Is Levocetrizine (levocetrizine) safe to use during pregnancy?

Levocetirizine in Pregnancy

Avoid levocetirizine during pregnancy, especially in the first trimester, and use cetirizine or loratadine instead, which have extensive safety data and are the preferred second-generation antihistamines for pregnant women. 1, 2

Why Levocetirizine Should Be Avoided

• Limited pregnancy data exists for levocetirizine, making it a less desirable option compared to its parent compound cetirizine, according to major allergy societies 1
• The FDA drug label for levocetirizine advises pregnant women to "ask a health professional before use," reflecting the lack of robust safety data 3
• Levocetirizine should be avoided during the first trimester if possible due to insufficient safety data specifically for this medication 4

Preferred Alternatives: Cetirizine and Loratadine

• Cetirizine is the preferred second-generation antihistamine for pregnancy based on extensive safety data from large birth registries, case-control studies, and cohort studies 1, 2
• The American College of Obstetricians and Gynecologists recommends cetirizine as a preferred option, with benefits of symptom control outweighing theoretical risks 1
• Cetirizine and loratadine are classified as FDA Pregnancy Category B drugs, meaning animal studies show no fetal risk, though well-controlled human studies are limited 1, 2
• Second-generation antihistamines in general do not show a significant increase in congenital malformations when used during the first trimester 1

Clinical Decision-Making Algorithm

Step 1: First Trimester Considerations

• The first trimester is the most critical period when organogenesis occurs and medication-related congenital malformations are most likely 1, 4
• Consider non-pharmacological approaches first, such as saline nasal rinses, before adding antihistamines 1
• If antihistamine therapy is necessary, choose cetirizine or loratadine over levocetirizine 4

Step 2: Second and Third Trimester Management

• Cetirizine remains the preferred choice throughout pregnancy 1, 5
• Use the lowest effective dose to minimize theoretical fetal exposure 2
• For more severe symptoms, combine cetirizine with intranasal corticosteroids, particularly budesonide, which has strong safety data 1, 6

Step 3: Special Circumstances

• If a patient has had a uniquely favorable response to levocetirizine before pregnancy and other options have failed, discuss the limited safety data with the patient using shared decision-making 1
• In patients with renal impairment, halve the cetirizine dose 2
• Avoid cetirizine in severe renal impairment (creatinine clearance <10 mL/min) 2

Medications to Avoid

• Do not use oral decongestants during the first trimester due to conflicting reports of associations with gastroschisis and small intestinal atresia 1, 4
• Avoid diphenhydramine if possible due to lingering concerns about cleft palate association 1, 2
• Hydroxyzine is specifically contraindicated in early pregnancy based on animal data showing potential risks 2, 4
• First-generation antihistamines should generally be avoided due to sedative and anticholinergic properties 1

Key Clinical Principle

The fundamental principle is that controlled maternal allergic disease is safer for the fetus than uncontrolled disease, making cetirizine an acceptable and preferred choice when antihistamine therapy is medically necessary during pregnancy 2, 6

Common Pitfalls to Avoid

• Do not assume all antihistamines have equivalent safety profiles during pregnancy—they do not 4
• Do not continue levocetirizine simply because the patient was taking it before pregnancy; switch to cetirizine, which has the same therapeutic effect but better safety documentation 1
• Do not combine decongestants with acetaminophen or salicylates, as this may increase risk of malformations 4
• Avoid unjustified hesitation in treating pregnant women, as suboptimal treatment of maternal allergic disease may be more harmful to the unborn child than appropriate medication use 5