What antihypertensives (blood pressure medications) are compatible with lactation (breastfeeding)?

Antihypertensive Medications Compatible with Lactation

Methyldopa, labetalol, propranolol, and enalapril are the most suitable antihypertensive medications for breastfeeding mothers, with enalapril being the preferred ACE inhibitor due to its safety profile and favorable pharmacokinetics. 1

First-Line Options

• Beta-blockers: Propranolol and labetalol are preferred if a beta-blocker is indicated during lactation due to their high protein binding and minimal transfer into breast milk. 1, 2
• Methyldopa: Has a well-established safety record in lactation with no short-term adverse effects reported in breastfed infants. 1
• ACE inhibitors: Enalapril is specifically recommended as the most widely used ACE inhibitor during lactation due to its safety and favorable pharmacokinetics. 1
• Calcium channel blockers: Nifedipine and amlodipine are considered safe during breastfeeding with minimal excretion in breast milk. 1, 3

Medications to Use with Caution or Avoid

• Diuretics: Furosemide, hydrochlorothiazide, and spironolactone may reduce milk production and are generally not preferred in breastfeeding women. 1
• Beta-blockers with low protein binding: Should be avoided as they have higher milk-to-plasma ratios and greater potential for infant exposure. 4
• ARBs (Angiotensin Receptor Blockers): Should be avoided during lactation based on limited safety data. 1

Clinical Approach to Antihypertensive Selection During Lactation

1. For mild hypertension (Stage 1):

   • Consider withholding antihypertensive medication with close blood pressure monitoring if the mother wishes to breastfeed for only a few months. 1
   • Reinstitute therapy after discontinuation of nursing if needed. 1

2. For moderate to severe hypertension requiring treatment:

   • First-line: Methyldopa, labetalol, or propranolol 1
   • Second-line: Enalapril (preferred ACE inhibitor) unless the neonate is premature or has renal failure 1, 5
   • Third-line: Calcium channel blockers like nifedipine or amlodipine 1, 3

Special Considerations

• Postpartum hypertension management: The same therapeutic regimen used during pregnancy can be maintained initially, with early withdrawal of methyldopa when possible. 3

• Monitoring recommendations:

  • Closely monitor breastfed infants of mothers taking antihypertensive agents for potential adverse effects. 1
  • For beta-blockers: Monitor infant heart rate 1
  • For ACE inhibitors: Monitor infant weight 1

• Medication timing: When possible, take medications immediately after breastfeeding or before the infant's longest sleep interval to minimize exposure. 6

Important Caveats

• The amount of medication that enters breast milk depends on maternal serum concentration and pharmacologic properties of the medication. 6

• While ACE inhibitors like enalapril are generally safe during lactation, they should not be used if the infant is premature or has renal failure. 1, 5

• Home blood pressure monitoring is suggested for breastfeeding mothers on antihypertensive therapy. 1

• Antihypertensive medication is usually continued until blood pressure has normalized, which may take days to several weeks postpartum. 1