What medications are safe for a breastfeeding patient with hypercholesterolemia (high total cholesterol)?

Medication Options for Breastfeeding Patients with Hypercholesterolemia

Bile acid sequestrants are the only cholesterol-lowering medications that should be used during breastfeeding for patients with hypercholesterolemia. 1

First-Line Treatment Approach

• Lifestyle modifications should be prioritized as the foundation of treatment during breastfeeding, including heart-healthy diet low in saturated fat (<10% of total calories), increased physical activity, and weight management 1
• Bile acid sequestrants (such as cholestyramine, colestipol, or colesevelam) are the only pharmacological agents recommended during breastfeeding 1
• When using bile acid sequestrants, routine monitoring for malabsorption of fat-soluble vitamins (particularly vitamin K) and folate is necessary 1

Why Bile Acid Sequestrants Are Preferred

• Bile acid sequestrants work locally in the intestine and are not systemically absorbed, making them safe during lactation 1
• These medications do not pass into breast milk in significant amounts 1
• They can effectively reduce LDL cholesterol while posing minimal risk to the breastfed infant 1

Medications to Avoid During Breastfeeding

• Statins (including pravastatin) should be discontinued during breastfeeding as they may decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol that could harm the breastfed infant 2
• Ezetimibe, PCSK9 inhibitors, and other systemically absorbed cholesterol-lowering drugs should be avoided during lactation 1
• Niacin and fibrates have insufficient safety data in breastfeeding and should be avoided 1

Special Considerations

For Severe Hypercholesterolemia (Familial Hypercholesterolemia)

• In women with homozygous familial hypercholesterolemia (HoFH) and established atherosclerotic cardiovascular disease (ASCVD), lipoprotein apheresis should be considered during breastfeeding 1
• For women with severe heterozygous familial hypercholesterolemia (HeFH) with lipoprotein(a) concentration ≥125 nmol/l, lipoprotein apheresis may also be appropriate 1

Timing Considerations

• Ideally, bile acid sequestrants should be initiated 3 months before planned pregnancy and continued throughout pregnancy and lactation 1
• Women who were on statins or other lipid-lowering medications before pregnancy should be counseled about resuming these medications after completing breastfeeding 1

Common Pitfalls to Avoid

• Assuming all cholesterol-lowering medications are contraindicated during breastfeeding (bile acid sequestrants are safe) 1
• Failing to monitor for vitamin deficiencies when using bile acid sequestrants 1
• Discontinuing breastfeeding unnecessarily when hypercholesterolemia treatment is needed 1
• Underestimating the importance of continued treatment for women with familial hypercholesterolemia, as untreated severe hypercholesterolemia poses significant cardiovascular risks 3

Long-term Considerations

• Breastfeeding itself may have beneficial effects on lipid profiles later in life, with studies showing adults who were breastfed having higher HDL cholesterol levels 4
• After completing breastfeeding, patients with hypercholesterolemia should be promptly transitioned to appropriate lipid-lowering therapy based on their cardiovascular risk 3