Bevacizumab use while Breastfeeding
Drugs containing Bevacizumab: Avastin
Bevacizumab Levels and Effects while Breastfeeding
Summary of Use during Lactation
No information is available on the intravenous use of bevacizumab during breastfeeding. Because bevacizumab is a large protein molecule with a molecular weight of about 149,000, the amount in milk is likely to be very low and absorption is unlikely because it is probably destroyed in the infant's gastrointestinal tract. Until more data become available, intravenous bevacizumab should be used with caution during breastfeeding, especially while nursing a newborn or preterm infant. The manufacturer recommends that breastfeeding be discontinued during bevacizumab therapy.
Several infants have been breastfed, apparently without noticeable harm, following maternal intravitreal bevacizumab injections. Bevacizumab was undetectable in the milk of one mother, but vascular endothelial growth factor (VEGF) levels in breastmilk were suppressed following the injection. Because the breast and neonatal intestine have VEGF receptors, some authors recommend use of intravitreal ranibizumab, which does not appear to depress milk VEGF levels.
Maternal Levels. A woman was given 3 intravitreal injections of bevacizumab for scar-associated choroidal neovascularization in her left eye. Her breastfed infant was 12 weeks old at the start of therapy. The bevacizumab dose and interval were not stated in the published report, but the usual intravitreal dose is 1.25 mg. After the first injection, bevacizumab was detectable in the maternal serum with a peak between 0.6 and 0.7 mcg/L at one week, but bevacizumab was not detectable in breastmilk at any time over the 42 days following injection. Vascular endothelial growth factor (VEGF) was also measured in serum and breastmilk. After the intravitreal injection of bevacizumab, the VEGF level in breastmilk decreased from 13.3 to 8.6 mcg/L over a 2-week period. After changing therapy to ranibizumab, no decrement in breastmilk VEGF was seen.
Two women received intravitreal injections of bevacizumab 1.25 mg at 1- to 2-month intervals while breastfeeding. Breastmilk samples were obtained one day before and one week after injections for 6 months in one and 16 months in the other woman. Bevacizumab was undetectable (<3 mcg/L) in any of the samples.
Infant Levels. Relevant published information was not found as of the revision date.
Effects in Breastfed Infants
A 33-year-old woman was treated with 14 intravitreal bevacizumab injections of 1.25 mg over a 20-month period. Five of these injections were given while she was breastfeeding (age of infant not stated). No mention was made of adverse effects in this infant, but she became pregnant again, received 3 additional injections, and delivered an infant who developed normally at 12 months of age.
A woman was given 3 intravitreal injections of bevacizumab for scar-associated choroidal neovascularization in her left eye. Her breastfed infant was 12 weeks old at the start of therapy. No mention was made of adverse effects in this infant. Two women received intravitreal injections of bevacizumab 1.25 mg at 1- to 2-month intervals while breastfeeding. They breastfed their infants (extent not stated) for several months. No adverse effects in the infants were noted.
Effects on Lactation and Breastmilk
Relevant published information was not found as of the revision date.
Alternate Drugs to Consider
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. Ehlken C, Martin G, Stahl A, Agostini HT. Reduction of vascular endothelial growth factor a in human breast milk after intravitreal injection of bevacizumab but not ranibizumab. Arch Ophthalmol. 2012;130:1226-7. PMID: 22965611
3. McFarland TJ, Rhoads AD, Hartzell M et al. Bevacizumab levels in breast milk after long-term intravitreal injections. Retina. 2015;35:1670-3. PMID: 25830694
4. Tarantola RM, Folk JC, Boldt HC, Mahajan VB. Intravitreal bevacizumab during pregnancy. Retina. 2010;30:1405-11. PMID: 20924262
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