LDL-Lowering Medication During Breastfeeding
Bile acid sequestrants (cholestyramine, colestipol, or colesevelam) are the only lipid-lowering medications approved and recommended for use during breastfeeding, as they are not systemically absorbed and do not enter breast milk. 1
Why Bile Acid Sequestrants Are the Preferred Choice
Bile acid sequestrants work by binding cholesterol in the intestine and are not absorbed into the maternal bloodstream, which means they cannot pass into breast milk and pose no risk to the nursing infant. 1 With your LDL of 191 mg/dL, you meet the threshold for pharmacotherapy (LDL ≥190 mg/dL warrants treatment regardless of other risk factors). 1
The three available options are:
- Cholestyramine 8-12 g daily 1
- Colestipol 10-12 g daily 1
- Colesevelam 3.75 g daily (better tolerated with fewer gastrointestinal side effects) 1
These agents typically reduce LDL-C by 15-20% when used as monotherapy. 1
Why Statins Are Contraindicated
Statins are absolutely contraindicated during breastfeeding. 1 Although the FDA label for ezetimibe states "it is not known if ezetimibe passes into breast milk" and advises that "you and your healthcare provider should decide the best way to feed your baby if you take ezetimibe tablets," 2 the lack of safety data means this medication should be avoided during lactation. 3
The fundamental principle when prescribing medications to lactating mothers is to choose drugs that have been studied, are minimally released into maternal milk, and pose no apparent risk to infant health. 4 Statins do not meet these criteria.
Alternative Consideration: Ezetimibe
Ezetimibe may be considered if bile acid sequestrants are not tolerated or ineffective, though data on safety during breastfeeding are limited. 2, 3 Ezetimibe has minimal systemic absorption (similar to bile acid sequestrants in this regard) and reduces LDL-C by 15-20%. 5 A recent review suggests that ezetimibe "might be considered if benefits outweigh the potential risk" during lactation. 3
However, the FDA label explicitly states uncertainty about breast milk excretion, 2 making bile acid sequestrants the safer first-line choice.
Practical Implementation
Start with colesevelam 3.75 g daily (taken as tablets with meals), as it has the best tolerability profile among bile acid sequestrants. 1 Common side effects include constipation, bloating, and gastrointestinal discomfort, but these are generally manageable. 1
Important timing consideration: If you need to take other medications, bile acid sequestrants can interfere with their absorption. Take other medications at least 2 hours before or 4 hours after the bile acid sequestrant. 2
Concurrent Lifestyle Modifications
While on medication, continue aggressive lifestyle modifications: 1
- Reduce saturated fat to <7% of total calories
- Limit dietary cholesterol to <200 mg/day
- Eliminate trans fats to <1% of caloric intake
- Add 10-25 g/day of soluble fiber
- Include 2 g/day of plant sterols/stanols
- Engage in at least 30 minutes of moderate exercise most days
Pregnant and lactating women should limit fish intake to minimize methylmercury exposure, 1 but omega-3 supplementation with purified EPA/DHA can be considered as an alternative.
Monitoring
Recheck your lipid panel 6-12 weeks after starting therapy to assess response. 6 Your goal should be LDL-C <100 mg/dL. 1, 6
Critical Caveat
Never discontinue breastfeeding unnecessarily due to medication concerns. 7 The overwhelming evidence shows breastfeeding is the most healthful form of nutrition for infants and should be strongly encouraged. 7 Bile acid sequestrants allow you to treat your hyperlipidemia safely while continuing to breastfeed without risk to your infant.