Last update: Feb. 11, 2020

Maternal Rheumatoid arthritis (RA)

Low Risk for breastfeeding


Moderately safe. Probably compatible.
Mild risk possible. Follow up recommended.
Read the Comment.

Autoimmune disease where the immune system mistakenly attacks cells and tissues, potentially damaging the joints, but also the heart, skin, eyes, lungs and arteries and veins.
It is more frequent in women than in men. The disease usually occurs in the form of outbreaks with intermediate periods without symptoms. Smoking is a major trigger.

About half of women with active rheumatoid arthritis improve with pregnancy and most relapse in the first months postpartum making it difficult for them to care for their baby and breastfeed (Bermas 2017 de Jong 2017, Krause 2016, Østensen 2007).
Some studies found a higher risk of recurrence with breastfeeding, especially in the first pregnancy (Vieira 2019). High levels of prolactin have been found in patients with rheumatoid arthritis (Wu 2019).
A lower risk of subsequent arthritis has been found in women who have breastfed (Orellana 2017, Chen 2015).
Having been breastfed decreases the risk of suffering from rheumatoid arthritis (Colebatch 2011, Young 2007, Jacobsson 2003,).

Expert authors and rheumatology associations consulted do not contraindicate breastfeeding but advocate carefully choosing anti-inflammatory and immunosuppressive drugs (Paizis 2019, Anderson 2019, Bermas 2017, de Jong 2017, Krause 2016, Ngian 2016, Götestam-EULAR 2016, Flint 2106 , Kavanaugh 2015, Sammaritano 2014, Makol 2011, Weber 2008, Østensen 2009, 2008 and 2007, Needs 1985).

Ibuprofen, paracetamol, hydroxychloroquine, corticosteroids, cyclosporine, sulfasalazine and methotrexate at doses up to 25 mg per week are safe (Thorne 2014).
Among monoclonal antibodies against tumor necrosis factor (antiTNF) adalimumab, certolizumab and infliximab are safe during breastfeeding because they are not excreted in breastmilk.
There is no data to date to suggest that Janus kinase inhibitors such as baricitinib and tofacitinib are safe (Anderson 2018 and 2016, de Jong 2017).

Suggestions made at e-lactancia are done by APILAM´s pediatricians and pharmacists, and are based on updated scientific publications.
It is not intended to replace the relationship you have with your doctor but to compound it.

Jose Maria Paricio, Founder & President of APILAM/e-Lactancia

Your contribution is essential for this service to continue to exist. We need the generosity of people like you who believe in the benefits of breastfeeding.

Thank you for helping to protect and promote breastfeeding.

José María Paricio, founder of e-lactancia.

Group

Maternal Rheumatoid arthritis (RA) belongs to this group or family:

