Angiotensin converting enzyme ( ACE ) inhibitors and angiotensin II receptor antagonists ( sartans ) are licensed for a range of conditions including hypertension and may be particularly suitable for young patients with high blood pressure ( but not those of black ethnic origin ) and those with some comorbidities such as diabetic nephropathy.

Methyldopa is recognised to be the antihypertensive of choice during pregnancy and breastfeeding, but will not be suitable for some women and other options may need to be explored.

Use in pregnancy

Angiotensin II is essential for normal kidney development, and the use of ACE inhibitors and angiotensin II receptor antagonists in late pregnancy has been associated with adverse effects on the kidney and other congenital anomalies. Some data have also suggested an increased risk of congenital anomaly after exposure during the first trimester of pregnancy. Therefore, ACE inhibitors and angiotensin II receptor antagonists should not be used at any stage of pregnancy unless absolutely necessary, and only then after the potential risks and benefits have been discussed with the patient.

Use during breastfeeding

a) ACE inhibitors - In general, ACE inhibitors have a small molecular size and so their transfer to breast milk is possible. With the exception of Captopril, the active metabolites of ACE inhibitors have long elimination half-lives; however, these metabolites are poorly absorbed orally. Data on the use of ACE inhibitors in breastfeeding are sparse and relate mostly to Captopril, Enalapril, and Quinapril; findings indicate that drug is transferred to breast milk.
Although the levels transferred to an infant via breastfeeding are unlikely to be clinically relevant, there are insufficient data to exclude a possible risk of profound neonatal hypotension, particularly in preterm babies.

b) Angiotensin II receptor antagonists - No data on the use of angiotensin II receptor antagonists are available. These agents are also small enough to pass into breast milk, and some unpublished studies have found them in the milk of lactating rats. However, most angiotensin II receptor antagonists are highly bound to maternal plasma proteins, which can substantially limit their transfer into breast milk. The effects of potential exposure on a nursing infant are unknown.

Source: Drug Safety Update – MHRA, 2009

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