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A few questions *please read if you have Chron's or UC*

Posted by on Jan. 19, 2013 at 8:09 PM
  • 8 Replies

Hey there..I'm having a procedure done on Tuesday and will be getting IV drugs to knock me out for it. Just wondering how much I should pump for baby and when I can nurse again? The procedure will be about an hour. Also, part of my prep the day before is to drink GoLytely to cleanse my system..does anyone have any info on if that passes through the breast milk? 

And depending on the results of my procedure, I may have to get heavy doses of Humira injections to try and control this flare up. My dr has already informed me that he will not prescribe the injecections if I'm still nursing since it is present in breastmilk and there is no research on the long term effect of it in nursing babies. My daughter is 5.5 months. What would be the best way to wean her quickly if this is needed? Please don't suggest me seeing another dr..we are stationed in Japan and that is literally not possible unless we go back stateside. He is the only GI here. I am going to talk to him about starting with the less severe meds first, but I've been dealing with this flare up since Nov and it's only getting worse :/ 

Thanks in advance for any help!


**This is my update, also in reply #4**

Thanks so much for the info everyone! The procedure went fine and Taliyah was able to nurse when I woke up. I had also asked the anesthesiologist and she said according to LLL it would be ok, but if it made me more comfortable then I could always pump and dump the first session. Gotta love a dr who is pro-breastfeeding!!!

Well, my GI seems to be on a different track with me nursing. He is now talking about bi-monthly IV infusions of Remicade. He is VERY adamant about me stopping breastfeeding. He again reminded me that his research doesn't show the long term effects on breastfed babies, so he won't prescribe it if I'm still nursing. He wrote on ALL of my discharge papers to stop breastfeeding, and this morning I called to verify a medication's dosage he gave, and he reminded me again to stop breastfeeding. To be quite honest, I'm feeling bullied :/ I don't mind Taliyah being on formula if she HAS to be..but if she doesn't then my goal is 2 years minimum. I checked lactmed for Remicade, and it has some studies that show a very minimal amount pass the barrier. What I need to know is, how respected is the info from lactmed.com to doctors? I want to print it out and show it to him, but I don't want him to turn around and tell me that it's not a reliable source of info, ya know?

I had told him before my procedure that I'd much rather start off with the lower grade Chron's meds than to jump right into the big bang ones. He seemed against that right away and again told me that I may be able to find a dr willing to do that, but I'd have to go back stateside. But he said, let's wait and see what's going first. Well, my procedure showed ulcers, bleeding and an area so swollen that it may cause blockage. So I'm thinking he's really going to push for the bigger meds :/

I'm not really sure what I'm asking other than the reliability of the lactmed site. Like, if it's respected by mainstream drs. I'm just also really kind of sad and bummed out :( And maybe there is someone else who has/is going through this that might have some advice??

Thanks for letting me ramble..

by on Jan. 19, 2013 at 8:09 PM
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Replies (1-8):
aehanrahan
by Group Mod - Amy on Jan. 19, 2013 at 8:26 PM
1 mom liked this
You only need to pump enough for any feedings that will be missed during the procedure. You can nurse as soon as you can hold the baby safely.
You can call the infantrisk hotline about the medications. Dr. Hale is who I would trust in regard to medications and breastfeeding.
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ckroch
by Colleen on Jan. 19, 2013 at 8:26 PM
You likely don't need to pump & dump for procedure. Find out exactly what meds are being used.
Check lactmed online
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gdiamante
by Group Mod - Gina on Jan. 20, 2013 at 9:48 AM

LactMed info on Humira:

Adalimumab
CASRN: 331731-18-1
Chemical structure for Adalimumab
For other data, click on the Table of Contents


Drug Levels and Effects:


Summary of Use during Lactation: 
Limited information indicates that maternal adalimumab injections produce low levels in milk and do not adversely affect the nursing infant. Because little is excreted into breastmilk and is not likely to be absorbed, some experts feel that the drug is probably safe during nursing.[1][2][3][4] However, until more data become available, an alternative drug may be preferred, especially while nursing a newborn or preterm infant.


