肝胆相照论坛

标题: （定期更新，新加母乳讨论）大三阳妈妈19周开始吃替诺， [打印本页]

作者: 喵小鱼儿 时间: 2012-6-5 13:43 标题: （定期更新，新加母乳讨论）大三阳妈妈19周开始吃替诺，

本帖最后由喵小鱼儿于 2012-9-9 14:42 编辑

。。
高中体检时发现是乙肝携带，之后查过几次肝功都正常，自己也不是很在意，一直没有采取任何措施。
最近怀孕，10周左右查血时发现肝功不正常，AST 50，ALT 106  DNA在10的9次方以上貌似。。
去看了肝病医生，说要治疗。医生说现在两种药的疗效比较好，一个是替诺，一个是替恩。因为我在怀孕，所以开的是替诺viread，很安全，对胎儿影响最小。医生让我18周做大b超后吃，并且说我这样的情况在他们那里很普遍，孕妇都是吃这个，没有问题。回家也搜集了很多资料，看来这个药的确是目前最安全高效的药。我的情况又是非治不可（后来打电话时，医生说b超结果显示我的肝有肿大。虽然还没有到下次问诊时间，但看来是必需要治疗的）

现在马上20周，替诺韦弗第一天准备开吃！！

更新一点情报：
1. 我在美国，这边789月不打那三针免疫蛋白的，貌似就直接出生后打针，如果需要怀孕期间抗病毒。
2.这边的医生说可以母乳的。我想等生完再决定。
3.和国内不同，这边貌似即使肝功还正常，但如果病毒太高，也是建议抗病毒治疗的，和怀孕无关。只是怀孕期间抗病毒的话，好处是宝宝被感染的几率也会大大减小，就是治疗主要针对大人，但是宝宝也跟着受益。最开始医生还吓我说毕竟我的肝功不正常，如果放任不管，到后期肝脏衰竭的话，连大人都危险，更别说孩子了。。吓个我半死。后来知道我的转氨酶不算很高，还是觉得抗病毒治理是正确的决定，毕竟对妈妈来说，宝宝健康比什么都重要啊。

为我的宝宝祈福，希望他平安健康出生！！
我会定期上来更新，谢谢大家！

更新，我的肝没肿大，是正常，电话里听错了。害我吓个半死。。

我来更新了！！不好意思我手机更新的格式什么的不好换，大家凑活看吧。。
____________________________
4月27日血检： AST 42，ALT 98
RESULT       >50000000             IU/mL
RESULT       LOG 10       >7.70          这两个值都已经超出了能测量出的最高范围，所以病毒量真的很高。

6月4日第19周开始吃viread

6月27日血检：AST 62，ALT 110
RESULT       68500             IU/mL
RESULT       LOG 10       4.84                这见效很快啊。。有点吓倒哈

9月5日体检： AST 37. ALT. 63
RESULT             175                      IU/mL
RESULT       LOG 10       2.24                         见效很快哈哈。ALT 下降了不少。另外血检结果中白蛋白(albumin, Alb)低于正常值，磷酸酶Alkaline phosphatase高于正常值，这在孕后期是正常的。详情见我另外一个帖子。    http://www.hbvhbv.com/forum/thread-1199111-1-1.html

作者: qi163 时间: 2012-6-5 13:45

祝福下

作者: 风中追风 时间: 2012-6-5 14:19

你在哪？

作者: 喵小鱼儿 时间: 2012-6-5 14:31

我在美国

作者: 风中追风 时间: 2012-6-5 14:43

祝顺利~

作者: 喵小鱼儿 时间: 2012-6-5 14:51

风中追风发表于 2012-6-5 14:43
祝顺利~

谢谢mm。：）

作者: lisa163lisa 时间: 2012-6-5 14:57

还是美国好，可以这么容易的吃到viread.bless u

作者: 丹淡 时间: 2012-6-5 16:30

替诺见效快，BB会安全的，不用担心

作者: caicai18 时间: 2012-6-5 19:34

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美女，美国的医生都觉得替诺对宝宝绝对安全么？临床数据多不？我现在在纠结于要不要吃药抗病毒。谢谢哦

作者: 只想健康好 时间: 2012-6-6 15:18

我准备全程替诺，但是国内临床很少啊

作者: xiaozhanshi 时间: 2012-6-6 15:40

美国的战友，

祝福~~~是应该抗病毒治疗的。

作者: 只想健康好 时间: 2012-6-6 16:48

在外国就是好啊

作者: 喵小鱼儿 时间: 2012-6-15 07:54

本帖最后由喵小鱼儿于 2012-7-10 11:10 编辑

caicai18 发表于 2012-6-5 19:34
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美女，美国的医生都觉得替诺对宝宝绝对安全么？临床数据多不？我现在在纠结于要不要 ...

这边医生说有两种药比较好可供选择，一个是替诺，还一个是恩替卡韦。但是他说怀孕吃前者更安全，后者现在的临床数据没那么多。他这边的病人都是18周大b超之后开始吃，不是说之前不能吃，而是大b超排畸，确认宝宝正常再开始吃。万一有什么问题，能证明不是吃药吃的问题。

作者: 喵小鱼儿 时间: 2012-6-15 08:01

本帖最后由喵小鱼儿于 2012-6-15 08:03 编辑

只想健康好发表于 2012-6-6 15:18
我准备全程替诺，但是国内临床很少啊

国内临床少因为国内刚刚引进啊。而且比较贵。这个药最开始治疗艾滋病人的。因为很多爱滋病妇女同时患有乙肝，所以有比较多怀孕艾滋乙肝妇女的临床数据。这个药之前我的保险不太好还没给我开呢，那是两年前。当时开的是什么米，就是有耐药性的那个，不过我没吃。歪打正着，现在直接吃替诺了。而且我的医生说可以母乳。这个到后期我再决定吧。

作者: 喵小鱼儿 时间: 2012-6-15 08:03

xiaozhanshi 发表于 2012-6-6 15:40
美国的战友，祝福~~~是应该抗病毒治疗的。

谢谢！我们一起加油啊！

作者: xiaozhanshi 时间: 2012-6-15 09:38

喵小鱼儿发表于 2012-6-15 08:03
谢谢！我们一起加油啊！

请问你在美国工作吗？这个病有没有影响你的工作呢？

作者: 只想健康好 时间: 2012-6-15 10:01

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很纠结啊

作者: caicai18 时间: 2012-6-15 13:19

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谢谢美女，你的医生让你孕期吃替诺，有没有同时要监控肾功的指标之类的？

作者: 喵小鱼儿 时间: 2012-7-10 02:06

caicai18 发表于 2012-6-15 13:19
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谢谢美女，你的医生让你孕期吃替诺，有没有同时要监控肾功的指标之类的？

完全没有！

作者: 喵小鱼儿 时间: 2012-7-10 02:18

6月27日血检结果出来了，viread真猛啊！！！我才吃了不到一个月呢

作者: 千年灵芝 时间: 2012-7-10 02:51

作者: 喵小鱼儿 时间: 2012-7-10 11:00

xiaozhanshi 发表于 2012-6-15 09:38
请问你在美国工作吗？这个病有没有影响你的工作呢？

没有影响。吃药本身什么感觉都没有。如果说大三阳的话健康状况是个人隐私。和工作无关。
当然如果是食品行业之类比较特殊的我就不清楚了

作者: xiaozhanshi 时间: 2012-7-10 15:03

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谢谢你哦！希望你和宝宝都健康！

作者: voilete 时间: 2012-7-10 15:15

希望一切顺利

作者: holly174 时间: 2012-8-14 20:08

喵小鱼儿发表于 2012-6-5 13:43
。。
高中体检时发现是乙肝携带，之后查过几次肝功都正常，自己也不是很在意，一直没有采取任何措施。
最近 ...

