What alternative medication can be used to lower cholesterol and triglycerides in a lactating woman, considering atorvastatin (Lipitor) is not safe for breastfeeding?

Safe Cholesterol and Triglyceride-Lowering Medications During Breastfeeding

Bile acid sequestrants (cholestyramine, colestipol, or colesevelam) are the only recommended pharmacological agents for lowering cholesterol and triglycerides during breastfeeding, as they work locally in the intestine and are not systemically absorbed into breast milk. 1, 2

Why Bile Acid Sequestrants Are the Preferred Choice

• Bile acid sequestrants bind bile acids in the intestine, preventing their reabsorption, which forces the liver to use cholesterol to produce new bile acids, thereby lowering LDL cholesterol by approximately 10-27% depending on the agent and dose. 2

• These medications pose minimal risk to the breastfed infant because they are not absorbed systemically and do not pass into breast milk in significant amounts. 1

• Cholestyramine provides approximately 10-20% LDL cholesterol reduction, colestipol provides 22-27% reduction at doses of 10-15 g/day, and colesevelam provides approximately 15% reduction at 3.75 g daily. 2

Specific Dosing and Administration

• Colesevelam should be dosed as 6 tablets (3.75 g) orally once daily or 3 tablets twice daily with meals. 2

• All other medications must be administered at least 4 hours before or after bile acid sequestrants to prevent binding and reduced absorption, including oral contraceptives, thyroid replacement therapy, cyclosporine, phenytoin, and sulfonylureas. 2

Critical Monitoring Requirements

• Monitor for vitamin K deficiency and other fat-soluble vitamin deficiencies (A, D, E, K) as well as folate, since bile acid sequestrants interfere with their absorption. 1, 2

• Administer oral vitamin supplements at least 4 hours before or after the bile acid sequestrant to prevent binding and malabsorption. 2

Medications That Must Be Avoided During Breastfeeding

• All statins (including atorvastatin, simvastatin, rosuvastatin, pravastatin) are contraindicated during breastfeeding due to insufficient safety data. 2

• Ezetimibe, PCSK9 inhibitors (alirocumab, evolocumab), bempedoic acid, fibrates (fenofibrate, gemfibrozil), and niacin should all be avoided during lactation due to insufficient safety data or potential risk to the breastfed infant. 1, 2

For Elevated Triglycerides Specifically

• If triglycerides are moderately elevated (150-499 mg/dL), lifestyle modifications including weight loss, increased physical activity, a heart-healthy diet low in saturated fat (<10% of total calories), and alcohol abstinence should be the foundation of treatment. 3, 1, 2

• Bile acid sequestrants can increase triglyceride concentrations, so they should be used cautiously in patients with baseline hypertriglyceridemia. 3

• For severe hypertriglyceridemia (≥500 mg/dL) during breastfeeding, dietary fat restriction and alcohol abstinence are essential to prevent acute pancreatitis, but pharmacological options are extremely limited. 3

• Fibrates are the drugs of choice for severe hypertriglyceridemia in non-breastfeeding patients, and prescription omega-3 fatty acids (2-4 g/day) can be added if triglycerides remain elevated, but both lack safety data during lactation. 3

Special Considerations for High-Risk Patients

• For women with homozygous familial hypercholesterolemia (HoFH) and established atherosclerotic cardiovascular disease (ASCVD), lipoprotein apheresis should be considered during breastfeeding as a non-pharmacological intervention. 1

• For women with severe heterozygous familial hypercholesterolemia (HeFH) with lipoprotein(a) concentration ≥125 nmol/L, lipoprotein apheresis may also be appropriate. 1

Common Pitfalls to Avoid

• Do not assume all cholesterol-lowering medications are contraindicated during breastfeeding—bile acid sequestrants are safe and effective. 1, 2

• Do not fail to monitor for vitamin deficiencies (particularly vitamin K and folate) when using bile acid sequestrants, as this can lead to serious complications. 1, 2

• Do not administer other medications simultaneously with bile acid sequestrants without proper timing (4-hour separation), as this will reduce their effectiveness. 2

When to Resume Other Lipid-Lowering Medications

• Women who were on statins or other lipid-lowering medications before pregnancy should be counseled about resuming these medications after completing breastfeeding. 1

• Lipid-lowering therapy may be resumed after completion of breastfeeding, allowing for more aggressive pharmacological management if needed. 4