Medications in Pregnancy

I. See Also http://www.fpnotebook.com/ob/Pharm/MdctnsInPrgncy.htm A. Analgesic Medications in Pregnancy B. Antibiotics in Pregnancy C. Cardiovascular Medications in Pregnancy D. Cold Preparations in Pregnancy E. Endocrine Medications in Pregnancy F. Fetal Hydantoin Syndrome G. Gastrointestinal Medications in Pregnancy H. Hematology Medications in Pregnancy I. Lactation Safe Medications J. Neuro-Psychiatric Medications in Pregnancy K. Respiratory Medications in Pregnancy L. Teratogen Exposure II. General Recommendations . Avoid medications if possible in first trimester A. Limit use to safe, short-acting, non-combination drugs B. Topical medications are preferred over systemic agents C. Use the lowest effective dose of a medication III. Class A . No risk in controlled human studies A. Examples 1. Acetaminophen (Tylenol) 2. Pyridoxine (Vitamin B6) IV. Class B . No risk in controlled animal studies A. Examples 1. Amoxicillin 2. Cephalosporin antibiotics V. Class C . Small risk in controlled animal studies A. Examples 1. Codeine 2. Dicloxacillin VI. Class D . Strong evidence of risk to the human fetus A. Examples 1. Coumadin 2. Valium VII. Class X (Never to be used in Pregnancy) . Very high risk to the human fetus A. Examples 1. Xanax 2. Accutane VIII. Resources . FDA Hotline regarding Teratogen Exposure information 1. Phone: 1-800-532-3749 IX. References . Briggs (1998) Drugs in Pregnancy and Lactation, 5th ed A. Larimore (2000) Prim Care 27(1):35-53 I. See Also

A. II. . A. B. C. 1. III. . A. B. C. D. E. F. IV. . A. B. C. V. . 1. 2. 3. A. 1. 2. 3. 4. 5. 6. a. b. B. 1. 2. 3. VI. . 1. 2. A. 1. 2. 3. VII. . 1. . a. b. 2.

Medications in Pregnancy General Assess benefit versus risk for medication Choose medications safe for Lactation Use medications with short half lives Patient Education Ask physician or pharmacist before new medication Management: Antibiotics considered safe in Lactation Penicillin Antibiotics Cephalosporin Antibiotics Erythromycin (concentrated in human milk, increased risk of pyloric stenosis) Clindamycin Aminoglycosides Fluoroquinolones (considered safe by AAP, risk of arthropathy) Sulfa antibiotics (avoid in first month of life due toHyperbilirubinemia risk) Management: Analgesics considered safe in Lactation Acetaminophen (Tylenol) Aspirin (AAP recommends use with caution) Codeine Ibuprofen Management: Anticonvulsants in Lactation Very low Breast Milk concentrations (highly bound) Phenytoin (Dilantin) Tiagabine (Gabitril) Valproate Low to moderate Breast Milk concentrations Carbamazepine Phenobarbital Lamotrigine Topiramate (Topamax) Zonegran Primidone (metabolized in part to phenobarbital) Risk of infant Sedation AAP recommends using with caution High Breast Milk concentration (minimally bound) Gabapentin Levetiracetam (Keppra) Ethosuximide (AAP: Compatible with Lactation) Management: Antidepressants considered potentially safe in Lactation AAP recommends use with caution Unknown longterm effect Use if benefits outweigh risk Preferred agents Fluoxetine (risk of colic, irritability, sleep disorders, feeding problems, decreased growth) Sertraline Paroxetine Management: Cardiovascular Medications in Lactation Antihypertensives safe in Lactation ACE Inhibitors (avoid in first 6 weeks, risk of renal toxicity in premature infants) Captopril Enalapril No data on Lisinopril Hydrochlorothiazide (may decrease milk production)

3. A. 1. 2. 3. VIII. . A. B. C. IX. . A. 1. 2. 3. 4. 5. B. 1. 2. 3. 4. 5. 6. X. . 1. 2. A. 1. 2. 3. 4. 5. 6. 7. B. 1. 2. 3. 4. 5. C. 1. 2. 3. D. 1. 2. 3. 4. 5. 6.