美国的替诺贵吗？

作者: 四月花开 时间: 2012-8-16 17:50

怎么样了现在？

作者: 喵小鱼儿 时间: 2012-8-27 22:16

四月花开发表于 2012-8-16 17:50
怎么样了现在？

下个月再去见医生。看看病毒情况。然后就准备要生了。。。。。还没确定要不要母乳。打算下次好好问问医生的看法
不过他之前强调可以母乳的。

大家等我的更新吧

作者: 喵小鱼儿 时间: 2012-8-27 22:19

holly174 发表于 2012-8-14 20:08
美国的替诺贵吗？

据我了解。绝大部分有保险的都是15美元最多25美元一个月

作者: 喵小鱼儿 时间: 2012-8-27 22:21

xiaozhanshi 发表于 2012-7-10 15:03
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谢谢你哦！希望你和宝宝都健康！

谢谢！希望大家都能顺顺利利有一个健康的宝宝！

作者: 喵小鱼儿 时间: 2012-8-27 22:21

voilete 发表于 2012-7-10 15:15
希望一切顺利

谢谢！

作者: 丢乙乙 时间: 2012-8-28 13:49

祝福了

作者: 漫天飞絮326 时间: 2012-8-29 17:34

能告诉我的你qq或邮箱吗？我也吃着替诺，现在怀孕20周了，希望和你常交流，了解下美国那边的治疗方案及能不能母乳等问题~~谢谢

作者: 风风风风 时间: 2012-8-30 13:32

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同等

作者: 喵小鱼儿 时间: 2012-8-30 15:48

漫天飞絮326 发表于 2012-8-29 17:34
能告诉我的你qq或邮箱吗？我也吃着替诺，现在怀孕20周了，希望和你常交流，了解下美国那边的治疗方案及能不 ...

我不用qq啊。。还是这里方便。我会定期上来更新你可以给我发信息
我下个月中旬见医生到时候会来更新的~

作者: liver411 时间: 2012-8-31 14:17

喵小鱼儿发表于 2012-8-27 22:16
下个月再去见医生。看看病毒情况。然后就准备要生了。。。。。还没确定要不要母乳。打算下次好好问问医 ...

理论上和大部分医生是不建议哺乳期间用核苷类似物药物抗病毒的，因为药物会出现在母乳中。但实际上，近来有医生认可可用替诺，也给/有患者使用，而且孩子没有问题。不过，这个仍没有一个统一标准，有些是根据临床得到的认知，比如：拉米虽然是C级妊娠药物，但仍可在怀孕期间使用一样。

有临床试验记载或医生报告的很少，几乎没有。能找到的文献大约有2个。第一个是法国医生写的文献；第一个是美国国立卫生研究院（NIH），国立医学图书馆（NLM）下属的国家生物技术信息中心（NCBI）上一个对于哺乳期的猕猴做的临床试药文献。

法国的文献认为不会被吸收入母乳，美国对猕猴的试验说明母乳中量非常低未造成影响（给猴子的剂量是30毫克/每公斤体重呢）。

另外，还有一个依据，是第8届亚太肝病年会专题研讨会[APASLSTC 2011]上被《国际肝病》采访的Kumar Visvanathan医生/教授的录像和笔录中提到关于替诺和拉米哺乳期使用的问题答复。

答案与上两个相同，“替诺福韦和拉米夫定也都会出现在母乳中，不过其含量非常低，可能不会有太大影响。”

我想，这个要衡量得失，如果母亲产后HBV爆发（妊娠期间机体免疫抑制会增强，以保证胎儿不会被排斥。同时，在妊娠期间，针对乙肝的免疫反应也被抑制，分娩后病毒复制则突然加速。这就是产后乙肝复发的原因。），必须抗病毒且 + 喂奶，就应该用；如果没有，可告知患者有人用，也有医生建议/给用，包括上述几个目前的依据，患者可自己选择。国外有论坛有母亲服用替诺哺乳孩子没有问题的例子。

作者: liver411 时间: 2012-8-31 14:18

这个是法国医生的文献，说替诺不会被母乳吸收：

Clin Res Hepatol Gastroenterol.
2011 Jun 7. [Epub ahead of print]
Hepatitis B virus infection and pregnancy.
Pol S, Corouge M, Fontaine H.
Source Inserm U-1016, unité d'hépatologie, université Paris Descartes, AP-HP, hôpital
Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.

Abstract

Pregnancy only mildly affects that natural progression of
acute and chronic infection by the hepatitis B virus (HBV) but it does
bring to light three important questions. Mother to child (vertical)
transmission risk is best prevented by mandatory HBs antigen testing in all
pregnant women in their second trimester and by systemic serovaccination of
newborns of infected mothers. In mothers with high viral load, vertical
infection in utero could be prevented by lamivudine, telbivudine or
tenofovir treatment. Invasive obstetric or gynecological procedures (such
as amniocentesis, forceps, etc.) do not seem to increase the risk of
vertical infection. Breastfeeding is not contraindicated in maternal HBV
infection after serovaccination of the newborn. This holds true for mothers
on active treatment with tenofovir which is not absorbed into breast milk.
When it comes to managing active antiviral treatment, in absence of
virosuppression with lamivudine, tenofovir remains a logical step-up
treatment; in absence of virosuppression with adefovir, tenofovir also
remains a logical step-up choice as do tenofovir/emtricitabine combinations
or lamivudine in absence of preexisting resistance which may have been
induced during combination treatment of adefovir and lamivudine. In cases
of effective virosuppression with treatment by analogues, lamivudine should
be continued and entecavir should eventually be replaced by lamivudine,
telbivudine or tenofovir; adefovir should be replaced by tenofovir or
lamivudine in absence of resistance (which would require tenofovir therapy)

作者: liver411 时间: 2012-8-31 14:18

哺乳期的猕猴做的临床试药文献: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1087653/

看图标可直接去链接：

Pharmacokinetics of Tenofovir in Breast Milk of Lactating Rhesus Macaques
Koen K. A. Van Rompay,1,* Marta Hamilton,2,† Brian Kearney,2 and Norbert Bischofberger2
Author information ► Article notes ► Copyright and License information ►
This article has been cited by other articles in PMC.
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ABSTRACT
To study tenofovir transfer into milk, two lactating macaques were given a subcutaneous dose of tenofovir (30 mg/kg of body weight). Peak concentrations and area under the curve values of tenofovir in milk were ∼3 and ∼20% of those detected in serum, respectively.

For lactating mothers taking medications, the drug concentration in breast milk is usually lower than that in plasma; it is generally of negligible concern for the nursing infant, but some exceptions exist (reviewed in reference 2). A growing number of human immunodeficiency virus (HIV)-infected people in developing countries are gaining access to treatment with anti-HIV drugs, including lactating mothers for whom avoidance of breast-feeding is not always an option. Thus, questions are raised regarding possible biological implications of anti-HIV drugs that may be transferred to the nursing infant (4, 5). It is difficult to predict drug transfer into milk based on physicochemical properties (6). Accordingly, animal models can be useful to gather preliminary information on the transfer of compounds into breast milk prior to obtaining such data from human studies (1).

