Breastfeeding and MS Drugs: What Is Safe to Take?
In the summer of 2005, I met several MS patients who were undergoing Solumedrol treatments. I was in the infusion clinic for a release as were several other patients. One patient (I’ll call her Mary), however, was there for a different reason. She had just had a baby.
Before the baby was born, Mary had a plan. She had gone off of her disease-modifying drug (Rebif) when she learned she was pregnant and she planned to breastfeed for a certain period of time before going back on Rebif. The Solumedrol treatment was to ward off any postpartum MS rebounds.
The decision to breastfeed was an important one to Mary as she felt that it was vital to the well-being of her new daughter. But how did Mary decide what drugs to take or not take during that time period?
This week is World Breastfeeding Week and thanks to the LactMed database, offered by the National Library of Medicine, we can research the effect of different drugs and chemicals on lactation.
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 doctor.
Medications Used in MS and Their Effect on Breastfeeding
In searching the MS disease-modifying drugs, I found a common theme. For Avonex and Rebif (interferon beta-1a), Betaseron and Extavia (interferon beta-1b), and Copaxone (glatiramer acetate) - No data is available, however any amount of the drug found in breastmilk is thought to be very low and is probably destroyed in the infant’s gastrointestinal track. For Tysabri (natalizumab) - No data is available. For Gilenya (fingolimod) - No data is available; an alternate drug may be preferred, especially while nursing a newborn or preterm infant. For Novantrone (mitoxantrone) - Most sources consider breastfeeding to be contraindicated.
For treatment of exacerbations, limited information is available for Solumedrol (methylprednisolone). With high doses (especially intravenous doses), avoid breastfeeding for 3-4 hours after dose to decrease the dose received by the infant. No information is available regarding Decadron (dexamethasone), so an alternate drug may be preferred. Limited information regarding Deltasone (prednisone) indicates that low doses up to 20mg produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants. With high doses, the use of prednisolone (instead of prednisone) and waiting to breastfeed until 3-4 hours should decrease the dose received by the infant. H.P. Acthar Gel (adrenocorticotropic hormone, ACTH) - Not listed in LactMed.
The new walking drug, Ampyra (dalfampridine), and its predecessor 4-aminopyridine are not listed in the LactMed database. Drugs to treat fatigue, Provigil (modafinil) and Nuvigil (armodafinil), are not listed in the LactMed database. Nursing mothers should not take amantadine while breastfeeding. The newly approved drug for pseudobulbar affect disorder, Nuedexta (dextromethorphan + quinidine), is not listed in LactMed.
For nausea, vomiting, dizziness, occasional doses of Antivert and Bonamine (meclizine) are probably acceptable during breastfeeding. Large doses or prolonged use may decrease the milk supply or have an effect on the infant. For paroxysmal itching, small doses of Atarax (hydroxyzine) would not be expected to cause any adverse effects in breastfed infants. Larger doses or more prolonged use may cause drowsiness and other effects in the infant or decrease the milk supply.
Among drugs to treat spasticity, limited information is available for Lioresal (baclofen), however low levels in milk would not be expected to cause any adverse effects in breastfed infants, especially if older than 2 months. Monitor newborn infants for signs of sedation. No data exists for Botox (onabotulinumtoxin A), but it is expected to be safe. Information regarding long-term use of Dantrium (dantrolene) during breastfeeding is not available so an alternate drug may be preferred. After short-term use, the drug would be expected to be eliminated from milk in 1-2 days. Valium (diazepam) is excreted into breastmilk and its half-life is long, so other agents are preferred, especially while nursing a newborn or preterm infant. Zanaflex (tizanidine) is not listed in LactMed.
In drugs to treat tremor, Laniazid and Nydrazid (isoniazid) is unlikely to cause adverse effects in infants due to low levels found in breastmilk. Monitor for rare instances of jaundice. Nursing mothers should also take 25mg of oral pyridoxine daily when taking isoniazid. As limited information is available for Klonopin and Rivotril (clonazepam), monitor infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when used in combination with psychotropic drugs.
