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Liu BD, Starkey M, Virani A, Pichette SL, Fass S, Song G. Review article: Functional dyspepsia and pregnancy-Effects and management in a special population. Aliment Pharmacol Ther 2023; 57:1375-1396. [PMID: 37129241 DOI: 10.1111/apt.17534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/23/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy. AIMS AND METHODS To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions. RESULTS Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD. CONCLUSIONS Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.
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Affiliation(s)
- Benjamin D Liu
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Morgan Starkey
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Aleena Virani
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Sandra L Pichette
- Department of Obstetrics and Gynecology, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Shira Fass
- Department of Psychiatry, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Gengqing Song
- Division of Gastroenterology and Hepatology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio, USA
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Altuwaijri M. Evidence-based treatment recommendations for gastroesophageal reflux disease during pregnancy: A review. Medicine (Baltimore) 2022; 101:e30487. [PMID: 36107559 PMCID: PMC9439837 DOI: 10.1097/md.0000000000030487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) occurs in approximately two-thirds of all pregnancies. Around 25% of pregnant women experience heartburn daily. Symptomatic GERD usually presents in the first trimester and progresses throughout pregnancy. The treatment goal is to alleviate heartburn and regurgitation without jeopardizing the pregnancy or its outcome. An English language electronic literature search of MEDLINE, EMBASE, and Cochrane Reviews was undertaken to identify randomized controlled trials, observational studies, management recommendations and reviews of GERD and its treatment during pregnancy. The search period was defined by the date of inception of each database. The treatment in a pregnant GERD patient should follow the step-up approach, starting with lifestyle modification as the first step. If heartburn is severe, medication should be started after consultation with a physician (Recommendation Grade C). The preferred choice of antacids is calcium-containing antacids (Recommendation Grade A). If symptoms persist with antacids Sucralfate can be introduced at a 1g oral tablet, 3 times daily (Recommendation Grade C). Followed by histamine-2 receptor antagonist (Recommendation Grade B). Inadequate control while on histamine-2 receptor antagonist and antacid may mandate a step-up to proton pump inhibitors along with antacids as rescue medication for breakthrough GERD (Recommendation Grade C). This article presented the treatment recommendations for pregnant women with typical GERD, based on the best available evidence.
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Affiliation(s)
- Mansour Altuwaijri
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- *Correspondence: Mansour Altuwaijri, Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia (e-mail: )
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Hansen C, Desrosiers TA, Wisniewski K, Strickland MJ, Werler MM, Gilboa SM. Use of antihistamine medications during early pregnancy and selected birth defects: The National Birth Defects Prevention Study, 1997-2011. Birth Defects Res 2020; 112:1234-1252. [PMID: 32657014 PMCID: PMC9168970 DOI: 10.1002/bdr2.1749] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/24/2020] [Accepted: 06/08/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND It is estimated that approximately 10-15% of pregnant women report antihistamine use during pregnancy. Although antihistamines are generally considered safe during pregnancy, results from published studies are inconsistent. METHODS Using a case-control study design we analyzed 41,148 pregnancies (30,091 cases and 11,057 controls) from the National Birth Defects Prevention Study (1997-2011). Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals for 64 birth defect groupings in relation to early pregnancy exposure to 14 distinct antihistamines. Models were adjusted for maternal age, race, parity, education level, prenatal care, folic acid use, smoking and alcohol use, and study site. RESULTS Approximately 13% of cases and controls were exposed to an antihistamine during early pregnancy. Analyses were restricted to those defects where more than five cases were exposed to the antihistamine of interest, generating 340 analyses which yielded 20 (5.9%) significant positive associations (adjusted ORs ranging from 1.21 to 4.34). CONCLUSIONS Only a few of our findings were consistent with previous studies. There is a lack of strong evidence to conclude that birth defects are associated with exposure to antihistamines during early pregnancy.
