MEDICATIONS AND MEDICATIONS AND BREASTFEEDING: BREASTFEEDING: BREASTFEEDING: BREASTFEEDING: What Dispensing Pharmacists What Dispensing Pharmacists Need To Know Need To Know Frank J. Nice, RPh, DPA, CPHP Frank J. Nice, RPh, DPA, CPHP Derwood, MD 20855 Derwood, MD 20855 fjncat@hotmail.com fjncat@hotmail.com www.nicebreastfeeding.com www.nicebreastfeeding.com g 301 301- -840 840- -0270 (H) 0270 (H) 240 240- -506 506- -2568 (C) 2568 (C)
OBJECTIVES OBJECTIVES OBJECTIVES OBJECTIVES � Be able to identify the benefits and risks of Be able to identify the benefits and risks of y medication use during breastfeeding medication use during breastfeeding � Be able to identify available resources for Be able to identify available resources for medication use during breastfeeding medication use during breastfeeding di di ti ti d d i i b b tf tf di di � Be able to utilize tools and techniques for Be able to utilize tools and techniques for evaluating medication use during breastfeeding evaluating medication use during breastfeeding evaluating medication use during breastfeeding evaluating medication use during breastfeeding � Be able to identify adverse effects in children of Be able to identify adverse effects in children of mothers who are breastfeeding and taking mothers who are breastfeeding and taking medications medications di di ti ti � Be able to counsel mothers who are Be able to counsel mothers who are breastfeeding and taking or will take medications breastfeeding and taking or will take medications breastfeeding and taking or will take medications breastfeeding and taking or will take medications 2 2
3 3 Photo Courtesy of NIH Photo Courtesy of NIH
Benefit Benefit-Risk Analysis Benefit Benefit Risk Analysis Risk Analysis Risk Analysis � Benefits of breastfeeding (See Handout) + � Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) + Benefits of the drug (from the package Benefits of the drug (from the package insert and/ or literature) insert and/ or literature) Versus Versus � Risks of formula use or NOT breastfeeding Risks of formula use or NOT breastfeeding g (See Handout) + Risks of the drug (from (See Handout) + Risks of the drug (from the package insert and/ or literature) the package insert and/ or literature) 4 4
SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION � Journal Articles Journal Articles Nice References Nice References Nice References Nice References AAP Committee on Drugs AAP Committee on Drugs (See Website List) (See Website List) MICROMEDEX (See Website List) MICROMEDEX (See Website List) � Books Books Books Books nd Edition onprescription Drugs for the Breastfeeding Mother, 2 nd Nonprescription Drugs for the Breastfeeding Mother, 2 Edition Nice (See Slide) Nice (See Slide) th Edition Medications and Mothers’ Milk 15 th Medications and Mothers Milk, 15 Medications and Mothers’ Milk 15 Medications and Mothers Milk, 15 Edition Edition Edition Hale Hale (See Slide) (See Slide) th Edition Drugs in Pregnancy and Lactation, 9 th Drugs in Pregnancy and Lactation, 9 Edition Briggs, Freeman, and Yaffe (See Slide) Briggs, Freeman, and Yaffe (See Slide) nd Edition Drugs and Human Lactation, 2 nd Drugs and Human Lactation, 2 Edition Bennett (WHO) Bennett (WHO) 5 5
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SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION � Pharmaceutical Companies � Pharmaceutical Companies Pharmaceutical Companies Pharmaceutical Companies � Websites Websites (See Next Slide) (See Next Slide) � Lactation Study Center � Lactation Study Center Lactation Study Center Lactation Study Center Ruth Lawrence, MD Ruth Lawrence, MD University of Rochester University of Rochester University of Rochester University of Rochester 601 Elmwood Avenue, Rochester, NY 14642 601 Elmwood Avenue, Rochester, NY 14642 (585) 275 (585) 275-0088; Mon (585) 275 (585) 275 0088; Mon 0088; Mon-Fri 8AM 0088; Mon Fri, 8AM Fri 8AM-5PM Fri, 8AM 5PM 5PM 5PM 10 10
BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES � Nice Breastfeeding Nice Breastfeeding www.nicebreastfeeding.com www.nicebreastfeeding.com � LactMed / TOXNET / NLM / NIH � LactMed / TOXNET / NLM / NIH LactMed / TOXNET / NLM / NIH LactMed / TOXNET / NLM / NIH http://toxnet.nlm.nih.gov/cgi http://toxnet.nlm.nih.gov/cgi- - bi / i /ht bin/sis/htmlgen?LACT bin/sis/htmlgen?LACT bi / i /ht l l ?LACT ?LACT � Thomas Hale InfantRisk Center Thomas Hale InfantRisk Center http://www.infantrisk.com/category/ http://www.infantrisk.com/category/ breastfeeding breastfeeding breastfeeding breastfeeding 11 11
BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES Breastfeeding Online Breastfeeding Online � http://breastfeedingonline.com http://breastfeedingonline.com KellyMom KellyMom y � http: / / www.KellyMom.com http: / / www.KellyMom.com American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of � � Drugs and Other Chemicals Into Human Milk Drugs and Other Chemicals Into Human Milk http://aappolicy.aappublications.org/cgi/ http://aappolicy.aappublications.org/cgi/ content/full/pediatrics%3b108/3/776 content/full/pediatrics%3b108/3/776 p MICROMEDEX Healthcare Series MICROMEDEX Healthcare Series � (Subscription Required) (Subscription Required) (Subscription Required) (Subscription Required) http: / / www.micromedex.com/ products/ hcs/ http: / / www.micromedex.com/ products/ hcs/ 12 12
DRUG FACTORS- DRUG FACTORS -I I G G General Guidelines General Guidelines l G id li l G id li Most drugs appear in breast milk to some degree Most drugs appear in breast milk to some degree 1. 1. Levels of most drugs in breast milk do not usually Levels of most drugs in breast milk do not usually Levels of most drugs in breast milk do not usually Levels of most drugs in breast milk do not usually 2 2. 2. exceed 1% to 2% of ingested maternal dosage exceed 1% to 2% of ingested maternal dosage If the milk/plasma ratio of drug and active If the milk/plasma ratio of drug and active If the milk/plasma ratio of drug and active If the milk/plasma ratio of drug and active 3 3. 3. metabolites is less than 1:1, it is metabolites is less than 1:1, it is usually usually safe to safe to breastfeed breastfeed If infant dose is less than 10% of maternal dose If infant dose is less than 10% of maternal dose 4. 4. (weight adjusted), it is usually safe to breastfeed (weight adjusted), it is usually safe to breastfeed 13 13
DRUG FACTORS DRUG FACTORS- -II II Pharmacokinetics Pharmacokinetics Volume of Distribution Volume of Distribution 1. 1. (1- (1 -20 L/Kg) 20 L/Kg) pH (breast milk more acidic) pH (breast milk more acidic) pH (breast milk more acidic) pH (breast milk more acidic) 2. 2. Lipids Lipids 3. 3. Protein Protein-Bound Drugs (85%) Protein Protein-Bound Drugs (85%) Bound Drugs (85%) Bound Drugs (85%) 4 4. 4. Molecular Size (Daltons) Molecular Size (Daltons) 5. 5. (200 (200- -400) 400) Active Transport Active Transport 6. 6. 14 14
MATERNAL FACTORS MATERNAL FACTORS Pharmacodynamics Pharmacodynamics Mammary epithelium may have drug Mammary epithelium may have drug - - 1. 1. metabolizing capacity metabolizing capacity g g p p y y Milk volume is usually greatest in the Milk volume is usually greatest in the 2. 2. early morning early morning early morning early morning Fat content of milk is usually highest in Fat content of milk is usually highest in 3. 3. the late morning the late morning Stage of breastfeeding is factor Stage of breastfeeding is factor Stage of breastfeeding is factor Stage of breastfeeding is factor 4 4. 4. 15 15
Stage of Breastfeeding Stage of Breastfeeding Stage of Breastfeeding Stage of Breastfeeding � Newborns feed every 1 � Newborns feed every 1 Newborns feed every 1 2 hours Newborns feed every 1-2 hours 2 hours 2 hours � Colostrum (0 Colostrum (0- -3 days) 3 days) � Transitional Milk (4 T Transitional Milk (4-7 days) T iti iti l Milk (4 7 d l Milk (4 7 d 7 days) ) ) � Mature Milk (7 Mature Milk (7- -10 days) 10 days) � Alveolar Spaces (0 Alveolar Spaces (0- -7 days) 7 days) 16 16
INFANT FACTORS INFANT FACTORS Pharmacodynamics Pharmacodynamics Infant’s ability to absorb drug Infant’s ability to absorb drug 1. 1. Infant s ability to detoxify and excrete Infant s ability to detoxify and excrete Infant’s ability to detoxify and excrete Infant’s ability to detoxify and excrete 2. 2. the drug the drug 17 17
18 18 Photo Courtesy of NIH Photo Courtesy of NIH
QUESTIONS TO ASK IN DRUG / BREASTFEEDING SITUATIONS 1. What is the name, strength, and dosage of the drug? 2. Do you still have the prescription? Or, have you already filled it and are taking the drug? 3. Why is the drug being prescribed? 4. Do you feel you need to take the drug? 5. What does your doctor say regarding breastfeeding y y g g g outcome and taking the drug? 6. What is the drug dosage schedule and how often do you nurse? 19 19
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