Lamivudine use while Breastfeeding
Drugs containing Lamivudine: Combivir, Epivir, Triumeq, Epzicom, Trizivir, Epivir-HBV
Lamivudine Levels and Effects while Breastfeeding
Summary of Use during Lactation
In the United States and other developed countries, HIV-infected mothers should generally not breastfeed their infants. In countries in which no acceptable, feasible, sustainable and safe replacement feeding is available, exclusive breastfeeding for 6 months is recommended for HIV-infected mothers to reduce the risk of HIV transmission from the mother to the infant compared with mixed feeding. In these settings, abrupt weaning at 4 months does not reduce the risk of HIV transmission or produce an overall health benefit compared to continued breastfeeding, and increases the risk of infant death in HIV-infected infants. Lamivudine is recommended by the World Health Organization to be given as part of a 3-drug combination to all antiretroviral-naive women who are breastfeeding their infants. Extended antiretroviral prophylaxis in breastfed infants with antiretroviral drugs appears to reduce the rate of HIV transmission during breastfeeding by about half, but the optimal regimen and duration of prophylaxis has not yet been defined. The infants who do become HIV infected during breastfeeding by mothers receiving a HAART regimen that includes lamivudine are often infected with multi-class resistant HIV. Lamivudine is often used as part of a regimen that decreases mother-to-child transmission of HIV and is generally well tolerated by the breastfed infant. Breastfed infants whose mothers receive highly active antiretroviral therapy (HAART) have higher rates of neutropenia during the first month and severe anemia during the first 6 months of life.
Lamivudine has not been studied in HIV-negative nursing mothers being treated for hepatitis B infection, but the low doses used would not be expected to cause any serious adverse effects in breastfed infants. Some sources recommend not breastfeeding during lamivudine therapy for hepatitis B. In a survey, 226 physicians with a practice interest in liver disease in the United States responded. Of these, 31% stated that they recommend breastfeeding for their patients with hepatitis B who are taking antiviral therapy, 44% stated that they do not recommend breastfeeding during antiviral therapy and 25% stated that they were unsure.
Maternal Levels. Milk samples were taken daily before breastfeeding from women receiving lamivudine from 2 groups of women. In the group (n = 10) receiving lamivudine 300 mg twice daily (n = 10), the average milk concentration was 1.2 mg/L (range <0.5 to 6.1 mg/L). In the group receiving 150 mg twice daily plus zidovudine (n = 10), the average milk lamivudine concentration was 0.9 mg/L (range <0.5 to 8.2 mg/L).
Twenty women who were receiving oral lamivudine 150 mg twice daily as part of a combination antiretroviral regimen had their milk analyzed at either 2 or 5 months postpartum. Milk samples were provided at a median of 4 hours (range 1 to 8.5 hours) after the last dose. The median lamivudine concentration in breastmilk was 1.8 mg/L.
Forty women were given postpartum prophylaxis with unstated dosages of lamivudine, nevirapine, and zidovudine (or stavudine if the hemoglobin <8 g/dL). Blood and milk samples were collected once during the first 3 days postpartum and once at 7 days postpartum. The median times after a dose that samples were collected were 5.3 hours (range 0 to 99 hours) for the first sample and 6 hours (range 4.3 to 20 hours) for the 7-day sample. Average breastmilk lamivudine concentrations were calculated only for samples that had detectable (>20 mcg/L) concentrations of nevirapine. The mean breastmilk concentrations were 0.4 (n = 20) and 0.4 mg/L (n = 30), respectively, at the two sampling times, which was 2.9 to 3.3 times the simultaneous maternal serum concentrations.
Forty-seven samples of breastmilk and maternal serum were obtained at 6, 12 and 24 weeks postpartum from mothers taking lamivudine as part of a combination of antiretrovirals. The lamivudine dosage the mothers were taking was not stated in the abstract. The median breastmilk concentrations of lamivudine at a median of 14 hours after the last maternal dose were 510 (17 samples), 387 (17 samples) and 310 mcg/L (13 samples). Median milk concentrations were 2.6 times (interquartile range 1.1 to 3.5 times) the maternal plasma concentrations. In a related study by the same authors, the lamivudine milk to plasma ratio was found to be 2.96 in 49 patients.
Fifty-eight mothers who were taking a combination regimen of lamivudine, nevirapine and zidovudine had their serum and breastmilk analyzed for the presence of these drugs. Mothers took lamivudine 150 mg twice daily starting at 34 to 36 weeks postpartum and continuing until 6 months postpartum. Breastmilk was collected within 24 hours after delivery and at 2, 6, 14 and 24 weeks postpartum at variable times after the previous dose. The median breastmilk lamivudine concentration across all visits was 1214 mcg/L. The authors estimated that a fully breastfed infant would receive a daily dosage of 182 mcg/kg of lamivudine.
Sixty-six mothers who were receiving lamivudine 150 mg twice daily as part of a combination antiretroviral regimen provided a total of 206 milk samples at birth, 1 month, 3 months and/or 6 months postpartum. Milk samples were collected at a median of 4.5 hours (range 3.5 to 6 hours) after the previous dose. The median breastmilk lamivudine concentration was 446 mcg/L (range 269 to 683 mcg/L).
Fifteen women had been taking lamivudine 150 mg twice daily for 53 to 182 days as part of a drug combination that included either abacavir and zidovudine or lopinavir, ritonavir, and zidovudine. Breastmilk samples were collected at just before a dose at a median of 1 month postpartum. Whole breastmilk levels contained a median of 0.14 mg/L of lamivudine, which was a median of 74% of maternal blood levels.
