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Ishikawa H, Furugen A, Nishimura A, Umazume T, Ishikawa S, Aoyagi R, Narumi K, Okamoto K, Takekuma Y, Sugawara M, Kobayashi M. Validated UPLC-MS/MS method for quantification of melatonin receptor agonists and dual orexin receptor antagonists in human plasma and breast milk: Application to quantify suvorexant and lemborexant in clinical samples. J Pharm Biomed Anal 2024; 251:116432. [PMID: 39180895 DOI: 10.1016/j.jpba.2024.116432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/08/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
Pharmaceutical care is important for mental health during the perinatal period, which is often characterized by insomnia. In recent years, prescriptions of melatonin receptor agonists (MRAs) and dual orexin receptor antagonists (DORAs) for insomnia have increased; however, their use during the perinatal period has scarcely been reported. In the present study, we developed a UPLC-MS/MS method for the quantification of ramelteon, its metabolite M-II, suvorexant, and lemborexant in human plasma and breast milk to accumulate information on the safety and transfer of MRAs and DORAs into breast milk. Samples of MRAs (ramelteon and M-II) in plasma and breast milk were prepared using liquid-liquid extraction (LLE) with ethyl acetate. For DORAs (suvorexant and lemborexant), LLE with ethyl acetate was applied to plasma samples. For breast milk samples, significant ion suppression was observed for LLE with ethyl acetate. Solid-phase extraction (SPE) cartridges capable of removing phospholipids improved the matrix effects. Finally, protein precipitation with methanol and an SPE cartridge, InertSep® Phospholipid Remover, were selected for breast milk sample preparation. An ACQUITY UPLC BEH C18 column was used for analyte separation. MRAs and DORAs were eluted using isocratic and gradient elution, respectively, and analyzed using electrospray ionization in the positive mode with multiple reaction monitoring. The range of calibration curve for MRAs and DORAs was 0.1-25 and 0.5-50 ng/ml, respectively. Both the plasma and breast milk samples exhibited good linearity over this range. The method was validated by evaluating its accuracy and precision, matrix effect, recovery, carry-over, stability, and dilution integrity. The validated method was successfully applied to clinical samples donated by breastfeeding women and the milk/plasma (M/P) ratio and relative infant dose (RID) of lemborexant (one case) and suvorexant (two cases) were estimated. The M/P ratio of lemborexant was <1, and the RID was 1.05 %. The M/P ratio of suvorexant was <0.1, and RID was 0.11-0.20 %. This method will be useful for future studies evaluating the safety of these drugs during breastfeeding.
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Affiliation(s)
- Hina Ishikawa
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan
| | - Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan.
| | - Ayako Nishimura
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-jo, Nishi-5-chome, Kita-ku, Sapporo 060-8648, Japan
| | - Takeshi Umazume
- Department of Obstetrics, Hokkaido University Hospital, Kita-14-jo, Nishi-5-chome, Kita-ku, Sapporo 060-8648, Japan
| | - Shuhei Ishikawa
- Department of Psychiatry, Hokkaido University Hospital, Kita-14-jo, Nishi-5-chome, Kita-ku, Sapporo 060-8648, Japan
| | - Ryoichi Aoyagi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan
| | - Keisuke Okamoto
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-jo, Nishi-5-chome, Kita-ku, Sapporo 060-8648, Japan
| | - Mitsuru Sugawara
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-jo, Nishi-5-chome, Kita-ku, Sapporo 060-8648, Japan
| | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan.
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Diab H, Fuquay T, Datta P, Bickel U, Thompson J, Krutsch K. Subcutaneous Semaglutide during Breastfeeding: Infant Safety Regarding Drug Transfer into Human Milk. Nutrients 2024; 16:2886. [PMID: 39275201 PMCID: PMC11397063 DOI: 10.3390/nu16172886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Revised: 08/15/2024] [Accepted: 08/20/2024] [Indexed: 09/16/2024] Open
Abstract
Postpartum mothers and their healthcare providers often face the challenge of limited data regarding the safety of drug therapies during lactation. Pregnancy can lead to sustained weight gain, and obesity can negatively impact both physical and psychological well-being. The introduction of GLP-1 agonists to augment weight loss has become a topic of interest for many postpartum mothers. Our study aims to investigate the transmission of semaglutide into human milk in the first steps to ensure the safety and health of both lactating mothers and their breastfed infants. Semaglutide quantification was performed using high-resolution liquid chromatography-mass spectrometry. InfantRisk Center Human Milk biorepository released milk samples from eight women collected at 0, 12 and 24 h post-semaglutide administration. Semaglutide was extracted using protein precipitation in methanol, followed by chromatographic separation. Linear calibration curves for the method ranged between 2.5-30 ng/mL, with a limit of detection of 1.7 ng/mL and a limit of quantification of 5.7 ng/mL (LLOQ). Semaglutide was not detected in any of the collected human milk samples. A worst-case scenario of the relative infant dose (RID) was calculated using the LLOQ as the drug concentration in milk when considering semaglutide's bioavailability and long-acting dose profile. The maximum RID projected was 1.26%, far below the standard 10% safety threshold. While questions about long-term infant outcomes, the safety of maternal nutrient intake, and the nutrient content of breast milk remain, our findings suggest that semaglutide concentrations in human milk are unlikely to pose clinical concerns for breastfed infants. These results support healthcare providers in making informed decisions regarding postpartum therapeutic interventions.
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Affiliation(s)
- Hanin Diab
- School of Veterinary Medicine, Texas Tech University, Amarillo, TX 79106, USA
| | - Taylor Fuquay
- School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Palika Datta
- School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Ulrich Bickel
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Jonathan Thompson
- School of Veterinary Medicine, Texas Tech University, Amarillo, TX 79106, USA
| | - Kaytlin Krutsch
- School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
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Wood ND, Smith D, Kinrade SA, Sullivan MT, Rayner CR, Wesche D, Patel K, Rowland-Yeo K. The use of quantitative clinical pharmacology approaches to support moxidectin dosing recommendations in lactation. PLoS Negl Trop Dis 2024; 18:e0012351. [PMID: 39102440 PMCID: PMC11326704 DOI: 10.1371/journal.pntd.0012351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 08/15/2024] [Accepted: 07/08/2024] [Indexed: 08/07/2024] Open
Abstract
Moxidectin is approved by the US Food and Drug Administration (US FDA) for the treatment of onchocerciasis (river-blindness) due to Onchocerca volvulus in patients aged 12 years and older. In onchocerciasis-endemic areas, mass drug administration (MDA) programs with ivermectin, with or without vector control, aim to control the disease, reduce morbidity, interrupt transmission, and more recently, achieve elimination. Moxidectin has the potential to be used in MDA programs. In countries where onchocerciasis is endemic, infants are often breastfed up to the age of 2 years, suggesting that some women are likely to be lactating during such periodic MDA programs. Quantitative analyses of non-clinical and clinical data using non-compartmental analysis and population based pharmacokinetic (popPK) modeling as well as physiologically based pharmacokinetic modeling (PBPK) were performed to determine the amount of moxidectin excreted in breast milk and subsequent exposures in the infant. The results of the analyses were similar. Concentrations of moxidectin in breast milk followed a similar pattern to those in plasma, with maximum concentrations occurring approximately 4 hours after dosing followed by a rapid decline in both breast milk and plasma. As early as two days after dosing, concentrations of moxidectin in breast milk were below the threshold for acceptable daily intake levels established by the European Medicines Agency (EMA) and FDA for secondary exposures from veterinary use, and below the WHO recommended relative infant dose (RID) safety threshold. The analyses were conducted to support prescribers and policy makers on dosing recommendations for moxidectin in lactation.
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Affiliation(s)
- Nolan D Wood
- Certara, Princeton, New Jersey, United States of America
| | - Danelle Smith
- Medicines Development for Global Health, Southbank, Victoria, Australia
| | - Sally A Kinrade
- Medicines Development for Global Health, Southbank, Victoria, Australia
| | - Mark T Sullivan
- Medicines Development for Global Health, Southbank, Victoria, Australia
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Craig R Rayner
- Certara, Princeton, New Jersey, United States of America
| | - David Wesche
- Certara, Princeton, New Jersey, United States of America
| | - Kashyap Patel
- Certara, Princeton, New Jersey, United States of America
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Deligiannidis KM, Bullock A, Nandy I, Dunbar J, Lasser R, Witte M, Leclair B, Wald J. Zuranolone Concentrations in the Breast Milk of Healthy, Lactating Individuals: Results From a Phase 1 Open-Label Study. J Clin Psychopharmacol 2024; 44:337-344. [PMID: 38739007 DOI: 10.1097/jcp.0000000000001873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
PURPOSE/BACKGROUND Zuranolone is a positive allosteric modulator of both synaptic and extrasynaptic γ-aminobutyric acid type A receptors and a neuroactive steroid approved as an oral, once-daily, 14-day treatment course for adults with postpartum depression in the United States. This study assessed zuranolone transfer into breast milk. METHODS/PROCEDURES Healthy, nonpregnant, lactating adult female participants received once-daily 30 mg zuranolone from day (D)1 through D5 in this phase 1 open-label study. The relative infant dose (RID; weight-adjusted proportion of the maternal dose in breast milk over 24 hours) for 30 mg zuranolone was assessed at D5. An RID for 50 mg zuranolone was estimated using a simulation approach across a range of infant ages and weights. FINDINGS/RESULTS Of 15 enrolled participants (mean age, 30.1 years), 14 completed the study. The mean RID for 30 mg zuranolone at D5 was 0.357%; the mean steady-state milk volume over D3 to D5 decreased from baseline by 8.3%. Overall unbound zuranolone in plasma was low (≤0.49%). Plasma concentrations peaked at D5 before decreasing in a biexponential manner. There was strong concordance between the temporal profiles of zuranolone concentrations in plasma and breast milk. The estimated mean RID for 50 mg zuranolone based on a milk intake of 200 mL/kg per day was 0.984%. All treatment-emergent adverse events reported by participants were mild, the most common being dizziness (n = 3). IMPLICATIONS/CONCLUSIONS Zuranolone transfer into the breast milk of healthy, nonpregnant, lactating adult female participants was low; the estimated RID for 50 mg zuranolone was <1%, well below the <10% threshold generally considered compatible with breastfeeding.
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Dai J, Fuquay T, Huseman S, Patel D, Datta P, Krutsch K. Low Nirmatrelvir and Ritonavir Exposure through Breastmilk: Analyzing Milk Concentrations and Infant Risk. Clin Pharmacol Ther 2024. [PMID: 38923506 DOI: 10.1002/cpt.3352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Abstract
This research study investigates the intricate relationship among COVID-19, maternal and infant health, and breastfeeding practices, with a specific focus on assessing the transfer of nirmatrelvir and ritonavir into human milk. Our aim is to provide critical insights to those managing COVID-19 treatment in lactating individuals. The InfantRisk Center Human Milk Biorepository contained human milk and corresponding health information for eight mother-infant dyads exposed to standard doses of maternal nirmatrelvir with ritonavir (300 mg nirmatrelvir and 100 mg ritonavir taken orally twice daily for 5 days). The primary outcomes measured were drug levels in milk using liquid chromatography-mass spectrometry and reporting the tolerance of the breastfed infant. Nirmatrelvir with ritonavir was measurable in all participants at a mean concentration of 33.48 ng/mL (ritonavir) and 729 ng/mL (nirmatrelvir). The estimated infant dose via milk was 0.0024 mg/kg/12 h (ritonavir) and 0.054 mg/kg/12 h (nirmatrelvir). The estimated relative infant dose was 0.19% (ritonavir) and 1.43% (nirmatrelvir) well under the standard 10% safety threshold. Among the eight infants exposed in this study, there were no reported adverse events. Nirmatrelvir with ritonavir is the recommended treatment for ambulatory COVID-19 patients with mild-to-moderate COVID-19 infection at high risk for progression to severe disease. Although its use is recommended in lactating women, there are no previous studies on the transfer of nirmatrelvir into human milk. The study findings endorse the current approach of nirmatrelvir/ritonavir use in lactating women and encourage healthcare providers to consider prescribing this treatment irrespective of lactation status when indicated.
