What is the recommended treatment for hyperlipidemia in pregnancy?

Treatment of Hyperlipidemia in Pregnancy

Bile acid sequestrants are the only lipid-lowering medications considered safe for use during pregnancy, while statins and other systemically absorbed lipid-lowering drugs should be discontinued at least 3 months before planned conception and during pregnancy. 1, 2

General Management Approach

Pre-Pregnancy Planning

• Women with hyperlipidemia planning pregnancy should:
  • Discontinue statins and other systemically absorbed lipid-lowering medications 3 months before planned conception 1
  • Consider bile acid sequestrants as the primary pharmacological treatment option 2, 1
  • Receive pre-pregnancy counseling before starting any lipid-lowering therapy 1
  • Use effective contraception while on lipid-lowering medications 1

During Pregnancy

• Physiologic changes:
  • Pregnancy naturally causes progressive increases in both LDL-cholesterol and triglyceride levels 1
  • Routine monitoring of lipid levels during pregnancy is not recommended unless results would change management 1, 2

Pharmacological Management

First-line therapy:

• Bile acid sequestrants (e.g., cholestyramine, colestipol):
  • Only lipid-lowering medications considered safe during pregnancy 1
  • Should be initiated ideally before pregnancy 1
  • Require monitoring for malabsorption of fat-soluble vitamins (particularly vitamin K with INR) and folate 2

Contraindicated medications:

• Statins: Should be discontinued at least 3 months before conception 2, 1
• Ezetimibe, PCSK9 inhibitors, bempedoic acid: Should be discontinued when pregnancy is recognized 1
• Inclisiran and lomitapide: Not recommended due to concerns for fetal harm 1

Special Considerations

High-Risk Patients

1. Homozygous Familial Hypercholesterolemia (HoFH):

   • Lipoprotein apheresis should be continued or initiated during pregnancy 2, 1
   • Statin continuation may be considered, particularly after the first trimester if LDL-cholesterol goal is not achieved and apheresis is not available 2
   • Cardiovascular imaging (CT angiography or echocardiography) should be offered before planned pregnancy 2, 1

2. Severe Heterozygous FH (HeFH):

   • Lipoprotein apheresis can be considered for those with LDL-C ≥300 mg/dL 1
   • Cardiovascular imaging should be offered before planned pregnancy for high-risk HeFH 2, 1

3. Severe Hypertriglyceridemia:

   • For women with triglycerides >500 mg/dL: Consider omega-3-fatty acids and strict fat-restricted diet (<20g total fat/day) 3
   • For triglycerides >1000 mg/dL or signs of pancreatitis: Consider plasmapheresis 3
   • Close monitoring in the third trimester for women with pre-pregnancy triglycerides ≥500 mg/dL 1

Unplanned Pregnancy

• If pregnancy is unplanned and the woman is taking lipid-lowering medications:
  • Stop medications immediately upon confirmation of pregnancy 1
  • Reassure that brief exposure to statins or other lipid-lowering therapies is unlikely to harm the fetus 2

Non-Pharmacological Management

• Heart-healthy diet and appropriate physical activity should be prioritized before, during, and after pregnancy 2, 1
• Referral to a registered dietitian for dietary counseling
• Regular monitoring of blood pressure and metabolic factors 1
• Weight management appropriate for pregnancy 1

Monitoring During Pregnancy

• High-risk women should have triglyceride levels checked once every trimester 3
• If fasting triglycerides >250 mg/dL: Implement monthly triglyceride monitoring, screening for gestational diabetes, and strict low-carbohydrate, low-fat diet 3

Post-Pregnancy Care

• Lipid-lowering medications may be resumed after completion of breastfeeding 1
• Continue lifestyle modifications, blood pressure control, and metabolic factor management 1

Caution

While recent research suggests statins may not be as harmful as previously thought 4, current guidelines still recommend against their use during pregnancy except in rare high-risk cases. The decision to use any lipid-lowering therapy during pregnancy should carefully weigh potential benefits against risks, with priority given to maternal and fetal morbidity and mortality outcomes.