Guidelines for treating psychosis in pregnancy?

[bisell26]

Do you guys have any guidelines you follow for treating psychosis in pregnant women? like how much Haldol to start with and what dose? Can you provide me with literature on this?

Thanks

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[st2205]

Do you guys have any guidelines you follow for treating psychosis in pregnant women? like how much Haldol to start with and what dose? Can you provide me with literature on this?

Thanks

I'd start with a risk/benefit analysis before deciding any specific medication. I'd look at their actual history and not their diagnosis on paper. If they're stable on their current regimen and have a real history of psychosis that's necessitated hospitalization, delusions, unable to safely care for themself, etc., then I'd have a hard time justifying a change (inducing a real risk of decompensation) just to try to minimize or negate a theoretical risk. On the flip side, if they have an on paper diagnoses of a "psychotic disorder" and they're "sorta stable" on Latuda, Prozac, clonazepam, BuSpar, Trileptal and Seroquel, then I'm wouldn't be stratifying their risk based on the "diagnosis."

I know that doesn't exactly answer the question but something to consider. We recently had someone taken off lithium so they could get pregnant with disastrous consequences.

 

[bisell26]

I'd start with a risk/benefit analysis before deciding any specific medication. I'd look at their actual history and not their diagnosis on paper. If they're stable on their current regimen and have a real history of psychosis that's necessitated hospitalization, delusions, unable to safely care for themself, etc., then I'd have a hard time justifying a change (inducing a real risk of decompensation) just to try to minimize or negate a theoretical risk. On the flip side, if they have an on paper diagnoses of a "psychotic disorder" and they're "sorta stable" on Latuda, Prozac, clonazepam, BuSpar, Trileptal and Seroquel, then I'm wouldn't be stratifying their risk based on the "diagnosis."

I know that doesn't exactly answer the question but something to consider. We recently had someone taken off lithium so they could get pregnant with disastrous consequences.

Thanks. I'm referring to someone who has been off of medications for a while and is very psychotic (bizarre delusions, active self talk, near danger to fetus). Is there evidence to suggest that in this particular person, Latuda would be safer/more efficiacious then Haldol?

Thanks

 

[Armadillos]

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[Merovinge]

Thanks. I'm referring to someone who has been off of medications for a while and is very psychotic (bizarre delusions, active self talk, near danger to fetus). Is there evidence to suggest that in this particular person, Latuda would be safer/more efficiacious then Haldol?

Thanks

Latuda and Seroquel are good bets if, and only if, they manage the psychosis. First priority is allowing her to be able to care for herself and her unborn baby, so if need Haldol to do so that's reasonable.

 

[PistolPete]

Haldol has the most evidence so I'd use that. Latuda another option but I wonder how effective it would be in someone who has very pronounced delusions.

 

[st2205]

I don't think there are great guidelines or great evidence for this situation other than opinions that may be grounded in theory. If there is, I'd be interested in seeing it (certainly not saying there not may be some out there). If she hasn't been on anything I'd also be curious if she was on anything previously that helped with stability (not that I'd necessarily go with that). Other than that, I would dose Haldol to where it was effective at controlling whatever may be putting her and her baby at risk from a psychiatric perspective because that is a very real and tangible risk rather than the theoretical risk of a woman being exposed to Haldol in pregnancy. How far along is she?

I had an experience, as an aside, that summed up my frustrations with guidelines in pregnancy (and medicine in general) where we stop looking at the patient in front of us. I had a patient who had failed multiple medications for depression (granted a bit of axis II stuff going on but not extreme) and she ended up doing actually reasonably well on Cymbalta and Remeron. She did fine on this for a while and then ended up pregnant. She wanted to stop all medications and we discussed risks and benefits and thought it was fine but also told her that I felt perfectly comfortable resuming later, if need be, but we'd probably prioritize just Cymbalta alone. Anyway, check out to an attending (had several other issues aside from this) who I told her the plan that she was okay with until I mentioned I'd just restart Cymbalta in the future if we needed to. She then asked if I knew the risks of that, referenced the dearth of data on it, then she pulled out some guideline from somewhere stating to use Zoloft or Celexa for depression in pregnancy and asked me if I wanted to do that, which I declined, stating that she had responded to Cymbalta but hadn't responded to the other two. She got upset and asked me why I didn't wish to follow evidence-based guidelines. With it all boiling down to risk and benefit, we know the benefit she got from Zoloft and Celexa -- nothing. Somehow we feel better being "evidence based" by exposing her to risk without any benefit.

Anyway, data for safety in pregnancy lags (obviously) as everyone feels most comfortable providing something that we have more data on. More data doesn't necessarily mean more safe, just more data.

Anyway, you have a real situation in front of you with real risk. If it were me I'd address and prioritize that first. I wouldn't feel good about an inadequate Haldol dose in favor of other concerns and I'd err on the side of overtreatment if there's active risk. This is simply my opinion, though. I'm no expert on intrapartum psychosis treatment.