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Affiliation(s)
- Jean Dai
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas, USA
| | - Taylor Fuquay
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas, USA
| | - Samuel Huseman
- MountainView Regional Medical Center, Internal Medicine, Las Cruces, New Mexico, USA
| | - Dhavalkumar Patel
- Department of Pharmaceutical Sciences, Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, Texas, USA
| | - Palika Datta
- Texas Tech University Health Sciences Center, Infant Risk Center, Amarillo, Texas, USA
| | - Kaytlin Krutsch
- Texas Tech University Health Sciences Center, Infant Risk Center, Amarillo, Texas, USA
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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Lanzi C, Davanzo R, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Mannaioni G, Salvatori G, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:551. [PMID: 38791766 PMCID: PMC11121006 DOI: 10.3390/ijerph21050551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Our consensus statement aims to clarify the use of antidepressants and anxiolytics during breastfeeding amidst clinical uncertainty. Despite recent studies, potential harm to breastfed newborns from these medications remains a concern, leading to abrupt discontinuation of necessary treatments or exclusive formula feeding, depriving newborns of benefits from mother's milk. METHODS A panel of 16 experts, representing eight scientific societies with a keen interest in postpartum depression, was convened. Utilizing the Nominal Group Technique and following a comprehensive literature review, a consensus statement on the pharmacological treatment of breastfeeding women with depressive disorders was achieved. RESULTS Four key research areas were delineated: (1) The imperative to address depressive and anxiety disorders during lactation, pinpointing the risks linked to untreated maternal depression during this period. (2) The evaluation of the cumulative risk of unfavorable infant outcomes associated with exposure to antidepressants or anxiolytics. (3) The long-term impact on infants' cognitive development or behavior due to exposure to these medications during breastfeeding. (4) The assessment of pharmacological interventions for opioid abuse in lactating women diagnosed with depressive disorders. CONCLUSIONS The ensuing recommendations were as follows: Recommendation 1: Depressive and anxiety disorders, as well as their pharmacological treatment, are not contraindications for breastfeeding. Recommendation 2: The Panel advocates for the continuation of medication that has demonstrated efficacy during pregnancy. If initiating an antidepressant during breastfeeding is necessary, drugs with a superior safety profile and substantial epidemiological data, such as SSRIs, should be favored and prescribed at the lowest effective dose. Recommendation 3: For the short-term alleviation of anxiety symptoms and sleep disturbances, the Panel determined that benzodiazepines can be administered during breastfeeding. Recommendation 4: The Panel advises against discontinuing opioid abuse treatment during breastfeeding. Recommendation 5: The Panel endorses collaboration among specialists (e.g., psychiatrists, pediatricians, toxicologists), promoting multidisciplinary care whenever feasible. Coordination with the general practitioner is also recommended.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Addiction Centre, Ser.D, Local Health Unit, 28100 Novara, Italy
| | - Cecilia Lanzi
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Riccardo Davanzo
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Maternal and Child Health Institute IRCCS “Burlo Garofolo”, 34137 Trieste, Italy
- Task Force on Breastfeeding, Ministry of Health, 00144 Rome, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella, Drug Addiction Service, 13875 Biella, Italy;
- Italian Society of Addiction Diseases (S.I.Pa.D), Via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
- Italian Society for Drug Addiction (SITD), Via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
| | - Guido Mannaioni
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
- Italian Society of Pharmacology, Via Giovanni Pascoli, 3, 20129 Milan, Italy
| | - Guglielmo Salvatori
- Italian Society of Pediatrics, Via Gioberti 60, 00185 Rome, Italy;
- Department of Medical and Surgical Neonatology Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
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Van Neste M, Nauwelaerts N, Ceulemans M, Van Calsteren K, Eerdekens A, Annaert P, Allegaert K, Smits A. Determining the exposure of maternal medicines through breastfeeding: the UmbrelLACT study protocol-a contribution from the ConcePTION project. BMJ Paediatr Open 2024; 8:e002385. [PMID: 38599799 PMCID: PMC11015172 DOI: 10.1136/bmjpo-2023-002385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Breastfeeding is beneficial for the health of the mother and child. However, at least 50% of postpartum women need pharmacotherapy, and this number is rising due to the increasing prevalence of chronic diseases and pregnancies at a later age. Making informed decisions on medicine use while breastfeeding is often challenging, considering the extensive information gap on medicine exposure and safety during lactation. This can result in the unnecessary cessation of breastfeeding, the avoidance of pharmacotherapy or the off-label use of medicines. The UmbrelLACT study aims to collect data on human milk transfer of maternal medicines, child exposure and general health outcomes. Additionally, the predictive performance of lactation and paediatric physiologically based pharmacokinetic (PBPK) models, a promising tool to predict medicine exposure in special populations, will be evaluated. METHODS AND ANALYSIS Each year, we expect to recruit 5-15 breastfeeding mothers using pharmacotherapy via the University Hospitals Leuven, the BELpREG project (pregnancy registry in Belgium) or external health facilities. Each request and compound will be evaluated on relevance (ie, added value to available scientific evidence) and feasibility (including access to analytical assays). Participants will be requested to complete at least one questionnaire on maternal and child's general health and collect human milk samples over 24 hours. Optionally, two maternal and one child's blood samples can be collected. The maternal medicine concentration in human milk will be determined along with the estimation of the medicine intake (eg, daily infant dose and relative infant dose) and systemic exposure of the breastfed child. The predictive performance of PBPK models will be assessed by comparing the observed concentrations in human milk and plasma to the PBPK predictions. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee Research UZ/KU Leuven (internal study number S67204). Results will be published in peer-reviewed journals and presented at (inter)national scientific meetings. TRIAL REGISTRATION NUMBER NCT06042803.
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Affiliation(s)
- Martje Van Neste
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
| | - Nina Nauwelaerts
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Michael Ceulemans
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kristel Van Calsteren
- Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - An Eerdekens
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- BioNotus GCV, Niel, Belgium
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Anne Smits
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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Pesonen A, Hakomäki H, Kokki H, Ranta VP, Rinne V, Kokki M. Breast milk oxycodone concentrations in mothers given oxycodone for post-Caesarean delivery pain management. Br J Clin Pharmacol 2024. [PMID: 38308454 DOI: 10.1111/bcp.16008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/15/2023] [Accepted: 01/13/2024] [Indexed: 02/04/2024] Open
Abstract
AIMS Both effective analgesia and early breastfeeding play an important role in maternal and neonatal well-being after Caesarean delivery. We studied controlled-release oxycodone tablet treatment for postoperative pain management and determined the excretion of oxycodone into breast milk. METHODS Controlled-release oxycodone/naloxone 10/5-mg tablets (n = 21) or controlled-release oxycodone 10-mg tablets (n = 22) were administered to mothers twice a day for the first 3 days after elective Caesarean delivery as a part of multimodal analgesia. Maternal plasma and breast milk samples were collected daily. Oxycodone, noroxycodone, oxymorphone and noroxymorphone concentrations were analysed with ultra-performance liquid chromatography-mass spectrometry. Maternal pain intensity was recorded with an 11-point Numeric Rating Scale (0-10). Neonatal oxycodone exposure was estimated by simulating five different exposure scenarios, including the highest possible exposure through breast milk. RESULTS The mean oxycodone and noroxycodone milk-to-maternal plasma ratios were 3.2 and 3.0, respectively. A strong correlation was found between plasma and breast milk oxycodone (R2 = 0.87) and noroxycodone concentrations (R2 = 0.91). In the simulated highest neonatal exposure scenario, the neonate's maximum plasma concentration was estimated to be 5.4 ng/mL and the estimated weight-adjusted infant oxycodone dose was less than 10% of the maternal dose. Pain intensities were similarly low between the two treatment groups. CONCLUSIONS The oxycodone dose received from colostrum and breast milk during the first three postoperative days after Caesarean delivery is assumed safe for healthy, term neonates, but in extreme cases it is possible for the neonate to receive a dose through breast milk that may elicit opioid effects.
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Affiliation(s)
- Aino Pesonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | - Merja Kokki
- Department of Anesthesia and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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9
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Fodor E, Nagy RN, Nógrádi A, Toovey S, Kamal MA, Vadász P, Bencsik P, Görbe A, Ferdinandy P. An Observational Study on the Pharmacokinetics of Oseltamivir in Lactating Influenza Patients. Clin Pharmacol Ther 2024; 115:318-323. [PMID: 37975276 DOI: 10.1002/cpt.3107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023]
Abstract
Influenza infection may lead to serious complications in the postpartum period, therefore, oseltamivir treatment in these patients and their breastfed infants is of great importance. However, the pharmacokinetics of oseltamivir in postpartum lactating women with acute influenza infection, and the consequent infant exposure to oseltamivir are still unknown, and these data would help in assessing risk and the need for dose adjustment in breastfed infants. Six lactating women with influenza-like symptoms, at a standard dose of 75 mg oral oseltamivir twice daily for 5 days, were recruited in this phase IV clinical study during the 2011/2012 H1N1 pandemic seasons. Breast milk/colostrum and venous blood samples were taken at multiple timepoints, maternal urine samples were obtained from total output within the 12-hour observational period following the seventh dose of oseltamivir. Oseltamivir phosphate (OP) reached a maximum 69.5 ± 29.4 ng/mL concentration in breast milk, higher than that found in the plasma, and showed elimination within ~ 8 hours. Oseltamivir carboxylate (active metabolite of OP) showed a lower, nearly steady-state concentration in breast milk during the observational period (maximum plasma concentration (Cmax ) = 38.4 ± 12.9 ng/mL). Based on estimated daily milk consumption of exclusively breastfed infants, their calculated daily exposure is < 0.1% of the infant dose of oseltamivir for treatment of influenza as per marketing authorization. Here, we provide the first maternal breast milk pharmacokinetic data for oral multiple-dose oseltamivir in lactating patients with influenza and showed that its concentration in the breast milk is not sufficient to reach a therapeutic dose for breastfed infants.
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Affiliation(s)
| | - Regina N Nagy
- MTA-SE System Pharmacology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | | | | | | | - Péter Vadász
- Department of Obstetrics and Gynecology, Selye János Hospital, Komárom, Hungary
| | - Péter Bencsik
- Pharmahungary Group, Szeged, Hungary
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Anikó Görbe
- Pharmahungary Group, Szeged, Hungary
- MTA-SE System Pharmacology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Péter Ferdinandy
- Pharmahungary Group, Szeged, Hungary
- MTA-SE System Pharmacology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
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10
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Damoiseaux D, Amant F, Beijnen JH, Barnett S, Veal GJ, Huitema ADR, Dorlo TPC. Physiologically-based pharmacokinetic model to predict doxorubicin and paclitaxel exposure in infants through breast milk. CPT Pharmacometrics Syst Pharmacol 2023; 12:1931-1944. [PMID: 37798909 PMCID: PMC10725259 DOI: 10.1002/psp4.13043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
Limited information is available concerning infant exposure and safety when breastfed by mothers receiving chemotherapy. Whereas defining distribution to breast milk is important to infer drug exposure, infant pharmacokinetics also determine to what extent the infant will be exposed to potential toxic effects. We aimed to assess the impact of chemotherapy containing breast milk on infants by predicting systemic and local (intestinal) exposure of paclitaxel and doxorubicin in infants through breast milk using a physiologically-based pharmacokinetic (PBPK) approach. Whole-body PBPK models of i.v. paclitaxel and doxorubicin were extended from the literature, with an oral absorption component to enable predictions in infants receiving paclitaxel or doxorubicin-containing breast milk. For safety considerations, worst-case scenarios were explored. Finally, paclitaxel and doxorubicin exposures in plasma and intestinal tissue of infants following feeding of breast milk from paclitaxel- or doxorubicin-treated mothers were simulated and breast milk discarding strategies were evaluated. The upper 95th percentile of the predicted peak concentrations in peripheral venous blood were 3.48 and 0.74 nM (0.4%-1.7% and 0.1%-1.8% of on-treatment) for paclitaxel and doxorubicin, respectively. Intestinal exposure reached peak concentrations of 1.0 and 140 μM for paclitaxel and doxorubicin, respectively. Discarding breast milk for the first 3 days after maternal chemotherapy administration reduced systemic and tissue exposures even further, to over 90% and 80% for paclitaxel and doxorubicin, respectively. PBPK simulations of chemotherapy exposure in infants after breastfeeding with chemotherapy containing breast milk suggest that particularly local gastrointestinal adverse events should be monitored, whereas systemic adverse events are not expected.
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Affiliation(s)
- David Damoiseaux
- Department of Pharmacy and PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Frédéric Amant
- Department of GynecologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Gynecologic OncologyUZ LeuvenLeuvenBelgium
| | - Jos H. Beijnen
- Department of Pharmacy and PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Utrecht Institute of Pharmaceutical SciencesUtrecht UniversityUtrechtThe Netherlands
| | - Shelby Barnett
- Newcastle University Centre for CancerNewcastle UniversityNewcastle upon TyneUK
| | - Gareth J. Veal
- Newcastle University Centre for CancerNewcastle UniversityNewcastle upon TyneUK
| | - Alwin D. R. Huitema
- Department of Pharmacy and PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of PharmacologyPrincess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
- Department of Clinical Pharmacy, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Thomas P. C. Dorlo
- Department of Pharmacy and PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of PharmacyUppsala UniversityUppsalaSweden
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11
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de Jong K, Damoiseaux D, Pluim D, Rosing H, Beijnen JH, van Thienen H, Dorlo TPC, Huitema ADR, Amant F. High accumulation of nivolumab in human breast milk: A case report. Biomed Pharmacother 2023; 166:115354. [PMID: 37625324 DOI: 10.1016/j.biopha.2023.115354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023] Open
Abstract
Nivolumab is an immunotherapeutic monoclonal antibody (mAb) that is used for the treatment of several types of cancer. The evidence on its use during lactation is lacking. Here, we report on a 39-year-old woman with metastasized melanoma who was treated with 480 mg nivolumab every four weeks during lactation. Breast milk samples were collected over the course of 34 days, including two cycles of nivolumab. The highest measured concentration of nivolumab during the first cycle was 503 ng/mL at day 13. The cumulative relative infant dose (RID) over the first cycle (28 days) was 9.8 %. The highest overall measured nivolumab concentration was 519 ng/mL at day 33, five days after administration of the second nivolumab cycle. Nivolumab seems to accumulate in breast milk over two consecutive cycles, hence the RIDs of consecutive cycles are expected to be higher. To draw further conclusions regarding safety of breastfeeding during nivolumab therapy, more information about the oral bioavailability of nivolumab in newborns, the nivolumab steady-state concentrations in breast milk and its pharmacodynamic effects are needed.
