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Antidepressants During Pregnancy and Lactation: Pharmacokinetics and Clinical Implications

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ClinicalTrials.gov Identifier: NCT01796132
Recruitment Status : Unknown
Verified July 2015 by Chantal Csajka, Centre Hospitalier Universitaire Vaudois.
Recruitment status was:  Recruiting
First Posted : February 21, 2013
Last Update Posted : July 28, 2015
University Hospital, Geneva
Hospices Civils de Lyon
Central Hospital, Nancy, France
Information provided by (Responsible Party):
Chantal Csajka, Centre Hospitalier Universitaire Vaudois

Brief Summary:

Background: The childbearing years are a time of increased vulnerability to the onset of mood disorders in women and a high prevalence of exposure to antidepressant drugs during pregnancy and postpartum has been reported. However, the lack of information regarding the milk transfer and the safety of these drugs in breastfed infants and the related fear of adverse events for the sucking infant are some of the factors responsible for stopping prematurely breast-feeding or avoiding drug therapy. Selective serotonin reuptake inhibitors (SSRI) and selective serotonin and noradrenaline reuptake inhibitors (SNRI) are the most frequently prescribed antidepressant drugs during pregnancy and the post-partum period. They exhibit a wide interpatient variability in their concentration profiles that has been related to numerous environmental, stereochemical, demographic and genetic influences that might alter the level of exposure of breastfed newborns. Limited information is available regarding the safety of use of these antidepressant drugs during lactation, and is generally derived from small studies. A comprehensive description of their distribution and quantification in milk in a larger cohort of patients under various influences and the resulting impact on milk concentrations is lacking.

Objectives: The current proposal addresses the primary objectives of quantifying the range of concentration to citalopram, escitalopram, sertraline, fluoxetine, paroxetine, fluvoxamine, duloxetine and venlafaxine in mother plasma and breast milk in relation to genetic polymorphisms, stereochemistry, demographics and environmental factors in a large cohort of depressive mothers. This will enable to derive the exposure to the breast-fed child taking into account this variability and therefore better adjust treatment to potential influences. As secondary objectives, we will examine the neurodevelopmental outcome of a sub-set of infants subjected to SSRI/SNRI in utero and/or during breastfeeding at birth, 6, 18 and 36 months, and compared to that of a control population of infants not subjected to this treatment.

Expected Results: The proposed strategy will offer new information regarding the expected level of drug exposure associated with each or with a combination of risk factors and help for optimizing the security and rationalizing the use of antidepressant treatment in lactating women. Hence, research on the safety of use of these drugs for the developing child is an area of great public health significance.

Condition or disease Intervention/treatment Phase
Depressive Disorder Lactation Drug: SSRI/SNRI Phase 4

Detailed Description:
see brief summary

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 500 participants
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Official Title: Antidepressant Treatments During Pregnancy and Lactation: Prediction of Drug Exposure Through Breastfeeding and Evaluation of Drug Effect on the Neonatal Adaptation and the Development of the Young Child
Study Start Date : August 2012
Estimated Primary Completion Date : December 2016
Estimated Study Completion Date : December 2018

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
No Intervention: Control
Pregnant and/or nursing mothers not taking a SSRI or SNRI antidepressant are recruited in a non-exposed group (Control or no SSRI/SNRI). Control group participates only in the sub-studies related to neonatal adaptation, neurodevelopment, growth and early mother-infant relationship.
Experimental: SSRI/SNRI exposure
Pregnant and/or nursing mothers under SSRI or SNRI treatment are recruited in an exposed group (SSRI/SNRI exposure). Drug regimen including dosage, frequency and duration is not modified by the study.
Exposed group of mothers taking one of the mentioned antidepressant drugs of the class of selective serotonin reuptake inhibitors (SSRI) or serotonin/noradrenalin reuptake inhibitors (SNRI).
Other Names:
  • citalopram
  • duloxetine
  • escitalopram
  • fluoxetine
  • fluvoxamine
  • paroxetine
  • sertraline
  • venlafaxine

Primary Outcome Measures :
  1. Evaluate the pharmacokinetics of SSRI/SNRI antidepressant drugs in breast milk secretion [ Time Frame: week 1 and week 4-6 postpartum ]

    The principal aim is to derive exposure to the breast-fed child by simulation while integrating influencing factors on pharmacokinetics (as genetic polymorphism, stereochemistry, demographics or environmental aspects).

