Ziprasidone and Breastfeeding

Summary of use during lactation

Because there is little published experience with ziprasidone during breastfeeding, other antipsychotic agents may be preferred, especially while nursing a newborn or preterm infant. A safety scoring system finds ziprasidone possible to use cautiously during breastfeeding.[1] Infants breastfed during maternal use of ziprasidone should be monitored for excess sedation, irritability, poor feeding, and extrapyramidal symptoms, such as tremors and abnormal muscle movements.

Drug levels in milk and infant serum

Maternal Levels. In one woman, ziprasidone was started at 9 days postpartum (dosage not stated, but presumably at a low dose and titrated upward). Serum and milk concentrations were obtained 10 minutes before the morning dose every day for 16 days. By day 7 of therapy, the patient was taking 80 mg of ziprasidone twice daily. Ziprasidone was not detectable in milk until day 10 of therapy when the milk concentration was 11 mcg/L; thereafter, the milk concentrations were not quantifiable (<10 mcg/L).[2] Infant Levels. Relevant published information was not found as of the revision date.

Effects in breastfed infants

A woman took ziprasidone 40 mg and citalopram 60 mg daily throughout pregnancy and postpartum. She breastfed extensively, except for occasional formula feedings by others. At 6 months of age, a pediatrician found the infant to be healthy with normal growth and development.[3] Patients enlisted in the National Pregnancy Registry for Atypical Antipsychotics who were taking a second-generation antipsychotic drug while breastfeeding (n = 576) were compared to control breastfeeding patients who were not treated with a second-generation antipsychotic (n = 818). Of the patients who were taking a second-generation antipsychotic drug, 60.4% were on more than one psychotropic. A review of the pediatric medical records, no adverse effects were noted among infants exposed or not exposed to second-generation antipsychotic monotherapy or to polytherapy.[4] The number of women taking ziprasidone was not reported.

Effects on lactation and breastmilk

Prolactin elevation has occurred during ziprasidone treatment,[5-10] and galactorrhea has been reported, often in adolescents.[7-12] However, prolactin elevation might be more transient and less severe than with phenothiazines.[13-15] The prolactin level in a mother with established lactation may not affect her ability to breastfeed. Patients enlisted in the National Pregnancy Registry for Atypical Antipsychotics who were taking a second-generation antipsychotic drug while breastfeeding (n = 576) were compared to control breastfeeding patients who had primarily diagnoses of major depressive disorder and anxiety disorders, most often treated with SSRI or SNRI antidepressants, but not with a second-generation antipsychotic (n = 818). Among women on a second-generation antipsychotic, 60.4% were on more than one psychotropic compared with 24.4% among women in the control group. Of the women on a second-generation antipsychotic, 59.3% reported “ever breastfeeding” compared to 88.2% of women in the control group. At 3 months postpartum, 23% of women on a second-generation antipsychotic were exclusively breastfeeding compared to 47% of women in the control group.[4] The number of women taking ziprasidone was not reported.

Alternative drugs to consider

Haloperidol, Olanzapine, Quetiapine, Risperidone

References

1. Uguz F. A new safety scoring system for the use of psychotropic drugs during lactation. Am J Ther 2021;28:e118-e26.30601177 PubMed
2. Schlotterbeck P, Saur R, Hiemke C, et al. Low concentration of ziprasidone in human milk: A case report. Int J Neuropsychopharmacol 2009;12:437-8.19203410 PubMed
3. Werremeyer A. Ziprasidone and citalopram use in pregnancy and lactation in a woman with psychotic depression. Am J Psychiatry 2009;166:1298.19884241 PubMed
4. Viguera AC, Vanderkruik R, Gaccione P, et al. Breastfeeding practices among women taking second-generation antipsychotics: Findings from the National Pregnancy Registry for Atypical Antipsychotics. Arch Womens Ment Health 2022;25:511-6.34318375 PubMed
5. Ginsberg DL. Ziprasidone-induced galactorrhea. Prim Psychiatry 2003;10:22-3.
6. Ginsberg DL. Ziprasidone-induced hyperprolactinemia. Prim Psychiatry 2004;11:26-7.
7. Jordan MP. Ziprasidone-associated galactorrhea in a female teenager. J Am Acad Child Adolesc Psychiatry 2003;42:4-5.12500070 PubMed
8. Kopecek M, Bares M, Mohr P. Ziprasidone-induced galactorrhea: A case report. Neuro Endocrinol Lett 2005;26:69-70.15726024 PubMed
9. Ramadan M, Khan A, Preskorn S. D2-blockade and possible ziprasidone-induced galactorrhea. Int Clin Psychopharmacol 2005;20:113-4.15729088 PubMed
10. Saldaña SN, Delgado SV. Ziprasidone-associated galactorrhea in an adolescent female. J Child Adolesc Psychopharmacol 2007;17:259-60.17489723 PubMed
11. Myers WT. A lacting adolescent on atypical antipsychotics: A case report of an emerging challenge. J Investig Med 2014;62:485. doi:10.2310/JIM.0000000000000055 PubMed
12. Raza S, Haq F. Ziprasidone-induced galactorrhea in an adolescent female: A case report. Prim Care Companion J Clin Psych 2010;12:PCC.09l00855. doi:10.4088/PCC.09l00855gry
13. Goodnick PJ, Rodríguez L, Santana O. Antipsychotics: Impact on prolactin levels. Expert Opin Pharmacother 2002;3:1381-91.12387684 PubMed
14. Maguire GA. Prolactin elevation with antipsychotic medications: Mechanisms of action and clinical consequences. J Clin Psychiatry 2002;63 (Suppl 4):56-62.11913677 PubMed
15. Weiden PJ, Daniel DG, Simpson G, et al. Improvement in indices of health status in outpatients with schizophrenia switched to ziprasidone. J Clin Psychopharmacol 2003;23:595-600.14624190 PubMed