ACE inhibitors and breastfeeding
Last edited 05/2023 and last reviewed 05/2023
ACE inhibitors and angiotensin II receptor antagonists (A2RAs) (angiotensin receptor blockers (ARBs)) use during breastfeeding
- ACE inhibitors and A2RAs (ARBs) should not be used at any stage of pregnancy,
as exposure during pregnancy has been associated with adverse kidney effects
and other congenital anomalies
- ACE inhibitors and A2RAs (ARBs) should not be used by breastfeeding mothers
in the first few weeks after delivery because of possible profound neonatal
hypotension; preterm babies may be at particular risk
- in mothers who are breastfeeding older infants, the use of captopril, enalapril, or quinapril may be considered, although careful follow-up of the infant for possible signs of hypotension is recommended (1)
A review by the NHS Specialist Pharmacy Service noted with respect to use of A2RAs (ARBs) during breastfeeding (2):
- there is almost no published evidence of the use of any medicine in this class during breastfeeding
- if there are no other therapeutic options, angiotensin-II receptor antagonists (ARBs) can be used with caution during breastfeeding
- candesartan, losartan or valsartan have the most favourable pharmacokinetics and would therefore be preferred
- however, given the very limited published evidence it would usually be preferable to choose a medicine from a different class which has more information supporting their use in breastfeeding
- infants at most risk of side-effects
- neonates and infants less than 2 months are at the most risk from the side-effects of angiotensin-II receptor antagonists, particularly hypotension, because they have underdeveloped clearance capacities, which means they can’t metabolise the medicines as effectively
- in addition, there is theoretical concern that angiotensin-II receptor antagonists could affect kidney development. However, this has not been proven
- if an angiotensin-II receptor antagonists is the best therapeutic option, extra caution should be taken when breastfeeding younger infants and neonates
- candesartan, losartan or valsartan have the most favourable pharmacokinetics and would therefore be preferred
Reference:
- 1. MeReC Monthly No.16 July 2009.
- NHS Specialist Pharmacy Service (May 2023). Using angiotensin-II receptor antagonists during breastfeeding