    5ml blood, 10ml fore-milk and 10ml hind-milk are taken from the mother during the same feed at week 1 and week 4-6 postpartum. Antidepressant drug concentrations are determined by LC-MS/MS and milk composition by human milk analyzer.Pharmacogenetic tests are performed with PCR-Taqman on maternal blood samples and cover genes involved in the metabolism (e.g CYP) and distribution (e.g. p-Gp) of antidepressants. Simulation of antidepressant drug secretion into breast milk will take into account all this information and will be performed with non-linear mixed effects modelling techniques.

Secondary Outcome Measures :
  1. Examine neonatal adaptation [ Time Frame: delivery and week 1 postpartum ]

    The specific aim is to evaluate neonatal adaptation after in utero exposure to antidepressants and its relation to cord blood concentration.

    5ml blood are taken from the umbilical cord and the mother at delivery. Antidepressant drug concentrations are determined by LC-MS/MS. Finnegan Score is used to evaluate the severity of possible withdrawal or discontinuation syndrome in exposed newborns.

  2. Examine neurodevelopment [ Time Frame: week 1, month 6, 18 and 36 postpartum ]

    The specific aim is to evaluate neurodevelopment of a sub-set of infants exposed to any SSRI/SNRI in utero and/or during breastfeeding compared to a control population of infants not exposed to this treatment.

    During week 1 postpartum, somatic and neurologic state of the newborn are evaluated by a pediatrician using routine measures as well as specific tools (Dubowitz's neurologic assessment, Prechtl's general movements). At month 6,18 and 36, neurodevelopment of the infants are assessed using Hammersmith Infant Neurological Examination and Bayley Scales of Infant Development III. At the same time, mother's mental well-being is determined by using self-administered questionnaires (Edinburgh Postnatal Depression Scale, State-Trait Anxiety Inventory, Parental Sens of Competence and Revised Infant Temperament Questionnaire).

  3. Study of growth [ Time Frame: birth, month 6, 18 and 36 postpartum ]

    The specific aim is to evaluate growth of infants exposed to any of the SSRI/SNRI commercialized, compared to standardized growth charts.

    Usual infant growth information (size, body weight, head circumference) are collected routinely at birth and month 6,18,36.

  4. Examine early mother-infant relationship [ Time Frame: Month 6 postpartum ]

    The specific aim is to explore the quality of early mother-infant relationship of a sub-set of infants whose mothers are treated with SSRI/SNRI, compared to that of a control population of infants not exposed to this treatment.

    At month 6 postpartum, mother-infant relationship is evaluated by pedopsychiatrists using Care Index.

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   Female
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Patients planning to deliver in the 5 maternities involved in the study;
  • Mothers under treatment by any SSRI/SNRI (fluvoxamine, fluoxetine, paroxetine, duloxetine, citalopram, escitalopram, sertraline or venlafaxine);
  • Mothers who intent to breastfeed their child;
  • Ability to understand and willingness to sign a written informed consent document for plasma and milk withdrawal and pharmacogenetic testing.
  • For the neurodevelopment follow-up part,all babies of the Maternity of Lausanne, Morges or Geneva exposed to SSRI/SNRI will be enrolled. A control group of infants of the same socio-economic status as the subset of exposed patients will be recruited in the Maternity Hospital of Lausanne.

