Can hydroxychloroquine (HCQ) and sulfasalazine (Salazopyrine) be given during lactation?

Hydroxychloroquine and Sulfasalazine During Lactation

Both hydroxychloroquine and sulfasalazine are compatible with breastfeeding and can be safely given during lactation. 1

Safety of Hydroxychloroquine During Lactation

• Hydroxychloroquine is considered safe during lactation as it transfers into breast milk in very small amounts that are not harmful to the nursing infant 1, 2
• The amount of hydroxychloroquine received by infants through breast milk is very low, with no reported cases of retinal toxicity or ototoxicity in breastfed infants 2, 3
• Current evidence does not indicate any increased risk of adverse effects in breastfed infants whose mothers take hydroxychloroquine 1, 2

Safety of Sulfasalazine During Lactation

• Sulfasalazine is compatible with breastfeeding and can be continued during lactation 1, 4
• While sulfasalazine is present in breast milk, the levels are considered insignificant, though the active metabolite sulfapyridine reaches about 30-60% of maternal serum levels 5
• There are limited reports of bloody stools or diarrhea in breastfed infants, which resolved after discontinuation of the medication or breastfeeding, but a causal relationship has not been definitively established 5
• Monitoring breastfed infants for signs of diarrhea or bloody stools is recommended 5

Special Considerations

• Folic acid supplementation is essential when using sulfasalazine due to its inhibition of folate absorption 1, 6
• The 2025 EULAR recommendations explicitly list both hydroxychloroquine and sulfasalazine as compatible with breastfeeding 1
• Both medications are considered part of the group of DMARDs that can be safely continued during pregnancy and lactation 7

Monitoring Recommendations

• For mothers taking sulfasalazine, monitor the breastfed infant for:
  • Signs of diarrhea or bloody stools 5
  • Potential jaundice (though sulfapyridine has poor bilirubin-displacing capacity) 5
• Regular laboratory monitoring is recommended for mothers on sulfasalazine, including complete blood counts and liver function tests 5

Common Pitfalls to Avoid

• Unnecessarily discontinuing effective medications during lactation can lead to disease flares, which may negatively impact the mother's ability to care for her infant 7
• Failing to provide folic acid supplementation with sulfasalazine can lead to folate deficiency 1, 6
• Overlooking the benefits of breastfeeding when making medication decisions - the benefits of breastfeeding often outweigh the theoretical risks of medication exposure 4, 8

In conclusion, both hydroxychloroquine and sulfasalazine are considered safe during lactation according to current guidelines, with the benefits of continuing these medications while breastfeeding generally outweighing any potential risks 1, 4.