Cyclosporine and Breastfeeding

[peggyfagan]

Hi Dr. Hale & team,

I have CIDP and my latest treatment with plasmapheresis didn't work. My condition continues to decline so my neurologist is starting me on Cyclosporine. While I was in my previous treatments of IV solumedrol and plasmapheresis, I caught bugs easily and both time I developed pneumonia (once in Sep and once in Dec). So my neurologist also prescribed me with a few meds to reduce the risk of infections. My daily meds will be below for six months with further evaluation.

Cyclosporine 50mg 2 times/day (eventually work up to 100mg x 2 times/day I believe)
Clotrimazole 10mg 2 times/day
Acyclovir 800mg once/day
Sulfamethoxazole-trimethoprim 400-80mg once/day

My 11 months old still nurses 4-5 times a day. With these new meds, can I continue to breastfeed as usual? Or it's time to wean?

Thanks so much.

Peggy

[Sandra]

peggyfagan,

Cyclosporine is rated an L2-limited data-probably compatible. The amount that transfers into breastmilk is 0.05-3% of your dose. The infant should be monitored closely for signs of toxicity including monitoring the infants plasma levels of cyclosporine. Also monitor for vomiting, diarrhea, weight gain. If signs of liver dysfunction (yellowing of skin or whites of eyes) check liver enzymes and bilirubin; if signs of toxicity check drug level.

Acyclovir is rated an L2-limited data probably compatible. The amount that transfers into breast milk is 1.09-1.53% of your dose. Toxicities associated with acyclovir are few and usually minor. Acyclovir therapy in neonates is common and produces few toxicities. Monitor for vomiting and diarrhea.

Sulfamethoxazole-trimethoprim (Bactrim) is rated an L3-limited data-probably compatible. The amount that transfers into breast milk is 2-3% of the sulfamethoxazole and 4-9% of the trimethoprim. "Use of TMP-SMZ for durations longer than what is used for treatment of acute bacterial infections, such as more chronic use over several months, appears to be safe overall. However, the well-known potential for TMP-SMZ to cause rare but severe adverse events, especially severe cutaneous reactions, hematological changes, and hyperkalemia, must always be kept in mind when considering use of TMP-SMZ." ([url]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168244/[/url]) Monitor for vomiting, diarrhea, rash, thrush, and if any yellowing of the skin and eyes, check bilirubin; CBC if risk of hemolytic anemia.

Clotrimazole is rated an L2-no data-probably compatible. "Oral administration of clotrimazole may pass into human milk, although we have no data available. However, clotrimazole has low oral absorption, and so the passage of clotrimazole through breast milk has low clinical relevance." (Medications and Mothers' Milk database, Dr Thomas Hale, PhD). We believe short term use is compatible with breastfeeding, however long term use of antifungals can be hepatotoxic. If you decide to breastfeed while taking these medications we recommend periodic liver function test in the infant.


This is a decision you need to discuss with your Dr. You need to weigh the risk of these medications vs benefits of breastfeeding. The majority of passive immunities are passed in the last trimester of pregnancy and the first 6 months of nursing. Short term use would be ok, but long term use may cause some issues.

Sandra Lovato R.N.
InfantRisk Center
806-352-2519