Exclusion Criteria:

  • Mothers <18 years of age patients;
  • Infants of gestational age < 34 weeks;
  • Mothers giving birth to infants with major malformations;
  • Inability to communicate due to language problems for the mother;
  • Patients with a socio-economic context making close monitoring of the child by the mother or a relative not possible.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01796132

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Contact: Chantal Csajka, Prof PhD 0041 21 314 42 63 chantal.csajka@chuv.ch
Contact: Alice Panchaud, PhD 0041 21 314 42 76 alice.panchaud@chuv.ch

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Service d'Obstétrique, Service de Néonatologie; Centre Hospitalier Universitaire Nancy Recruiting
Nancy, Meurthe-et-Moselle, France
Contact: Jean-Michel Hascoët, Prof MD       jm.hascoet@maternite.chu-nancy.fr   
Principal Investigator: Jean-Michel Hascoët, Prof MD         
Sub-Investigator: Catherine Lamy, MD         
Service d'Obstétrique, Service de Néonatologie; Hospices civiles de Lyon (HCL) Recruiting
Lyon, Rhône, France
Contact: Olivier Claris, Prof MD       olivier.claris@chu-lyon.fr   
Principal Investigator: Olivier Claris, Prof MD         
Sub-Investigator: Pascal Gaucherand, Prof MD         
Sub-Investigator: Etienne Beaufils, MD         
Sub-Investigator: Kim NGuyen, MD         
Division de Pharmacologie Clinique, Service d'Obstétrique, Service de Néonatologie, Service de Pédopsychiatrie de liaison, Unité de Pharmacogénétique et Psychopharmacologie Clinique; Centre Hospitalier Universitaire Vaudois (CHUV) Recruiting
Lausanne, Vaud, Switzerland
Contact: Chantal Csajka, Prof PhD       chantal.csajka@chuv.ch   
Principal Investigator: Chantal Csajka, Prof PhD         
Sub-Investigator: Alice Panchaud, PhD         
Sub-Investigator: Chin B Eap, Prof PhD         
Sub-Investigator: Jean-Francois Tolsa, Prof MD         
Sub-Investigator: Yvan Vial, MD MER         
Sub-Investigator: Myriam Bickle Graz, MD         
Sub-Investigator: Mathilde Morisod Harari, MD         
Sub-Investigator: Céline Fischer, MD         
Service d'Obstétrique, Service de Pédiatrie; Ensemble Hospitalier de la Côte (EHC) Recruiting
Morges, Vaud, Switzerland
Contact: Sylvie Rouiller, MD       sylvie.rouiller@ehc.vd.ch   
Principal Investigator: Sylvie Rouiller, MD         
Service d'Obstétrique, Service du Développement et de la Croissance; Hopitaux Universitaires Genevois (HUG) Recruiting
Geneva, Switzerland
Contact: Manuella Epiney, MD       manuella.epiney@hcuge.ch   
Principal Investigator: Manuella Epiney, MD         
Principal Investigator: Cristina Borradori Tolsa, MD         
Sponsors and Collaborators
Centre Hospitalier Universitaire Vaudois
University Hospital, Geneva
Hospices Civils de Lyon
Central Hospital, Nancy, France
Layout table for investigator information
Principal Investigator: Chantal Csajka, Prof PhD Centre Hospitalier Universitaire Vaudois (CHUV)

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: Chantal Csajka, Prof PhD, Centre Hospitalier Universitaire Vaudois
ClinicalTrials.gov Identifier: NCT01796132    
Other Study ID Numbers: SSRI-Milk
320030_135650 ( Other Grant/Funding Number: Swiss National Science Foundation (SNSF) )
2012-004509-29 ( EudraCT Number )
First Posted: February 21, 2013    Key Record Dates
Last Update Posted: July 28, 2015
Last Verified: July 2015
Keywords provided by Chantal Csajka, Centre Hospitalier Universitaire Vaudois:
Additional relevant MeSH terms:
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Depressive Disorder
Mood Disorders
Mental Disorders
Duloxetine Hydrochloride
Venlafaxine Hydrochloride
Serotonin Uptake Inhibitors
Neurotransmitter Uptake Inhibitors
Membrane Transport Modulators
Molecular Mechanisms of Pharmacological Action
Neurotransmitter Agents
Serotonin Agents
Physiological Effects of Drugs
Antidepressive Agents, Second-Generation
Antidepressive Agents
Psychotropic Drugs
Peripheral Nervous System Agents
Serotonin and Noradrenaline Reuptake Inhibitors
Sensory System Agents
Dopamine Agents
Cytochrome P-450 CYP2D6 Inhibitors
Cytochrome P-450 Enzyme Inhibitors
Enzyme Inhibitors
Anti-Anxiety Agents
Tranquilizing Agents