What medication adjustments are recommended for a 26-year-old female with uncontrolled depression, currently taking fluoxetine (Prozac) 80 mg daily, trazodone 150 mg nightly, buspirone (BuSpar) 15 mg three times daily as needed, and brexpiprazole (Rexulti) 0.5 mg daily, who has just become pregnant?

From the Guidelines

The patient should consult with her psychiatrist and obstetrician immediately to develop a pregnancy-safe medication plan, prioritizing the continuation of Fluoxetine (Prozac) at the lowest effective dose due to its relatively safer profile during pregnancy, as suggested by the American Academy of Pediatrics 1. When considering medication adjustments during pregnancy, it's crucial to weigh the risks and benefits, especially for medications with limited safety data like Rexulti (brexpiprazole), Trazodone, and BuSpar (buspirone). Key considerations include:

• The potential for neonatal drug withdrawal symptoms, such as continuous crying, irritability, and jitteriness, associated with third-trimester use of SSRIs like Fluoxetine 1.
• The importance of maintaining mental health stability, as untreated severe depression poses significant risks to both mother and baby.
• The need for gradual medication changes to avoid discontinuation symptoms.
• The potential benefits of non-pharmacological approaches like psychotherapy as adjunctive treatment.
• Regular monitoring throughout pregnancy, with dose adjustments as needed due to pregnancy-related physiological changes that can affect medication metabolism.

Given the information from the American Academy of Pediatrics 1, the primary concern is balancing the risks associated with medication use during pregnancy against the need to maintain the patient's mental health. The patient's current regimen includes:

• Prozac 80 mg daily, which is considered relatively safer during pregnancy.
• Trazodone 150 mg nightly, with limited pregnancy safety data.
• BuSpar 15 mg 3 times daily as needed, also with limited pregnancy safety data.
• Rexulti 0.5 mg daily, for which there is limited safety data in pregnancy.

Continuing Fluoxetine at the lowest effective dose is recommended, while the use of Trazodone, BuSpar, and Rexulti should be carefully evaluated for risk-benefit, considering the potential for adverse effects on the fetus and the importance of maintaining the patient's mental health stability 1.

From the FDA Drug Label

Brexpiprazole tablets may harm your unborn baby. Taking brexpiprazole tablets during your third trimester of pregnancy may cause your baby to have abnormal muscle movements or withdrawal symptoms after birth.

PregnancyPregnancy Category CIn embryo–fetal development studies in rats and rabbits, there was no evidence of teratogenicity following administration of up to 12.5 and 15 mg/kg/day, respectively (1.5 and 3. 6 times, respectively, the MRHD of 80 mg on a mg/m2 basis) throughout organogenesis. However, in rat reproduction studies, an increase in stillborn pups, a decrease in pup weight, and an increase in pup deaths during the first 7 days postpartum occurred following maternal exposure to 12 mg/kg/day (1.5 times the MRHD on a mg/m2 basis) during gestation or 7.5 mg/kg/day (0. 9 times the MRHD on a mg/m2 basis) during gestation and lactation.

The patient should discuss the potential risks and benefits of continuing her current medications, including Prozac and Rexulti, with her healthcare provider. The provider should carefully consider the potential risks of brexpiprazole and fluoxetine to the fetus, including abnormal muscle movements or withdrawal symptoms after birth, and stillborn pups, decreased pup weight, and increased pup deaths.

• The patient's healthcare provider may recommend alternative treatments or adjusting the current medication regimen to minimize potential risks to the fetus.
• It is essential to weigh the potential benefits of continuing the medications against the potential risks to the fetus.
• The healthcare provider should closely monitor the patient and the fetus throughout the pregnancy 2 3.

From the Research

Medication Use During Pregnancy

The patient is currently taking Prozac (fluoxetine) 80 mg daily, trazodone 150 mg nightly, BuSpar (buspirone) 15 mg 3 times daily as needed, and Rexulti (brexpiprazole) 0.5 mg daily. Considering the patient's pregnancy, it is essential to evaluate the safety of these medications.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Fluoxetine (Prozac) has been associated with an increased risk of major congenital malformations, congenital heart defects, preterm birth, neonatal adaptation symptoms, and persistent pulmonary hypertension of the newborn 4, 5, 6.
• The use of SSRIs during pregnancy should be carefully considered, and alternative treatments should be explored 4, 5.

Other Medications

• Trazodone has not been extensively studied in pregnancy, but it is generally considered to be relatively safe 7.
• Buspirone has limited data on its use during pregnancy, but it is often used as an alternative to benzodiazepines 7.
• Brexpiprazole (Rexulti) has limited data on its use during pregnancy, and its safety has not been well established 7.

Recommendations

• The patient should discuss the risks and benefits of continuing or modifying her medication regimen with her healthcare provider 4, 5, 7.
• Alternative treatments, such as psychotherapy or other medications with a more established safety profile during pregnancy, should be considered 4, 5, 7.
• The patient's medication regimen should be closely monitored, and adjustments should be made as necessary to minimize potential risks to the fetus 4, 5, 7.