Managing dyslipidemia in pregnant women challenging
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There are few evidence-based options for managing women with dyslipidemia who become pregnant or are thinking about it, a speaker said at the virtual National Lipid Association Scientific Sessions.
“There are unique challenges for clinicians caring for women with dyslipidemia contemplating pregnancy, and during pregnancy and lactation,” Pamela B. Morris, MD, FACC, FAHA, FASPC, FNLA, director of preventive cardiology and co-director of women’s heart care at the Medical University of South Carolina, said during her presentation.
The 2018 American College of Cardiology/American Heart Association Guideline on the Management of Blood Cholesterol identifies instances in which women of childbearing age may be placed on statin therapy. These include women with severe elevation of LDL and familial hypercholesterolemia; if LDL is at least 160 mg/dL and there is a family history of premature atherosclerotic CVD; if a woman is aged at least 40 years and has diabetes; and if a woman is aged at least 40 years, has LDL at least 70 mg/dL and has a 10-year ASCVD risk of at least 20%, Morris said. The guideline also identifies female-specific risk enhancers such as preeclampsia and premature menopause.
Lipid levels elevate during pregnancy, which can be a concern for women with already elevated lipid levels, Morris said. However, she said, a Norwegian study found no difference between women with familial hypercholesterolemia and women without it in prematurity, low birth weight, congenital malformations or hypertensive complications of pregnancy, and no difference between statin users and nonusers in prematurity, low birth weight or premature termination.
Women who are considering pregnancy or who become pregnant are advised to stop using statins, Morris said, but noted that “there are a limited number of studies” addressing this area.
“There have been some studies addressing the lipophilic statins being implicated in holoprosencephaly and VACTERL, which is a multisystem congenital malformation,” she said. “There are no known malformations with exposure to hydrophilic statins. In lactation, rosuvastatin, atorvastatin, pravastatin and fluvastatin have been detected in breast milk.”
There are not adequate data on the use of ezetimibe, PCSK9 inhibitors, bempedoic acid (Nexletol, Esperion), lomitapide (Juxtapid, Aegerion), fenofibrate and icosapent ethyl (Vascepa, Amarin) in pregnant or lactating women. Omega-3 fatty acids have been identified in the breast milk of women taking them, Morris said. She noted there is no evidence that LDL apheresis is harmful to pregnant women.
She said the only lipid-lowering therapy approved for treatment of pregnant women with hyperlipidemia is bile acid sequestrants, which are not systemically absorbed and have been shown to be safe in breastfeeding.
Although statins are not recommended for use during pregnancy, they might be able to prevent preeclampsia, Morris said.
“Statins have been found to correct similar pathophysiological pathways that underlie the development of preeclampsia,” she said. “With reassuring and positive findings from pilot studies and strong biological plausibility, statins should be investigated in large clinical randomized controlled trials for the prevention of preeclampsia.”
Women who are thinking of becoming pregnant should be screened for dyslipidemia, and those on lipid-lowering medications other than bile acid sequestrants should stop them 1 to 2 months before attempting to become pregnant, or stop them immediately upon learning of pregnancy, Morris said. Women with dyslipidemia who are not thinking of becoming pregnant should be advised about contraception, she said.
Regardless of whether the patient has normal lipid levels, hyperlipidemia or familial hypercholesterolemia, “lifestyle therapies are the foundation of management,” Morris said.
References:
- Balla S. et al. Curr Atheroscler Rep. 2020;doi:10.1007/s11883-020-00881-5.
- Grundy SM, et al. J Am Coll Cardiol. 2019;doi:10.1016/j.jacc.2018.11.002.
- Rosenbloom JI, et al. Obstet Gynecol. 2020;doi:10.1097/AOG.0000000000003567.
- Toleikyte I, et al. Circulation. 2011;doi:10.1161/CIRCULATIONAHA.110.990929.
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Morris PB. Session I: Cardiovascular preventive care in pregnancy. Presented at: National Lipid Association Scientific Sessions; Dec. 10-12, 2020 (virtual meeting).
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