We performed a pilot study to determine the transfer of tenofovir {9-[2-(phosphonomethoxy)propyl]adenine; PMPA} in breast milk of rhesus macaques. Two healthy lactating adult rhesus macaques (Macaca mulatta), which were multiparous and 5 to 11 years of age, were used. The animals were housed in accordance with American Association for Accreditation of Laboratory Animal Care standards, and we strictly adhered to the Guide for the Care and Use of Laboratory Animals (9). When necessary, animals were immobilized with ketamine HCl (Parke-Davis, Morris Plains, New Jersey) at a concentration of 10 mg/kg of body weight injected intramuscularly. Both female macaques had been lactating for 10 to 11 weeks, and their infants had been weaned the day prior to the pharmacokinetic study. A single dose of tenofovir (30 mg/kg) was administered subcutaneously. Pre- and postdose blood samples (without anticoagulant) were collected over a 24-h time period (at 0, 0.5, 1, 2, 4, 6, 8, and 24 h, with an additional time point at 10 h for animal 24964) and were spun immediately for the collection of serum; at the same times, all milk that could be expressed manually from both nipples was collected (up to 7.5 ml per time point). Our study has the caveat that this milk collection schedule (especially the absence of sample collections between 10 and 24 h of dosing) does not completely mimic the more regular drinking activity of a nursing infant macaque. Serum and milk samples were stored at −70°C and subsequently analyzed by MDS Pharma Services (Montreal, Canada) using high-performance liquid chromatography methods with mass spectrometry detection (liquid chromatography-mass spectrometry-mass spectrometry), previously validated for monkey plasma and rat milk (unpublished data). For monkey plasma, the limit of quantitation was 10 ng/ml, standard curve linearity r2 was 0.999, and within- and between-run quantitative comparison [QC] accuracy and precision were <2% bias and 95%, respectively; for monkey milk, the limit of quantitation was 10 ng/ml, r2 was 0.9932, and within-run QC accuracy was <3% bias. Tenofovir concentrations were measured in whole milk (i.e., without prior separation of the different milk fractions). The values of the pharmacokinetic parameters were derived by noncompartmental analysis with WinNonlin software (version 3.1; Pharsight Corporation, Mountain View, California).

Tenofovir concentrations in serum and milk are shown in Fig. Fig.1,1, while pharmacokinetic parameters are presented in Table Table1.1. Tenofovir was detected in the milk of both animals, but the peak concentrations (∼0.6 to 0.8 μg/ml, corresponding to ∼2 to 3 μM) were ∼2 to 4% of those detected in serum, with milk area under the curve (AUC) values being ∼20% of the serum AUC values.

FIG. 1.

Concentrations of tenofovir in serum and milk following a single subcutaneous dose of 30 mg of tenofovir/kg of body weight.

TABLE 1.

Tenofovir pharmacokinetics in lactating rhesus macaques
Other anti-HIV drugs (nevirapine, zidovudine, and lamivudine) are also found in breast milk (7, 8). Treatment of HIV-infected lactating mothers with anti-HIV drugs is expected to benefit the infant indirectly (by improving the mother's health and reducing maternal systemic virus levels, thus potentially lowering the infectivity of the breast milk). However, could such levels of anti-HIV drugs in breast milk have any direct biological effects, either harmful or beneficial for the infant? It was recently reported that concentrations of lamivudine and nevirapine in breast milk were high enough to give detectable serum levels in their nursing infants, which may provide prophylactic effects but may also have toxic effects (R. Shapiro et al., 42nd Ann. Meet. Infect. Dis. Soc. Am., Boston, Late Breaker abstr. LB-1, 2004). Concerns have also been raised that infants who become infected may be exposed for relatively long periods to subtherapeutic levels of drug, which may lead to resistance and limit the future treatment options for the infant (4, 5).

For breast-feeding mothers taking the orally bioavailable prodrug tenofovir disoproxyl fumarate, breast milk is expected to contain almost exclusively the parental compound tenofovir, which due to its charged anionic nature exhibits low oral bioavailability in animals (5% in cynomolgus macaques) and is expected to also show low oral bioavailability after ingestion by the nursing infant (3, 10). A previous study in macaques suggests that the concentration of tenofovir in milk is unlikely to give topical prophylaxis against oral HIV infection (13). Instead, infant macaque studies suggest that direct administration of tenofovir disoproxyl fumarate to the nursing infant at regimens that give systemic drug levels is needed to prevent infection through breast-feeding (12; K. Van Rompay, J. Lawson, R. Colón, N. Bischofberger, and M. Marthas, XV Int. AIDS Conf., Bangkok, Late Breaker abstr. LbOrB10, 2004). Considering the volume of ingested breast milk, the tenofovir concentrations we observed in breast milk of lactating macaques are unlikely to be toxic for the infant, especially because our previous studies demonstrated a favorable safety profile of prolonged daily treatment of infant macaques with a dose of tenofovir (10 mg/kg subcutaneously) that is much higher than the daily amount of tenofovir likely to be ingested and absorbed from breast milk (11). Because of its low oral bioavailability, small amounts of tenofovir in milk are also very unlikely to select for resistance in an already infected infant, thus preserving future treatment options.

In conclusion, this pilot pharmacokinetic study in lactating rhesus macaques demonstrates that tenofovir, similar to most other drugs, is found in milk but at lower levels than in maternal blood. The available data suggest that such low tenofovir levels in milk will most likely have no biological effects whatsoever for the nursing infant.

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ACKNOWLEDGMENTS
We thank L. Hirst and the staff of the Veterinary & Colony Services of the California National Primate Research Center for expert technical assistance and M. Marthas for critical review of the manuscript.

This research was supported by Gilead Sciences and E. Glaser Pediatric AIDS Foundation grant PG-51014 to K.K.A.V.R.

