The safety of proton pump inhibitors in pregnancy: a multicentre prospective controlled study

Use of proton pump inhibitors during pregnancy: A systematic review and meta-analysis of congenital malformations

Use of proton pump inhibitors (PPI) are common among pregnant women to relieve gastrointestinal symptoms. The number of exposed pregnancies is therefore considerable, and a recent meta-analysis (MA) from 2020 raised concern about their teratogenicity. The aim of the study was to provide a MA of the risk of major congenital malformations (MCM) after PPI exposure during the first trimester of pregnancy. A systematic review and random-effects model approach were performed using a collaborative WEB-based meta-analysis platform (metaPreg.org) with a registered protocol (osf.io/u4gva). The primary outcome was the incidence of overall MCM. The secondary outcomes of interest were specific MCM reported by at least three studies. All comparative studies assessing these outcomes in PPI exposed pregnancies were searched from inception to April 2022. From the 211 initially identified studies, 11 were included in the MA. The pooled odds ratio (OR) for the primary outcome showed no significant results based on 5 618 exposed pregnancies (OR 1.10, 95% CI [0.95;1.26]; I²=0%). Similarly, no result was significant for the secondary outcomes. The total exposed sample size ranged from 3 161-5 085; OR ranged between 0.60 and 1.92; heterogeneity was between 0% and 23%. Based on the results of the present MA, first trimester PPI exposure was not associated with a significantly increased risk of overall or specific MCM. However, this MA included only observational studies which are prone to bias and there were insufficient data to evaluate PPI at a substance level. Future studies are needed to address this concern.

Population-based cohort study: proton pump inhibitor use during pregnancy in Sweden and the risk of maternal and neonatal adverse events

BACKGROUND

Approximately half of all women suffer from heartburn at some stage during pregnancy. The most effective treatment is proton pump inhibitors, but the safety of use during pregnancy cannot be guaranteed. This study aimed to elucidate the effect of proton pump inhibitors on the risk of pre-eclampsia, gestational diabetes mellitus, preterm birth, an Apgar score at 5 min below 7, and a child being small or large for its gestational age.

METHODS

This Swedish population-based study included 1,089,514 live singleton deliveries between July 2006 and December 2016 in Sweden. Multiple logistic regression was used to model the outcomes as a function of the covariates. Results were presented as odds ratios with 95% confidence intervals.

RESULTS

In 1.4% of all pregnancies, the mother used proton pump inhibitors in the period from 3 months before the last menstrual period up to delivery. The use of proton pump inhibitors was associated with higher odds of pre-eclampsia (odds ratio = 1.19, 1.10-1.29), gestational diabetes mellitus (odds ratio = 1.29, 1.16-1.43), preterm birth (odds ratio = 1.23, 1.14-1.32), and small for gestational age (odds ratio = 1.27, 1.16-1.40) and lower odds of large for gestational age (odds ratio = 0.84, 0.77-0.91). No significant association was found with a low Apgar score 5 min after birth.

CONCLUSIONS

Proton pump inhibitor use was associated with a higher risk of pre-eclampsia, gestational diabetes, preterm birth, and being born small for gestational age.

Drug use for gastrointestinal symptoms during pregnancy: A French nationwide study 2010-2018

PURPOSE

To describe drug prescription for gastrointestinal symptoms during pregnancy.

METHODS

Using the French national health database, we identified pregnancies ending with a birth between April 2010 and December 2018, in France. We studied prescription of antacids, antispasmodics, antinauseants, laxatives and antidiarrheals during pregnancy, between two trimesters before and two trimesters after delivery. We also assessed hospitalization for gastrointestinal symptoms during pregnancy.

RESULTS

Among 6,365,471 pregnancies, 4,452,779 (74.0%) received at least one gastrointestinal drug during pregnancy; 2,228,275 (37.0%) received an antacid, 3,096,858 (51.5%) an antispasmodic, 1,861,731 (31.0%) an antinauseant, 919,116 (15.3%) a laxative and 617,808 (10.3%) an antidiarrheal. Prescription of proton pump inhibitors doubled from 12.2% in 2010 to 26.0% in 2018, while domperidone use decreased from 18.3% in 2010 to 2.2% in 2018. In addition, prescription of antacids increased from 7.0% during the trimester before pregnancy to 11.8% during the 1st trimester, 17.0% during the 2nd trimester and 23.4% during the 3rd trimester. Antispasmodic use was 10.6% during the trimester before pregnancy, 23.1% during the 1st trimester, 25.2% during the 2nd trimester and 24.0% during the 3rd trimester. Prescription of antinauseant drugs increased from 5.0% during the trimester before pregnancy to 25.7% during the 1st trimester, then decreased to 6.4% during the 2nd trimester and 3.2% during the 3rd trimester. Nausea/vomiting was the most common cause of hospitalization for gastrointestinal symptoms or diseases during pregnancy, although it accounted for only 1.0% of pregnancies.

CONCLUSIONS

Approximately three-quarters of women use drugs for gastrointestinal symptoms during pregnancy in France. Prescription of gastrointestinal drugs during pregnancy should be the subject of more detailed risk-benefit assessment and recommendations.

