Psychiatric Symptoms Upon Withdrawal of Domperidone
by Anne Eglash MD, IBCLC, FABM
Is Domperidone safe during lactation, and can there be withdrawal symptoms?
Domperidone and metoclopramide are medications indicated for gastrointestinal purposes. Both decrease nausea/vomiting and improve gut motility, although they are also commonly used off label during lactation to increase milk production. Both medications raise the prolactin level by blocking dopamine receptors, thereby releasing more prolactin from the anterior pituitary gland. Increasing prolactin can increase milk production in some lactating people.
Domperidone is considered safer with fewer side effects as compared to metoclopramide, because metoclopramide passes through the blood brain barrier and its psychiatric side effects are well known. Acute anxiety, restlessness, fatigue, dizziness, sadness and depression are common side effects during metoclopramide therapy. Unlike metoclopramide, domperidone does not easily pass through the blood brain barrier, so reports of acute psychiatric side effects upon starting or continuing domperidone are much less common.
The authors of today’s article review case reports of psychiatric symptoms that have occurred among lactating individuals discontinuing domperidone. Nearly all case reports involve people taking doses of domperidone that are higher than the doses recommended by manufacturers.
The psychiatric side effects of domperidone withdrawal include anxiety, depression, decreased appetite, insomnia, intrusive thoughts, and suicidal ideation. Some individuals report having had psychiatric hospitalization and/or multiple suicide attempts, and these side effects have taken many months to resolve.
The authors point out that many physicians in the USA know nothing about domperidone since it is not FDA approved and are often not aware that their patients are taking it.
What doses were involved in these case reports? See the question!
- Doses of 150mg-250mg were associated with psychiatric side effects vs the manufacturer’s recommended dose of 10mg-30mg a day.
- Doses of 120mg-150mg were associated with psychiatric side effects vs the manufacturer’s recommended dose of 60mg-90mg a day.
- Doses of 90mg-150mg were associated with psychiatric side effects vs the manufacturer’s recommended dose of 30mg-40mg a day.
See the Answer
Abstract
Background
Domperidone is a dopamine-2 antagonist used off-label to increase breast milk production. Dosages commonly promoted for lactation are often far above those of studied on-label indications and might pose additional risks, especially upon discontinuation of the drug.
Patients
Three U.S. patients are presented who used domperidone for lactation and experienced varying degrees of psychiatric withdrawal symptoms lasting months during dosage tapering and after cessation.
Conclusion
Domperidone as a galactagogue may pose a significant psychiatric risk upon discontinuation. This presentation is commonly confused with, but clinically distinct from, postpartum depression. Lactating mothers who present with psychiatric symptoms should be explicitly probed about domperidone use, even in areas where domperidone is not authorized for use. Maternal hesitancy to disclose domperidone use may lead to suboptimal outcomes for the patient and delay management of withdrawal manifestations. The best course of treatment remains unknown, but a slow hyperbolic taper to gently discontinue domperidone may minimize withdrawal symptoms in these patients. Individuals exploring domperidone use should be informed of potential risks upon withdrawal, including psychiatric manifestations, requisite taper, and potential impacts of using unstudied high doses.
The authors of this case-report series found that psychiatric withdrawal symptoms were most often associated with domperidone doses of 90-150mg. Only one case report of psychiatric symptoms occurred upon abrupt withdrawal from 30mg of domperidone.
Manufacturers recommend no more than 30-40mg of domperidone a day.
These case reports describe how slower withdrawal of domperidone by 2.5-5mg a week may be helpful to prevent or alleviate psychiatric withdrawal symptoms.
Domperidone use by lactating people, at least in the USA, is generally unsupervised because people can purchase domperidone from other countries, and dose themselves according to what they learn on social media.
This is a great example of how lack of breastfeeding and lactation education in health professional schools in the USA has led to dangerous health behavior. We have public health and professional societies encouraging people to breastfeed their babies, yet physicians and other providers have no idea how to manage health complications of lactation. Lactating people with low milk production, who have engaged optimal behavioral strategies to increase milk production, need medical evaluation yet they have no access to such medical care. So, they seek nonevidence-based treatments with no medical supervision.
From my professional experience, domperidone does not increase milk production when one’s prolactin level is properly elevated- the pituitary is already working hard to increase milk production. People who have low milk production due to a variety of medical conditions, such as insufficient glandular tissue, thyroid disease, testosterone-secreting tumors or medication side effects are unlikely to respond to domperidone because they tend to have high prolactin levels. When the prolactin level is low, domperidone 10mg 3-4 times a day can work like a charm, without needing to prescribe a higher dose.
This is one more glaring example of why breastfeeding and lactation medicine must be incorporated into standard medical training. There is no other health behavior that at least 85% of birthing people engage in, that physicians know nothing about. This lack of professional education not only pushes lactating people into self-care, it is also simply unethical.