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REFERENCES
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2. American Academy of Pediatrics. 2001. The transfer of drugs and other chemicals into human milk. Pediatrics 108:776-789. [PubMed]
3. Cundy, K. C., C. Sueoka, G. R. Lynch, L. Griffin, W. A. Lee, and J.-P. Shaw. 1998. Pharmacokinetics and bioavailability of the anti-human immunodeficiency virus nucleotide analog 9-[(R)-2-(phosphonomethoxy)propyl]adenine (PMPA) in dogs. Antimicrob. Agents Chemother. 42:687-690. [PMC free article] [PubMed]
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5. John-Stewart, G., D. Mbori-Ngacha, R. Ekpini, E. N. Janoff, J. Nkengasong, J. S. Read, P. Van de Perre, and M.-L. Newell. 2004. Breastfeeding and transmission of HIV-1. J. Acquir. Immune Defic. Syndr. 35:196-202. [PMC free article] [PubMed]
6. Larsen, L. A., S. Ito, and G. Koren. 2003. Prediction of milk/plasma concentration ratio of drugs. Ann. Pharmacother. 37:1299-1306. [PubMed]
7. Moodley, J., D. Moodley, K. Pillay, H. Coovadia, J. Saba, R. van Leeuwen, C. Goodwin, P. R. Harrigan, K. H. Moore, C. Stone, R. Plumb, and M. A. Johnson. 1998. Pharmacokinetics and antiretroviral activity of lamivudine alone or when coadministered with zidovudine in human immunodeficiency virus type 1-infected pregnant women and their offspring. J. Infect. Dis. 178:1327-1333. [PubMed]
8. Musoke, P., L. A. Guay, D. Bagenda, M. Mirochnick, C. Nakabiito, T. Fleming, T. Elliott, S. Horton, K. Dransfield, J. W. Pav, A. Murarka, M. Allen, M. G. Fowler, L. Mofenson, D. Hom, F. Mmiro, and J. B. Jackson. 1999. A phase I/II study of the safety and pharmacokinetics of nevirapine in HIV-1-infected pregnant Ugandan women and their neonates (HIVNET 006). AIDS 13:479-486. [PubMed]
9. National Research Council. 1996. Guide for the care and use of laboratory animals. National Academy Press, Washington, D.C.
10. Shaw, J. P., C. M. Sueoka, R. Oliyai, W. A. Lee, M. N. Arimilli, C. Kim, and K. C. Cundy. 1997. Metabolism and pharmacokinetics of a novel oral prodrug of 9-[(R)-2-(phosphonomethoxy)propyl]adenine (PMPA) in dogs. Pharm. Res. 14:1824-1829. [PubMed]
11. Van Rompay, K. K. A., L. L. Brignolo, D. J. Meyer, C. Jerome, R. Tarara, A. Spinner, M. Hamilton, L. L. Hirst, D. R. Bennett, D. R. Canfield, T. G. Dearman, W. Von Morgenland, P. C. Allen, C. Valverde, A. B. Castillo, R. B. Martin, V. F. Valerie, F. Samii, R. Bendele, J. Desjardins, M. L. Marthas, N. C. Pedersen, and N. Bischofberger. 2004. Biological effects of short-term and prolonged administration of 9-[2-(phosphonomethoxy)propyl]adenine (PMPA; tenofovir) to newborn and infant rhesus macaques. Antimicrob. Agents Chemother. 48:1469-1487. [PMC free article] [PubMed]
12. Van Rompay, K. K. A., M. B. McChesney, N. L. Aguirre, K. A. Schmidt, N. Bischofberger, and M. L. Marthas. 2001. Two low doses of tenofovir protect newborn macaques against oral simian immunodeficiency virus infection. J. Infect. Dis. 184:429-438. [PubMed]
13. Van Rompay, K. K. A., K. A. Schmidt, J. R. Lawson, R. Singh, N. Bischofberger, and M. L. Marthas. 2002. Topical administration of low-dose tenofovir disoproxyl fumarate to protect infant macaques against multiple oral exposures of low doses of simian immunodeficiency virus. J. Infect. Dis. 186:1508-1513. [PubMed]
Articles from Antimicrobial Agents and Chemotherapy are provided here courtesy of American Society for Microbiology (ASM)

作者: liver411 时间: 2012-8-31 14:21

妊娠及哺乳期间的抗HBV治疗热点答疑

在2:53, 3:17 到 3:24 说的就是替诺和拉米...哺乳期用药...

http://video.sina.com.cn/v/b/63511558-2294010801.html

视频：
http://you.video.sina.com.cn/api ... hAQps6dP8j0hU/s.swf

作者: liver411 时间: 2012-8-31 14:22

上面视频的中英文对照解释：

http://www.haodf.com/zhuanjiaguandian/Doctorpanye_549868379.htm

[APASLSTC 2011]妊娠及哺乳期间的抗HBV治疗热点答疑——Prof. Kumar Visvanathan 访谈
发表者：潘业 (访问人次：131)

妊娠期间机体免疫抑制会增强，以保证胎儿不会被排斥。同时，在妊娠期间，针对乙肝的免疫反应也被抑制，分娩后病毒复制则突然加速。这就是产后乙肝复发的原因。对于妊娠期妇女的治疗，Visvanathan教授认为应该选用有良好安全性参数的药物尽量在孕期持续进行治疗，而不应该推迟治疗。这对于母亲来说比较重要。

Hepatology Digest: We know that during pregnancy， the immune system undergoes great change and we also know that hepatitis B is a disease closely correlated to the immune response. Do you think there is an interaction between pregnancy and hepatitis B?

　　《国际肝病》：我们知道在妊娠期，免疫系统会有很大的变化，而乙肝是一种与免疫密切相关的疾病，您是否认为妊娠与乙肝之间有相互影响呢？

　　Dr Visvanathan: The answer is yes. As you suggested， we know that there is a lot of immunosuppression in pregnancy and this is mainly to ensure the fetus is not rejected during the term of pregnancy. In the same way， the immune response to hepatitis B is suppressed during pregnancy and after pregnancy it is suddenly accelerated. That is why we get flares in hepatitis B post-partum.

　　Visvanathan博士：答案是肯定的。就像你所说的，我们知道妊娠期间机体免疫抑制会增强，以保证胎儿不会被排斥。同时，在妊娠期间，针对乙肝的免疫反应也被抑制，分娩后病毒复制则突然加速。这就是产后乙肝复发的原因。

　　Hepatology Digest: Because the management of hepatitis B infection in pregnant women is very complex， it is thought by some that it is reasonable to postpone treatment until after delivery to avoid exposure to the drugs. What is your opinion on this?

　　《国际肝病》：由于妊娠期妇女乙肝治疗非常复杂，一些人认为应该将治疗推迟到产后以避免胎儿受到药物的影响。您的意见呢？

　　Dr Visvanathan: There are two separate questions: one is to treat the women who need treatment during pregnancy because they are decompensating in terms of their liver disease; and secondly， how to prevent the transmission of the virus from the mother to the fetus? In terms of the treatment of women during pregnancy， we believe that providing the drugs used have a good safety parameter， we should try to continue treatment through the pregnancy and not defer. It is important for the mother.

　　Visvanathan博士：这是两个相互独立的问题：一方面对需要治疗的妊娠期妇女要进行治疗，因为她们的肝脏疾患处于失代偿期；另一方面，如何阻止病毒从母亲传染给胎儿？对于妊娠期妇女的治疗，我们认为应该选用有良好安全性参数的药物尽量在孕期持续进行治疗，而不应该推迟治疗。这对母亲来说是重要的。

　　Hepatology Digest: What do you think is the optimal strategy for women with chronic hepatitis B during pregnancy?

　　《国际肝病》：您认为对于慢性乙肝妊娠期妇女，什么样的治疗策略最适合？

　　Dr Visvanathan: If the mother is already on treatment and becomes pregnant， ordinarily we wouldn’t stop therapy if it was based on tenofovir or lamivudine therapy. We would be worried if it was entecavir or another of the class C drugs.

　　Visvanathan博士：如果母亲正在治疗中而妊娠，常规来说，如果是基于替诺福韦或拉米夫定的治疗，我们不会停止治疗。如果是应用恩替卡韦或其它C级药物，我们会担心（有影响）。

　　Hepatology Digest: Currently the presence of HBV DNA， HBeAg and HBsAg in breast milk has been confirmed. Is there a risk of transmission of the virus when the mother breastfeeds their baby?

《国际肝病》：目前已经确定母乳中可存在HBV DNA、HBeAg和HBsAg。当母亲哺乳时有没有把病毒传染给婴儿的危险？

　　Dr Visvanathan: We believe in universal vaccination， so providing the baby is vaccinated when it is born， the risk of transmission is in fact non-existent. Remember also， the drugs tenofovir and lamivudine both appear in breast milk but in very low levels and probably have little effect.

