It is very common for a woman with rheumatoid arthritis to suffer a disease flare within three months of the delivery of the baby. Unfortunately, there is not a lot of data regarding the degree of absorption of rheumatoid arthritis drugs into breast milk. Also, there is not much data regarding the effect of such drugs on the nursing infant.
Most anti-inflammatory drugs are compatible with breast feeding, but many physicians prefer to use the anti-inflammatory drug ibuprofen because it has a short half life and is found in breast milk in lower levels compared to others. Prednisone is metabolized to prednisolone, and a minuscule amount of that is received by the nursing child. No adverse effects have been reported in the nursing children of mothers taking prednisone.
Plaquenil in one study was found in nursing infants of mothers taking that drug, but the concentration was equivalent to about 2% of the mothers’ weight-adjusted dose. Importantly, there appears to be no need to follow these children for retinal or other toxicity related to Plaquenil usage.
Sulfasalazine should be used with caution if a nursing mother has a preterm infant or one with a high bilirubin level.
The more potent drugs used in the treatment of rheumatoid arthritis, such as Imuran, methotrexate, and cyclosporine, have been generally avoided by doctors if their patients are nursing. There is a concern regarding immunosuppression and the increased risk of infection, impaired response to vaccinations, growth retardation, and the increased risk for cancer. The limited data on these drugs during nursing tends to support the position that perhaps these drugs could be used, but again, more study of this subject is necessary.
Imuran use was studied in a small sample of nursing mothers; there were no adverse effects associated with the use. The children observed had normal growth rates, normal blood counts, normal rates of infection, and normal neurological development.
Even less is known about methotrexate.
Cyclosporin, according to the National Transplantation Pregnancy Registry, was found to cause no problems in 27 infants who were breastfed for up to two years during a period of cyclosporine use.
There is no published data on the effects of the anti-tumor necrosis factor drugs in breastfed infants. There was a case in which a woman had Remicade detectable in breast milk, and another in which Enbrel was detected in breast milk. However, there are no studies examining the impact of these drugs on the nursing infant, so once more no conclusions regarding safety can be made.
So, it would seem that a conservative approach would be to neglect disease control for lactation if a woman insists on breast feeding her infant. There are too many unknowns. In addition, ethically, setting up studies to search for drug effects on nursing infants is a task that many doctors’ attorneys would not advise.
Published On: July 02, 2007