World Breastfeeding Week is August 1-7, 2011.   Choosing to breastfeed is an important decision for every mother, especially mothers who live with rheumatoid arthritis.  The medications we take for RA are powerful drugs with serious and potential side-effects.  Every mother wants to know that the health of her child is not being affected by these medications.

Knowledge of what are safe medications to take is vital.  BabyCenter.com offers a consolidated chart of medications which are usually safe to take while breastfeeding, probably safe in usual doses, hazardous, and not safe to take.  The list was compiled by Philip Anderson, a pharmacist and editor of LactMed which is the National Library of Medicine’s drug and lactation database.

Mothers want to know how various medications or chemicals may impact their children, especially breastfeeding infants.  LactMed provides information regarding the impact of many drugs and chemicals on lactation, infants, and breastfeeding mothers.  The database also offers summaries on individual reports and studies involving infants exposed to different medications in breastmilk.

LactMed is “A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider.”

Searching the LactMed database is easy and the information is presented in clear language.  All data comes from scientific literature and is fully referenced.  Statements regarding a drug’s compatibility with breastfeeding are provided by the American Academy of Pediatrics (AAP).

A new feature for the database is the LactMed App for iPhone and Android mobile devices.  The app presents the very same information which is available on the website, including hot links to supporting reference materials.  The app was very easy to use and is the source of the information shared below.  This information is not intended to be complete nor provide medical advice.  It is only a sampling of what is shared in LactMed.  Please discuss options with your rheumatologist.

Medications Used in RA and Their Effect on Breastfeeding

STEROIDS:

Prednisone – Limited information indicates maternal doses up to 20mg produce low levels in breastmilk and would not be expected to cause any adverse effects in breastfed infants;.  With high doses, the use of prednisolone (instead of prednisone) and avoiding breastfeeding for 3-4 hours after a dose should decrease the amount received by the infant.

Prednisolone – Limited information indicates that maternal doses up to 50mg produce low levels in breastmilk and would not be expected to cause any adverse effects in breastfed infants.  With high doses, avoiding breastfeeding for 4 hours after a dose should markedly decrease the dose received by the infant.

Dexamethasone– Because no information is available on use during breastfeeding, an alternate corticosteroid may be preferred especially while nursing a newborn or preterm infant.

BIOLOGIC AGENTS:

Cimzia (certolizumab pegol) – *

Enbrel (etanercept) – *

Humira (adalimumab) – *

Remicade (infliximab) – *

Simponi (golimumab) – “since no information is available… an alternate drug may be preferred.”

Actemra (tocilizumab) – not listed in LactMed

Kineret (anakinra) – not listed in LactMed

Orencia (abatacept) – not listed in LactMed

Rituxan (rituximab) – not listed in LactMed

*Preliminary data indicates this medication is minimally excreted into breastmilk, which would be expected because of its high molecular weight and size.  Since the medication is not orally absorbed, any amount found in breastmilk is unlikely to adversely affect the breastfed infant over 1 month of age.  LactMed includes information regarding the normal growth and development of infants who were breastfed while the mothers used one of these medications.  However, until more data becomes available, an alternative drug may be preferred, especially when nursing a newborn or preterm infant.
DMARDs:

Arava (leflunomide) – not listed in LactMed

Rheumatrex, Trexall (methotrexate) – Some authors state that the low, weekly doses used in RA are of low-risk to breastfed infants.  Exclusively breastfed infants should be monitored with complete blood count with differential if methotrexate is used during lactation.

Plaquenil (hydroxychloroquine) – Generally considered safe; infants receive only small amounts in breastmilk and no evidence of visual or hearing deficits were seen in one study.

Azulfidine (sulfasalazine) – Generally considered safe, but carefully observe breastfed infants for signs of diarrhea as some cases have been reported.

Cuprimine, Depen (penicillamine) – Some authors state that use of penicillamine is unacceptable during lactation, however others stress that transfer to infant through breastmilk is likely to be low.

Dynacin, Minocin (minocycline) – Short-term use is acceptable in nursing mothers; monitor infant for rash or possible effects on gastrointestinal flora.

Ridaura (auranofin, oral gold) – Recommendations are mixed; monitoring for possible adverse effects in the breastfed infant would seem prudent.

Myochrysine (gold sodium thiomalate, injectable gold) – Recommendations are mixed; monitoring for possible adverse effects in the breastfed infant would seem prudent.

IMMUNOSUPPRESSANTS:

Cytoxan (cyclophosphamide) – Sources consider breastfeeding to be contraindicated.

Imuran, Azasan (azathioprine) – Exclusively breastfed infants should be monitored with complete blood count with differential and liver function tests if azathioprine is used during lactation.  Avoiding breastfeeding for 4-6 hours after a dose should markedly decrease the amount received by the infant in breastmilk.

Neoral, Sandimmune, Gengraf (cyclosporine) – Cyclosporine concentration in milk is variable, probably more concentrated in the milk fat in hindmilk.  Most infants studied have not had detectable cyclosporine blood levels.

NSAIDs:

Motrin, Advil (ibuprofen) – Ibuprofen is a good choice as an anti-inflammatory agent in nursing mothers.

Tylenol, Favarall, Tempra (acetaminophen) – Acetaminophen is a good choice for analgesia and fever reduction in nursing mothers.

Aleve (naproxen sodium) – Limited information available; however because of naproxen’s long half-life and reported serious adverse reaction in a breastfed newborn, the mother may prefer to use other agents.

Actron, Orudis KT (ketoprofen) – No published literature available; but with low levels found in breastmilk and a short half-life, ketaprofen is unlikely to adversely affect the breastfed infant. 

Celebrex (celecoxib) – Because of low levels in breastmilk, amounts ingested by the infant are small and would not be expected to cause any adverse effects.

OxyContin, Roxicodone (oxycodone) – Maternal use of maximum dosages of oral narcotics while breastfeeding can cause infant drowsiness; monitor for drowsiness, adequate weight gain, and development milestones.  If the baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, breathing difficulties, or limpness, contact a physician immediately.

Ultram (tramadol) – Tramadol produces low levels in milk and is unlikely to adversely affect healthy, full-term infants and acceptable to use during breastfeeding.

Voltaren(diclofenac sodium) – Available data is limited, however most reviewers consider diclofenac to be acceptable during breastfeeding.

The National Library of Medicine also offers DailyMed, a website which provides healthcare providers and consumers comprehensive information regarding FDA-approved drugs.  You can read up-to-date label information for any of the drugs you may be taking. 

Lisa Emrich is author of the blog Brass and Ivory: Life with MS and RA and founder of the Carnival of MS Bloggers.