看了一篇文献，似乎已经证明了替诺对母乳的孩子没有影响

smilingcloud

回复 familyjiankang 的帖子

Tenofovir has limited penetration in breast milk, which would limit potential toxicity for the breastfeeding infant.

跟你在1楼贴的内容是一致的。

结论是，WHO认为服用替诺的哺乳期妇女给孩子母乳，通过乳汁传递给孩子而出现毒性副作用的风险很低。

familyjiankang

回复 smilingcloud 的帖子

可以这样理解吗？WHO对于服用替诺的女性哺乳这个事情，是保持中性的，既不推荐也不反对

smilingcloud

回复 familyjiankang 的帖子

WHO的叙述都是基于事实的客观中性表述。

［不推荐］与［不反对］之间程度上还是有相当大的距离。

WHO的意见可以理解为［不反对］。  

StephenW

回复 familyjiankang 的帖子

哦，让我道歉,
"世卫组织和所有指南推荐HBV母亲服用替诺给孩子哺乳" - 这是错误的, 他们推荐HBV母亲哺乳.
下面的链接, 有指南的在线链:
http://www.hepb.org/treatment-an ... ?platform=hootsuite

有一个文献, 代表澳大利亚，英国。 新西兰主要意见领袖, 不反对HBV母亲服用替诺给孩子哺乳:
    Format: Abstract

Send to
Gut. 2016 Feb;65(2):340-50. doi: 10.1136/gutjnl-2015-310317. Epub 2015 Oct 15.
Managing HBV in pregnancy. Prevention, prophylaxis, treatment and follow-up: position paper produced by Australian, UK and New Zealand key opinion leaders.
Visvanathan K1, Dusheiko G2, Giles M3, Wong ML4, Phung N5, Walker S6, Le S7, Lim SG8, Gane E9, Ngu M10, Hardikar W11, Cowie B12, Bowden S13, Strasser S14, Levy M15, Sasaduesz J16.
Author information

    1St. Vincent's Hospital, Fitzroy, Australia Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
    2Institute of Liver and Digestive Health, Royal Free Hospital London, London, UK.
    3Department of Infectious Diseases and Department of Obstetrics and Gynaecology Monash Health, The Alfred Hospital, The Royal Women's Hospital, Melbourne, Victoria, Australia.
    4Department of Gastroenterology, Box Hill Hospital, Melbourne, Victoria, Australia.
    5Liver Addiction Research Unit and Storr Liver Unit, Westmead Millennium Institute, University of Sydney and Westmead Hospital, Westmead, New South Wales, Australia Drug Health Western Sydney Local Health District, Westmead, New South Wales, Australia.
    6Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Victoria, Australia Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia.
    7Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia.
    8Department of Hepatology, National University Health System, Singapore, Singapore.
    9Liver Transplant Unit, Auckland City Hospital Auckland, Auckland, New Zealand.
    10Gastroenterology and Hepatology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.
    11Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia Murdoch Childrens Research Institute, Parkville, Victoria, Australia.
    12Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia Victorian Infectious Disease Reference Laboratory, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
    13Victorian Infectious Disease Reference Laboratory, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
    14AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Australia.
    15Liverpool Hospital, Sydney, New South Wales, Australia Department of Medicine, University of NSW, Sydney, New South Wales, Australia.
    16Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
https://www.ncbi.nlm.nih.gov/pubmed/26475631

StephenW

回复 familyjiankang 的帖子

Tenofovir and breast feeding
Tenofovir disoproxil fumarate (TDF) is a prodrug that is con-
verted in tissues into tenofovir as the active moiety. Tenofovir
has a very low oral bioavailability due to its anionic hydrophilic
state (serum Cmaxis reached at 1–2 h); however in in vitro
studies, the intracellular half-life was 50 h.

To improve bio-availability, tenofovir is administered as the prodrug TDF, which
is converted in tissues into tenofovir as the active moiety.
Transmission of active drug from maternal circulation across the
placenta into fetal circulation is minimal.
In the lactating mother who is receiving TDF, the low amounts of active drug
found in breast milk are not absorbed through the baby's GI tract. Hence, treatment of the mother with TDF results in minimal exposure of the fetus and the breastfed infant to active tenofovir.

In a phase I trial of tenofovir administered to HIV-infected pregnant women in Malawi and Brazil at the onset of labour, or 4 h prior to caesarean section, tenofovir was detectable in 4/25 (16%) breast milk samples collected during the week following birth, with a median (range) concentration of 13 (6–18) ng/mL.

The median concentration of tenofovir measured in breast milk was
approximately 3% of the median maximum concentration measured in serum samples.
A small pharmacokinetic study of HIV-positive mothers who
received tenofovir at delivery post partum found the median
infant dose of tenofovir through breast feeding was 4.2mg/day,
which is <0.03% of the proposed infant oral dose.

In a study of infants born to HIV-infected mothers who were
treated with tenofovir during pregnancy, no significant differences in survival outcomes were observed between breastfed
infants versus those who were never breast fed, at year 3 of
follow-up; furthermore, there were few cases of transient
decreases in phosphate or creatinine clearance.

There was also no evidence of an effect of tenofovir exposure on infant growth
at year 2 of follow-up.

Longer-term studies of the effects of tenofovir on the fetus are unclear. In a prospective study of 449
infants where the mother received tenofovir in an HIV setting,
there were slightly lower values for length and head circumfer-
ence at 1 year and a significantly decreased bone mineral
content, but the significance of this finding is unclear.

A new oral prodrug of tenofovir, tenofovir alafenamide
fumarate (TAF), is in development. TAF is a next-generation
oral prodrug of tenofovir that, compared with TDF, delivers tar-
geted increased intracellular levels of tenofovir, allowing for a
reduction in circulating tenofovir exposure.

