Co-Director Kathryn Emerick, MD
photo: Jamie Manser
Patients don’t always come to us on medications that have perinatal data and that can make collaborative decision making difficult — especially if the patient has greatly benefited from their current regimen. For example, Auvelity, a newer antidepressant that combines bupropion with dextromethorphan - can be a life-changing treatment for major depression, especially for patients who did not respond well to other antidepressants such as SSRIs or SNRIs.
When we consider this medication in pregnancy, we know that there is no data for Auvelity itself. Instead, we can look at the data for the individual components. Bupropion (Wellbutrin) has some data in pregnancy and breastfeeding, and current evidence does not associate bupropion with an increased risk of major congenital malformation. It is generally considered a reasonable option when antidepressant treatment is needed during pregnancy especially if it is a medication someone is already on and it has been effective. It also passes into breast milk in small amounts, with no consistent reports of harmful effects in breastfed infants.
Dextromethorphan, the other ingredient in Auvelity, is commonly used in cough medicines and available data have not linked it to birth defects; it, too, appears to transfer into breast milk in low levels. However, what remains uncertain is the impact of its combination in Auvelity. The formulation includes a higher dose of dextromethorphan than typical over-the-counter use, and bupropion inhibits the metabolism of dextromethorphan. We do not yet know how this altered metabolism affects placental passage, newborn exposure, or infant sensitivity during breastfeeding.
Until more data is available, clinicians and patients must carefully weigh the well-established benefits of treating depression against these remaining uncertainties. In the case of Auvelity, this will include, among other considerations, weighing the likelihood of non-response to other treatments, the number of prior medication trials and the severity of illness with decompensation.