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Affiliation(s)
- Karen de Jong
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - David Damoiseaux
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands,.
| | - Dick Pluim
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands,; Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Hans van Thienen
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands,; Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands,; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands,; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frédéric Amant
- Department of Gynecology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Gynecologic Oncology, UZ Leuven, Leuven, Belgium
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12
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Harris M, Schiff DM, Saia K, Muftu S, Standish KR, Wachman EM. Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023). Breastfeed Med 2023; 18:715-733. [PMID: 37856658 PMCID: PMC10775244 DOI: 10.1089/bfm.2023.29256.abm] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.
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Affiliation(s)
- Miriam Harris
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
| | - Davida M. Schiff
- Divisions of Newborn Medicine and Mass General Hospital for Children, Boston, Massachusetts, USA
- Divisions of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Kelley Saia
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Serra Muftu
- Divisions of Newborn Medicine and Mass General Hospital for Children, Boston, Massachusetts, USA
- Divisions of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Katherine R. Standish
- Department of Family Medicine, and Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Elisha M. Wachman
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
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13
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Furugen A, Nishimura A, Umazume T, Ishikawa H, Narumi K, Kobayashi M. Simple and validated method to quantify lacosamide in human breast milk and plasma using UPLC/MS/MS and its application to estimate drug transfer into breast milk. J Pharm Health Care Sci 2023; 9:26. [PMID: 37653499 PMCID: PMC10472561 DOI: 10.1186/s40780-023-00295-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/05/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Epilepsy is a common neurological disorder. Lacosamide is a third-generation antiepileptic drug used to treat partial-onset seizures. Limited information is currently available on the transfer of lacosamide to breast milk. To facilitate studies on the safety of lacosamide use during breastfeeding, we aimed to develop a method to quantify lacosamide in human breast milk and plasma using ultra-performance liquid chromatography/tandem mass spectrometry. METHODS Fifty microliters of breast milk or plasma was used, and samples were prepared by protein precipitation using methanol containing lacosamide-d3 as an internal standard (IS). Chromatography was performed using an ACQUITY HSS T3 column with an isocratic flow of 10 mM ammonium acetate solution/methanol (70:30, v/v). Lacosamide and IS were detected by multiple reaction monitoring in positive ion electrospray mode. The run time was 3.5 min. RESULTS Calibration curves were linear and in the range of 0.5 to 100 ng/mL both in breast milk and plasma. The validation assessment indicated that precision, accuracy, matrix effects, selectivity, dilution integrity, and stability were acceptable. The developed method was successfully applied to quantify lacosamide in breast milk and plasma obtained from a volunteer who had been orally administered lacosamide twice a day (100 mg × 2). Relative infant dose of lacosamide was estimated to be 14.6% in breast milk at five time points. CONCLUSIONS We developed a simple and robust method to quantify of lacosamide in human breast milk and plasma. This method could be useful for in future studies investigating the safety of lacosamide use during breastfeeding.
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Affiliation(s)
- Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan
| | - Ayako Nishimura
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
| | - Takeshi Umazume
- Department of Obstetrics, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
| | - Hina Ishikawa
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan
| | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan.
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14
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Dekkers C, El Amrani M, van Luin M, Bakker D, Plusjé L, van Wijk F, de Bruin-Weller M. Limited excretion of dupilumab into breastmilk: A case report. J Eur Acad Dermatol Venereol 2023; 37:e1154-e1155. [PMID: 37143362 DOI: 10.1111/jdv.19164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Coco Dekkers
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mohsin El Amrani
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daphne Bakker
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leon Plusjé
- Department of Dermatology, Red Cross Hospital Beverwijk, Beverwijk, The Netherlands
| | - Femke van Wijk
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolein de Bruin-Weller
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Cardoso E, Guidi M, Nauwelaerts N, Nordeng H, Teil M, Allegaert K, Smits A, Gandia P, Edginton A, Ito S, Annaert P, Panchaud A. Safety of medicines during breastfeeding - from case report to modeling : A contribution from the ConcePTION project. Expert Opin Drug Metab Toxicol 2023. [PMID: 37269321 DOI: 10.1080/17425255.2023.2221847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/01/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Despite many research efforts, current data on the safety of medicines during breastfeeding are either fragmented or lacking, resulting in restrictive labeling of most medicines. In the absence of pharmacoepidemiologic safety studies, risk estimation for breastfed infants is mainly derived from pharmacokinetic (PK) information on the medicine. This manuscript provides a description and a comparison of the different methodological approaches that can yield reliable information on medicine transfer into human milk and the resulting infant exposure. AREA COVERED Currently, most information on medicine transfer in human milk relies on case reports or traditional PK studies, which generate data that can hardly be generalized to the population. Some methodological approaches, such as population PK (popPK) and physiologically-based PK (PBPK) modeling, can be used to provide a more complete characterization of infant medicine exposure through human milk and simulate the most extreme situations, while decreasing the burden of sampling in breastfeeding women. EXPERT OPINION PBPK and popPK modeling are promising approaches to fill the gap of knowledge in medicine safety in breastfeeding, as illustrated with our escitalopram example.
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Affiliation(s)
- Evelina Cardoso
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nina Nauwelaerts
- Drug Delivery and Disposition Lab, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Karel Allegaert
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy,erasmus MC, Rotterdam, GA, The Netherlands
| | - Anne Smits
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Peggy Gandia
- Laboratory of Pharmacokinetics and Toxicology, Purpan Hospital, University Hospital of Toulouse
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, ON, Canada
| | - Pieter Annaert
- Drug Delivery and Disposition Lab, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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16
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Monfort A, Cardoso E, Eap CB, Fischer Fumeaux CJ, Graz MB, Morisod Harari M, Weisskopf E, Gandia P, Allegaert K, Nordeng H, Hascoët JM, Claris O, Epiney M, Csajka C, Guidi M, Ferreira E, Panchaud A. Infant exposure to Fluvoxamine through placenta and human milk: a case series - A contribution from the ConcePTION project. Front Psychiatry 2023; 14:1167870. [PMID: 37275991 PMCID: PMC10232980 DOI: 10.3389/fpsyt.2023.1167870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/27/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction Fluvoxamine is widely used to treat depression during pregnancy and lactation. However, limited data are available on its transfer to the fetus or in human milk. This case series provides additional information on the infant exposure to fluvoxamine during pregnancy and lactation. Case presentation Two women, aged 38 and 34 years, diagnosed with depression were treated with 50 mg fluvoxamine during pregnancy and lactation. At delivery a paired maternal and cord blood sample was collected for each woman. The first mother exclusively breastfed her child for 4 months and gave one foremilk and one hindmilk sample at 2 days and 4 weeks post-partum, whereas the second mother did not breastfeed. Results The cord to plasma concentration ratios were 0.62 and 0.48, respectively. At 2 weeks post-partum, relative infant doses (RID) were 0.47 and 0.57% based on fluvoxamine concentrations in foremilk and hindmilk, respectively. At 4 weeks post-partum, the RIDs were 0.35 and 0.90%, respectively. The child from the first mother was born healthy and showed a normal development at the 6th, 18th and 36th month follow-ups. One of the twins from the second woman was hospitalized for hypoglycemia that was attributed to gestational diabetes and low birth weight. The second one was born healthy. Conclusion These results suggest a minimal exposure to fluvoxamine during lactation which is in accordance with previously published data. Larger clinical and pharmacokinetic studies assessing the long-term safety of this drug during lactation and the variability of its exposure through breastmilk are warranted.
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Affiliation(s)
- Anaëlle Monfort
- CHU Sainte-Justine, Montréal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - Evelina Cardoso
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Chin B. Eap
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Céline J. Fischer Fumeaux
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Myriam Bickle Graz
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Mathilde Morisod Harari
- Division of Child and Adolescent Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Etienne Weisskopf
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Peggy Gandia
- Laboratory of Pharmacokinetics and Toxicology, Purpan Hospital, University Hospital of Toulouse, Toulouse, France
| | - Karel Allegaert
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Jean-Michel Hascoët
- Department of Neonatology, Maternité Régionale, Université de Lorraine, Nancy, France
| | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Lyon, France
- Claude Bernard University, P2S 4129, Lyon, France
| | - Manuella Epiney
- Department of Women, Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Monia Guidi
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ema Ferreira
- CHU Sainte-Justine, Montréal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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17
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Monfort A, Morin C, Jutras M, Charest S, Leclair G, Ferreira E. Transfer of Mexiletine into Breast Milk: A Case Report. Breastfeed Med 2023. [PMID: 37184533 DOI: 10.1089/bfm.2023.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background: Mexiletine is a class 1B antiarrhythmic agent, used to treat ventricular arrhythmias, and noncardiac-related problems such as myotonia. Limited safety data are available on the transfer of this drug into breast milk. Case Report: We report the case of a woman diagnosed with myotonia congenita who breastfed two children after two consecutive pregnancies. During the breastfeeding of the first and the second infant, she collected, respectively, five and seven samples at 0, 2, 4, 6, and 8 hours and 0, 1, 2, 3, 4, 6, and 8 hours after taking 200 mg of mexiletine thrice daily for seven doses. One week after the collection, samples were analyzed with a validated liquid chromatography tandem mass spectrometry method. No side effect was observed in either child according to the mother. Results: Using the mean milk concentrations, it is estimated that an exclusively breastfed infant would receive a maximum of 5.14% of the initial pediatric mexiletine dosage. We calculated a maximum of 2.67% for the first infant in our case, considering a nonexclusive breastfeeding. Maximal concentrations were observed 1-2 hours after the dose of mexiletine. Results seem to be in accordance with the two cases previously published. Conclusions: Mexiletine transfers into breast milk in low levels. However, results are obtained from only one woman. Therefore, caution should be used when mexiletine is prescribed to breastfeeding women. More cases are needed to evaluate the interindividual variability and to guide women regarding breastfeeding with mexiletine.
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Affiliation(s)
- Anaëlle Monfort
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Caroline Morin
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Martin Jutras
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphane Charest
- Department of Neurology, CIUSSS Mauricie et Centre du Québec, Trois-Rivières, Quebec, Canada
| | - Grégoire Leclair
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Ema Ferreira
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Quebec, Canada
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18
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Liu BD, Starkey M, Virani A, Pichette SL, Fass S, Song G. Review article: Functional dyspepsia and pregnancy-Effects and management in a special population. Aliment Pharmacol Ther 2023; 57:1375-1396. [PMID: 37129241 DOI: 10.1111/apt.17534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/23/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy. AIMS AND METHODS To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions. RESULTS Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD. CONCLUSIONS Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.
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Affiliation(s)
- Benjamin D Liu
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Morgan Starkey
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Aleena Virani
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Sandra L Pichette
- Department of Obstetrics and Gynecology, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Shira Fass
- Department of Psychiatry, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Gengqing Song
- Division of Gastroenterology and Hepatology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio, USA
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Dubbelboer IR, Le Roux-Pullen L, Gehring R. Systematic review of physiologically based kinetic lactation models for transfer of xenobiotic compounds to milk. Toxicol Appl Pharmacol 2023; 467:116495. [PMID: 36996912 DOI: 10.1016/j.taap.2023.116495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/11/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
Lactational elimination has been described mathematically for nearly 50 years. Over 40 published articles, containing >50 physiologically based kinetic (PBK) lactation models were included in the systematic review. These PBK models described the lactational elimination of xenobiotic compounds in humans, rats, mice, and dairy cows and goats. A total of 78 compounds have been modelled, ranging from industrial chemicals, pesticides, to pain medication, antibiotics, and caffeine. Few models included several species or compounds, and models were thus generally not translational or generic. Three dairy cow models mechanistically described the intramammary disposition of pharmaceuticals after intramammary administration, including volume changes caused by milking, while empirically describing the remaining pharmacokinetics. The remaining models were semi- or whole body PBK models, describing long-term exposure of environmental pollutants, or short-term exposure of pharmaceuticals. The absolute majority described the disposition to the mammary gland or milk with perfusion limited compartments, but permeability limited models were available as well. With long-term exposure, models often included changes in milk volume and/or consumption by the offspring, and changes in body weight of offspring. Periodic emptying of the mammary gland, as with feeding or milking, was sparsely applied. Rodent models used similar physiological parameters, while values of physiological parameters applied in human models could range widely. When milk composition was included in the models, it most often included the fat content. The review gives an extensive overview of the applied functions and modelling strategies of PBK lactation models.