 

[JustAGuy]

Unless there are compelling safety reasons, which there generally aren't when it comes to antipsychotics and pregnancy, or lack of efficacy of the current regimen, I would attempt to minimize the number of exposures.

 

[HarryMTieboutMD]

By "psychosis," do you mean schizophrenia? Regardless, SCZ, bipolar, and depression are all teratogenic, which should be considered when planning on treatment. Clozapine and Latuda are category B, but other than that it doesn't really matter what you use. Here is a recent retrospective study from JAMA Psych using medicaid data showing virtually no correlation between antipsychotics and congential malformations, excepting a small effect for risperdal (which Kathy Wisner who is the national expert in this area and wrote the editorial just thinks this needs more study). https://www.ncbi.nlm.nih.gov/pubmed/27540849

 

[tr]

Haldol has not been very extensively studied in a formal way, the evidence in its favor amounts to lots of clinical experience but little in the way of controlled studies. First generation in general are not as well tolerated and are associated with lower birth weights.

I would not give Latuda to a pregnant woman, we have no human data on this drug in pregnancy. The Category B rating is based on the fact that it didn't cause birth defects in high doses in rats/rabbits unlike most other antipsychotics. But teratogenicity varies a lot across species so this information is irrelevant for humans.
In general the FDA rating system is totally uninformative. Clozaril is category B also but I wouldn't give that to a pregnant woman either.

We have better data on the older atypicals, and most of the commonly used antipsychotics (except possibly risperidone) don't appear to be teratogenic at clinical doses in humans.
https://www.ncbi.nlm.nih.gov/pubmed/27540849

Issues are more with birth weight, term of gestation, metabolic impairment/diabetes, neonatal adaptation, and of course the almost total black box of potential neurodevelopmental effects. But when you need it, you need it.

Without more information it's hard to know whether your patient needs an antipsychotic or which one to use. In general your best bet is whatever worked best in the past. In the absence of such information I lean towards Seroquel for its lower rates of placental transfer.

https://www.ncbi.nlm.nih.gov/pubmed/17671284


This is no longer so current but still a useful overview.

http://www.mdedge.com/currentpsychi...r-psychotic-disorders/atypical-antipsychotics

 

[bisell26]

Haldol has not been very extensively studied in a formal way, the evidence in its favor amounts to lots of clinical experience but little in the way of controlled studies. First generation in general are not as well tolerated and are associated with lower birth weights.

I would not give Latuda to a pregnant woman, we have no human data on this drug in pregnancy. The Category B rating is based on the fact that it didn't cause birth defects in high doses in rats/rabbits unlike most other antipsychotics. But teratogenicity varies a lot across species so this information is irrelevant for humans.
In general the FDA rating system is totally uninformative. Clozaril is category B also but I wouldn't give that to a pregnant woman either.

We have better data on the older atypicals, and most of the commonly used antipsychotics (except possibly risperidone) don't appear to be teratogenic at clinical doses in humans.
https://www.ncbi.nlm.nih.gov/pubmed/27540849

Issues are more with birth weight, term of gestation, metabolic impairment/diabetes, neonatal adaptation, and of course the almost total black box of potential neurodevelopmental effects. But when you need it, you need it.

Without more information it's hard to know whether your patient needs an antipsychotic or which one to use. In general your best bet is whatever worked best in the past. In the absence of such information I lean towards Seroquel for its lower rates of placental transfer.

https://www.ncbi.nlm.nih.gov/pubmed/17671284


This is no longer so current but still a useful overview.

http://www.mdedge.com/currentpsychi...r-psychotic-disorders/atypical-antipsychotics

Thank you. I think the teratogenicity thing and FDA rating schematic is not all that helpful.

From what I gather, Latuda just doesn't have any studies on humans.

For my patient, she has not been on an antipsychotic in a long time and I don't have previous records. However, she has a detailed psychiatric history of several hospitalizations and it is important to treat her with right now. I found Latuda to be more of a mood stabilizer and would not really target her psychotic symptoms.

 

[Johnson21]

I am locum speciality doctor in UK [ done my 3.5 years of core training and retaking CASC, membership examination to get into higher training]
I would follow Maudsley guidelines here as its evidence based and safe.
I have seen few, many had an affective component with mood congruent delusions [guilt]
I believe Haloperidol is safe in breast feeding , hopefully EPSE does not develop, but have seen EPSEs more commonly to Haloperidol in BPAD in females [ crude observation only ]

 

[birchswing]

Regardless, SCZ, bipolar, and depression are all teratogenic, which should be considered when planning on treatment.

Is this because of the biological nature of these illnesses (in the way that mania is damaging to the brain) or because of behaviors people have with these illnesses (not taking care of themselves, etc.)?