What are the guidelines for using corticosteroids (e.g. prednisolone) in a lactating woman?

Corticosteroid Use During Breastfeeding

Prednisone or prednisolone at doses ≤20 mg daily (or equivalent non-fluorinated corticosteroids) are safe and compatible with breastfeeding, with minimal infant exposure of approximately 10% of the maternal dose. 1, 2

Recommended Corticosteroids for Breastfeeding

Low-Dose Prednisone/Prednisolone (Preferred)

• Prednisone or prednisolone ≤20 mg daily is strongly recommended as compatible with breastfeeding 1, 2
• Only approximately 10% of the maternal dose reaches the infant through breast milk 1, 2
• The American College of Rheumatology provides strong evidence supporting this practice 1

Higher-Dose Prednisone (>20 mg daily)

• For doses >20 mg daily, discard breast milk obtained within 4 hours following medication administration 1
• This timing recommendation is based on peak serum-to-milk equilibrium concentrations 1
• After 4 hours, breastfeeding can resume safely 1

Alternative Non-Fluorinated Corticosteroids

• Methylprednisolone is an acceptable alternative with similar safety profile to prednisone/prednisolone 2
• Hydrocortisone is compatible with breastfeeding when parenteral administration is necessary 2

Corticosteroids to AVOID During Breastfeeding

Fluorinated Corticosteroids

• Do NOT use dexamethasone or betamethasone during breastfeeding 1, 2
• These fluorinated steroids are not well metabolized by the placenta and cross more readily into infant circulation 2

Other Contraindicated Medications

• Do NOT use methotrexate (conditional recommendation) 1
• Strongly avoid leflunomide, mycophenolate mofetil, cyclophosphamide, and thalidomide 1

Inhaled Corticosteroids (for Asthma/Respiratory Conditions)

Preferred Agents

• Budesonide and beclomethasone are the preferred inhaled corticosteroids due to extensive safety data 2
• Fluticasone is classified as compatible with breastfeeding 2

Other Compatible Medications During Lactation

The American College of Rheumatology provides strong or conditional recommendations for the following medications as compatible with breastfeeding: 1

Strong recommendations:

• Hydroxychloroquine
• TNF inhibitors: infliximab, etanercept, adalimumab, golimumab, certolizumab
• Rituximab

Conditional recommendations:

• NSAIDs (use lowest effective dose)
• Sulfasalazine
• Colchicine
• Azathioprine
• Calcineurin inhibitors: cyclosporine, tacrolimus
• Other biologics: anakinra, belimumab, abatacept, tocilizumab, secukinumab, ustekinumab

Clinical Management Principles

Disease Control Priority

• Maintaining maternal disease control is paramount - uncontrolled maternal disease poses greater risks than appropriate corticosteroid use 2
• Use the lowest effective dose to maintain disease control 2

Monitoring Considerations

• The FDA label notes that systemically administered corticosteroids appear in human milk and could theoretically suppress infant growth or interfere with endogenous corticosteroid production 3
• However, clinical evidence at recommended doses has not demonstrated these adverse effects in practice 1

Common Pitfalls to Avoid

• Do not unnecessarily discontinue effective low-dose prednisone - the benefits of maternal disease control outweigh minimal infant exposure 1, 2
• Do not switch to fluorinated corticosteroids (dexamethasone/betamethasone) thinking all steroids are equivalent - these have different pharmacokinetics and greater infant exposure 1, 2
• Do not advise complete cessation of breastfeeding for women on appropriate doses of compatible corticosteroids - this deprives the infant of breastfeeding benefits unnecessarily 1
• For doses >20 mg daily, ensure the 4-hour waiting period is clearly explained to maximize safety while maintaining breastfeeding 1