Long-term use of proton pump inhibitors as a risk factor for various adverse manifestations

The long-term use of proton pump inhibitors (PPIs) can lead to increased gastric pH, hypochlorhydria and in some cases to achlorhydria when compared to other acid-suppressing agents like histamine-2 (H2) receptor blockers and antacids. These consequences by the use of long-term PPIs may lead to significant vitamin (B₁₂ and C) and mineral (iron, calcium and magnesium) deficiencies which needs gastric acid for their absorption and bioavailability. Long-term use of PPIs by the pregnant patients may impose a potential risk of congenital malformations. Various studies have recommended the life style modifications and antacid use as first choice among pregnant womens by preserving PPIs (omeprazole as a safe choice of PPI) for severe conditions of gastroesophageal reflux disease. The long-term acid suppression by PPIs can also lead to enteric, respiratory and urinary tract infections. The hypochlorhydria by chronic PPIs use may induce hypergastrinemia, which ultimately mediates the gastric polyps, gastric carcinoids and gastric cancer. The concomitant use of PPIs with antiplatelet drugs like clopidogrel can impose the patients to major adverse cardiac events. This review has enlisted the comprehensive information regarding the adverse effects induced by long-term use of PPIs and their possible relations. Considerable studies like case-control, randomized trials, cohort studies and meta-analysis were reported in supporting these adverse effects. The clinicians and patients should be cautious about these effects so that they can avoid the serious outcomes. PPIs should be avoided for long-term use mainly in older adults unless there is a proper indication.

Systematic review with meta-analysis: the risks of proton pump inhibitors during pregnancy

BACKGROUND

There have been safety concerns considering long-term proton pump inhibitor (PPI) use, also during pregnancy.

AIMS

To assess the risk of adverse neonatal outcomes associated with maternal intake of PPIs by means of systematic review and meta-analysis.

METHODS

The systematic search included PubMed, Web of Science, Cochrane Database and Embase (inception until June 2019). All studies reporting ≥1 adverse pregnancy outcome comparing PPI users to non-users. Histamine-2 receptor antagonists (H2RA) were also compared to both non-users and PPI users. Outcomes included congenital malformations, abortion, stillbirth, neonatal death, preterm birth, small for gestational age and low birth weight. Pooled odds ratios (OR) and 95% confidence intervals (CI) were obtained by random-effects modelling. PROSPERO study-protocol: CRD42018103320.

RESULTS

In total, 26 observational studies (20 cohort, 6 case-control studies) were identified, of which 19 assessed PPIs and 12 H2RA. PPI use was associated with an increased risk of congenital malformations (OR 1.28, 95% CI 1.09-1.52), especially in case-control studies (OR 2.04, 1.46-2.86). No associations were found between H2RA and congenital malformations. No significant associations were found between PPI use and abortions, stillbirth, neonatal death, preterm birth and low-birth weight, although H2RA use may be associated with an increased risk of preterm birth (OR 1.25, 95% CI 1.02-1.56). Although statistical heterogeneity and the risk of bias were overall low, clinical heterogeneity, information and selection bias may be present in the individual studies.

CONCLUSIONS

This meta-analysis suggests an association between maternal PPI use and congenital malformations in humans, yet power was insufficient to assess specific malformations and drugs.

Review article: the management of heartburn during pregnancy and lactation

BACKGROUND

Gestational reflux is common, affecting up to 80% of pregnant women. Most symptoms will abate during lactation. During both of these periods, interventions used to relieve symptoms focus on a "step-up" methodology with progressive intensification of treatment. This begins with lifestyle modifications.

AIM

To provide guidance in the treatment of reflux in pregnancy and lactation, as well as briefly summarising the pathogenesis, clinical presentation and diagnostic workup.

METHODS

A comprehensive search, using online databases PubMed and MEDLINE, along with relevant manuscripts published in English between 1966 and 2019 was used. All abstracts were screened, potentially relevant articles were researched, and bibliographies were reviewed.

RESULTS

Only a small percentage of relevant drugs are contraindicated for use in pregnancy or while breastfeeding. However, not all drug agents have been extensively evaluated in pregnant women or during the breastfeeding period. Antacids, alginates, and sucralfate are the first-line therapeutic agents. If symptoms persist, any of the H₂ RAs can be used except for nizatidine (due to foetal teratogenicity or harm in animal studies). PPIs are reserved for women with intractable symptoms or complicated GERD; all are FDA category B drugs, except for omeprazole, which is a category C drug.

CONCLUSIONS

The management of heartburn during pregnancy and lactation begins with lifestyle modifications. In situations where disease severity increases, medical providers must discuss risks and benefits of these medicines with the patient in detail.

Autoimmune connective tissue diseases and pregnancy

Autoimmune connective tissue-diseases are more frequent in women and deserve a multidisciplinary approach in which the dermatologist play a major role together with other physicians. Pregnancy in these patients has to be considered a high-risk situation, because of possible worsening of the mother's disease and increased morbility and mortality for the fetus; also, therapies have to be chosen carefully because some drugs cannot be used during pregnancy. For all these reasons, the decision to become pregnant needs to consider the type of disease, stage of disease, age and clinical condition, and requires a multidisciplinary approach. A correct counselling, a close monitoring, a specific approach based on the risks involved and the use of appropriate therapies are the keys to obtain optimal pregnancy outcomes.