Drug Levels: 
Maternal Levels. One woman received a single 40 mg of adalimumab subcutaneously at 4 weeks postpartum. Milk samples were obtained every 2 days for 8 days. A peak milk adalimumab level of 31 mcg/L was detected on day 6 after injection. Milk levels on days 5 and 8 were about 10 mcg/L.[5]

Two mothers received adalimumab 40 mg subcutaneously for inflammatory bowel disease. Breastmilk infliximab was 200 mcg/L in one mother (time after dose not stated), which was about 4.3% of her serum concentration. The second mother began infliximab at 3 months postpartum. Her breastmilk infliximab levels were 94.6 mcg/L on day 1 after the first dose and 119.7 mcg/L on day 4 after the dose.[6]

Two women received adalimumab 40 mg subcutaneously for treatment of inflammatory bowel disease at unstated intervals. The first woman received the drug during pregnancy and postpartum. At 21 weeks postpartum and 7 days after the previous dose, her breastmilk adalimumab was 4.83 mcg/L while her serum level was 6.7 mg/L. In the second woman, the milk adalimumab concentration at 8 weeks postpartum and 9 days after the last dose was 4.88 mcg/L with a simultaneous serum concentration of 5.5 mg/L.[6]

Infant Levels. A woman received adalimumab 40 mg subcutaneously at unstated intervals while breastfeeding (extent not stated). At 8 weeks postpartum and 9 days after the prior dose, the infant had an undetectable (<0.65 mcg/L) adalimumab serum concentration.[6]


Effects in Breastfed Infants: 
One woman with Crohn's disease received adalimumab 40 mg subcutaneously every week during pregnancy and breastfeeding (extent not stated). Her infant demonstrated normal growth and development at 6 months of age.[7] The authors reported a brief follow-up stating that the woman also breastfed her second infant during adalimumab therapy with no adverse consequences.[1]

Another woman with Crohn's disease received adalimumab 40 mg subcutaneously every 2 weeks during pregnancy and breastfeeding (extent not stated). Her infant demonstrated normal growth and development at 6 months of age.[8]

Two women nursed their infants (extent not stated) while receiving adalimumab 40 mg subcutaneously at unstated intervals for inflammatory bowel disease. They breastfed for at least 21 weeks and 8 weeks, respectively, but the total duration was not stated. At 14.5 and 15 months of age, respectively, neither infant had any signs of adverse drug reactions, allergic reactions or severe infections leading to hospitalization. Developmental milestones were reached on time by both infants.[6]


Possible Effects on Lactation: 
Relevant published information was not found as of the revision date.


Alternate Drugs to Consider: 
EtanerceptInfliximab


References: 
1. Mahadevan U. Pregnancy, fertility and therapies for IBD. Gastroenterol Hepatol. 2006;2:234-6. 2. Skomsvoll JF, Wallenius M, Koksvik HS et al. Drug Insight: anti-tumor necrosis factor therapy for inflammatory arthropathies during reproduction, pregnancy and lactation . Nature Clin Pract Rheumatol. 2007;3:156-64. PMID: 17334338 3. Ostensen M. Management of early aggressive rheumatoid arthritis during pregnancy and lactation. Expert Opin Pharmacother. 2009;10:1469-79. PMID: 19505214 4. van der Woude CJ, Kolacek S, Dotan I et al. European evidenced-based consensus on reproduction in inflammatory bowel disease. J Crohn's Colitis. 2010;4:493-510. PMID: 21122553 5. Ben-Horin S, Yavzori M, Katz L et al. Adalimumab level in breast milk of a nursing mother. Clin Gastroenterol Hepatol. 2010;8:475-6. PMID: 20005982 6. Fritzsche J , Pilch A, Mury D et al. Infliximab and adalimumab use during breastfeeding. J Clin Gastroenterol. 2012;46:718-9. PMID: 22858514 7. Vesga L, Terdiman JP, Mahadevan U. Adalimumab use in pregnancy. Gut. 2005;54:890. PMID: 15888806 8. Mishkin DS, Van Deinse W, Becker JM, Farraye FA. Successful use of adalimumab (Humira) for Crohn's disease in pregnancy. Inflamm Bowel Dis. 2006;12:827-8. PMID: 16917239


Substance Identification:


Substance Name: Adalimumab

CAS Registry Number: 331731-18-1

Drug Class: 
Antibodies, Monoclonal, Humanized
Antirheumatic Agents
Dermatologic Agents
Gastrointestinal Agents

Administrative Information:


LactMed Record Number: 
513


Last Revision Date: 
20121002

Disclaimer: Information presented in this database is not meant as a substitute for professional judgment. You should consult your healthcare provider for breastfeeding advice related to your particular situation. The U.S. government does not warrant or assume any liability or responsibility for the accuracy or completeness of the information on this Site. 


tashntim
by on Jan. 22, 2013 at 6:54 PM

Thanks so much for the info everyone! The procedure went fine and Taliyah was able to nurse when I woke up. I had also asked the anesthesiologist and she said according to LLL it would be ok, but if it made me more comfortable then I could always pump and dump the first session. Gotta love a dr who is pro-breastfeeding!!!