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20
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Maeshima T, Yoshida S, Watanabe M, Itagaki F. Prediction model for milk transfer of drugs by primarily evaluating the area under the curve using QSAR/QSPR. Pharm Res 2023; 40:711-719. [PMID: 36720832 PMCID: PMC10036427 DOI: 10.1007/s11095-023-03477-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/25/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE Information on milk transferability of drugs is important for patients who wish to breastfeed. The purpose of this study is to develop a prediction model for milk-to-plasma drug concentration ratio based on area under the curve (M/PAUC). The quantitative structure-activity/property relationship (QSAR/QSPR) approach was used to predict compounds involved in active transport during milk transfer. METHODS We collected M/P ratio data from literature, which were curated and divided into M/PAUC ≥ 1 and M/PAUC < 1. Using the ADMET Predictor® and ADMET Modeler™, we constructed two types of binary classification models: an artificial neural network (ANN) and a support vector machine (SVM). RESULTS M/P ratios of 403 compounds were collected, M/PAUC data were obtained for 173 compounds, while 230 compounds only had M/Pnon-AUC values reported. The models were constructed using 129 of the 173 compounds, excluding colostrum data. The sensitivity of the ANN model was 0.969 for the training set and 0.833 for the test set, while the sensitivity of the SVM model was 0.971 for the training set and 0.667 for the test set. The contribution of the charge-based descriptor was high in both models. CONCLUSIONS We built a M/PAUC prediction model using QSAR/QSPR. These predictive models can play an auxiliary role in evaluating the milk transferability of drugs.
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Affiliation(s)
- Tae Maeshima
- Department of Clinical & Pharmaceutical Sciences, Faculty of Pharma Science, Teikyo University, Itabashi-Ku, Tokyo, 173-8605, Japan
| | - Shin Yoshida
- Department of Clinical & Pharmaceutical Sciences, Faculty of Pharma Science, Teikyo University, Itabashi-Ku, Tokyo, 173-8605, Japan
| | - Machiko Watanabe
- Department of Clinical & Pharmaceutical Sciences, Faculty of Pharma Science, Teikyo University, Itabashi-Ku, Tokyo, 173-8605, Japan
| | - Fumio Itagaki
- Department of Clinical & Pharmaceutical Sciences, Faculty of Pharma Science, Teikyo University, Itabashi-Ku, Tokyo, 173-8605, Japan.
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21
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Cardoso E, Monfort A, Ferreira E, Nordeng H, Winterfeld U, Allegaert K, Gandia P, Guidi M, Panchaud A. Maternal drugs and breastfeeding: Risk assessment from pharmacokinetics to safety evidence - A contribution from the ConcePTION project. Therapie 2023; 78:149-156. [PMID: 36804048 DOI: 10.1016/j.therap.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
Human milk is the most appropriate form of nutrition for infants while taking medication during the postpartum period is common. Discontinuation of breastfeeding is sometimes wrongly recommended for fear of adverse effects in the breastfed infant whereas only a few drugs are strictly contraindicated while breastfeeding. Most drugs are transferred from the mother's blood to the milk, but the breastfed infant usually ingests a small drug amount through human milk. As population-based evidence is still scarce on safety of drugs during breastfeeding, risk assessment relies on the little clinical evidence available and on pharmacokinetic principles, as well as on specialized sources of information that are essential for clinical decision-making. Risk assessment should not only be based on the drug's potential risk for the breastfed infant but should always take into account the benefits associated to breastfeeding, the risks of untreated maternal disease and the maternal willingness to breastfeed. Identifying situations with potential for drug accumulation in the breastfed infant is decisive while assessing the risk. Health care providers should always assume that mothers will be concerned and use risk communication as a key to ensure medication adherence and prevent unnecessary interruption of breastfeeding. When a mother still expresses concerns, decision support algorithms may facilitate communication and some strategies can be offered to minimize the drug exposure in the breastfed infant even when clinically not justified.
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Affiliation(s)
- Evelina Cardoso
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland.
| | - Anaëlle Monfort
- Platform of Biopharmacy, Faculty of Pharmacy, University of Montreal, Montreal, H3T 1J4 QC, Canada; CHU Sainte-Justine, Montreal, H3T 1C5 QC, Canada; Faculty of Pharmacy, University of Montreal, Montreal, H3C 3J7 QC, Canada
| | - Ema Ferreira
- CHU Sainte-Justine, Montreal, H3T 1C5 QC, Canada; Faculty of Pharmacy, University of Montreal, Montreal, H3C 3J7 QC, Canada
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, 0316 Oslo, Norway; Department of Child Health and Development, Norwegian Institute of Public Health, 0473 Oslo, Norway
| | - Ursula Winterfeld
- Swiss Teratogen Information Service, Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Karel Allegaert
- Child and Youth Institute, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; Department of Hospital Pharmacy, Erasmus MC, 3000 GA Rotterdam, the Netherlands
| | - Peggy Gandia
- Laboratory of Pharmacokinetics and Toxicology, Purpan Hospital, University Hospital of Toulouse, 31073 Toulouse, France
| | - Monia Guidi
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, 3012 Bern, Switzerland
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22
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Callegari I, Schneider M, Aebischer V, Voortman MM, Proschmann U, Ziemssen T, Lindberg R, Fischer-Barnicol B, Khalil M, Kappos L, Kuhle J, Sanderson NS, Derfuss T. Natalizumab in cerebrospinal fluid and breastmilk of patients with multiple sclerosis. Ther Adv Neurol Disord 2023; 16:17562864221150040. [PMID: 36741352 PMCID: PMC9896084 DOI: 10.1177/17562864221150040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/18/2022] [Indexed: 02/03/2023] Open
Abstract
Background Natalizumab is a highly effective monoclonal antibody for the treatment of multiple sclerosis (MS), which can diffuse in different anatomical compartments, including cerebrospinal fluid (CSF) and milk. Objectives Starting from incidental detection of natalizumab in the CSF of MS patients, the objective of this study was to develope a flow-cytometry-based assay and apply it to quantify natalizumab in body fluids, including milk collected from nursing patients over 180 days and in patients with neutralizing antibodies against natalizumab. Methods CSF, milk and sera samples from patients with multiple sclerosis were tested by flow-cytometry for binding to a VLA-4 expressing cell line or to a control cell line. A standard curve was prepared by incubating the same cells with natalizumab at 50 μg/ml and serially diluted to 0.005 ng/ml. Binding specificity was confirmed using an anti-natalizumab neutralizing antibody. Results Our assay was sensitive enough to detect natalizumab in CSF, with a lower detection limit of 1.5 ng/ml. Neutralizing antibodies against natalizumab inhibited binding to the cell line. In breastmilk, the peak concentration was observed during the first 2 weeks after infusion and the average concentration over the observation time was 173.3 ng/ml, with a trend toward increased average milk concentration over subsequent administrations. Conclusion Routine use of such an assay would enable a better understanding of the safety of therapeutic antibody administration during pregnancy and lactation.
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Affiliation(s)
- Ilaria Callegari
- Department of Biomedicine, University of Basel
and University Hospital Basel, Basel, Switzerland,Neurologic Clinic and Policlinic, MS Center and
Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB),
University Hospital Basel and University of Basel, Basel, Switzerland
| | - Mika Schneider
- Department of Biomedicine, University of Basel
and University Hospital Basel, Basel, Switzerland
| | - Vera Aebischer
- Department of Biomedicine, University of Basel
and University Hospital Basel, Basel, Switzerland
| | | | - Undine Proschmann
- Neuroimmunological Lab, Center of Clinical
Neuroscience, Department of Neurology, University Hospital Carl Gustav
Carus, Technical University Dresden, Dresden, Germany
| | - Tjalf Ziemssen
- Neuroimmunological Lab, Center of Clinical
Neuroscience, Department of Neurology, University Hospital Carl Gustav
Carus, Technical University Dresden, Dresden, Germany
| | - Raija Lindberg
- Department of Biomedicine, University of Basel
and University Hospital Basel, Basel, Switzerland
| | - Bettina Fischer-Barnicol
- Neurologic Clinic and Policlinic, MS Center and
Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB),
University Hospital Basel and University of Basel, Basel, Switzerland
| | - Michael Khalil
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, MS Center
and Research Center for Clinical Neuroimmunology and Neuroscience Basel
(RC2NB), University Hospital Basel and University of Basel, Basel,
Switzerland
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, MS Center
and Research Center for Clinical Neuroimmunology and Neuroscience Basel
(RC2NB), University Hospital Basel and University of Basel, Basel,
Switzerland
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23
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Polic A, Eutsler KM, Patel SS. Breastfeeding and the patient's perspective. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:1629-1636. [PMID: 36625897 DOI: 10.1007/s00261-022-03791-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE The purpose of this article is to summarize available data on breastfeeding in patients with a cancer diagnosis. MATERIALS AND METHODS A review of available literature in the MEDLINE database was performed and the data summarized. In addition, two patient interviews were conducted to gain insight into the patient perspective. RESULTS Breastmilk is the nutritional standard for human infants and understanding the implications of a cancer diagnosis on lactation is important in optimizing maternal and infant outcomes. Though limited, available data suggest that breastfeeding may be a safe and appropriate option for some patients undergoing treatment of a malignancy. CONCLUSIONS Patient experiences with breastfeeding in the setting of a cancer diagnosis vary widely, and depend on the type of malignancy, the timing of the diagnosis, and the indicated treatment. Breastfeeding may be an appropriate option for certain patients after multidisciplinary counseling. Alternatives to breastfeeding exist for patients who are unable to or do not desire to breastfeed.
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Affiliation(s)
- Aleksandra Polic
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA.
| | - Kaitlin M Eutsler
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
| | - Soha S Patel
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
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24
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Zhang T, Zou P, Fang Y, Li Y. Physiologically based pharmacokinetic model to predict drug concentrations of breast cancer resistance protein substrates in milk. Biopharm Drug Dispos 2022; 43:221-232. [PMID: 36265038 DOI: 10.1002/bdd.2335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/12/2022] [Accepted: 10/14/2022] [Indexed: 01/07/2023]
Abstract
Many mothers need to take some medications during breastfeeding, which may carry a risk to breastfed infants. Thus, determining the amount of a drug transferred into breast milk is critical for risk-benefit analysis of breastfeeding. Breast cancer resistance protein (BCRP), an efflux transporter which usually protects the body from environmental and dietary toxins, was reported to be highly expressed in lactating mammary glands. In this study, we developed a mechanistic lactation physiologically based pharmacokinetic (PBPK) modeling approach incorporating BCRP mediated transport kinetics to simulate the concentration-time profiles of five BCRP drug substrates (acyclovir, bupropion, cimetidine, ciprofloxacin, and nitrofurantoin) in nursing women's plasma and milk. Due to the lack of certain physiological parameters and scaling factors in nursing women, we combine the bottom up and top down PBPK modeling approaches together with literature reported data to optimize and determine a set of parameters that are applicable for all five drugs. The predictive performance of the PBPK models was assessed by comparing predicted pharmacokinetic profiles and the milk-to-plasma (M/P) ratio with clinically reported data. The predicted M/P ratios for acyclovir, bupropion, cimetidine, ciprofloxacin, and nitrofurantoin were 2.48, 3.70, 3.55, 1.21, and 5.78, which were all within 1.5-fold of the observed values. These PBPK models are useful to predict the PK profiles of those five drugs in the milk for different dosing regimens. Furthermore, the approach proposed in this study will be applicable to predict pharmacokinetics of other transporter substrates in the milk.
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Affiliation(s)
- Tao Zhang
- Department of Pharmaceutical Sciences, SUNY-Binghamton University, Johnson City, New York, USA
| | - Peng Zou
- Daiichi Sankyo, Inc, Basking Ridge, New Jersey, USA
| | - Yingsi Fang
- Department of Pharmaceutical Sciences, SUNY-Binghamton University, Johnson City, New York, USA
| | - Yanyan Li
- School of Food and Agriculture, College of Natural Sciences, Forestry, and Agriculture, University of Maine, Orono, Maine, USA
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25
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Leggett C, Ritchie U, Costi L, Elliot D, Mangoni AA, Hague WM. Infant Exposure to Armodafinil Through Human Milk Following Maternal Use of Modafinil. J Hum Lact 2022; 39:218-222. [PMID: 36384330 DOI: 10.1177/08903344221134273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Narcolepsy, a condition adversely affecting psychological, social, and cognitive function, is more prevalent in females of childbearing age than the general population. Modafinil and armodafinil are central nervous system stimulants approved for treatment of narcolepsy. Infant exposure to these agents through human milk has not been investigated. Poor quality medication safety information during lactation is associated with early cessation of breastfeeding and suboptimal healthcare for the breastfeeding family. MAIN ISSUE In this case study, we measured the concentration of armodafinil (the most active form of modafinil) in human milk and infant plasma to quantify infant exposure. MANAGEMENT The participant was a 30-year-old primipara with narcolepsy, taking modafinil (300 mg morning, 100 mg noon) while breastfeeding her 6-week-old infant despite the paucity of safety information. Armodafinil concentrations were measured in eight serial human milk samples collected over a 26-hr period and in single maternal and infant plasma samples using ultra performance liquid chromatography - tandem mass spectrometry. The average concentration of armodafinil in human milk was 1.96 mg/L; the relative infant dose was 4.85%; the theoretical infant dose was 0.294 mg/kg/day. Maternal and infant plasma concentrations of armodafinil were 12.02 mg/L and 0.19 mg/L, respectively. The participant continued to exclusively breastfeed the infant, who had normal growth and development. CONCLUSION Based on these findings, relatively small amounts of armodafinil pass into human milk, with consequent limited infant exposure. Consideration can be given to the use of modafinil or armodafinil during breastfeeding, provided the infant is monitored. Further studies are needed to confirm these findings.
