Espresso: Zuranolone for Postpartum Depression
/We’re back! While we’ll operate for a bit on a reduced schedule (new episodes every-other-week), we are so excited to get back to podcasting and covering the need-to-know in OB/GYN. Thanks for all the love and support over the last few months! <3 Nick & Fei
Reading: Zuranolone for the Treatment of Postpartum Depression (ACOG Practice Advisory)
What is zuranolone and why is it important?
We know that postpartum/perinatal mental health conditions and some of the leading causes of preventable maternal mortality
PPD affects approximately 14% of women
Understanding/discussing/recommending medication and treatment can potentially decrease maternal morbidity and mortality
Medication type
Neuroactive steroid gamma-aminobutyric acid (GABA) A receptor positive modulator
Oral medication
Recent FDA approval for use in PPD
Why is zuranolone recommended, and what else is out there?
Why is it recommended?
Two phase 3 randomized double-blind, placebo-controlled multicenter studies
Primary endpoint in both: change in depressive symptoms in the Hamilton depression rating scale (HAMD-17)
17 point scale
Assesses somatic (physical ie. loss of appetite), affective (mood ie. sadness), cognitive (thinking, ie. difficulty concentrating), and behavioral (ie. social withdrawal) symptoms of depression
Reliable and valid method of assessing and measuring depression
In both studies, those on Zuranolone showed significantly more improvement in their symptoms compared those in placebo
Treatment effect maintained at day 42 (4 weeks after last dose of zuranolone)
Why the HAMD-17?
More used in research settings, but anticipated that other validated tools (like EPDS or PHQ9) will be used in clinical settings
What else is out there?
Brexanolone - first FDA approved medication specifically for postpartum depression
However, unlike zuranolone which is oral, brexanolone consists of a 60 hour in-hospital IV infusion, which may not be readily accessible
May be difficult to arrange inpatient admission
May also be difficult for patients to leave their newborns for 60 hours to get infusion
SSRIs
Not specific for postpartum/perinatal depression
Can be effective, but also may be difficult to find the correct SSRI
Many SSRIs also require uptitration of dosage
What to consider when prescribing zuranolone
Consideration of zuranolone in the postpartum period (within 12 months postpartum) for depression that has onset in the third trimester or within 4 weeks postpartum
Benefits:
Significantly improved and rapid resolution of symptoms
Risks:
Potential suicidal thoughts or behavior
Sedation - can make it so you can’t drive
Lack of efficacy data beyond 42 days
How to prescribe and take zuranolone
Daily recommended dose is 50 mg
Take in evening with fatty meal (400-1000 calories, 25-50% fat) for 14 days
Can reduce dose to 40 mg if CNS depression effects occur
If hepatic or renal impairment, start dose at 30 mg
Can be used alone or as an adjunct to other oral antidepressant therapy like SSRIs
Recommendation is to have effective contraception during treatment and for 1 week after final dose. There is a registry if pregnancy occurs
Warn patients about adverse reactions
Impaired ability to drive
CNS depressant effects
Increased suicidal thoughts and behaviors
Zuranolone does pass into breastmilk, but relative infant dose is smaller than that of SSRIs