Disease-modifying therapy | Description | Detectable in breast milk? | Transluminal transfer?* | Possible effects with infant exposure¶ | Compatible with lactation? |
Large molecules | |||||
Glatiramer acetate | Large molecule (4.7 to 13 kDa) heterogeneous strings of amino acids | Not done, unlikely | Yes, as with any amino acid | None | Yes |
Interferon beta | Large molecule, protein | 0.0006% relative infant dose | Exceedingly low | Flulike symptoms | Yes |
Monoclonal antibodies | |||||
Natalizumab | IgG4; 149 kDa | <1:200 of maternal serum level; 2 to 5% relative infant dose | Low | InfectionsΔ, impaired vaccine responses or disseminated disease from live vaccinesΔ, hepatitisΔ, anemiaΔ | Probably |
Rituximab | IgG1; 145 kDa | Approximately 1:240 of maternal serum level; <1% relative infant dose | Low | B-cell depletion, infectionsΔ, impaired vaccine responses or disseminated disease from live vaccinesΔ | Probably |
Ocrelizumab | IgG1; 145 kDa | Humans not done; monkeys yes | Low | InfectionsΔ, impaired vaccine responses or disseminated disease from live vaccinesΔ, hepatitisΔ, anemiaΔ | Probably |
Ofatumumab | IgG1; 146 kDa | Humans not done; animals not reported | Low | InfectionsΔ, impaired vaccine responses or disseminated disease from live vaccinesΔ, hepatitisΔ, anemiaΔ | Probably |
Small molecules | |||||
Dimethyl fumarate | Immediately metabolized to monomethyl fumarate (129 Da), low protein binding | Animals yes/humans not done but highly likely in high amounts | High | Neurocognitive impairment, lymphopenia, gastrointestinal upset, infectionsΔ, vaccine responsesΔ | No |
Sphingosine-1-phosphate (S1P) receptor modulators (fingolimod, ozanimod, ponesimod, siponimod) | Highly protein bound, long half-life | Animals yes/humans not done but highly likely in low amounts | Moderate | InfectionsΔ, vaccine responsesΔ, cardiovascular effectsΔ, pulmonary toxicityΔ, hepatitisΔ | No |
Teriflunomide | Inhibits pyrimidine synthesis, highly protein bound, very long half-life | Animals yes/humans not done but highly likely | High | Pancytopenia, infections, vaccine responsesΔ, hepatotoxicity, later-life neoplasmsΔ | No |
Cladribine | Inhibits nucleoside metabolism, low protein binding, short half-life | Humans not done | High | LymphopeniaΔ, infectionsΔ, liver injuryΔ, later-life neoplasmsΔ | No |
IgG: immunoglobulin G; kDa: kilodalton.
* Likelihood of transfer of disease-modifying therapy from infant's gut into its circulation assuming a large amount of disease-modifying therapy is present in breast milk.
¶ Assumes large amounts of the disease-modifying therapy have entered the infant's circulation.
Δ Plausible but unknown risk.From: Bove RM, Houtchens MK. Pregnancy management in multiple sclerosis and other demyelinating diseases. Continuum (Minneap Minn) 2022; 28:12. DOI: 10.1212/CON.0000000000001108. Copyright © 2022 American Academy of Neurology. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.
Do you want to add Medilib to your home screen?