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| I have a patient who has just been told by her physician she has high cholesterol. Her doctor is encouraging her to consider weening to start drug therapy. Is there any information about any lipid lowering agents(lopid, niacin or hmg coreductase inhib ie lipitor, zocor, pravachol) and breastfeeding. Thank you in advance. |
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Tara:
There are no data on any of the anticholesterol products as yet that I have seen. "High" cholesterol is relative. If her levels are 200 to 300, I would not be overly concerned that these levels would be a problem for her to breastfeed for a year or two.
If the levels are much much higher, then a briefer breastfeeding could probably be undertaken without a major risk to the mom.
But I would not at this time use the HMG CoA reductase inhibitors (Lipitor, Zocor, Pravachol, etc) until we have more data on their transfer to the infant. Infants need lots of cholesterol early on to sustain brain growth. Any medication that could drastically reduce cholesterol production in infants could be detremental.
Tom Hale, Ph.D.
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A few points that this mom might want to discuss with her physician:
1. Does she have high *total* cholesterol - or a high *total/HDL ratio*? To put it simply, total cholesterol is made up of LDL (low density lipoprotein, the "bad stuff") and HDL (high density lipoprotein, the "good stuff.") High total cholesterol is only a problem when it is high because LDL is high. If the total cholesterol is high because HDL is high and the LDL isn't, it is *not* a problem. (I should point out that we calculate the total/HDL ratio in my area to assess risk, in which case lower is better, but some areas use the HDL/total ratio, in which case higher is better.)
2. Breastfeeding in and of itself probably acts to improve the lipid profile (see below.)
3. You say the mom has "just been told." The basis of cholesterol control is a good diet - which sometimes will fix the problem all by itself. Has there been an adequate trial of dietary therapy - you know, lots of fruits and vegies and whole grains and fish and (if tolerated) low-fat dairy and modest portions of lower-fat meats and poultry and swearing off the fatty oily junk food? (Except, of course, for really good chocolate occasionally - cocoa fat is lipid-neutral!)
4. No problem with low thyroid? (Post partum hypothyroidism is really common and hypothyroidism is sometimes first recognized because it puts up LDL cholesterol.)
Hope this is helpful -
Gillian Arsenault MD IBCLC
Info from the literature:
I did a search at http://www.biomednet.com (search term (breastfeeding OR lactation) AND cholesterol - by root of words) and selected studies that looked at breastfeeding humans and lipid profile in the mothers. (Abstracts pasted in below.) The abstracts from these studies suggest that breastfeeding is linked to a better lipid profile, and that things get *worse* when breastfeeding stops.
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Serum cholesterol and lipoprotein concentrations in mothers during and after prolonged exclusive lactation.
Kallio MJ, Siimes MA, Perheentupa J, Salmenperä L, Miettinen TA
Metabolism 1992 Dec 41(12):1327-30
Abstract
The effect of exclusive lactation on lipid levels was investigated by evaluating serum concentrations of total and lipoprotein cholesterol, triglyceride (TG), and apoprotein (apo) B in mothers during and after exclusive, prolonged lactation. Serum total cholesterol concentrations were measured at delivery (n = 195), at 2 (n = 165), 6 (n = 119), 9 (n = 74), and 12 months (n = 32) of lactation, and 2 months (n = 27) after ending this exclusive lactation. In a subgroup of 34 mothers, serum levels of very-low-density lipoprotein (VLDL), low-density lipoprotein (LDL), high-density lipoprotein 2 (HDL2), HDL3, and LDL apo B were determined at 2, 6, 9, and 12 months of lactation.
The mean value of serum total cholesterol concentrations decreased from 6.2 +/- 0.12 (SEM; n = 195) at delivery to 4.8 +/- 0.1 mmol/L (n = 116) at 6 months of exclusive lactation (P < .001). The average decrement in total cholesterol level was 0.80 mmol/L (P < .001) from delivery to 2 months of lactation and 0.55 mmol/L (P < .001) from 2 to 6 months of lactation, and levels were stable thereafter. In the 27 mothers who were exclusively breast-feeding their infants at 9 months of lactation and whose serum cholesterol levels were measured 2 months after the end of lactation, cholesterol levels increased rapidly to 5.7 +/- 0.21 mmol/L (P = .001). In the subgroup of 34 mothers who were examined more closely, the course just described was also true for serum TG, LDL and VLDL cholesterol, and LDL apo B levels.(ABSTRACT TRUNCATED AT 250 WORDS)
Author Address
Children's Hospital, University of Helsinki, Finland.
Effects of pregnancy, postpartum lactation, and oral contraceptive use on the lipoprotein cholesterol/triglyceride ratio.
