Ursodeoxycholic acid in pregnancy?

Itching for Answers: A Comprehensive Review of Cholestatic Pruritus Treatments

Cholestasis is a clinical and laboratory syndrome indicating impaired bile production or excretion. One of the hallmark symptoms of cholestasis is pruritus. Itch can be severe and debilitating for patients, impacting their quality of life similarly to pain, and, in some cases, it can be refractory. Current therapies like anion exchange resins and rifampicin, offer partial relief but with side effects. Effective, well-tolerated treatments are urgently needed. This literature review examines existing options (bile acid sequestrants, antihistamines, opioid antagonists, sertraline, and rifampicin) and explores novel therapies (monoclonal antibodies, PPAR agonists, and bile-acid-based therapies). We analyze mechanisms, limitations, and adverse effects to aid clinicians and researchers. Novel approaches include monoclonal antibodies to inhibit bile recirculation and PPAR agonists targeting pruritus signaling. Despite the limited current options, ongoing research promises better treatments for cholestatic pruritus, addressing its distressing impact. In summary, cholestasis-associated pruritus poses a significant challenge with limited treatments. Advancements in understanding its pathophysiology offer hope for more effective therapies in the future.

Intrahepatic cholestasis of pregnancy: Introduction and overview 2024

Considerable progress has been made to explain the aetiology of intrahepatic cholestasis of pregnancy (ICP) and of the adverse pregnancy outcomes associated with high maternal total serum bile acids (TSBAs). The reported thresholds for non-fasting TSBA associated with the risk of stillbirth and spontaneous preterm birth can be used to identify pregnancies at risk of these adverse outcomes to decide on appropriate interventions and to give reassurance to women with lower concentrations of TSBA. Data also support the use of ursodeoxycholic acid to protect against the risk of spontaneous preterm birth. A previous history of ICP may be associated with higher rates of subsequent hepatobiliary disease: if there is a suspicion of underlying susceptibility, clinicians caring for women with ICP should screen for associated disorders or for genetic susceptibility and, where appropriate, refer for ongoing hepatology review.

Gradual dosing of ursodeoxycholic acid in mothers with intrahepatic cholestasis of pregnancy may improve composite neonatal outcome

INTRODUCTION AND OBJECTIVES

Intrahepatic cholestasis of pregnancy (ICP) is often accompanied by fetal and maternal complications.

MATERIALS AND METHODS

Retrospective review of the clinical course of women with ICP and their neonates treated at our medical center over a 10-year period. Special attention was paid to the maternal and neonatal response to 2 different modes of ursodeoxycholic acid (UDCA) administration.

RESULTS

Neonates of mothers with high total bile acid levels had a poorer composite neonatal outcome. Twenty-seven women who presented at an advanced stage of their pregnancies did not receive UDCA. UDCA was administered in 2 modes: either a full dose at admission (76 women) or a gradually increasing dose until the desired dosage was reached (25 women). The mean gestational age at delivery for the 94 neonates that were exposed to full UDCA dose was the lowest (36±2.3 weeks for the full dose, 37±1.4 weeks for the 30 neonates from the gradually increasing dose, 38±1.6 weeks for the 29 neonates from the no treatment group, p<0.001). The group of neonates that were exposed to full UDCA dose had the highest rate of unfavorable composite neonatal outcome (53% for full dose, 30% for gradually increasing dose, 24% for the no treatment group, p=0.006).

CONCLUSIONS

Compared to the administration of a full UDCA dose, the administration of a gradually increasing dose of UDCA may be associated with a greater gestational age at delivery and fewer events of unfavorable composite neonatal outcomes. These novel findings should be retested prospectively in a large cohort of patients.

Outcomes of 38 patients with PFIC3: Impact of genotype and of response to ursodeoxycholic acid therapy

Background & Aims

Progressive familial intrahepatic cholestasis type 3 (PFIC3) is a rare liver disease caused by biallelic variations in ABCB4. Data reporting on the impact of genotype and of response to ursodeoxycholic acid (UDCA) therapy on long-term outcomes are scarce.

Methods

We retrospectively describe a cohort of 38 patients with PFIC3 with a median age at last follow-up of 19.5 years (range 3.8-53.8).

