Risk Factor: C
Class: Anti-infectives/ Antituberculosis
Fetal Risk Summary
Isoniazid is used in the prevention and treatment of pulmonary tuberculosis. Reproduction studies in mice, rats, and rabbits have not revealed teratogenic effects, but embryocidal effects were observed in rats and rabbits (1).
An official statement of the American Thoracic Society, published in 1986, recommends isoniazid as part of the treatment regimen for women who have tuberculosis during pregnancy (2). Other reviewers also consider isoniazid as part of the treatment of choice for tuberculosis occurring during pregnancy (3).
Isoniazid crosses the placenta to the fetus (4,5 and 6). In a 1955 study, 19 women in labor were given a single 100-mg dose of isoniazid 0.254.25 hours before delivery (4). The mean maternal serum concentration at birth was 0.32 g/mL compared with a cord blood level of 0.22 g/mL. The mean cord:maternal ratio was 0.73, but in 7 of the patients, cord blood concentrations exceeded those in the maternal plasma. Another study examined the placental transfer of isoniazid in two women who had been treated with 300 mg/day during the 3rd trimester (5). One hour before delivery, the women were given a single 300-mg IM dose. Mean cord blood and maternal serum concentrations were 4 and 6.5 g/mL, respectively, a ratio of 0.62. These studies and the elimination kinetics of intrauterine acquired isoniazid in the newborn were reviewed in 1987 (6).
Reports discussing fetal effects of isoniazid during pregnancy reflect multiple drug therapies. Early reports identified retarded psychomotor activity, psychic retardation, convulsions, myoclonia, myelomeningocele with spina bifida and talipes, and hypospadias as possible effects related to isoniazid therapy during pregnancy (7,8). The Collaborative Perinatal Project monitored 85 patients who received isoniazid during the 1st trimester (9, pp. 299, 313). They observed 10 malformations, an incidence almost twice the expected rate, but they cautioned that their findings required independent confirmation. For use anytime during pregnancy, 146 mother-child pairs were exposed to isoniazid, with malformations that may have been produced after the 1st trimester observed in 4 infants (9, p. 435). This was close to the expected frequency. Adverse outcomes in the fetus and newborn after intrauterine exposure to isoniazid have not been confirmed by other studies (10,11,12,13,14 and 15). Retrospective analysis of more than 4,900 pregnancies in which isoniazid was administered demonstrated rates of malformations similar to those in control populations (0.7%2.3%). A 1980 review also found no association between isoniazid and fetal anomalies (16).
In a surveillance study of Michigan Medicaid recipients involving 229,101 completed pregnancies conducted between 1985 and 1992, 11 newborns had been exposed to isoniazid during the 1st trimester (F. Rosa, personal communication, FDA, 1993). One (9.1%) major birth defect was observed (0.5 expected), a case of polydactyly.
A case report of a malignant mesothelioma in a 9-year-old child who was exposed to isoniazid in utero was published in 1980 (17). The authors suggested a possible carcinogenic effect of isoniazid because of the rarity of malignant mesotheliomas during the first decade and supportive animal data. However, an earlier study examined 660 children up to 16 years of age and found no association with carcinogenic effects (18).
An association between isoniazid and hemorrhagic disease of the newborn has been suspected in two infants (19). The mothers were also treated with rifampin and ethambutol and in a third case, only with these latter two drugs. Although other reports of this potentially serious reaction have not been found, prophylactic vitamin K1 is recommended at birth (see Phytonadione).
In summary, isoniazid does not appear to be a human teratogen. The American Thoracic Society recommends use of the drug for tuberculosis occurring during pregnancy because, Untreated tuberculosis represents a far greater hazard to a pregnant woman and her fetus than does treatment of the disease. (2)
Breast Feeding Summary
No reports of isoniazid-induced effects in the nursing infant have been located, but the potential for interference with nucleic acid function and for hepatotoxicity may exist (20,21). Both isoniazid and its metabolite, acetylisoniazid, are excreted in breast milk (21,22 and 23). A woman was given a single oral dose of 300 mg after complete weaning of her infant (21). Both isoniazid and the metabolite were present in her milk within 1 hour with peak levels of isoniazid (16.6 g/mL) occurring at 3 hours and those of the metabolite (3.76 g/mL) at 5 hours. At 5 and 12 hours after the dose, isoniazid levels in the milk were twice the levels in simultaneously obtained plasma. Levels of acetylisoniazid were similar in plasma and milk at 5 and 12 hours. The elimination half-life for milk isoniazid was calculated to be 5.9 hours, whereas that of the metabolite was 13.5 hours. Both were detectable in milk 24 hours after the dose. The 24-hour excretion of isoniazid was estimated to be 7 mg. Two other studies also reported substantial excretion of isoniazid into human milk (22,23). A milk:plasma ratio of 1.0 was reported in one of these studies (22). In another, milk levels 3 hours after a maternal dose of 5 mg/kg were 6 g/mL (23). Doubling the maternal dose doubled the milk concentration.
