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Biologics and breastfeeding

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  • Biologics and breastfeeding

    About 4 or 5 weeks after giving birth to my twins I started having random joint pain. It continued to get a little worse as time went on and eventually I went to my family doctor. He did initial blood work and sent me to a rheumatologist after my rheumatoid factor was elevated. Upon seeing the rheumatologist they found my anti-CCP was negative. My rheumatologist still believes that what I have is rheumatoid arthritis and if I am willing wants to start me on medication. I am torn because I have worked very hard to exclusively nurse my girls (they are 4 months old currently) and I don't want to give that up. Also, part of me wonders if this is going to get better with time and do I need to start such a long term medicine. I have been on two short courses of prednisone in the past 4 weeks and take Motrin every day to function at work and care for my kids (the twins were a big surprise as we also have two boys, 5 and 3)! I have read other posts about these meds and it seems there is more data with Enbrel and how much comes thru the milk. My rheumatologist doesn't seem to have a preference between Enbrel and Humira. I guess my question is because of the data would you start Enbrel over Humira if I want to continue to breastfeed? Any info you can give is much appreciated!

  • #2

    I don't think there would be much difference in Enbrel or Humira as far as milk levels or effect on your infants. They are both large immunoglobulins and as such barely penetrate the milk compartment, and even that would not be orally absorbed in a 4 month-old infant.

    Tom Hale Ph.D.


    • #3
      Actemra and Breastfeeding

      I was diagnosed with Sjogrens and mixed connective tissue disease in 2011. While pregnant, I was taking 10 mg of prednisone and 200 mg of Plaquenil. The Plaquenil would provide some relief with the hand and foot joint swelling and stiffness but would cause a rash all over my body. I had put up with the rash so I could breastfeed my son who is now 4 months old. On Friday, my Rheumatologist and I decided to try Actemra and I had my first injection. I thought I might be able to continue breastfeeding due to the high molecular weight of the Actemra however after reading all of the information on the internet, most information said that you should not breastfeed and take Actemra. So, over the weekend, I crash weaned my son and went to 100% formula. I had been supplementing some with formula (about 50%) while I was at work and nursing exclusively in the morning, nights and weekends. Over the weekend I pumped a few times and the milk seemed like it had a green tint to it. When I put the milk in the refrigerator, the fat part of the milk clumped up more than normal. I am not sure if this is due to the Actemra or the engorgement I experienced due to rapid weaning. At this point, I don't know if I should continue with weaning my son or continue with a few nursing sessions to get the benefits of breastfeeding. I just don't want to put him at risk due to the Acemra being in my system. He is a very healthy 4 month old who is growing great and just had a good bill of health at his 4 month checkup. Any thoughts or recommendations would be appreciated.


      • #4
        Hi RyGuysMom did you bf on Actemra? Did you figure out cause of green tint? Did you get any more info? I'm due to start this drug for RA but I too am nursing. Hope you and baby are well


        • #5
          Hi, thanks for your post.

          I have no idea about the green tint or fat clumping that you observed. Did it persist?

          Tocilizumab (Actemra) is not very well studied with respect to breastfeeding safety. There are no studies on the passage of tocilizumab into human milk. Tocilizumab has a large molecular weight and is unlikely to pass into breastmilk, at least not in significant quantities. The studies on a similar medication, infliximab, have demonstrated no passage into milk. Although some studies suggest that other drugs of this class get into breastmilk, there is evidence that oral absorption (in the baby) is generally poor. There are no long term data concerning the safety of using immune modulating medications in breastfeeding mothers. Therefore, some caution is recommended and each woman should understand the benefits and risk of using this type of medication in lactation. Fever, diarrhea, abnormal weight gain, and frequent infections are possible reactions in a child, although none have been reported so far.

          In general, the risk of breastfeeding on any drug declines as the child gets older. A child's liver and kidneys get progressively better at clearing drugs and he or she drinks less and less breastmilk relative to body weight. After nine months, the risk drops dramatically for all but the most dangerous of drugs. Keep that in mind when making your decision.

          Please call us at the InfantRisk Center if this has not completely answered your question.*(806)352-2519

          -James Abbey, MD
          -Thomas W. Hale, Ph.D.


          • #6
            Humira while Breastfeeding

            Hi! Do you have any research data available for Humira while breastfeeding? My arthritis has been in remission since delivery but is starting to flare up. I would like to continue breastfeeding while on the medication because I feel it us best for my 5 1/2 week old daughter. I must convince my rheumatologist of this! I could also switch to Enbrel if it is considered safer.


            • #7
              We do not have data on Humira. We do for infliximab(Remicade) and etanercept(Enbrel). Both the latter transfer into human milk very minimally. Only 0.07% - 0.154% of the dose of Enbrel enters milk, and only about 0.3% of infliximab enters milk. This is about as low as you can get.

              Neither have been found to cause problems for the breastfed infant. I would assume the same for Humira since it is largely the same product. Even if present in milk, they would only be digested like proteins and none would likely be absorbed.

              In my opinion, you and your infant are far better off continuing to breastfeed while taking these medications than to formula feed. Lets face it, formula is hazardous for an infant. There is simply nothing that is as good as mothers milk for a newborn infant.

              -InfantRisk Staff


              • #8
                Hi, I am considering starting Enbrel, my baby is 11 weeks old, exclusively breastfed and i am having a bad flare up of psoriatic arthritis. I have never taken this drug before.
                I have been given differing advice from consultants from stop breastfeeding and start methotrexate, to take Enbrel but with risks. I was wondering if ther has been any more recent research done into this drug since the last post from 2015.
                many thanks,


                • #9

                  Enbrel (etanercept) is an L2-limited data-probably compatible. Etanercept is a large molecular IgG protein. Three studies in breastfeeding women confirm that levels in milk are exceedingly low. No untoward effects were reported in any of the infants. Etanercept was undetectable in infant plasma. All the authors suggest it should be quite safe for breastfeeding mothers and their infants. Monitor your infant for frequent infections, fever, and weight gain.

                  Sandra Lovato R.N.
                  InfantRisk Center