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Affiliation(s)
- Craig Hansen
- CDT Analytics, Adelaide, South Australia, Australia
| | - Tania A. Desrosiers
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Kathy Wisniewski
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Martha M. Werler
- Boston University School of Public Health, Boston, Massachusetts
| | - Suzanne M. Gilboa
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia
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Middleton PG, Gade EJ, Aguilera C, MacKillop L, Button BM, Coleman C, Johnson B, Albrechtsen C, Edenborough F, Rigau D, Gibson PG, Backer V. ERS/TSANZ Task Force Statement on the management of reproduction and pregnancy in women with airways diseases. Eur Respir J 2020; 55:13993003.01208-2019. [PMID: 31699837 DOI: 10.1183/13993003.01208-2019] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/30/2019] [Indexed: 11/05/2022]
Abstract
This European Respiratory Society/Thoracic Society of Australia and New Zealand statement outlines a review of the literature and expert opinion concerning the management of reproduction and pregnancy in women with airways diseases: asthma, cystic fibrosis (CF) and non-CF bronchiectasis. Many women with these diseases are now living into reproductive age, with some developing moderate-to-severe impairment of lung function in early adulthood. The statement covers aspects of fertility, management during pregnancy, effects of drugs, issues during delivery and the post-partum period, and patients' views about family planning, pregnancy and parenthood. The statement summarises current knowledge and proposes topics for future research, but does not make specific clinical recommendations.
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Affiliation(s)
- Peter G Middleton
- CF Research Group, Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, University of Sydney, Sydney, Australia
| | - Elisabeth J Gade
- Dept of Gynecology and Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Cristina Aguilera
- Dept of Clinical Pharmacology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Lucy MacKillop
- Oxford University Hospitals NHS Foundation Trust, Nuffield Dept of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Brenda M Button
- Dept of Medicine, Nursing and Health Sciences, Monash Institute of Medical Research, Monash University, Melbourne Australia
| | | | | | | | - Frank Edenborough
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield, UK
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Peter G Gibson
- Centre for Asthma and Respiratory Diseases, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Vibeke Backer
- Centre for Physical Activity Research, Rigshospitalet and Copenhagen University, Copenhagen, Denmark
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Li CM, Zhernakova A, Engstrand L, Wijmenga C, Brusselaers N. Systematic review with meta-analysis: the risks of proton pump inhibitors during pregnancy. Aliment Pharmacol Ther 2020; 51:410-420. [PMID: 31909512 DOI: 10.1111/apt.15610] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/14/2019] [Accepted: 11/23/2019] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Cheng Mei Li
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Science for Life Laboratory, Stockholm, Sweden.,Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Alexandra Zhernakova
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lars Engstrand
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Science for Life Laboratory, Stockholm, Sweden
| | - Cisca Wijmenga
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nele Brusselaers
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Science for Life Laboratory, Stockholm, Sweden
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Thélin CS, Richter JE. Review article: the management of heartburn during pregnancy and lactation. Aliment Pharmacol Ther 2020; 51:421-434. [PMID: 31950535 DOI: 10.1111/apt.15611] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/15/2019] [Accepted: 11/24/2019] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Camille S Thélin
- Division of Digestive Diseases & Nutrition, Department of Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Joel E Richter
- Joy Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases & Nutrition, Department of Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Zachariah SK, Fenn M, Jacob K, Arthungal SA, Zachariah SA. Management of acute abdomen in pregnancy: current perspectives. Int J Womens Health 2019; 11:119-134. [PMID: 30804686 PMCID: PMC6371947 DOI: 10.2147/ijwh.s151501] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.
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Affiliation(s)
- Sanoop Koshy Zachariah
- Department of General, Gastrointestinal & Laparoscopic Surgery, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India,
| | - Miriam Fenn
- Department of Obstetrics and Gynecology, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India
| | - Kirthana Jacob
- Department of Obstetrics and Gynecology, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India
| | - Sherin Alias Arthungal
- Department of General, Gastrointestinal & Laparoscopic Surgery, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India,
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Robinson LB, Camargo CA. Acid suppressant medications and the risk of allergic diseases. Expert Rev Clin Immunol 2018; 14:771-780. [PMID: 30113236 PMCID: PMC6332498 DOI: 10.1080/1744666x.2018.1512405] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acid suppressant medications (ASMs), such as proton pump inhibitors and histamine-2 receptor antagonists, are used often and throughout the lifespan. These medications have been linked to the development of a variety of allergic diseases. Areas covered: This review discusses prior studies investigating the association between acid ASM exposure and the development of allergic diseases. We performed a thorough literature search to identify potentially relevant studies for inclusion. In summary, exposure to these medications prenatally, in childhood and in adulthood, may increase the risk of allergic diseases. The current evidence is limited by primarily observational study design and potential bias and confounding. The mechanism of action is not yet known, but there are several proposed theories. Expert commentary: There is a growing body of evidence to support that exposure to acid ASMs increases the risk of developing allergic diseases. Further research is needed to not only clarify this relationship but to define the potential mechanism of action. If further research confirms these observations, we believe that could warrant changes in the patterns of prescribing and use of acid ASMs.
