Transfer of triptans into human breast milk and estimation of infant drug exposure through breastfeeding

Abstract

Clinical data on the transfer of triptans into human breast milk remain scarce. In a lactation study including 19 breastfeeding women with migraine, we examined the excretion of six different triptans into milk. Following intake of a single dose, each participant collected seven breast milk samples at predefined intervals up to 24 hours after dose. Triptan concentrations in milk were measured using liquid chromatography‐tandem mass spectrometry (LC‐MS/MS). Infant drug exposure was estimated by calculating the relative infant dose (RID). Twenty‐two breast milk sample sets were obtained for sumatriptan (n = 8), rizatriptan (n = 5), zolmitriptan (n = 4), eletriptan (n = 3), almotriptan (n = 1) and naratriptan (n = 1). Based on the average concentration in milk throughout the day, estimated mean RIDs (with range in parenthesis) were as follows: eletriptan 0.6% (0.3%‐0.8%), sumatriptan 0.7% (0.2%‐1.8%), rizatriptan 0.9% (0.3%‐1.4%), almotriptan 1.8% (‐), zolmitriptan 2.1% (0.7%‐5.3%) and naratriptan 5.0% (‐). Infant drug exposure through breastfeeding appears to be low and indicates that use of the triptans in this study is compatible with breastfeeding. Naratriptan may not be first choice in breastfeeding mothers initiating triptans during the neonatal period.

Headaches in Pregnancy and Postpartum

“…Low levels of sumatriptan are present in breastmilk, but because of poor bioavailability, the amount of sumatriptan transferred to fetal circulation is very small. In a study comparing concentrations in breast milk among six different triptans, both eletriptan and sumatriptan were shown to have very low fetal exposure: mean (range) relative infant dose of 0.6% (0.3–0.8%) and 0.7% (0.2–1.8%), respectively, compared with the two triptans with the greatest exposure, zolmitriptan, 2.1% (0.7–5.3%) and naratriptan, 5.0% (one participant) (148).…”

“…ACOG suggests triptans may be used by lactating patients but advises a shared decision-making model regarding the need to avoid breastfeeding for a specified timeframe after its use (27–29, 36, 115, 148).…”

Acute Treatment of Migraine

“…Second-line treatments include other NSAIDs and triptans (with eletriptan being preferred if effective due to its likely lower excretion in breast milk). 51 The safety of gepants and lasmiditan in the setting of lactation is currently unknown, although the excretion of rimegepant into breastmilk is low. 52 These treatments should be avoided until more information is available.…”

“…Acute treatments with the best evidence for safe use in lactation are acetaminophen and ibuprofen. Second-line treatments include other NSAIDs and triptans (with eletriptan being preferred if effective due to its likely lower excretion in breast milk) 51 . The safety of gepants and lasmiditan in the setting of lactation is currently unknown, although the excretion of rimegepant into breastmilk is low 52 .…”