I’m really saddened that so many mothers are recommended to stop breastfeeding in order to be treated with medication. There is some evidence that breastfeeding in itself protects the mother
I hope that this factsheet provides some alternatives. The information is taken from Breastfeeding and Chronic Medical Conditions – https://tinyurl.com/mbbebe8x
RA and Breastfeeding Factsheet
“Recovering from childbirth is horrendous enough (well it was for me), never mind having RA
symptoms on top of it. I met with my consultant 3 weeks after the birth, and straight away she was
urging me to stop breastfeeding and trying to get me to begin courses of strong medication.
Overwhelmed by the pain, the sleepless night, and the huge amount of information she was throwing
at me, I found it very hard to take much of what she said in. I just knew I wanted to do the best for
my baby. Appointments with rheumatology since have been similar, pushing me to stop
breastfeeding, not listening to my reasons for wanting to breastfeed, and pushing the stronger
meds.”
“In autumn 2016 I noticed my left thumb was sore a lot of the time. Thinking I had hurt it in
somehow, I did not do anything more about it. Soon after I noticed the rest of my fingers and hands
starting to ache. There were days in work where I could not do my job properly, because my hands
were so sore, and I could barely stand to wash my hands, the pain was so severe. A few bloods taken
in January 2017 by my GP, revealed that I had developed Rheumatoid Arthritis. There is no history of
it in my family, and I knew very little about it. I waited several months for my first rheumatology
appointment at the hospital. When I eventually got my appointment, several months later, I was
pregnant with our second baby, and was amazed that the pregnancy had almost completely
eliminated my RA pains. The consultant warned me that after my baby arrived the RA would hit me
hard. And wow was she right.”
“I have seropositive erosive rheumatoid arthritis. I was diagnosed in July 2019. I breastfed my toddler
until he was nearly 17 months but stopped due to entering the 2nd trimester of pregnancy, by then
he was ready to stop and so was l. When l was diagnosed my baby was 10months old. It appears l
may have had RA since l was 17 but did not realise. I was told to stop breastfeeding by many nurses,
GPs and rheumatologists. As l had 7 years of infertility and 3 failed IVF l was desperate to not stop
breastfeeding until l thought my son was ready. I thought he would be my only baby. I have anxiety
and suffer from frequent panic attacks, but breastfeeding helped me manage the emotions and
exhaustion of motherhood. Through seeking guidance from you l asked my rheumatologist if l could
be put on Sulfasalazine which is safe for breastfeeding. It was very slow and ineffective to treat my
active inflammation at the start but allowed me to continue my breastfeeding journey. They wanted
to put me on methotrexate which is not suitable for breastfeeding. They gave me 4 massive injections
of steroids to try and get my RA under control over a period of a few months. My inflammation was
still sky high. When l found out l was pregnant in November 2019 l went into remission with the
change in hormones. I was put on Cimzia (biologic) just before Christmas to prevent any further
erosions in my feet. I have had to come off Cimzia a few days ago, due to a high risk of severe
symptoms if l catch Corona Virus as technically, they think my disease activity has only been reduced
due to pregnancy hormones. I am now 26 weeks pregnant. I hope l do not flare in trimester 3 or
when the baby is born because then they may force me to take methotrexate and another immune
suppressing biologic. I desperately hope to breastfeed baby 2 but understand this pandemic may not
be going away any time soon. I want to be safe for my children. Thank you for your advice because
you enabled me to continue to feed my baby for another 9 months more after diagnosis. I feel a lot of
people including many in the medical profession think if you have fed your baby until they are on
solids then it is not necessary to keep on breastfeeding. By understanding what meds are safe for
breastfeeding a lot of women have more choice to decide when it is right for them to give up.”
“Would I be in a better position if I weren’t breastfeeding? The consultant could not answer that.
Every case is different, and everyone responds differently to the medicine. There is no proof that if I
stopped, I would be in less pain, so I am happy to feed my boys for as long as they keep wanting me
to. I am trying exercise, physio and dietary changes to help reduce pain, instead of relying solely on
medication. I am taking it one day at a time, and I love being a Mummy more than anything.
Breastfeeding is so much more than just giving your child nourishment, it is quality time together, a
special bond between mum and baby, which I will never forget. I will always cherish my years of
breastfeeding, the cuddles, smiles and love we have shared together. Yes, I have rheumatoid
arthritis, but it does not define me. Always remember, never give up on a hard day. Tomorrow is
another beginning.”
Description
Rheumatoid arthritis (RA) is a common chronic inflammatory autoimmune disease. It is associated
with significant pain and disability. Control of the inflammation in the early stages can prevent long
term damage which is why consultants are keen to use disease modifying agents as soon as possible.