　　Visvanathan博士：我们信赖常规免疫。所以当婴儿出生时接种疫苗后，实际上是不存在传染风险的。但我们也要记住，替诺福韦和拉米夫定也都会出现在母乳中，不过其含量非常低，可能不会有太大影响。

　　Hepatology Digest: So even if the mother takes the drugs， the baby is safe?

　　《国际肝病》：那么即使母亲服药，婴儿也是安全的？

　　Dr Visvanathan: I think so.

　　Visvanathan博士：我是这样认为。

　　Hepatology Digest: When intra-uterine transmission happens， the vaccination and hepatitis B immunoglobulin might not be functional. What is the incidence of this and how might we prevent it?

　　《国际肝病》：如果在子宫内发生了传染，可能疫苗和乙肝免疫球蛋白就会不起作用了。这种情况发生的几率有多大，我们如何防止这种情况？

　　Dr Visvanathan: Most of the infection is prevented by the immunoglobulin and vaccination – 90% of the infection is stopped that way. The problem is the remaining 7%-10% that is not stopped. This situation is directly related to how much virus is in the mother. If there are very high levels of virus present， we believe the best treatment would be with one of the antiviral drugs in the last trimester of pregnancy to reduce transmission. This would be one of the class B drugs (telbivudine or tenofovir) hopefully or lamivudine.

　　Visvanathan博士：大部分感染都可以通过免疫球蛋白和疫苗来防止，90%的感染可以通过这种方式预防。问题是，还有剩下的7%~10%感染几率无法被预防。这直接与母亲体内病毒量相关。如果病毒水平很高，我们认为最好在妊娠期的最后三个月进行抗病毒治疗以降低传染几率。应该选用B级药物（替比夫定或替诺福韦）或拉米夫定。

发表于：2011-11-08 19:31

作者: 喵小鱼儿 时间: 2012-8-31 14:32

liver411 发表于 2012-8-31 14:17
理论上和大部分医生是不建议哺乳期间用核苷类似物药物抗病毒的，因为药物会出现在母乳中。但实际上，近 ...

哈哈谢谢你的回复我昨天晚上正好也看了一堆资料文献正准备整理之后拿上来和大家分享一下呢到时候去见医生也有的讨论我这一两天会慢慢把了解到的资料放上来并做个简易翻译
到时候可以一起讨论啊。

作者: 雁过留声 时间: 2012-8-31 16:06

首先，迄今并没有文献和科研数据来支持服用核苷酸类药物的妈妈可以母乳喂养。（世卫及各国乙肝指南并没有公开支持服用核苷酸类药物期间的妈妈可以母乳喂养）
虽然替诺福韦在国外已经上市十年左右，但在我国偿没有正式上市，更不可能有支持替诺期间可以母乳之文献、科研数据等。
虽然目前国外已有一些动物试验成果和一些医生的观点认可某类核苷酸可以母乳喂养，不影响到宝宝，但整体还处于摸索阶段，暂时还没有被医学界广泛认可。也许在不久将来随着医学的发展对药物的了解，拉米与替诺会被世卫或各国乙肝指南纳入可以母乳范畴，但目前还没有。

作者: 雁过留声 时间: 2012-8-31 16:14

感谢411老师的转载！

相信随着医学的发展，对核苷酸药物的了解，临床经验的累积，对核苷酸药物期间是否能母乳的定论将会越来越清晰。

作者: 林子云 时间: 2012-8-31 17:43

我在网上看到美国有报道78例孕期服用替诺福韦后婴儿有毒性反应；同时还看到有报道孕期服用替诺福韦后婴儿长到1岁时身高和头围比未服用替诺的婴儿小1厘米，各位是怎么看待这两个问题的？这能说明替诺不比替比或拉米在孕期使用更安全吗？

作者: 雁过留声 时间: 2012-8-31 17:56

林子云发表于 2012-8-31 17:43
我在网上看到美国有报道78例孕期服用替诺福韦后婴儿有毒性反应；同时还看到有报道孕期服用替诺福韦后婴儿长 ...

请提供链接。

作者: MP4 时间: 2012-8-31 19:04

林子云发表于 2012-8-31 17:43
我在网上看到美国有报道78例孕期服用替诺福韦后婴儿有毒性反应；同时还看到有报道孕期服用替诺福韦后婴儿长 ...

不知你原文在哪？你写反了吧

1.
我找到的是这个
“最近美国一篇报道指出，78例爱滋病患者在妊娠期使用替诺福韦酯，她们的78名新生儿均未获得HIV感染和均未显示有毒性反应。”

2.
AIDS：替诺福韦对孕期胎儿影响较小

http://infect.dxy.cn/article/21076

http://news.dxy.cn/bbs/thread/22683381

2012-04-10 13:20 来源：丁香园作者：bailangwang

近日在线发表于AIDS网络版的的一项报告称，感染HIV的女性在怀孕期间使用替诺福韦与早产儿或低体重儿的出生无关。美国国家卫生研究院的George K. Siberry博士通过电子邮件告知路透健康报说：“总的来说，这项研究应该可以打消医生和孕妇的疑虑。因为结果表明孕期服用替诺福韦不会导致胎儿和婴儿的生长问题。”

虽然证实了替诺福韦用于治疗成年HIV感染的安全性和有效性。但出于对副作用的担心，此药被禁止用于治疗HIV感染的孕妇以及预防母婴间HIV的传播。为了推翻这一论断，研究者对2029名未感染儿童进行了队列研究，这些儿童的母亲在孕期都接受过抗逆转录病毒治疗。数据显示，孕期服用替诺福韦母亲的比例从2003年的14%上升到2010年的43%。整个研究中服用此药物的孕妇总计449人，占21%。

结果显示，对于暴露于和非暴露于替诺福韦的新生儿来说，二者的早产儿风险（校正优势比 0.96；p=0.58），低体重风险（aOR 0.73；p=0.14），体长随年龄的Z评分（aOR 1.18；p=0.58），和头围随年龄的Z评分(aOR 0.82; p=0.39)之间的差异都无统计学意义。然而1岁时，暴露于替诺福韦婴儿的校正后平均LAZ (-0.17 vs -0.03; p=0.04)和HCAZ(0.17 vs 0.42; p=0.02)都显著低于非暴露婴儿。

Siberry 博士评论道：“我们无法解释为什么孕期服用替诺福韦的母亲产出的婴儿在1岁时的体长和头围会稍微低于同龄儿。并且我们不确定这些小差异是否有意义。”他总结道：“我们认为在婴儿1岁时的这些发现并不能作为禁止孕期使用替诺福韦的理由。但如果在其它大样本研究中出现类似结果，那么就要对这些结果引起足够的重视。”

3.我认为这些不能作为禁止孕期使用替诺福韦的理由，补充维生素D可预防可能骨骼问题。
拉米有耐药风险，替比有CK风险，替诺有肾风险，但可逆。
清楚有风险，但不一定风险都会发生。
目前最安全序列依然是替诺>拉米>曲滨>替比>阿德>恩替
替诺和拉米中可以母乳。

作者: 林子云 时间: 2012-8-31 21:03

回MP4：
如何预防乙型肝炎传给胎儿2011-02-15 09:10:26 来源: 39健康网社区

　　二、特异性预防阻断措施

　　(一)主动与被动联合免疫

　　HBeAg阳性和阴性孕妇经母婴传播导致婴儿HBV感染的概率分别约为90%和40%。经胎盘的传播在母婴传播的构成比≤5%。导致经胎盘传播的危险因素包括产妇HBeAg阳性、HBsAg高滴度、HBV DNA高载量。分娩方式不会影响母婴传播结果。