Ethical approval for multicenter cohort studies on drug exposure during pregnancy: A survey among members of the European Network of Teratology Information Services (ENTIS)

The European Network of Teratology Information Services (ENTIS) is in a privileged position to perform independent post-marketing surveillance of drugs in pregnancy. The aim of this survey was to describe the legal requirements and procedures involved in obtaining ethical approval for collaborative cohort studies. We sent a survey questionnaire to all 28 Teratology Information Services (TIS), of which 25 (89%) in 18 countries completed our questionnaire. For 15 TIS, specific research ethical approval was mandatory. The review process was estimated to last from 2 up to 16 weeks. Procedures for patients' information and consent were oral (12), written (5) or both (3). Five TIS had no requirement to inform patients and seek consent. Since data on drug exposure during pregnancy are scarce, ENTIS research efforts should be further encouraged, and procedures optimized so that legitimate ethical and legal requirements do not translate into deterrent administrative constraints and costs.

Pregnancy in systemic sclerosis

This comprehensive review summarizes retrospective and prospective studies on pregnancy in systemic sclerosis in order to educate physicians on critical management issues. Fertility is normal in women with established systemic sclerosis. Their rates of spontaneous losses are comparable to the general population, except for patients with late diffuse systemic sclerosis and severe internal organ involvement who may have higher risks of abortion. Prematurity is clearly higher among systemic sclerosis women, similarly to other rheumatic diseases such as systemic lupus erythematosus and anti-phospholipid antibody syndrome. A placental vasculopathy has been observed in some women with systemic sclerosis. Overall, the disease generally remains stable in most pregnancies. Women with pulmonary hypertension should avoid pregnancy on account of the high maternal mortality risk. Management of systemic sclerosis patients before and during pregnancy includes evaluation of organ involvement and autoantibody analysis, preconceptional folic acid, and discontinuation of drugs with teratogenic potential (bosentan, mycophenolate mofetil, methotrexate, etc.). Management by high-risk pregnancy teams including neonatologists is very important to ensure the best outcomes.

Helicobacter pylori Infection Is Associated with an Increased Risk of Hyperemesis Gravidarum: A Meta-Analysis

Background. Several studies have shown a possible involvement of Helicobacter pylori (H. pylori) infection in individuals with hyperemesis gravidarum (HG), but the relationship remains controversial. This meta-analysis was performed to validate and strengthen the association between HG and H. pylori infection. Methods. PubMed, Embase, and Web of Science databases up to March 20, 2014, were searched to select studies on the prevalence of H. pylori infection between pregnant women with HG and the normal pregnant control subjects. Results. Of the HG cases, 1289 (69.6%) were H. pylori-positive; however, 1045 (46.2%) were H. pylori-positive in control group. Compared to the non-HG normal pregnant controls, infection rate of H. pylori was significantly higher in pregnant women with HG (OR = 3.34, 95% CI: 2.32–4.81, P < 0.001). Subgroup analysis indicated that H. pylori infection was a risk factor of HG in Asia, Africa, and Oceania, especially in Africa (OR = 12.38, 95% CI: 7.12–21.54, P < 0.001). Conclusions. H. pylori should be considered one of the risk factors of HG, especially in the developing countries. H. pylori eradication could be considered to relieve the symptoms of HG in some intractable cases.

Management of gastrointestinal and liver diseases during pregnancy

In the majority of patients with chronic gastrointestinal and liver diseases, maintenance therapy is required during pregnancy to control the disease, and disease follow-up or disease control might necessitate endoscopy. Evidence on the safety of drugs and imaging techniques during pregnancy is scarce and sometimes difficult to interpret. In this review we summarise existing literature with the aim of optimising counselling of patients with common chronic gastrointestinal and liver diseases who want to conceive.

Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date

Symptoms of gastro-oesophageal reflux disease (GORD or GERD) are estimated to occur in 30-50% of pregnancies, with the incidence approaching 80% in some populations. As with many other conditions in pregnancy, medical therapy with pharmaceutical agents is a concern, as the potential teratogenicity of medications is not well known. Although prevalence numbers are high, many patients have mild and infrequent symptoms, which often respond to lifestyle and dietary modifications. The exact mechanism and pathogenesis of GERD associated with pregnancy is likely multifactorial. Treatment strategies for patients not responding to conservative therapies include a step-up approach initially starting with antacids and alginates, and progressing to histamine H(2) receptor antagonists followed by proton pump inhibitor (PPI) therapy if indicated by symptoms. Although PPI therapy is the most effective treatment available for GERD, the data related to the safety for use during pregnancy and postpartum breastfeeding are mostly obtained from cohort analysis. Given the significant adverse impact of GERD on quality of life and functionality, the use of this class of medications should not be overly restricted based solely on the pregnancy. Based on the studies presented, exposure to PPI therapy during pregnancy seems to predispose the fetus to minimal risk and, overall, these medications should be discussed with the primary physician if symptomatically necessary in the pregnant patient. This evidence-based review will address the management and safety of PPI therapy during pregnancy and lactation, and briefly review the pathogenesis, clinical presentation and diagnosis of GERD in this population.

Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date

Symptoms of gastro-oesophageal reflux disease (GORD or GERD) are estimated to occur in 30-50% of pregnancies, with the incidence approaching 80% in some populations. As with many other conditions in pregnancy, medical therapy with pharmaceutical agents is a concern, as the potential teratogenicity of medications is not well known. Although prevalence numbers are high, many patients have mild and infrequent symptoms, which often respond to lifestyle and dietary modifications. The exact mechanism and pathogenesis of GERD associated with pregnancy is likely multifactorial. Treatment strategies for patients not responding to conservative therapies include a step-up approach initially starting with antacids and alginates, and progressing to histamine H(2) receptor antagonists followed by proton pump inhibitor (PPI) therapy if indicated by symptoms. Although PPI therapy is the most effective treatment available for GERD, the data related to the safety for use during pregnancy and postpartum breastfeeding are mostly obtained from cohort analysis. Given the significant adverse impact of GERD on quality of life and functionality, the use of this class of medications should not be overly restricted based solely on the pregnancy. Based on the studies presented, exposure to PPI therapy during pregnancy seems to predispose the fetus to minimal risk and, overall, these medications should be discussed with the primary physician if symptomatically necessary in the pregnant patient. This evidence-based review will address the management and safety of PPI therapy during pregnancy and lactation, and briefly review the pathogenesis, clinical presentation and diagnosis of GERD in this population.

The safety of fetal exposure to proton-pump inhibitors during pregnancy

BACKGROUND

Proton-pump inhibitors (PPIs) are often needed in pregnancy due to the high rates of acid reflux. Previous studies did not include medical pregnancy terminations data, which may cause a bias toward the null hypothesis. We assessed the fetal safety of PPIs following exposure during gestation including data from medical pregnancy terminations.

METHODS

A unified computerized database was created by linking a computerized database of medications dispensed from 1998 to 2009 to all women registered in "Clalit" HMO, southern district of Israel, with computerized databases containing maternal and infant hospitalization records from the district hospital. Rates of congenital malformations in PPIs exposed and unexposed pregnancies, as well as other adverse fetal effects were compared. Medical pregnancy termination data were included in the analysis.

RESULTS

A total of 114,960 (75%) infants were born during the study period to women registered at "Clalit," 110,783 of them were singleton pregnancies; 1,239 women had medical pregnancy terminations, of which 468 were performed due to fetal malformations. A total of 1,186 infants and abortuses had been exposed to PPIs during the first trimester of pregnancy. Exposure to PPIs was not associated with an increased risk of congenital malformations (adjusted OR 1.06; 95% CI = 0.84-1.33). Similarly, exposure to PPIs during the third trimester of pregnancy was not associated with increased risk of perinatal mortality, premature delivery, low birth weight, or low Apgar scores.

CONCLUSIONS

Intrauterine exposure to PPIs was not associated with increased risk for congenital malformations, perinatal mortality, or morbidity. These results are strengthened with the inclusion of data from medical pregnancy terminations.

Feasibility study of the zebrafish assay as an alternative method to screen for developmental toxicity and embryotoxicity using a training set of 27 compounds

To anticipate to increased testing needs for reproductive toxicity and 3R approaches, we studied zebrafish embryo/larva as an alternative for animal testing for developmental toxicity and embryotoxicity and evaluated a training set of 27 compounds with a standardized protocol. The classification of compounds in the zebrafish embryo/larva assay, based on a prediction model using a TI (teratogenic index) cut-off value of 2, was compared to available animal and human data. When comparing the classification of compounds in the zebrafish embryo/larva assay to available animal classification, a sensitivity of 72% and specificity of 100% were obtained. The predictive values obtained in comparison to a limited set of human data were 50, 60% respectively for teratogens, non-teratogens. Overall, we demonstrated that the zebrafish embryo/larva assay, may be used as screening tool for prioritization of compounds and could contribute to reduction of animal experiments in the field of developmental toxicology.

Gastroesophageal reflux disease and Barrett's esophagus

Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. The spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epithelium (Barrett's esophagus), and adenocarcinoma. Barrett's esophagus is a premalignant lesion detected in the majority of patients with esophageal and gastroesophageal adenocarcinoma. The incidence of these cancers has been increasing in the United States and they are associated with a low rate of survival (5-year survival rate, 15-20%). When symptoms of gastroesophageal reflux disease are typical and the patient responds to therapy, no diagnostic tests are necessary to verify the diagnosis. Endoscopy is the primary test in patients whose condition is resistant to empirical therapy but its yield in this setting is low because of the poor correlation between symptoms attributed to the condition and endoscopic features of the disease. Clinical experience suggests that lifestyle modifications may be beneficial for gastroesophageal reflux disease although trials of the clinical efficacy of dietary or behavioral changes are lacking. Abundant data from randomized trials show benefits of inhibiting gastric acid secretion and suggest that proton-pump inhibitors are superior to H2-blockers and that both are superior to placebo. In patients with Barrett's esophagus, antireflux interventions are intended to control symptoms of reflux and promote healing of the esophageal mucosa. If a patient has symptoms refractory to proton-pump inhibitors or cannot tolerate such therapy, antireflux surgery, most commonly Nissen fundoplication, may be an alternative management approach. In patients with high-grade dysplasia, endoscopic therapies or surgical resection must be considered.

Ear, Nose, and Throat Manifestations during Pregnancy

Objective. The objective of this clinical review is to highlight the otolaryngological symptoms that occur in pregnancy. Where available, the authors discuss the current evidence of the etiology and management of the various presentations. While it is appreciated that many of these complaints are transient, their impact on the maternal quality of life can be significant, and therefore, medical practitioners should be aware of what to expect in order to provide reassurance to patients and also to safely manage such symptoms.

Data Sources. MEDLINE and EMBASE databases were searched for publications related to otolaryngology and pregnancy.

Review Methods. All literature was searched for and reviewed by 2 authors independently. Search results were then cross-examined, and any differences were settled by consensus.

