Duration of cisplatin excretion in breast milk

Persistence of Oxaliplatin Transfer into Human Milk: A Case Report

Background: Oxaliplatin is an alkylating chemotherapeutic agent commonly used for malignancies in women of reproductive age, including colorectal cancer. No research previously exists regarding the transfer of platinum into milk after administration of oxaliplatin. Methods: We present a case of a lactating patient with stage 3a colorectal cancer requiring chemotherapy including oxaliplatin (130 mg/m²) infused every 4 weeks. Milk levels of platinum were tested at Lactation Lab, Inc., using a previously published mass spectrometry method. Results: Milk platinum concentrations 34 and 65 days after treatment were 7.8 and 10.3 ng/mL, respectively. Conclusion: These levels are similar to cisplatin or carboplatin in the immediate weeks after their administration, suggesting that the equivalent platinum exposure risk persists for longer with oxaliplatin than with other platinum analogues. Findings from this report support current recommendations to cease breastfeeding after oxaliplatin administration.

Presence of Five Chemotherapeutic Drugs in Breast Milk as a Guide for the Safe Use of Chemotherapy During Breastfeeding: Results From a Case Series

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.

Drug development research in pregnant and lactating women

Pregnant and lactating women are considered "therapeutic orphans" because they generally have been excluded from clinical drug research and the drug development process owing to legal, ethical, and safety concerns. Most medications prescribed for pregnant and lactating women are used "off-label" because most of the clinical approved medications do not have appropriate drug labeling information for pregnant and lactating women. Medications that lack human safety data on use during pregnancy and lactation may pose potential risks for adverse effects in pregnant and lactating women as well as risks of teratogenic effects to their unborn and newborn babies. Federal policy requiring the inclusion of women in clinical research and trials led to considerable changes in research design and practice. Despite more women being included in clinical research and trials, the inclusion of pregnant and lactating women in drug research and clinical trials remains limited. A recent revision to the "Common Rule" that removed pregnant women from the classification as a "vulnerable" population may change the culture of drug research and drug development in pregnant and lactating women. This review article provides an overview of medications studied by the Obstetric-Fetal Pharmacology Research Units Network and Centers and describes the challenges in current obstetrical pharmacology research and alternative strategies for future research in precision therapeutics in pregnant and lactating women. Implementation of the recommendations of the Task Force on Research Specific to Pregnant Women and Lactating Women can provide legislative requirements and opportunities for research focused on pregnant and lactating women.

Biological barriers, and the influence of protein binding on the passage of drugs across them

Drug-protein binding plays a key role in determining the pharmacokinetics of a drug. The distribution and protein binding ability of a drug changes over a lifetime, and are important considerations during pregnancy and lactation. Although proteins are a significant fraction in plasma composition, they also exist beyond the bloodstream and bind with drugs in the skin, tissues or organs. Protein binding influences the bioavailability and distribution of active compounds, and is a limiting factor in the passage of drugs across biological membranes and barriers: drugs are often unable to cross membranes mainly due to the high molecular mass of the drug-protein complex, thus resulting in the accumulation of the active compounds and a significant reduction of their pharmacological activity. This review describes the consequences of drug-protein binding on drug transport across physiological barriers, whose role is to allow the passage of essential substances-such as nutrients or oxygen, but not of xenobiotics. The placental barrier regulates passage of xenobiotics into a fetus and protects the unborn organism. The blood-brain barrier is the most important barrier in the entire organism and the skin separates the human body from the environment.

Case Report: Prolonged Excretion of Platinum in Human Breast Milk After Cisplatin Therapy

Introduction

Cisplatin is used to treat cancers that affect women of childbearing age and those that may breastfeed. Prior literature regarding the duration of cisplatin excretion in human milk is sparse and suggests complete clearance days after initial administration.

Method

We present the case of a postpartum woman who received three doses of weekly cisplatin for cervical cancer. Platinum levels were measured in expressed milk for several months after cisplatin administration.

Results

Levels of the parent element platinum were detected 159 days (over 22 weeks) followingadministration. These results demonstrate persistence of detectable platinum levels for a muchlonger period than previously reported.