Among drugs used to treat pain, low levels of Dilantin (phenytoin) are found in breastmilk; amounts ingested by infant are small and usually cause no difficulties. Limited information regarding Neurontin (gabapentin) indicates that doses up to 2.1g daily produce low levels in infant serum. Monitor for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when used in combination with other anticonvulsant or psychotropic drugs. Low levels of Pamelor and Aventyl (nortriptyline) are found in breastmilk and amounts ingested by infants are small and not detected in serum of infant. Most authorities consider nortriptyline one of the preferred antidepressants during breastfeeding.
With Elavil (amitriptyline), milk levels are low and immediate side-effects in breastfed infants have not been reported. Other agents may be preferred when large doses are required or while nursing a newborn or preterm infant. Relatively high levels of Tegretol (carbamazepine) are found in breastmilk and measurable levels are found in serum of breastfed infants. Monitor infant for jaundice, drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when used in combination with anticonvulsant or psychotropic drugs. Consider monitoring infant serum levels, liver enzymes, and complete blood count during therapy.
Among drugs to treat depression, Paxil (paroxetine) and Zoloft (sertraline) are considered preferred antidepressants to use during breastfeeding. Low levels are found in breastmilk and amounts ingested by infants are small. Effexor (venlafaxine) does appear in breastmilk and can be found in the plasma of breastfed infants, however no proven drug-related side-effects have been reported. Monitor for excessive sedation and adequate weight gain, especially in newborn or preterm infants. No published information is available for Cymbalta (duloxetine hydrochloride), however the dose found in milk is low. Monitor the infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of psychotropic drugs. Limited information is available for Wellbutrin (bupropion) which is not expected to cause any adverse effects in breastfed infants. Monitor serum levels in exclusively breastfed infants if there is a concern. Prozac (fluoxetine) is found in breastmilk. Adverse effects such as colic, fussiness, and drowsiness have been reported in breastfed infants. If Prozac is required, it is not a reason to discontinue breastfeeding.
Among drugs to treat bladder dysfunction, no information is available for Detrol (tolterodine), Ditropan and Oxytrol (oxybutynin), and Pro-Banthine (propantheline bromide), however long-term use might decrease milk production or milk letdown. No information is available for Hytrin (terazosin) and Minipress (prazosin), so an alternate drug may be preferred, especially while nursing a newborn or preterm infant. Because no published data is available and Vesicare (solifenacin succinate) has a long half-life, an alternate drug may be preferred, especially when nursing a newborn or preterm infant. Enablex (darifenacin), Flomax (tamsulosin), and Sanctura (trospium chloride) are not listed in LactMed. With Tofranil (imipramine) use, milk levels are low and it is not detected in serum of infants; immediate side-effects have not been reported. Some experts consider imipramine one of the antidepressants of choice for nursing mothers. As negligible amounts of DDAVP (desmopressin) are excreted in breastmilk and poorly absorbed by the infant, it is considered acceptable to use during breastfeeding.
Among drugs to treat urinary tract infection, Hiprex and Mandalamine (methenamine) does appear in breastmilk in small quantities but is acceptable to use, even while nursing newborns. Bactrim and Septra (sulfamethoxazole) is acceptable to use with healthy, full-term infants during breastfeeding, however alternate agents should probably be used in infants with certain health concerns. Recent studies of Cipro (ciprofloxacin) indicate little risk, however ciprofloxacin does show up in breastmilk. Doses of Macrodantin (nitrofuratoin) are low in breastmilk and it is considered safe to use while breastfeeding older infants (over 1 month of age) who are not G-6-PD deficient. For Pyridium (phenazopyridine), safety has not been established and it should be avoided while breastfeeding, especially an infant under 1 month of age or with G-6-PD deficiency.
Among drugs used to treat constipation, Metamucil (psyllium hydrophilic mucilloid) and Phillips’ Milk of Magnesia (magnesium hydroxide), are considered safe and acceptable to use during breastfeeding. Colace (docusate) and Enemeez Mini Enema (docusate stool softener laxative) are minimally absorbed from the gastrointestinal tract and not likely to be found in breastmilk. Dulcolax (bisacodyl) hasn’t been studied, but is not expected to be found in breastmilk. Sani-Supp suppository (glycerin) is not listed in Lactmed.
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.