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Using antiplatelet medicines during breastfeeding

Published
Topics: AspirinCardiovascular system disordersClopidogrel · DipyridamolePrasugrelSafety in BreastfeedingTicagrelor ·

Antiplatelets can be used with caution in breastfeeding. Avoid exposure to aspirin if infant has a fever. Recommendations apply to full term, healthy infants.

Contents

  1. General considerations
  2. Recommendations
  3. Choice considerations
  4. Aspirin and the risk of Reye’s syndrome
  5. Specific recommendations
    1. Aspirin
    2. Clopidogrel
    3. Dipyridamole
    4. Prasugrel
    5. Ticagrelor
  7. Patient Information
  8. Contact us
  9. About our recommendations
  10. Bibliography

General considerations

It is important to complete an individual risk assessment for your patient and to apply the principles of prescribing in breastfeeding when looking at the available information and making treatment decisions.

Recommendations

There is little or no published evidence on the use of antiplatelet medicines during breastfeeding.

Limited published information on low-dose aspirin (defined here as 75mg to 150mg daily) shows milk levels are negligible.

However the pharmacokinetic parameters of all antiplatelet medicines suggest all are likely to pass into breast milk in low amounts and any antiplatelet medicine can be used with caution during breastfeeding.

There is insufficient information to recommend a preferred agent.

Choice considerations

Choice of antiplatelet medicines in breastfeeding will be dependent on a number of factors, including patient-specific characteristics, clinical condition and patient preference.

More than one antiplatelet medicine may need to be used in combination and therefore their additive suitability in breastfeeding will need to be considered.

Several antiplatelet medicines require a loading dose when starting treatment.  There is limited or no information on higher doses for short durations and enhanced infant monitoring is recommended if breastfeeding is maintained through any acute illness.

Treatment choice should primarily be directed at managing the clinical condition, with safety in breastfeeding a secondary consideration.

Breastfeeding itself can also help to reduce the risk of cardiovascular disease.

Aspirin and the risk of Reye’s syndrome

Reye’s syndrome is a disorder characterised by acute encephalopathy and fatty degeneration of the liver.  The exact cause is unknown- but it most commonly affects children and young adults recovering from a viral infection.

Aspirin has been associated with Reye’s syndrome when administered to children with a fever.  It is unknown whether the negligible amounts of aspirin present in breast milk following an antiplatelet dose could cause Reye’s syndrome in a breastfed infant.

To minimise the risk, if the infant has symptoms of a viral infection or fever, consider temporarily discontinuing the aspirin if clinically justified, or temporarily withholding breast milk.

Specific recommendations

Use with caution

Low dose aspirin (75mg to 150mg daily)  passes into breast milk in negligible amounts.  It can be used with caution during breastfeeding but monitoring is required..  Avoid if the infant has symptoms of a viral infection or fever.

Monitoring

As a precaution, monitor the infant for poor feeding, irritability or skin reactions, and for signs of bruising or bleeding, which may be prolonged.

Further information

Much of the evidence relates to higher analgesic or anti-inflammatory doses, and there is only very limited evidence relating to low dose aspirin as an antiplatelet agent during breastfeeding.

Its pharmacokinetics are likely to limit the amount excreted into breast milk.  Published data found negligible levels in milk after daily doses of 81mg.  Infants would have ingested approximately 0.4% of the weight-adjusted maternal dose.

It can be used therapeutically in full-term neonates from birth.

Aspirin has irreversible anti-platelet effects so any that is absorbed by the infant could have a prolonged effect

No side effects have been reported in infants after exposure to low doses of aspirin via breastmilk. Single case reports of metabolic acidosis, thrombocytopenia, petechiae, and anorexia in infants exposed to high or unknown doses of aspirin through breastmilk have been reported, although there are insufficient details to confirm a causal link.

See above for information about aspirin and Reye’s syndrome.

Use with caution

There is no information on the amount of clopidogrel which passes into breast milk although levels are likely to be low.  It can be used with caution during breastfeeding but monitoring is required.

Monitoring

As a precaution, monitor the infant for diarrhoea, constipation or skin reactions, and for signs of bruising or bleeding which could be prolonged.

Further information

There is no published evidence of use of clopidogrel during breastfeeding.

Its pharmacokinetic properties, including high protein binding and short half life are likely to limit the amount in breast milk, and its reduced oral bioavailability will limit absorption by the infant.  However, clopidogrel has a metabolite that irreversibly binds to platelets so any that is absorbed by the infant could have a prolonged effect.

The manufacturers state that no side effects have been reported in breastfed infants in a small number of post marketing cases.

Use with caution

There is no published information on the amount of dipyridamole which passes into breast milk although levels are likely to be low.  It can be used with caution during breastfeeding but monitoring is required.

Monitoring

As a precaution, monitor the infant for diarrhoea, vomiting, skin reactions, irritability and for signs of bruising or bleeding.

Further information

There is no published evidence of use of dipyridamole during breastfeeding although the manufacturers state that low levels were found in breast milk.

Its pharmacokinetic properties are likely to limit the amount which passes into breast milk, and absorption by the infant.

No side effects have been reported in breastfed infants.

Dipyridamole can be used therapeutically in infants from one month old.

Use with caution

There is no information on the amount  of prasugrel which passes into breast milk although levels are likely to be low.  It can be used with caution during breastfeeding but monitoring is required.

Monitoring

As a precaution, monitor the infant for skin reactions, and for signs of bruising or bleeding which could be prolonged.

Further information

There is no published evidence of use of prasugrel during breastfeeding.

Its high protein binding is likely to limit the amount excreted into milk.  However, prasugrel irreversibly binds to platelets so any that is absorbed could have a prolonged effect.

No side effects have been reported in breastfed infants

Use with caution

There is no information on the amount of ticagrelor which passes into breast milk although levels are likely to be low.  It can be used with caution during breastfeeding but monitoring is required.

Monitoring

As a precaution, monitor the infant for diarrhoea, vomiting, irritability, or for signs of bruising or bleeding.

Further information

There is no published evidence of use of ticagrelor during breastfeeding.

Its high protein binding is likely to limit the amount excreted into milk, and its low bioavailability will limit absorption by the infant.

No side effects have been reported in breastfed infants.  As ticagrelor has a reversible antiplatelet effect, the duration of any potential side effects relating to bleeding would be less than with an irreversible antiplatelet agent.

Patient Information

The NHS website provides advice for patients on the use of specific medicines in breastfeeding.

Contact us

Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS) (SPS page), our specialist breastfeeding medicines advice service if you need support in the following situations:

  • you need further advice
  • the medicine in question is not included here
  • the infant is unwell or premature
  • multiple medicines are being taken

About our recommendations

Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.

If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data are now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.

Bibliography

Full referencing is available on request.