Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions

Kristen M. Krysko, Sara C. LaHue, Annika Anderson, Alice Rutatangwa, William Rowles, Ryan D. Schubert, Jacqueline Marcus, Claire S. Riley, Carolyn Bevan, Thomas W. Hale, Riley Bove

Research output: Contribution to journalArticle

Abstract

OBJECTIVE: To determine the transfer of rituximab, an anti-CD20 monoclonal antibody widely used for neurologic conditions, into mature breast milk. METHODS: Breast milk samples were collected from 9 women with MS who received rituximab 500 or 1,000 mg intravenous once or twice while breastfeeding from November 2017 to April 2019. Serial breast milk samples were collected before infusion and at 8 hours, 24 hours, 7 days, and 18-21 days after rituximab infusion in 4 patients. Five additional patients provided 1-2 samples at various times after rituximab infusion. RESULTS: The median average rituximab concentration in mature breast milk was low at 0.063 μg/mL (range 0.046-0.097) in the 4 patients with serial breast milk collection, with an estimated median absolute infant dose of 0.0094 mg/kg/d and a relative infant dose (RID) of 0.08% (range 0.06%-0.10%). Most patients had a maximum concentration at 1-7 days after infusion. The maximum concentration occurred in a woman with a single breast milk sample and was 0.29 μg/mL at 11 days postinfusion, which corresponds with an estimated RID of 0.33%. Rituximab concentration in milk was virtually undetectable by 90 days postinfusion. CONCLUSIONS: We determined minimal transfer of rituximab into mature breast milk. The RID for rituximab was less than 0.4% and well below theoretically acceptable levels of less than 10%. Low oral bioavailability would probably also limit the absorption of rituximab by the newborn. In women with serious autoimmune neurologic conditions, monoclonal antibody therapy may afford an acceptable benefit to risk ratio, supporting both maternal treatment and breastfeeding.

Original languageEnglish (US)
JournalNeurology(R) neuroimmunology & neuroinflammation
Volume7
Issue number1
DOIs
StatePublished - Jan 1 2020

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Human Milk
Monoclonal Antibodies
Breast Feeding
Nervous System
Breast Milk Expression
Rituximab
Biological Availability
Milk
Odds Ratio
Mothers
Newborn Infant
Therapeutics

ASJC Scopus subject areas

  • Neurology
  • Clinical Neurology

Cite this

Krysko, Kristen M. ; LaHue, Sara C. ; Anderson, Annika ; Rutatangwa, Alice ; Rowles, William ; Schubert, Ryan D. ; Marcus, Jacqueline ; Riley, Claire S. ; Bevan, Carolyn ; Hale, Thomas W. ; Bove, Riley. / Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions. In: Neurology(R) neuroimmunology & neuroinflammation. 2020 ; Vol. 7, No. 1.
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title = "Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions",
abstract = "OBJECTIVE: To determine the transfer of rituximab, an anti-CD20 monoclonal antibody widely used for neurologic conditions, into mature breast milk. METHODS: Breast milk samples were collected from 9 women with MS who received rituximab 500 or 1,000 mg intravenous once or twice while breastfeeding from November 2017 to April 2019. Serial breast milk samples were collected before infusion and at 8 hours, 24 hours, 7 days, and 18-21 days after rituximab infusion in 4 patients. Five additional patients provided 1-2 samples at various times after rituximab infusion. RESULTS: The median average rituximab concentration in mature breast milk was low at 0.063 μg/mL (range 0.046-0.097) in the 4 patients with serial breast milk collection, with an estimated median absolute infant dose of 0.0094 mg/kg/d and a relative infant dose (RID) of 0.08{\%} (range 0.06{\%}-0.10{\%}). Most patients had a maximum concentration at 1-7 days after infusion. The maximum concentration occurred in a woman with a single breast milk sample and was 0.29 μg/mL at 11 days postinfusion, which corresponds with an estimated RID of 0.33{\%}. Rituximab concentration in milk was virtually undetectable by 90 days postinfusion. CONCLUSIONS: We determined minimal transfer of rituximab into mature breast milk. The RID for rituximab was less than 0.4{\%} and well below theoretically acceptable levels of less than 10{\%}. Low oral bioavailability would probably also limit the absorption of rituximab by the newborn. In women with serious autoimmune neurologic conditions, monoclonal antibody therapy may afford an acceptable benefit to risk ratio, supporting both maternal treatment and breastfeeding.",
author = "Krysko, {Kristen M.} and LaHue, {Sara C.} and Annika Anderson and Alice Rutatangwa and William Rowles and Schubert, {Ryan D.} and Jacqueline Marcus and Riley, {Claire S.} and Carolyn Bevan and Hale, {Thomas W.} and Riley Bove",
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Krysko, KM, LaHue, SC, Anderson, A, Rutatangwa, A, Rowles, W, Schubert, RD, Marcus, J, Riley, CS, Bevan, C, Hale, TW & Bove, R 2020, 'Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions', Neurology(R) neuroimmunology & neuroinflammation, vol. 7, no. 1. https://doi.org/10.1212/NXI.0000000000000637

Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions. / Krysko, Kristen M.; LaHue, Sara C.; Anderson, Annika; Rutatangwa, Alice; Rowles, William; Schubert, Ryan D.; Marcus, Jacqueline; Riley, Claire S.; Bevan, Carolyn; Hale, Thomas W.; Bove, Riley.

In: Neurology(R) neuroimmunology & neuroinflammation, Vol. 7, No. 1, 01.01.2020.

Research output: Contribution to journalArticle

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T1 - Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions

AU - Krysko, Kristen M.

AU - LaHue, Sara C.

AU - Anderson, Annika

AU - Rutatangwa, Alice

AU - Rowles, William

AU - Schubert, Ryan D.

AU - Marcus, Jacqueline

AU - Riley, Claire S.

AU - Bevan, Carolyn

AU - Hale, Thomas W.

AU - Bove, Riley

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N2 - OBJECTIVE: To determine the transfer of rituximab, an anti-CD20 monoclonal antibody widely used for neurologic conditions, into mature breast milk. METHODS: Breast milk samples were collected from 9 women with MS who received rituximab 500 or 1,000 mg intravenous once or twice while breastfeeding from November 2017 to April 2019. Serial breast milk samples were collected before infusion and at 8 hours, 24 hours, 7 days, and 18-21 days after rituximab infusion in 4 patients. Five additional patients provided 1-2 samples at various times after rituximab infusion. RESULTS: The median average rituximab concentration in mature breast milk was low at 0.063 μg/mL (range 0.046-0.097) in the 4 patients with serial breast milk collection, with an estimated median absolute infant dose of 0.0094 mg/kg/d and a relative infant dose (RID) of 0.08% (range 0.06%-0.10%). Most patients had a maximum concentration at 1-7 days after infusion. The maximum concentration occurred in a woman with a single breast milk sample and was 0.29 μg/mL at 11 days postinfusion, which corresponds with an estimated RID of 0.33%. Rituximab concentration in milk was virtually undetectable by 90 days postinfusion. CONCLUSIONS: We determined minimal transfer of rituximab into mature breast milk. The RID for rituximab was less than 0.4% and well below theoretically acceptable levels of less than 10%. Low oral bioavailability would probably also limit the absorption of rituximab by the newborn. In women with serious autoimmune neurologic conditions, monoclonal antibody therapy may afford an acceptable benefit to risk ratio, supporting both maternal treatment and breastfeeding.

AB - OBJECTIVE: To determine the transfer of rituximab, an anti-CD20 monoclonal antibody widely used for neurologic conditions, into mature breast milk. METHODS: Breast milk samples were collected from 9 women with MS who received rituximab 500 or 1,000 mg intravenous once or twice while breastfeeding from November 2017 to April 2019. Serial breast milk samples were collected before infusion and at 8 hours, 24 hours, 7 days, and 18-21 days after rituximab infusion in 4 patients. Five additional patients provided 1-2 samples at various times after rituximab infusion. RESULTS: The median average rituximab concentration in mature breast milk was low at 0.063 μg/mL (range 0.046-0.097) in the 4 patients with serial breast milk collection, with an estimated median absolute infant dose of 0.0094 mg/kg/d and a relative infant dose (RID) of 0.08% (range 0.06%-0.10%). Most patients had a maximum concentration at 1-7 days after infusion. The maximum concentration occurred in a woman with a single breast milk sample and was 0.29 μg/mL at 11 days postinfusion, which corresponds with an estimated RID of 0.33%. Rituximab concentration in milk was virtually undetectable by 90 days postinfusion. CONCLUSIONS: We determined minimal transfer of rituximab into mature breast milk. The RID for rituximab was less than 0.4% and well below theoretically acceptable levels of less than 10%. Low oral bioavailability would probably also limit the absorption of rituximab by the newborn. In women with serious autoimmune neurologic conditions, monoclonal antibody therapy may afford an acceptable benefit to risk ratio, supporting both maternal treatment and breastfeeding.

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