What is the appropriate management for a 20-year-old female in her third trimester of pregnancy with a history of familial hyperlipidemia (high cholesterol)?

From the Guidelines

For a 20-year-old female in her third trimester with familial hyperlipidemia, the appropriate management involves discontinuing statins and other lipid-lowering medications during pregnancy and focusing on dietary management, as recommended by the most recent guidelines 1. The management of familial hyperlipidemia during pregnancy is crucial to balance maternal and fetal safety.

Key Considerations

• Discontinuation of statins and other lipid-lowering medications during pregnancy, unless the patient has homozygous familial hypercholesterolemia (HoFH) or clinical atherosclerotic cardiovascular disease (ASCVD), in which case the continued use of statin therapy should be considered 1.
• Dietary management is essential, with a focus on a low-fat diet (less than 30% of calories from fat) and emphasis on fruits, vegetables, whole grains, lean proteins, and avoidance of trans fats.
• Regular monitoring of lipid levels is important, but aggressive treatment is generally deferred until after delivery and completion of breastfeeding.
• Severe hypertriglyceridemia (>1000 mg/dL) may require additional interventions like omega-3 fatty acid supplements or, in extreme cases, plasmapheresis to prevent pancreatitis.

Recommendations

• Bile acid sequestrants should be considered to treat hypercholesterolemia, ideally 3 months before a planned pregnancy, as well as during pregnancy and lactation, with routine monitoring for malabsorption of fat-soluble vitamins and folate 1.
• Lipoprotein apheresis should be continued or initiated during pregnancy in women with HoFH, especially in those with established ASCVD and in whom LDL-cholesterol levels are not at guideline-recommended goal 1.
• After delivery, lipid-lowering medications can be resumed, but statins and most other lipid-lowering drugs should be avoided during breastfeeding. This approach is supported by the most recent guidelines from the International Atherosclerosis Society 1 and is consistent with the recommendations from other studies 1.

From the FDA Drug Label

1. 1 Pregnancy Risk Summary Discontinue atorvastatin calcium when pregnancy is recognized. Alternatively, consider the ongoing therapeutic needs of the individual patient Atorvastatin calcium decreases synthesis of cholesterol and possibly other biologically active substances derived from cholesterol; therefore, atorvastatin calcium may cause fetal harm when administered to pregnant patients based on the mechanism of action

The appropriate management for a 20-year-old female in her third trimester of pregnancy with a history of familial hyperlipidemia is to discontinue statins.

• The drug label recommends discontinuing atorvastatin calcium when pregnancy is recognized due to the potential risk of fetal harm.
• Treatment of hyperlipidemia is not generally necessary during pregnancy, and discontinuation of lipid-lowering drugs during pregnancy should have little impact on the outcome of long-term therapy of primary hyperlipidemia for most patients 2.

From the Research

Management of Familial Hyperlipidemia in Pregnancy

• The management of familial hyperlipidemia in a 20-year-old female in her third trimester of pregnancy requires careful consideration of the potential risks and benefits of treatment 3.
• Statins, which are commonly used to lower LDL cholesterol levels, are generally avoided in pregnancy due to potential fetal risks 4.
• Other treatment options, such as ezetimibe, bile acid sequestrants, niacin, lomitapide, mipomersen, and low-density lipoprotein (LDL) apheresis, may be considered, but their safety and efficacy in pregnancy are not well established 3.
• Lifestyle modifications, such as dietary changes and increased physical activity, may be recommended to help manage hyperlipidemia during pregnancy.

Considerations for Hypertriglyceridemia in Pregnancy

• Hypertriglyceridemia is a common condition in pregnancy, and elevated triglyceride levels have been linked to an increased risk of cardiovascular events and acute pancreatitis 5, 6.
• Treatment options for hypertriglyceridemia, such as fibrates, niacin, and long-chain omega-3 fatty acids, may be considered, but their safety and efficacy in pregnancy are not well established 5, 7, 6.
• The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are commonly used to treat pain and inflammation, should be avoided in the third trimester of pregnancy due to potential fetal risks 4.

Treatment Priorities

• The primary goal of treatment for familial hyperlipidemia in pregnancy is to reduce the risk of cardiovascular events and other complications 3, 7.
• The choice of treatment should be individualized based on the patient's specific needs and medical history, and should take into account the potential risks and benefits of each treatment option 3, 7.
• Lifestyle modifications, such as dietary changes and increased physical activity, should be recommended as first-line treatment for hyperlipidemia in pregnancy, with pharmacological treatment considered only if necessary 7.