How to manage ulcerative colitis while breastfeeding?

Question

Hello doctor,

My 32-year-old wife has had ulcerative colitis for six years, but it has gotten so much worse since she had our baby eight months ago. She was in remission during pregnancy, but two months after delivery, everything flared up badly.

Now she has bloody diarrhea 12 to 15 times per day and cannot leave the house. Her hemoglobin dropped to 7.8 due to all the bleeding, and she needed iron infusions.

The GI doctor did a colonoscopy and said the ulcerative colitis inflammation extends all the way to the cecum now, when it used to be just the rectum.

Her calprotectin is over 1200, and CRP is 67. She was on Mesalamine, but it stopped working, so they switched her to Prednisone 40 mg, which helped. But now she is gaining weight, and her face is all puffy.

Biologics like Remicade were mentioned,d but she is still breastfeeding and worried about medications passing to the baby. She has already lost 22 pounds and is too weak to take care of our daughter.

Her ulcerative colitis symptoms get worse with stress and sleep deprivation, which is impossible to avoid with a new baby. So, my concerns are:

Is it safe to take strong ulcerative colitis medications while breastfeeding?
Should she stop nursing to get proper treatment?

Kindly suggest.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concerns.

Based on your description, your wife has a medical history of ulcerative colitis (UC). The inflammation has now extended up to the cecum, which is termed pancolitis.

Your investigations reports (the attachments were removed to protect the patient’s identity) show the presence of active inflammation with an elevated fecal calprotectin level of 1200 µg/g (micrograms per gram) and C-reactive protein (CRP) of 67 mg/dL (milligrams per deciliter).

Additionally, anemia (hemoglobin level 7.8 g/dL) along with frequent bloody stools indicates a significant disease burden.

This is not a mild disease anymore, and needs escalated treatment; remission is essential to prevent hospitalization or colectomy (surgical removal of colon).

A postpartum flare of ulcerative colitis is common. UC worsens after delivery due to rapid hormonal shifts, physical stress, sleep deprivation, and overall exhaustion. In some cases, UC medications may be reduced or stopped during pregnancy or in the postpartum period.

Hence, the immune system naturally rebounds after pregnancy, as the immunosuppressive state of pregnancy resolves. This immune rebound triggers disease relapse in UC, which was previously well controlled.

Regarding breastfeeding, most medications used to treat ulcerative colitis, and many biologic therapies, are considered safe and compatible with breastfeeding.

Mesalamine 5-ASA (5-aminosalicylic acid) is safe, with only a very small amount passing into breast milk and no known harm to the infant.
Prednisone or Prednisolone is also considered safe at doses up to 40 mg per day, with very low transfer into breast milk; if desired, breastfeeding can be timed about four hours after dosing to minimize exposure.
Azathioprine and 6-mercaptopurine are regarded as safe according to ACG (American College of Gastroenterology) and ECCO (European Crohn's and Colitis Organisation) guidelines, as only negligible amounts are detected in breast milk, and they are suitable for long-term use.
Anti-TNF biologics such as Infliximab (Remicade), Adalimumab (Humira), and Golimumab have minimal transfer into breast milk and are broken down in the infant’s gastrointestinal tract; many breastfeeding mothers use these medications safely.
Vedolizumab (Entyvio) has more limited data, but available evidence is reassuring, and it is generally considered safe during breastfeeding.

I hope this helps.

Thank you.

How to manage ulcerative colitis while breastfeeding?

Ulcerative Colitis flare while breastfeeding?