What medications can be stopped in a pregnant woman with diabetes after pregnancy is confirmed?

Medications to Stop After Pregnancy Confirmed in Women with Diabetes

ACE inhibitors, ARBs, and statins must be discontinued immediately upon pregnancy confirmation, while most oral diabetes medications should be transitioned to insulin, with the exception that metformin and glyburide may be continued if already in use. 1, 2, 3

Medications That MUST Be Stopped Immediately

ACE Inhibitors and Angiotensin Receptor Blockers (ARBs)

• Stop immediately upon pregnancy confirmation or ideally before conception in sexually active women not using reliable contraception 1, 2, 3
• These agents cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, intrauterine growth restriction, and fetal death when exposed during second and third trimesters 1
• First-trimester exposure does not appear to increase congenital malformations after adjusting for confounders, but must still be stopped as soon as possible to avoid second- and third-trimester fetopathy 1, 4
• Switch to: methyldopa, labetalol, long-acting nifedipine, or clonidine for blood pressure control 1, 2, 5

Statins and Other Lipid-Lowering Medications

• Stop all lipid-lowering medications (statins, bempedoic acid, PCSK9 inhibitors, fibrates) at the first pregnancy visit 1, 2
• Statins are pregnancy category X and contraindicated in all sexually active women of childbearing age not using reliable contraception 2, 3
• The teratogenic risk appears low based on available evidence, but data remain limited 1, 6
• Rare exception: Hydrophilic statins like pravastatin may be considered only in high-risk cases (atherosclerotic cardiovascular disease, homozygous familial hypercholesterolemia) through shared decision-making, but this is not standard practice 1

Atenolol

• Stop atenolol specifically if used for hypertension, as it is associated with fetal growth restriction and lower birth weight 3, 5, 7
• Other beta-blockers (particularly labetalol) may be used if necessary 1, 5

Medications That Can Be CONTINUED

Metformin

• May be continued throughout pregnancy if already in use 2, 3
• Does not increase fetal anomalies and may reduce neonatal hypoglycemia and maternal weight gain 2, 3

Glyburide

• May be continued alongside insulin if already in use 2, 3, 8
• More effective than metformin at lowering blood glucose, though with potentially higher treatment failure rates 2
• Should be discontinued at least two weeks before expected delivery date due to risk of prolonged neonatal hypoglycemia (4-10 days) 8

Insulin

• Continue and optimize - insulin is first-line therapy for all women with preexisting diabetes in pregnancy 3, 9
• Insulin requirements drop dramatically (approximately 34% lower than prepregnancy) immediately postpartum with placental delivery 1

Antihypertensive Medication Substitutions

Safe Alternatives for Blood Pressure Control

• First-line options: methyldopa, labetalol, long-acting nifedipine 1, 2, 5
• Additional safe options: clonidine, diltiazem, prazosin 5
• Target blood pressure: 110-135/85 mmHg to balance maternal hypertension risk against fetal growth impairment 1, 2, 5

Diuretics

• Generally not recommended during pregnancy 1
• May be used at lower doses in specific circumstances (chronic kidney disease with reduced GFR) 1

Additional Medication to START

Low-Dose Aspirin

• Start aspirin 100-150 mg daily (or 162 mg, commonly available as 81 mg tablets in the U.S.) at 12-16 weeks gestation to reduce preeclampsia risk 1, 2
• Doses >100 mg are required for effectiveness; 81 mg daily is insufficient 1

Critical Implementation Points

• Timing is crucial: Medication review must occur immediately upon pregnancy confirmation to minimize teratogenic exposure 2
• Contraception counseling: All women with diabetes of childbearing potential should have effective contraception until medications are optimized and glycemic goals achieved (A1C <6.5%, ideally <6%) 2, 3
• Hypoglycemia risk: Insulin sensitivity increases dramatically postpartum, requiring dose adjustments and glucagon availability 1, 9
• Breastfeeding: ACE inhibitors and most diabetes medications can be restarted postpartum during breastfeeding, but glyburide may cause neonatal hypoglycemia if nursing 8, 4