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Affiliation(s)
- Lacey B. Robinson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Cox 201 Boston MA 02114, USA.
| | - Carlos A. Camargo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Cox 201 Boston MA 02114, USA.
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston MA 02114, USA.
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9
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Panchaud A, Di Paolo ER, Koutsokera A, Winterfeld U, Weisskopf E, Baud D, Sauty A, Csajka C. Safety of Drugs during Pregnancy and Breastfeeding in Cystic Fibrosis Patients. Respiration 2016; 91:333-48. [PMID: 26942733 DOI: 10.1159/000444088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/13/2016] [Indexed: 11/19/2022] Open
Abstract
Health management of cystic fibrosis (CF) patients should be maximized during pregnancy and breastfeeding because of its significant impact on the maternal and newborn outcomes. Thus, numerous drugs will have to be continued during pregnancy and lactation. Most of the drugs representing CF treatment lines cross the placenta or are excreted into human milk. Research addressing the risks and benefits of drugs used in CF patients during pregnancy and lactation is often incomplete or challenged by limited methodology, which often leads to conflicting or inconclusive results. Yet, potential treatment benefits for CF pregnant patients most often outbalance potential risks for the unborn child.
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Affiliation(s)
- Alice Panchaud
- School of Pharmaceutical Sciences, University of Geneva and University of Lausanne, Geneva, Switzerland
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10
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Yitshak-Sade M, Gorodischer R, Aviram M, Novack L. Prenatal exposure to H2 blockers and to proton pump inhibitors and asthma development in offspring. J Clin Pharmacol 2015; 56:116-23. [PMID: 26096778 DOI: 10.1002/jcph.574] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 06/12/2015] [Indexed: 01/08/2023]
Abstract
Fetal exposure to H2 blockers (H2 Bs) or proton pump inhibitors (PPIs) has been reported to be associated with asthma in children. We evaluated the risk of asthma in offspring following prenatal H2 Bs. We enrolled 91 428 children and their mothers who resided in southern Israel during 1998-2011. The computerized medications database was linked with records from the district hospital. Of the eligible children, 11 227 developed asthma, and overall 5.5% had been exposed to H2 Bs or PPIs prenatally. The risk of developing asthma was slightly higher in the group exposed to H2 Bs or PPIs (RR, 1.09; P = .023). At greater risk were children whose mothers purchased these medications more than 3 times (RR, 1.22; P = .038) or exposed to >20 defined daily doses or prenatally exposed to lansoprazole. The statistical association was significant and depended on magnitude of exposure and specific medication, but the absolute risk was low. The association between maternal consumption of H2 Bs or PPIs and asthma and childhood remained statistically significant 2 years after delivery, raising the possibility of confounding by the indication phenomenon. In view of the findings, a causal relationship could not be ascertained, and an unidentified etiological factor could be operative.
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Affiliation(s)
- Maayan Yitshak-Sade
- Clinical Research Center, Ben Gurion University of the Negev, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.,Soroka Medical Center, Beer-Sheva, Israel
| | - Rafael Gorodischer
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.,Soroka Medical Center, Beer-Sheva, Israel.,Department of Pediatrics, Ben Gurion University of the Negev, Beer-Sheva, Israel.,"Clalit" Health Services (Southern District), Beer-Sheva, Israel
| | - Micha Aviram
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.,Soroka Medical Center, Beer-Sheva, Israel.,Department of Pediatrics, Ben Gurion University of the Negev, Beer-Sheva, Israel.,"Clalit" Health Services (Southern District), Beer-Sheva, Israel
| | - Lena Novack
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.,Department of Public Health, Ben Gurion University of the Negev, Beer-Sheva, Israel
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11
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Gilboa SM, Ailes EC, Rai RP, Anderson JA, Honein MA. Antihistamines and birth defects: a systematic review of the literature. Expert Opin Drug Saf 2014; 13:1667-98. [PMID: 25307228 DOI: 10.1517/14740338.2014.970164] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Approximately 10 - 15% of women reportedly take an antihistamine during pregnancy for the relief of nausea and vomiting, allergy and asthma symptoms, or indigestion. Antihistamines include histamine H1-receptor and H2-receptor antagonists. AREAS COVERED This is a systematic evaluation of the peer-reviewed epidemiologic literature published through February 2014 on the association between prenatal exposure to antihistamines and birth defects. Papers addressing histamine H1- or H2-receptor antagonists are included. Papers addressing pyridoxine plus doxylamine (Bendectin in the United States, Debendox in the United Kingdom, Diclectin in Canada, Lenotan and Merbental in other countries) prior to the year 2001 were excluded post hoc because of several previously published meta-analyses and commentaries on this medication. EXPERT OPINION The literature on the safety of antihistamine use during pregnancy with respect to birth defects is generally reassuring though the positive findings from a few large studies warrant corroboration in other populations. The findings in the literature are considered in light of three critical methodological issues: i) selection of appropriate study population; ii) ascertainment of antihistamine exposures; and iii) ascertainment of birth defect outcomes. Selected antihistamines have been very well studied (e.g., loratadine); others, especially H2-receptor antagonists, require additional study before an assessment of safety with respect to birth defect risk could be made.
