What are the risks of using Enalapril (Angiotensin-Converting Enzyme (ACE) inhibitor) during breastfeeding?

Risk of Using Enalapril During Breastfeeding

Enalapril is generally safe to use during breastfeeding as it has very low levels in breast milk and poses minimal risk to the breastfed infant. 1

Safety Profile of Enalapril in Breastfeeding

• Enalapril is specifically listed as an ACE inhibitor that is compatible with breastfeeding due to its favorable pharmacokinetics and safety profile 1
• Studies have shown that enalapril has very low levels in breast milk, with minimal transfer to the breastfed infant 1, 2
• The European Society of Cardiology (ESC) and European Society of Hypertension position paper specifically mentions enalapril as one of several ACE inhibitors (along with captopril, benazepril, and quinapril) that have very low levels in breast milk 1
• The likelihood of significant levels of enalapril in a breastfed infant is small, making it a safe option for nursing mothers requiring antihypertensive therapy 1

Specific Considerations for Enalapril Use

• Caution is advised when using enalapril in mothers who are breastfeeding infants during their first month of life due to theoretical concerns about neonatal hypotension 1
• Despite the FDA drug label stating that enalapril has been detected in human breast milk and recommending a decision between discontinuing nursing or discontinuing the medication 3, more recent clinical guidelines support its use during breastfeeding 1, 2
• A systematic review of antihypertensive medications in breast milk found that ACE inhibitors, including enalapril, appear to be safe treatments for hypertension in nursing mothers due to their low milk-to-plasma ratios 4

Recommendations for Clinical Practice

• Enalapril is considered safe during the postpartum period and breastfeeding, with minimal excretion in breast milk 5
• For women with peripartum cardiomyopathy who require ACE inhibitor therapy, enalapril may be particularly suitable due to its safety and favorable pharmacokinetics during lactation 1
• When treating hypertension in breastfeeding women, enalapril is a preferred option compared to beta-blockers with low protein binding, which should be avoided 4
• If a mother requires enalapril for a serious medical condition (such as heart failure or significant hypertension), the benefits of treatment generally outweigh the minimal risks to the breastfed infant 1

Balancing Risks and Benefits

• The risk-benefit assessment should consider that untreated maternal hypertension or heart failure poses greater risks than the minimal exposure of the infant to enalapril through breast milk 1
• While ACE inhibitors are contraindicated during pregnancy due to significant fetal risks 1, 6, these concerns do not apply to breastfeeding due to minimal drug transfer through breast milk 2
• The American Heart Association acknowledges that while breastfeeding is generally not recommended for women with decompensated heart failure requiring significant medical therapy, the risks and benefits for both mother and child need to be carefully balanced 1

In conclusion, current evidence supports the use of enalapril during breastfeeding as a safe option with minimal risk to the infant, particularly when maternal treatment is necessary for conditions like hypertension or heart failure.