Research — 20 June 2013

The antidepressants fluoxetine and paroxetine should not be used first-line in women who may become pregnant, Australian researchers suggest after their metaanalysis found the SSRIs were linked to major birth defects.

The results contradict earlier studies that concluded fluoxetine was not teratogenic and may be a safer alternative to paroxetine.

The analysis of 29 studies and 69 data samples found both SSRIs were associated with a small but significantly increased risk of major fetal malformations, with paroxetine carrying a higher risk of cardiac malformations.

But two other SSRIs sertraline and citalopram were not significantly associated with fetal defects, the researchers reported this week in the ANZJP.

Based on these findings, “neither paroxetine nor fluoxetine should be used electively as a first-line antidepressant therapy in those wishing to become pregnant or in the first trimester of pregnancy,” the authors advised.

“An argument might also be made for avoiding these medications where accidental pregnancy is likely.”

Prescribers should instead consider sertraline or citalopram as first-line SSRI treatment in pregnancy and women of childbearing age, they said.

But the researchers warned against switching medications during pregnancy, saying the change would come too late to avoid the critical period of first-trimester exposure and could potentially induce fetal withdrawal that has been associated with premature delivery and stillbirth.

The authors also flagged the possibility of moving fluoxetine from category C to D under the Therapeutic Goods Administration’s classification system for medication in pregnancy.

Paroxetine already carries a D classification, which indicates that the drug has been linked to an “increased incidence of human fetal malformations or irreversible damage”.

The authors also noted that cognitive behavioural therapy was just as effective as drug treatment for pregnant women with mild depression and anxiety, and would avoid the risk of teratogenicity.

As first appeared in Psychiatry Update, 19 June 2013. Source: ANZJP 2013; online


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