Results

Twenty patients presented with symptoms before 1 year of age. Thirty-one patients received ursodeoxycholic acid (UDCA) therapy resulting in serum liver test improvement in 20. Twenty-seven patients had cirrhosis at a median age of 8.1 years of whom 18 received a liver transplant at a median age of 8.5 years. Patients carrying at least one missense variation were more likely to present with positive (normal or decreased) canalicular MDR3 expression in the native liver and had prolonged native liver survival (NLS; median 12.4 years [range 3.8-53.8]). In contrast, in patients with severe genotypes (no missense variation), there was no detectable canalicular MDR3 expression, symptom onset and cirrhosis occurred earlier, and all underwent liver transplantation (at a median age of 6.7 years [range 2.3-10.3]). The latter group was refractory to UDCA treatment, whereas 87% of patients with at least one missense variation displayed an improvement in liver biochemistry in response to UDCA. Biliary phospholipid levels over 6.9% of total biliary lipid levels predicted response to UDCA. Response to UDCA predicted NLS.

Conclusions

Patients carrying at least one missense variation, with positive canalicular expression of MDR3 and a biliary phospholipid level over 6.9% of total biliary lipid levels were more likely to respond to UDCA and to exhibit prolonged NLS.

Impact and implications

In this study, data show that genotype and response to ursodeoxycholic acid therapy predicted native liver survival in patients with PFIC3 (progressive familial intrahepatic cholestasis type 3). Patients carrying at least one missense variation, with positive (decreased or normal) immuno-staining for canalicular MDR3, and a biliary phospholipid level over 6.9% of total biliary lipids were more likely to respond to ursodeoxycholic acid therapy and to exhibit prolonged native liver survival.

EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.

Familial clustering of intrahepatic cholestasis of pregnancy: A nationwide population-based study in Denmark

BACKGROUND AND AIMS

Genetics plays a role in the pathogenesis of intrahepatic cholestasis of pregnancy (ICP); however, empirical evidence on familial clustering of ICP is scarce. We aimed to assess the extent of familial recurrence of ICP.

APPROACH AND RESULTS

This population-based cohort study included all 668,461 primiparous women who gave birth between 1995 and 2018 in Denmark. Women diagnosed with ICP were included to the index cohort. Kinship with index women was determined with the Danish Civil Registration System. Log-binomial regression was used to calculate the relative recurrence risk (RRR) of ICP in relatives of index women. A total of 6722 (1.0%) primiparous women were diagnosed with ICP. In co-twins (n=57), first-degree (n=2279), second-degree (n=1373), and third-degree (n=1758) relatives of the index women, the incidence of ICP reached 5.3%, 2.6%, 0.7%, and 1.4%, respectively, corresponding to adjusted RRRs of 4.82 (95% CI, 1.60-14.48), 2.54 (1.98-3.26), 0.81 (0.44-1.51), and 1.15 (0.77-1.71), respectively. The first-degree relatives of women who had recurrent ICP or first-trimester ICP seemed to be at higher risks [RRR, 4.30 (2.85-6.48), 3.04 (1.93-4.77), respectively]. A minor increased risk was observed in nonbiological relatives [RRR, 1.35 (1.05-1.73); n=4274, including women's full-brothers' partner and women's husbands' full sisters].

CONCLUSIONS

Co-twins and first-degree relatives of ICP patients were at ~5- and ~2.5-fold increased risk of ICP, respectively. No increased risk was observed in second-degree and third-degree relatives. Recurrent ICP and first-trimester ICP might indicate a higher degree of family clustering. Further investigation is needed to investigate the increased risk of ICP in nonbiological relatives.

