Dear Gaurav Gulati,

In addition to hydroxychloroquin and prednisolone, sulphasalazine is a reasonably safe choice. If your patients responds to the combination of these thee, well and good.

Methotrexate and leflunomide are a strict NO NO.

That leaves biologicals. Most biologicals are secreted in breast milk in very miniscule amounts. Being proteins, they can be digested in the baby's gut. Higher the molecular weight, lesser the concentration in breast milk. For eg etanercept is present in a slightly higher percentage than infliximab in breast milk.

By and large, biologicals are not recommended in lactation, but mostly there is inadequate evidence. If the disease is indeed refractory, one can always choose to shift the baby to alternate feeds and focus on mother's treatment as in any other RA.

In case one has decided that breast milk is mandatory AND the disease is not getting under control with combination of the 3 drugs in para 1, I would choose a biological. I might settle for Infliximab due to its high molecular weight (hence less secretion into milk)

Hope this helps

regards

Thanks for your response. I did think about sulfasalazine as the next possibility, but again, it does have enterocolitic effects of the breastfed child with instances of bloody diarrhea etc reported. And the TNF's are a concern for obvious reasons. Others are already out of the picture including rituximab etc.

So short of asking her to stop breastfeeding which will solve all these issues, I was wondering what else could be done. Of all TNFs considering remade, bight be less transferable, but still the risk will be substantial and possibility of tolerance in the absence of MTX with it might make it ineffective also over time.

Does any one have experience with IL based therapy for RA in lactating mothers? That was something else to consider I guess. What about abatacept? Safety unknown in lactation but unsafe in pregnancy...

Theoretically Anakinra might be an acceptable choice as IL-ra has naturally been detected in breast milk.

I have no experience with it thoiugh

Anakinra is a good idea !

You can also try  Cimzia  there good results in the literature !

Pred , plaqunil , sulfasalaazine if the disease not controlled

certolizumab will be the next choice

None of the biologics approved for use during pregnancy to my knowledge, although negative data in small groups receiving certolizumab and abatacept.

Would stick with prednisone and consider a higher dose to allow the woman to continue breast feeding; would also discuss with her the "pros and cons" of what she is doing and how this partial therapeutic hiatus might be affecting her now and might be affecting how she can care for her child later.

NSAIDS, Hydroxychloroquine, Sulphasalazine and prednisolone

if biologics needed TNF inhibitors may be used