Methyldopa Miscellaneous drugs considered safe in Lactation Digoxin Coumadin Heparin (not excreted into Breast Milk) Management: Assorted medications considered safe in Lactation Magnesium Sulfate RhoGAM RubellaVaccine Oral Contraceptives (avoid until Breast Feeding is established, after 60-90 days) Management: Herbs and Teas considered safe in Lactation Avoid Caffeine more than 2 beverages per day Herbs Chamomile Garlic Ginger Ginseng Valerian Teas Chicory Orange Spice Peppermint Raspberry Red bush tea Rose hips Management: Contraindicated Drugs in Lactation Medications that decrease milk production Bromocriptine Diuretics Chemotherapeutic Medications Cyclophosphamide Cyclosporine Doxorubicin Methotrexate Gold salts Propylthiouracil Methimazole Radioactive Chemicals used in Nuclear Medicine Gallium-67 (in Breast Milk up to 14 days) Indium-111 (in Breast Milk up to 20 hours) Iodine 131 (in Breast Milk up to 14 days) Radioactive Sodium (in Breast Milk up to 96 hours) Technetium-99m (in Breast Milk up to 3 days) Cardiovascular medications to avoid in Lactation Avoid Atenolol and use other Beta Blockers only with caution Avoid Acebutolol Avoid Amiodarone Miscellaneous Medications Dextroamphetamine Ergotamine Lithium Metronidazole Chloramphenicol Potassium iodide

7. E. 1. 2. 3. 4. 5. 6. XI. . 1. XII. . A. B. C. D. E.

Phenindione (anticoagulant) Drugs of Abuse Amphetamine Cocaine Heroin Marijuana Nicotine Phencyclidine Resources LactMed http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT References (2000) Harriet Lane Handbook, Mosby, p. 913 Hale (2006) Medications and Mother's Milk, Hale Publishing Briggs (1998) Drugs in Pregnancy and Lactation, 5th ed Middleton (1998) Allergy, Mosby, p. 941 (1994) Pediatrics 93:137-50 Howard (2001) Pediatr Clin North Am 48(2):485-504

I. See Also A. Asthma in Pregnancy B. Medications in Pregnancy II. Class B: No risk in controlled animal studies . Cromolyn Sodium (Intal) A. Ipratropium Bromide (Atrovent) B. Terbutaline (Brethine, Brethaire) C. Montelukast (Singulair) - not in Briggs (1998) D. Nedocromil (Tilade) - not in Briggs (1998) E. Zafirlukast (Accolate) - not in Briggs (1998) III. Class C: Small risk in controlled animal studies . Albuterol (Proventil, Ventolin) A. Beclomethasone (Vanceril, Beclovent) 1. Most used Inhaled Corticosteroid in pregnancy B. Budesonide (Pulmicort) - not in Briggs (1998) C. Flunisolide (AeroBid) - not in Briggs (1998) D. Fluticasone (Flovent) - not in Briggs (1998) E. Inhaled Triamcinolone (Azmacort) F. Metaproterenol (Alupent) G. Pirbuterol (Maxair) - not in Briggs (1998) H. Salmeterol (Serevent) - not in Briggs (1998) I. Theophylline J. Zileuton (Zyflo) - not in Briggs (1998) IV. References . Briggs (1998) Drugs in Pregnancy and Lactation, 5th ed A. Larimore (2000) Prim Care 27(1):35-53 I. See Also A. Medications in Pregnancy II. Precautions: Pregnancy . NSAIDs should generally be avoided in pregnancy (despite Category B before third trimester) 1. Second trimester use is likely safe 2. Miscarriage risk in first trimester 3. Premature Ductus Arteriosus closure in third trimester

A. 1. 2. 3. B. 1. III. . 1. A. 1. 2. 3. 4. 5. 6. 7. 8. B. 1. 2. 3. 4. 5. 6. IV. . 1. 2. 3. 4. A. 1. a. B. 1. 2. 3. 4. 5. V. . 1. 2. 3. . A. B. C. D. VI. . A.