　　为了减少我国新生儿感染乙肝的风险，国家免费为所有的新生儿注射乙肝疫苗，由注射没有致病性的抗原诱发产生乙肝表面抗体，最终起到预防乙肝的目的，被称为主动免疫方法，对大数人疗效可靠，但需要6个月才能完全生效。直接注射乙型肝炎免疫球蛋白预防乙型肝炎是被动免疫措施。国内外的研究证明，分娩后给新生儿加用乙型肝炎免疫球蛋白，可以进一步减少HBV感染的相对风险。

　　(二)抗HBV药物对母婴阻断的意义及其生殖安全性研究

　　1.　宫内感染的发生机制及危险因素

　　宫内感染通过胎盘传播，发生机制可能是： ①胎盘部分损伤导致母血进入胎儿体循环，使胎儿感染;②HBV在胎盘内复制并在细胞间蔓延，使胎儿绒毛毛细血管内皮细胞受染而引起胎儿感染。③母亲HBV复制高水平，胎盘损伤发生及HBV在胎盘内复制是宫内感染发生的危险因素。

　　干扰素类和核苷(酸)类药物是目前治疗乙型肝炎的主流药物，可以有效地降低血液里的乙肝病毒颗粒。随着FDA-B类核苷(酸)类药物替比夫定，替诺福韦等的上市，给部分乙肝孕妇抗病毒治疗带来了希望。替比夫定(telbivudine， LdT)在生殖毒性研究中，雌雄大鼠暴露于人类推荐治疗剂量14倍的LdT时，未观察到有损害生育能力的证据。在临床前研究中，未观察到LdT有致畸作用，亦未发现替比夫定对胚胎的发育有不良影响。对妊娠大鼠和家兔的研究显示，替比夫定可以通过胎盘。对大鼠和家兔的发育毒理学研究表明，在暴露剂量分别高出人类推荐治疗剂量的6倍和37倍时，未观察到替比夫定对胎仔有损害的证据。美国一家艾滋病观察哨所，观察了1200多名应用拉米夫定孕产妇所生的新生儿，没有发现因药物引起的畸形发生。我国一项研究提示，在孕晚期接受替比夫定抗病毒药治疗，可安全、有效地阻断HBV的母婴传播。

　　2、替诺福韦 ( tenofovir，TNV)动物实验表明，妊娠3～21周的恒河猴暴露于人类推荐治疗剂量的25倍时，未发现其胎儿显著的发育异常，最近美国报道78例患者在妊娠期使用TNV，78名新生儿虽均未获得HIV感染，但示有毒性反应。动物实验的结果不主张在妊娠前6个月以及妊娠的任何时期采用恩替卡韦、阿德福韦或干扰素类药物治疗HBV感染的孕妇，也不主张采用这3种药物预防HBV母婴传播。

　　注：美国FDA妊娠安全级别分类

　　A类药物：对照研究未见到对胎儿有明显危害的迹象;

　　B类药物：现有的动物研究(没有人类对照研究)或动物风险研究证实无致畸型/胚胎风险的发生，但未得到人类对照研究的肯定;

　　C类药物：在动物研究中有致畸型/胚胎风险发生，没有人类对照研究;

　　D类药物：具有对胎儿危害的确凿证据，但孕妇用药后有绝对的好处(利大于弊);

　　X类药物：有确凿证据表明会导致胎儿的危险，并且在孕妇中使用所产生的风险明显大于任何可能的收益(弊大于利)。

作者: MP4 时间: 2012-9-1 01:50

林子云发表于 2012-8-31 21:03
回MP4：
如何预防乙型肝炎传给胎儿2011-02-15 09:10:26 来源: 39健康网社区

你的是盗版。

以下正解：

78例爱滋病患者在妊娠期使用替诺福韦酯，她们的78名新生儿均未获得HIV感染和均未显示有毒性反应。
In our study TDF was effective and safe. All 78 exposed children were HIV-negative and had no signs of TDF related toxicity.
http://retroconference.org/2008/PDFs/627a.pdf

作者: 林子云 时间: 2012-9-1 07:38

怎么会呢，百度搜索一下，很多条都是“最近美国报道78例患者在妊娠期使用TNV，78名新生儿虽均未获得HIV感染，但示有毒性反应”，只有1，2条是78例爱滋病患者在妊娠期使用替诺福韦酯，她们的78名新生儿均未获得HIV感染和均未显示有毒性反应。其实我也希望是你正确的，因为我老婆也正在吃替诺。这盗版得也太离谱了吧，我英文不好，请大家帮弄清一下这怎么回事？

作者: 喵小鱼儿 时间: 2012-9-2 13:50

林子云发表于 2012-9-1 07:38
怎么会呢，百度搜索一下，很多条都是“最近美国报道78例患者在妊娠期使用TNV，78名新生儿虽均未获得HIV感染 ...

我看了一下上面的pdf 的确说使安全的，78名实验对象婴儿均未被传染hiv，也没有发现有与替诺相关的中毒迹象。结论很清楚，是安全的。而且应该推广。

作者: 喵小鱼儿 时间: 2012-9-2 14:22

本帖最后由喵小鱼儿于 2012-9-2 14:45 编辑

http://www.atout-org.com/p2t2012/abstract_display!fr!!!!f3f5d35c-6c95-102f-b1e6-855e464587d5!session11_1

上面链接是我看到的一篇法文：
我用ipad不太方便打字，所以就取重要内容翻译好了。

Résumé

11-O017
Tenofovir exposure through breast feeding: serum concentrations in neonates and clinical follow-up

Dr. Aurore GOURAUDa, Dr. Anne MILLARETa, Dr. Nathalie BERNARDa, Dr. Meri BRUELa, Dr. Nathalie PARETa, Pr. Jacques DESCOTESa, Dr. Thierry VIALa

a Centre de Pharmacovigilance de Lyon

Objective: The prevalence of chronic viral hepatitis B during pregnancy is estimated between 0.1% and 6%. Since recommendations for immunoprophylactic treatment in neonates born to infected mothers, several studies have shown that breast-feeding does not increase the risk of postnatal mother-to-child transmission in these properly immunized newborns. Tenofovir disoproxil fumarate (TDF) is a prodrug of the active nucleotide analogue tenofovir (TVF) used in HIV and HBV infections, including during pregnancy. Although the available data on human milk transfer indicate that only very limited amounts of TVF are excreted into breast milk, clinical data on the safety of breast-feeding for the newborn of TDF-treated patients are lacking. Lyon Pharmacovigilance Center is regularly asked about the compatibility of breast-feeding in HBV-positive TDF-treated women. Our experience regarding TDF during breast-feeding is described.

Patients and method: After individual assessment, clinical and biological surveys were proposed to each patient. To monitor infant exposure to tenofovir through breast-feeding, serum level measurement in the newborn was systematically proposed after 2 to 3 weeks of breast-feeding. A clinical follow-up was also performed.

Results Since 2010, a follow-up has been obtained from 4 patients that exclusively breast fed 5 neonates (1 pair of twins) for a mean duration of 1.8 months. Two neonates were premature with a gestational age of 33 weeks. All mothers have been treated with tenofovir 245 mg/d throughout pregnancy for chronic viral hepatitis B. Associated drugs in one mother included hydroxychloroquine and corticosteroids. Serum tenofovir levels were measured in all 5 neonates. Tenofovir was undetectable (lower limit of detection <0.005 mg/L) in 4, and close to the limit of detection in one (0.0055 mg/L). Short-term follow-up (4 months of age) of 2 infants exclusively breastfed during 3 months did not show any adverse outcome regarding standard developmental growth parameters.

