Psyllium laxative-induced anaphylaxis, asthma, and rhinitis

Interventions for treating constipation in pregnancy

BACKGROUND

Constipation is a common symptom experienced during pregnancy. It has a range of consequences from reduced quality of life and perception of physical health to haemorrhoids. An understanding of the effectiveness and safety of treatments for constipation in pregnancy is important for the clinician managing pregnant women.

OBJECTIVES

To assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We considered all published, unpublished and ongoing randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs, evaluating interventions (pharmacological and non-pharmacological) for constipation in pregnancy. Cross-over studies were not eligible for inclusion in this review. Trials published in abstract form only (without full text publication) were not eligible for inclusion.We compared one intervention (pharmacological or non-pharmacological) against another intervention, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Four studies were included, but only two studies with a total of 180 women contributed data to this review. It was not clear whether they were RCTs or quasi-RCTs because the sequence generation was unclear. We classified the overall risk of bias of three studies as moderate and one study as high risk of bias. No meta-analyses were carried out due to insufficient data.There were no cluster-RCTs identified for inclusion. Comparisons were available for stimulant laxatives versus bulk-forming laxatives, and fibre supplementation versus no intervention. There were no data available for any other comparisons.During the review process we found that studies reported changes in symptoms in different ways. To capture all data available, we added a new primary outcome (improvement in constipation) - this new outcome was not prespecified in our published protocol. Stimulant laxatives versus bulk-forming laxativesNo data were identified for any of this review's prespecified primary outcomes: pain on defecation, frequency of stools and consistency of stools.Compared to bulk-forming laxatives, pregnant women who received stimulant laxatives had significantly more improvement in constipation (risk ratio (RR) 1.59, 95% confidence interval (CI) 1.21 to 2.09; 140 women, one study, moderate quality of evidence), but also significantly more abdominal discomfort (RR 2.33, 95% CI 1.15 to 4.73; 140 women, one study, low quality of evidence), and borderline difference in diarrhoea (RR 4.50, 95% CI 1.01 to 20.09; 140 women, one study, moderate quality of evidence). In addition, there was no significant difference in women's satisfaction (RR 1.06, 95% CI 0.77 to 1.46; 140 women, one study, moderate quality of evidence).No usable data were identified for any of this review's secondary outcomes: quality of life; dehydration; electrolyte imbalance; acute allergic reaction; or asthma. Fibre supplementation versus no interventionPregnant women who received fibre supplementation had significantly higher frequency of stools compared to no intervention (mean difference (MD) 2.24 times per week, 95% CI 0.96 to 3.52; 40 women, one study, moderate quality of evidence). Fibre supplementation was associated with improved stool consistency as defined by trialists (hard stool decreased by 11% to 14%, normal stool increased by 5% to 10%, and loose stool increased by 0% to 6%).No usable data were reported for either the primary outcomes of pain on defecation and improvement in constipation or any of this review's secondary outcomes as listed above. Quality Five outcomes were assessed with the GRADE software: improvement in constipation, frequency of stools, abdominal discomfort, diarrhoea and women's satisfaction. These were assessed to be of moderate quality except for abdominal discomfort which was assessed to be of low quality. The results should therefore be interpreted with caution. There were no data available for evaluation of pain on defecation or consistency of stools.

AUTHORS' CONCLUSIONS

There is insufficient evidence to comprehensively assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy, due to limited data (few studies with small sample size and no meta-analyses). Compared with bulk-forming laxatives, stimulant laxatives appear to be more effective in improvement of constipation (moderate quality evidence), but are accompanied by an increase in diarrhoea (moderate quality evidence) and abdominal discomfort (low quality evidence) and no difference in women's satisfaction (moderate quality evidence). Additionally, fibre supplementation may increase frequency of stools compared with no intervention (moderate quality evidence), although these results were of moderate risk of bias.There were no data for a comparison of other types of interventions, such as osmotic laxatives, stool softeners, lubricant laxatives and enemas and suppositories.More RCTs evaluating interventions for treating constipation in pregnancy are needed. These should cover different settings and evaluate the effectiveness of various interventions (including fibre, osmotic, and stimulant laxatives) on improvement in constipation, pain on defecation, frequency of stools and consistency of stools.

Occupational asthma related to aescin inhalation

BACKGROUND

More than 400 agents are recognized as causes of occupational asthma, a work-related disease that can be induced by an immunologic or a nonimmunologic mechanism.

OBJECTIVE

To describe a 57-year-old man employed in the pharmaceutical industry who developed bronchial asthma while working with products such as Plantago ovata and aescin, an active ingredient with anti-inflammatory and venotonic properties.

METHODS

Various tests were performed, including radiography, total serum IgE titer measurements, skin tests against common pneumoallergens and Plantago species, pulmonary function studies, a methacholine test, and specific inhalation challenge with P. ovata and aescin.

RESULTS

The results of these tests, including specific inhalation challenge, confirmed the diagnosis of occupational asthma due to aescin exposure, whereas the results of specific challenge with P. ovata, a known cause of occupational asthma, were negative.

CONCLUSIONS

Aescin may represent a new causative agent of occupational asthma in personnel working in the pharmaceutical industry. The mechanism by which aescin can produce asthma is unknown, but analysis of the characteristics of our patient suggests a non-IgE immunologic mechanism, although an irritative mechanism secondary to long-term low-level exposure to aescin, a possible irritant, cannot be ruled out.