Tramadol should be avoided in pregnancy Second trimester use may be safe Fetal toxicity in animals (highest risk in first trimester) Respiratory problems and withdrawal symptoms in newborn (avoid in third trimester) Opioids should be avoided in pregnancy unless there is no viable alternative First trimester use is associated with heart defects and Spina bifida Class B: No risk in controlled animal studies Acetaminophen (Tylenol) Analgesic of choice in pregnancy Narcotics (Class D if prolonged use or high dose) Nalbuphine (Nubain) Meperidine (Demerol) Butorphanol (Stadol) Fentanyl (Duragesic) Hydromorphone (Dilaudid) Methadone (Dolophine) Morphine Sulfate Oxycodone (Percocet) NSAIDs (first and second trimester only) Ibuprofen (Motrin) Indomethacin (Indocin) Ketoprofen (Orudis) Naproxen (Naprosyn) Piroxicam (Feldene) Sulindac (Clinoril) Class C: Small risk in controlled animal studies Narcotics (Class D if prolonged use or high dose) Codeine (Tylenol with codeine) Hydrocodone (Vicodin) Tramadol (Ultram) Propoxyphene (Darvocet) Barbiturates Butalbital (Fiorinal) Class D if prolonged use or high dose NSAIDs (first or second trimester only) Aspirin Etodolac (Lodine) Ketorolac (Toradol) Nabumetone (Relafen) Oxaprozin (Daypro) Class D: Strong evidence of risk to the human fetus Aspirin Used only with specific indications in pregnancy Risk of neonatal Hemorrhage, IUGR, perinatal death Low dose Aspirin may be safer Hauth (1995) Obstet Gynecol 85:1055-8 All NSAIDs (Third Trimester) Prolonged use or high dose of any Narcotic Prolonged use or high dose Butalbital (Fiorinal) General Anesthesia - not in Briggs (1998) Preparations: Lactation Safe Analgesic Medications Acetaminophen (Tylenol) Ibuprofen (Motrin)

B. 1. VII. . 1. 2. 3. A. 1. B. 1. . a. 2. 3. VIII. . A. B. C.

Tramadol Small amount crosses into Breast Milk Preparations: Avoid Opioids in Lactation Opioids that are converted to active metabolites by CYP2D6 Codeine Hydrocodone Oxycodone Risk of overdose in babies if mother is a ultra-rapid CYP2D6 metabolizer Ultrarapid CYP2D6 metabolism occurs in 10% caucasians, 3% african americans, 1% chinese and hispanic Preacutions if these Opioids are used in Lactation Avoid use beyond 4 days of life when milk intake increasing substantially Consider pumping and dumping while taking the Opioid Transition to Acetaminophen or NSAID as soon as possible Use the lowest effective dose of the shortest acting agent Limit dosing to immediately after feeding References Briggs (1998) Drugs in Pregnancy and Lactation, 5th ed (2012) Presc Lett 19(2): 11 Black (2003) Am Fam Physician 67(12):2517-24 Larimore (2000) Prim Care 27(1):35-53

I. See Also A. Vaccination in Pregnancy B. Medications in Pregnancy C. Acute Cystitis in Pregnancy D. Pyelonephritis in Pregnancy E. HIV in Pregnancy II. Class B: No risk in controlled animal studies . Antifungal Topical Agents 1. Nystatin (Mycostatin) A. Antiparasitic agents 1. Metronidazole or Flagyl (after first Trimester) a. Avoid single dose therapy 2. Praziquantel - not in Briggs 3. Permethrin (topical) - not in Briggs (1998) B. Anti-Tuberculosis agents 1. Ethambutol 2. Didanosine - not in Briggs (1998) C. Antiviral agents 1. Nelfinavir - not in Briggs (1998) 2. Ritonavir 3. Saquinavir 4. Famciclovir 5. Valacyclovir D. Antibiotics 1. All Cephalosporin Antibiotics (except Moxalactam) 2. All Erythromycin except Erythromycin Estolate 3. Azithromycin (Zithromax) 4. All Penicillin Antibiotics 5. Clindamycin 6. Macrodantin (before third trimester) 7. Sulfa antibiotics (before third trimester) III. Class C: Small risk in controlled animal studies

