Dr. Melanie Pinchbeck

GI Update 2013

May 11, 2013.

Faculty/Presenter Disclosure

• Faculty: Dr. Melanie Pinchbeck

• Relationships with commercial interests:

–Not Applicable

Disclosure of Commercial Support This program has received financial support from Abbvie,

Aptalis, Ferring, Janssen, Olympus, Pendopharm and Takeda in the form of unrestricted educational grants

• Potential for conflict(s) of interest:

– Takeda markets a product that will be discussed in this program: pantoprazole, dexlansoprazole

– Aptalis markets a product that will be discussed in this program: sucralfate

Mitigating Potential Bias

In addition to drugs produced by the sponsors of this program, drugs of the same class produced by other manufacturers will also be discussed in the same context

Objectives At the conclusion of this presentation, the learner will:

Understand how physiologic changes of pregnancy affect the normal function of the gastrointestinal (GI) tract

Be able to interpret liver biochemistry in pregnant patients and recognize which patterns of biochemistry require further investigation and referral

Have an approach to treatment of gastroesophageal reflux disease, constipation, nausea and vomiting, and hyperemesis gravidarum in pregnancy

Know which common GI medications can be safely prescribed in pregnancy and breastfeeding

Physiologic Changes in Pregnancy

Plasma volume ↑ ~50%

Physical exam

spider angiomas

palmar erythema

liver not palpable

Fasting GB volume & residual volume ↑

GI adaptation to pregnancy

Gastrointestinal motility significantly altered

→ nausea, vomiting, constipation

Enlarging uterus displaces bowel

→ displacement of appendix

Decreased gallbladder motility & increased bile lithogenicity

→ increased risk of gallstones

Clin Colon Rectal Surg. 2010. 23(2): 80-9.

Liver biochemistry in pregnancy

KEY POINT: ↑ ALT, AST, bilirubin and/or fasting total bile acids should be considered pathologic

Liver tests affected by pregnancy

Liver tests NOT affected by pregnancy

↓ serum albumin Aminotransferases (ALT, AST)

↑ Alkaline phosphatase (ALP)

Prothrombin time (INR)

↓ serum bilirubin Total bile acids

Hyperemesis gravidarum (HG) Severe nausea & vomiting of pregnancy which can result

in complications & hospitalization

Caused by steroid hormones & hCG

Differential diagnosis Urinary tract infections, peptic ulcer disease, pancreatitis

Decreased risk Smoking

Maternal age > 30

J Obs Gyn. 2011. 31: 708-12.

HG – Risk Factors Hx of hyperemesis gravidarum (15%)

Helicobacter pylori

Psychiatric disorders

Previous molar pregnancy

Pre-existing diabetes

Asthma

Female fetus

Multiple gestation

J Obs Gyn. 2011. 31: 708-12.

HG - Diagnosis Profuse vomiting & dehydration

Ketonuria

Abnormal electrolytes

Elevated liver enzymes

Loss of > 5% of pre-pregnancy weight

Elevated amylase (salivary)

J Obs Gyn. 2011. 31: 708-12.

Treatment of HG Intravenous fluids

Saline & dextrose solutions

Monitor electrolytes and urinary ketones

Antiemetics

Post-pyloric feeding tubes & total parenteral nutrition only used in severe refractory cases

Thiamine supplementation

J Obs Gyn. 2011. 31: 708-12.

Medications in pregnancy

Gastroenterology. 2006. 131(3): 283-311.

Safety of Antiemetics Drug Risk Factor Type of Study

Diphenhydramine C

Domperidone C Safety unknown

Metoclopramide B No teratogenicity; population-based study

Ondansetron B Controlled trial

Prochlorperazine C No teratogenicity; large database study

Promethazine C No teratogenicity; large database study

Gastroenterology. 2006. 131(3): 283-311.

GERD in pregnancy

30 – 50% of pregnant women

Lifestyle modification

Adequate for mild symptoms

Antacids

H2 – blockers

Proton pump inhibitors

Aliment Pharmacol Ther. 2005. 22(9): 749-57.