References

  1. Wu Q, Dan YL, Zhao CN, Mao YM, Liu LN, Li XM, Wang DG, Pan HF. Circulating levels of prolactin are elevated in patients with rheumatoid arthritis: a meta-analysis. Postgrad Med. 2019 Mar;131(2):156-162. Abstract
  2. Vieira Borba V, Shoenfeld Y. Prolactin, autoimmunity, and motherhood: when should women avoid breastfeeding? Clin Rheumatol. 2019 May;38(5):1263-1270. Abstract
  3. Paizis K. Immunomodulatory drugs in pregnancy and lactation. Aust Prescr. 2019 Jun;42(3):97-101. Abstract
  4. Anderson PO. Drug Treatment of Rheumatoid Arthritis During Breastfeeding. Breastfeed Med. 2018 Nov;13(9):575-577. Abstract
  5. Morita T, Fujimoto K, Shima Y, Ogata A, Kumanogoh A. Minimal neonatal transfer of certolizumab pegol in a Japanese patient with rheumatoid arthritis. Ann Rheum Dis. 2018 Sep;77(9):e56. Abstract
  6. de Jong PH, Dolhain RJ. Fertility, Pregnancy, and Lactation in Rheumatoid Arthritis. Rheum Dis Clin North Am. 2017 May;43(2):227-237. Abstract
  7. Louthrenoo W, Kasitanon N, Katchamart W, Aiewruengsurat D, Chevaisrakul P, Chiowchanwisawakit P, Dechanuwong P, Hanvivadhanakul P, Mahakkanukrauh A, Manavathongchai S, Muangchan C, Narongroeknawin P, Phumethum V, Siripaitoon B, Suesuwan A, Suwannaroj S, Uea-Areewongsa P, Ukritchon S, Asavatanabodee P, Koolvisoot A, Nanagara R, Totemchokchyakarn K, et al. 2016 updated Thai Rheumatism Association Recommendations for the use of biologic and targeted synthetic disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis. Int J Rheum Dis. 2017 Sep;20(9):1166-1184. Abstract
  8. Bermas BL. Lactation and Management of Postpartum Disease. Rheum Dis Clin North Am. 2017 May;43(2):249-262. Abstract
  9. Orellana C, Saevarsdottir S, Klareskog L, Karlson EW, Alfredsson L, Bengtsson C. Oral contraceptives, breastfeeding and the risk of developing rheumatoid arthritis: results from the Swedish EIRA study. Ann Rheum Dis. 2017 Nov;76(11):1845-1852. Abstract
  10. Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, Arthanari S, Cunningham J, Flanders L, Moore L, Crossley A, Purushotham N, Desai A, Piper M, Nisar M, Khamashta M, Williams D, Gordon C, Giles I; BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford). 2016 Sep;55(9):1693-7. Abstract Full text (link to original source) Full text (in our servers)
  11. Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, Arthanari S, Cunningham J, Flanders L, Moore L, Crossley A, Purushotham N, Desai A, Piper M, Nisar M, Khamashta M, Williams D, Gordon C, Giles I; BSR and BHPR Standards, Guidelines and Audit Working Group.. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part II: analgesics and other drugs used in rheumatology practice. Rheumatology (Oxford). 2016 Sep;55(9):1698-702. Abstract Full text (in our servers)
  12. Götestam Skorpen C, Hoeltzenbein M, Tincani A, Fischer-Betz R, Elefant E, Chambers C, da Silva J, Nelson-Piercy C, Cetin I, Costedoat-Chalumeau N, Dolhain R, Förger F, Khamashta M, Ruiz-Irastorza G, Zink A, Vencovsky J, Cutolo M, Caeyers N, Zumbühl C, Østensen M. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis. 2016 May;75(5):795-810. Abstract Full text (link to original source) Full text (in our servers)
  13. Anderson PO. Monoclonal Antibodies. Breastfeed Med. 2016 Apr;11:100-1. Abstract
  14. Ngian GS, Briggs AM, Ackerman IN, Van Doornum S. Safety of anti-rheumatic drugs for rheumatoid arthritis in pregnancy and lactation. Int J Rheum Dis. 2016 Sep;19(9):834-43. Abstract
  15. Krause ML, Makol A. Management of rheumatoid arthritis during pregnancy: challenges and solutions. Open Access Rheumatol. 2016 Mar 23;8:23-36. eCollection 2016. Review. Abstract
  16. Chen H, Wang J, Zhou W, Yin H, Wang M. Breastfeeding and Risk of Rheumatoid Arthritis: A Systematic Review and Metaanalysis. J Rheumatol. 2015 Sep;42(9):1563-9. Abstract
  17. Kavanaugh A, Cush JJ, Ahmed MS, Bermas BL, Chakravarty E, Chambers C, Clowse M, Curtis JR, Dao K, Hankins GD, Koren G, Kim SC, Lapteva L, Mahadevan U, Moore T, Nolan M, Ren Z, Sammaritano LR, Seymour S, Weisman MH. Proceedings from the American College of Rheumatology Reproductive Health Summit: the management of fertility, pregnancy, and lactation in women with autoimmune and systemic inflammatory diseases. Arthritis Care Res (Hoboken). 2015 Abstract Full text (link to original source) Full text (in our servers)
  18. Sammaritano LR, Bermas BL. Rheumatoid arthritis medications and lactation. Curr Opin Rheumatol. 2014 Abstract
  19. Thorne JC, Nadarajah T, Moretti M, Ito S. Methotrexate use in a breastfeeding patient with rheumatoid arthritis. J Rheumatol. 2014 Abstract Full text (link to original source) Full text (in our servers)
  20. Makol A, Wright K, Amin S. Rheumatoid arthritis and pregnancy: safety considerations in pharmacological management. Drugs. 2011 Abstract
  21. Colebatch AN, Edwards CJ. The influence of early life factors on the risk of developing rheumatoid arthritis. Clin Exp Immunol. 2011 Jan;163(1):11-6. Abstract
  22. Ostensen M. Management of early aggressive rheumatoid arthritis during pregnancy and lactation. Expert Opin Pharmacother. 2009 Abstract
  23. Østensen M, Lockshin M, Doria A, Valesini G, Meroni P, Gordon C, Brucato A, Tincani A. Update on safety during pregnancy of biological agents and some immunosuppressive anti-rheumatic drugs. Rheumatology (Oxford). 2008 Abstract Full text (link to original source) Full text (in our servers)
  24. Weber JC, Kuhnert C. Traitements de fond des affections inflammatoires systémiques au cours de l’allaitement. [Breastfeeding and drug management in connective tissue and rheumatic diseases]. Rev Med Interne. 2008 Abstract
  25. Young KA, Parrish LA, Zerbe GO, Rewers M, Deane KD, Michael Holers V, Norris JM. Perinatal and early childhood risk factors associated with rheumatoid factor positivity in a healthy paediatric population. Ann Rheum Dis. 2007 Feb;66(2):179-83. Abstract
  26. Østensen M, Motta M. Therapy insight: the use of antirheumatic drugs during nursing. Nat Clin Pract Rheumatol. 2007 Abstract
  27. Jacobsson LT, Jacobsson ME, Askling J, Knowler WC. Perinatal characteristics and risk of rheumatoid arthritis. BMJ. 2003 May 17;326(7398):1068-9. No abstract available. Abstract
  28. Needs CJ, Brooks PM. Antirheumatic medication during lactation. Br J Rheumatol. 1985 Abstract

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