. Antifungal agents 1. CDC recommends only Topical Antifungal in pregnancy . Avoid Antifungals in first trimester if possible 2. Terbinafine (Lamisil) - not in Briggs (1998) 3. Clotrimazole (Mycelex, Lotrimin) 4. Butoconazole (Femstat) 5. Miconazole (Monistat) 6. Amphotericin B 7. Fluconazole (Diflucan) . No fetal adverse effects seen in one study a. King (1998) Clin Infect Dis 27:1151-60 8. Itraconazole (Sporanox) 9. Ketoconazole (Nizoral) . Teratogenic and Embryotoxic in animals 10. Griseofulvin . Teratogenic and Embryotoxic in animals A. Antimalarial agents 1. Mefloquine (Lariam) 2. Chloroquine 3. Primaquine B. Antiparasitic agents 1. Albendazole - not in Briggs (1998) 2. Ivermectin - not in Briggs (1998) 3. Mebendazole 4. Pentamidine 5. Thiabendazole 6. Pyrantel C. Anti-Tuberculosis agents 1. Dapsone 2. Isoniazid (INH) 3. Pyrazinamide 4. Rifampin D. Antiviral agents 1. Lamivudine 2. Stavudine 3. Zalcitabine 4. Zidovudine 5. Delavirdine - not in Briggs (1998) 6. Nevirapine 7. Indinavir 8. Cidofovir 9. Foscarnet 10. Ganciclovir 11. Acyclovir 12. Amantadine 13. Rimantadine 14. Interferon alpha E. Antibiotics 1. Imipenem-Cilastin 2. All Fluoroquinolone antibiotics 3. Clarithromycin (Biaxin) 4. Pediazole - not in Briggs (1998) 5. Sulfisoxazole - not in Briggs (1998) 6. Trimethoprim

7. 8. 9. IV. . 1. . a. A. 1. 2. 3. 4. 5. 6. . a. b. 7. . a. 8. . a. b. B. 1. V. . 1. A. 1. 2. B. 1. 2. 3. 4. 5. 6. . a. VI. . A. B.

Vancomycin Chloramphenicol Gentamicin Class D: Strong evidence of risk to the human fetus Antiparasitic agents Metronidazole or Flagyl (First Trimester) New evidence suggests first trimester safety Burtin (1995) Am J Obstet Gynecol 172:525-9 Antibiotics Amikacin (Class D per manufacturer) Kanamycin Streptomycin Tobramycin (Class D per manufacturer) Sulfa (Third Trimester) All Tetracycline antibiotics Doxycycline Tetracycline Minocycline Erythromycin Estolate (llosone) Due to hepatotoxicity in pregnant women McCormack (1977) Antimicrob Agents Chemother 12:630 Macrobid and Nitrofurantoin (Third Trimester) Do not use either of these past 38 weeks Can cause Hemolytic Anemia in newborns Related to immature liver and G6PD Deficiency Vaccines Yellow Fever Vaccine Class X: Very high risk to the human fetus Antimalarial agents Quinine Antiviral agents Ribavirin Rebetron - not in Briggs (1998) Vaccines MeaslesVaccine Mumps Vaccine RubellaVaccine Small PoxVaccine TC-83 Venezuelan Equine EncephalitisVaccine Varicella Vaccine Risk if vaccinated within 4 weeks of conception Theoretic risk only; not an indication for EAB References Briggs (1998) Drugs in Pregnancy and Lactation, 5th ed Black (2003) Am Fam Physician 67(12):2517-24 Larimore (2000) Prim Care 27(1):35-53