Medications Can Exacerbate Symptoms of Celiac Disease

Pharmacy Times Health Systems Edition, May 2022, Volume 11, Issue 3

Be aware of products containing gluten, nonsteroidal anti-inflammatory drugs, and olmesartan.

Celiac disease, also called Celiac Sprue, is an autoimmune disorder that affects the digestive system and can damage the small intestine. The disease is triggered by ingesting gluten, a protein commonly found in barley, rye, and wheat and present in foods such as bread, cake, cookies, and pasta. Experts estimate there are more than 2 million individuals in the United States with celiac disease, most of whom have not received a diagnosis.1

Although there is no cure, individuals with celiac disease can manage symptoms with gluten-free diets.2,3 Being aware of presenting symptoms is critical, because if left untreated, the disease can lead to permanent and serious complications.

Avoiding gluten presents a problem when there are hidden or undisclosed sources. For example, gluten can be found in personal care products, such as lip balm, lipstick, toothpaste, and mouthwash, as well as vitamins and prepackaged foods.2 Medications and supplements also can contain gluten, although this is rare, or exacerbate the symptoms of celiac disease.

Risk Factors and Symptoms

Common symptoms of celiac disease are abdominal pain, bloating, constipation, diarrhea, fatigue, mood changes, nausea, vomiting, and weight loss. Less common symptoms include anemia, blisters, neurological issues, peripheral neuropathy, rash, and reproductive problems. Celiac disease is different from a food allergy or gluten sensitivity, although the symptoms may be similar, as those conditions do not show damage to the small intestine or an immune response.

The cause of celiac disease is unknown, but there are certain documented risk factors, including a greater risk if a family member is affected.4 The disease is also more common among White and female individuals, and in those who already have an autoimmune disorder.1

Gluten and Medications

Although the majority of orally administered drug products do not contain gluten, the FDA is aware that a potential interaction could happen. Manufacturers of OTC or prescription medications are not required to include on the package labeling whether a product contains gluten, but the FDA has issued a draft guidance statement for manufacturers for voluntary disclosure.5 “Based on information available to the agency, we are aware of no oral drug products currently marketed in the United States that contain wheat gluten or wheat flour intentionally added as an inactive ingredient,” the FDA noted on its website.5

Because manufacturers are not required to divulge information about gluten in products, pharmacists should know how to find the information. This can include contacting a manufacturer, evaluating the ingredient list of medications and supplements, and reading package inserts.5,6

Identifying Gluten

For prescription medications, ingredients are generally listed on the label in the “Description” section. For nonprescription products, ingredients are listed on the “Drug Facts” label in the “Inactive Ingredients” section.1 If the list of ingredients does not mention wheat flour or wheat gluten, then the product should not contain gluten in an amount that would harm a typical (nonrefractory) individual with celiac disease.

The FDA also recommends the US National Library of Medicine’s DailyMed database as a resource to look up the labeling for more than 140,000 nonprescription and prescription drug products.1

Medications to Watch Out For

Pharmacists should pay particular attention to several medications or types of medications, including the following:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). An ibuprofen pill may not contain gluten but it could exacerbate celiac disease in those whoare genetically prone. Because NSAIDs affect the permeability of the gut, the passage of gluten nay increase, thus increasing the celiac disease symptoms.7-9
  • Olmesartan. This drug can cause an enteropathy that mimics celiac disease clinically. Although it has not been shown to worsen celiac disease, it may prevent dignosis or look like refractory celiac disease if a patient does not respond to a gluten-free diet.10
  • Starch-containing products. Starches can be used as an excipient in drug products and are often derived from corn, potatoes, rice, or tapioca, which are gluten free. However, if the source of the starch is not stated, the product may contain gluten. Sources of excipients that contain gluten include barley, farina, Kamut, rye, spelt, triticale, and wheat.6 These may be identified on a label as dextrates, dextri-maltose, dextrins, maltodextrin, modified starch, pregelatinized starch, or sodium starch glycolate and may require further investigation.6,11

Conclusion

Pharmacists can educate patients about gluten-containing medications and supplements. They should be aware of the signs and symptoms of individuals with celiac disease, as well as where to find information about consumer products. Pharmacists should also understand which medications exacerbate the disease and what OTC products may contain gluten.

ABOUT THE AUTHOR

Joanna Lewis, PharmD, MBA, is the 340B compliance coordinator at Baptist Health in Jacksonville, Florida.

REFERENCES

1. Choung RS, Unalp-Arida A, Ruhl CE, Brantner TL, Everhart JE, Murray JA. Less hidden celiac disease but increased gluten avoidance without a diagnosis in the United States: findings from the Nati onal Health and Nutrition Examination Surveys from 2009 to 2014. Mayo Clin Proc. 2016;S0025-6196(16)30634-6. doi:10.1016/j.mayocp.2016.10.012

2. Definition & facts for celiac disease. National Institute of Dia betes and Digestive Kidney Diseases. Updated October 2020. Accessed March 15, 2022. https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/definition-facts#:~:text=gluten%2Dsensitive%20enteropathy.-,How%20common%20is%20celiac%20disease%3F,the%20world%20have%20celiac%20disease

3. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA, American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013;108(5):656-677. doi:10.1038/ajg.2013.79

4. Sarno M, Discepolo V, Troncone R, Auricchio R. Risk factors for celiac disease. Ital J Pediatr. 2015;41:57. doi:10.1186/s13052-015-0166-y

5. Medications and gluten. FDA. Updated December 17, 2017. Accessed April 11, 2022. https://www.fda.gov/drugs/ensuring-safe-use-medicine/medications-and-gluten

6. Johnson AN, Skaff AN, Senesac L. Medication and supplement use in celiac disease. US Pharm. 2014;39(12):44-48.

7. Jordan R, Shannahan S, Lewis SK, et al. The impact of acid suppression medications and non-steroidal anti-inflammatory drugs on clinical and histologic features in celiac disease. Dig Liver Dis. 2017;49(8):883-886. doi:10.1016/j.dld.2017.03.018

8. Van Wijck K, Lenaerts K, Van Bijnen AA, et al. Aggravation of exercise-induced intestinal injury by ibuprofen in athletes. Med Sci Sports Exerc. 2012;44(12):2257-2262. doi:10.1249/MSS.0b013e318265dd3d

9. Bjarnason I, Zanelli G, Prouse P, Williams P, Gumpel MJ, Levi AJ. Effect of nonsteroidal anti-inflammatory drugs on the human small intestine. Drugs. 1986;32(suppl 1):35-41. doi:10.2165/00003495-198600321-00007

10. Adike A, Corral J, Rybnicek D, Sussman D, Shah S, Quigley E. Olmesartan-induced enteropathy. Methodist Debakey Cardiovasc J. 2016;12(4):230-232. doi:10.14797/mdcj-12-4-230

11. Plogsted S. Medications and celiac disease—tips from a pharmacist. Pract Gasteroenterol. 2007;31(1):58-64.