What are the recommendations for cholesterol medications, specifically statins like Crestor (rosuvastatin), during pregnancy in a 29-year-old female with hyperlipidemia and elevated Lipoprotein(a) [Lp(a)], and a family history of myocardial infarction (MI)?

From the Guidelines

For a 29-year-old female with hyperlipidemia, elevated Lp(a) in the upper 200s, family history of early MI, and currently on Crestor who is considering pregnancy, statins should be discontinued before conception and throughout pregnancy, unless the patient is at very high risk of heart attack or stroke, in which case the benefits and risks of continuing statin therapy should be carefully considered with her healthcare provider. The patient's history of hyperlipidemia and elevated Lp(a) puts her at increased risk of cardiovascular disease, and her family history of early MI further increases this risk 1. However, the potential risks of statin use during pregnancy, including teratogenic effects and interference with fetal cholesterol synthesis, must be carefully weighed against the potential benefits of continued therapy 1.

Management During Pregnancy

During pregnancy, management should focus on non-pharmacological approaches, including:

• A heart-healthy diet
• Regular physical activity as tolerated
• Weight management For patients with very high cardiovascular risk, bile acid sequestrants like cholestyramine or colestipol may be considered as they are not systemically absorbed 1. Close monitoring of lipid levels is recommended during pregnancy, though some elevation is expected as part of normal physiological changes.

Postpartum Management

Postpartum, statins should be avoided during breastfeeding, but can be resumed once breastfeeding is completed 1. The patient should have a cardiovascular risk reassessment 3-6 months after delivery to determine appropriate long-term lipid management. It is also important to note that recent large observational studies have not demonstrated evidence of harm to mother or fetus with statin use, and hydrophilic statins like pravastatin may be associated with less fetal harm than lipophilic statins 1.

Considerations for High-Risk Patients

For patients who are at very high risk of heart attack or stroke, such as those with homozygous familial hypercholesterolemia or clinical ASCVD, the benefits of continued statin therapy during pregnancy may outweigh the risks, and this decision should be made on a case-by-case basis with careful consideration of the individual patient's circumstances 1.

From the FDA Drug Label

Pregnancy:May cause fetal harm. The FDA drug label does not answer the question.

From the Research

Cholesterol Medications During Pregnancy

• The patient is currently on Crestor (a statin) and is considering pregnancy.
• According to the available evidence, there is no direct information on the use of cholesterol medications during pregnancy 2, 3, 4, 5, 6.
• However, it is known that statins are generally contraindicated during pregnancy due to the potential risk of harming the fetus.
• The patient's history of hyperlipidemia and elevated lipoprotein(a) levels, as well as her family history of myocardial infarction, suggest that alternative treatments may be necessary during pregnancy.
• Some studies suggest that non-statin therapies, such as bile acid sequestrants and ezetimibe, may be effective in lowering LDL-C levels 3, 4, 5, 6.
• However, the safety and efficacy of these medications during pregnancy are not well established, and more research is needed to determine the best course of treatment for pregnant women with hyperlipidemia.

Alternative Treatment Options

• Bile acid sequestrants may be a viable alternative to statins for lowering LDL-C levels, especially in patients who are intolerant to statins or require additional LDL-C reduction 5.
• Ezetimibe has also been shown to be effective in lowering LDL-C levels and may be considered as an alternative to statins during pregnancy 3, 4, 6.
• However, the use of these medications during pregnancy should be carefully considered and monitored by a healthcare provider due to the potential risks and lack of established safety data.

Considerations for Pregnant Women with Hyperlipidemia

• Pregnant women with hyperlipidemia should be closely monitored by a healthcare provider to manage their condition and prevent potential complications.
• Lifestyle modifications, such as diet and exercise, may be recommended to help manage hyperlipidemia during pregnancy.
• The use of cholesterol medications during pregnancy should be carefully considered and individualized based on the patient's specific needs and medical history.