Maternal and Neonatal Outcomes in Intrahepatic Cholestasis of Pregnancy

The aims of our study were to evaluate the maternal and fetal outcomes of intrahepatic cholestasis of pregnancy (ICP). In this observational, retrospective case-control study, we included all pregnant women who gave birth with a diagnosis of ICP between January 2010 and December 2020 at the Unit of Obstetrics and Gynecology, University Hospital of Messina. The data were compared with those from a control group of pregnant women who did not have ICP. One hundred twenty-nine and eighty-five patients were included, respectively, in the study and in the control group. There was a significant difference between the two groups in the incidence of hypothyroidism, thrombophilia, gestational diabetes, gestational hypertension, postpartum hemorrhage, and preterm delivery, which were more frequent in the ICP patients. No neonatal adverse events were recorded, although a significant difference in the meconium-stained amniotic fluid condition was noted. After a 24-month follow-up, 48/129 patients with ICP accepted to be reassessed by liver ultrasound, elastographic examination, and liver function blood tests. No patient showed signs of chronic liver disease. This study confirmed a higher probability of adverse short-term maternal outcomes in ICP pregnant patients, but a lower probability of adverse short-term fetal outcomes and the absence of a long-term maternal risk of chronic liver disease.

Primary biliary cholangitis: Epidemiology, prognosis, and treatment

Primary biliary cholangitis (PBC) is a chronic cholestatic autoimmune liver disease characterized by a destructive, small duct, and lymphocytic cholangitis, and marked by the presence of antimitochondrial antibodies. The incidence and prevalence of PBC vary widely in different regions and time periods, and although disproportionally more common among White non-Hispanic females, contemporary data show a higher prevalence in males and racial minorities than previously described. Outcomes largely depend on early recognition of the disease and prompt institution of treatment, which, in turn, are directly influenced by provider bias and socioeconomic factors. Ursodeoxycholic acid remains the initial treatment of choice for PBC, with obeticholic acid and fibrates (off-label therapy) reserved as add-on therapy for the management of inadequate responders or those with ursodeoxycholic acid intolerance. Novel and repurposed drugs are currently at different stages of clinical development not only for the treatment of PBC but also for its symptomatic management. Here, we summarize the most up-to-date data regarding the epidemiology, prognosis, and treatment of PBC, providing clinically useful information for its holistic management.

Mechanisms of pruritus in cholestasis: understanding and treating the itch

Pruritus in cholestatic liver diseases can be a major burden and dramatically impair the quality of life of those affected. Here, we provide an update on the latest insights into the molecular pathogenesis of and novel therapeutic approaches for cholestasis-associated itch. Endogenous and exogenous small-molecule pruritogen candidates bind to their receptors on unmyelinated itch C-fibres in the skin. Candidate pruritogens in cholestasis include certain lysophospholipids and sulfated progesterone metabolites, among others, whereas total bile acid or bilirubin conjugates seem unlikely to have a dominant role in the pathogenesis of cholestasis-associated pruritus. Transmission of itch signals via primary, secondary and tertiary itch neurons to the postcentral gyrus and activation of scratch responses offer various targets for therapeutic intervention. At present, evidence-based treatment options for pruritus in fibrosing cholangiopathies, such as primary biliary cholangitis and primary sclerosing cholangitis, are the peroxisome proliferator-associated receptor (PPAR) agonist bezafibrate and the pregnane X receptor (PXR) agonist rifampicin. In pruritus of intrahepatic cholestasis of pregnancy, ursodeoxycholic acid is recommended and might be supported in the third trimester by rifampicin if needed. Alternatively, non-absorbable anion exchange resins, such as cholestyramine, can be administered, albeit with poor trial evidence. Liver transplantation for intolerable refractory pruritus has become an extremely rare therapeutic strategy.

Ursodeoxycholic acid use in lactating female patients is associated with clinically negligible concentrations of this bile acid in breast milk

In the literature on the safety of ursodeoxycholic acid (UDCA) during breastfeeding, insufficient data has been reported to date. Thus, the aim of our study was to analyze bile acid (BA) concentrations in breast milk in a cohort of patients, treated with UDCA, and with various cholestatic liver diseases. The study was carried out on a cohort of 20 patients with various cholestatic diseases. All the patients were treated with UDCA (500-1500 mg daily). Concentrations of BA, sampled on day 3 after delivery were analyzed using the GS-MS technique, and then compared to untreated women. Total BA concentrations in the breast milk of the UDCA-treated patients were equal to those of the untreated women controls (3.2 ± 1 vs. 3.2 ± 0.2 µmol/L, respectively). The UDCA concentrations in breast milk remained negligible in UDCA-treated patients (0.69 µmol/L), and in any event did not contribute to the newborn BA pool. No apparent side-effects of the maternal UDCA treatment were observed in any newborn infant, and no deterioration in postnatal development was observed during the routine 1-year follow-ups. Therapeutic administration of UDCA during lactation is safe for breastfed babies since UDCA only gets into breast milk in negligible amounts. UDCA treatment should be allowed and included into the guidelines for the therapy of cholestatic diseases in breastfeeding mothers.

