Medication Options for Breastfeeding Patients with Hypercholesterolemia

First-Line Treatment Approach

The American College of Cardiology recommends lifestyle modifications, including a heart-healthy diet low in saturated fat (<10% of total calories), increased physical activity, and weight management, as the foundation of treatment during breastfeeding 3, 4
Bile acid sequestrants, such as cholestyramine, colestipol, or colesevelam, are the only pharmacological agents recommended during breastfeeding, as they are not systemically absorbed and do not pass into breast milk in significant amounts 1, 3

Bile acid sequestrants work locally in the intestine, making them safe during lactation, and can effectively reduce LDL cholesterol while posing minimal risk to the breastfed infant 3
The American Heart Association notes that bile acid sequestrants do not decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol that could harm the breastfed infant 1

Ezetimibe, PCSK9 inhibitors, and other systemically absorbed cholesterol-lowering drugs should be avoided during lactation, as they may pose a risk to the breastfed infant 3, 4
Niacin and fibrates have insufficient safety data in breastfeeding and should be avoided, according to the American College of Cardiology 5

Lipoprotein apheresis should be considered during breastfeeding for women with homozygous familial hypercholesterolemia (HoFH) and established atherosclerotic cardiovascular disease (ASCVD), as recommended by the American College of Cardiology 3, 4
For women with severe heterozygous familial hypercholesterolemia (HeFH) with lipoprotein(a) concentration ≥125 nmol/l, lipoprotein apheresis may also be appropriate, according to the European Atherosclerosis Society 3

Ideally, bile acid sequestrants should be initiated 3 months before planned pregnancy and continued throughout pregnancy and lactation, as recommended by the American College of Obstetricians and Gynecologists 3
Women who were on statins or other lipid-lowering medications before pregnancy should be counseled about resuming these medications after completing breastfeeding, according to the American Heart Association 3

Assuming all cholesterol-lowering medications are contraindicated during breastfeeding is incorrect, as bile acid sequestrants are safe, according to the American College of Cardiology 1, 3
Failing to monitor for vitamin deficiencies, particularly vitamin K and folate, when using bile acid sequestrants is a common pitfall, as recommended by the National Institutes of Health 3