Can therapy be taken during breastfeeding?

Medication Use During Breastfeeding

Most medications can be safely taken during breastfeeding, and women should be encouraged to breastfeed if they desire and are able to do so, with appropriate medication selection and monitoring. 1

General Principles for Medication Use While Breastfeeding

• The benefits of breastfeeding generally outweigh the minimal risks of medication exposure for most drugs
• Medication transfer to breast milk depends on:
  • Pharmacokinetic properties of the drug
  • Maternal serum concentration
  • Relative infant dose (RID) - values <10% are generally considered safe 2
  • Infant age and metabolism capacity

Safe Medication Categories During Breastfeeding

Strongly Recommended as Compatible with Breastfeeding:

• Hydroxychloroquine
• Colchicine
• Sulfasalazine
• TNF inhibitors
• Rituximab 2
• Prednisone <20 mg daily (or equivalent non-fluorinated glucocorticoid) 2
• Pain medications:
  • Acetaminophen (paracetamol)
  • Ibuprofen
  • Diclofenac 1

Conditionally Recommended as Compatible with Breastfeeding:

• Azathioprine/6-mercaptopurine
• Calcineurin inhibitors
• NSAIDs
• Non-TNF inhibitor biologics (anakinra, belimumab, abatacept, tocilizumab, secukinumab, ustekinumab) 2
• Antidepressants:
  • Paroxetine and sertraline are preferred first-line agents 3
  • Fluoxetine, citalopram, and venlafaxine have higher infant plasma levels but can be used if mother was on these during pregnancy 3

Medications to Avoid During Breastfeeding

Strongly Recommended Against:

• Cyclophosphamide
• Leflunomide
• Mycophenolate mofetil
• Thalidomide 2

Conditionally Recommended Against:

• Methotrexate - despite minimal passage into breast milk, may accumulate in neonatal tissues 2
• Viloxazine - no published studies on safety during breastfeeding 2

Practical Recommendations for Medication Use

1. Timing of medication:

   • Take medications immediately after breastfeeding to maximize clearance time before next feeding 1
   • For prednisone ≥20 mg daily, delay breastfeeding or discard breast milk accumulated in the 4 hours following administration 2

2. Dosing considerations:

   • Use lowest effective dose for shortest duration possible 1
   • Standard adult dosing is often appropriate with no special adjustment needed for lactation 1

3. Special precautions:

   • Exercise extra caution when infant is <6 weeks old due to immature hepatic and renal function 1
   • Older infants (>6 months) generally have more mature metabolism and lower risk 1

4. Monitoring:

   • Watch for potential adverse effects in infants when using medications with limited safety data
   • For certain medications, monitoring infant serum drug concentrations may be advisable 4

Important Considerations

• Adequate medication treatment is important not only for maternal health but also for successful breastfeeding 1
• Untreated conditions (like pain or depression) can interfere with breastfeeding success 1
• When mental health conditions occur during lactation, priority should be given to effectively treating the mother, often with medications that were effective during pregnancy 5

Remember that most medications produce very low or undetectable plasma concentrations in nursing infants, and the benefits of breastfeeding typically outweigh potential risks from medication exposure 3. Always consult current, evidence-based resources like LactMed when prescribing for breastfeeding mothers 5.