Results. Pregnancy leads to circulatory changes and increased susceptibility to viral reactivation, and along with the exertion of parturition, it can lead to tinnitus, facial palsies, and deafness. Rising levels of sex hormones and heightened sensitivity to allergens may influence the nasal mucosa, precipitating epistaxis and rhinitis. Increased progesterone and the increased intra-abdominal pressure of the growing fetus can lead to symptoms and sequelae of laryngopharyngeal reflux. Evidence for the treatment of pregnancy-induced symptoms is principally restricted to case reports and retrospective studies.

Conclusion. Recognition and understanding of pregnancy-related ear, nose, and throat complaints will allow otolaryngologists to reassure and manage these patients, improving their experience of the gestational period. High-quality evidence for their management is limited, with further research required.

Adverse effects of long-term proton pump inhibitor therapy

Proton pump inhibitors have an excellent safety profile and have become one of the most commonly prescribed class of drugs in primary and specialty care. Long-term, sometimes lifetime, use is becoming increasingly common, often without appropriate indications. This paper is a detailed review of the current evidence on this important topic, focusing on the potential adverse effects of long-term proton pump inhibitor use that have generated the greatest concern: B12 deficiency; iron deficiency; hypomagnesemia; increased susceptibility to pneumonia, enteric infections, and fractures; hypergastrinemia and cancer; drug interactions; and birth defects. We explain the pathophysiological mechanisms that may underlie each of these relationships, review the existing evidence, and discuss implications for clinical management. The benefits of proton pump inhibitor use outweigh its risks in most patients. Elderly, malnourished, immune-compromised, chronically ill, and osteoporotic patients theoretically could be at increased risk from long-term therapy.

Short and long-term PPI treatment for GERD. Do we need more-potent anti-secretory drugs?

Because the reflux of the acidic gastric content into the esophagus plays a major role in the pathogenesis of symptoms of GERD and lesions of erosive esophagitis, acid suppression with a proton pump inhibitor (PPI) is currently the mainstay of anti-reflux therapy. There is a strong correlation between the degree of acid suppression provided by a given drug and its efficacy. The superiority of PPIs over other drugs (antacids, prokinetics and H(2)-receptor antagonists) has now been established beyond doubt, both for short- and long-term treatment. However, there are still some unmet therapeutic needs in GERD; hence, patients with non-erosive reflux disease (NERD) are less responsive to PPIs than those with erosive esophagitis. Moreover, the efficacy of PPIs in patients with atypical symptoms is frequently limited to the relief of associated heartburn or regurgitation. With respect to safety, although most studies on short- and long-term PPI use have provided reassuring data, recent reports have drawn attention to potential side effects or drug-drug interference. Better healing rates in the most severe forms of esophagitis, or a faster onset of symptom relief, may require optimization of acid suppressive therapy with regard to the daily course of acid secretion, especially during the night. Different pharmacological approaches can be considered, with the ultimate goals of achieving faster, stronger and more-sustained acid inhibition. How a better pharmacological profile may translate into clinical benefit should now be tested in appropriate, controlled studies.

Use of proton-pump inhibitors in early pregnancy and the risk of birth defects

BACKGROUND

Symptoms of gastroesophageal reflux are common in pregnancy, but there are limited data on the risk of birth defects associated with exposure to proton-pump inhibitors (PPIs) in early pregnancy.

METHODS

We conducted a cohort study to assess the association between exposure to PPIs during pregnancy and the risk of major birth defects among all infants born alive in Denmark between January 1996 and September 2008. We linked data from nationwide registries, including individual-level information on exposure to PPIs (prescriptions), birth defects, and potential confounders. Major birth defects, diagnosed within the first year of life, were categorized according to the standardized classification scheme of the European surveillance of congenital anomalies (EUROCAT). Our primary analyses assessed the use of PPIs from 4 weeks before conception through 12 weeks of gestation and from 0 through 12 weeks of gestation (first trimester).

RESULTS

Among 840,968 live births, 5082 involved exposure to PPIs between 4 weeks before conception and the end of the first trimester of pregnancy. There were 174 major birth defects in infants whose mothers had been exposed to PPIs during this period (3.4%), as compared with 21,811 in the group whose mothers had not been exposed (2.6%) (adjusted prevalence odds ratio, 1.23; 95% confidence interval [CI], 1.05 to 1.44). In analyses limited to exposure during the first trimester, there were 118 major birth defects among 3651 infants exposed to PPIs (3.2%), and the adjusted prevalence odds ratio was 1.10 (95% CI, 0.91 to 1.34). The risk of birth defects was not significantly increased in secondary analyses of exposure to individual PPIs during the first trimester or in analyses limited to the offspring of women who had filled PPI prescriptions and received enough doses to have a theoretical chance of first-trimester exposure.

CONCLUSIONS

In this large cohort, exposure to PPIs during the first trimester of pregnancy was not associated with a significantly increased risk of major birth defects. (Funded by the Danish Medical Research Council and the Lundbeck Foundation.).

Safety of proton pump inhibitor exposure

Proton pump (H(+)/K(+)-adenosine triphosphatase) inhibitors (PPIs) are widely used to treat patients with acid-related disorders because they are generally perceived to be safe and effective. However, as with any pharmacologic agent, they have the potential for side effects. Many studies have examined the side effects of long-term or short-term PPI exposure. We review the mechanism of action of PPIs, focusing on recently released products that might have greater risks of adverse effects than older products because of increased potency and/or duration of action. We summarize the data available on the putative adverse effects of PPI therapy and propose guidelines for clinicians who prescribe these agents to limit the potential for adverse outcomes in users of these effective therapeutic agents.

