Can Rituximab Be Taken By Breastfeeding Women With Rheumatoid Arthritis?

Ask the Experts

My husband and I are finally in a financial position where we want to have children. The problem is, I have rheumatoid arthritis. When my flares first got diagnosed, it took me almost a year to find the right medication, but when I did it was such a relief!

Now that we’ve started family planning, I see from my early research that Rituxan is contraindicated for pregnancy and breastfeeding. This is quite a disappointment for me, as Rituxan has been the only medication that reduced the severity and frequency of my RA flares to the point I can function relatively normally.

I’m expecting some problems conceiving anyway, just as a symptom of my rheumatoid arthritis, so I’m resigned to stopping the medication as directed to get pregnant

But is there any way I can safely breastfeed my baby and still take Rituxan? I want to give my future little boy or girl all the great benefits of breastfeeding, but I don’t know if I can handle it if I’m getting constant, painful RA flares.

Doctor’s Response

As with any medication, every patient is different and you must consult with your own doctor before changing, removing or adding drugs to your rheumatoid arthritis treatment regimen.

That, said, you should either formula-feed your baby if you want to get back on Rituxan (rituximab) or wait until your baby is weaned to resume therapy. 

Lactating women should not breastfeed during treatment and for at least six months after the last dose of Rituxan due to the potential for serious adverse reactions in breastfed infants, as per the U.S. Food and Drug Administration.

In general, do not take Rituxan (rituximab) if you are pregnant or plan to become pregnant within a year -- it can cause harm to the fetus in the form of lowered white blood cell counts, making the newborn prone to dangerous infections.

B-cell lymphocytopenia is a danger for infants exposed to rituximab in the womb, based on human study data filed with the FDA.  Women of childbearing potential should use contraception while receiving Rituxan and for 12 months following the last dose.

Rituxan is a genetically-engineered monoclonal antibody that mimics the action of antibodies produced by a healthy immune system. The Rituxan antibodies, however, target the CD20 antigen, one white blood cell protein implicated in contributing to the autoimmune flares of rheumatoid arthritis

CD20 is also a marker of certain blood cancers and tumors, according to Cancer.gov.

What are safer alternative drugs for RA during pregnancy and breastfeeding?

No rheumatoid arthritis drug is completely safe during pregnancy, but doctors and their pregnant patients should figure out a medication regimen that controls RA symptoms during pregnancy. 

Poorly controlled RA, itself, can cause low birth weight and other problems with the fetus.

Some of these drugs require you to pump and discard milk you produce within a couple hours after your dose, but you may breastfeed as normal through the rest of the day.

Anti-rheumatoid drugs that are somewhat safer to use during pregnancy are as follows:

  • Plaquenil (hydroxychloroquine): It is safe to take throughout pregnancy. Do not breastfeed while taking this drug.
  • Infliximab/adalimumab: It is safe to use up to 20 weeks of pregnancy period. In exceptional cases, it can be used throughout pregnancy.
  • Enbrel (Etanercept): It can be continued up to 30 to 32 weeks of pregnancy. In extreme cases, it may be used throughout pregnancy.
  • Certolizumab: It is safe to use in all nine months of the pregnancy.
  • Golimumab: It is advised to take this medicine only in the first three months of pregnancy.
  • Kineret (Anakinra): This drug is used to treat severe rheumatoid arthritis and prescribed when most of the options fail during pregnancy. In the first three months, this is relatively safe, but in the following months, the drug may cause ill effects in the unborn baby.
  • Orencia (abatacept): It is not safe in pregnancy and may cause side effects like cleft palate, facial abnormalities, and brain developmental abnormalities in the unborn baby. It is to be used only if no other options are available.

How does pregnancy affect RA?

The good news is that pregnancy often reduces the symptoms of RA - sometimes causing a full remission for the course of the pregnancy. This happens in a majority of pregnant women with RA, as the conditions of pregnancy tend to suppress the immune system and cause the release of anti-inflammatory compounds.

Beware, however; a significant minority of women experience worsening RA with the onset of pregnancy. 

Once again, you should involve your rheumatologist along with your OB/GYN in your family planning to navigate these treatment decisions.

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Reviewed on 9/4/2020
References
Medscape Medical Reference



FDA Prescribing Information for Rituxan