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Affiliation(s)
- Catherine Leggett
- SA Pharmacy, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Usha Ritchie
- SA Pharmacy, Women's and Children's Hospital, North Adelaide, SA, Australia.,SA Pharmacy, Royal Adelaide Hospital, Port Road, SA, Australia
| | - Lynn Costi
- SA Pharmacy, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - David Elliot
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Bedford Park, SA, Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Bedford Park, SA, Australia.,Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - William M Hague
- Robinson Research Institute, University of Adelaide, North Adelaide, SA, Australia
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Al-Faraj AO, Pang TD. Breastfeeding recommendations for women taking anti-seizure medications. Epilepsy Behav 2022; 136:108769. [PMID: 35690572 DOI: 10.1016/j.yebeh.2022.108769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
The literature regarding breastfeeding and effects of anti-seizure medication (ASM) exposure on the breastfed infant has been evolving rapidly over the last decade as new studies advance our understanding of the extent of medication exposure via breastfeeding and the long-term developmental outcomes of breastfed infants. Currently, strong evidence supports the safety of breastfeeding for women with epilepsy (WWE) taking most prescribed ASMs. In this review, we present a comprehensive overview of the data regarding ASM exposure in breastfed infants and neurodevelopmental outcomes in breastfed infants of mothers taking various ASMs. In addition, we present current breastfeeding recommendations and the reported adverse effects of various ASMs to facilitate decision making in the clinical care of WWE.
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Affiliation(s)
- Abrar O Al-Faraj
- Boston Medical Center, Boston University School of Medicine, United States.
| | - Trudy D Pang
- Beth Israel Deaconess Medical Center, Harvard Medical School, United States.
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Outcomes of Children with Fetal and Lactation Immunosuppression Exposure Born to Female Transplant Recipients. Paediatr Drugs 2022; 24:483-497. [PMID: 35870080 DOI: 10.1007/s40272-022-00525-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 10/16/2022]
Abstract
Solid organ transplantation (SOT) is a lifesaving procedure for those with end-stage kidney, liver, heart, lung, and intestinal diseases, including females of childbearing age who wish to proceed with pregnancy following transplantation. While there is clear risk associated with use of mycophenolate during pregnancy, the risks associated with use of other immunosuppressant agents are less well understood, and the timing of use in pregnancy may be pertinent when considering the risk versus benefit for individual patients. In addition to overall fetal outcomes, including gestational age, birth weight, and mortality, this review summarizes published literature on additional complications that have been examined in association with maternal use during pregnancy and postpartum while breastfeeding. Compared with non-transplant pregnancies, pregnancies in transplant recipients are associated with lower birth weight and earlier gestational age. Effects associated with particular immunosuppressant agents in the infant include renal dysfunction from calcineurin inhibitors, myelosuppression from azathioprine, and decreased circulating immune cells with several agents. However, these effects are noted to primarily be transient, though the decrease in immune cells may predispose the infant to increased infectious complications in the first year of life. Utilizing relative infant dose estimations, nearly all commonly utilized immunosuppressants are likely safe during breastfeeding given the limited exposure to the infant.
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28
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Buonfrate D, Rodari P, Barda B, Page W, Einsiedel L, Watts M. Current pharmacotherapeutic strategies for Strongyloidiasis and the complications in its treatment. Expert Opin Pharmacother 2022; 23:1617-1628. [PMID: 35983698 DOI: 10.1080/14656566.2022.2114829] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Strongyloidiasis, an infection caused by the soil-transmitted helminth Strongyloides stercoralis, can lead immunocompromised people to a life-threatening syndrome. We highlight here current and emerging pharmacotherapeutic strategies for strongyloidiasis and discuss treatment protocols according to patient cohort. We searched PubMed and Embase for papers published on this topic between 1990 and May 2022. AREAS COVERED Ivermectin is the first-line drug, with an estimated efficacy of about 86% and excellent tolerability. Albendazole has a lower efficacy, with usage advised when ivermectin is not available or not recommended. Moxidectin might be a valid alternative to ivermectin, with the advantage of being a dose-independent formulation. EXPERT OPINION The standard dose of ivermectin is 200 µg/kg single dose orally, but multiple doses might be needed in immunosuppressed patients. In the case of hyperinfection, repeated doses are recommended up to 2 weeks after clearance of larvae from biological fluids, with close monitoring and further dosing based on review. Subcutaneous ivermectin is used where there is impaired intestinal absorption/paralytic ileus. In pregnant or lactating women, studies have not identified increased risk with ivermectin use. However, with limited available data, a risk-benefit assessment should be considered for each case.
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Affiliation(s)
- Dora Buonfrate
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria hospital, via Sempreboni 5, 37024 Negrar, Verona, Italy
| | - Paola Rodari
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria hospital, via Sempreboni 5, 37024 Negrar, Verona, Italy
| | - Beatrice Barda
- Ospedale La Carità, Ospedale regionale di Locarno, Locarno 6600, Switzerland
| | - Wendy Page
- Miwatj Health Aboriginal Corporation, 1424 Arnhem Rd, Nhulunbuy NT 0880, Australia
| | - Lloyd Einsiedel
- Peter Doherty Institute, University of Melbourne, 792 Elizabeth St, Melbourne VIC 3000, Australia
| | - Matthew Watts
- Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research - New South Wales Health Pathology and Sydney Institute for Infectious Diseases, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
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29
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Jordan S, Bromley R, Damase-Michel C, Given J, Komninou S, Loane M, Marfell N, Dolk H. Breastfeeding, pregnancy, medicines, neurodevelopment, and population databases: the information desert. Int Breastfeed J 2022; 17:55. [PMID: 35915474 PMCID: PMC9343220 DOI: 10.1186/s13006-022-00494-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The pharmacoepidemiology of the long-term benefits and harms of medicines in pregnancy and breastfeeding has received little attention. The impact of maternal medicines on children is increasingly recognised as a source of avoidable harm. The focus of attention has expanded from congenital anomalies to include less visible, but equally important, outcomes, including cognition, neurodevelopmental disorders, educational performance, and childhood ill-health. Breastfeeding, whether as a source of medicine exposure, a mitigator of adverse effects or as an outcome, has been all but ignored in pharmacoepidemiology and pharmacovigilance: a significant 'blind spot'. WHOLE-POPULATION DATA ON BREASTFEEDING WHY WE NEED THEM: Optimal child development and maternal health necessitate breastfeeding, yet little information exists to guide families regarding the safety of medicine use during lactation. Breastfeeding initiation or success may be altered by medicine use, and breastfeeding may obscure the true relationship between medicine exposure during pregnancy and developmental outcomes. Absent or poorly standardised recording of breastfeeding in most population databases hampers analysis and understanding of the complex relationships between medicine, pregnancy, breastfeeding and infant and maternal health. The purpose of this paper is to present the arguments for breastfeeding to be included alongside medicine use and neurodevelopmental outcomes in whole-population database investigations of the harms and benefits of medicines during pregnancy, the puerperium and postnatal period. We review: 1) the current situation, 2) how these complexities might be accommodated in pharmacoepidemiological models, using antidepressants and antiepileptics as examples; 3) the challenges in obtaining comprehensive data. CONCLUSIONS The scarcity of whole-population data and the complexities of the inter-relationships between breastfeeding, medicines, co-exposures and infant outcomes are significant barriers to full characterisation of the benefits and harms of medicines during pregnancy and breastfeeding. This makes it difficult to answer the questions: 'is it safe to breastfeed whilst taking this medicine', and 'will this medicine interfere with breastfeeding and/ or infants' development'?
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Affiliation(s)
- Sue Jordan
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, UK.
| | - Rebecca Bromley
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Christine Damase-Michel
- Faculté de Médecine, Center for Epidemiology and Research in POPulation Health (CERPOP), Université Toulouse III, CHU Toulouse INSERM, Pharmacologie Médicale, Toulouse, France
| | - Joanne Given
- Faculty Life & Health Sciences, University of Ulster, Co Antrim, Newtownabbey, N Ireland, UK
| | - Sophia Komninou
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, UK
| | - Maria Loane
- Faculty Life & Health Sciences, University of Ulster, Co Antrim, Newtownabbey, N Ireland, UK
| | - Naomi Marfell
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, UK
| | - Helen Dolk
- Faculty Life & Health Sciences, University of Ulster, Co Antrim, Newtownabbey, N Ireland, UK
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Kayes T, Crane H, Symonds A, Dumond J, Cottrell M, Di Girolamo J, Manandhar S, Lim TH, Gane E, Kashuba A, Levy MT. Plasma and breast milk pharmacokinetics of tenofovir alafenamide in mothers with chronic hepatitis B infection. Aliment Pharmacol Ther 2022; 56:510-518. [PMID: 35599363 DOI: 10.1111/apt.17040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/06/2022] [Accepted: 05/08/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Antenatal antiviral therapy (AVT) is effective in preventing mother-to-child transmission (MTCT) in chronic hepatitis B (CHB); tenofovir disoproxil fumarate (TDF) is the preferred agent. Tenofovir alafenamide (TAF) is a prodrug of tenofovir (TFV) similar to TDF, with improved bone and renal safety. There are no data on TAF breast milk pharmacokinetics and exposure to breastfeeding infants in CHB. AIM To assess the pharmacokinetics of TAF/TFV in breastfeeding women with CHB on TAF monotherapy. METHODS Pregnant women with CHB requiring AVT commenced TAF 25 mg daily at third trimester or postpartum. Sample collection occurred while breastfeeding and taking TAF for minimum 4 weeks. Maternal blood, breast milk and infant urine samples were collected. Drug concentrations were measured by LCMS/MS analyses using validated methods. Non-compartmental analyses were performed to quantify the pharmacokinetic parameters. RESULTS Eight women provided samples. In breast milk and plasma, median TAF half-life was 0.81 and 0.94 h, respectively, and Cmax 1.69 and 120.5 ng/ml, respectively. Median maternal breast milk to plasma (M/P) ratio of TAF was 0.029; for and TFV it was 2.809. The relative infant dose of TAF was 0.005% of maternal dose, well below safety threshold of 5-10%. TFV was detectable in three out of seven infant urine samples with median steady-state concentration of 5 ng/ml being 300-2500 times less than reported adult steady-state urine concentrations in those taking TAF and TDF, respectively. CONCLUSIONS In this first pharmacokinetic study of TAF monotherapy in breastfeeding women with CHB, concentrations of TAF and TFV were low in breast milk with negligible infant exposure, supporting the use of TAF to prevent MTCT.
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Affiliation(s)
- Tahrima Kayes
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Harry Crane
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Allison Symonds
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Julie Dumond
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Mackenzie Cottrell
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Julia Di Girolamo
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Sicha Manandhar
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Tien Huey Lim
- Department of Gastroenterology and Hepatology, Middlemore Hospital, Auckland, New Zealand
| | - Edward Gane
- Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Angela Kashuba
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Miriam T Levy
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales Sydney, Liverpool, New South Wales, Australia
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31
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Rød BE, Torkildsen Ø, Myhr KM, Bø L, Wergeland S. Safety of breast feeding during rituximab treatment in multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 94:jnnp-2022-329545. [PMID: 35879056 PMCID: PMC9763193 DOI: 10.1136/jnnp-2022-329545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are limited data on the safety of breast feeding during rituximab therapy. Our objective is to determine exposure from breast feeding and biological effects of rituximab in breastfed infants. METHODS In our case series of six mother-infant pairs, the nursing mothers with relapsing-remitting multiple sclerosis received rituximab during breast feeding. As part of clinical follow-up, six serial breast milk samples, and blood samples from both mothers and infants, were collected and analysed. RESULTS The median average rituximab concentration (Cavg) in breast milk was 0.04 µg/mL and the estimated relative infant dose (RID) was 0.07%. The highest measured concentration of rituximab in the breast milk samples was 0.25 µg/mL, giving an estimated RID of 0.26%.All infant serum rituximab concentrations were below 0.01 µg/mL. The CD19 +B cell count values were within the 10th- 90th percentiles of reported normal ranges in healthy infants. CONCLUSIONS We found minimal transfer of rituximab into breast milk and could not reliably detect levels of rituximab in infant serum. B cell counts in infants were unaffected.