The effect of Acid-reducing pharmacotherapy on the severity of nausea and vomiting of pregnancy

Background. Heartburn and acid reflux (HB/RF) are associated with increased severity of nausea and vomiting. The ability of acid-reducing drugs to reduce symptoms of nausea and vomiting of pregnancy has not been previously tested. Objective. To determine whether acid-reducing pharmacotherapy decreases the severity of NVP symptoms. Methods. We studied a cohort of women experiencing NVP, who were also experiencing HB/RF. Women were counseled to commence acid-reducing pharmacotherapy. The effectiveness of the acid-reducing medication in decreasing symptoms of both HB/RF and NVP was measured. Results. Acid-reducing drugs resulted in significant decreases in PUQE (9.6 ± 3.0 to 6.5 ± 2.5, P < .0001) and well-being scores from the initial (4.0 ± 2.0) to the follow-up interview (6.8 ± 1.6, P < .0001). After intervention with acid-reducing pharmacotherapy, a reduction in acid symptoms correlated significantly with reduction in NVP (R² = 0.72, P < .001). Conclusion. This is the first study to demonstrate that management of HB/RF can reduce the severity of NVP.

The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis

OBJECTIVES

Heartburn and acid reflux are common medical disorders in pregnancy and can result in serious discomfort and complications. Furthermore, some pregnant women also experience more severe gastrointestinal conditions, such as Helicobacter pylori infections, peptic ulcers, and Zollinger-Ellison syndrome. To allow the use of proton pump inhibitors (PPIs) in pregnancy, the fetal safety of this drug class must be established. The aim of this study is to determine the fetal safety of PPIs during early pregnancy through systematic literature review.

METHODS

All original research assessing the safety of PPIs in pregnancy was sought from inception to July 2008. Two independent reviewers identified articles, compared results, and settled differences through consensus. The Downs-Black scale was used to assess quality. Data assessed included congenital malformations, spontaneous abortions, and preterm delivery. A random effects meta-analysis combined the results from included studies.

RESULTS

Of the 60 articles identified, 7 met our inclusion criteria. Using data from 134,940 patients, including 1,530 exposed and 133,410 not exposed to PPIs, the overall odds ratio (OR) for major malformations was 1.12 (95% confidence interval, CI: 0.86-1.45). Further analysis revealed no increased risk for spontaneous abortions (OR=1.29, 95% CI: 0.84-1.97); similarly, there was no increased risk for preterm delivery (OR=1.13, 95% CI: 0.96-1.33). In the secondary analysis of 1,341 exposed and 120,137 not exposed to omeprazole alone, the OR and 95% CI for major malformations were 1.17 and 0.90-1.53, respectively.

CONCLUSIONS

On the basis of these results, PPIs are not associated with an increased risk for major congenital birth defects, spontaneous abortions, or preterm delivery. The narrow range of 95% CIs is further reassuring, suggesting that PPIs can be safely used in pregnancy.

Proton pump inhibitors: actions and reactions

Proton pump inhibitors are the second most commonly prescribed drug class in the United States. The increased utilization of PPIs parallels the rising incidence of reflux disease. Owing to their clinical efficacy and relative lack of tachyphylaxis, PPIs have largely displaced H-2 receptor antagonists in the treatment of acid peptic disorders. The elevation of intragastric pH and subsequent alterations of gastric physiology induced by PPIs may yield undesired effects within the upper GI tract. The ubiquity of the various types of H(+), K(+)-ATPase could also contribute to non-gastric effects. PPIs may influence physiology in other ways, such as inducing transepithelial leak.

Esomeprazole: a proton pump inhibitor

Proton pump inhibitors (PPIs) are the most potent inhibitors of gastric acid secretion available, and they are effective for treating all acid-related disorders. Esomeprazole is one of several most recent PPIs that became available to the market in 2001. Esomeprazole is indicated for the treatment of gastroesophageal reflux disease in adults and children, risk reduction of NSAIDs-associated gastric ulcer, Helicobacter pylori eradication and control of pathological hypersecretory conditions associated with Zollinger-Ellison syndrome. Esomeprazole is available in both oral and intravenous formulations. A number of studies have compared esomeprazole with other PPIs. While differences supporting esomeprazole have been reported, the magnitude of differences has been variable and of uncertain clinical importance. Cost plays a major role in prescribing patterns of PPIs.

Clinical practice. Gastroesophageal reflux disease

A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment?

Interventions for heartburn in pregnancy

BACKGROUND

Heartburn is a common symptom in pregnancy affecting up to 80% of women in the third trimester. The reasons for the increase in symptoms in pregnancy are not well understood, but the effects of pregnancy hormones on the lower oesophageal sphincter and gastric clearance are thought to play a part. A range of interventions have been used to relieve symptoms including advice on diet and lifestyle, antacids, antihistamines, and proton pump inhibitors. The safety and effectiveness of these interventions to relieve heartburn in pregnancy have not been established.

OBJECTIVES

To assess the effect of interventions to relieve heartburn in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2008).

SELECTION CRITERIA

We included randomised controlled trials evaluating interventions to relieve heartburn.

