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  • Glaucoma treatment (eye drops) during beastfeeding

    Good morning,
    I have a patient with non-operational galucoma. She is currently pregnant and advised to withdraw treatment, but it is risky for her, so as soon as possible she will be back on treatment. She is ordered timolol 0,5% eye drops 1xday, dorzolamide 2% eye drops and bimatoprost eye drops 0,01% 1xday.

    There aren't any specialists in ophtalmology with experience in breastfeeding in my country that I know of. and can consult. I know that the risk for nursing infant is low due to low maternal serum level of the drugs, but I would like a second opinion.

    Also perhaps there are safer combinations of these drugs and/or other that are recommended during breastfeeding (asked patient, she would like to consult every option with her doctor)?. And lastly - when is safe to be back on treatment? Perhaps you have experience with such cases, and it is not necessary to stop taking eye drops during pregnancy (or at least the treatment does not to be witheld through all trimesters)?

    Thank you in advance for your time and advice.

    Best regards,
    Karolina Morze


  • #2
    Karolina Morze,


    Pregnancy:

    Timolol is rated a P-3-unknown-risk to fetus cannot be ruled out. "In a case report, the use of timolol, in addition to other drug therapies, to treat metastatic pheochromocytoma during a pregnancy resulted in the birth of growth-retarded infant who was otherwise healthy [1]. Residual effects of non selective beta blockers might cause beta blockade in the newborn when administered near term [2]. Fetuses who are exposed to nonselective beta blockers during pregnancy may hace an increased risk of intrauterine growth retardation [2]."(Medications and Mothers' Milk database, DrThomas Hale PhD).

    1.## Devoe LD et al: Metastatic pheochromocytoma in pregnancy and fetal biophysical assessment after maternal administration of alpha-adrenergic, beta-adrenergic, and dopamine antagonists. Obstet Gynecol 68:15s-18s, 1986.

    Dorzolamide is rated a P-3-unknown-risk to fetus cannot be ruled out. "There are no adequate and well-controlled studies in pregnant women. Developmental toxicity studies with dorzolamide hydrochloride in rabbits at oral doses of ? 2.5 mg/kg/day (31 times the recommended human ophthalmic dose) revealed malformations of the vertebral bodies. These malformations occurred at doses that caused metabolic acidosis with decreased body weight gain in dams and decreased fetal weights. No treatment-related malformations were seen at 1.0 mg/kg/day (13 times the recommended human ophthalmic dose). There are no adequate and well-controlled studies in pregnant women. Dorzolamide should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus." (Medications and Mothers Milk database, Dr Thomas Hale PhD).

    Bimatoprost is rated a P-3-unknown-risk to fetus cannot re ruled out. "There are no adequate and well- controlled studies in pregnant women. In embryo/fetal developmental studies in pregnant mice and rats, abortion was observed at oral doses of bimatoprost which achieved at least 33 or 97 times, respectively, the maximum intended human exposure (based on blood AUC levels after topical ophthalmic administration to the cornea or conjunctival sac). At doses at least 41 times the maximum intended human exposure, the gestation length was reduced in the dams, the incidence of dead fetuses, late resorptions, peri- and postnatal pup mortality was increased, and pup body weights were reduced. There are no adequate and well-controlled studies of bimatoprost ophthalmic solution 0.03% administration in pregnant women. Because animal reproductive studies are not always predictive of human response, bimatoprost should be administered during pregnancy only if the potential benefit justifies the potential risk to the fetus.

    Breastfeeding:

    Timolol is rated an L-2-limited data-probably compatible. The amount that transfers into breast milk is only 1.1% of moms dose. This amount is probably to small to be clinically relevant, so mom could breastfeed while using this medication. We still recommend monitoring the infant for drowsiness, lethargy, pallor, poor feeding and weight gain, but these side effects are unlikely with the small amount absorbed.

    Dorzolamide is rated an L-3-no data-probably compatible. "We do not have data on transfer to milk, but because plasma levels are incredibly low, levels in milk are probably low to undetectable. Do not use in mothers with infants who have poor creatinine clearance, such as premature infants. Risk level with this product is probably quite low."(Medications and Mothers' Milk database, DrThomas Hale PhD).

    Bimatoprost is rated an L-3-no data-probably compatible. "No breastfeeding data are available. However, after intraocular administration, plasma levels peak at 10 minutes, then fall rapidly to undetectable levels within 1.5 hours. Combined with low plasma levels and high protein binding, it is unlikely this product would produce measurable levels in human milk."(Medications and Mothers' Milk database, DrThomas Hale PhD).

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

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    • #3
      Hi!
      Thank you for this information!
      I have an additional question.
      I was diagnosed with glaucoma a few weeks ago when my baby was 12 weeks old. At first I was prescribed Timosan eye drops (timolol 0,1%), but this caused me systemic side effects. I was then switched to Azopt eye drops (brinzolamide). Then, most recently Betoptic eye drops (betaxolol) were added for one eye only. So, currently I'm taking Azopt and Betoptic. My eye doctor thinks that it's fine to go on nursing my infant while taking these drugs, but I still lack confidence to do so freely. For the time being I have only given him very limited amounts of breast milk after the maximum interval between taking the medication (the eye drops have to be administered twice a day) to give my body the time to metabolize the drug as much as possible before nursing. This, however, has undesirable effects: 1. while on formula the baby gets really bad tummy problems and it is very hard for him to poop 2. my milk is starting to run out because there is no demand (no regular suckling).
      What is your advice? Could I switch my baby back to breast milk exclusively? What would be the optimum interval after administrating the eye drops to wait before nursing?
      I would very much appreciate your help on this, because I need to do what is best for my baby. If possible, please give me information on all three drugs. I'm not currently on timolol, but it's possible I'll have to give it another try if the other two I'm currently on won't be effective enough in lowering my IOP s. These two are Azopt (brinzolamide) and Betoptic (betaxolol).
      Yours sincerely,
      Alice

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