2010年来开展了就5个完全母乳的新生儿的跟踪研究，其中有一对33周早产的双胞胎。所有母亲在整个怀孕期间接受每日245 mg的替诺的抗乙肝病毒治疗。其中一位母亲还同时服用hydroxychloroquine and corticosteroids。对这5个新生儿体内检查替诺含量，其中4名婴儿体内未检测出（就是含量非常低，小于最低可检测值即 <0.005 mg/L），1名婴儿接近最低可检测值(0.0055 mg/L）。对在严格母乳喂养3个月后的2名四个月大婴儿的跟踪调查表明，婴儿身体发育良好，满足各项发育指数。

大意就是在5名受调查的母乳喂养的婴儿身体中几乎检测不到替诺，或者刚刚等于可监测到的最小值。

Conclusion: This is the first study investigating tenofovir exposure in infants exposed through breast-feeding. The results confirm previous information suggesting that tenofovir is probably safe during breast-feeding. Until more data are available, careful infant monitoring is recommended especially in infants with renal dysfunction.

结论是，调查试验结果结果肯定了以前的推论：替诺对母乳喂养应该是安全的。在更多数据出现之前，建议对母乳喂养的婴儿密切监测，尤其是有肾功能失调问题的婴儿。

作者: 喵小鱼儿 时间: 2012-9-2 14:56

本帖最后由喵小鱼儿于 2012-9-2 15:01 编辑

还有一篇
http://www.drugs.com/breastfeeding/tenofovir.html

大意是在新生儿中检测到的替诺含量很低，仅为提案的推荐新生儿用量的0。03% （此推荐药量还未正式批准，仅为提案中估计值），所以应该是安全的。等我回头再来更新详细点的翻译。

Tenofovir Levels and Effects while Breastfeeding

Summary of Use during Lactation

In the United States and other developed countries, HIV-infected mothers should generally not breastfeed their infants. In countries in which no acceptable, feasible, sustainable and safe replacement feeding is available, exclusive breastfeeding for 6 months is recommended for HIV-infected mothers to reduce the risk of HIV transmission from the mother to the infant compared with mixed feeding.[1][2][3][4][5][6] In these settings, abrupt weaning at 4 months does not reduce the risk of HIV transmission or produce an overall health benefit compared to continued breastfeeding, and increases the risk of infant death in HIV-infected infants.[7] Extended antiretroviral prophylaxis in breastfed infants with antiretroviral drugs appears to reduce the rate of HIV transmission during breastfeeding by about half, but the optimal regimen and duration of prophylaxis has not yet been defined.[8][9][10][11] Limited published experience with tenofovir during breastfeeding in HIV-positive mothers indicates that the exposure of the infant to the drug is trivial and unlikely to have any adverse consequences.

Tenofovir has not been studied in HIV-negative nursing mothers being treated for hepatitis B infection. In a survey, 226 physicians with a practice interest in liver disease in the United States responded. Of these, 31% stated that they recommend breastfeeding for their patients with hepatitis B who are taking antiviral therapy, 44% stated that they do not recommend breastfeeding during antiviral therapy and 25% stated that they were unsure.[12]

Drug Levels

Maternal Levels. Five exclusively breastfeeding mothers received oral tenofovir 300 mg plus emtricitabine 200 mg and nevirapine 200 mg at the start of labor, then oral tenofovir 300 mg daily and emtricitabine 200 mg for 7 days postpartum. A total of 16 concurrent maternal blood and milk samples were collected on days 1, 2, 3, and 7 postpartum between 10 minutes and 21 hours after the mothers' doses. Median peak and trough tenofovir concentrations in breastmilk were 14.1 mcg/L and 6.8 mcg/L, respectively. The authors estimated that an exclusively breastfed infant would receive about 0.03% of the proposed infant dose for tenofovir and achieve trivial infant serum concentrations that would likely have no adverse consequences.[13]

Infant Levels. Relevant published information was not found as of the revision date.

Effects in Breastfed Infants

Relevant published information was not found as of the revision date.

Possible Effects on Lactation

Relevant published information was not found as of the revision date.

Alternate Drugs to Consider

Lamivudine, Nelfinavir, Nevirapine, Zidovudine

References

1. World Health Organization. HIV and infant feeding: update. 2007. http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf

2. Dao H, Mofenson LM, Ekpini R et al. International recommendations on antiretroviral drugs for treatment of HIV-infected women and prevention of mother-to-child HIV transmission in resource-limited settings: 2006 update. Am J Obstet Gynecol. 2007;197 (3 Suppl):S42-55. PMID: 17825650

3. Branson BM, Handsfield HH, Lampe MA et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55 (RR-14):1-17. PMID: 16988643

4. McIntyre J, Dabis F, Mofenson LM et al. Rapid advice: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. World Health Organization. Geneva. 2009;1-23.

5. Chasela CS, Hudgens MG, Jamieson DJ et al. Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. N Engl J Med. 2010;362:2271-81. PMID: 20554982

6. Shapiro RL, Hughes MD, Ogwu A et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med. 2010;362:2282-94. PMID: 20554983

7. Kuhn L, Aldrovandi GM, Sinkala M et al. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. N Engl J Med. 2008;359:130-41. PMID: 18525036

8. Kumwenda NI, Hoover DR, Mofenson LM et al. Extended antiretroviral prophylaxis to reduce breast-milk HIV-1 transmission. N Engl J Med. 2008;359:119-29. PMID: 18525035

9. Mofenson LM. Antiretroviral prophylaxis to reduce breast milk transmission of HIV type 1: new data but still questions. J Acquir Immune Defic Syndr. 2008;48:237-40. PMID: 18545160

10. Bedri A, Gudetta B, Isehak A et al. Extended-dose nevirapine to 6 weeks of age for infants to prevent HIV transmission via breastfeeding in Ethiopia, India, and Uganda: an analysis of three randomised controlled trials. Lancet. 2008;372:300-13. PMID: 18657709

11. Chigwedere P, Seage GR, Lee TH, Essex M. Efficacy of antiretroviral drugs in reducing mother-to-child transmission of HIV in Africa: a meta-analysis of published clinical trials. AIDS Res Hum Retroviruses. 2008;24:827-37. PMID: 18544018

12. Ahn J, Salem SB, Cohen SM. Evaluation and management of hepatitis B in pregnancy: a survey of current practices. Gastroenterol Hepatol (N Y). 2010;6:570-8. PMID: 21088746

13. Benaboud S, Pruvost A, Coffie PA et al. Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan, Cote d'Ivoire, in the ANRS 12109 TEMAA Study, step 2. Antimicrob Agents Chemother. 2011;55:1315-7. PMID: 21173182

作者: 喵小鱼儿 时间: 2012-9-2 15:05

还有一篇
先占地儿

作者: 喵小鱼儿 时间: 2012-9-2 15:10

liver411 发表于 2012-8-31 14:17
理论上和大部分医生是不建议哺乳期间用核苷类似物药物抗病毒的，因为药物会出现在母乳中。但实际上，近 ...