It is expected that the improved safety profile of long-term TAF administration
will lead to replacement of standard tenofovir with TAF within the next
five years. The enhanced safety profile of TAF would
make this the ideal antiviral to use in pregnant women and
breastfeeding mothers.
In summary: While the current recommendation is that
women co-infected with HIV and HBV should not breast feed
their infants to avoid vertical transmission of HIV and HBV, the
risk of HBV transmission with breast feeding in mothers with
HBV monoinfection will be negligible if infants receive HBIG/
HBV vaccine at birth. Therefore, it is recommended that breast
feeding is only contraindicated in mothers with HBV monoinfec-
tion when the mother receives an antiviral therapy that is asso-
ciated with significant exposure and toxicity in infants. An
important question is whether mothers receiving tenofovir
should be advised to continue breast feeding. Based on available
data, (mainly in HIV-infected patients), the pharmacology of
tenofovir suggests that breast feeding should not be contraindi-
cated in women receiving tenofovir for prophylaxis or treatment
.
替诺福韦和哺乳
替诺福韦地索普西富马酸盐（TDF）是一种前药，
在组织中作为活性部分转移到替诺福韦。替诺福韦
由于其阴离子亲水性而具有非常低的口服生物利用度
状态（在1-2小时达到血清C max）;然而在体外
研究，细胞内半衰期为50 h。

为了提高生物利用度，替诺福韦作为前药TDF给药
在组织中转化为替诺福韦作为活性部分。
活性药物从母体循环传播
胎盘进入胎儿循环最小。
在接受TDF的哺乳期母亲中，低量的活性药物
发现在母乳中不吸收通过婴儿的胃肠道。因此，用TDF治疗母亲导致胎儿和母乳喂养的婴儿暴露于活性替诺福韦的最小暴露。

在马拉维和巴西在开始分娩时或在剖宫产术前4小时给予艾滋病毒感染的孕妇的替诺福韦的I期试验中，在本周收集的4/25（16％）母乳样品中可检测到替诺福韦出生后，中位数（范围）浓度为13（6-18）ng / mL。

在母乳中测得的替诺福韦的中值浓度
大约是在血清样品中测量的中值最大浓度的3％。
对HIV阳性母亲的小的药代动力学研究
收到替诺福韦在交货后产后发现中位数
通过母乳喂养的替诺福韦的婴儿剂量为4.2mg /天，
其为所提议的婴儿口服剂量的<0.03％。

在对感染艾滋病毒的母亲出生的婴儿的研究中
在妊娠期间用替诺福韦治疗，在母乳喂养之间没有观察到存活结果的显着差异
婴儿与那些从未母乳喂养的人，在第3年
跟进;此外，几乎没有短暂的病例
磷酸盐或肌酐清除率降低。

也没有证据表明替诺福韦暴露对婴儿生长的影响
在随访的第2年。

替诺福韦对胎儿的影响的长期研究尚不清楚。在449的前瞻性研究
婴儿，其中母亲在HIV设置中接受替诺福韦，
长度和头部周长的值略低，
1年和骨矿物质明显减少
内容，但这个发现的意义不清楚。

替诺福韦，替诺福韦艾拉酚胺的新口服前药
富马酸盐（TAF），正在开发中。 TAF是下一代
替诺福韦的口服前药，与TDF相比，
获得增加的细胞内水平的替诺福韦，允许a
减少循环替诺福韦暴露。

预期长期TAF给药的安全性改善
将导致替换标准替诺福韦与TAF在下一个
5年。 TAF的增强的安全性能
使这是用于孕妇的理想抗病毒药物
母乳喂养的母亲。
总结：虽然目前的建议是
共感染HIV和HBV的妇女不应母乳喂养
他们的婴儿避免HIV和HBV的垂直传播，
母亲携带母乳喂养的HBV传播风险
如果婴儿接受HBIG / HBV感染，HBV单一感染可以忽略不计，
HBV疫苗在出生时。因此，建议乳房
喂养只有在HBV单基因 -
当母亲接受抗病毒治疗时，
结合婴儿的显着暴露和毒性。一个
重要的问题是母亲是否接受替诺福韦
应建议继续哺乳。基于可用
数据，（主要是HIV感染患者），药理学
替诺福韦认为，母乳喂养不应该禁忌，
包括接受替诺福韦用于预防或治疗的妇女

familyjiankang

回复 StephenW 的帖子

非常感谢斯蒂芬大哥的耐心回帖，请问你在15楼贴的这篇文章"Tenofovir and breast feeding‘’是某一个国家的治疗指南吗？还是一篇正常的学术文章？
非常感谢。

familyjiankang

回复 smilingcloud 的帖子

感谢耐心回帖。
想问下，您知道日本那边的医生或者别的国家的医生对替诺妈妈带药母乳是什么态度吗？
拜读过您之前的大作，似乎您对日本的情况非常熟悉。

StephenW

回复 familyjiankang 的帖子

是一篇正常的学术文章, 代表澳大利亚，英国,  新西兰主要意见领袖, 不反对HBV母亲服用替诺给孩子哺乳.这是在2016年3月出版.
Gut. 2016 Feb;65(2):340-50. doi: 10.1136/gutjnl-2015-310317. Epub 2015 Oct 15.
Managing HBV in pregnancy. Prevention, prophylaxis, treatment and follow-up: position paper produced by Australian, UK and New Zealand key opinion leaders.


许多指南在2016年前发布, 没有服用替诺给孩子哺乳最新的临床结果.

familyjiankang

回复 StephenW 的帖子

您的意思是，之后的指南很有可能更新这些替诺妈妈哺乳的数据，并在指南里支持替诺妈妈哺乳。

StephenW

回复 familyjiankang 的帖子

是的，在我看来.