From the Guidelines
ACE inhibitors are not contraindicated in lactation, but ARBs are generally not recommended due to limited safety data. According to the most recent and highest quality study 1, ACE inhibitors such as enalapril and captopril are considered compatible with breastfeeding, with minimal transfer into breast milk and no reported adverse effects in nursing infants. In contrast, ARBs are not recommended due to limited safety data and potential effects on the developing infant's renin-angiotensin system.
Key Considerations
- ACE inhibitors (e.g., enalapril, captopril) are preferred over ARBs during lactation due to their extensive safety data and minimal transfer into breast milk.
- Alternative antihypertensives with well-established safety in lactation include labetalol, nifedipine, and methyldopa.
- The decision to use these medications should balance maternal benefit against potential risk, with consideration of monitoring the infant for hypotension, poor feeding, or lethargy if these medications are used.
- Diuretics (e.g., furosemide) can suppress lactation, but may be used with caution and close monitoring of the infant.
Supporting Evidence
- A 2022 study by the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines 1 recommends the use of ACE inhibitors (e.g., enalapril, captopril) during lactation, citing their minimal transfer into breast milk and no reported adverse effects in nursing infants.
- A 2020 study by the European Society of Cardiology 1 also supports the use of ACE inhibitors during lactation, noting that they are generally considered safe and effective for the treatment of hypertension in breastfeeding women.
- A 2011 study by the European Society of Cardiology 1 provides additional evidence for the safety of ACE inhibitors during lactation, reporting that some ACE inhibitors (e.g., benazepril, captopril, enalapril) have been sufficiently tested in breastfeeding women and are considered safe for use.
From the Research
ACE Inhibitors and ARBs in Lactation
- There is no direct evidence in the provided studies to suggest that ACE inhibitors and ARBs are contraindicated in lactation 2, 3, 4, 5, 6.
- The studies primarily focus on the comparison of ACE inhibitors and ARBs in terms of their efficacy and safety in patients with hypertension, heart failure, and other cardiovascular conditions.
- None of the studies mention lactation as a consideration for the use of ACE inhibitors and ARBs.
Safety and Efficacy of ACE Inhibitors and ARBs
- A study published in 2014 found that ACE inhibitors and ARBs have similar effects on total mortality and cardiovascular events, but ARBs may have a slightly lower incidence of withdrawals due to adverse effects 2.
- Another study published in 2009 suggested that the combination of an ACE inhibitor and an ARB may lead to worse renal outcomes 3.
- A 2015 review discussed the use of ACE inhibitors and ARBs in patients with end-stage renal disease, highlighting the importance of individualizing therapy and considering patient comorbidities 4.
Clinical Guidelines and Recommendations
- A 2021 study examined national trends in the use of ACE inhibitors and ARBs among hypertensive US adults with albuminuria, finding that there was no consistent trend in guideline-concordant utilization over time 5.
- A 2005 review compared the effectiveness of ARBs and ACE inhibitors in preventing death and myocardial infarction in high-risk populations, concluding that ACE inhibitors have been definitively shown to prevent these outcomes, while ARBs have not 6.