L1/2+L2+L2, chronic use, breastfeeding a toddler

[oli-vka]

I am a breastfeeding mother and a physician from Poland.
I suffer from Lyme disease and was diagnosed only a few weeks ago. My son is 1 year old, I decided to continue breastfeeding at night (it is extremely important for us). Now I am on amoxycilin 3g a day, azithromycin 2 g a week and hydroxychloroquine 200mg a day. I take my L2 medications in the early morning to avoid nursing at Tmax.
Would it be safe for my child to use rifampin in place of amoxycillin?
Should I take any other (than avoiding Tmax) precautions while breastfeeding?
I know I should not use tetracyclines but what about fluorochinolones? Is ofloxacin safe enough to use it chronically?

Sincerely,

oli-vka.

[admin]

Dear Oli-vka

Amoxicillin is commonly used in neonates and infants and is safe to use during breastfeeding. No adverse effects have been reported in breastfed infants. It has a half life of 1.7 hours, so taking it in the morning is a good idea. Experience with the use of Azithromycin in breastfeeding women is limited. However, there is no evidence that the use of it will have an adverse effect in the breastfed infant. The predicted dose of azithromycin received by the infant would be approximately 0.4 mg/kg/day. This would suggest that the level of azithromycin ingested by a breastfeeding infant is not clinically relevant.

Hydroxychloroquine has a huge volume of distribution, milk levels are generally quite low, and therefore this drug maybe considered compatible with breastfeeding. However, hydroxychloroquine is known to produce significant retinal damage and blindness if used over a prolonged period, and this could occur (theoretically but unlikely) in breastfed infants. Try to not use it for more than 10 weeks.

Rifampin usage in breastfeeding is relatively safe. Rifampin is secreted into human milk, although there have been no reports of adverse effects in breastfed infants. I would suggest you observe for diarrhea in the breastfed infant. It has a half life of 3.5hours, so taking it in the morning is also a good idea.

Ofloxacin is a typical fluoroquinolone antimicrobial. Breastmilk concentrations are reported equal to maternal plasma levels. In one study in lactating women who received 400 mg oral doses twice daily, drug concentrations in breastmilk averaged 0.05-2.41 mg/L in milk (24 hours and 2 hours post-dose respectively). The only probable risk is a change in gut flora, diarrhea, and a remote risk of overgrowth of C. difficile. Ofloxacin levels in breastmilk are consistently lower (37%) than ciprofloxacin. If a fluoroquinolone is required, ofloxacin, levofloxacin, or norfloxacin are probably the better choices for breastfeeding mothers.

For further questions, please contact the InfantRisk Center at 806-352-2519.

Tassneem Abdel Karim MD
InfantRisk Center

[oli-vka]

Thank you. For how long could I take ofloxacin?
I use only 200mg of hydroxychloroquine (half of typical dose) - is the dose likely to produce significant retinal damage and blindness in breastfed infants if used over a 10-week period?
What about metronidazol? For how long could it be used?

[admin]

Dear Oli-vka,

We do not have any reported cases of Hydroxychloroquine causing retinal damage in breastfed infants, like I mentioned above, this is only theoretical. Long term metronidazole is probably okay, nevertheless, observe your baby for diarrhea and gastrointestinal disturbances. However, Dr. Hale says using ofloxacin chronically is probably not a good idea, because of the increased risk of tendinitis and tendon rupture in the mother, and theoretically in the breastfed infant.

Tassneem Abdel Karim MD
InfantRisk Center