Knopp RH, Bergelin RO, Wahl PW, Walden CE
Metabolism 1985 Oct 34(10):893-9
Abstract
Lipoprotein cholesterol/triglyceride ratio changes have been observed previously with sex hormone use. To determine if the lipoprotein cholesterol/triglyceride ratio is similarly changed by pregnancy and postpartum lactation, we examined pregnant subjects at 36 weeks gestation and the same women at 6 weeks postpartum and compared them to age-matched, nonpregnant women using or not using oral contraceptives. The cholesterol/triglyceride ratios were examined as means and medians and as curvilinear functions of increasing triglyceride concentration. Median ratios did not predict all ratio changes identified graphically. At very-low-density lipoprotein (VLDL) triglyceride concentrations below 40 mg/dL, the VLDL ratio is less than control in oral contraceptive users and further reduced in pregnant women. Above triglyceride concentrations of 40-60 mg/dL, the curves in the three groups are indistinguishable. No effect of lactation is observed. The low-density lipoprotein (LDL) cholesterol/triglyceride ratio is comparably lower in pregnant subjects and oral contraceptive users at all concentrations of lipoprotein triglyceride and again there is no effect of lactation. In high-density lipoprotein (HDL), there is no effect of either pregnancy or oral contraceptive use on the cholesterol/triglyceride ratio, while it is significantly higher with lactation. Postpartum decreases in the VLDL and LDL cholesterol/triglyceride ratio are seen at all lipoprotein concentrations independent of lactation. We conclude that triglyceride enriches VLDL at low concentrations and LDL at all concentrations in pregnancy and with oral contraceptive use, suggesting a common, hormonal mechanism. HDL is enriched with cholesterol during postpartum lactation, consistent with decreased transfer of cholesterol to other lipoproteins.(ABSTRACT TRUNCATED AT 250 WORDS)
Hyperlipidaemia during normal pregnancy, parturition and lactation.
Qureshi IA, Xi XR, Limbu YR, Bin HY, Chen MI
Ann Acad Med Singapore 1999 Mar 28(2):217-21
Abstract
Excessive accumulation of one or more of the major lipids in plasma can produce a marked increase in the risk of coronary heart diseases and other vascular complications. During and after pregnancy, changes in the levels of total cholesterol, triglyceride, low density lipoprotein-cholesterol, and high density lipoprotein-cholesterol have been described, but the amount of change varies from study to study. Therefore, the present study investigated changes in lipids and lipoproteins throughout the pregnancy and puerperium. We also investigated for the factors which may affect the plasma lipids during pregnancy. Concentrations of cholesterol and triglyceride of total plasma and lipoproteins were determined in 42 pregnant women throughout their pregnancy and puerperium together with a control group of 42 non-pregnant women.
Compared to the control group, concentrations of cholesterol and triglyceride of total plasma and lipoproteins increased significantly during the second trimester and reached maximum in the third trimester. Concentrations of both, cholesterol and triglyceride, decreased significantly during post-partum. There was, however, a strikingly more rapid fall of plasma triglyceride and cholesterol in those mothers who breast-fed their infants compared with that in those in whom lactation was never established. In the majority of subjects, cholesterol and triglycerides remained significantly high until the fourth week of post-partum. The magnitude of the plasma cholesterol increment appeared in part to be related to that of plasma triglycerides, but these increments appeared to be independent of age, weight gain, numbers of previous pregnancies and sex of the foetus. This study concludes that hyperlipidaemia is a common finding during pregnancy and during post-partum. The concentrations of both cholesterol and triglycerides remain significantly higher in bottle-feeding than in breast-feeding mothers.
Author Address
Department of Biochemistry, Rawalpindi Medical College, Pakistan.
One-year follow-up of lipoprotein metabolism after pregnancy.
Erkkola R, Viikari J, Irjala K, Solakivi-Jaakkola T
Biol Res Pregnancy Perinatol 1986 7(2):47-51
Abstract
Serum lipid and lipoprotein fractions one day after delivery, 3 months later in lactating and nonlactating mothers and 12 months later after initiation of menstruation were investigated in a group of 62 women, 29 of which formed a truly longitudinal group. Total serum cholesterol decreased significantly within 3 months after delivery and a further significant decrease occurred during the following 9 months. LDL- and HDL-cholesterols showed also a significant decrease within the postpartal year. Serum triglycerides decreased within 3 months after delivery but no more significantly later. Apolipoprotein AI and B also decreased within 3 months after delivery. In lactating mothers, HDL-cholesterol: cholesterol ratio, apolipoprotein AI and apolipoprotein AI:B ratio were higher than in nonlactating women. During the luteal phase, serum cholesterol and LDL-cholesterol were lower and the HDL-cholesterol: cholesterol ratio was higher than earlier during the menstrual cycle. Data prove that pregnancy related changes in lipid metabolism did not wane within 3 months after delivery. They also show that lactation affects lipid metabolism.
