Can a 9-week postpartum patient with severe mania take lithium (lithium) and Zyprexa (olanzapine) while breastfeeding?

Treatment of Severe Mania While Breastfeeding: Lithium and Olanzapine

In a severely manic postpartum patient at 9 weeks, olanzapine (Zyprexa) is acceptable for use during breastfeeding with close infant monitoring, while lithium should be avoided and replaced with an alternative mood stabilizer. 1, 2, 3

Olanzapine (Zyprexa) During Breastfeeding

Safety Profile

• Olanzapine is compatible with breastfeeding based on favorable pharmacokinetic data and clinical experience 3, 4
• The relative infant dose (RID) is approximately 0.3%, well below the 10% threshold generally considered safe for breastfeeding 4
• The milk-plasma ratio is approximately 0.5, indicating limited transfer into breast milk 4
• Olanzapine concentrations in infant plasma are typically below detectable limits (<5 ng/mL) even with maternal doses up to 15 mg daily 4

Infant Monitoring Requirements

• Monitor the infant closely for: excess sedation, irritability, poor feeding, and extrapyramidal symptoms (tremors and abnormal muscle movements) 1
• These adverse effects have been reported in some breastfed infants, though serious complications are rare 1, 3
• The FDA label specifically warns about these potential effects and mandates monitoring 1

Clinical Context

• Olanzapine has been studied in breastfeeding mothers with postpartum psychosis, demonstrating rapid improvement in maternal psychopathology without observed infant adverse effects in case reports 4
• The drug is categorized as "acceptable for breastfeeding" based on available safety data 3

Lithium During Breastfeeding

Strong Contraindication

• Breastfeeding should be avoided while using lithium 2, 5
• Lithium is generally not recommended during lactation due to significant infant exposure and toxicity risk 2
• Unlike olanzapine, lithium has a high milk-plasma ratio and substantial transfer into breast milk 2

Neonatal Risks

• Lithium exposure through breast milk can cause neonatal cyanosis, lethargy, flaccidity, and non-toxic goiter 6
• These risks are clinically significant and outweigh the benefits of breastfeeding while on lithium 2

Alternative Mood Stabilizers for Severe Mania

Preferred Options

• Carbamazepine and sodium valproate (valproic acid) are generally better tolerated by breastfed infants than lithium 2
• Anticonvulsant mood stabilizers are compatible with breastfeeding and can be substituted for lithium 5
• Antipsychotic drugs (including olanzapine) can effectively substitute for mood stabilizers in the acute management of severe mania during breastfeeding 5

Lamotrigine Consideration

• Data on lamotrigine during breastfeeding remain sparse, limiting firm recommendations 2
• However, lamotrigine is generally considered safer than lithium or valproate in the postpartum period 5

Clinical Algorithm for This Patient

Immediate Management

1. Discontinue lithium immediately given the breastfeeding context 2
2. Continue or initiate olanzapine at an effective dose for severe mania (typically 10-20 mg daily) 1, 4
3. Implement close infant monitoring for sedation, feeding difficulties, irritability, and movement abnormalities 1

Mood Stabilizer Substitution

• Add carbamazepine or valproate as lithium replacement if additional mood stabilization is needed beyond olanzapine monotherapy 2, 5
• Consider lamotrigine as an alternative, acknowledging limited breastfeeding data 2

Risk-Benefit Context

• Untreated severe mania poses substantial risks including harm to mother and infant, impaired maternal-infant bonding, and potential for psychotic symptoms 6, 5
• The risks of untreated maternal psychiatric illness during the postpartum period often outweigh the relatively low risks of medication exposure through breast milk 5
• Severe mania requires immediate intervention, and the pregnant/postpartum manic patient presents a therapeutic challenge that necessitates pharmacologic treatment 6

Common Pitfalls to Avoid

• Do not continue lithium during breastfeeding based on outdated practices or incomplete risk assessment 2
• Do not delay treatment of severe mania due to breastfeeding concerns when safer alternatives (olanzapine) are available 5
• Do not fail to monitor the infant when using olanzapine, as individual infant sensitivity varies 1
• Do not assume all mood stabilizers have equivalent breastfeeding safety profiles—lithium is distinctly more problematic than alternatives 2, 5