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Chart Data current as of April 2008 This chart is intended for clinicians who provide primary care to pregnant and postpartum women. See reverse side for notes.

Usual Daily [Relative infant Reported side e ects in dose=RID] (2) Half-life (t1/2)/ breastfed infants (3) Dose (1) Bene ts Risks CLASS: Selective Serotonin Reuptake Inhibitors (SSRIs) * r4PNOPMFODF r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r#FIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO r%SVHIBTJOUFSNFEJBUFU  EBZT 20-40mg r'FXJOUFSBDUJPOTXJUIPUIFSNFEJDBUJPOT 3.6% 1/2 r%FDSFBTFEGFFEJOH (Celexa®) r.BUFSOBMTJEFFíFDUTJODMVEFOBVTFB JOTPNOJB EJ[[JOFTT BOETPNOPMFODF rXFBLNFUBCPMJUFTXJUIMJUUMFBDUJWJUZ r8FJHIUMPTT r/PTZTUFNBUJDTUVEJFTJOIVNBOQSFHOBODZ r.PSQIPMPHJDBOECFIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO r4PNOPMFODF 10-20mg r'FXJOUFSBDUJPOTXJUIPUIFSNFEJDBUJPOT 5.3% r%SVHBOEBDUJWFNFUBCPMJUFIBWFJOUFSNFEJBUF r%FDSFBTFEGFFEJOH (Lexapro®) r.BUFSOBMTJEFFíFDUTJODMVEFOBVTFB JOTPNOJB TPNOPMFODF EJ[[JOFTT GBUJHVF EJBSSIFB TFYVBMEZTGVODUJPO t1/2 EBZT  BOEESZNPVUI r8FJHIUMPTT r.PSFTUVEJFTJOIVNBOQSFHOBODZ JODMVEJOHNFUBBOBMZTJTBOEOFVSPEFWFMPQNFOUBMGPMMPXVQ r.PSFSFQPSUTPGOFPOBUBMTJEFFíFDUTUIBOTPNFPUIFSBOUJEFQSFTTBOUT r%SVHBOEBDUJWFNFUBCPMJUFTIBWFWFSZMPOH r4FWFSFDPMJD t1/2 EBZTUPXFFLT (Prozac®) 20-60mg r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r.BUFSOBMTJEFFíFDUTJODMVEFOBVTFB ESPXTJOFTT BOETFYVBMEZTGVODUJPO 6.8% r4FSVNMFWFMTTJNJMBSUPUIPTFJOBEVMUTSFQPSUFEJO r'VTTJOFTT r/PBEWFSTFCFIBWJPSBMDPOTFRVFODFTGPSJOGBOUGPVOE r1PTTJCMFESVHJOUFSBDUJPOT some symptomatic infants r$SZJOH r#FIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO 50-200mg r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r.BUFSOBMTJEFFíFDUTJODMVEFOBVTFB ESPXTJOFTT BOPSFYJB BOYJFUZ BOETFYVBMEZTGVODUJPO 1.3% r%SVHIBTTIPSUU1/2 IPVST r/PSFQPSUFEDPODFSOT (Luvox®) r1PTTJCMFESVHJOUFSBDUJPOT r.BKPSNFUBCPMJUFOPUBDUJWF

r1PTTJCMFBTTPDJBUJPOXJUIDBSEJPWBTDVMBSNBMGPSNBUJPOTJOJOGBOU r%SVHIBTSFMBUJWFMZTIPSUU1/2, but variable r/VNFSPVTTUVEJFTTVHHFTU 20-60mg r#FIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO 2.1% (Paxil®) r/POFBWPJEEVSJOHQSFHOBODZJGQPTTJCMF r.PSFSFQPSUTPGOFPOBUBMTJEFFíFDUTUIBONPTUPUIFSBOUJEFQSFTTBOUT  IPVSTUPEBZT   NJOJNBMUPOPFíFDUPOCSFBTUGFE r.BUFSOBMTJEFFíFDUTJODMVEFOBVTFB ESPXTJOFTT GBUJHVF EJ[[JOFTT BOETFYVBMEZTGVODUJPO r/PBDUJWFNFUBCPMJUFT infants

