From the Guidelines
Managing hypercholesterolemia during lactation requires a cautious approach. The primary strategy is to optimize lifestyle and non-cholesterol risk factors, such as diet, physical activity, and psychological well-being, as recommended in 1.
Key Considerations
- Discontinuation of statins and other systemically absorbed cholesterol-lowering drugs is recommended during lactation, unless the woman has homozygous familial hypercholesterolaemia (HoFH) and clinical atherosclerotic cardiovascular disease (ASCVD), in which case the continued use of statin therapy may be considered 1.
- Bile acid sequestrants may be considered to treat hypercholesterolaemia during lactation, with routine monitoring for malabsorption of fat-soluble vitamins 1.
- Lipoprotein apheresis may be continued or initiated during lactation in women with HoFH, especially those with established ASCVD and elevated LDL-cholesterol levels 1.
Important Recommendations
- Pre-pregnancy counselling should be offered to all women with familial hypercholesterolaemia (FH) before starting a statin, ezetimibe, PCSK9 inhibitor, or other lipid-modifying therapies 1.
- Assessment of ASCVD risk should be performed in women with HoFH or high-risk heterozygous familial hypercholesterolaemia (HeFH) before a planned pregnancy 1.
- Reinforcement of heart-healthy behaviours should be prioritized before, during, and after pregnancy and breastfeeding 1.
From the Research
Strategies for Managing Hypercholesterolemia during Lactation
- Non-pharmacologic strategies, such as lifestyle interventions, form the backbone of cardiovascular disease (CVD) prevention 2
- Pharmacologic lipid-lowering therapies during lactation are limited by safety concerns, and women are often advised to stop lipid-lowering drugs until the end of lactation 3
- The effect of exclusive lactation on lipid levels has been investigated, and serum total cholesterol concentrations have been found to decrease during lactation, with a mean decrement of 0.80 mmol/L from delivery to 2 months of lactation and 0.55 mmol/L from 2 to 6 months of lactation 4
- Cholesterol content in breast milk is highly variable and depends on individual factors, such as mother's diet, age, and lactation stage 5
Lipid Changes during Lactation
- Serum total cholesterol concentrations decrease during lactation, with a mean value of 4.8 +/- 0.1 mmol/L at 6 months of exclusive lactation 4
- Cholesterol content in breast milk decreases from 31 mg/100cm(3) in colostrum to 16 mg/100 cm(3) in mature milk 5
- Triglyceride and LDL cholesterol levels also decrease during lactation 4
Considerations for Women with Hypercholesterolemia during Lactation
- Women with familial hypercholesterolemia should discontinue statins during pregnancy and lactation due to safety concerns 3
- Lifestyle interventions and non-pharmacologic strategies should be prioritized for managing hypercholesterolemia during lactation 2
- More research is needed to understand the effects of lipid-lowering therapies during lactation and to develop safe and effective treatment options for women with hypercholesterolemia 2