Amitriptyline (Tryptomer) Use in Postpartum Breastfeeding Women
Amitriptyline is a reasonable choice for postpartum depression in breastfeeding women, as it is not detectable in quantifiable amounts in nursing infants and no adverse effects have been reported in the available literature. 1
Evidence for Safety During Breastfeeding
Amitriptyline is excreted into breast milk but has an excellent safety profile during lactation. 2 In one documented case, a mother receiving 100 mg/day had breast milk levels of 135-151 ng/mL, but no trace of the drug was detected in the infant's serum. 2
Amitriptyline is among the preferred antidepressants for breastfeeding women because it was not found in quantifiable amounts in nursing infants across multiple studies, with no adverse effects reported. 1
The drug transfers at low levels into breast milk and is typically undetectable in infant serum, making it one of the safer tricyclic antidepressants during lactation. 1
Clinical Management Algorithm
Step 1: Assess Severity of Depression
- Determine if pharmacological treatment is essential, as untreated postpartum depression carries significant risks including negative impact on infant emotional development and, in severe cases, risk of suicide or infanticide. 3
Step 2: Dosing Strategy
- Use the lowest effective therapeutic dose, typically starting at 25-50 mg at bedtime and titrating upward as needed. 2
- The FDA label indicates maximum recommended doses up to 150 mg/day for depression. 2
Step 3: Infant Monitoring Protocol
- Monitor the infant closely for sedation, poor feeding, irritability, or developmental delays, particularly in the first 10 weeks of life when infants are at highest theoretical risk. 1
- Ensure the infant is gaining weight appropriately and meeting developmental milestones. 4
- Newborns and premature infants require especially careful observation. 5
Step 4: Timing Considerations
- Consider timing breastfeeding to avoid peak milk concentrations of the medication when feasible, though this is less critical with amitriptyline given its minimal infant serum detection. 5
Important Caveats and Contraindications
The FDA requires a decision about whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother, due to potential for serious adverse reactions. 2 However, the clinical literature strongly supports continuing both medication and breastfeeding given the favorable safety data. 1
Amitriptyline should be used with caution in mothers with cardiovascular disorders, history of seizures, urinary retention, or angle-closure glaucoma, as these conditions may be exacerbated. 2
The drug may enhance the response to alcohol and CNS depressants, which is particularly relevant in the postpartum period. 2
Infants older than 10 weeks are at particularly low risk for adverse effects from tricyclic antidepressants, with no evidence of drug accumulation. 1
Comparison to Alternative Agents
While sertraline is often considered one of the safest antidepressants during breastfeeding with extensive safety data, amitriptyline has comparable or superior safety based on undetectable infant serum levels. 5, 1
Amitriptyline, nortriptyline, desipramine, clomipramine, dothiepin, and sertraline are collectively considered drugs of choice for breastfeeding women based on lack of quantifiable amounts in nursing infants. 1
Avoid doxepin and fluoxetine as first-line agents, as adverse effects have been described in young infants exposed through breast milk. 1
Risk-Benefit Framework
The degree of severity of maternal depression is the most relevant parameter for deciding to initiate pharmacological treatment during breastfeeding. 3
Untreated depression poses significant risks: mothers with depression negatively impact their children's emotional development, and severe depression may lead to suicide attempts or infanticide. 3
The benefits of treating maternal depression typically outweigh the minimal risks of infant exposure to amitriptyline through breast milk. 3, 1