Sertraline r3FMBUJWFMZXFMMTUVEJFEJOIVNBOQSFHOBODZ r1PTTJCMFTQFDJñDBTTPDJBUJPOXJUIPNQIBMPDFMFBOETFQUBMEFGFDUT r%SVHBOEXFBLMZBDUJWFNFUBCPMJUFIBWF rSFQPSUPGCFOJHOOFPOBUBMTMFFQ 50-200mg r/PBEWFSTFCFIBWJPSBMDPOTFRVFODFTGPSJOGBOUTGPVOE r.BUFSOBMTJEFFíFDUTJODMVEFOBVTFB MPPTFTUPPMT USFNPST JOTPNOJB BOETFYVBMEZTGVODUJPO 2.2%  JOUFSNFEJBUFU1/2 EBZT  NZPDMPOVT SFMBUJPOTIJQ (Zoloft®) r'FXFSSFQPSUTPGOFPOBUBMTJEFFíFDUTUIBOPUIFSBOUJEFQSFTTBOUT r1PTTJCMFESVHJOUFSBDUJPOT r(FOFSBMMZOPUEFUFDUBCMFJOJOGBOUT unknown)

DRUG CLASS: Tricyclic Antidepressants (TCAs) r.PSFTUVEJFTJOIVNBOQSFHOBODZ JODMVEJOHOFVSPEFWFMPQNFOUBMGPMMPXVQ r'FUBMBOEOFPOBUBMTJEFFíFDUTJODMVEFUBDIZDBSEJBBOEVSJOBSZSFUFOUJPO Desipramine r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r.BUFSOBMTJEFFíFDUTJODMVEFTFEBUJPO XFJHIUHBJO ESZNPVUI DPOTUJQBUJPO BOEPSUIPTUBUJD r%SVHBOEBDUJWFNFUBCPMJUFIBWF r/PSFQPSUFEBEWFSTFFWFOUTJO (Norpramin®) 100-300mg r/PBEWFSTFCFIBWJPSBMDPOTFRVFODFTGPSJOGBOUGPVOE  IZQPUFOTJPOCBTFMJOF&$(SFDPNNFOEFE 1%  JOUFSNFEJBUFU1/2 EBZT   JOGBOUTGPVOE r.BZCFVTFGVMJGTFEBUJPOEFTJSFE r1PTTJCMFESVHJOUFSBDUJPOT r/PUEFUFDUFEJOJOGBOUT

r.PSFTUVEJFTJOIVNBOQSFHOBODZ JODMVEJOHOFVSPEFWFMPQNFOUBMGPMMPXVQ r'FUBMBOEOFPOBUBMTJEFFíFDUTJODMVEFUBDIZDBSEJBBOEVSJOBSZSFUFOUJPO r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r.BUFSOBMTJEFFíFDUTJODMVEFTFEBUJPO XFJHIUHBJO ESZNPVUI DPOTUJQBUJPO BOEPSUIPTUBUJD r%SVHIBTJOUFSNFEJBUFU1/2 ŶEBZ r/PSFQPSUFEBEWFSTFFWFOUTJO (Pamelor®) 50-150mg r/PBEWFSTFCFIBWJPSBMDPOTFRVFODFTGPSJOGBOUGPVOE  IZQPUFOTJPOCBTFMJOF&$(SFDPNNFOEFE 1.5% r/PBDUJWFNFUBCPMJUFT  JOGBOUTGPVOE r.BZCFVTFGVMJGTFEBUJPOEFTJSFE r1PTTJCMFESVHJOUFSBDUJPOT r/PUEFUFDUFEJOJOGBOUT : Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) r/PTZTUFNBUJDTUVEJFTJOIVNBOQSFHOBODZ 40-60mg r#BMBODFEBOUJEFQSFTTBOUNBZCFFíFDUJWFXIFOTFMFDUJWFBHFOUTBSFOPU r.PSQIPMPHJDBOECFIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO Unknown r%SVHIBTTIPSUU1/2 IPVST  r/PEBUBJOCSFBTUGFFEJOHBWBJMBCMF (Cymbalta®) r$PNNPOTJEFFíFDUTJODMVEFOBVTFB ESZNPVUI DPOTUJQBUJPO EJBSSIFB WPNJUJOH EFDSFBTFEBQQFUJUF GBUJHVF r/PBDUJWFNFUBCPMJUFT  EJ[[JOFTT TPNOPMFODF USFNPST TXFBUJOH CMVSSFEWJTJPO BOEJOTPNOJB r/PCFIBWJPSBMTUVEJFTJOIVNBOQSFHOBODZ r%FUFDUBCMFQMBTNBMFWFMTJOTFWFSBM Venlafaxine 75-300mg r#BMBODFEBOUJEFQSFTTBOUNBZCFFíFDUJWFXIFOTFMFDUJWFBHFOUTBSFOPU r#FIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO 6.4% r%SVHBOEBDUJWFNFUBCPMJUFIBWFTIPSUU  IPVST  CSFBTUGFEJOGBOUTXFSFOPU (E exor®) r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r.BUFSOBMTJEFFíFDUTJODMVEFOBVTFB TXFBUJOH ESZNPVUI EJ[[JOFTT JOTPNOJB TPNOPMFODF 1/2  BTTPDJBUFEXJUIBOZBEWFSTF  BOETFYVBMEZTGVODUJPO e ects DRUG CLASS: Other

