Analgesics and breast-feeding: safety considerations

HPLC determination of tramadol in human breast milk

Tramadol is a centrally acting analgesic used for prevention and treatment of moderate to severe pain. It is estimated that 0.1% of the administered dose passes into breast milk causing potentially unwanted effects in nursing babies. Pharmacokinetically, breast milk is supposed to be a separate compartment into which the drug is excreted-mainly by passive diffusion. Due to a complex composition of breast milk, a suitable sample preparation procedure is needed with a subsequent chromatographic analysis for drug determination. Among several sample cleanup procedures tested we chose the liquid-liquid extraction procedure using n-hexane as an organic phase with back extraction into aqueous phase since it was considered the most suitable and the most compatible with the subsequent HPLC analysis. The precision and the reproducibility of the method were improved approximately two times by using metoprolol as an internal standard thus making the method also more robust with regard to a variable composition of milk samples. These characteristics, together with low detection limit and short analysis time, proved that the developed method is suitable for monitoring of tramadol in human breast milk.

Use of Antibiotic and Analgesic Drugs during Lactation

During lactation, multiple situations can arise that require maternal pharmacological treatment. Because of the many health advantages of human milk to infants, breast feeding should be interrupted only when the needed drug might be harmful to the nursing child and exposure via the breast milk will be sufficient to pose a risk. Since the majority of drugs have not been shown to cause adverse effects when used during lactation, and even temporary interruption of breast feeding can be difficult for the nursing dyad, decisions regarding maternal medication use during breast feeding should be based on accurate and up-to-date information. This article reviews available data on the most commonly used antibiotics and analgesics. The use of most antibiotics is considered compatible with breast feeding. Penicillins, aminopenicillins, clavulanic acid, cephalosporins, macrolides and metronidazole at dosages at the low end of the recommended dosage range are considered appropriate for use for lactating women. Fluoroquinolones should not be administered as first-line treatment, but if they are indicated, breast feeding should not be interrupted because the risk of adverse effects is low and the risks are justified. Paracetamol (acetaminophen), low-dose aspirin (acetylsalicylic acid) [up to 100 mg/day] and short-term treatment with NSAIDs, codeine, morphine and propoxyphene are considered compatible with breast feeding. Safer alternatives should be considered instead of dipyrone, aspirin at a dosage >100 mg/day and pethidine (meperidine). In the light of the many safe alternatives for pain control, breast-feeding mothers should not be allowed to experience pain or be made to feel that they must choose between analgesia and breast feeding.

Risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications in individuals receiving outpatient physical therapy services

STUDY DESIGN

Prospective, multicenter, observational research study.

BACKGROUND

Minimal research exists that describes the potential for serious gastrointestinal complications in individuals receiving outpatient physical therapy care.

OBJECTIVE

To identify the prevalence of risk factors for gastrointestinal complications induced by anti-inflammatory drugs or aspirin in individuals receiving outpatient physical therapy services.

METHODS AND MEASURES

A self-administered questionnaire was used at 65 ambulatory physical therapy clinics to document past medical history, history of present illness, and medication use. Risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications were identified and the proportion of patients reporting each factor was determined.

RESULTS

A total of 2433 patients completed the survey. Of the 2311 evaluable patients included in the study, 78.6% reported over-the-counter or prescribed use of an anti-inflammatory drug or aspirin during the week prior to the survey. Forty-nine percent of the patients reported at least 1 risk factor for drug-induced gastrointestinal complications, while 12.9% reported 2 or more risk factors. The most frequently reported established risk factors among anti-inflammatory drug or aspirin users were (1) combination (dual) therapy (22.3% reported concomitant use of anti-inflammatory and aspirin therapy), (2) advanced age (15.7% were over the age of 61 years), (3) history of peptic ulcer disease (7.8% had a history of peptic ulcer disease), and (4) significant systemic illness (6.8% reported having rheumatoid arthritis or heart disease). A frequently encountered risk factor combination was advanced age with a history of peptic ulcer disease (12.7%).

CONCLUSIONS

Patients seen at physical therapy ambulatory clinics present with multiple risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications and provide a potential opportunity for risk reduction by clinicians working in this environment.

High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia

Although the use of non-steroidal anti-inflammatory drugs (NSAIDs) is well established in the postoperative setting, their use after caesarean sections is still controversial. In a randomised, double-blinded, placebo controlled study we have estimated the opioid-sparing effect of diclofenac suppositories after elective caesarean sections in spinal anaesthesia. Eighty-two women ASA class I or II scheduled for caesarean section were randomised to receive either diclofenac suppositories 100 mg or placebo every 12 h after the operation. The diclofenac group (n = 40) consumed significantly less morphine in the postoperative period (14.0 +/- 1.5 mg in 32 h) compared with the placebo group (21.5 +/- 1.6 mg in 32 h, P < 0.05). The average level of postoperative pain as estimated by a visual analogue scale (VAS) and a verbal scale tended to be lower in the diclofenac group, but this was not significant. There were no differences in demographic data, perioperative bleeding, side-effects or discharge time between the groups. Diclofenac suppositories 100 mg given twice daily after caesarean section are opioid sparing.