Which therapy is best for me if I am breastfeeding my baby?

Question:
I was diagnosed with Nonprogressive relapsing multiple sclerosis in March 2017. During that time I found out I was pregnant and not able to start therapy. Now, it is time to choose a therapy to go on and I am having trouble deciding. I recently had an MRI and it showed new activity and my symptoms are optic neuritis. I am a 24 year old woman looking to get pregnant in about 1-2 years. The two therapy's that have been mentioned to me are glatopa and rituximab. I was told by my doctor rituximab would be the better choice if I want to continue breast feeding my current baby and if I plan the infusion correctly it would be safe for me to be pregnant. However, when doing some research about rituximab, I am nervous to say yes. When reading I saw there was some controversy to rituximab actually helping as it is unknown what role the Bcell plays in MS, as well as the higher risk factor there is in comparison to glatopa. I guess the simple question is, with my condition and my future plans on expanding my family and wanting the ability to breast feed. What is the best therapy for me?

Answer:
There is no evidence that glatopa is harmful either during pregnancy or with breast feeding. There is also some evidence that exclusive breastfeeding (no supplemental feeding allowed) is protective against post partum relapses.

The most appropriate therapy depends on your risk factors for frequent relapses and/or the early development of more severe disease. 

Rituximab is a great therapy but long term therapy would be more risky than glatopa and an odd choice for someone naive to therapy unless you had a lot of risk factors. Then again, if you had a lot of risk factors why would they be considering glatopa.
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Some Rituximab is likely to get in the breast milk but not likely to get into the babies circulation. 

There are many other choices as well, but I would tend to stay away from small molecule therapies (i.e. pills). These tend to go everywhere in the body and some would require more careful and timed discontinuation before the next pregnancy.

Good luck

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego