Dear Lizabeth,

Hale states that Keppra is

a) "not bound by protein" - it is only the unbound portion of the drug which is able to enter into the milk; since this drug does not bind to protein, that means that most of it will have at least some ability to transfer into the breastmilk.

b) "it is low in molecular weight" - the larger the molecular weight, the larger the molecule and the more difficult it is for the molecule to move between compartments in the body, in this case from the mother's plasma into her breastmilk - smaller molecules can squeeze through tiny pores in the cell walls;  since this drug has a low molecular weight, it will be easier for it to penetrate into the alveoli.

c) "it is 100% orally bioavailable" - oral bioavailability refers to the ability for the drug to survive passage through the stomach and into the GI tract where it can be absorbed into the bloodstream;  this drug survives wonderfully and delivers a large dose into the bloodstream whereas some other drugs get broken down rather quickly and a large percentage does not end up getting to the point where it can be absorbed.

d) "it is lipophilic" - this means that it is highly soluble in lipids (fats) which means that it will more easily penetrate into the milk since there are lipids both in the cell walls of the alveoli and the milk itself.

e) "it is neuroactive" - these drugs affect the central nervous system and often can enter the milk easily.

So basically, this drug has all the characteristics that you don't want to see in a drug being taken by a breastfeeding mother.  Of course, there are other things which influence the amount of drug found in the milk, but I would certainly use a lot of caution with this particular medication.  Is she on this because the tegretol alone is not controlling her seizures?  Is there another course of treatment that would control her symptoms while still being relatively safe for her baby?  Would it be possible to do a trial of the drug while breastfeeding, watching the baby carefully for drug-related symptoms and subsequently drawing drug levels on the baby after a week or two of nursing?

This is one of those difficult situations where a mother's underlying illness must be treated adequately.  For many psychotrophic illnesses, there is great variation between what works for one person and the next, or even for the same person over a period of time.  Different drug dosages and combinations work differently.  However, there is always the lure for the doctor of trying the newest drug on the market when other drugs may do the job just as well.  This mom needs to continue dialoguing with her physician and exploring all possiblities for treatment.  If it turns out that Keppra is the drug that she needs at this time, then she may be facing some tough decisions.  I know that some of you feel that breastfeeding is always best, but I for one am leary of exposing newborns to powerful drugs which can affect the brain and CNS.  A drug level on the baby may be the best way to determine the level of risk that actually exists.  Since this drug peaks in one hour and has a half-life of 6-8 hours, there may be at least a coupld of times during the day when she could breastfeed more safely (although usually with longterm dosing, you are trying to reach a steady state of drug levels in the milk at all times). Donated breastmilk may be the next best solution if she determines that the risks outweigh the benefits if she breastfeeds her baby.

Good luck to you and to this mom.

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