS:
Four mothers with partial epilepsy on LTG monotherapy were evaluated. Serum LTG
levels in nursing newborns ranged from <1.0 to 2.0 microg/mL on Day 10 of life.
Three babies had LTG levels >1.0 microg/mL. After excluding one child with an
undetectable level, the LTG levels in newborns were on average 30% (range
20-43%) of the maternal drug level. No decline was noted in two children with
repeat levels at 2 months. CONCLUSION: Serum concentrations of LTG in breast-fed
children were higher than expected, in some cases reaching "therapeutic" ranges.
These high levels may be explained by poor neonatal drug elimination due to
inefficient glucuronidation. Our observation that not all newborns had a high
LTG level suggests considerable genetic variability in metabolism. Our limited
data suggest monitoring blood levels in nursing children and the need for
individual counseling for women with epilepsy regarding breast-feeding.
PMID: 14751214 [PubMed - indexed for MEDLINE]
2: Paediatr Drugs. 2000 Mar-Apr;2(2):113-26.
Anticonvulsants and breast feeding: a critical review.
Bar-Oz B, Nulman I, Koren G, Ito S.
The Department of Neonatology, Hadassah Medical Center, Jerusalem, Israel.
Progress in the diagnosis and management of seizure disorders and the
availability of effective anticonvulsive medications has enabled increasing
numbers of epileptic women of child-bearing age to raise families. Breast
feeding, which these women may wish to choose, provides health, nutritional,
immunological, developmental, social, economic and environmental benefits. The
traditional anticonvulsants, such as phenytoin, carbamazepine and valproic acid
(valproate sodium), are generally considered safe for use during breast feeding;
however, observation for adverse effects is recommended. The use of
phenobarbital while breast feeding is controversial because of its slow
elimination by the nursing infant. The newer anticonvulsants, such as clobazam,
felbamate, gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and
vigabatrin, are used mainly as adjunctive therapy. Data on the use of these
drugs in pregnancy and lactation, and regarding long term effects on cognition
and behaviour, are sparse. Weighing the benefits of breast feeding against the
potential risk to the nursing infant, breast feeding is considered to be safe
when the mother is taking carbamazepine, valproic acid or phenytoin. Infant
monitoring for potential adverse effects is advisable when the mother is taking
phenobarbital, clobazam, gabapentin, lamotrigine, oxcarbazepine or vigabatrin.
Monitoring of infant serum drug concentrations is advisable but not compulsory.
The use of felbamate, tiagabine and topiramate during breast feeding should
await further study.
Publication Types:
Review
Review, Academic
PMID: 10937463 [PubMed - indexed for MEDLINE]
3: J Clin Psychiatry. 2000 Feb;61(2):79-90.
Mood stabilizers during breastfeeding: a review.
Chaudron LH, Jefferson JW.
William S. Middleton Memorial Veterans Affairs Hospital and the University of
Wisconsin Medical School, USA.
BACKGROUND: The postpartum period is an exceptionally high-risk time for
recurrence of depression, mania, or psychosis for women with bipolar disorder.
Puerperal prophylaxis with mood stabilizers decreases this risk. To allow
patients and clinicians to make informed decisions about mood-stabilizer use
during breastfeeding, there is a need for a critical review and analysis of the
data. DATA SOURCES: A search of MEDLINE (1966-1998) and the Lithium Database,
Madison Institute of Medicine, was conducted to obtain articles about lithium,
valproate, carbamazepine, gabapentin, or lamotrigine use during lactation.
Search terms used were pregnancy, teratogenesis, breastfeeding, lactation,
breast milk levels and lithium, anticonvulsants, mood stabilizers. No other
search restrictions were used. Unpublished data on gabapentin and lamotrigine
were provided by the manufacturers. RESULTS: The search revealed 11 cases of
lithium use during breastfeeding, 8 of which reported infant serum levels. Two
cases reported symptoms consistent with lithium toxicity in the infants.