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Affiliation(s)
- Brit Ellen Rød
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Bø
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian MS-Registry and Biobank, Haukeland University Hospital, Bergen, Norway
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Job KM, Dallmann A, Parry S, Saade G, Haas DM, Hughes B, Berens P, Chen JY, Fu C, Humphrey K, Hornik C, Balevic S, Zimmerman K, Watt K. Development of a Generic Physiologically-Based Pharmacokinetic Model for Lactation and Prediction of Maternal and Infant Exposure to Ondansetron via Breast Milk. Clin Pharmacol Ther 2022; 111:1111-1120. [PMID: 35076931 PMCID: PMC10267851 DOI: 10.1002/cpt.2530] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 11/11/2022]
Abstract
Ondansetron is commonly used in breastfeeding mothers to treat nausea and vomiting. There is limited information in humans regarding safety of ondansetron exposure to nursing infants and no adequate study looking at ondansetron pharmacokinetics during lactation. We developed a generic physiologically-based pharmacokinetic lactation model for small molecule drugs and applied this model to predict ondansetron transfer into breast milk and characterize infant exposure. Drug-specific model inputs were parameterized using data from the literature. Population-specific inputs were derived from a previously conducted systematic literature review of anatomic and physiologic changes in postpartum women. Model predictions were evaluated using ondansetron plasma and breast milk concentration data collected prospectively from 78 women in the Commonly Used Drugs During Lactation and infant Exposure (CUDDLE) study. The final model predicted breast milk and plasma exposures following a single 4 mg dose of intravenous ondansetron in 1,000 simulated women who were 2 days postpartum. Model predictions showed good agreement with observed data. Breast milk median prediction error (MPE) was 18.4% and median absolute prediction error (MAPE) was 53.0%. Plasma MPE was 32.5% and MAPE was 43.2%. The model-predicted daily and relative infant doses were 0.005 mg/kg/day and 3.0%, respectively. This model adequately predicted ondansetron passage into breast milk. The calculated low relative infant dose indicates that mothers receiving ondansetron can safely breastfeed. The model building blocks and population database are open-source and can be adapted to other drugs.
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Affiliation(s)
- Kathleen M. Job
- Division of Clinical Pharmacology, Department of Pediatrics, The University of Utah, Salt Lake City, Utah, USA
| | - André Dallmann
- Pharmacometrics/Modeling & Simulation, Research & Development, Bayer AG, Leverkusen, Germany
| | - Samuel Parry
- Division of Maternal-Fetal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Saade
- University of Texas Medical Branch–Galveston, Galveston, Texas, USA
| | - David M. Haas
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brenna Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Pamela Berens
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Jia-Yu Chen
- The Emmes Company, LLC, Rockville, Maryland, USA
| | - Christina Fu
- The Emmes Company, LLC, Rockville, Maryland, USA
| | | | - Christoph Hornik
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Stephen Balevic
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Kanecia Zimmerman
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, The University of Utah, Salt Lake City, Utah, USA
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33
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Oberhelman-Eaton S, Chang A, Gonzalez C, Braith A, Singh RJ, Lteif A. Initiation of Gender-Affirming Testosterone Therapy in a Lactating Transgender Man. J Hum Lact 2022; 38:339-343. [PMID: 34490813 DOI: 10.1177/08903344211037646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Transgender and gender diverse individuals may choose to provide their infants with human milk. Lactating transgender men may experience gender dysphoria and desire to initiate or reinitiate gender-affirming testosterone therapy. However, there is limited safety data regarding use of testosterone during lactation. MAIN ISSUE A 30-year-old G2P2 transgender man with gender dysphoria sought to initiate gender-affirming testosterone therapy while lactating. MANAGEMENT Subcutaneous testosterone was self-administered beginning at 13 months post-partum. We prospectively collected data on circulating testosterone concentrations in parent serum, milk, and infant serum over 5 months until the infant self-weaned. The infant was monitored for growth and development at routine pediatric outpatient appointments. Parent serum testosterone concentrations rose with the initiation of testosterone therapy, reaching therapeutic concentrations by Day 14. Milk testosterone concentrations also increased with a maximum concentration of 35.9 ng/dl when the lactating parent was on a dose of 80 mg subcutaneous testosterone cypionate weekly. The calculated milk/plasma ratio remained under 1.0 and the calculated relative infant dose remained under 1%. The infant had no observable side effects, and his serum testosterone concentrations remained undetectable throughout the study period. CONCLUSION This is the first study with data regarding human milk and infant serum testosterone concentrations during the initiation of gender-affirming testosterone therapy in a lactating individual. This evidence can help families and clinicians with decisions regarding lactation and testosterone use.
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Affiliation(s)
| | - Alice Chang
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Cesar Gonzalez
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Braith
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Ravinder J Singh
- Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aida Lteif
- Department of Pediatrics, Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
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34
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Damoiseaux D, Calpe S, Rosing H, Beijnen JH, Huitema ADR, Lok C, Dorlo TPC, Amant F. Presence of Five Chemotherapeutic Drugs in Breast Milk as a Guide for the Safe Use of Chemotherapy During Breastfeeding: Results From a Case Series. Clin Pharmacol Ther 2022; 112:404-410. [PMID: 35486426 DOI: 10.1002/cpt.2626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Abstract
Little is known about infant's safety of chemotherapy during breastfeeding where evidence is limited to a few case reports. This lack of knowledge has led to a general tendency to advise against breastfeeding during cytotoxic therapy despite the overwhelming benefits that breastfeeding offers to both the mothers and their children. In this case series, the presence of five chemotherapies in breast milk was determined. The aim was to obtain insight into the presence of these drugs in breast milk to inform and help clinicians in making informed decisions for women who want to breastfeed. Three patients collected 24-hour samples of breast milk every day for 1, 2, or 3 weeks after chemotherapy, 210 in total. After determination of drug concentrations, the infant daily dose, relative daily infant dose (RID%) and cumulative RID were calculated. Cumulative RIDs in patients varied from 10% to values lower than 1%. Rich data allowed us to design a table which gives predictions on the amount of days that breast milk has to be discarded to reach cumulative RIDs below 5, 1, and 0.1% for each compound. For cyclophosphamide, paclitaxel, and carboplatin, cumulative RIDs below 1 or 0.1% are reached if breast milk is discarded for 1-3 days after administration. This might suggest that breastfeeding in between cycles is an option. However, other pharmacological parameters should also be taken into consideration. For doxorubicin, also the levels of the active metabolite doxorubicinol need quantification. Similarly, breastfeeding during treatment with cisplatin might give substantial exposure and we advise caution.
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Affiliation(s)
- David Damoiseaux
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Silvia Calpe
- Gynecologic Oncology Department, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Christianne Lok
- Department of Gynecology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Frédéric Amant
- Department of Gynecology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Gynecologic Oncology, UZ Leuven, Leuven, Belgium
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35
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Shawahna R, Zaid L. Concentrations of antiseizure medications in breast milk of lactating women with epilepsy: A systematic review with qualitative synthesis. Seizure 2022; 98:57-70. [PMID: 35427849 DOI: 10.1016/j.seizure.2022.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/20/2022] [Accepted: 03/25/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Recent position papers and guidelines encourage women with epilepsy (WWE) to exclusively breastfeed their infants because the benefits to their infants outweigh the potential adverse effects caused by exposure to antiseizure medications (ASMs). OBJECTIVE The objectives of this review were: to evaluate concentrations of ASMs in breastmilk of lactating WWE, qualitatively synthesize evidence that can be used to estimate theoretical doses as estimated daily intake (EDI) and relative infant dose (RID) of ASMs, and to evaluate potential risks to infants as a result of exposure to ASMs from breastmilk. METHODS This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42020223645. The databases: MEDLINE/PubMed, EMBASE, CINAHL/EBSCO, COCHRANE, SpringerLink, ScienceDirect, Summon, WHO International Clinical Trials Registry Platform, and SCOPUS were systematically searched. A qualitative synthesis was adopted in this study. RESULTS A total of 15 records were included in this systematic review. The included studies reported levels of 8 ASMs in the breastmilk of WWE. The highest RIDs of carbamazepine, lamotrigine, primidone, phenobarbital, gabapentin, valproic acid, ethosuximide, levetiracetam, and topiramate were 3.70%, 36.33%, 4.96%, 3.15%, 4.37%, 1.90%, 31.49%, 12.50%, and 12.18%, respectively. Breastfeeding might be limited or even discontinued when signs of excessive sedation/drowsiness and/or poor weight gain are evident on infants exposed to primidone and phenobarbital, ethosuximide/primidone, or ethosuximide/phenobarbital. CONCLUSIONS Concentrations of ASMs can be detected in breastmilk of WWE and plasma/serum of infants exposed via breastmilk. Healthcare providers and WWE might use the findings of this study to make informed decisions on the safety of breastfeeding while taking ASMs.
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36
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Shum S, Yadav A, Fay E, Moreni S, Mao J, Czuba L, Wang C, Isoherranen N, Hebert MF. Infant dextromethorphan and dextrorphan exposure via breast milk from mothers who are CYP2D6 extensive metabolizers. J Clin Pharmacol 2021; 62:747-755. [PMID: 34889461 DOI: 10.1002/jcph.2012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/03/2021] [Indexed: 11/11/2022]
Abstract
The risk of infant exposure to dextromethorphan (DM) and its active metabolite, dextrorphan (DX), through breast milk has not been evaluated. In this study, bound and unbound DM and DX concentrations in breast milk and plasma at 2 h post-dose were measured in 20 lactating women (n = 20) following a single 30 mg oral dose of DM. The DM and DX concentrations in breast milk were positively correlated with their respective plasma concentrations. The breast milk-to-plasma (M/P) ratios of 1.0 and 1.6 and the unbound M/P ratios of 1.1 and 2.0 for DM and DX, respectively, suggested that DM and DX are extensively distributed into breast milk. The infant exposure following a single dose of 30 mg DM was estimated using the breast milk concentrations to be 0.33 ± 0.32 μg/kg/day and 1.8 ± 1.0 μg/kg/day for DM and DX, respectively. The steady-state infant exposure was estimated using the M/P ratios and previously reported AUC of DM and DX following repeated dosing of DM 60 mg orally twice daily to be 0.64 ± 0.22 μg/kg/day and 1.23 ± 0.38 μg/kg/day, respectively. Based on these estimated infant doses, the relative infant doses (RIDs) were estimated to be <1%, suggesting the infant is only exposed to a minor fraction of adult dose through breast milk; however, one nursing infant developed an erythematous rash during this study which warrants additional research to fully elucidate the risks of infant exposure to DM and DX through breast milk. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sara Shum
- University of Washington, Department of Pharmaceutics, Seattle, WA, USA
| | - Aprajita Yadav
- University of Washington, Department of Pharmaceutics, Seattle, WA, USA
| | - Emily Fay
- University of Washington, Department of Obstetrics and Gynecology, Seattle, WA, USA
| | - Sue Moreni
- University of Washington, Department of Obstetrics and Gynecology, Seattle, WA, USA
| | - Jennie Mao
- University of Washington, Department of Obstetrics and Gynecology, Seattle, WA, USA
| | - Lindsay Czuba
- University of Washington, Department of Pharmaceutics, Seattle, WA, USA
| | - Celine Wang
- University of Washington, Department of Pharmacy, Seattle, WA, USA
| | - Nina Isoherranen
- University of Washington, Department of Pharmaceutics, Seattle, WA, USA
| | - Mary F Hebert
- University of Washington, Department of Obstetrics and Gynecology, Seattle, WA, USA.,University of Washington, Department of Pharmacy, Seattle, WA, USA
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Debong MW, N'Diaye K, Owsienko D, Schöberl D, Ammar T, Lang R, Buettner A, Hofmann T, Loos HM. Dietary Linalool is Transferred into the Milk of Nursing Mothers. Mol Nutr Food Res 2021; 65:e2100507. [PMID: 34658145 DOI: 10.1002/mnfr.202100507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/12/2021] [Indexed: 12/11/2022]
Abstract
SCOPE Breast milk is repeatedly postulated to shape the first aroma and taste impressions of infants and thus impact their flavor learning. The objective of this study is to assess the transition of aroma compounds from a customary curry dish into milk. METHODS AND RESULTS The article prepares a standardized curry dish and administers the dish to nursing mothers (n = 18) in an intervention study. The participants donate one milk sample before and three samples after the intervention. Due to their olfactory or quantitative relevance in the curry dish, 1,8-cineole, linalool, cuminaldehyde, cinnamaldehyde, 4-hydroxy-2,5-dimethyl-3(2H)-furanone, sotolone, eugenol, vanillin, and γ-nonalactone are defined as target compounds, and their transition into milk is quantified by gas chromatography-mass spectrometry. A significant transition into the milk is observed for linalool, and its olfactory relevance in this respect is supported by calculated odor activity values. In contrast, no relevant levels are detected for the other eight target compounds. CONCLUSION Ingestion of a customary curry dish can lead to an alteration of the milk aroma, which might be perceived by the infant during breastfeeding. The current study also demonstrates that the extent of aroma transfer differs between both substances and individuals.
