Tuesday, 24 February 2015

ClinicSpeak: steroid use and breast feeding

Pulsed high-dose steroids are safe during breast feeding. #ClinicSpeak #MSBlog #MSResearch

"The case study below of a lactating MSer treated with high-dose intravenous steroids for a relapse shows that only a small amount of the actual steroids crosses over into the breast milk. The actual dose the baby gets from breast feeding is low. Women MSers who want to start or extend their families will find this small bit of evidence reassuring."

"You are probably already aware that during pregnancy the attack rate of MS falls, particular in the middle and last thirds, with a rebound post-partum, or after delivery. Breast-feeding seems to blunt the rebound after delivery. Managing MS in pregnancy is quite an art, in particular in woman who are a DMT and want to fall pregnant. None of the drugs are recommended by manufactures to be used in pregnancy hence we have to rely on data collected in registries and from animal studies to ascertain which drugs are safe in pregnancy. At the moment glatiramer acetate, and possibly interferon-beta and dimethyl fumarate, appear to be safe in pregnancy. Natalizumab is emerging as being relatively safe with an increasing number of woman falling pregnant having good outcomes on the drug. Alemtuzumab, and other induction therapies, are probably the most appealing as they are given as short courses and are out of the system quite quickly making them safe in pregnancy. The latter is provided you are not pregnant whilst having the induction course. The one caveat with alemtuzumab is secondary autoimmunity; the auto-antibodies can cross the placenta and cause transient autoimmunity in the unborn child. The latter is a particular problem with thyroid disease; hence all woman of childbearing age who opt for alemtuzumab therapy need to be  told of the risks of autoimmunity to the unborn child. My endocrinology colleagues tell me that transient neonatal hyperthyroidism is quite common and is usually quite simple to managed. Based on my limited experience to date the risk of transient neonatal autoimmunity has not affected decision-making with regard to being treated with alemtuzumab."


"Pregnancy and MS is complex and expanding topic and is almost becoming a sub-specialty on its own."

Epub: Cooper et al. Transfer of Methylprednisolone into Breast Milk in a Mother with Multiple Sclerosis. J Hum Lact. 2015 Feb 17. pii: 0890334415570970.

Background: High-dose intravenous methylprednisolone, a glucocorticoid with powerful anti-inflammatory activities, has become increasingly important in treating acute relapses of MS. 

Case report: This is a case report of a 36-year-old lactating female who was receiving a 3-day course of high-dose methylprednisolone (1000 mg IV) to treat MS. Breast milk samples were obtained at 1, 2, 4, 8, and 12 hours following a 2-hour intravenous infusion on days 1, 2, and 3. The relative infant dose was found to be 1.45%, 1.35%, and 1.15% for days 1, 2, and 3, respectively. Using the average measured concentrations (Cavg) for days 1, 2, and 3, the estimated infant exposure was 0.207, 0.194, and 0.164 mg/kg/day, respectively, which is below the recommended dose given to neonates requiring methylprednisolone drug therapy. 

Conclusion: Infant exposure is low and mothers could continue to breastfeed if treatment with IV methylprednisolone is very brief. However, if the mother wishes to limit infant exposure further, she could wait 2 to 4 hours after IV methylprednisolone administration, thus significantly limiting the amount of drug in the breast milk.

CoI: multiple

9 comments:

  1. Is there work going on to tackle the secondary autoimmunity risk? You mentioned in a previous post administering Rituximab at the same time to reduce the risk... Can you explain this idea a little further, and let us know the status of this work to tackle 2ndary AI (and who's doing it)? How long until we see human trials, or even. Something hitting the market?

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    1. not sure if giving at the same time is worthwhile as you would have B cell depleion at the same time as Tand B cell depletion. However in humanised CD52 mice lemtrada depletes B cells in blood but does not deplete B cells in lymph nodes very much. After Lemtrada you have a massive overshoot of B cells to 150% their normal levels I wonder if this is the cause of B cell autoimmunity because you have B cell actovity when T cell regulation is knocked out of sight.

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    2. I would think give lemtrada and delete B cells to stop the hyperproliferation and maybe this stops the autoimmunity

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    3. not sure if giving at the same time is worthwhile as you would have B cell depleion at the same time as Tand B cell depletion. However in humanised CD52 mice lemtrada depletes B cells in blood but does not deplete B cells in lymph nodes very much. After Lemtrada you have a massive overshoot of B cells to 150% their normal levels I wonder if this is the cause of B cell autoimmunity because you have B cell actovity when T cell regulation is knocked out of sight.

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  2. Do we know why/how Lemtrada causes this?

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    1. it is not known definatively I have my suspicions. We have created a hypothesis and it is testable.

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    2. it is not known definatively I have my suspicions. We have created a hypothesis and it is testable.

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  3. There is a trial going on run by Dr. Coles at Cambridge, the CAM-THY trial, looking at adding kepivance to alemtuzumab to reduce the problem of secondary auto immunity. The info is on the colescambridge website

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  4. I would dread the next feeding because it just hurt so bad! Michael always said it made no sense breastfeeding guide

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