Based on the above information, at least one review concluded that women can safely breast-feed their infants while taking isoniazid if, among other precautions, the infant is periodically examined for signs and symptoms of peripheral neuritis or hepatitis (20). Moreover, the American Academy of Pediatrics considers isoniazid to be compatible with breast feeding (24).
- Product information. Rifamate. Hoechst Marion Roussel, 2000.
- American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986;134:35563.
- Medchill MT, Gillum M. Diagnosis and management of tuberculosis during pregnancy. Obstet Gynecol Surv 1989;44:814.
- Bromberg YM, Salzberger M, Bruderman I. Placental transmission of isonicotinic acid hydrazide. Gynaecologia 1955;140:1414.
- Miceli JN, Olson WA, Cohen SN. Elimination kinetics of isoniazid in the newborn infant. Dev Pharmacol Ther 1981;2:2359.
- Holdiness MR. Transplacental pharmacokinetics of the antituberculosis drugs. Clin Pharmacokinet 1987;13:1259.
- Weinstein L, Dalton AC. Host determinants of response to antimicrobial agents. N Engl J Med 1968;279:52431.
- Lowe CR. Congenital defects among children born to women under supervision or treatment for pulmonary tuberculosis. Br J Prev Soc Med 1964;18:146.
- Heinonen OP, Slone D, Shapiro S. Birth Defects and Drugs in Pregnancy. Littleton, MA:Publishing Sciences Group, 1977.
- Marynowski A, Sianozecka E. Comparison of the incidence of congenital malformations in neonates from healthy mothers and from patients treated because of tuberculosis. Ginekol Pol 1972;43:713.
- Jentgens H. Antituberkulose Chimotherapie und Schwangerschaft sabbruch. Prax Klin Pneumol 1973;27:479.
- Ludford J, Doster B, Woolpert SF. Effect of isoniazid on reproduction. Am Rev Respir Dis 1973;108:11704.
- Scheinhorn DJ, Angelillo VA. Antituberculosis therapy in pregnancy; risks to the fetus. West J Med 1977;127:1958.
- Good JT, Iseman MD, Davidson PT, Lakshminarayan S, Sahn SA. Tuberculosis in association with pregnancy. Am J Obstet Gynecol 1981;140:4928.
- Kingdom JCP, Kennedy DH. Tuberculous meningitis in pregnancy. Br J Obstet Gynaecol 1989;96:2335.
- Snider DE Jr, Layde PM, Johnson MW, Lyle MA. Treatment of tuberculosis during pregnancy. Am Rev Respir Dis 1980;122:6579.
- Tuman KJ, Chilcote RR, Gerkow RI, Moohr JW. Mesothelioma in child with prenatal exposure to isoniazid. Lancet 1980;2:362.
- Hammond DC, Silidoff IJ, Robitzek EH. Isoniazid therapy in relation to later occurrence of cancer in adults and in infants. Br Med J 1967;2:7925.
- Eggermont E, Logghe N, Van De Casseye W, Casteels-Van Daele M, Jaeken J, Cosemans J, Verstraete M, Renaer M. Haemorrhagic disease of the newborn in the offspring of rifampicin and isoniazid treated mothers. Acta Paediatr Belg 1976;29:8790.
- Snider DE Jr, Powell KE. Should women taking antituberculosis drugs breast-feed? Arch Intern Med 1984;144:58990.
- Berlin CM Jr, Lee C. Isoniazid and acetylisoniazid disposition in human milk, saliva and plasma. Fed Proc 1979;38:426.
- Vorherr H. Drugs excretion in breast milk. Postgrad Med 1974;56:97104.
- Ricci G, Copaitich T. Modalta di eliminazione dili’isoniazide somministrata per via orale attraverso il latte di donna. Rass Clin Ter 19545;209:534.
- Committee on Drugs, American Academy of Pediatrics. The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:13750.