DATA COLLECTION AND ANALYSIS

We assessed eligibility for inclusion and extracted data independently.

MAIN RESULTS

Three studies were eligible for inclusion, together they included a total of 286 women. All three were placebo controlled trials, each examining a different medication to relieve heartburn (intramuscular prostigmine, an antacid preparation and an antacid plus ranitidine). All three produced positive findings in favour of the intervention groups. It was not possible to pool findings from studies to produce an overall treatment effect.

AUTHORS' CONCLUSIONS

There was little information to draw conclusions on the overall effectiveness of interventions to relieve heartburn in pregnancy.

Proton pump inhibitors: an update of their clinical use and pharmacokinetics

BACKGROUND

Proton pump inhibitors (PPIs) represent drugs of first choice for treating peptic ulcer, Helicobacter pylori infection, gastrooesophageal reflux disease, nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal lesions (complications), and Zollinger-Ellison syndrome.

RESULTS

The available agents (omeprazole/esomeprazole, lansoprazole, pantoprazole, and rabeprazole) differ somewhat in their pharmacokinetic properties (e.g., time-/dose-dependent bioavailability, metabolic pattern, interaction potential, genetic variability). For all PPIs, there is a clear relationship between drug exposure (area under the plasma concentration/time curve) and the pharmacodynamic response (inhibition of acid secretion). Furthermore, clinical outcome (e.g., healing and eradication rates) depends on maintaining intragastric pH values above certain threshold levels. Thus, any changes in drug disposition will subsequently be translated directly into clinical efficiency so that extensive metabolizers of CYP2C19 will demonstrate a higher rate of therapeutic nonresponse.

CONCLUSIONS

This update of pharmacokinetic, pharmacodynamic, and clinical data will provide the necessary guide by which to select between the various PPIs that differ-based on pharmacodynamic assessments-in their relative potencies (e.g., higher doses are needed for pantoprazole and lansoprazole compared with rabeprazole). Despite their well-documented clinical efficacy and safety, there is still a certain number of patients who are refractory to treatment with PPIs (nonresponder), which will leave sufficient space for future drug development and clinical research.

Treating common problems of the nose and throat in pregnancy: what is safe?

Although all kinds of medications should be avoided during pregnancy, the majority of pregnant women receive at least one drug and 6% of them during the high-risk period of the first trimester. The aim of the present paper is to discuss the appropriate management of rhinologic and laryngeal conditions that may be encountered during pregnancy. A literature review from Medline and database sources was carried out. Related books and written guidelines were also included. Controlled clinical trials, prospective and retrospective studies, case-control studies, laboratory studies, clinical and systematic reviews, metanalyses, and case reports were analysed. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), clindamycin, metronidazole (better avoided in the first trimester), amphotericin-B (especially in immunocompromised situations during the second and third trimester) and acyclovir. First-line antituberculous agents isoniazid, ethambutol, pyrazinamide, and ciprofloxacine in drug-resistant tuberculosis can be also used. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, second generation antihistamines (cetirizine in the third trimester, or loratadine in the second and third trimester), H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole) can be used to relieve patients from the related symptoms. In cases of emergencies, epinephrine, prednisone, prednisolone, methylprednisolone, dimetindene and nebulised b(2) agonists can be used with extreme caution. By contrast, selective COX-2 inhibitors and BCG vaccination are contraindicated in pregnancy. When prescribing to a pregnant woman, the safety of the materno-foetal unit is considered paramount. Although medications are potentially hazardous, misconceptions and suboptimal treatment of the mother might be more harmful to the unborn child. Knowledge update is necessary to avoid unjustified hesitations and provide appropriate counselling and treatment for pregnant women.

Omeprazole stimulates the induction of human insulin-like growth factor binding protein-1 through aryl hydrocarbon receptor activation

5-Methoxy-2-{(4-methoxy-3,5-dimethyl-pyridin-2-yl)methylsulfinyl}-3H-benzoimidazole (omeprazole), a benzoimidazole-derived gastric H(+)/K(+)-ATPase proton pump inhibitor (PPI) extensively prescribed for the treatment of gastroesophageal acid reflux disease, can stimulate the expression of CYP1A1 via activation of the human aryl hydrocarbon receptor (hAhR) in an apparent nonligand-binding manner. Here, we have examined the effect of nonclassical, i.e., nonligand binding, AhR activation by omeprazole upon human insulin-like growth factor binding protein (hIGFBP)-1, a secreted phosphoprotein involved in regulation of insulin-like growth factor-I/II bioavailability and mitogenic activity. Analysis of the proximal promoter of the hIGFBP-1 gene reveals the presence of an aryl hydrocarbon binding/dioxin response element (DRE). Quantitative mRNA analysis revealed hIGFBP-1 expression to be responsive to both ligand (TCDD) and nonligand (omeprazole) modes of hAhR activation in the human hepatocarcinoma HepG2 cell line. Furthermore, mutagenesis of the DRE renders the hIGFBP-1 promoter unresponsive to both compounds in HepG2 cells. Likewise, small interfering RNA-mediated hAhR ablation inhibits TCDD and omeprazole-dependent hIGFBP-1 induction, as determined by quantitative mRNA analysis. Cotreatment with cycloheximide further suggests a direct transcriptional role for hAhR at the hIGFBP-1 promoter. Omeprazole exposure prompted a significant increase in both hIGFBP-1 mRNA and secreted protein from HepG2 cells. In addition, we present in vitro evidence indicating that omeprazole at a concentration comparable with that found circulating in subjects undergoing PPI therapy can stimulate the expression of hIGFBP-1. These data demonstrate that activation of hAhR by pharmaceuticals such as omeprazole can alter IGFBP-1 expression and thus may influence IGFBP-1-dependent physiological processes.