The overall occurrence of RA is two to four times greater in women than in men. The peak age of
incidence in the UK for both genders is the 40s, but people of all ages can develop the disease. There
is a genetic influence in developing the condition, but it is also linked with environmental factors,
such as high birth weight, smoking, silica exposure, alcohol abstention, obesity, and diabetes
mellitus.
There is evidence (NICE 2015) that the first 12-week period of the disease represents a unique
opportunity to influence the progress of the disease. The challenge is to recognise early symptoms
see a specialist. Presenting symptoms can be very variable: profound fatigue, influenza-like
symptoms, fever, sweats and weight loss are common. Other organs can be involved. Typically, there
may be periods of exacerbations and remissions, but it may be mild self-limiting condition or a
chronic progressive illness.
Treatment
There is evidence that breastfeeding protects against the risk of developing rheumatoid arthritis
(Chen 2015). No protective effect was noted from simply having children and not breastfeeding, or
from taking oral contraceptives (Pikwer 2008)
Drugs for rheumatoid arthritis which can be taken during breastfeeding:
Non-steroidal anti-inflammatory drugs (NSAIDS)
Ibuprofen: very low levels in breastmilk. Can be used even when baby needs direct
ibuprofen syrup e.g. during teething or fever
diclofenac: has historically been widely used in breastfeeding
naproxen: longer half-life than diclofenac or ibuprofen but levels in breastmilk low
celecoxib: low levels in breastmilk
Mefenamic acid – no studies but BNF states “amount in milk too small to be
harmful”
Ketoprofen: low levels in breastmilk, one centre in France 8/174 incidences of
adverse events including oesophageal ulceration, erosive gastritis, meningeal
haemorrhage, and renal insufficiency.
Meloxicam: Limited oral bioavailability but no studies.
Etoricoxib – no data , celecoxib preferable
Indometacin: One case of seizure reported in neonate exposed through milk. Avoid as safer
alternatives
all of the above with PPI omeprazole to protect the mother’s stomach.
DMARDS such as Hydroxychloroquine (see Lupus) but not methotrexate are acceptable
Biologicals – etanercept, infliximab, adalimumab, rituximab. All have large molecular
weights which produce zero oral bioavailability. Certolizumab pegol has a licence for use by
breastfeeding mothers.
Where opiates are required dihydrocodeine would be the drug of choice as it has a cleaner
metabolism than codeine. Tramadol is also acceptable
References
- Davies NM, Anderson KE, Clinical pharmacokinetics of naproxen, Clin Pharmacokinet,
1997;32:268–93. - Eeg-Olofsson O, Malmros I, Elwin CE, Steen B. Convulsions in a breast-fed infant after
maternal indomethacin. Lancet. 1978;2 (8082):215. Letter Gardiner SJ, Doogue MP, Zhang
M, Begg EJ, Quantification of infant exposure to celecoxib through breastmilk, Br J Clin
Pharmacol, 2006;61:101–4. - Hale TW, McDonald R, Boger J, Transfer of celecoxib into human milk, J Hum Lact,
2004;20(4):397–403.
- Ito S, Blajchman A, Stephenson M, Prospective follow-up of adverse reactions in breastfed
infants exposed to maternal medication, Am J Obstet Gynecol, 1993;168:1393–9. - Jamali F, Stevens DRS, Naproxen excretion in milk and its uptake by the infant, Drug Intell
Clin Pharm, 1983;17:910–11. - Knoppert DC, Stempak D, Baruchel S, Koren G, Celecoxib in human milk: a case report,
Pharmacotherapy, 2003;23(1):97–100. - NICE CG 79 2015. Rheumatoid arthritis in adults: management
- Soussan C, Gouraud A, Portolan G et al. Drug-induced adverse reactions via breastfeeding: a
descriptive study in the French Pharmacovigilance Database. Eur J Clin Pharmacol. 2014;
70:1361-6 - Townsend RJ, Benedetti TJ, Erickson SH, Cengiz C, Gillespie WR, Gschwend J, Albert KS,
Excretion of ibuprofen into breastmilk, Am J Obstet Gynecol, 1984;149(2):184–6. - Walter K, Dilger C, Ibuprofen in human milk, Br J Clin Pharmacol, 1997;44:211–12.
- Weibert RT, Townsend RJ, Kaiser DG, Naylor AJ, Lack of ibuprofen secretion into human milk,
Clin Pharm, 1982;1:457–8.
.
Further Information
National Rheumatoid Arthritis Society https://www.nras.org.uk/