Well, my GI seems to be on a different track with me nursing. He is now talking about bi-monthly IV infusions of Remicade. He is VERY adamant about me stopping breastfeeding. He again reminded me that his research doesn't show the long term effects on breastfed babies, so he won't prescribe it if I'm still nursing. He wrote on ALL of my discharge papers to stop breastfeeding, and this morning I called to verify a medication's dosage he gave, and he reminded me again to stop breastfeeding. To be quite honest, I'm feeling bullied :/ I don't mind Taliyah being on formula if she HAS to be..but if she doesn't then my goal is 2 years minimum. I checked lactmed for Remicade, and it has some studies that show a very minimal amount pass the barrier. What I need to know is, how respected is the info from lactmed.com to doctors? I want to print it out and show it to him, but I don't want him to turn around and tell me that it's not a reliable source of info, ya know?

I had told him before my procedure that I'd much rather start off with the lower grade Chron's meds than to jump right into the big bang ones. He seemed against that right away and again told me that I may be able to find a dr willing to do that, but I'd have to go back stateside. But he said, let's wait and see what's going first. Well, my procedure showed ulcers, bleeding and an area so swollen that it may cause blockage. So I'm thinking he's really going to push for the bigger meds :/

I'm not really sure what I'm asking other than the reliability of the lactmed site. Like, if it's respected by mainstream drs. I'm just also really kind of sad and bummed out :( And maybe there is someone else who has/is going through this that might have some advice??

Thanks for letting me ramble..

aehanrahan
by Group Mod - Amy on Jan. 22, 2013 at 8:20 PM
Lactmed is from the national institutes of health.
I still say that a call to Dr. Hale's infantrisk bottling is also in order.
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tashntim
by on Jan. 22, 2013 at 9:30 PM


Quoting aehanrahan:

Lactmed is from the national institutes of health.
I still say that a call to Dr. Hale's infantrisk bottling is also in order.

Thanks!! I actually have my husband coming home with a new phone card so I can give them a call :D

maggiemom2000
by Ruby Member on Jan. 22, 2013 at 9:42 PM

Argh. That doc is makin' me mad! The risk of stopping breastfeeding is very well documented, both short term ad long term effects, and this drug appears to have very, very, little possible risk. So, what this doctor is saying is that the known short and long term risks of stopping breastfeeding is a better option than mom taking a med with practically no risk to baby. I thought you were supposed to pick the option with the LOWEST risk! Clearly that is continuing to breastfeed with the medication.

The following information comes from MEDICATIONS AND MOTHERS’ MILK by Thomas Hale, 2012.  He assigns every drug a lactation risk category:  L1, safest; L2, safer; L3, moderately safe; L4, possible hazardous; and L5, contraindicated. He also lists if a drug has been reviewed and/or approved by the American Academy of Pediatrics (AAP) for use in nursing mothers.  Possible risks to mother and baby are listed as well as possible effect on milk supply.


For more info you can call Dr. Hale’s InfantRisk hotline at (806) 352-2519

www.infantrisk.org

INFLIXIMAB (Remicade)

Listed as L2, safer. Pediatric concerns: none reported in three patients

“Infliximab is probably too large to enter milk in clinically measurable amounts. It would not be orally bioavailable.”


The decision about continuing breastfeeding when the mother takes a drug is far more involved than whether the baby will get any in the milk. It also involves taking into consideration the risks of not breastfeeding, for the mother and the baby. And there are plenty of risks in not breastfeeding, so the question essentially boils down to:  Does the addition of a small amount of medication to the mother’s milk make breastfeeding more hazardous than exclusive formula feeding? The answer is almost never. Breastfeeding with a little drug in the milk is almost always safer. Dr, Jack Newman http://www.breastfeedinginc.ca/content.php?pagename=doc-B-M


aehanrahan
by Group Mod - Amy on Jan. 22, 2013 at 10:04 PM
That ^^^ is the information that you will get from the hotline!
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