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Therapy Insight: the use of antirheumatic drugs during nursing

Nature Clinical Practice Rheumatology volume 3, pages 400–406 (2007)Cite this article

Abstract

In 90% of cases, women with rheumatoid arthritis suffer a disease flare within 3 months of delivery of their baby. Drug treatment is, therefore, required; however, such therapies have implications for mothers who decide to nurse their infants. Unfortunately, because of a paucity of data, little is known about the transfer of antirheumatic drugs into breast milk, and even less is known about whether small amounts of these agents ingested during nursing could harm the infant. Our review of the literature indicates that paracetamol, prednisone, antimalarial agents, sulfasalazine and most NSAIDs can safely be used by lactating mothers. Expert opinions differ regarding the use of azathioprine, ciclosporin, and methotrexate during lactation because of varying views on the potential for short-term and long-term adverse effects. Evidence regarding the transfer of leflunomide and biologic drugs into breast milk is insufficient; therefore, until more studies are conducted, the use of these drugs in breastfeeding mothers should be restricted. At present, many patients feel they have to choose between postpartum disease control and lactation. Extended studies of the transfer of antirheumatic drugs into breast milk and the resulting consequences are, therefore, urgently needed.

Key Points

  • Most drugs given to a lactating mother appear in breast milk at approximately maternal plasma levels

  • For the drugs discussed in this article, the total daily exposure of the breastfed infant is less than 10% of the therapeutic dose in children

  • NSAIDs, paracetamol, corticosteroids, antimalarial agents, and sulfasalazine are compatible with breastfeeding

  • Infants breastfed by mothers receiving azathioprine, methotrexate or ciclosporin should be monitored for adverse effects

  • Drug exposure can be reduced by timing breastfeeding to avoid peak drug concentrations in milk

  • The lack of data on biologic agents in lactating patients with rheumatoid arthritis means that these patients are often not treated with the most effective therapies

  • Further studies of the transfer of antirheumatic drugs into breast milk and the resulting consequences are urgently needed

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. M Østensen is Professor of Rheumatology and is the Director of the Center for Women with Rheumatic Disease in the Department of Rheumatology, University Hospital of Bern, Bern, Switzerland.,

    Monika Østensen

  2. M Motta is a neonatologist in the Division of Newborn Medicine, Brescia Hospital, Brescia, Italy.,

    Mario Motta

Authors
  1. Monika Østensen
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  2. Mario Motta
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Corresponding author

Correspondence to Monika Østensen.

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The authors declare no competing financial interests.

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Østensen, M., Motta, M. Therapy Insight: the use of antirheumatic drugs during nursing. Nat Rev Rheumatol 3, 400–406 (2007). https://doi.org/10.1038/ncprheum0532

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  • DOI: https://doi.org/10.1038/ncprheum0532

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