REVIEW www.nature.com/clinicalpractice/rheum Therapy Insight: the use of antirheumatic drugs during nursing Monika Østensen* and Mario Motta Continuing Medical Education online Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn CME credit. Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide CME for physicians. Medscape, LLC designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits TM . Physicians should only claim credit commensurate with the extent of their participation in the activity. All other clinicians completing this activity will be issued a certificate of participation. To receive credit, please go to http://www.medscape.com/cme/ncp and complete the post-test. Learning objectives Upon completion of this activity, participants should be able to: 1 Identify the prevalence of disease flare-up in women with rheumatoid arthritis (RA) after pregnancy. 2 List immunosuppressive drugs recommended for use in women with RA during lactation. 3 Identify anti-inflammatory agents least likely to appear in high levels in breast milk during lactation. 4 Describe corticosteroid levels in breast milk with maternal ingestion. 5 Describe precautions for caring for infants of lactating women with RA who use azathioprine or methotrexate. INTRODUCTION Although rheumatoid arthritis (RA) tends to improve in most patients during pregnancy, 90% of patients experience flares within 3 months of delivery of their baby. The postpartum reactivation of disease symptoms is equally common in patients with ankylosing spondylitis, psoriatic arthritis, and juvenile idiopathic arthritis. As a consequence, drug treatments are often required during lactation. Effective disease control is of critical importance in order to inhibit disease progression and to enable the mother to care for her baby. Breastfeeding is the best method of feeding neonates and young infants because of the nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits. 1 Studies on the excre- tion of drugs into breast milk are rare, and prima- rily based on single-dose or short-term treatment. In many cases, the effects of antirheumatic drugs on nursing infants have not been studied and, In 90% of cases, women with rheumatoid arthritis suffer a disease flare within 3 months of delivery of their baby. Drug treatment is, therefore, required; however, such therapies have implications for mothers who decide to nurse their infants. Unfortunately, because of a paucity of data, little is known about the transfer of antirheumatic drugs into breast milk, and even less is known about whether small amounts of these agents ingested during nursing could harm the infant. Our review of the literature indicates that paracetamol, prednisone, antimalarial agents, sulfasalazine and most NSAIDs can safely be used by lactating mothers. Expert opinions differ regarding the use of azathioprine, ciclosporin, and methotrexate during lactation because of varying views on the potential for short- term and long-term adverse effects. Evidence regarding the transfer of leflunomide and biologic drugs into breast milk is insufficient; therefore, until more studies are conducted, the use of these drugs in breastfeeding mothers should be restricted. At present, many patients feel they have to choose between postpartum disease control and lactation. Extended studies of the transfer of antirheumatic drugs into breast milk and the resulting consequences are, therefore, urgently needed. KEYWORDS antirheumatic drugs, breastfeeding, lactation, side effects in infants M Østensen is Professor of Rheumatology and is the Director of the Center for Women with Rheumatic Disease in the Department of Rheumatology, University Hospital of Bern, Bern, Switzerland. M Motta is a neonatologist in the Division of Newborn Medicine, Brescia Hospital, Brescia, Italy. Correspondence *Department of Rheumatology, University Hospital of Bern, CH-3010 Bern, Switzerland monika.oestensen@insel.ch Received 8 November 2006 Accepted 30 April 2007 www.nature.com/clinicalpractice doi:10.1038/ncprheum0532 REVIEW CRITERIA A PubMed search of English-language journals from 1960 to the present was performed with the following terms: “lactation”, “breastfeeding”, and a combination of the names of specific medications with “excretion into human breast milk”. In addition, the database “LactMed” and the website “Motherisk” were searched. The authors also referred to their private libraries. SUMMARY CME 400 NATURE CLINICAL PRACTICE RHEUMATOLOGY JULY 2007 VOL 3 NO 7