What are the safest antipsychotic medications for use during pregnancy?

From the Guidelines

The safest antipsychotic for pregnancy is not definitively established, but second-generation antipsychotics like quetiapine and olanzapine are generally considered relatively safer options when treatment is necessary, as indicated by the most recent evidence 1. The decision to use antipsychotics during pregnancy should always involve careful consideration of the risks versus benefits, as untreated severe mental illness can pose significant risks to both mother and baby. Some key points to consider when evaluating the safety of antipsychotics during pregnancy include:

• The potential risks of congenital defects and other adverse outcomes associated with antipsychotic use during pregnancy, such as the increased risk of ventricular and septal defects with olanzapine 1
• The importance of using the lowest effective dose of antipsychotic medication to minimize potential risks to the fetus
• The need for close monitoring by both psychiatric and obstetric providers, with particular attention to maternal weight, blood glucose, and fetal growth
• The potential benefits of antipsychotic treatment in reducing symptoms of mental illness and improving outcomes for both mother and baby It is also important to note that the evidence on the safety of antipsychotics during pregnancy is not always consistent, and different studies may have different findings. However, based on the most recent and highest-quality evidence, quetiapine and olanzapine are generally considered to be relatively safer options for use during pregnancy, although the decision to use these medications should always be made on a case-by-case basis and in consultation with a healthcare provider 1. Additionally, other factors such as the severity of the mental illness, the patient's medical history, and the potential risks and benefits of treatment should be taken into account when making decisions about antipsychotic use during pregnancy. Overall, the safest approach is to use antipsychotics during pregnancy only when necessary, and to carefully weigh the potential risks and benefits of treatment in each individual case.

From the FDA Drug Label

USE IN SPECIFIC POPULATIONS SECTION 8. 1 Pregnancy Pregnancy Category C: Risk Summary There are no adequate and well-controlled studies of quetiapine use in pregnant women.

When using ZYPREXA and fluoxetine in combination, also refer to the Use in Specific Populations section of the package insert for Symbyax. 8. 1 Pregnancy Pregnancy Exposure Registry There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to atypical antipsychotics, including ZYPREXA, during pregnancy.

The safest antipsychotic for pregnancy cannot be determined from the provided information. Key points to consider:

• Both quetiapine and olanzapine have limited data on their use during pregnancy.
• Extrapyramidal and/or withdrawal symptoms have been reported in neonates exposed to these antipsychotics during the third trimester.
• Fetal toxicities were observed in animal studies with both quetiapine and olanzapine.
• The FDA labels do not provide a clear comparison of the safety of these antipsychotics during pregnancy. Given the lack of direct and clear information, no conclusion can be drawn about the safest antipsychotic for pregnancy 2 3.

From the Research

Safety of Antipsychotics During Pregnancy

The safety of antipsychotics during pregnancy is a concern due to the potential risks to the fetus and the mother. According to 4, there is no definitive association between the use of antipsychotics during pregnancy and an increased risk of birth defects or other adverse outcomes. However, the study notes that there is a lack of large, well-designed, prospective comparative studies.

Types of Antipsychotics and Their Safety

Different types of antipsychotics have varying levels of safety during pregnancy. The following are some key points to consider:

• First-generation antipsychotics (e.g., promethazine, chlorpromazine, prochlorperazine, haloperidol, perphenazine, trifluoperazine, loxapine, thioridazine, flupenthixol, fluphenazine) do not appear to cause consistent, congenital harm to the fetus 4.
• Second-generation antipsychotics (e.g., clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone) have been associated with some risks, such as gestational diabetes 5, 6, 7, 8.
• Risperidone may be associated with an increased risk of malformations, and its use during pregnancy is not recommended as a first-line agent 5.
• Olanzapine, quetiapine, and clozapine have been linked to an increased risk of gestational diabetes and fetal growth disturbances 7, 8.

Key Findings

Some key findings from the studies include:

• Women who require antipsychotic treatment during pregnancy should continue the medication that has been most effective for symptom remission 5.
• Antipsychotic use during pregnancy may be associated with an increased risk of gestational diabetes, particularly with olanzapine, quetiapine, and clozapine 7, 8.
• Enhanced metabolic monitoring should be considered for pregnant women using these drugs 8.
• The majority of studies do not show associations with major malformations and antipsychotic use in pregnancy, except for risperidone 5.

Considerations for Pregnant Women

Pregnant women who require antipsychotic treatment should discuss the risks and benefits of pharmacotherapy with their physician, considering the potential risks and benefits of each medication 4. The decision to continue or discontinue antipsychotic treatment during pregnancy should be made on a case-by-case basis, taking into account the individual woman's needs and medical history.