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Affiliation(s)
- Suzanne M Gilboa
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Birth Defects and Developmental Disabilities , Mail Stop E-86, 1600 Clifton Road, Atlanta, GA 30333 , USA , +1 404 498 4425 ;
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12
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Aldridge TD, Hartmann KE, Michels KA, Velez Edwards DR. First-trimester antihistamine exposure and risk of spontaneous abortion or preterm birth. Pharmacoepidemiol Drug Saf 2014; 23:1043-50. [PMID: 24789281 DOI: 10.1002/pds.3637] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 02/18/2014] [Accepted: 03/31/2014] [Indexed: 11/11/2022]
Abstract
PURPOSE We tested whether antihistamine exposure during early pregnancy is associated with spontaneous abortion (SAB) or preterm birth (PTB). METHODS Women were enrolled in Right from the Start (2004-2010), a prospective pregnancy cohort. Data about first-trimester antihistamine use were obtained from screening and first-trimester interviews. Self-reported outcomes included SAB and PTB and were verified by medical records. Cox proportional hazards models were used to test for an association between antihistamine use and each outcome, both performed adjusting for confounders. RESULTS Among the 2685 pregnancies analyzed, 14% (n = 377) reported use of antihistamines. Among antihistamine users, 12% (n = 44) experienced SABs, and 6% (n = 21) had PTBs. Antihistamine exposure was not associated with SAB (adjusted hazard ratio [aHR] = 0.88, 95% confidence interval [CI] 0.64, 1.21) or PTB, which was modified by maternal race (aHR = 1.03, 95%CI 0.61, 1.72 among White women and aHR = 0.43, 95%CI 0.14, 1.34 among Black women). CONCLUSIONS Despite the biologic plausibility that antihistamine use may influence pregnancy outcomes, we did not detect evidence of an association with SAB or PTB. These data demonstrate the utility of large prospective cohorts for evaluating drug safety in pregnancy when concerns are raised from animal models.
