Quetiapine: Difference between revisions

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| pregnancy_details = Quetiapine crosses the placenta in modest amounts (umbilical cord-to-maternal plasma ratio approximately 24%, lower than risperidone or olanzapine).<ref name="newport2007">Newport DJ, Calamaras MR, DeVane CL, Donovan J, Beach AJ, Winn S, Knight BT, Gibson BB, Viguera AC, Owens MJ, Nemeroff CB, Stowe ZN. Atypical antipsychotic administration during late pregnancy: placental passage and obstetrical outcomes. American Journal of Psychiatry. 2007;164(8):1214-1220. PMID: 17671284.</ref> The pregnancy literature on atypical neuroleptics has substantially attenuated earlier concerns about teratogenicity; recent large cohort analyses using active-comparator designs and confounding-by-indication adjustment have found no consistent signal for major congenital malformations with quetiapine specifically.<ref name="huybrechts2016">Huybrechts KF, Hernandez-Diaz S, Patorno E, Desai RJ, Mogun H, Dejene SZ, Cohen JM, Panchaud A, Cohen L, Bateman BT. Antipsychotic use in pregnancy and the risk for congenital malformations. JAMA Psychiatry. 2016;73(9):938-946. PMID: 27540849.</ref> Quetiapine is therefore frequently used in pregnancy when neuroleptic treatment is clinically necessary, both for primary indications such as bipolar disorder and schizophrenia and as a substitute for higher-risk medicines such as [[Valproic acid|valproate]].

Third-trimester exposure is associated with transient neonatal symptoms, including extrapyramidal signs, feeding difficulty, respiratory distress, and uncommonly withdrawal, typically resolving within days. [[Gestational diabetes|Gestational diabetes]] risk may be modestly elevated by maternal quetiapine; routine glucose screening in pregnancy applies. Breastfeeding while taking quetiapine produces low infant ~~drug~~ exposure (relative infant dose typically less than 1%), and quetiapine is among the neuroleptics considered compatible with breastfeeding.

Third-trimester exposure is associated with transient neonatal symptoms, including extrapyramidal signs, feeding difficulty, respiratory distress, and uncommonly withdrawal, typically resolving within days. [[Gestational diabetes|Gestational diabetes]] risk may be modestly elevated by maternal quetiapine; routine glucose screening in pregnancy applies. Breastfeeding while taking quetiapine produces low infant medicine exposure (relative infant dose typically less than 1%), and quetiapine is among the neuroleptics considered compatible with breastfeeding.

For women with bipolar disorder or schizophrenia maintained on quetiapine who become pregnant, continuation is generally preferred to discontinuation because of relapse risk; the medicine's relative safety profile in pregnancy makes the maternal mental health argument straightforward. For women on quetiapine off-label for sleep or anxiety, pregnancy is an appropriate occasion to deprescribe in favor of behavioral interventions or, where pharmacotherapy is required, evidence-based alternatives such as the SSRI [[Sertraline|sertraline]].

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Management is primarily supportive: airway protection, intravenous fluids for hypotension, ECG monitoring with attention to QT and arrhythmias, cardiac monitoring for at least 24 hours in significant ingestions. [[Activated charcoal|Activated charcoal]] may be considered within one hour of ingestion if the airway is protected. [[:Category:Vasopressors|Vasopressors]] ([[Norepinephrine (medication)|norepinephrine]] preferred over [[Dopamine (medication)|dopamine]], given quetiapine's alpha-1 antagonism) for refractory hypotension. There is no specific antidote. [[Hemodialysis|Hemodialysis]] is not effective owing to the large volume of distribution.

Co-ingestion is the rule rather than the exception in quetiapine overdose; alcohol, benzodiazepines, and opioids substantially worsen prognosis. The widespread availability of quetiapine in homes where it is prescribed off-label for insomnia has contributed to its prominence in suicidal overdose attempts; counseling about safe ~~medication~~ storage and limited dispense quantities in at-risk patients is appropriate.

Co-ingestion is the rule rather than the exception in quetiapine overdose; alcohol, benzodiazepines, and opioids substantially worsen prognosis. The widespread availability of quetiapine in homes where it is prescribed off-label for insomnia has contributed to its prominence in suicidal overdose attempts; counseling about safe medicine storage and limited dispense quantities in at-risk patients is appropriate.

| counseling = '''Off-label use: most quetiapine prescriptions are for indications the medicine is not formally approved to treat.''' If quetiapine has been prescribed for sleep, anxiety, agitation, or PTSD, the patient should understand that the prescribing is off-label, that the evidence base for these indications is modest, that the metabolic and cardiovascular risk profile applies even at low doses, and that evidence-based alternatives exist ([[Cognitive behavioral therapy for insomnia|cognitive behavioral therapy for insomnia]], SSRIs and SNRIs for anxiety, exposure-based therapies for PTSD).

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