r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r.BZJODSFBTFSJTLPGNJTDBSSJBHF r%SVHBOEBDUJWFNFUBCPMJUFIBWF r#FIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO r0OFSFQPSUFEDBTFPGTFJ[VSFJOB 300-450mg r)FMQTXJUITNPLJOHDFTTBUJPO OFWFSUFTUFEJOQSFHOBODZ 0.6-2%  JOUFSNFEJBUFU1/2 _EBZ (Wellbutrin®) r.BUFSOBMTJEFFíFDUTJODMVEFEJ[[JOFTT IFBEBDIF ESZNPVUI TXFBUJOH USFNPS BHJUBUJPO JOTPNOJB BOESBSFTFJ[VSFT r1MBTNBMFWFMTVOEFUFDUBCMFJOCSFBTUGFEJOGBOU  NPOUIPME r1PTTJCMFESVHJOUFSBDUJPOT

r/PBEWFSTFNPSQIPMPHJDDPOTFRVFODFTGPSJOGBOUGPVOE r.BZJODSFBTFSJTLPGQSFUFSNCJSUI r%SVHBOEBDUJWFNFUBCPMJUFIBWF r/PQVCMJTIFESFQPSUTPGBEWFSTF Mirtazapine  JOUFSNFEJBUFU1/2 _EBZ (Remeron®) 15-45mg r)FMQTSFTUPSFBQQFUJUFJOXPNFOXIPBSFOPUHBJOJOHXFJHIU r#FIBWJPSBMDPOTFRVFODFTGPSJOGBOUVOLOPXO 1.9% r7FSZMPXQMBTNBMFWFMEFUFDUFEJOPG e ects r-FTTMJLFMZUPFYBDFSCBUFOBVTFBBOEWPNJUJOH r.BUFSOBMTJEFFíFDUTJODMVEFTPNOPMFODF OBVTFB XFJHIUHBJO BOEEJ[[JOFTT  JOGBOUTUFTUFE r0CTFSWFGPSTFEBUJPO

WAPC_Med_Chart.indd 1 4/2/08 4:57:48 PM Notes Breastfeeding and : Breastfeeding and Medications: Assess Severity-Impact On: (1) Dosage information taken from Treatment Guidelines from The Medical Letter®: for Psychiatric Disorders. July 2003; Maternal Considerations Neonatal Considerations - Self Care 1(11): 69-76. - 1. Avoid random switching of medications based 1. Evaluate the infant for risks: Be slightly more - Psycho-social Table based on Wisner et al N Eng J Med, Vol. 347, No. 3, July 18, 2002, pg. 196 and related articles. on data alone. Choose drugs for which published cautious with premature infants or neonates. Be less Risk of Illness > Risk of Treatment data is available, rather than those recently concerned about older infants. Breastfeeding information from Hale, T.W. (2006). Medications and Mothers’ Milk (12th ed.) and Micromedix® Healthcare introduced. Series. 1974-2008. Greenwood Village, Colo: Thomson Healthcare. 2. Inquire about the infant: "MXBZTJORVJSFBCPVUUIF .PTUESVHTBSFRVJUFTBGFJOCSFBTUGFFEJOHNPUIFST JOGBOUTBHF TJ[F BOETUBCJMJUZ5IJTJTQFSIBQTUIF Clinicians may consider initiating treatment with these agents at half of the lowest recommended therapeutic dose. The risk of not breastfeeding and instead using most important criteria to be evaluated prior to Treatment decisions should be based on characteristics and clinical judgment. Recommended dosages can be infant formula is much higher for the infant. using the medication. found in the most recent editions of the ’s Desk Reference and the Drug Information Handbook. 3. If the Relative Infant Dose (RID) is less than 10%, most 3. Infant age: Premature and newborn infants are at (2) A relative infant dose < 10% is generally considered safe to breastfeed; however, all infants must be observed for adverse NFEJDBUJPOTBSFRVJUFTBGFUPVTF5IF3*%PGUIFWBTU somewhat greater risk. Older mature infants can majority of drugs is <1%. metabolize and clear medications much easier. events during maternal drug .

