Cholesterol Medications During Pregnancy
Bile acid sequestrants are the only cholesterol-lowering medications recommended during pregnancy, while statins and other lipid-lowering therapies should generally be discontinued before conception. 1, 2, 3
General Recommendations for Cholesterol Management During Pregnancy
- Women taking statins for primary prevention should discontinue therapy at least 1 month and preferably 3 months before attempted conception, or immediately if already pregnant 1, 2
- Women of childbearing age who are treated with statin therapy should use reliable contraception 1
- Bile acid sequestrants (cholestyramine, colestipol, colesevelam) are the only lipid-lowering medications considered safe during pregnancy as they are not systemically absorbed 3, 4
- Pregnant patients managed with bile acid sequestrants should be monitored for vitamin K deficiency 1, 3
- Lipid-lowering therapy may be resumed after completion of breastfeeding 1, 2
Special Considerations for High-Risk Patients
Very High-Risk Patients Who May Consider Continuing Statins
- Patients with homozygous familial hypercholesterolemia (HoFH) 1, 2, 5
- Patients with established clinical atherosclerotic cardiovascular disease (ASCVD) at very high risk for heart attack or stroke 1, 2
- For these patients, the FDA has removed the absolute contraindication against statin use in pregnancy, allowing for individual risk-benefit assessment 1
Management Options for High-Risk Patients
- Lipoprotein apheresis should be considered during pregnancy for women with HoFH and established ASCVD 3, 5
- For women with severe heterozygous familial hypercholesterolemia (HeFH) with elevated lipoprotein(a), lipoprotein apheresis may also be appropriate 3
- Pravastatin may be safer than other statins if statin therapy is deemed necessary during pregnancy 6
Other Lipid-Lowering Medications in Pregnancy
- Ezetimibe should only be used if potential benefit justifies the risk to the fetus; there are no adequate studies in pregnant women 1
- Bempedoic acid should be discontinued when pregnancy is recognized unless benefits outweigh potential risks 1
- PCSK9 inhibitors (evolocumab, alirocumab) and inclisiran lack sufficient safety data for use during pregnancy 4
- Fibrates and niacin have insufficient safety data in pregnancy and should be avoided 3
Monitoring During Pregnancy
- All pregnant women should be monitored for significant elevations in LDL-C and triglycerides during pregnancy 1, 2
- A progressive rise in both LDL-C and triglycerides is physiologic during pregnancy 1
- Intensive lifestyle modifications should be recommended for all pregnant women with lipid disorders 1, 2, 3
- Referral to a lipid specialist is strongly recommended for pregnant women with severe hyperlipidemia 1
Common Pitfalls to Avoid
- Failing to discontinue statins before planned pregnancy in women taking them for primary prevention 1, 2
- Not providing adequate contraception counseling to women of childbearing age on statin therapy 1
- Overlooking the need to monitor for vitamin deficiencies when using bile acid sequestrants during pregnancy 3
- Assuming all cholesterol-lowering medications are equally harmful during pregnancy, when bile acid sequestrants are considered safe 3, 4