From the Guidelines
Benazepril, captopril, and enalapril are the safest ACE inhibitors to use during breastfeeding, as they have been shown to be safe during lactation. According to the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease 1, these medications can be used in breastfeeding mothers without significant risk to the infant. The safety of these medications is due to their minimal transfer into breast milk and low risk of adverse effects in the nursing infant.
- Key characteristics of these safe ACE inhibitors include:
- Low milk-to-plasma ratio
- Limited oral bioavailability in infants
- Short half-lives, reducing potential exposure to the infant
- When prescribing these medications to breastfeeding mothers, it is recommended to start with lower doses and monitor both maternal response and infant well-being, as with any medication.
- Regular monitoring of the infant for potential side effects such as hypotension, poor feeding, or lethargy is also recommended, although these are rarely observed with the preferred agents.
- It is essential to choose the safest option, such as benazepril, captopril, or enalapril, over other ACE inhibitors with limited safety data during breastfeeding, to minimize potential risks to the infant.
From the FDA Drug Label
Milk of lactating rats contains radioactivity following administration of 14C lisinopril. It is not known whether this drug is excreted in human milk Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from ACE inhibitors, a decision should be made whether to discontinue nursing or discontinue lisinopril, taking into account the importance of the drug to the mother.
The FDA drug label does not answer the question.
From the Research
ACE Inhibitors Safe in Breastfeeding
- The available data suggest that ACE inhibitors appear to be safe treatments for hypertension in nursing mothers, with low milk to plasma (M/P) ratios 2.
- Specific ACE inhibitors that are considered safe during breastfeeding are not explicitly listed in the studies, but the general class of ACE inhibitors is mentioned as having low M/P ratios 2.
- Examples of ACE inhibitors include captopril, enalapril, lisinopril, benazepril, fosinopril, and ramipril, although their safety during breastfeeding is not individually confirmed 3, 4.
Key Considerations
- The evidence for the safety of ACE inhibitors during breastfeeding is limited, and further studies are needed to confirm these findings 2, 5.
- The studies available focus on the general safety of ACE inhibitors during breastfeeding, rather than providing specific guidance on individual medications 2, 6.
- Other factors, such as the mother's health and the baby's health, should be considered when deciding whether to use ACE inhibitors during breastfeeding 6.