What medications can help decrease milk supply?

Medications to Decrease Milk Supply

Cabergoline is the most effective medication for decreasing milk supply, with a single 1mg dose achieving complete lactation inhibition in 90.2% of women. 1

First-Line Option: Cabergoline

• Cabergoline is a dopamine agonist that effectively inhibits prolactin secretion, which is necessary for milk production 2
• Dosing options:
  • For prevention of lactation: Single 1mg oral dose within 24 hours after delivery 1
  • For suppression of established lactation: 0.25mg twice daily for 2 days 2
• Cabergoline has been shown to be superior to other options with:
  • Complete inhibition of lactation in 90.2% of women with a single 1mg dose 1
  • Significantly lower incidence of rebound lactation compared to alternatives 2
  • Longer-lasting effect with prolactin-lowering impact evident up to 14-21 days after a single dose 2

Second-Line Option: Clonidine

• Clonidine may reduce prolactin secretion and therefore could reduce milk production in the early postpartum period 3
• It is minimally secreted into milk with no reports of neonatal toxicity during breastfeeding 3
• Consider when cabergoline is contraindicated 3

Third-Line Option: Pyridoxine (Vitamin B6)

• Can be used as an alternative when cabergoline is contraindicated 4
• Dosing: 200mg three times daily for 7 days 4
• Less effective than cabergoline (35% vs 78% success rate at day 7) but has fewer adverse effects 4
• May be appropriate for women with hypertensive disorders, fibrotic, cardiac, or hepatic diseases where cabergoline is contraindicated 4

Fourth-Line Option: Atropine

• A tertiary amine that may inhibit lactation 3
• Found in trace concentrations in breast milk 3
• Compatible with breastfeeding but may have antimuscarinic effects in the infant 3

Contraindications and Precautions

• Cabergoline:
  • Contraindicated in patients with hypertensive disorders, fibrotic, cardiac, or hepatic diseases 4
  • Should not be given to women who are planning to breastfeed 5
  • May cause orthostatic hypotension, especially at initial doses higher than 1mg 5
• Bromocriptine (older alternative):
  • Associated with increased risk of serious thromboembolic events in the puerperium 2
  • Higher incidence of adverse effects compared to cabergoline 6

Adverse Effects

• Cabergoline:
  • Generally better tolerated than bromocriptine 6, 2
  • Common side effects include nausea, vomiting, headache, and dizziness, but these are typically mild and transient 2
  • Higher rate of adverse effects than pyridoxine (31% vs 9%) but all effects were mild 4
• Clonidine:
  • No reports of neonatal toxicity during breastfeeding 3
• Pyridoxine:
  • Fewer adverse effects than cabergoline (9% vs 31%) 4
  • No major adverse effects documented 4

Monitoring and Follow-up

• Monitor for breast engorgement, pain, and milk leakage 4
• Watch for signs of mastitis (fever, breast pain, redness) 4
• For cabergoline, be alert for orthostatic hypotension, especially with initial doses 5
• Patients taking cabergoline should be advised to follow "missed pill rules" if they are also taking oral hormonal contraceptives 3

Clinical Pearls

• Cabergoline has largely replaced bromocriptine as the first-line agent due to better efficacy and tolerability profile 6, 2
• A single dose of cabergoline is as effective as a 14-day course of bromocriptine, making it more convenient 7
• Consider pyridoxine in women with contraindications to cabergoline, as it successfully inhibits lactation in approximately 67% of patients 4
• Avoid metoclopramide and domperidone as they are galactagogues that may increase milk supply rather than decrease it 3