Women do not need to choose between treating their rheumatic disease and breastfeeding! Almost all women will be able to safely do both.
LactMed is a terrific, free, and constantly updated resource about the safety of breastfeeding on all medications.
- Most older anti-rheumatic oral medications:
- Ibuprofen up to 800mg three times per day. Ibuprofen is the preferred NSAID with breastfeeding, but others may be acceptable.
- Prednisone – use up to 20mg a day without impacting the baby. At higher doses, avoid breastfeeding for 4-6 hours after the prednisone dose.
- Steroid joint injections
- All biologic medications (including rituximab, tocilizumab, and others) – the size and type of molecule prevents significant transfer of any anti-rheumatic biologic medication into breastmilk
A special case:
Methotrexate – The ACR Reproductive Health Guidelines conditionally recommend against using methotrexate with breastfeeding. However, the blood and milk level of methotrexate is likely back to zero about 24 hours after the mother takes her weekly dose. For this reason, it could be safe to use with breastfeeding as long as the mother does not give the baby breastmilk produced in the 24 hours after her weekly methotrexate dose.
Medications to Avoid with Breastfeeding
There is not sufficient information about transfer into breastmilk for the following medications. Each of these medications is a ‘small molecule’ that, in theory, could transfer into breastmilk:
- Thalidomide and lenalidomide
- New small-molecule medications (tofacitinib, baricitinib, apremilast, and others) – the small size of these medications suggest they may transfer into breastmilk. The amount of transfer hasn’t been measured, so it is prudent to avoid these.