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Affiliation(s)
- Tiara D Aldridge
- Vanderbilt Epidemiology Center, Nashville, TN, USA; Vanderbilt University, Institute of Medicine and Public Health, Nashville, TN, USA; Vanderbilt University, Department of Obstetrics and Gynecology, Nashville, TN, USA
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13
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Etwel F, Hutson JR, Madadi P, Gareri J, Koren G. Fetal and Perinatal Exposure to Drugs and Chemicals: Novel Biomarkers of Risk. Annu Rev Pharmacol Toxicol 2014; 54:295-315. [DOI: 10.1146/annurev-pharmtox-011613-135930] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Fatma Etwel
- The Motherisk Program, Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada M5G 1X8;
| | - Janine R. Hutson
- The Motherisk Program, Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada M5G 1X8;
| | - Parvaz Madadi
- The Motherisk Program, Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada M5G 1X8;
| | - Joey Gareri
- The Motherisk Program, Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada M5G 1X8;
| | - Gideon Koren
- The Motherisk Program, Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada M5G 1X8;
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14
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Cannabidiol enhances xenobiotic permeability through the human placental barrier by direct inhibition of breast cancer resistance protein: an ex vivo study. Am J Obstet Gynecol 2013; 209:573.e1-573.e15. [PMID: 23933222 DOI: 10.1016/j.ajog.2013.08.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 07/29/2013] [Accepted: 08/05/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Drugs of abuse affect pregnancy outcomes, however, the mechanisms in which cannabis exerts its effects are not well understood. The aim of this study was to examine the influence of short-term (1-2 hours) exposure to cannabidiol, a major phytocannabinoid, on human placental breast cancer resistance protein function. STUDY DESIGN The in vitro effect of short-term exposure to cannabidoil on breast cancer resistance protein in BeWo and Jar cells (MCF7/P-gp cells were used for comparison) was tested with mitoxantrone uptake, and nicardipine was used as positive control. The ex vivo perfused cotyledon system was used for testing the effect of cannabidoil on glyburide transport across the placenta. Glyburide (200 ng/mL) was introduced to maternal and fetal compartments through a recirculating 2 hour perfusion, and its transplacental transport was tested with (n = 8) or without (n = 8) cannabidoil. RESULTS (1) Cannabidoil inhibition of breast cancer resistance protein-dependent mitoxantrone efflux was concentration dependent and of a noncell type specific nature (P < .0001); (2) In the cotyledon perfusion assay, the administration of cannabidoil to the maternal perfusion media increased the female/male ratio of glyburide concentrations (1.3 ± 0.1 vs 0.8 ± 0.1 at 120 minutes of perfusion, P < .001). CONCLUSION (1) Placental breast cancer resistance protein function is inhibited following even a short-term exposure to cannabidoil; (2) the ex vivo perfusion assay emphasize this effect by increased placental penetration of glyburide to the fetal compartment; and (3) these findings suggest that marijuana consumption enhances placental barrier permeability to xenobiotics and could endanger the developing fetus. Thus, the safety of drugs that are breast cancer resistance protein substrates is questionable during cannabis consumption by pregnant women.
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Abstract
PURPOSE OF REVIEW To review the recent advances and current controversies in patients with Zollinger-Ellison syndrome (ZES). RECENT FINDINGS Recent advances in the management of ZES include: improved understanding of the pathogenesis of gastrinoma and pancreatic neuroendocrine tumors, new prognostic classification systems, new diagnostic algorithms, more sensitive localization studies, new treatment strategies including improved control of gastric acid secretion and role for surgery, and new approaches to patients with advanced disease. Controversies include: the best approach to a patient with hypergastrinemia suspected of possibly having ZES, the appropriate gastrin assay to use, the role of surgery in patients with ZES, especially those with multiple endocrine neoplasia type 1, and the precise order of therapeutic modalities in the treatment of patients with advanced disease. SUMMARY This review updates clinicians regarding important advances and controversies required to optimally diagnose and manage patients with ZES.
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Affiliation(s)
- Tetsuhide Ito
- aDepartment of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan bDigestive Diseases Branch, NIDDK, NIH, Bethesda, Maryland, USA
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Feinshtein V, Erez O, Ben-Zvi Z, Erez N, Eshkoli T, Sheizaf B, Sheiner E, Huleihel M, Holcberg G. Cannabidiol changes P-gp and BCRP expression in trophoblast cell lines. PeerJ 2013; 1:e153. [PMID: 24058883 PMCID: PMC3775628 DOI: 10.7717/peerj.153] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/15/2013] [Indexed: 12/13/2022] Open
Abstract
Objectives. Marijuana is the most commonly used illicit drug during pregnancy. Due to high lipophilicity, cannabinoids can easily penetrate physiological barriers like the human placenta and jeopardize the developing fetus. We evaluated the impact of cannabidiol (CBD), a major non-psychoactive cannabinoid, on P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP) expression, and P-gp function in a placental model, BeWo and Jar choriocarcinoma cell lines (using P-gp induced MCF7 cells (MCF7/P-gp) for comparison). Study design. Following the establishment of the basal expression of these transporters in the membrane fraction of all three cell lines, P-gp and BCRP protein and mRNA levels were determined following chronic (24-72 h) exposure to CBD, by Western Blot and qPCR. CBD impact on P-gp efflux function was examined by uptake of specific P-gp fluorescent substrates (calcein-AM, DiOC2(3) and rhodamine123(rh123)). Cyclosporine A (CsA) served as a positive control. Results. Chronic exposure to CBD resulted in significant changes in the protein and mRNA levels of both transporters. While P-gp was down-regulated, BCRP levels were up-regulated in the choriocarcinoma cell lines. CBD had a remarkably different influence on P-gp and BCRP expression in MCF7/P-gp cells, demonstrating that these are cell type specific effects. P-gp dependent efflux (of calcein, DiOC2(3) and rh123) was inhibited upon short-term exposure to CBD. Conclusions. Our study shows that CBD might alter P-gp and BCRP expression in the human placenta, and inhibit P-gp efflux function. We conclude that marijuana use during pregnancy may reduce placental protective functions and change its morphological and physiological characteristics.
