Can you take ranibizumab while breastfeeding?

What LactMed would consider instead

LactMed ends this record by naming the drugs it would consider in place of ranibizumab. Whether any of them fits depends on what you are treating — this is the database’s list, not a recommendation from us.

• Aflibercept
• Bevacizumab

How much ranibizumab gets into breastmilk

Maternal Levels. One mother who was nursing a 16-month-old infant received an unspecified dose of ranibizumab intraocular injection for myopic choroidal neovascularization. At the time of her first dose, breastfeeding was stopped, and milk samples were obtained 1 hour before the injection and on days 1 through 7, 14, 21, and 28 after injection. Ranibizumab was undetectable (<1.6 mcg/L) for the first 2 days after injection and then was 34.7 mcg/L on day 3. On day 6, the concentration was about 55 mcg/L, then it drifted slowly up to a concentration of about 130 mcg/L on day 28 after the injection.

Another mother was given ranibizumab 0.5 mg intravitreal injections for myopic choroidal neovascularization and continued to breastfeed her 1 month-old infant. A trough milk sample was taken 4 weeks after a dose and then on days 1 through 7, 14, 21, and 28 after injection. All milk samples had ranibizumab concentrations below the lower limit of quantification of 1.6 mcg/L. The investigators hypothesized that continuous nursing resulted in the low levels of ranibizumab in milk.

A woman received an injection of ranibizumab 0.5 mg in each eye with a 1-week interval between eyes. Milk samples were obtained at baseline and then daily for 14 days after the first injection. Ranibizumab levels in the mother’s breast milk remained below the lower limit of quantitation of the assay at all time points.

A woman who was breastfeeding her 6-month-old infant received a single intravitreal injection of ranibizumab 0.5 mg in 0.05 mL into her right eye. Serum and milk samples were obtained 1 hour prior to the injection and at 2 and 6 hours after injection, then again 1 day, 3 days, 7 days, 14 days, and 28 days after the injection. Ranibizumab was highest in serum at 1 to 3 days after the injection. The highest concentration in milk was 3.4 mcg/L one day after the injection. By 3 days after the injection, the concentration dropped to 1.5 mcg/L and remained below this level until 28 days after the injection when it was 1.8 mcg/L.

Infant Levels. A woman received an injection of ranibizumab 0.5 mg in each eye with a 1-week interval between eyes. Her infant was breastfed exclusively, except for the 3 days after each injection during which formula was given exclusively. Infant blood samples were obtained daily for 11 days starting on the day before breastfeeding was resumed. Ranibizumab levels remained below the lower limit of quantitation of the assay at all time points in the infant’s serum. Plasma VEGF-A levels in the infant remained undetectable at all time points, except for days 9 and 11 when slightly low levels were found.

What has been seen in breastfed infants

Relevant published information was not found as of the revision date.

Effects on milk supply

A woman was given 3 intravitreal injections of bevacizumab for scar-associated choroidal neovascularization in her left eye. Vascular endothelial growth factor (VEGF) was measured in serum and breastmilk. After the intravitreal injection of bevacizumab, the VEGF level in breastmilk decreased from 13.3 to 8.6 mcg/L over a 2-week period. After changing therapy to ranibizumab therapy, no decrement in breastmilk VEGF was seen during the 42 days following injection. It is not clear from the article if the mother continued breastfeeding after the injection.

Two women received ranibizumab intraocular injections for myopic choroidal neovascularization. In one who did not breastfeed, VEGF decreased from 22.8 mcg/L at baseline to 12.3 mcg/L on day 1 and to 4.9 mcg/L on day 28 after her dose. The second woman who did breastfeed her infant, had VEGF levels that were largely unchanged, varying between about 8 and 12 mcg/L over the 28-day follow up. The investigators hypothesized that continuous nursing resulted in the lower levels in the relative lack of VEGF reduction in milk.

A woman received an injection of ranibizumab 0.5 mg in each eye with a 1-week interval between eyes. Milk samples were obtained at baseline and then daily for 14 days after the first injection. VEGF-A levels in the breast milk gradually decreased from 5266 ng/L at baseline to 1,626 pg/mL at Day 4, and then then gradually increased to 1,998 ng/L on Day 7 (when the second eye was injected), then reduced to 1,471 ng/L on Day 9, and then presented with higher and fluctuating levels from Day 12 to Day 14.

The mother of a breastfed 6-month-old infant was given 4 intravitreal injections of ranibizumab 0.5 mg for choroidal neovascularization. VEGF was measured in breastmilk before the first two injections and at 1 to 3, 6, 12, 24, 48 and 72 hours after all of the injections. The greatest decrease in milk VEGF levels occurred 6 to 12 hours after each dose and was about a 40% decrease. Milk VEGF levels returned to pretreatment levels by 24 hours.

A mother with macular edema and decreased visual acuity was breastfeeding a 3-week-old infant. She received intravitreal injections of ranibizumab (dose not stated) every 4 weeks for 2 doses and then every 6 weeks for 2 doses. She then received injections at intervals of 12 weeks. By 9 months postpartum she had discontinued breastfeeding. There was no indications of a developmental disorder of children up to the 2nd year of age.

A woman who was breastfeeding her 6-month-old infant received a single intravitreal injection of ranibizumab 0.5 mg in 0.05 mL into her right eye. Milk samples were obtained 1 hour prior to the injection and at 2 and 6 hours after injection, then again 1 day, 3 days, 7 days, 14 days, and 28 days after the injection. The VEGF-A concentration in milk decreased from a baseline of 29.5 mcg/L to a low of 12.7 mcg/L on day 3 and gradually increased to 25.6 mcg/L on 28 days after the dose.