What allergy medications are safe to use during pregnancy and breastfeeding?

Safe Allergy Medications During Pregnancy and Breastfeeding

For pregnant and breastfeeding women with allergies, second-generation antihistamines like cetirizine and loratadine are the safest options, while nasal saline rinses and intranasal corticosteroids can be used for nasal symptoms. 1

Antihistamines

Oral Antihistamines

• Second-generation antihistamines (cetirizine, loratadine) are preferred during pregnancy due to their safety profile and FDA Pregnancy Category B classification 2, 1
• First-generation antihistamines (chlorphenamine/chlorpheniramine) have a longer safety record but should be avoided due to their sedative and anticholinergic properties 2, 3
• All antihistamines should ideally be avoided during the first trimester if possible, though none have been proven teratogenic in humans 2
• All antihistamines are considered safe during breastfeeding as minimal amounts are excreted in breast milk 3

Intranasal Antihistamines

• Should be avoided during pregnancy 1

Nasal Treatments

Intranasal Corticosteroids

• Considered safe and effective for allergic rhinitis during pregnancy 4, 5
• Budesonide has the most safety data and is the preferred intranasal corticosteroid during pregnancy 1, 6
• Beclomethasone is also considered safe based on data from asthma treatment during pregnancy 4

Saline Nasal Rinses

• First-line therapy for nasal symptoms during pregnancy 2
• Safe and effective with no risk to the fetus 2

Decongestants

• Oral decongestants should not be used during pregnancy, especially in the first trimester 2
• May increase risk of fetal gastroschisis and contribute to maternal hypertension 2
• Intranasal decongestants have limited safety data and should be used with caution 4

Leukotriene Modifiers

• Montelukast (pregnancy category B) can be considered for recalcitrant asthma during pregnancy if the patient has shown a favorable response prior to pregnancy 2
• About 1% of montelukast passes into breast milk, but the benefits of breastfeeding generally outweigh this minimal exposure 2
• Consider breastfeeding prior to taking montelukast to further limit infant exposure 2
• 5-lipoxygenase inhibitors (zileuton) should be avoided during both pregnancy and breastfeeding 2, 1

Immunotherapy

• Continuation of established allergen immunotherapy is considered safe during pregnancy 2, 5
• Initiation or dose escalation of immunotherapy should be avoided during pregnancy due to risk of anaphylaxis 2
• Sublingual immunotherapy is generally contraindicated during pregnancy 2

Practical Recommendations

• For mild allergic rhinitis: saline nasal rinses as first-line therapy 2
• For moderate symptoms: add intranasal corticosteroids (preferably budesonide) 1, 5
• For systemic symptoms: add cetirizine or loratadine 2, 1
• If breastfeeding: take medications immediately after feeding to minimize infant exposure 2
• Avoid combination products containing decongestants 2

Important Considerations

• The benefit of treating allergic symptoms during pregnancy often outweighs potential risks, as poorly controlled allergies and rhinitis can affect quality of life and sleep 5
• FDA drug labeling for many allergy medications states they should be avoided during pregnancy due to lack of comprehensive safety data, but clinical experience and observational studies generally support their safety 4
• Always use the lowest effective dose for the shortest duration needed 2