Methotrexate use while Breastfeeding

Drugs containing Methotrexate: Otrexup, Trexall, Methotrexate LPF Sodium, Rheumatrex Dose Pack, Rasuvo, Folex PFS

Methotrexate Levels and Effects while Breastfeeding

Summary of Use during Lactation

Most sources consider breastfeeding to be contraindicated during maternal antineoplastic drug therapy. An abstinence period of at least 1 week after chemotherapy doses of methotrexate has been suggested.[1] Limited information indicates that a maternal dose of methotrexate up to 65 mg (or 50 mg/square meter) produces low levels in milk, leading some authors to state that low single or weekly doses, such as those used for ectopic pregnancy or rheumatoid arthritis, are of low risk to the breastfed infant.[2][3][4][5] If breastfeeding during long-term, low-dose methotrexate use is undertaken, monitoring of the infant's complete blood count and differential could be considered.

Drug Levels

Maternal Levels. One patient who was 1 month postpartum given 22.5 mg (15 mg/square meter) methotrexate daily by mouth for choriocarcinoma. Milk was collected at various times of the first 12 days of therapy. A peak milk level of 2.3 mcg/L occurred 10 hours after the first dose. However, the milk level was relatively constant during the period from 4 to 10 hours after the dose, after which it began to drop. Peak milk levels on the second and third days of administration were 2.7 mcg/L. The authors estimated that a cumulative amount of 0.32 mcg would be excreted in milk during the first 12 hours after this dose.[2]

A woman was given a single intramuscular dose of 65 mg (50 mg/square meter) of methotrexate for ectopic pregnancy. Six milk samples were obtained from 1 to 24 hours after the dose. Methotrexate was undetectable (<22.7 mcg/L) in all milk samples.[5]

Infant Levels. Relevant published information was not found as of the revision date.

Effects in Breastfed Infants

Relevant published information was not found as of the revision date.

Possible Effects on Lactation

Relevant published information was not found as of the revision date.

Alternate Drugs to Consider

(Rheumatoid Arthritis) Auranofin, Etanercept, Gold Sodium Thiomalate, Hydroxychloroquine, Infliximab, Penicillamine, Sulfasalazine

References

1. Pistilli B, Bellettini G, Giovannetti E et al. Chemotherapy, targeted agents, antiemetics and growth-factors in human milk: How should we counsel cancer patients about breastfeeding? Cancer Treat Rev. 2013;39:207-11. PMID: 23199900

2. Johns DG, Rutherford LD et al. Secretion of methotrexate in human milk. Am J Obstet Gynecol. 1972;112:978-80. PMID: 5042796

3. Moretti ME, Lee A, Ito S. Which drugs are contraindicated during breastfeeding? Can Fam Physician. 2000;46:1753-7. PMID: 11013791

4. Ostensen M. Management of early aggressive rheumatoid arthritis during pregnancy and lactation. Expert Opin Pharmacother. 2009;10:1469-79. PMID: 19505214

5. Tanaka T, Walsh W, Verjee Z et al. Methotrexate use in a lactating woman with an ectopic pregnancy. Birth Defects Res A Clin Mol Teratol. 2009;85:494. Abstract. Assay sensitivity per Shinya Ito, MD. DOI: doi:10.1002/bdra.20605

Methotrexate Identification

Substance Name

Methotrexate

CAS Registry Number

59-05-2

Drug Class

  • Abortifacient Agents, Nonsteroidal
  • Antimetabolites, Antineoplastic
  • Antirheumatic Agents
  • Folic Acid Antagonists
  • Immunosuppressive Agents

Administrative Information

LactMed Record Number

466

Information from the National Library of Medicine's LactMed Database.

Last Revision Date

2014-07-08

Disclaimer

Information presented in this database is not meant as a substitute for professional judgment. You should consult your healthcare provider for breastfeeding advice related to your particular situation. The U.S. government does not warrant or assume any liability or responsibility for the accuracy or completeness of the information on this Site.

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