Patient Selection and Safety With TNF Inhibitors - Episode 27
Christopher Robinson, MD, MSCR, FACOG: When we go into pregnancy, we start talking very early on in the course of prenatal care about the plan for infant nutrition after delivery. And the focus here is, am I going to bottle feed, or am I going to breastfeed? Breastfeeding is very important for the development of the infant. It’s important for bonding between the mother and infant. But it also brings special challenges when we talk about autoimmune disease.
For instance, some autoimmune diseases may be more difficult to maintain good hydration throughout, especially if diarrhea is present or flares are present. And so we focus on how to achieve successful lactation in breastfeeding. Breastfeeding can and should be considered strongly in women of autoimmune disease. And so it’s a great option for continuing. The American Academy of Pediatrics recommends up to a year of breastfeeding after delivery, and we really don’t modify that recommendation. What we do, however, is look at what medications that person is on to make decisions about safety of medication use and lactation.
When we look at the majority of our patients who are managed on TNF [tumor necrosis factor]—alpha inhibitors, those inhibitors get transmitted to breast milk at very, very low concentrations, and in some cases, even to levels that cannot be easily measured. There have not been effects shown that there are developmental differences in babies who were born to mothers with or without the use of immunologic agents. We also don’t see any differences in their development when measuring if the baby is on time for developing, crawling, activities, and pediatric care. So we don’t see differences there, and we believe those are very safe options.
And again, autoimmune disease, just as we talked about, goes to sleep in many patients during pregnancy. But after pregnancy has ended and delivery has taken place, autoimmune disease does come back. And so 1 of the key things here is achieving and continuing remission in the postpartum period. This is also very, very important for the mother and the infant. So 1 of our focuses is in finding those medications that are safe.
Now this is a good discussion that should be ideally had prior to holding the baby after delivery. And the reason for that: 1 of the greatest misconceptions and dissatisfiers among women is when you have a care team that may have slightly changed after delivery. For instance, you go to postpartum. On the postpartum floor, you have new nurses, and new individuals coming into your room to see you maybe on the morning after delivery. Suddenly there may be confusing information. In other words, 1 person may come in and say, ”Well, should you be breastfeeding based on your medications?” It’s good to already have that information available. In other words, we like to think about arming the person with as much information as possible about safety before they get there.
And then there are decisions being made. I’ll give you an example of 1 that’s often brought up. The example is, “Should I pump and dump? Should I pump milk and dump milk to get rid of medications in breast milk?” The answer is no. In biologics, anti—TNF-alpha agents, there’s no role for pumping and dumping. And so those women can breastfeed. This can be supported through lactation assistance. A lactation specialist can assist with that, and they can also assist these patients in making decisions about medication use along with maternal-fetal medicine. This is 1 of the things that we address early on in pregnancy. The reason for that is because we know that women are more likely to be successful breastfeeders if they have been armed with this information, not at the time when we’re making a decision—when the baby is in our arms—but when it was planned beforehand.
One of the other things that you will see occur, and this is in normal pregnancy as well as in women with autoimmune disease, is milk supply. “Can I make enough milk, and am I going to have problems with making milk?” Certainly, in inflammatory states and with flares, milk supply will go down. And so 1 of the key features there is keeping the person in remission, keeping them well hydrated, and then also addressing nutrition again. Coming back to nutrition, you do need additional caloric intake to support the ability to lactate. There are some things that may be used in assisting keeping breast milk up.
There is 1 medication—it’s kind of an herbal—that is out there, that is used in some cases to support lactation. However, we do not recommend using it. The drug is called fenugreek. Fenugreek can predispose people to additional bleeding. So if the patient were to have problems, especially with bowel or autoimmune disease involving Crohn disease or colitis, that could potentiate that effect of bleeding. And so we do avoid that. But otherwise, green tea, good hydration, and bringing the baby to breast frequently can help support and keep lactation adequate throughout that time period, so that breastfeeding can be just as if the disease were not present.
This is a common question: “If my baby has been exposed to a biologic agent throughout pregnancy and then after delivery, do I need to have concerns? Are there any different needs that should be taken into consideration?” Pediatrics will discuss this with patients, but immunizations may change slightly. There is 1 immunization that is given at under 6 months that is a live attenuated vaccine for rotavirus. And so if a person were to receive the rotavirus vaccine at 2 months and 4 months, that may be delayed. This is a vaccine that helps prevent a certain type of diarrhea that may take place in infants. So that may be delayed slightly, even though the evidence from the best registries that we have going forward suggest that there is no impact on vaccination schedule or need for vaccination schedule to be changed based on exposure to immunomodulators or biologic agents in pregnancy.