Antacids Drug Risk

Factor Use in pregnancy Safety in lactation

Aluminum-containing

none Most low risk Low risk

Calcium-containing

none Most low risk

Low risk

Magnesium- containing

none Most low risk

Low risk

Sodium bicarbonate

none NOT SAFE (alkalosis)

Low risk

Sucralfate B Low risk No human data

Gastroenterology. 2006. 131(3): 283-311.

Antacids Drug Risk

Factor Use in pregnancy Safety in lactation

Aluminum-containing

none Most low risk Low risk

Calcium-containing

none Most low risk

Low risk

Magnesium- containing

none Most low risk

Low risk

Sodium bicarbonate

none NOT SAFE (alkalosis)

Low risk

Sucralfate B Low risk No human data

Gastroenterology. 2006. 131(3): 283-311.

H2-blockers

Drug Pregnancy Risk Factor

Lactation

Famotidine B Enters breast milk; not recommended

Ranitidine B Enters breast milk; use caution

Cimetidine B Enters breast milk; not recommended

Gastroenterology. 2006. 131(3): 283-311.

Proton pump inhibitors

Drug Pregnancy Risk Factor

Lactation

Esomeprazole B Excretion in breast milk unknown; not recommended

Dexlansoprazole B Excretion in breast milk unknown; not recommended

Lansoprazole B Excretion in breast milk unknown; not recommended

Omeprazole C Enters breast milk; not recommended

Pantoprazole B Enters breast milk; not recommended

Rabeprazole B Excretion in breast milk unknown; not recommended

Gastroenterology. 2006. 131(3): 283-311.

Proton pump inhibitors

Drug Pregnancy Risk Factor

Lactation

Esomeprazole B Excretion in breast milk unknown; not recommended

Dexlansoprazole B Excretion in breast milk unknown; not recommended

Lansoprazole B Excretion in breast milk unknown; not recommended

Omeprazole C Enters breast milk; not recommended

Pantoprazole B Enters breast milk; not recommended

Rabeprazole B Excretion in breast milk unknown; not recommended

Aliment Pharmacol Ther. 2005. 22(9): 749-57.

Bloating and constipation

Slowing of intestinal motility, mechanical obstruction, iron supplementation

First line therapy

Gradual fiber supplementation

↑ water intake

Second line therapy

Docusate

Osmotic laxatives

Gastroenterology. 2006. 131(3): 283-311.

Laxatives Laxative Pregnancy

Risk Factor Use in pregnancy & lactation

Mineral oil None Not recommended; ↓ fat-soluble vitamin absorption

Castor oil X Uterine contraction

Lactulose B No human studies in pregnancy

PEG C Effective; negligible absorption

Senna C Low risk for short-term use; secreted in breast milk

Bisacodyl C Low risk for short-term use

Docusate C Low risk

Gastroenterology. 2006. 131(3): 283-311.

Laxatives Laxative Pregnancy

Risk Factor Use in pregnancy & lactation

Mineral oil None Not recommended; ↓ fat-soluble vitamin absorption

Castor oil X Uterine contraction

Lactulose B No human studies in pregnancy

PEG C Effective; negligible absorption

Senna C Low risk for short-term use; secreted in breast milk

Bisacodyl C Low risk for short-term use

Docusate C Low risk

Gastroenterology. 2006. 131(3): 283-311.

Summary & Take Home Points

The appendix can be displaced by an enlarging uterus; appendicitis may present with an atypical location of pain

Elevated serum aminotransferases, bilirubin & serum bile acids are NOT normal in pregnancy & require further investigation

Hyperemesis gravidarum is an extreme form of nausea & vomiting in pregnancy characterized by maternal electrolyte abnormalities, dehydration, elevated liver enzymes, & need for hospitalization

Summary & Take Home Points

Sodium bicarbonate-containing antacids are NOT safe in pregnancy

The use of H2-blockers and proton pump inhibitors in pregnancy is safe Only omeprazole is pregnancy risk factor category C

Fiber supplementation is the 1st line treatment for constipation in pregnancy; osmotic laxatives are the preferred 2nd line therapy

Castor oil is contraindicated in pregnancy

Questions?