Conclusion

This case report is the first to follow platinum levels in expressed milk after multiplepostpartum cisplatin doses. Our results demonstrate a biphasic elimination with detectionspanning several months after cessation of treatment. Women should be advised to abstainfrom breastfeeding until long after completion of cisplatin therapy.

Complications and Outcomes of Endoscopic Treatment in a Cohort of Patients With Biliary Stenosis After Orthotopic Liver Transplant: A Retrospective Observational Study

OBJECTIVES

Liver transplant represents the criterion standard therapy for end-stage liver disease. Biliary complications after liver transplant have shown an increased trend and are characterized by anastomotic and nonanastomotic stenoses.

MATERIALS AND METHODS

This retrospective single-center observational study included 217 patients who underwent liver transplant between January 2004 and December 2014; 18 patients had anastomotic (8.3%) and 29 (13.4%) had non-anastomotic stenoses. Patients with and without biliary stenosis were compared with regard to their preoperative, intraoperative, and postoperative parameters and donor characteristics. Patients with biliary stenosis were divided into 3 cohorts according to the type of endoscopic treatment performed (single plastic, multiple plastic, and fully covered self-ex-pandable metal stents). We compared the patients with different types of endoscopic biliary drainages for length and type of stenosis, presence of stones, time of onset and treatment, number of procedures, complications, and success rate.

RESULTS

Preoperative Child-Pugh and Model for End-Stage Liver Disease scores, complication and reoperation rates, and donor age were significantly higher in the stenosis group. We found no statistical differences other than length of stenosis between patients with multiple stents and self-expanding metal stents.

CONCLUSIONS

Preoperative recipient conditions and postoperative morbidities may represent risk factors for development of biliary strictures. Consequently, the optimal endoscopic treatment should be tailored to the type and the onset of stenosis and the patient's condition.

Inclusion of pregnant and breastfeeding women in research - efforts and initiatives

Pregnant and breastfeeding women have been rendered therapeutic orphans as they have been historically excluded from clinical trials. Labelling for most approved drugs does not provide information about safety and efficacy during pregnancy. This lack of data is mainly due to ethico-legal challenges that have remained entrenched in the post-diethylstilbestrol and thalidomide era, and that have led to pregnancy being viewed in the clinical trial setting primarily through a pharmacovigilance lens. Policy considerations that encourage and/or require the inclusion of pregnant or lactating women in clinical trials may address the current lack of available information. However, there are additional pragmatic strategies, such the employment of pharmacometric tools and the introduction of innovative clinical trial designs, which could improve knowledge about the safety and efficacy of medication use during pregnancy and lactation. This paper provides a broad overview of the pharmacoepidemiology of drugs used during pregnancy and lactation, and offers recommendations for regulators and researchers in academia and industry to increase the available pharmacokinetic and -dynamic understanding of medication use in pregnancy.

Effect of chemotherapy on the microbiota and metabolome of human milk, a case report

BACKGROUND

Human milk is an important source of bacteria for the developing infant and has been shown to influence the bacterial composition of the neonatal gut, which in turn can affect disease risk later in life. Human milk is also an important source of nutrients, influencing bacterial composition but also directly affecting the host. While recent studies have emphasized the adverse effects of antibiotic therapy on the infant microbiota, the effects of maternal chemotherapy have not been previously studied. Here we report the effects of drug administration on the microbiota and metabolome of human milk.

METHODS

Mature milk was collected every two weeks over a four month period from a lactating woman undergoing chemotherapy for Hodgkin's lymphoma. Mature milk was also collected from healthy lactating women for comparison. Microbial profiles were analyzed by 16S sequencing and the metabolome by gas chromatography-mass spectrometry.

FINDINGS

Chemotherapy caused a significant deviation from a healthy microbial and metabolomic profile, with depletion of genera Bifidobacterium, Eubacterium, Staphylococcus and Cloacibacterium in favor of Acinetobacter, Xanthomonadaceae and Stenotrophomonas. The metabolites docosahexaenoic acid and inositol known for their beneficial effects were also decreased.

CONCLUSION

With milk contents being critical for shaping infant immunity and development, consideration needs to be given to the impact of drugs administered to the mother and the long-term potential consequences for the health of the infant.