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The Direct Factor Xa Inhibitor Rivaroxaban Passes Into Human Breast Milk

Martin H.J. Wiesen, MD; Cornelia Blaich; Carsten Müller, MD; Thomas Streichert, MD; Roman Pfister, MD; Guido Michels, MD, Prof
Author and Funding Information

aCentre of Pharmacology, Department of Therapeutic Drug Monitoring, University Hospital of Cologne, Cologne, Germany

bDepartment of Clinical Chemistry, University Hospital of Cologne, Cologne, Germany

cDepartment III of Internal Medicine, Heart Center, University Hospital of Cologne, Cologne, Germany

CORRESPONDENCE TO: Martin Wiesen, MD, Centre of Pharmacology, Department of Therapeutic Drug Monitoring, University Hospital of Cologne, Gleueler Str 24, 50931 Cologne, Germany


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(1):e1-e4. doi:10.1016/j.chest.2016.01.021
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Thromboembolic disorders frequently require antithrombotic treatment during pregnancy and lactation. Vitamin K antagonists and heparins are the treatment options of choice in breastfeeding women. Factors including the route of administration, discomfort during treatment, and fetal and neonatal safety affect women’s choices about anticoagulant therapy. Direct-acting oral anticoagulants (DOACs) have emerged as alternatives to these agents and may offer advantages compared with vitamin K antagonists. As breastfeeding women were excluded from clinical trials evaluating DOACs, no safety and efficacy data are available for these special patients and, crucially, estimates for infant exposure are lacking. Therefore, the manufacturer recommends against using DOACs during the lactation period. We present the case of a patient who stopped breastfeeding owing to a diagnosis of postpartum cardiomyopathy. Anticoagulation with enoxaparin that commenced after the diagnosis of postpartum pulmonary embolism was switched to rivaroxaban. At that time, breast milk samples were collected and rivaroxaban concentrations were determined by liquid chromatography tandem-mass spectrometry. Rivaroxaban appears in human breast milk in comparatively small amounts; its safety has not been determined.

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