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."
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.