Adverse events of herbal food supplements for body weight reduction: systematic review

Herbal weight-loss supplements are marketed with claims of effectiveness. Our earlier systematic review identified data from double-blind, randomized controlled trials for a number of herbal supplements. The aim of this systematic review was to assess all clinical evidence of adverse events of herbal food supplements for body weight reduction for which effectiveness data from rigorous clinical trials exist. We assessed Ephedra sinica, Garcinia cambogia, Paullinia cupana, guar gum, Plantago psyllium, Ilex paraguariensis and Pausinystalia yohimbe. Literature searches were conducted on Medline, Embase, Amed and The Cochrane Library. Data were also requested from the spontaneous reporting scheme of the World Health Organization. We hand-searched relevant medical journals and our own files. There were no restrictions regarding the language of publication. The results show that adverse events including hepatic injury and death have been reported with the use of some herbal food supplements. For herbal ephedra and ephedrine-containing food supplements an increased risk of psychiatric, autonomic or gastrointestinal adverse events and heart palpitations has been reported. In conclusion, adverse events are reported for a number of herbal food supplements, which are used for reducing body weight. Although the quality of the data does not justify definitive attribution of causality in most cases, the reported risks are sufficient to shift the risk-benefit balance against the use of most of the reviewed herbal weight-loss supplements. Exceptions are Garcinia cambogia and yerba mate, which merit further investigation.

Psyllium-associated anaphylaxis and death: a case report and review of the literature

BACKGROUND

Psyllium use has increased significantly in the United States in part due to its lipid-lowering property. The increased prevalence of consumption has led to its recognition as an emerging food allergen.

OBJECTIVES

To report the case of a 42-year-old woman who experienced fatal anaphylaxis after ingesting a psyllium-based product and to review the literature.

METHODS

The MEDLINE database was searched for articles from 1966 to 2002 using the keywords psyllium or ispaghula and each of the following: allergy, hypersensitivity, anaphylaxis, and asthma. Both English and non-English articles were included.

RESULTS

Psyllium hypersensitivity has been well described in health care workers and pharmaceutical plant employees. Clinical manifestations of allergy range from upper respiratory tract symptoms on inhalation to anaphylaxis on ingestion. The prevalence of sensitization varies between these 2 groups. The allergenic epitope is not known.

CONCLUSIONS

We present a case of psyllium hypersensitivity that resulted in death. There is a clear association between atopy and psyllium allergy. The case underscores the fact that even nonprescription "natural" products can be harmful to people with allergies.

Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting

BACKGROUND

Gastro-oesophageal reflux disease (GERD) and constipation have a major impact on public health; however, the wide variety of treatment options presents difficulties for recommending therapy. Lack of definitive guidelines in pharmacy and general practice medicine further exacerbates the decision dilemma.

AIMS

To address these issues, a panel of experts discussed the principles and practice of treating GERD and constipation in the general population and in pregnancy, with the aim of developing respective treatment guidelines.

RESULTS

The panel recommended antacids 'on-demand' as the first-line over-the-counter treatment in reflux, and as rescue medication for immediate relief when reflux breaks through with proton pump inhibitors. Calcium/magnesium-based antacids were recommended as the treatment of choice for pregnant women because of their good safety profile. In constipation, current data do not distinguish a hierarchy between polyethylene glycol (PEG)-based laxatives and other first-line treatments, although limitations are associated with stimulant- and bulk-forming laxatives. Where data are available, PEG is superior to lactulose in terms of efficacy. In pregnancy, PEG-based laxatives meet the criteria for the ideal treatment.

CONCLUSIONS

The experts developed algorithms that present healthcare professionals with clear treatment options and management strategies for GERD and constipation in pharmacy and general practice medicine.

Adverse effects of laxatives

Laxatives are among the most commonly used drugs or additives. Most are quite safe when used judiciously, intermittently when possible, and in the absence of contraindications. Bulking agents and nonabsorbable compounds such as lactulose can cause bloating but have very few serious adverse effects except for the allergic reaction to psyllium preparations. Osmotic laxatives containing poorly absorbable ions such as magnesium or phosphate can cause metabolic disturbances, particularly in the presence of renal impairment. However, if taken intermittently, in the absence of conditions such as ileus or bowel obstruction, they have few adverse effects. Polyethylene glycol solutions are emerging as an effective and safe mode of treatment for chronic constipation. Of stimulant laxatives, senna compounds and bisacodyl are the most commonly used. Although there are data to support the neoplastic potential of this class of drugs in in vitro studies, epidemiologic data in humans so far has not established a clear link between these laxatives and colonic neoplasia. The link between stimulant laxatives and structural changes, such as the "cathartic colon" or enteric nerve damage, is not well established either. Danthron compounds should be avoided because of hepatotoxicity.

Occupational airway sensitizers: an overview on the respective literature

BACKGROUND

Worldwide, there is rigorous scientific activity concerning the further development of work safety regulations involving airway-sensitizing substances. Technical directives on hazardous substances are enforced in several countries and are being continuously updated. The European Union has established a code for several occupational substances, now labeled R 42 ("may cause sensitization by inhalation").

METHODS

We present an overview of the literature dealing with allergic occupational asthma. The literature was selected according to criteria of study design and diagnostic test methods. Approximately 300 publications were reviewed including both epidemiological studies and individual case reports.

RESULTS

Airway sensitizers are systematically arranged and separately listed according to chemicals and their origin from animals, plants, and microorganisms. The clinical data as well as threshold limit values (TLV) and R 42 labeling of 250 airway-sensitizing substances are presented.

CONCLUSIONS

The most common sensitizing substances causing occupational asthma were dust of cereal flours, enzymes, natural rubber latex, laboratory animals as well as low molecular substances such as isocyanates and acid anhydrides.