Can you take alprazolam while breastfeeding?

What LactMed would consider instead

LactMed ends this record by naming the drugs it would consider in place of alprazolam. Whether any of them fits depends on what you are treating — this is the database’s list, not a recommendation from us.

• Lorazepam
• Oxazepam
• Temazepam

How much alprazolam gets into breastmilk

Maternal Levels. Eight lactating women who averaged 11.8 weeks postpartum (range 6 to 28 weeks) were given a single 0.5 mg dose of alprazolam orally. Eleven breastmilk samples were obtained over the 36 hours after the dose. A mean peak alprazolam milk level of 3.7 mcg/L occurred at an average of 1.1 hours (range 0.47 to 3.8 hours) after the dose. The half-life of alprazolam in milk averaged 14.5 hours. The metabolites 4-hydroxyalprazolam and alpha-hydroxyalprazolam were not detected (<0.5 to 1 mcg/L) in milk. The authors calculated that an exclusively breastfed infant whose mother was taking alprazolam in the normal dosage range would receive a daily dosage of 0.5 to 5 mcg/kg or about 3% of the maternal weight-adjusted dosage.

A lactating woman was taking alprazolam and donated milk samples before a dose and 2 hours after a dose at day 3 postpartum and at 1 month postpartum. At 3 days postpartum, she was taking 0.8 mg daily. Her trough milk alprazolam concentration was 2.78 mcg/L, and 2-hour milk level was 3.4 mcg/L. At 1 month postpartum, she was taking 1 mg daily and her 2-hour milk level was 5.42 mcg/L. No metabolites were detected in breastmilk.

A woman who was taking an oral alprazolam dose of 2.4 mg daily donated milk samples at between 3 and 6 days postpartum. She had milk levels of 24.5 mcg/L at 2 hours after the dose and 23.8 mcg/L at 4 hours after the dose.

A woman with dissociative disorder and persistent dysthymic depression was treated during pregnancy with brotizolam 0.25 mg daily, propericiazine 10 mg daily, and zolpidem 5 mg daily. Zolpidem was discontinued at week 28 and sulpiride 100 mg daily was begun at week 33. On postpartum day 5, alprazolam 0.4 mg daily was begun. Milk samples taken at 7.5 and 11.5 hours after the previous dose on day 9 postpartum contained 0.9 and 0.5 mcg/L of alprazolam, respectively.

A physiologically based pharmacokinetic model was developed for alprazolam. The model predicted observed milk levels well. Milk pH did not affect excretion into milk, but milk fat affected the excretion of alprazolam, with higher milk fat content (lower skimmed-to-whole milk ratio) decreasing alprazolam excretion. The model predicted a relative infant dose of 6.51%.

Infant Levels. Relevant published information was not found as of the revision date.

What has been seen in breastfed infants

Increased infant irritability following withdrawal of breastfeeding occurred in a 1-week-old infant whose mother had taken alprazolam during pregnancy and continued to take it after delivery. This reaction probably indicates that there was sufficient alprazolam in breastmilk to prevent withdrawal. The authors reported correspondence with the manufacturer who stated that they had received spontaneous reports of infant withdrawal symptoms (crying, irritability and sleep disturbances) for 2 weeks in a 9-month-old exclusively breastfed infant after slow (over 3 weeks) maternal discontinuation of alprazolam (dosage unspecified).

In one telephone follow-up study of 5 infants (ages not stated) exposed to alprazolam during breastfeeding, 1 mother reported drowsiness in her infant. The reaction did not require medical attention.

In a telephone follow-up study, 124 mothers who took a benzodiazepine while nursing reported whether their infants had any signs of sedation. About 5% of mothers were taking alprazolam. One mother who was taking sertraline 50 mg daily, zopiclone 2.5 mg about every 3 days as needed, and also took alprazolam 0.25 mg on 2 occasions, reported sedation in her breastfed infant.

Effects on milk supply

Unlike other benzodiazepines, alprazolam can increase serum prolactin. One woman developed galactorrhea, amenorrhea and elevated serum prolactin after taking 3 mg of sustained-release alprazolam and 5 to 6 mg of immediate-release alprazolam daily for several months for self-treatment of fear, poor sleep, palpitations and gastrointestinal discomfort. After slow discontinuation of alprazolam and institution of quetiapine and fluvoxamine, galactorrhea ceased after about one month, menses normalized after about 2 months, and serum prolactin decreased to a normal level. The prolactin level in a mother with established lactation may not affect her ability to breastfeed.