你的文献资料基本和我看到的文献的观点一致，就是在母乳中的含量非常低，所以应该没有影响。目前还有一个比较大的替诺母乳研究项目正在进行，主要在非洲及其他地区，不过结果还没出来，那个出来就会有比较权威的正式结论了。

作者: 风风风风 时间: 2012-9-4 10:38

回复喵小鱼儿的帖子

你会母乳吗看起来是个好消息。不知道什么时候出结果

作者: 雁过留声 时间: 2012-9-4 19:53

喵小鱼儿发表于 2012-9-2 15:10
你的文献资料基本和我看到的文献的观点一致，就是在母乳中的含量非常低，所以应该没有影响。目前还有一个 ...

期待。。。
希望是个好结论，这部分宝宝也能享受到母乳的权力。

明年最新一届美国指南不知会不会对这方面也有个定论？一起期待吧。

作者: 喵小鱼儿 时间: 2012-9-8 13:54

本帖最后由喵小鱼儿于 2012-9-8 14:06 编辑

风风风风发表于 2012-9-4 10:38
回复喵小鱼儿的帖子

你会母乳吗看起来是个好消息。不知道什么时候出结果 ...

去见了医生。我跟他讨论了大家所担心的肾毒性等问题，他的意见是药的含量在母乳中非常少，不会有什么影响（话说回来这个副作用也只是极小部分人报告的症状，不是普遍的问题。我每次去见他的时候都验血，如果有什么问题的话也会反映在血检结果中。）而且母乳对宝宝的好处太大了。总之他非常坚持母乳，认为这根本不是个问题。他建议我如果还不放心的话，至少喂宝宝四个月，之后再作打算，比如可以母乳配方混搭。不过在他看来是没必要的，。

我自己后来想了想，怀孕的时候也是在吃这个药，羊水里也有的，对宝宝是安全的，难道生出来反而就不行啦？所以我的打算是，吃母乳（如果我有的话。。），然后一两个月左右去检查下宝宝，没问题的话就继续母乳。之后持续观察就行。这也和我看到的美国一个妈妈的做法大致相同：她是母乳，一个月后带宝宝检查，各项指标都没问题。几个月之后她是一半母乳一半配方。我回头再去看一遍确认一下。她的宝宝已经快两岁了，很健康。

所以我已经决定了：母乳！

作者: 喵小鱼儿 时间: 2012-9-9 14:28

最近刚查了血结果在第一页更新了。ast alt 下降了不错。

作者: 风风风风 时间: 2012-9-18 20:08

回复喵小鱼儿的帖子

终于等到你的消息了，其实我也默默决定母乳了，虽然上海的肝科，产科，新生儿科都不同意我母乳，我还是要坚持，至少3个月吧，定期检查，保持联系 ~~ 你有什么其他的方式吗这个论坛经常上不了，我的预产期是10,15

作者: 爱可儿 时间: 2012-9-19 00:22

mm你预产期什么时候呀，也是9月底吗？

作者: 爱可儿 时间: 2012-9-19 00:24

我在想怎么保护乳头呢，很多人说喂奶初期会出血被孩子嘬的，如果出血了是不是就不太安全呢？

作者: 喵小鱼儿 时间: 2012-9-25 16:35

风风风风发表于 2012-9-18 20:08
回复喵小鱼儿的帖子

终于等到你的消息了，其实我也默默决定母乳了，虽然上海的肝科，产科，新生儿科都不 ...

嗯！英雄所见略同哈哈
我是11月初紧张啊。。怕。。
祝福大家都大顺产！
宝宝健康！

作者: 喵小鱼儿 时间: 2012-9-25 16:40

爱可儿发表于 2012-9-19 00:24
我在想怎么保护乳头呢，很多人说喂奶初期会出血被孩子嘬的，如果出血了是不是就不太安全呢？ ...

之前就按摩增加乳头的柔韧性。。。另外吃奶的时候含整个乳晕才是正确的做法。
宝宝一生下来就打针的话应该没什么事我记得初乳一般生完三天才会有吧那个时候免疫的针早起作用了

另外血液吃的话不传染？不确定。。
不管怎样小心就是了但也不必如履薄冰该干吗干吗

作者: 千年灵芝 时间: 2012-9-29 17:28

祝福！关注...........

作者: 喵小鱼儿 时间: 2012-9-30 15:53

千年灵芝发表于 2012-9-29 17:28
祝福！关注...........

谢谢！现在心情越来越紧张了。希望能大顺产啊。

作者: 喵小鱼儿 时间: 2012-9-30 15:55

nfwzvq 发表于 2012-9-30 09:40
好帖,鉴定完毕，谢谢您了

初衷就是分享自己的情报，希望能给版上的其他姊妹一些有用的资讯
我们一起加油会有个健健康康的宝宝！

作者: 千年灵芝 时间: 2012-10-1 09:33

作者: 栀子花开86 时间: 2012-10-4 14:43

我是上海的。怀孕快两个月了。孕前吃了三个月的替诺。你们都是孕三个月才吃的，没事吧？担心中。。。。

作者: redpeachluo 时间: 2012-10-20 12:24

今天我也去医院开了替诺，28周中，神啊，请赐予我力量，保佑BB阻断成功！祝愿所有的BB 都能阻断成功，摆脱这个HBV。

作者: 千年灵芝 时间: 2012-10-20 16:59

作者: 臭美找我 时间: 2012-12-7 22:16

等待小鱼儿的出现。

作者: 丑丫丫啊 时间: 2012-12-8 21:58

等楼主出现。我下次去门诊再和医生咨询下，如果确认替诺可母乳，我也选择替诺。对拉米母乳无异议，无奈拉米耐药，医生拉米加阿德的方案，不免对阿德母乳怀有隐忧。

作者: 丑丫丫啊 时间: 2012-12-8 21:59

回复臭美找我的帖子

在吗？亲，你宝宝的第二针免疫球蛋白哪里打的？我是杭州的战友。

作者: 臭美找我 时间: 2012-12-15 21:23

等待楼主

作者: wozhiwunai 时间: 2013-4-11 22:43

楼主，宝宝出生了吧？一切都好吗？我正纠结该不该吃这个药。

作者: wuyu702 时间: 2013-4-16 17:21

好久没有见到lz来更新来哦

作者: 山东-大汉 时间: 2013-5-12 12:40

路过看一下，祝福战友

作者: 迷失的楠楠 时间: 2013-5-13 15:12

我当时也吃的替比，一下从7次方降到3次方了

作者: gimme 时间: 2013-5-15 12:19

楼主孩子应该都有半岁了，不知道现在是什么情况呢

作者: wozhiwunai 时间: 2013-5-20 00:25

我也吃替诺了，也很想母乳，可地坛的大夫明确不让我母乳，该怎么办？

作者: 恒心的恒心 时间: 2013-6-10 16:44

经验分享好及时，替诺参考了。

作者: 恒心的恒心 时间: 2013-6-10 16:51

这个帖子太有效了！！慢慢看，谢谢分享。

作者: 夏日香气w 时间: 2013-12-14 01:25

楼主咋不来更新了。不知道楼主跟宝宝现在情况如何？偶也在替诺中，孕14周。

作者: luoting0904 时间: 2013-12-14 20:19

回复夏日香气w 的帖子

你是全程替诺吗？我现在孕24周，全程替诺

作者: 夏日香气w 时间: 2013-12-15 04:12

回复 luoting0904 的帖子

是的，我是恩替卡韦换过来的。

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