238 9
methyldopa (
propranolol ) captopril enalapril
3 4
( Antihypertensive agents ) ( Breastfeeding )
( Lactation ) ( Hypertension )
20-54 14%
1
( plas- ma protein binding ) ( acid base character- istics ) ( lipid solubility )
( maternal serum concentration )
2
3 4
Wojnar
1 0 %
33% 6
5
( )
Maternal milk to plasma ratio ( M/P ratio )
( maternal milk to plasma ratio )
M/P ratio
Kate 1966 1988
M/P ratio ( )
6( Beta blockers ) ( calci-
um channel blockers )
( angiotensin-converting enzyme ( ACE ) inhibitors ) methyldopa
M/P ratio High
( 1 ) Intermediate ( 0.5-1.0 ) low ( 0.1-0.5 )
and negligible ( 0.1 ) M/P
ratio
( Beta blockers ) ( calcium channel blockers )
( ACE inhibitors ) negligible M/P ratio Methyldopa
M/P ratio
( Beta blockers )
7M/P ratio
Metoprolol nadolol acebutalol sotalol
Number of subjects on antihypertensive medications with high, intermediate, and low M/P ratio
Medication Total Sample size High M/P 1.0 Intermediate M/P 0.5-1.0 Low M/P 0.1-0.5 Negligible M/P 0.1 Reference Beta blockers
Metoprolol 23 21 1 1 - (19-22)
Nadolol 12 12 - - - (23)
Acebutolol 7 7 - - - (9)
Atenolol 7 7 - - - (24-26)
Sotalol 17 14 2 1 - (20,22,27,28)
Timolol 13 6 3 4 - (29)
Labetalol 3 2 1 - - (10)
Propranolol 13 1 8 4 - (28,30-34)
Ca channel blockers
Diltiazem 1 1 - - - (35)
Verapamil 1 - 1 - - (36)
Nimodipine 5 1 1 3 - (37)
Nifedipine 2 - - 2 - (38,39)
ACE inhibitors
Enalapril 9 - - 1 8 (40-42)
Captopril 11 - - - 11 (43)
Methyldopa 8 - 2 5 1 (17,18,44)
and atenolol high M/P ratio
2
8,91000ml
atenolol
8labetalol
10( adrenergic block ) ( )
mepidolol propranolol M/P ratio
( Calcium channel blockers )
11Dihydropyridine ( DHP ) verapamil M/P ratio intermediate
verapamil
12,13
diltiazem high M/P ra- t i o
Non-DHP nifedipine
1 4
N i m o d i p i n e Nicardipine
15
amlodipine felodipine
( ACE inhibitors )
16( ACE inhibitors ) M/P ratio
( A C E i n h i b i t o r s )
( A n g i o t e n s i n I I receptor blockers )
16Methyldopa
17,18methyldopa
Hydralazine
16Liedholm hydralazine
Recommendation of American Academy of Pediatrics for Antihypertensive medications during Breastfeeding
14Medication Recommendation
Beta blocker
Metoprolol Compatible with breastfeeding
Atenolol Safer alternatives over atenolol should be used Propranolol Safe
Nadolol Compatible with breastfeeding but should be monitored for adverse effect Sotalol Compatible with breastfeeding
Ca channel blocker
Nifedipine Safe
Amlodipine Should not be used
Nicardipine Not recommended
Verapamil Compatible with breastfeeding Diltiazem Safe
ACE inhibitor
Captopril Compatible with breastfeeding Enalapril Safe
Fosinopril Not recommended
( plas- ma protein binding ) ( acid base character- istics ) ( lipid solubility )
methyldopa
( propranolol ) captopril enalapril
3 4
American Academy of Pediatrics
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Choice of Antihypertensive Agents During Lactation
Sen-Chu Hong, and Chi-Tai Kuo
1Approximately 14% of women 20-54 years of age have hypertension. Some of these women need antihy- pertensive treatment postpartum, and wish to breastfeed. Many drugs taken by the mother eventually appear in human milk. The drug level in milk depends on the physiochemical properties of the drug, the degree of plasma protein binding, acid-base characteristics, lipid solubility and the maternal serum concentration. Both the clinician and the mother have to weigh the risk to benefit ratio when maternal medication is prescribed. This article dis- cusses the antihypertensive medication with regard to lactation by the maternal milk to plasma M/P ratios and indicates the choice of agents for the mother and infants. It seems reasonable to avoid diuretics, because of their potential to suppress lactation. By the available data to date, Methyldopa, beta blocker with high plasma protein binding ex propranolol , captopril, enalapril, and some calcium channel blockers are safe treatments of hy- pertension in a nursing mother, especially with slowly increasing dose and feeding 3-4 hours after taking antihy- pertensive medicine. ( J Intern Med Taiwan 2007; 18: 115-119 )
Cardiology Divisions, Department of Internal Medicine, ShuLin Ren-ai Hospital, Taiwan
1
