Is naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) safe for a breastfeeding lady with rheumatoid arthritis, and what about methotrexate (Disease-Modifying Antirheumatic Drug (DMARD)) use during breastfeeding for a child over 1 year of age?

Naproxen and Methotrexate Use During Breastfeeding in Rheumatoid Arthritis

Naproxen can be used during breastfeeding with conditional recommendation, while methotrexate should be avoided due to potential accumulation in neonatal tissues.

Naproxen During Breastfeeding

The American College of Rheumatology conditionally recommends NSAIDs, including naproxen, as compatible with breastfeeding for rheumatoid arthritis management 1. This recommendation applies regardless of the child's age, including children over 1 year.

Key Considerations for Naproxen Use:

• NSAIDs transfer into breast milk in low concentrations, with the relative infant dose typically remaining below the 10% safety threshold 1, 2
• Shorter-acting NSAIDs are preferred over longer-acting agents when possible, though naproxen's established safety profile and convenient twice-daily dosing make it a reasonable choice 2
• Special caution is warranted for premature infants, but for a child over 1 year of age, this concern is not applicable 2
• Naproxen is excreted into breast milk but comprises only a small fraction of maternal exposure, making the risk to the nursing infant minimal 3

Clinical Implementation:

• Naproxen can be initiated or continued without interruption of breastfeeding 1
• The standard dosing regimen for rheumatoid arthritis (typically 250-500 mg twice daily) does not require modification for breastfeeding 4, 5
• Monitor the infant for any unusual symptoms, though adverse effects are rare at therapeutic maternal doses 2

Methotrexate During Breastfeeding

The American College of Rheumatology conditionally recommends AGAINST methotrexate use while breastfeeding 1. This is a firm recommendation that should guide clinical practice.

Rationale for Avoiding Methotrexate:

• Methotrexate may accumulate in neonatal tissues despite minimal passage into breast milk, particularly with the once-weekly dosing used in rheumatoid arthritis 1
• The potential for tissue accumulation creates theoretical risk even when breast milk levels are low 1
• Methotrexate is strongly contraindicated during breastfeeding and should be discontinued if the mother wishes to nurse 2

Alternative Disease-Modifying Strategies:

If disease-modifying antirheumatic drug (DMARD) therapy is needed during breastfeeding, consider these compatible alternatives:

• Hydroxychloroquine (HCQ): Strongly recommended as compatible with breastfeeding 1, 2
• Sulfasalazine: Strongly recommended as compatible with breastfeeding 1, 2
• TNF inhibitors (infliximab, etanercept, adalimumab, golimumab, certolizumab): Strongly recommended as compatible 1
• Azathioprine: Conditionally recommended, with negligible transfer into breast milk and infant sera 1, 2

Clinical Algorithm for This Patient

Step 1: Assess Disease Activity

• If disease is well-controlled or mild: Use naproxen alone for symptomatic management 1
• If disease requires DMARD therapy: Discontinue methotrexate and transition to a breastfeeding-compatible DMARD 1

Step 2: Select Breastfeeding-Compatible Medications

• For symptomatic relief: Naproxen 250-500 mg twice daily 1, 4
• For disease modification: Hydroxychloroquine or sulfasalazine as first-line options 1, 2
• For inadequate response: Consider TNF inhibitors or other biologic agents with strong or conditional compatibility recommendations 1

Step 3: Timing Considerations

• Methotrexate must be discontinued before initiating breastfeeding due to tissue accumulation concerns 1, 2
• Allow appropriate washout period (typically 3-6 months given methotrexate's pharmacokinetics) before breastfeeding if recently discontinued 2
• Naproxen can be started immediately without washout period 1

Important Caveats

• The child's age (>1 year) does not change these recommendations, as the guidelines apply to all breastfeeding periods 1
• Disease control must be maintained to prevent maternal morbidity, which can also affect the child's wellbeing 1
• Collaboration with pediatrics is recommended when making medication decisions during lactation 1
• Individual risk-benefit assessment should account for disease severity, alternative feeding options, and maternal preferences 1

The evidence strongly supports using naproxen while avoiding methotrexate during breastfeeding, with multiple effective DMARD alternatives available if disease-modifying therapy is required 1, 2.