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Affiliation(s)
- Marcel W Debong
- Chair of Aroma and Smell Research, Friedrich-Alexander-Universität Erlangen-Nürnberg, Henkestr. 9, Erlangen, 91054, Germany
| | - Katharina N'Diaye
- Chair of Food Chemistry and Molecular Sensory Science, Technical University of Munich, Lise-Meitner-Straße 34, Freising, 85354, Germany
| | - Diana Owsienko
- Chair of Aroma and Smell Research, Friedrich-Alexander-Universität Erlangen-Nürnberg, Henkestr. 9, Erlangen, 91054, Germany.,Fraunhofer Institute for Process Engineering and Packaging IVV, Giggenhauser Str. 35, Freising, 85354, Germany
| | - Daniela Schöberl
- Chair of Aroma and Smell Research, Friedrich-Alexander-Universität Erlangen-Nürnberg, Henkestr. 9, Erlangen, 91054, Germany.,Fraunhofer Institute for Process Engineering and Packaging IVV, Giggenhauser Str. 35, Freising, 85354, Germany
| | - Tayyaba Ammar
- Chair of Aroma and Smell Research, Friedrich-Alexander-Universität Erlangen-Nürnberg, Henkestr. 9, Erlangen, 91054, Germany
| | - Roman Lang
- Chair of Food Chemistry and Molecular Sensory Science, Technical University of Munich, Lise-Meitner-Straße 34, Freising, 85354, Germany.,Leibniz-Institute for Food Systems Biology at Technical University Munich, Lise-Meitner-Str. 34, Freising, 85354, Germany
| | - Andrea Buettner
- Chair of Aroma and Smell Research, Friedrich-Alexander-Universität Erlangen-Nürnberg, Henkestr. 9, Erlangen, 91054, Germany.,Fraunhofer Institute for Process Engineering and Packaging IVV, Giggenhauser Str. 35, Freising, 85354, Germany
| | - Thomas Hofmann
- Chair of Food Chemistry and Molecular Sensory Science, Technical University of Munich, Lise-Meitner-Straße 34, Freising, 85354, Germany
| | - Helene M Loos
- Chair of Aroma and Smell Research, Friedrich-Alexander-Universität Erlangen-Nürnberg, Henkestr. 9, Erlangen, 91054, Germany.,Fraunhofer Institute for Process Engineering and Packaging IVV, Giggenhauser Str. 35, Freising, 85354, Germany
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Monfort A, Jutras M, Martin B, Boucoiran I, Ferreira E, Leclair G. Simultaneous quantification of 19 analytes in breast milk by liquid chromatography-tandem mass spectrometry (LC-MS/MS). J Pharm Biomed Anal 2021; 204:114236. [PMID: 34273657 DOI: 10.1016/j.jpba.2021.114236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/25/2021] [Accepted: 06/30/2021] [Indexed: 01/07/2023]
Abstract
A bioanalytical method by high performance liquid chromatography coupled to mass spectrometry (HPLC-MS/MS) for the simultaneous quantification of 17 drugs and 2 major active metabolites in breast milk was developed and validated. Breast milk samples (100 μL) were submitted to a simple protein precipitation for the extraction of the analytes after the addition of deuterated internal standards (10 μL). A Kinetex C8 column was used for the separation of analytes with mobile phases composed of acetonitrile with 0.1 % formic acid and water with 0.1 % formic acid in gradient elution mode. Analytes were detected using an AB/SCIEX 4000 QTRAP instrument with positive electrospray ionization and operating in scheduled multiple reaction monitoring mode. Validation covered a large range of concentrations (0.5-500 ng/mL) for most of the analytes except bisoprolol, lacosamide, vilazodone (1-500 ng/mL), acid mycophenolic, letrozole, clomiphene (2-500 ng/mL) and hydroxy-melatonin (10-500 ng/mL). Within-run and between-run accuracy and precision for 4 levels of quality controls (QC) spiked at the lower limit of quantification (LLOQ), at 3 times the LLOQ, 50 % of the upper limit of quantification (ULOQ) and 80 % of the ULOQ were in agreement with the criteria from international guidelines. Matrix effect and extraction recovery ranged from 40.7 to 106.5 % and 87.3 to 110.8 %, respectively with relative standard deviations less than 15 %. Furthermore, all analytes were stable in breast milk at room temperature for 24 h, at -20 °C for two weeks, at -80 °C for 1 month, and after 3 freeze-thaw cycles. Finally, the method was successfully applied to nursing women samples collected from an ongoing feasibility study on drug quantification in breast milk.
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Affiliation(s)
- Anaëlle Monfort
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada.
| | - Martin Jutras
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada.
| | | | - Isabelle Boucoiran
- CHU Sainte-Justine, H3T 1C5, Canada; Department of Obstetrics and Gynecology, Université de Montréal, H3T 1J4, Canada.
| | - Ema Ferreira
- Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada; Centre IMAGe, CHU Sainte-Justine, H3T 1C5, Canada.
| | - Grégoire Leclair
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada.
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Jahani Kondori M, Kolla BP, Moore KM, Mansukhani MP. Management of Restless Legs Syndrome in Pregnancy and Lactation. J Prim Care Community Health 2021; 11:2150132720905950. [PMID: 32054396 PMCID: PMC7025421 DOI: 10.1177/2150132720905950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Restless legs syndrome (RLS) affects about 20% of all pregnant women. RLS symptoms are usually moderate to severe in intensity during pregnancy and can result in insomnia, depression, and other adverse outcomes. Although iron deficiency has been implicated as a potential etiological factor, other mechanisms can also play a role. Nonpharmacologic methods are the primary recommended form of treatment for RLS in pregnancy and lactation. Iron supplementation may be considered when the serum ferritin is low; however, several patients are unable to tolerate iron or have severe symptoms despite oral iron replacement. Here, we describe a case of severe RLS in pregnancy and illustrate the dilemmas in diagnosis and management. We review the literature on the prevalence, diagnosis, course, possible underlying pathophysiologic mechanisms and complications of RLS in pregnancy. We describe current best evidence on the efficacy, and safety of nonpharmacologic therapies, oral and intravenous iron supplementation, as well as other medication treatments for RLS in pregnancy and lactation. We highlight gaps in the literature and provide a practical guide for the clinical management of RLS in pregnancy and during breastfeeding.
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40
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Akamine Y, Fujiyama N, Kagaya H, Saito M, Miura H, Terada Y, Takahashi T, Satoh S, Miura M. Tacrolimus concentrations after renal transplantation in a mother-neonate dyad: Maternal, neonatal and breast milk measurements. J Clin Pharm Ther 2021; 46:1800-1803. [PMID: 34041772 DOI: 10.1111/jcpt.13451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/26/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE We aim to add to the few reports on tacrolimus concentrations in breast milk and in maternal, umbilical vein and neonatal blood after maternal renal transplantation. CASE SUMMARY In a 30-year-old pregnant woman, the tacrolimus concentration at delivery was the same in maternal, umbilical vein and neonatal blood. The breast milk/maternal blood tacrolimus ratio ranged from 0.40 to 0.64. WHAT IS NEW AND CONCLUSION The maternal and neonatal blood tacrolimus concentrations at birth are equivalent; thus, one must assume that maternal tacrolimus concentrations directly affect the foetus and/or neonate. Tacrolimus is not detectable in the neonate 3 weeks after birth, suggesting that there is minimal transfer through breast milk.
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Affiliation(s)
- Yumiko Akamine
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Nobuhiro Fujiyama
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Hideaki Kagaya
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Mitsuru Saito
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroshi Miura
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yukihiro Terada
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tsutomu Takahashi
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita, Japan
| | - Shigeru Satoh
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
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41
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Yeung CHT, Ito S, Autmizguine J, Edginton AN. Incorporating Breastfeeding-Related Variability with Physiologically Based Pharmacokinetic Modeling to Predict Infant Exposure to Maternal Medication Through Breast Milk: a Workflow Applied to Lamotrigine. AAPS JOURNAL 2021; 23:70. [PMID: 34002327 DOI: 10.1208/s12248-021-00599-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
Current methods to assess risk in infants exposed to maternal medication through breast milk do not specifically account for infants most vulnerable to high drug exposure. A workflow applied to lamotrigine incorporated variability in infant anatomy and physiology, milk intake volume, and milk concentration to predict infant exposure. An adult physiologically based pharmacokinetic model of lamotrigine was developed and evaluated. The model was scaled to account for growth and maturation of a virtual infant population (n=100). Daily infant doses were simulated using milk intake volume and concentration models described by a nonlinear equation of weight-normalized intake across infant age and a linear function on the relationship of observed milk concentrations and maternal doses, respectively. Average infant plasma concentration at steady state was obtained through simulation. Models were evaluated by comparing observed to simulated infant plasma concentrations from breastfeeding infants based on a 90% prediction interval (PI). Upper AUC ratio (UAR) was defined as a novel risk metric. Twenty-five paired (milk concentrations measured) and 18 unpaired (milk concentrations unknown) infant plasma samples were retrieved from the literature. Forty-four percent and 11% of the paired and unpaired infant plasma concentrations were outside of the 90% PI, respectively. Over all ages (0-7 months), unpaired predictions captured more observed infant plasma concentrations within 90% PI than paired. UAR was 0.18-0.44 when mothers received 200 mg lamotrigine, suggesting that infants can receive 18-44% of the exposure per dose as compared to adults. UARs determined for further medications could reveal trends to better classify at-risk mother-infant pairs.
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Affiliation(s)
- Cindy H T Yeung
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Julie Autmizguine
- Department of Pediatrics & Department of Pharmacology and Physiology, Université de Montréal, Montréal, Québec, Canada.,Research Center, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Andrea N Edginton
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada.
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Daei M, Khalili H, Heidari Z. Direct oral anticoagulant safety during breastfeeding: a narrative review. Eur J Clin Pharmacol 2021; 77:1465-1471. [PMID: 33963877 DOI: 10.1007/s00228-021-03154-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/02/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE There are limited data regarding the safety of direct oral anticoagulants (DOACs) during breastfeeding. The aim of the present study is to investigate the extent of excretion of DOACs into human milk according to the available clinical and experimental studies. METHODS On 16th January 2021, we systematically searched PubMed, Scopus, Embase, and Web of Science for all studies which investigated DOACs in breastfeeding without any time frame and language limitation. Search keywords were [breastfeeding, breast feeding, breastfed, lactation, milk secretion OR milk] AND [apixaban OR Eliquist OR rivaroxaban OR Xarelto OR edoxaban OR Savaysa OR dabigatran OR Pradaxa OR dabigatran etexilate OR dabigatran etexilate mesylate OR direct oral anticoagulant OR DOAC OR new oral anticoagulant OR NOAC]. Finally, we identified six articles which reported DOAC use during breastfeeding or lactation. RESULTS AND CONCLUSION According to the available limited data, dabigatran has the least excretion in human breast milk. Rivaroxaban and dabigatran both have acceptable milk excretion cutoffs, whereas apixaban milk excretion is greater than the maximum allowed range. Further well-designed studies with larger sample sizes are required to generate consistent comparable data and clarify benefits and risks of each DOAC during breastfeeding.
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Affiliation(s)
- Maryam Daei
- Faculty of Pharmacy, Alborz University of Medical Sciences, Alborz, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Zinat Heidari
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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43
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Drug Exposure in Newborns: Effect of Selected Drugs Prescribed to Mothers During Pregnancy and Lactation. Ther Drug Monit 2021; 42:255-263. [PMID: 32068668 DOI: 10.1097/ftd.0000000000000747] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The number of newborns exposed to therapeutic drugs during pregnancy is growing because of the increased use of drugs during pregnancy. In recent years, advances in our understanding of drug placental transfer have augmented the likelihood of a healthy baby in mothers with chronic diseases needing drug therapy. Globally, for example, more than 1.4 million pregnancies in 2015 have been burdened with antiretroviral drugs due to an increasing number of HIV-positive women treated with these drugs, particularly in low- and middle-income countries. In most cases, the fetus is exposed to much higher drug doses in utero than the newborn nursed by the mother. Drug transfer through the placenta takes place by passive diffusion, active transport, or facilitated transport, and drug concentrations in the fetal circulation may be comparable to that in the mother's blood concentration. The excretion of drugs into breastmilk predominantly occurs by passive diffusion, allowing only the non-protein-bound fraction of the blood drug concentration to penetrate. Drug agencies in the United States and Europe highly recommend performing clinical trials in pregnant or breastfeeding women. However, only a few drugs have reported statistically sound data in these patient groups. Most available results concerning pregnancy are obtained from observational studies after birth, assessing outcomes in the newborn or by measuring drug concentrations in the mother and umbilical cord blood. In the case of the lactation period, some studies have evaluated drug concentrations in breastmilk and blood of the mother and/or infant. In this review, exposure to antiretrovirals, immunosuppressants used after solid organ transplantation, and antiepileptics during pregnancy and lactation has been discussed in detail.
