Breastfeeding & Rheumatoid Arthritis
Dr Nick Sheehan MBChB MD FRCP
Original article: 01/08/2001
Next review due: 06/03/2016
Rheumatoid arthritis (RA) is more than twice as common in women as in men and its incidence in women increases steadily up to their mid forties. Women of childbearing age therefore constitute a substantial percentage of people with rheumatoid arthritis. This raises the important question of which of the drugs prescribed for rheumatoid arthritis are safe to take during pregnancy and breastfeeding.
Firstly, there is no reason why the majority of women with rheumatoid arthritis should not have children and breastfeed them if they want to. The long-term outcome of rheumatoid arthritis is not adversely affected by pregnancy. Obstetric complications are infrequent and a successful pregnancy, normal delivery and healthy baby would generally be expected.
About three quarters of women find that their arthritis becomes less active or even goes into remission during pregnancy. The improvement usually begins in the first trimester and it normally continues throughout the pregnancy. A major bonus of this is that it allows their medication to be reduced to a minimum.
The downside is that the majority of women have a flare up of their RA after giving birth, sometimes within a matter of hours of delivery and often within three months. Typically the time between birth and the RA becoming more active is between four and six weeks. This flare-up can persist for six months but disease activity usually settles to pre-pregnancy levels within a year.
This postpartum (after giving birth) flare has particular implications for the choice of suitable anti-arthritic drugs in women who wish to breastfeed. Careful attention must be given to the choice of medication as some drugs can pass through the milk to the baby. Clear guidance as to which drugs can be taken safely and which should be avoided is given in the British National Formulary (BNF), a prescribing handbook used widely by doctors. However, as there is a lack of information on the transfer of many drugs to breast milk and their possible effects on the baby. As a general principle, it is advisable to reduce medication to a minimum while breastfeeding. It is important to remember that the benefits associated with breastfeeding may outweigh the risks of a short term increase in disease activity. Breastfeeding can protect a baby from infections, such as diarrhoea. Longer term benefits have been shown as well, including a reduced chance of developing obesity, diabetes, eczema and rheumatoid arthritis. There are also psychological benefits to both mother and baby from sharing this experience.
As can be seen from the Table, codeine and paracetamol can be taken safely by breastfeeding mothers. Generally, there is little risk with non-steroidal anti-inflammatory drugs (NSAIDs) either. However, where insufficient information is available about the secretion of a drug into maternal milk or its possible untoward effects on the baby are unknown, the manufacturer will usually advise that the drug be avoided during breastfeeding. This is the situation for many of the NSAIDs and even in the cases of ibuprofen and ketoprofen where the amount of drug reaching the breast milk is probably too small to be harmful, the manufacturers of some brands recommend that they should be avoided unless essential. Nevertheless, there are still plenty of safe NSAIDs to meet the needs of most breastfeeding mothers.
Acceptability of painkilling drugs during breastfeeding
Insufficient data–preferably avoid
Because individual drugs may have several different brand names, only the approved name is given in the table. The approved name, or generic name as it is otherwise known, is clearly shown somewhere on the tablet bottle, packet or drug information leaflet.
Disease-modifying drugs for rheumatoid arthritis, including corticosteroids
Most disease-modifying anti-rheumatoid drugs (DMARDs) are stopped during pregnancy and their reintroduction can usually be postponed until after the mother has finished breastfeeding. If her arthritis flares up severely and needs treatment, the choices are normally between stopping breastfeeding and reintroducing a DMARD or taking corticosteroids until breastfeeding is stopped completely. Small amounts of steroid can get into breastmilk, but it is thought that doses of up to 40mg a day of prednisolone can be taken without any adverse effect on the baby.
Amongst DMARDs, sulfasalazine and gold (by intramuscular injection as sodium aurothiomalate or in tablet form as auranofin) both pass into the breast milk in small amounts with a theoretical risk of causing side effects in the baby. However, sulfasalazine is considered safe to take whereas gold should preferably be avoided. Of the antimalarial drugs, the amount of chloroquine in breast milk is probably too small to be harmful but, although this is also likely to be true for hydroxychloroquine, the general advice is that both should be avoided because of the risk of toxicity in the baby.
The immuno-suppressant drugs methotrexate and cyclophosphamide must not be taken during breastfeeding. Cyclophosphomide is especially strongly contra-indicated as it is secreted in large amounts into breast milk. Leflunamide and ciclosporin are also both secreted into breast milk and should not be taken by breastfeeding mothers.
The low concentrations reached by azathioprine are probably not harmful to the baby but it is usually avoided during breastfeeding.
As the excretion of penicillamine in human breast milk has not been studied, its use during breastfeeding is contra-indicated. However, it is prescribed infrequently nowadays anyway.
If the introduction of a DMARD is unavoidable in a woman who is keen to continue breastfeeding, sulphasalazine, the antimalarials and azathioprine are probably the safest options.
Adalimumab, etanercept, infliximab, certolizumab pegol and golimumab suppress rheumatoid arthritis by blocking the actions of tumour necrosis factor-alpha (TNFα), a chemical which plays a major part in joint inflammation. Studies involving some of the anti-TNF drugs have offered reassuring results with regards to their possible safety during breastfeeding, with some studies showing that little or none of the anti-TNF drug was found in breastmilk. However, the advice on anti-TNF drugs and the level of study data available on them does vary, so a decision on whether or not to take these drugs while breastfeeding should be made on a case by case basis.
Rituximab suppresses joint inflammation by reducing the numbers of B lymphocytes. It should be avoided during breastfeeding on account of its unknown effects on the baby.
Abatacept, which targets T-cells, has been shown to be present in breast milk in animal studies, and should therefore be avoided.
Tocilizumab, which inhibits a chemical called interleukin 6 (IL6), has not been tested in animal studies for its safety during breastfeeding. The manufacturer recommends that a decision on whether or not the drug can be taken while breastfeeding should be made taking into account the benefits of breastfeeding to the baby and the benefits of this drug to the mother.
Some people receiving treatment for rheumatoid arthritis also require other drugs, for example to prevent indigestion caused by their anti-inflammatory medication. Drugs prescribed for dyspepsia associated with NSAIDs include H2-receptor antagonists (cimetidine, famotidine, nizatidine, ranitidine), proton-pump inhibitors (esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole) and the prostaglandin analogue, misoprostol.
Cimetidine, famotidine and ranitidine pass into breast milk in significant amounts and, although they are not known to be harmful to the baby, the manufacturers of cimetidine and famotidine advise that they be avoided during breastfeeding. The amount of nizatidine which reaches the milk is too small to be harmful. Lansoprazole and pantoprazole have been found in breast milk in animal studies and should not be used unless essential. Omeprazole reaches the milk but is not known to be harmful. No information is available for esomeprazole or rabeprazole and both should be avoided. Misoprostol should be avoided for the same reason.
Because of the protective effect of their natural sex hormones, only a small minority of women of childbearing age with rheumatoid arthritis need to take medication to prevent osteoporosis. However it may be advisable if they have been on corticosteroids for a long period of time. Commonly prescribed drugs for this purpose are disodium etidronate (Didronel), alendronic acid (Fosamax) and risedronate sodium (Actonel). As there is no information about these drugs in breastfeeding they should not be restarted until after the baby has been weaned.
Although there are considerable restrictions on the medication that it is advisable for a woman to take while breastfeeding, this should not deter a mother from breastfeeding her baby if she wishes to. If her arthritis flares up after giving birth there are various safe ways in which it can be treated while avoiding drugs which are potentially harmful to the baby or the effects of which are simply unknown.
References available on request