Thirty-nine cases of valproate use during breastfeeding were found, 8 of which
reported infant serum levels. There was 1 report of thrombocytopenia and anemia
in an infant. Fifty cases of carbamazepine use during breastfeeding were found,
10 of which reported infant serum levels. Two infants experienced hepatic
dysfunction. One unpublished study of gabapentin in breast milk was found. Three
reports of lamotrigine use during breastfeeding were found. DISCUSSION:
Available information remains limited to uncontrolled studies and case reports.
Carbamazepine and valproate, but not lithium, have generally been considered
compatible with breastfeeding. The overall paucity of data, data confounded by
polypharmacy and infant age differences, and adverse reactions reported with all
established mood stabilizers dictate a reassessment of these recommendations. We
propose that a woman's historical response to medication and the clinical
circumstances be the primary considerations when choosing a mood stabilizer
during breastfeeding, rather than strict adherence to categorical assignments.
Publication Types:
Review
Review, Tutorial
PMID: 10732654 [PubMed - indexed for MEDLINE]
4: Epilepsia. 1997 Sep;38(9):1039-41.
Lamotrigine in pregnancy and lactation: a case report.
Tomson T, Ohman I, Vitols S.
Department of Clinical Neuroscience, Karolinska Institute at Karolinska
Hospital, Stockholm, Sweden.
PURPOSE: We investigated the effect of pregnancy on the kinetics of lamotrigine
(LTG), passage of LTG over the placenta and the excretion of the drug in breast
milk. METHODS: We used high-performance liquid chromatography to determine
concentrations of LTG in plasma and in breast milk in a woman who was treated
with LTG monotherapy during pregnancy and lactation. RESULTS: Plasma levels of
LTG decreased as pregnancy progressed. The ratio of dose to plasma concentration
was 5.8 times higher at delivery and 3.6 times higher in late pregnancy as
compared with 5 months postpartum, suggesting enhanced clearance of LTG during
pregnancy. The concentration ratio of umbilical cord to mother's plasma was 1.2
indicating extensive passage of LTG over the placenta. The LTG plasma
concentration in the newborn was still 48 h after birth similar to the plasma
levels of the mother at delivery and in the umbilical cord. The ratio of milk to
plasma concentration was 0.6 2 weeks after delivery and the plasma concentration
in the breast-fed child was 25% of the mother's plasma levels. No adverse
effects were observed in the newborn. CONCLUSIONS: The kinetics of LTG may be
influenced by pregnancy to such a degree that dose adjustments may be indicated.
Due to an extensive passage of LTG into breast milk, and a slow elimination in
the newborn, LTG concentrations in the nursed infant may reach levels at which
pharmacological effects can be expected.
Publication Types:
Case Reports
PMID: 9579945 [PubMed - indexed for MEDLINE]
5: Eur J Clin Pharmacol. 1997;51(6):481-4.
Concentrations of lamotrigine in a mother on lamotrigine treatment and her
newborn child.
Rambeck B, Kurlemann G, Stodieck SR, May TW, Jurgens U.
Department of Biochemistry, Gesellschaft fur Epilepsieforschung, Bielefeld,
Germany.
OBJECTIVE: To investigate the transfer of lamotrigine in pregnancy and during
lactation from a mother on lamotrigine treatment to her child. METHODS:
Concentrations of lamotrigine were measured by high-pressure liquid
chromatography in umbilical cord serum and in serum samples of the mother and
her child as well as in the mother's milk during the first five postpartum
months. RESULTS: In the child lamotrigine serum concentrations (up to 2.8
micrograms ml-1) comparable to those usually achieved in active treatment with
lamotrigine were found not only after birth, but also during lactation. A
considerable amount of lamotrigine (2-5 mg per day) was excreted in breast milk.
No adverse effects were seen in the child. CONCLUSION: The transfer of
lamotrigine taking place during pregnancy and lactation should not be neglected.
In this case the child should be thoroughly observed for potential adverse
effects.