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44
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James AD, Schiller H, Marvalin C, Jin Y, Borell H, Roffel AF, Glaenzel U, Ji Y, Camenisch G. An integrated assessment of the ADME properties of the CDK4/6 Inhibitor ribociclib utilizing preclinical in vitro, in vivo, and human ADME data. Pharmacol Res Perspect 2021; 8:e00599. [PMID: 32524755 PMCID: PMC7287031 DOI: 10.1002/prp2.599] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 12/15/2022] Open
Abstract
Ribociclib (LEE011, Kisqali ®) is a highly selective small molecule inhibitor of cyclin-dependent kinases 4 and 6 (CDK4/6), which has been approved for the treatment of advanced or metastatic breast cancer. A human ADME study was conducted in healthy male volunteers following a single oral dose of 600 mg [14 C]-ribociclib. Mass balance, blood and plasma radioactivity, and plasma ribociclib concentrations were measured. Metabolite profiling and identification was conducted in plasma, urine, and feces. An assessment integrating the human ADME results with relevant in vitro and in vivo non-clinical data was conducted to provide an estimate of the relative contributions of various clearance pathways of the compound. Ribociclib is moderately to highly absorbed across species (approx. 59% in human), and is extensively metabolized in vivo, predominantly by oxidative pathways mediated by CYP3A4 (ultimately forming N-demethylated metabolite M4) and, to a lesser extent, by FMO3 (N-hydroxylated metabolite M13). It is extensively distributed in rats, based on QWBA data, and is eliminated rapidly from most tissues with the exception of melanin-containing structures. Ribociclib passed the placental barrier in rats and rabbits and into milk of lactating rats. In human, 69.1% and 22.6% of the radiolabeled dose were excreted in feces and urine, respectively, with 17.3% and 6.75% of the 14 C dose attributable to ribociclib, respectively. The remainder was attributed to numerous metabolites. Taking into account all available data, ribociclib is estimated to be eliminated by hepatic metabolism (approx. 84% of total), renal excretion (7%), intestinal excretion (8%), and biliary elimination (1%).
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Affiliation(s)
- Alexander D James
- PK Sciences (ADME), Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Hilmar Schiller
- PK Sciences (ADME), Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Cyrille Marvalin
- PK Sciences (ADME), Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Yi Jin
- PK Sciences (ADME), Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Hubert Borell
- PK Sciences (ADME), Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Ad F Roffel
- PRA Health Sciences, Scientific and Medical Affairs, Groningen, the Netherlands
| | - Ulrike Glaenzel
- PK Sciences (ADME), Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Yan Ji
- PK Sciences (Oncology TA), Novartis Institutes for Biomedical Research, East Hanover, USA
| | - Gian Camenisch
- PK Sciences (ADME), Novartis Institutes for Biomedical Research, Basel, Switzerland
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45
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Amundsen S, Nordeng H, Fuskevåg OM, Nordmo E, Sager G, Spigset O. Transfer of triptans into human breast milk and estimation of infant drug exposure through breastfeeding. Basic Clin Pharmacol Toxicol 2021; 128:795-804. [PMID: 33730376 DOI: 10.1111/bcpt.13579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 11/29/2022]
Abstract
Clinical data on the transfer of triptans into human breast milk remain scarce. In a lactation study including 19 breastfeeding women with migraine, we examined the excretion of six different triptans into milk. Following intake of a single dose, each participant collected seven breast milk samples at predefined intervals up to 24 hours after dose. Triptan concentrations in milk were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Infant drug exposure was estimated by calculating the relative infant dose (RID). Twenty-two breast milk sample sets were obtained for sumatriptan (n = 8), rizatriptan (n = 5), zolmitriptan (n = 4), eletriptan (n = 3), almotriptan (n = 1) and naratriptan (n = 1). Based on the average concentration in milk throughout the day, estimated mean RIDs (with range in parenthesis) were as follows: eletriptan 0.6% (0.3%-0.8%), sumatriptan 0.7% (0.2%-1.8%), rizatriptan 0.9% (0.3%-1.4%), almotriptan 1.8% (-), zolmitriptan 2.1% (0.7%-5.3%) and naratriptan 5.0% (-). Infant drug exposure through breastfeeding appears to be low and indicates that use of the triptans in this study is compatible with breastfeeding. Naratriptan may not be first choice in breastfeeding mothers initiating triptans during the neonatal period.
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Affiliation(s)
- Siri Amundsen
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.,Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Ole-Martin Fuskevåg
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.,Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Elisabet Nordmo
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), University Hospital of North Norway, Tromsø, Norway
| | - Georg Sager
- Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Abstract
PURPOSE OF REVIEW Over the past several decades, hydroxyurea has emerged as a well tolerated and potent disease-modifying therapy for children and adults with sickle cell anemia (SCA). Strong, evidence-based recommendations from the National Institutes of Health, American Society of Hematology, and British Society of Haematology document that hydroxyurea is now standard of care treatment for SCA. In low-resource settings, however, hydroxyurea is rarely utilized due to lack of availability, inadequate treatment guidance, and excessive costs. RECENT FINDINGS Research trials conducted within the Caribbean and sub-Saharan Africa confirm the efficacy of hydroxyurea as a well tolerated, feasible, and beneficial treatment in low-resource countries. Hydroxyurea is therefore vital to reaching the targets for control of SCA outlined by the WHO. To maximize its utilization toward real-world effectiveness, specific attention must be given to healthcare provider education and training, public and institutional awareness, and medication access and affordability. SUMMARY Efforts to introduce hydroxyurea effectively into low-resource countries should urgently address the lack of treatment guidelines, gaps in knowledge and clinical infrastructure, and medication inaccessibility. Partnerships among governmental, academic, pharmaceutical, and charitable organizations must tackle these barriers so that all individuals living with SCA worldwide can benefit from hydroxyurea.
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47
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Wu J, Lai X, Cui G, Chen Q, Liu J, Kang Y, Zhang Y, Feng X, Hu C, Shao L. Dual effects of JNK activation in blood-milk barrier damage induced by zinc oxide nanoparticles. JOURNAL OF HAZARDOUS MATERIALS 2020; 399:122809. [PMID: 32937690 DOI: 10.1016/j.jhazmat.2020.122809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/10/2020] [Accepted: 04/25/2020] [Indexed: 06/11/2023]
Abstract
Zinc oxide nanoparticles (ZnO-NPs) have been extensively applied in our daily life. Humans are at high risk of being exposed to ZnO-NPs, which induce potentially adverse health effects. Although a growing number of studies have investigated the toxic effects of ZnO-NPs, the available data concerning ZnO-NP interactions with the blood-milk barrier (BMB) remain highly limited. Herein, we systematically investigated the damage to BMB integrity induced by ZnO-NPs and the mechanisms involved. ZnO-NPs that were intravenously injected into lactating dams accumulated in the mammary gland and entered into the breast milk, inducing disruption to BMB integrity and changes in the tight junction (TJ) and adherens junction (AJ) components. Furthermore, using an in vitro BMB model composed of EpH4-Ev cells, we verified that ZnO-NP-triggered ROS generation and the activation of MKK4 and JNK are the main mechanism of cell-cell junction damage. More interestingly, JNK activation played different roles in inducing changes in the TJ and AJ complex, and these effects did not need to activate the downstream c-Jun. These data provide more information for understanding ZnO-NP interactions with the BMB and raise concern for the daily use and the intravenous use of ZnO-NPs by lactating mothers.
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Affiliation(s)
- Junrong Wu
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Guangzhou 510515, China
| | - Xuan Lai
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Guangman Cui
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Qiyue Chen
- Stomatological Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jia Liu
- Stomatological Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yiyuan Kang
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yanli Zhang
- Stomatological Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xiaoli Feng
- Stomatological Hospital, Southern Medical University, Guangzhou 510515, China
| | - Chen Hu
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Longquan Shao
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Guangzhou 510515, China.
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48
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Are apixaban and rivaroxaban distributed into human breast milk to clinically relevant concentrations? Blood 2020; 136:1783-1785. [DOI: 10.1182/blood.2020006231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/11/2020] [Indexed: 01/16/2023] Open
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49
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Verstegen RHJ, Anderson PO, Ito S. Infant drug exposure via breast milk. Br J Clin Pharmacol 2020; 88:4311-4327. [PMID: 32860456 DOI: 10.1111/bcp.14538] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/08/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022] Open
Abstract
More than half of women take medications during breastfeeding, predisposing their infants to medication exposure via breast milk. As a result, adverse drug reactions may emerge in the infant, although they are rarely reported. Disposition of maternal drugs in breast milk is described with several key parameters, which include relative infant dose (RID): infant drug intake via milk (weight- and time-adjusted) expressed as a percentage of the similarly adjusted mother's dose. Most drugs show RID values of <10%, indicating that drug concentrations in infant serum do not reach a level known to be therapeutic in adults unless drug clearance is markedly lower than the adult level on a weight basis. RID is a function of milk-to-(maternal) plasma drug concentration ratio (MP ratio) and maternal drug clearance. Therefore, MP ratio between drugs must be interpreted not by itself but with maternal drug clearance of each drug. This is why some drugs such as phenobarbital show an MP ratio of <1 but an RID as high as 50-70%, while morphine shows an MP ratio of 2 but an RID in the range of 5%. Using RID, we interpreted case reports of infant adverse outcomes, and we observed cases with relatively low infant serum concentrations of drug, consistent with low RID, as well as those with near- or above-adult therapeutic serum concentrations, with or without increased drug intake (i.e. high RID). It is important to consider both pharmacokinetic and pharmacodynamic factors in interpreting adverse outcomes in infants breastfed by a mother taking medications.
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Affiliation(s)
- Ruud H J Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Philip O Anderson
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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Birnbaum AK, Meador KJ, Karanam A, Brown C, May RC, Gerard EE, Gedzelman ER, Penovich PE, Kalayjian LA, Cavitt J, Pack AM, Miller JW, Stowe ZN, Pennell PB. Antiepileptic Drug Exposure in Infants of Breastfeeding Mothers With Epilepsy. JAMA Neurol 2020; 77:441-450. [PMID: 31886825 DOI: 10.1001/jamaneurol.2019.4443] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance There is limited information on infant drug exposure via breastfeeding by mothers who are receiving antiepileptic drug therapy. Objective To provide direct, objective information on antiepileptic drug exposure through breast milk. Design, Setting, and Participants This prospective cohort study was conducted between December 2012 to October 2016, with follow-up in children until 6 years of age at 20 sites across the United States. Data were collected via an observational multicenter investigation (Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs [MONEAD]) of outcomes in pregnant mothers with epilepsy and their children. Pregnant women with epilepsy who were aged 14 to 45 years, had pregnancies that had progressed to less than 20 weeks' gestational age, and had measured IQ scores of more than 70 points were enrolled and followed up through pregnancy and 9 postpartum months. Their infants were enrolled at birth. Data were analyzed from May 2014 to August 2019. Exposures Antiepileptic drug exposure in infants who were breastfed. Main Outcomes and Measures The percentage of infant-to-mother concentration of antiepileptic drugs. Antiepileptic drug concentrations were quantified from blood samples collected from infants and mothers at the same visit, 5 to 20 weeks after birth. Concentrations of antiepileptic drugs in infants at less than the lower limit of quantification were assessed as half of the lower limit. Additional measures collected were the total duration of all daily breastfeeding sessions and/or the volume of pumped breast milk ingested from a bottle. Results A total of 351 women (of 865 screened and 503 eligible individuals) were enrolled, along with their 345 infants (179 female children [51.9%]; median [range] age, 13 [5-20] weeks). Of the 345 infants, 222 (64.3%) were breastfed; the data collection yielded 164 matching infant-mother concentration pairs from 138 infants. Approximately 49% of all antiepileptic drug concentrations in nursing infants were less than the lower limit of quantification. The median percentage of infant-to-mother concentration for all 7 antiepileptic drugs and 1 metabolite (carbamazepine, carbamazepine-10,11-epoxide, levetiracetam, lamotrigine, oxcarbazepine, topiramate, valproate, and zonisamide) ranged from 0.3% (range, 0.2%-0.9%) to 44.2% (range, 35.2%-125.3%). In multiple linear regression models, maternal concentration was a significant factor associated with lamotrigine concentration in infants (Pearson correlation coefficient, 0.58; P < .001) but not levetiracetam concentration in infants. Conclusions and Relevance Overall, antiepileptic drug concentrations in blood samples of infants who were breastfed were substantially lower than maternal blood concentrations. Given the well-known benefits of breastfeeding and the prior studies demonstrating no ill effects when the mother was receiving antiepileptic drugs, these findings support the breastfeeding of infants by mothers with epilepsy who are taking antiepileptic drug therapy.
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Affiliation(s)
- Angela K Birnbaum
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | - Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, California
| | - Ashwin Karanam
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | | | - Ryan C May
- The Emmes Corporation, Rockville, Maryland
| | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | - John W Miller
- Department of Neurology, University of Washington, Seattle.,Department of Neurological Surgery, University of Washington, Seattle
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin at Madison, Madison
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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