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In Tso et al ’s article, it is stated that females on adalimumab should not breastfeed until at least 5 months after the last treatment, according to the manufacturer’s information.1 However, the majority of manufacturers have recently updated their information and now state that adalimumab can be used during breastfeeding.
The NICE guideline PH11 Maternal and Child Nutrition 2 recommends that supplementary sources of information should be consulted regarding the prescribing of drugs to breastfeeding mothers, and that the BNF should only be used as a ‘guide’.
The BNF contains little quantitative data on which to make informed decisions. The Summary of Product Characteristics of the vast majority of drugs recommends that they are not used during lactation. This does not imply risk, more that the manufacturers are not required to take responsibility.3
I consulted the UK Drugs in Lactation Advisory Service (UKDILAS — https://www.sps.nhs.uk/articles/ukdilas/) and Lactmed (https://toxnet.nlm.nih.gov/pda/lactmed.htm), both specialist sources of information for prescribing in lactation. Lactmed states:
‘Limited information indicates that maternal adalimumab injections produce low levels in breastmilk and do not adversely affect the nursing infant. Because adalimumab is a large protein molecule … absorption is unlikely because it is probably destroyed in the infant’s gastrointestinal tract. Most experts feel that the drug is probably safe during nursing. However, until more data become available, adalimumab should be used with caution while nursing a newborn or preterm infant.’
Although there is no published information on the use of secukinumab during breastfeeding, as it is a large protein molecule, the amount in milk is likely to be very low. Absorption is unlikely as it is probably destroyed in the infant’s gastrointestinal tract. As for adalimumab, until more data become available, secukinumab should be used with caution during breastfeeding, especially while nursing a newborn or preterm infant.
UKDILAS concludes that the benefits of breastfeeding on adalimumab and secukinumab outweigh the risks.
As breastfeeding is of proven benefit to both mother and baby, withholding breastfeeding should not be considered a ‘no-harm’ option. It is important that breastfeeding mothers are given informed choice with access to balanced information.
- © British Journal of General Practice 2019