Lialda (mesalamine) and breastfeeding

[Fiori1020]

Good Afternoon to all,
I had a baby 2 weeks ago and was diagnosed with ulcerative colitis, placed on 4 pills of Lialda 1.2mg dose (highest dose) along with rectal Rowasa (mesalamine). Both my GI and OB said it was fine to breastfeed although my pediatrician strongly recommended not to due to the highest dose 4.8 taken. Please advise as I was strongly looking forward to nurse my baby until I return to work in few weeks. Currently she's mostly on similac formula always cranky and fussy and I pump and spill away my milk crying. Please please advise on any new studies with this drug and what would be your advice on this matter. Thank you so very much.

[admin-james]

Hi, thanks for your post.

Lialda and Rowasa are different forms of mesalamine that are designed to go to different parts of the colon at different times. All forms of mesalamine carry similar risk in breastfeeding. I believe that this is a very safe medication for breastfeeding, even with your high dose. Watery diarrhea has been reported rarely in babies exposed to mesalamine via breastmilk. If your baby has this problem, try diluting your breastmilk with formula (50/50) until the diarrhea goes away. Mesalamine is discussed in more detail here:
https://www.infantrisk.com/forum/showthread.php?417-Breastfeeding-Remicade-and-infant-vaccines&highlight=mesalamine

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

-James Abbey, MD

[Fiori1020]

Lialda and Rowasa in breastfeeding

Thank you. Based on your recommendations, there is no need for me to pump and discard? Really this high dose concerns me and the fact how would I differentiate between side effect / allergic reaction of watery diarrhea vs the normal stool from breastfeeding which also looks like diarrhea? Thanks to your advice, I pray it is safe to breastfeed. I plan to now nurse her full time and monitor her although still concerned since it is a medication in her body. Thank you very much!

[admin-james]

Correct, there is no need to pump and discard. It is difficult to tell if diarrhea is normal or a medication side effect. If your child's bowel habits change significantly after exposure to the medication, consider side effects as a possibility. Your highest dose would deliver about 250 mg/day to the baby. Mesalamine is prescribed to older children starting at 50 mg/kg (of body weight)/day.

[Fiori1020]

Concerned mom

Correct, there is no need to pump and discard. It is difficult to tell if diarrhea is normal or a medication side effect. If your child's bowel habits change significantly after exposure to the medication, consider side effects as a possibility. Your highest dose would deliver about 250 mg/day to the baby. Mesalamine is prescribed to older children starting at 50 mg/kg (of body weight)/day.

Thank you for your previous reply! Baby is now 3 weeks old and that dose of 250mg/day does seem like a large dose for the baby. Should I be concerned that she is receiving that much medication through me? I noted she does have watery stool but if its from nursing full time or a side effect of the drug I am not sure. Which IBD/UC drug would you consider to be the safest to breastfeed with? I am seeing another GI specialist this week for a consult. Thank you so very much for all that you do!!!

[admin-james]

Mesalamine is one of the safest choices for treating IBD/UC while breastfeeding. Just because the dose is large, doesn't necessarily mean that it is dangerous. Have a look at this article for more information:

http://infantrisk.com/content/inflammatory-bowel-disease-pregnancy-and-breastfeeding

[Dom's Mom]

Hi. I am taking 3.6 gms of Lialda (2 pills in morning, 1 at night) and have a 2 month old I am exclusively breastfeeding. My UC became active when I became pregnant and took 4.8 gms the whole time. My UC is very mild but persistent. My GI and pediatrician are OK with me taking Lialda (with warning to look for persistent watery diarrhea) but I have some concerns.

What is considered a high dose of mesalamine? Does it target my son's colon like it does mine?

I am confused about whether mesalamine is considered a drug that increases risk for Reyes syndrome. I don't understand the difference between 5-aminosalicylic acid and salicylic acid, can you explain?

Also, I cannot take Ibuprofen or other NSAIDs while on Lialda. Does that mean my baby will not be able to take Ibuprofen when he reaches 6 months?

[admin-james]

Hi, thanks for your post.

Lialda is a formulation of mesalamine (5-ASA) that targets the colon. What allows it to do that is a special coating on the tablet that only dissolves in the colon, that's why is says not to crush Lialda before you take it. Mesalamine does most of its work directly on the colon wall, rather than in your bloodstream. Only 20% of what you take is actually absorbed and most of that is quickly metabolized. Overall, your baby gets between 1-8% of what you take during the day. Obviously, the tablet coating is not on the mesalamine in your breastmilk, so it does not target the baby's colon in the same way. It is unlikely that the amount of 5-ASA that your baby is exposed to will cause problems, but there have been a few isolated cases of diarrhea reported after exposure to 5-ASA via breastmilk.

Nobody knows exactly what it is about aspirin (acetylsalicylic acid) that causes Reye syndrome after a viral infection. Although 5-ASA and aspirin are very similar molecules in structure (use a Google image search to compare the structures), 5-ASA has never been associated with Reye syndrome. By "never," I mean that there are zero published cases in the medical literature, despite mesalamine being prescribed directly to babies. There are no guarantees in medicine, but this is pretty strong evidence that 5-ASA does not increase the risk of Reye syndrome.

I'm not sure about the question of your baby taking ibuprofen while you are on Lialda. There are no published practice guidelines addressing this question. A blood salicylate level on your baby at 6 months would be very helpful in deciding if it were a good idea or not. I think it is probably best to re-evaluate the situation at that time; your medications and breastfeeding habits could change a lot before then.

For anyone reading this, please post again or call us at the InfantRisk Center, (806)352-2519, if this has not completely answered your question. I would also appreciate you filling out a 2 minute survey about your time on the forum:

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-James Abbey, MD