Treating common ear problems in pregnancy: what is safe?

In everyday practise, more than 80% of pregnant women receive one at least medication, often for ENT causes. The aim of the present paper is to review the literature on safety and administration of medical treatment for ear diseases, in pregnant women. The literature review includes Medline and database sources. Electronic links, related books and written guidelines were also included. The study selection was as follows: controlled clinical trials, prospective trials, case-control studies, laboratory studies, clinical reviews, systematic reviews, metanalyses, and case reports. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), and acyclovir. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, first generation antihistamines, or cetirizine (third trimester) and loratadine (second and third trimester) from the second generation, H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole), can be used to relieve patients from the related symptoms. Meclizine and dimenhydrinate, as antiemetics in vertigo attacks; metoclopramide, vitamin B6 and ginger rhizome, alternatively. Low-dose diazepam and diuretics in severe cases of Meniere's disease (with caution). Systemic administration of prednisone and prednisolone can be considered in selected cases. By contrast, selective COX-2 inhibitors, betahistine and vasodilating agents are contraindicated in pregnancy. Since otologic and neurotologic manifestations during pregnancy tend to seriously affect the quality of life of the expectant mothers, ENT surgeons should familiarise themselves with the basic guidelines and safety precautions for any related medication, in order to provide appropriate treatment.

Gastroesophageal reflux disease in pregnancy

Gastroesophageal reflux disease during pregnancy is common. Altered structure and function of the normal physiological barriers to reflux of gastric contents into the oesophagus explain the high incidence of this problem in pregnant women. For the majority of patients, life-style modifications are helpful, but are not sufficient to control symptoms and medication is required. The optimum management of reflux in pregnant patients requires special attention and expertise, since the safety of the mother, foetus and neonate remain the primary focus. Gastroenterologists and obstetricians should work together to optimise treatment. Typically, one utilises a step-up program that starts with life-style modifications and antacids. If those methods fail, histamine-2 receptor antagonists and proton pump inhibitors are tried. Rarely, promotility agents are used. Initiation of these medications must be undertaken after a careful discussion of risks and benefits with patients. In patients without a prior history of reflux, symptoms usually abate after delivery.

Gastrointestinal medications in pregnancy

Management of the pregnant patient presents unique challenges to the treating physician. Current Food and Drug Administration classifications do not necessarily reflect clinical experience or recent literature. Ideally, one should use the lowest-risk drug possible, with attention to the appropriate level of efficacy for the patient's condition, the stage of pregnancy and dose adjustment. Every treatment decision should be fully discussed with the patient and a multidisciplinary team that should include the obstetrician and, if appropriate, the paediatrician. This review will cover the medications commonly used to treat gastrointestinal disease. The majority of medications can be categorised as 'low risk' or 'should be avoided'. The following medications should never be used during pregnancy due to the clear risk of teratogenicity or adverse events: bismuth, castor oil, sodium bicarbonate, methotrexate, ribavirin, doxycycline, tetracycline, and thalidomide.

The safety of pharmacological therapies for gastrointestinal conditions encountered during pregnancy

Properly assessing the safety of pharmacological therapies for gastrointestinal conditions encountered during pregnancy is a challenge on account of both the often limited controlled data available and the potentially confounding effect of the underlying disorders requiring treatment on fetal outcomes. Here, the available data with regard to gastrointestinal disorders specific to pregnancy, those that may be precipitated or exacerbated by pregnancy and those that may be pre-existing or arise concurrently during pregnancy are reviewed.

Zollinger Ellison syndrome, treated with lansoprazole, during pregnancy

BACKGROUND

Zollinger Ellison syndrome (ZES), an ulcerative disease of the upper gastrointestinal tract that involves the production of high levels of gastrin and gastric acid, is a rare, symptomatic, endocrine neoplastic disease.

CASE

We report a rare case of gastrinoma that was first diagnosed during pregnancy in which the primary tumor was located in the liver. The ZES was well controlled with Zoton (Lansoprazole) following surgery. The patient had an uneventful pregnancy and delivery without significant complications.

CONCLUSIONS

The present case suggests that treatment with Zoton for ZES during pregnancy is safe and effective.

Case Studies

Ms A was a 28 year old woman in her second pregnancy (she had one previous termination of pregnancy) who booked-in at 19 weeks’ gestation. She was known to have sickle cell disease (specifically sickle cell anaemia [HbSS]), and her last crisis had occurred 3 years before this pregnancy.

American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on February 22, 2006 and by the AGA Institute Governing Board on April 20, 2006.

Review article: the management of heartburn in pregnancy

Heartburn is a normal consequence of pregnancy. The predominant aetiology is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. Serious reflux complications during pregnancy are rare; hence upper endoscopy and other diagnostic tests are infrequently needed. Gastro-oesophageal reflux disease during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line drug therapy. If symptoms persist, any of the histamine2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. All but omeprazole are FDA category B drugs during pregnancy. Most drugs are excreted in breast milk. Of systemic agents, only the histamine2-receptor antagonists, with the exception of nizatidine, are safe to use during lactation.