Are anxiolytics (anti-anxiety medications) safe during pregnancy?

From the Guidelines

Managing anxiety during pregnancy requires careful consideration of medication safety, and selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft) and fluoxetine (Prozac) are generally considered safer options, as evidenced by recent studies 1.

Key Considerations

• Typical starting doses are 25-50mg daily for sertraline or 10-20mg daily for fluoxetine, with adjustments made under medical supervision.
• Benzodiazepines like lorazepam should be avoided when possible, especially in the first trimester, but may be used briefly for severe symptoms at the lowest effective dose.
• Non-medication approaches should be tried first, including cognitive behavioral therapy, mindfulness practices, regular exercise, adequate sleep, and pregnancy-safe relaxation techniques.

Decision-Making

The decision to use medication during pregnancy involves weighing the risks of untreated anxiety against potential medication effects, as noted in a study published in the Journal of Child Psychology and Psychiatry and Allied Disciplines 1.

Important Factors

• Untreated severe anxiety can negatively impact both maternal health and fetal development through stress hormones and behavioral changes.
• Always consult with both an obstetrician and mental health provider before starting, stopping, or changing any medication during pregnancy, as individual circumstances vary significantly, and consider the potential effects of prenatal antidepressant exposure on offspring neurodevelopmental problems, as discussed in a review of maternal antidepressant use during pregnancy 1.

Additional Guidance

Further research is needed to fully understand the implications of maternal antidepressant use during pregnancy, including the potential consequences of increased fetal exposure to norepinephrine and the role of timing of exposure, as highlighted in a study on future research directions 1.

Final Recommendation

In conclusion, while there are potential risks associated with anti-anxiety medication use during pregnancy, the benefits of treatment may outweigh these risks for some women, and a stepped approach to treatment, including non-medication approaches and careful consideration of medication safety, is recommended, as suggested by experts in the field 1.

From the FDA Drug Label

Pregnancy Category C In 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. Prozac should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus Infants exposed to SSRIs in late pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN)

• Key points:
  • The drug label indicates that fluoxetine is a Pregnancy Category C medication.
  • There is no evidence of teratogenicity in rats and rabbits, but there are potential risks to the fetus, including stillborn pups, decrease in pup weight, and increase in pup deaths.
  • SSRIs may increase the risk of persistent pulmonary hypertension of the newborn (PPHN).
• Clinical decision:
  • Fluoxetine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
  • Physicians should carefully consider both the potential risks and benefits of treatment when prescribing fluoxetine to pregnant women, especially during the third trimester 2.

From the Research

Anti-Anxiety Medications and Pregnancy

• The safety of anti-anxiety medications during pregnancy is a concern, as some studies suggest that these medications can have adverse effects on the fetus 3.
• However, other studies suggest that the risks of not treating anxiety during pregnancy may outweigh the potential risks of medication 4.
• Benzodiazepines, a type of anti-anxiety medication, have been shown to be effective in treating generalized anxiety disorder, but their use during pregnancy should be approached with caution 5, 6.
• Alternative medications, such as selective serotonin reuptake inhibitors (SSRIs), may be considered for treating anxiety during pregnancy, but their safety and efficacy should be carefully evaluated 7.
• It is essential to weigh the potential benefits and risks of anti-anxiety medications during pregnancy and to consider alternative treatments, such as therapy or lifestyle changes, under the guidance of a healthcare professional 3, 4.