Trazodone & 1st Trimester of Pregancy
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Q:  Can you take trazadone while in 1st trimester of pregnancy? I have bipolar and the effexor is keeping me from sleeping at all. If not, what sleep med can I take?

Dear Paula --

One might think this would be an easy question. And fortunately, demonstrating that something is "safe" in pregnancy takes a very long time and a lot of dedicated attention. For example, a medication that I use a lot, called lamotrigine (Lamictal) has been studied rather closely now for nearly a decade using a "registry". Every case that can be found of a woman who was taking lamotrigine won her pregnancy was conceived, and no other medications, has been entered into a research database. The outcome of that pregnancy is then observed.

Using this method, one can see whether the rate of fetal abnormalities exceeds the background rate -- the rate among women not taking any medication at all, which is about 2% of pregnancies. Not all of these abnormalities are dramatic, or serious, but something happens that can be recognized as "not normal". In women taking a given medication, a rate of fetal abnormalities greater than 2% means the medication is "not safe in pregnancy".

But you can imagine how long this takes: suppose the rate of abnormalities caused by something like lamotrigine is 3%, or 4%. In order to detect that slight difference, compared to the background rate, you have to watch hundreds of pregnancies, probably close to a thousand or more. Unfortunately, only when a company that makes a medication is trying to establish that their medication is "safe", and thereby obtain a competitive advantage they can trumpet -- and thereby make millions of dollars --, only then are such "registries" carefully maintained. 

Otherwise, we simply have to wait until so many fetal abnormalities have occurred in association with a given medication -- like trazodone -- that someone begins to pay close attention. Not a good system.

That's where we are with trazodone now. Most other antidepressants like it, which affects serotonin, were until quite recently thought to be "safe". However, with closer scrutiny in the last 2-3 years, concerns are beginning to be raised about even an old standard like fluoxetine (formerly "Prozac").

So unfortunately, the bottom line of all this is that one cannot really assume any medication "safe" in pregnancy unless it has had detailed attention to me for many years. The only psychiatric medications which come even close to this mark are the old-generation antipsychotics (e.g. Haldol, Thorazine, Mellaril -- that gang).

The other "bottom line" which emerges from all this is that women with bipolar disorder have to be extremely careful about planning their pregnancies, having detailed and thorough conversations with their psychiatrist.

While you're having a conversation with your psychiatrist (I hope that is possible), you should probably also be discussing whether Effexor is clearly helping and therefore should be continued, even when it is causing a problem like this sleep disturbance you mention. Good luck with the process --

Dr. Phelps

Published April, 2008

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