4. Choose drugs with a short half-life, high protein 4. Infant stability:6OTUBCMFJOGBOUTXJUIQPPS(* (3) Reported side effects in breastfeeding infants are based on case reports and case series. binding, low oral availability, or high molecular stability may increase the risk of using medications. weight. * All SSRI antidepressants (citalopram, escitalopram, fluoxetine, paroxetine, ) may be associated with the following 5. Pediatric Approved Drugs: These generally are risks: possible increased risk of ; gestational age decreased by an average of one week; possible increased risk .FEJDBUJPOTVTFEJOUIFmSTUEBZTQPTUQBSUVN less hazardous if long-term history of safety is of persistent pulmonary in the newborn with exposure after 20 weeks gestation, although no teratogenicity generally produce sub-clinical levels in the infant recognized. has been found in prospective, controlled studies or meta-analyses. One case-control study found a possible increased due to the limited volume of milk. risk of anencephaly, craniosynostosis and , and a retrospective prescription events monitoring study found an Adapted from Hale, T.W. (2006). Medications and increased risk of anomalies in general; absolute risks were small. 6. Avoid using medications when possible. Mothers’ Milk (12th ed.). t .FEJDBUJPOTWBSZJOUIFBNPVOUBOERVBMJUZPGEBUBBWBJMBCMFBCPVUFõFDUTJOIVNBOQSFHOBODZ"CFUUFSTUVEJFE drugs, high dose , unusual supplements, etc. medication may have more reported side effects than a less-studied medication because more is known about it, not that are simply not necessary should be avoided. necessarily because it is riskier. t %BUBQSFTFOUFEIFSFBSFCBTFEPOTUVEJFTEVSJOHIVNBOQSFHOBODZ5IF'PPEBOE%SVH"ENJOJTUSBUJPOT1SFHOBODZ Adapted from Hale, T.W. (2006). Medications and Risk Categories, as found in the Physician’s Desk Reference, are based on a combination of animal and human studies. Mothers’ Milk (12th ed.).

General Notes: This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice. This chart was compiled by a multidisciplinary work group of leaders in their respective disciplines including OB/GYN, family practice, psychiatry, , genetics, and , practicing in Wisconsin and representing WAPC and/or the Wisconsin t 3JTLTPGBOUJEFQSFTTBOUTEVSJOHQSFHOBODZBOEMBDUBUJPONVTUCFXFJHIFEBHBJOTUUIFSJTLTPGVOUSFBUFETZNQUPNT Section of ACOG. Treatment needs to be individualized. t .POJUPSGPSEPTFBEKVTUNFOUUISPVHIQSFHOBODZ5IFEPTFPGUIFNFEJDBUJPONBZOFFEUPCFJODSFBTFEUPNBJOUBJO response. t "MMBOUJEFQSFTTBOUT JGBCSVQUMZEJTDPOUJOVFEEVSJOHQSFHOBODZPSBUUIFUJNFPGCJSUI DBOMFBEUPEJTDPOUJOVBUJPOTJEF effects in the fetus or neonate. These signs can include respiratory distress, excessive crying, changes in sleep and McConnell Hall behavioral state, difficulty feeding, increased or decreased tone, hyperreflexia, seizures, or cardiac arrhythmias. 1010 Mound Street | Madison, WI 53715 Discontinuation side effects can be minimized by a partial dose taper during the last month of pregnancy, if the patient Phone: 608-417-6060 | Fax: 608-417-6089 is asymptomatic, with a return to full dose after delivery to prevent postpartum recurrence. t 4FFBMTP"$0(1SBDUJDF#VMMFUJO/P6TFPGQTZDIJBUSJDNFEJDBUJPOTEVSJOHQSFHOBODZBOEMBDUBUJPO "QS Web: www.perinatalweb.org Obstetrics and Gynecology 111(5): 1001-1020. t *GQBUJFOUJTPOPUIFSNFEJDBUJPOT DPOTVMUXJUIBQIBSNBDJTUPSPUIFSBQQSPQSJBUFTQFDJBMJTUTGPSJOUFSBDUJPOJOGPSNBUJPO t 'PSNPSFJOGPSNBUJPOPO443*TBOEDPOHFOJUBMCJSUIEFGFDUTTFF6TFPGTFMFDUJWFTFSPUPOJOSFVQUBLFJOIJCJUPSTJO ©2008 Wisconsin Association for Perinatal Care pregnancy and the risk of birth defects. N Eng J Med, Vol. 356, No. 26, June 28, 2007, pg. 2684-2692 and related articles. Produced in collaboration with the Wisconsin Section of the American College of Obstetricians and Gynecologists 'PSBEEJUJPOBMDPQJFT DPOUBDU8"1$BU   8"1$."QSJM McConnell Hall 1010 Mound Street | Madison, WI 53715 Phone: 608-417-6060 | Fax: 608-417-6089 web: www.perinatalweb.org

WAPC_Med_Chart.indd 2 4/2/08 4:57:49 PM