Small class for expectant mothers | Can proton pump inhibitors be used for gastroesophageal reflux during pregnancy?

Xiao Wang is 24 weeks pregnant. As the pregnancy progresses, acid reflux and heartburn occur frequently and worsen. She can feel the stomach acid rolling in her esophagus whether she is lying down or sitting. It is very painful. After examination, the doctor found that Xiao Wang has gastroesophageal reflux disease (GERD).

High incidence during pregnancy

GERD is a common disease during pregnancy. The main causes are:

1. During pregnancy, the amount of progesterone in women's bodies increases, the pyloric sphincter relaxes, and the contents of the stomach easily flow back into the esophagus.

2. During pregnancy, the nutritional demand increases, the food intake greatly increases, and the food cannot be digested in the stomach and intestines in time, which may also induce reflux.

3. As the fetus continues to grow, it squeezes the stomach, causing the pressure in the stomach to increase continuously. When the pressure exceeds the pressure in the esophagus, reflux occurs.

4. Pregnant women’s activity level is reduced, and gastrointestinal motility is weakened, further increasing the risk of GERD.

GERD not only seriously affects the diet and sleep quality of expectant mothers, but can even cause fetal malnutrition. Long-term presence can further cause complications such as esophagitis and esophageal ulcers. For the treatment of GERD, the first choice is to adjust the lifestyle. Antacids, H2 receptor antagonists, and gastric mucosal protectants can also be used. When the treatment effect is not good, especially for refractory and severe GERD during pregnancy, the use of proton pump inhibitors with strong acid suppression can be considered.

The "Prazole" family

The name "proton pump inhibitor" may be unfamiliar to many expectant mothers, but when it comes to omeprazole, lansoprazole, and pantoprazole, they are not so unfamiliar, right? Yes, these drugs called "prazoles" all belong to the large family of proton pump inhibitors.

Proton pump inhibitors are abbreviated as "PPIs" in English. They can efficiently and quickly inhibit the proton pump that transports H+ in gastric parietal cells, thereby inhibiting gastric acid secretion and reducing gastric acid production, thereby protecting the stomach and esophagus from excessive gastric acid erosion, and reducing symptoms such as acid reflux and heartburn.

The PPIs currently on the market in China mainly include omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole and ilaprazole. Omeprazole, lansoprazole and pantoprazole belong to the first generation of PPIs, while rabeprazole, esomeprazole and ilaprazole belong to the second generation of PPIs. The second generation has better acid suppression effect, faster onset, longer duration of action, fewer interactions with other drugs and fewer adverse reactions than the first generation.

Be careful when choosing

So, which PPIs should expectant mothers choose?

In December 2020, the National Health Commission issued the "Guidelines for the Clinical Application of Proton Pump Inhibitors (2020 Edition)" (hereinafter referred to as the "Guidelines"), in which the recommendations for pregnant and lactating people are shown in the table below:

Considering the particularity of the pregnancy stage and the fetal development cycle, pregnant women are advised to avoid abusing PPIs.

If pregnant mothers must take medication, they can choose omeprazole, which has been studied the most. Omeprazole is classified as Class C for pregnancy and has been widely used in pregnant women. Analysis of previous cases has confirmed that a dose of 20 to 80 mg/d has no significant correlation with neonatal teratogenicity and is relatively safe for use during pregnancy.

However, the Guidelines also emphasize that any proton pump inhibitors should be avoided in the first month of pregnancy and the first to third months of pregnancy because of the increased risk of fetal malformations.

I hope all expectant mothers will pay attention to developing good living habits, eat a balanced diet, avoid lying down after meals, and exercise appropriately to reduce the occurrence of GERD. When proton pump inhibitors must be selected in the second and third trimesters of pregnancy, omeprazole can be the first choice. At the same time, regular follow-up visits are required, and adverse reactions such as abdominal pain, diarrhea, allergies, and headaches should be monitored. Once adverse reaction symptoms occur, you should communicate with your doctor and pharmacist in a timely manner to redefine the treatment plan.

Author: Zhao Wenjia, deputy director and pharmacist of Dalian Women and Children's Medical Center

Review expert: Li Ling, chief pharmacist of Dalian Women and Children's Medical Center

Wei Guoyi, Chief Pharmacist, Beijing Anzhen Hospital, Capital Medical University