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Opiates and muscle relaxers

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  • Opiates and muscle relaxers

    I have a newly diagnosed autoimmune condition that causes me a lot of pain. I will be starting biologics as soon as I figure out which one will be safest while breastfeeding. In the mean time, my doctor is prescribing pain medication and a muscle relaxer (zanaflex) for me. He doesn't know the L rating system. We checked his hospital's med research system against my chart at length and alerts came up for every medication but morphine, suggesting that nothing but morphine looks to be compatible with breastfeeding. I've done the research and I know that is not entirely true, but if that is what he is comfortable prescribing, it is fine with me considering it will hopefully be very short term-until the Humira, etc becomes effective.

    Is morphine truly the safest among the opiate class, or simply the most well-studied? Other meds we checked were oxycodone, hydromorphone, tramadol and methadone. What are their L-ratings? Finally, what is your take on zanaflex? Is this considered safe? My daughter is 14 months old, and usually feeds roughly 3 times in 24 hours (5-7 hours apart during the day and then sleeps straight through-usually 12 hours overnight). She eats solids frequently through out the day (5 or so snacks per day) and weighs about 25 pounds.

  • #2
    Chrissycookies212,

    Zanaflex is rated an L4-no data-possibly hazardous. It is not known if it is transferred into human milk although the manufacturer states that due to its lipid solubility, it likely penetrates milk. This product has a long half-life, high lipid solubility, and significant CNS penetration, all factors that would increase milk penetration. While the half-life of the conventional formulation is only 4-8 hours, the half-life of the sustained release formulation is 13-22 hours. Further, 48% of patients complain of sedation. Use caution if used in a breastfeeding mother. Monitor the infant for Sedation, weakness, dry mouth, vomiting.

    We would recommend skelaxin as an alternative muscle relaxer. It is rated an L3-no data probably compatible. We do not know how much transfers, but it has a very short half-life of 2-3 hours so you could work around it pretty easy. Monitor the infant for sedation, vomiting, gastrointestinal upset.

    Oxycodone is rated an L3-limited data-probably compatible. The amount transferred is 1.5-3.5% of your dose. It is most concentrated in the first 2 hours so avoid that time and do not exceed 40mg in 24 hours. Monitor for sedation, slowed breathing rate, pallor, constipation and appropriate weight gain.

    Hydromorphone is rated an L3-limited data-probably compatible. The amount transferred is 0.67% of your dose. Hydromorphone is a potent semisynthetic narcotic analgesic used to alleviate moderate to severe pain. It is approximately 7-10 times more potent than morphine, but is used in equivalently lower doses. Wait 2-3 hours for immediate release and half the medication is out. Monitor the infant for sedation, slowed breathing rate, pallor, constipation and appropriate weight gain.

    Tramadol is rated an L3-limited data-probably compatible. The amount transferred is 1.05-2.86% of your dose. New data seem to suggest that transfer into milk is low. The relative infant dose was 2.24% and 0.64% for rac-tramadol and its desmethyl metabolite, respectively. No significant neurobehavioral adverse effects were noted between controls and exposed infants. Based on these studies, it may be concluded that tramadol is compatible with breastfeeding. Avoid first 2 hours after a dose as this is when it the most concentrated in breast milk. Monitor the infant for sedation, slowed breathing rate/apnea, pallor, constipation and not waking to feed/poor feeding.

    Methadone is rated an L2-signifcant data-compatible. The amount transferred is 1.9-6.5% of your dose. Methadone has been used in many breastfeeding mothers, and is usually compatible with breastfeeding. Even high doses of methadone transfer only small amounts into human milk. Avoid the first hour, and monitor the infant for sedation, slowed breathing rate/apnea, pallor, constipation and not waking to feed/poor feeding.

    Morphine is rated an L3-limited data-probably compatible. The amount transferred is 9.09-35% of your dose. Morphine is a potent narcotic analgesic. Morphine is the preferred opiate to use while breastfeeding due to its poor oral bioavailability. Do not use high doses for prolonged periods of time. Avoid the first 2 hours after a dose, and monitor for sedation, slowed breathing rate/apnea, pallor, constipation and appropriate weight gain.

    I hope this helps. If you have any other questions please call the InfantRisk Center at 806-352-2519. Thanks,

    Sandra Lovato R.N.
    InfantRisk Center

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