Thirty women were studied at 6, 12 or 24 weeks postpartum (10 at each time). Each mother was taking zidovudine 300 mg, lamivudine 150 mg, lopinavir 400 mg, and ritonavir 100 mg twice daily by mouth starting at delivery. On the study day, at a median of 14.9 hours after the previous evening's dose, maternal plasma and breastmilk samples were obtained prior to the morning dose and 2, 4 and 6 hours after the dose. One hundred seven of the 121 breastmilk samples contained detectable quantities (10 mcg/L or greater) of lamivudine, with an median breastmilk concentration of 0.94 mg/L over the 6 hours.
Infant Levels. Twenty nursing mothers were receiving oral lamivudine 150 mg twice daily as part of a combination antiretroviral regimen. Their infants had serum concentrations determined at either 2 or 5 months postpartum. Serum samples were provided at a median of 4 hours (range 1 to 8.5 hours) after the last dose. The median infant serum lamivudine concentration was 28 mcg/L (range <14 to 53 mcg/L). The average value was 5% of the IC50 for HIV.
The infants of postpartum mothers taking nevirapine as part of a combination of antiretrovirals had undetectable serum nevirapine concentrations by HPLC/MS analysis. The lamivudine dosage the mothers were taking and times of infant plasma sampling were not stated in the abstract. Infant serum concentrations were measured at 6 (17 samples), 12 (17 samples), and 24 (13 samples) weeks of age at an average of 14 hours after the last maternal dose. Median infant serum lamivudine concentrations were 13, 10, and 5 mcg/L, respectively, which was 6% of the maternal serum concentration.
Fifty-eight infants whose mothers were taking a combination regimen of lamivudine, nevirapine and zidovudine had their serum analyzed for the presence of these drugs. Mothers took lamivudine 150 mg twice daily starting at 34 to 36 weeks postpartum and continuing until 6 months postpartum and were instructed to exclusively breastfeed for 5.5 months. Serum samples were collected within 24 hours after delivery and at 2, 6, 14 and 24 weeks postpartum. The median infant dried blood spot lamivudine concentrations were 67 mcg/L at delivery, 32 mcg/L at week 2, 24 mcg/L at week 6, 20 mcg/L at week 14 and not measurable (<16 mcg/L) at week 24 postpartum.
Breastfed infants of 66 mothers who were receiving lamivudine 150 mg twice daily as part of a combination antiretroviral regimen had a total of 64 blood samples analyzed at 1 month, 3 months and/or 6 months postpartum. Samples were collected at a median of 4.5 hours (range 3.5 to 6 hours) after the previous maternal dose and a median of 30 minutes (range 20 to 60 minutes) after the previous nursing. The medial infants' lamivudine plasma concentration was 18 mcg/L (range 7 to 35 mcg/L), which was a median of 2% (range 0 to 4%) of the maternal serum concentration.
Twenty-four infants were breastfed either partially or exclusively by their mothers who had been taking lamivudine 150 mg twice daily for 53 to 182 days as part of a drug combination that included either abacavir and zidovudine or lopinavir, ritonavir, and zidovudine. Infant blood was collected at a median of 1 month postpartum at 11 to 18 hours after the last dose and a median of 1 hour (range 6 minutes to 35 hours) after the last breastfeeding. All of the infant plasma samples had undetectable (<7 mcg/L) plasma levels of lamivudine.
Thirty nursing mothers were studied at 6, 12 or 24 weeks postpartum (10 at each time). Each mother was taking lamivudine 150 mg twice daily by mouth starting at delivery. Infant plasma samples were obtained before their mother's first dose and at 2, 4 and 6 hours after the mother's dose. Infants were allowed to breastfeed ad libitum during the study period. Lamivudine was detectable (10 mcg/L or greater) in 107 of the 115 infant plasma samples, at a median concentration of 180 mcg/L.
Effects in Breastfed Infants
A study assigned pregnant women to zidovudine alone or highly active antiretroviral therapy (HAART: zidovudine, lamivudine and nevirapine) to prevent maternal-to-child transmission of HIV infection. After delivery, all infants received one month of zidovudine prophylaxis; some infants were breastfed and others were formula fed. A higher percentage of infants in the HAART-exposed group had neutropenia than those in the unexposed group at 1 month of age (15.9% and 3.7%, respectively). Hematologic toxicity was transient and asymptomatic. From 2 to 6 months postpartum, no differences in hematologic toxicity were seen between breastfed and formula-fed infants. No statistical difference in hepatic toxicity was seen between the breastfed and formula-fed infants.
Effects on Lactation and Breastmilk
Some case reports and in vitro studies have suggested that protease inhibitors might cause hyperprolactinemia and galactorrhea in some male patients, although this has been disputed. One case series found an incidence of gynecomastia of 2.4 cases per person annually among men receiving highly active antiretroviral therapy; 51% of the affected patients were taking lamivudine. Gynecomastia was unilateral initially, but progressed to bilateral in 53% of cases. No alterations in serum prolactin were noted and spontaneous resolution usually occurred within one year, even with continuation of the regimen. The relevance of these findings to nursing mothers is not known. The prolactin level in a mother with established lactation may not affect her ability to breastfeed.
Alternate Drugs to Consider
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