by Anne Eglash MD, IBCLC, FABM
What blood thinners are safe options for breastfeeding mothers? Many women who are breastfeeding need to take anticoagulant therapy (ACT) for various health reasons. Women who have had blood clots in the past are usually kept on ACT throughout pregnancy and into the first 6 weeks postpartum, because pregnancy itself increases the risk of clots. Some women have genetic risk factors for clots, and others develop a blood clot postpartum.
In the past, we have typically relied on either heparin or low molecular weight heparin (LMWH) injections, such as enoxaparin or dalteparin, during breastfeeding, because both types of heparin are large molecules that do not transfer well into breastmilk. Oral warfarin has also been an option for breastfeeding mothers because of its low transmission into breastmilk. It is far less expensive that injections of LMWH, does not require taking shots, but it requires close monitoring of the blood-thinning level, often every 1-4 weeks via blood testing, and dietary restrictions of foods high in vitamin K, such as vegetables.
The current trend in management of blood clots is to treat patients with one of the novel anticoagulants such as dabigatran (Pradaxa), apixaban (Eliquis), or rivaroxaban (Xarelto), among others. These do not require blood monitoring, are taken once a day, and do not require dietary restrictions. However, are they safe to use with breastfeeding?
Philip Anderson PharmD has been writing a regular Lactmed update column in Breastfeeding Medicine Journal, and recently he reviewed the use of anticoagulants during breastfeeding.
What are considered reasonable treatment strategies for anticoagulation for a breastfeeding mother with a blood clot? (choose 1 or more):
- One of the novel anticoagulants such as apixaban (Eliquis) should be chosen because they are safer and more effective for the mother’s health in comparison to warfarin. She should pump and dump because these medications are not safe during breastfeeding.
- The novel anticoagulants are safe during breastfeeding, so should be the first line of therapy for a breastfeeding mother who develops a blood clot.
- Warfarin is considered safe during breastfeeding, and should be the first line treatment for oral medication for a breastfeeding mother with a blood clot.
- Low molecular weight heparin is the gold standard for a breastfeeding mother because the only other option is warfarin, which requires excessive dietary restriction of vegetables, reducing the quality of breastmilk.
See the Answer
The answer is C
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
For non-breastfeeding patients, the novel anticoagulants have become the first line treatment for blood clots. These medications are easier to prescribe because patients don’t require the intensive teaching involved in heparin injections or warfarin use. Unlike with warfarin treatment, therapy with the novel anticoagulants does not require blood tests to monitor levels or special dietary guidelines.
Unfortunately, there is not enough information about the safety of novel anti-coagulants to recommend them as first line treatment for breastfeeding mothers. At this point, warfarin ought to be the mainstay for oral anticoagulation therapy.
Recently I saw a new mother in my lactation clinic who developed a blood clot in her calf. She had been seen in urgent care, placed on Apixaban (Eliquis), and told to either pump and dump for 3 months, or to wean! By the time I saw her, she was so convinced that Apixaban had to be her treatment, that she decided to wean, and was too anxious to consider my suggestion of switching to warfarin so that she could continue to breastfeed.
As medicine continues to be protocol driven with new recommendations constantly emerging, it is important for providers to recognize that older treatments, proven to be safe for breastfeeding dyads, may be the best options. Critical thinking is important to individualize care for patients. If the urgent care provider would have used the National Library of Medicine Lactmed database to evaluate the best option of treatment for this breastfeeding mother, he/she would have discovered that warfarin is the most appropriate treatment. Breastfeeding education for all health professionals, including nurses, physicians, nurse practitioners, pharmacists, physician assistants is crucial for the optimal medical care of the breastfeeding dyad!