What medications can be prescribed to suppress lactation (milk production)?

Medications for Lactation Suppression

Cabergoline is the first-line pharmacological treatment for lactation suppression, with a recommended dose of 1 mg as a single oral dose or 0.25 mg twice daily for 2 days. 1

First-Line Options

Cabergoline

• Dosing: 1 mg as a single oral dose OR 0.25 mg twice daily for 2 days
• Efficacy: Superior success rate (78%) for complete lactation inhibition by day 7 1
• Mechanism: Dopamine receptor agonist with high specificity for D2 receptors, potently inhibits prolactin secretion 2
• Advantages:
  • Long-acting (effects last up to 21 days after a single dose)
  • Better tolerated than bromocriptine
  • Lower incidence of rebound lactation
  • Simple administration schedule

Bromocriptine

• Dosing: 2.5 mg twice daily for 14 days
• Efficacy: Effective but inferior to cabergoline
• Disadvantages:
  • Higher incidence of adverse effects than cabergoline
  • More frequent dosing required (twice daily for 14 days vs. single dose)
  • Higher risk of rebound lactation in the third postpartum week 2
  • Associated with risk of serious thromboembolic events in postpartum women 2

Alternative Options

Pyridoxine (Vitamin B6)

• Dosing: 200 mg three times daily for 7 days
• Efficacy: Less effective than cabergoline (35% vs 78% success rate) 1
• Advantages: Fewer adverse effects than dopamine agonists
• Best use: Consider in women with contraindications to cabergoline, such as:
  • Hypertensive disorders
  • Fibrotic diseases
  • Cardiac diseases
  • Hepatic diseases 1

Contraindications and Precautions

Cabergoline

• Contraindications:
  • Hypertensive disorders
  • Fibrotic diseases
  • Cardiac diseases
  • Hepatic impairment 1, 3
  • Concurrent use with D2-antagonists (phenothiazines, butyrophenones, thioxanthenes, metoclopramide) 3

Bromocriptine

• Contraindications:
  • History of thromboembolic events
  • Hypertension
  • Coronary artery disease
  • Peripheral vascular disease 4

Adverse Effects

Cabergoline

• Most common: dizziness, headache, nausea 5
• Generally mild and self-limited
• Lower incidence compared to bromocriptine 4

Bromocriptine

• Higher incidence of nausea, vomiting, headache, dizziness 4
• Up to 12% of patients cannot tolerate therapeutic doses 4
• Risk of serious thromboembolic events in postpartum women 2

Clinical Algorithm for Lactation Suppression

1. Assess patient for contraindications to dopamine agonists:

   • If no contraindications → Cabergoline 1 mg single dose
   • If contraindicated → Pyridoxine 200 mg three times daily for 7 days

2. Monitor for effectiveness:

   • Assess breast engorgement, pain, and milk leakage
   • Complete success defined as absence of engorgement and pain by day 7

3. If treatment failure with pyridoxine:

   • Consider risk-benefit of adding cabergoline if no absolute contraindications
   • Approximately 21% of pyridoxine patients may require addition of cabergoline 1

4. Monitor for adverse effects:

   • Cabergoline: dizziness, headache, nausea (usually mild)
   • Pyridoxine: generally well-tolerated with minimal adverse effects

Important Considerations

• Cabergoline has largely replaced bromocriptine as the preferred agent due to better efficacy, simpler dosing, and improved side effect profile 4
• Non-pharmacological approaches should be considered when medications are contraindicated
• Untreated breast engorgement can lead to mastitis and fever, which occurred in approximately 5-9% of women regardless of treatment 1
• The decision to suppress lactation should be made with full understanding of the benefits of breastfeeding when possible