Table 5 Commonly used anti-rheumatic drugs and their use during breastfeeding
From: Managing pregnancy in inflammatory rheumatological diseases
Drug | Crosses into breast milk | Compatible with lactation |
|---|---|---|
Paracetamol | Amount too small to be harmful | Can be continued during breastfeeding |
Aspirin | Possible risk of Reye syndrome In large doses, could impair platelet function | Low doses (antithrombotic dose of 75 mg/day) acceptable, but avoid in large doses |
NSAIDs | Very small quantities in human breast milk Potential risk of jaundice and kernicterus | Approved for use (use short-acting NSAIDs such asibuprofen) |
Codeine | Amount usually too small to be harmful; however, mothers vary in capacity to catabolize codeine and infant at risk of morphine overdose | Use lowest effective dose if needed, but try to avoid |
Pethidine | Present in breast milk but not known to be harmful | Can be used |
Tramadol | Amount probably too small to be harmful | Should be avoided |
Morphine | Therapeutic doses unlikely to affect infant Withdrawal symptoms in infants of dependent mothers | Therapeutic doses may be used if needed, but try to avoid |
Corticosteroids | Trace amounts of hydrocortisone and up to 25% of maternal levels of prednisolone detectable in breast milk | Breastfeed 4 hours after last dose to minimize exposure if prednisolone of greater than 20 mg |
COX-2 (cyclo-oxygenase-2) inhibitors | Insufficient data in humans | Avoid due to theoretical risk |
Hydroxychloroquine | Found in breast milk but no abnormalities reported | Can be continued during breastfeeding |
Methotrexate | Excreted in low concentrations into breast milk | Contraindicated |
Leflunomide | No published data available | Contraindicated due to theoretical risk |
Sulfasalazine | Negligible amounts secreted in breast milk | To be used with folic acid supplements |
Gold salts | Excreted in breast milk and absorbed by infant Can lead to rash, nephritis, hepatitis, and hematological problems | Should be avoided |
Azathioprine | Azathioprine and its metabolites detected in breast milk in low amounts, but abnormalities rare | May be used at not more than 2 mg/kg per day after discussion with mother weighing up risk-benefit |
Cyclosporin | Wide variability in drug disposition | May be used after discussion with mother weighing up risk-benefit, preferably at doses lower than 2.5 mg/kg per day |
Cyclophosphamide | Excreted in breast milk | Contraindicated |
Mycophenolate mofetil | No human studies | Contraindicated due to theoretical risk |
Tumor necrosis factor-alpha antagonists (for example, infliximab, etanercept, and adalimumab) | Etanercept excreted in breast milk Infliximab undetectable No studies with adalimumab | Not enough data, therefore should be avoided |
Anakinra | Unknown whether excreted in breast milk | Not enough data, therefore should be avoided |
Abatacept | Not known whether excreted in breast milk or whether absorbed systematically after ingestion | Contraindicated due to theoretical risk |
Rituximab | Unknown whether excreted in breast milk | Not enough data, therefore should be avoided |
Intravenous immunoglobulin weighing up risk-benefit | No published data | May be used during breastfeeding after discussion |
Heparin and low-molecular- weight heparin | Not excreted in breast milk | Can be continued during breastfeeding |
Warfarin | Minimal excretion in breast milk | Can be used while breastfeeding |