Medications can exacerbate symptoms of celiac disease

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

Celiac disease, also called celiac disease, is an autoimmune disease 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 found in foods such as bread, cakes, cookies and pasta. Experts estimate that there are more than 2 million people in the United States with celiac disease, most of whom have not been diagnosed.1

Although there is no cure, people with celiac disease can manage symptoms with gluten-free diets.2.3 It is essential to be aware of the symptoms presented, 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 can also contain gluten, although this is rare, or exacerbate symptoms of celiac disease.

Risk factors and symptoms

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

The cause of celiac disease is unknown, but there are some documented risk factors, including a higher risk if a family member is affected.4 The disease is also more common in whites and women, and in those who already have an autoimmune disease.1

Gluten and Medicines

Although the majority of drugs taken by mouth do not contain gluten, the FDA is aware that a potential interaction could occur. Manufacturers of over-the-counter or prescription drugs are not required to state on the package label whether a product contains gluten, but the FDA has released a draft guidance statement for manufacturers for voluntary disclosure.5 “Based on information available to the agency, we are not aware of any oral medications currently marketed in the United States that contain wheat gluten or wheat flour intentionally added as an inactive ingredient,” a noted the FDA on its website.5

Since manufacturers are not required to disclose gluten information in products, pharmacists need to know how to find this information. This may include contacting a manufacturer, evaluating drug and supplement ingredient lists, and reading package inserts.5.6

Identify gluten

For prescription drugs, the ingredients are usually listed on the label in the “Description” section. For over-the-counter products, the ingredients are listed on the “Drug Facts” label in the “Inactive Ingredients” section.1 If the ingredient list does not mention wheat flour or wheat gluten, the product must not contain gluten in an amount that would harm a typical (non-refractory) individual with celiac disease.

The FDA also recommends the US National Library of Medicine’s DailyMed database as a resource for searching the labeling of more than 140,000 over-the-counter and prescription medications.1

Medications to watch out for

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

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). An ibuprofen pill may not contain gluten, but it could exacerbate celiac disease in genetically predisposed people. Because NSAIDs affect the permeability of the gut, the passage of gluten can increase, thus increasing symptoms of celiac disease.7-9
  • Olmesartan. This drug can cause enteropathy which clinically mimics celiac disease. Although it has not been shown to aggravate celiac disease, it may prevent dignosis or resemble refractory celiac disease if a patient does not respond to a gluten-free diet.ten
  • Products containing starch. Starches can be used as an excipient in pharmaceuticals and are often derived from corn, potatoes, rice, or tapioca, which are gluten-free. However, if the source of the starch is not indicated, the product may contain gluten. Sources of gluten-containing excipients include barley, flour, kamut, rye, spelled, 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 people with celiac disease, as well as where to find consumer product information. Pharmacists also need to understand which medications exacerbate the disease and which over-the-counter 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 undiagnosed gluten avoidance in the United States: results from the National Health and Nutrition Surveys 2009 to 2014. Mayo Clin Proc. 2016;S0025-6196(16)30634-6. doi:10.1016/j.mayocp.2016.10.012

2. Definition and facts for celiac disease. National Institute of Diabetes 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%20has%20celiac%20disease

3. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA, American College of Gastroenterology. CAG 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. Medicines 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. Use of medications and supplements in celiac disease. American pharmacy. 2014;39(12):44-48.

7. Jordan R, Shannahan S, Lewis SK, et al. The impact of antacid drugs and nonsteroidal anti-inflammatory drugs on the clinical and histological features of celiac disease. Dig the 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. Worsening of exercise-induced bowel injury by ibuprofen in athletes. Medical-scientific sports exercise. 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. Medications. 1986;32(supplement 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. Drugs and celiac disease—advice from a pharmacist. Practice gastroenterol. 2007;31(1):58-64.

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