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Affiliation(s)
- Valeria Feinshtein
- Department of Clinical Biochemistry and Pharmacology, Ben-Gurion University of the Negev , Israel
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Abstract
INTRODUCTION The role of pharmacotherapy in the management of patients with Zollinger-Ellison syndrome (ZES) is often equated with the medical management of acid hypersecretion. However, pharmacotherapy is also increasingly involved in the other management areas of these patients. AREAS COVERED This paper reviews the role of pharmacotherapy in all aspects of the management of patients with ZES. Newer aspects are emphasized. This includes the difficulty of diagnosing ZES in patients taking proton pump inhibitors. Also covered is the role of pharmacotherapy in controlling acid hypersecretion and other hormonal hypersecretory states these patients may develop, including hyperparathyroidism in patients with multiple endocrine neoplasia type 1 and ZES; tumor localization; and the treatment of advanced metastatic disease. The last includes chemotherapy, liver-directed therapies, biotherapy (somatostatin/interferon), peptide radio-receptor therapy and molecular-targeted therapies including the use of mTor inhibitors (everolimus) and tyrosine kinase inhibitors (sunitinib). EXPERT OPINION Pharmacotherapy is now involved in all aspects of the management of patients with ZES, with the result that ZES has progressed from being considered an entirely surgical disease initially to the present where medical treatment plays a major role in almost all aspects of the management of these patients.
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Affiliation(s)
- Tetsuhide Ito
- Kyushu University, Graduate School of Medical Sciences, Department of Medicine and Bioregulatory Science, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cikos S, Fabian D, Makarevich AV, Chrenek P, Koppel J. Biogenic monoamines in preimplantation development. Hum Reprod 2011; 26:2296-305. [PMID: 21771767 DOI: 10.1093/humrep/der233] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The involvement of biogenic monoamines in early ('preneural') embryogenesis has been well documented in lower vertebrates, but much less information is available about the role of these molecules in the earliest stages of development in mammals, including humans. METHODS Databases (PubMed, ISI Web of Knowledge and Scopus) were searched for studies relating to biogenic monoamines functioning in early embryos. The available data on the expression of histamine, serotonin and adrenergic receptors during mammalian preimplantation development were summarized, and the potential roles of biogenic monoamines in very early pregnancy were discussed. RESULTS The roles of biogenic monoamines in mammalian preimplantation embryo development can be diverse, depending on the embryo developmental stage, and the physiological status of the maternal organism. Several receptors for biogenic monoamines are expressed and biologically functional in cells of preimplantation embryos. Activation of histamine receptors can play a role in embryo implantation and trophoblast invasion. Activation of adrenergic and serotonin receptors can influence proliferation and survival of early embryonic cells. CONCLUSIONS Biogenic monoamines can play an important role in physiological conditions, contributing to embryo-maternal interactions, or can influence the early embryo under unfavorable or pathological conditions (e.g. in maternal stress, or in women taking certain antidepressants, anti-migraine or anti-ulcer drugs).
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Affiliation(s)
- Stefan Cikos
- Institute of Animal Physiology, Slovak Academy of Sciences, Košice, Slovakia.
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Abstract
Historically, pregnancy in women with many inflammatory rheumatic diseases was not considered safe and was discouraged. Combined care allows these pregnancies to be managed optimally, with the majority of outcomes being favorable. Disease activity at the time of conception and anti-phospholipid antibodies are responsible for most complications. Disease flares, pre-eclampsia, and thrombosis are the main maternal complications, whereas fetal loss and intrauterine growth restriction are the main fetal complications. Antirheumatic drugs used during pregnancy and lactation to control disease activity are corticosteroids, hydroxychloroquine, sulphasalzine, and azathioprine. Vaginal delivery is possible in most circumstances, with cesarean section being reserved for complications.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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