Change in meds

[Michelelc]

I am an IBCLC and posting for my daughter-in-law with RA and possibly psoriatic arthritis. She is not well controlled on current medications her rheumatologist is comfortable offering her at this time. She is encouraging weaning of her 20 month old. Toddler nurses 4-5 times during the day, 2-3 times at night. Mother will have no other children due to RA and she does not wish to wean at this time and would prefer full-term breastfeeding (she feels RA has already taken so much from her). This little one is very intense and parenting her w/o nursing as a tool will provide other stresses to mom emotionally and physically. The options her doc has recommended are: Continuing on Humira & sulfasalazine adding in methotrexate OR replacing the Humira with Tofacitinib Citrate (I am assuming continuing sulfasalazine, but have not confirmed).

Methotrexate recommendations seem to differ between this site and the toxnet information. Please provide the current recommendations and which plan may be the preferred treatment. Thank you.

[admin]

Michelelc,

Tofacitnib citrate is rated an L4-no data-possibly hazardous. The transfer of tofacitinib into human milk is still unknown. However, because of serious side effects that may occur in nursing infants it is advised to not use during breastfeeding.

Methotrexate is rated an L4-limited data-possibly hazardous. The amount transferred into breast milk is 0.13-0.95% of moms dose. Methotrexate is believed to be retained in human tissues (particularly gastrointestinal cells and ovarian cells) for long periods (months). It is apparent that the concentration of methotrexate in human milk is minimal, although due to the toxicity of this agent and the unknown effects on rapidly developing neonatal gastrointestinal cells, it is probably wise to pump and discard the mother's milk for a minimum of 24 hours post dose if given as a single dose (e.g. 50 mg/m2 IM for ectopic pregnancy) or administered once weekly (e.g. for RA). The period in which the mother discards her milk may require extending (consider 4 days of interruption) if the dose used is quite high (>75mg) or if the dose is frequently administered (more than once weekly). Being on scheduled doses more than once a week is likely to be a situation where the mother should not breastfeed at all.

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

[admin]

Micheleic:

One other option not mentioned are the biologicals such as Infliximab or Humira. Both would work well in this patient, and are generally quite safe in most cases. They have limited transfer into human milk. I'd suggest she look at these two options rather than the methotrexate. But these decisions are really up to her rheumatologist...

Tom Hale Ph.d.

[Michelelc]

Dr. Hale,

She is currently on Humira and sulfasalazine and it is not controlling pain or joint damage. She was previously on Embrel with good results but developed retinal issues. It sounds as though her best option may be Tofacitinib Citrate, correct?

Michele

[Michelelc]

Oh, dear...just saw the previous post from Sandra Lovato. So, would there be other alternatives if her doc gave you 'all a call? Or is she out of options in regards to medication?

Thank you,
Michele

[admin]

Micheleic:

You're rare ever out of options, but some of these drugs are simply too dangerous to use in a breastfeeding mother, and that includes methotrexate, and perhaps Tofacitinib at this time.

I think she needs to talk with her doctor, and get a list of suitable alternatives. Then you can call about these.

Tom Hale Ph.D