The effect of lactation on glucose and lipid metabolism in women with recent gestational diabetes.
Kjos SL, Henry O, Lee RM, Buchanan TA, Mishell DR
Obstet Gynecol 1993 Sep 82(3):451-5
Abstract
OBJECTIVE: To investigate the effect of lactation in the puerperium on glucose and lipid metabolism in women with recent gestational diabetes.
METHODS: In women with recent gestational diabetes, we examined the effect of 4-12 weeks of lactation on glucose tolerance (2-hour oral glucose tolerance test) and on fasting serum lipids (total cholesterol, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, and triglycerides). Of 809 women tested in the puerperium, 404 elected to breast-feed and 405 did not lactate.
RESULTS: The mean (+/- standard deviation) maternal age (31.6 +/- 5.9 versus 30.5 +/- 6.3 years), body mass index (28.8 +/- 5.1 versus 28.8 +/- 4.5 kg/m2), and parity (3.0 +/- 1.6 versus 2.8 + 1.7) were not different between the lactating and nonlactating groups, respectively. Glucose metabolism improved in the lactating group, indicated by a significantly lower total area under the glucose tolerance curve (17.0 +/- 4.2 versus 17.9 +/- 5.0 g.minute/dL; P = .01), mean fasting serum glucose (93 +/- 13 versus 98 +/- 17 mg/dL; P = .0001), and mean 2-hour glucose level (124 +/- 41 versus 134 +/- 49 mg/dL; P < .01). These differences were significant after adjusting for maternal age, body mass index (BMI), and the use of insulin in pregnancy. Nursing had no effect on total cholesterol, LDL cholesterol, or triglyceride levels. However, the mean serum HDL cholesterol was elevated in the lactating group after adjusting for maternal age, BMI, and pregnancy insulin use compared with the nonlactating group (48 +/- 11 versus 44 +/- 10 mg/dL; P < .01).
CONCLUSIONS: Lactation, even for a short duration, has a beneficial effect on glucose and lipid metabolism in women with gestational diabetes. Breast-feeding may offer a practical, low-cost intervention that helps reduce or delay the risk of subsequent diabetes in women with prior gestational diabetes.
Author Address
Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles. |
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Dr. Arsenault:
Excellent review of hyperlipoproteinemia. I often see physicians wanting to treat a breastfeeding mom with total cholesterol levels of 240.... While total cholesterol is important, the new NCEP guidelines (National Cholesterol Education Program) now stress the importance of 'family history'. If you have absolutely no family history, no risk factors (eg hypertension, overweight, etc) then you can do just fine with slightly higher cholesterol levels ( 200-250).
Thanks for the review.
Tom Hale, PH.D.
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 Mommacole
posted on Sunday, September 28, 2008 - 01:56 pm
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I am a LLLL trying to help a 41-year-old woman who has delayed beginning statin use for the past 5 years, because of pregnancy and breastfeeding. However, her BP, which was always fine, has risen significantly for the past 6+ months and she has been having some worrisome symptoms. Her total cholesterol is 366mg/dL.
She is still breastfeeding her 19-month old, and the baby is resisting weaning. From your book & forum, I know that, while he still needs significant dietary cholesterol, his need is less than if he was under a year old.
Would you kindly offer your opinion of the risks/benefits in her case?
Also - would managing the timing of taking a statin minimize levels of the drug and/or maximize levels of cholesterol in her milk?
Thank you.
Melissa Cole
LLLL, WIC Peer Counselor
(and hopefully a 2009 IBCLE exam candidate) |
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| Tom
posted on Monday, September 29, 2008 - 10:52 am
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Melissa:
We unfortunately do not know much about STATIN use in breastfeeding mothers. I did have a discussion with a colleague who has studied one of these drugs, and he told me that virtually none of it is in milk. I don't remember which one it was.
Now, this is not the best source of information. In your case with a 19 month-old infant, the infant is probably getting a really reduced volume of milk, hence the risk is probably quite low.
It would be different in a 3 month-old infant.
One thing the mom could do would be to do a lipid profile on the infant before starting, then do one again several months later. If no difference (which I expect), then no problem.
As for managing the timing, no, these things have long half-lives (Lipitor=14 hours). You couldn't wait long enough to get rid of all it.
Tom Hale Ph.d. |
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