EASL Clinical Practice Guidelines on sclerosing cholangitis

Management of primary or secondary sclerosing cholangitis is challenging. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics including diagnostic methods, prognostic assessment, early detection of complications, optimal care pathways and therapeutic (pharmacological, endoscopic or surgical) options both in adults and children.

Autoimmune hepatitis in pregnancy: Pearls and pitfalls

Autoimmune hepatitis (AIH) in pregnancy has many unique considerations. Evidence provided from single center studies with patient level data and nationwide population studies provide valuable insight into this complex situation. Because a planned pregnancy is a safer pregnancy, preconception counseling is a crucial opportunity to optimize care and risk stratify women with AIH. Women with chronic liver disease who receive preconception advice and counseling are more likely to achieve stable liver disease at conception and undergo appropriate variceal surveillance. Loss of biochemical response in pregnancy is associated with adverse outcomes in unstable disease. New onset AIH in pregnancy should be managed with classical treatment regimens. The continued use of immunosuppression in pregnancy, with the exception of mycophenolate mofetil, has not shown to adversely affect the rates of stillbirth or congenital malformation. Previously adopted immunosuppression withdrawal paradigms in pregnancy should no longer be considered advantageous, because remission loss postdelivery is likely (12%-86%). Population studies, report improved outcomes with preterm birth rates falling from 20% to 9%-13% in AIH pregnancies over a 20-year period. Newer data have also demonstrated an increased risk of gestational diabetes and hypertensive complications in AIH pregnancy, which has implications for management and preeclampsia prevention with aspirin use. This review aims to provide the framework to guide and manage pregnancy in AIH outlining pearls and pitfalls to ensure optimal outcomes for mother, baby and to reduce variation in practice.

Bile reflux and bile acids in the progression of gastric intestinal metaplasia

ABSTRACT

Gastric intestinal metaplasia (GIM) is a precancerous lesion of gastric cancer (GC) and is considered an irreversible point of progression for GC. Helicobacter pylori infection can cause GIM, but its eradication still does not reverse the process. Bile reflux is also a pathogenic factor in GIM and can continuously irritate the gastric mucosa, and bile acids in refluxed fluid have been widely reported to be associated with GIM. This paper reviews in detail the relationship between bile reflux and GIM and the mechanisms by which bile acids induce GIM.

The Effect of Tauroursodeoxycholic Acid (TUDCA) Treatment on Pregnancy Outcomes and Vascular Function in a Rat Model of Advanced Maternal Age

Advanced maternal age (≥35 years) increases the risk of vascular complications in pregnancy that can result in fetal growth restriction and preeclampsia. Endoplasmic reticulum (ER) stress has been linked to adverse pregnancy outcomes in these complicated pregnancies. However, the role of ER stress in advanced maternal age is not known. We hypothesize that increased ER stress contributes to altered vascular function and poor pregnancy outcomes, and that treatment with the ER-stress inhibitor TUDCA will improve pregnancy outcomes. First, young and aged non-pregnant/pregnant rats were used to assess ER stress markers in mesenteric arteries; mesenteric artery phospho-eIF2α and CHOP expression were increased in aged dams compared to young dams. In a second study, young and aged control and TUDCA-treated dams were studied on gestational day (GD) 20 (term = 22 days). TUDCA treatment was provided via the drinking water throughout pregnancy (GD0-GD20; calculated dose of 150 mg/kg/day TUDCA). ER stress markers were quantified in mesenteric arteries, blood pressure was measured, pregnancy outcomes were recorded, mesenteric and main uterine arteries were isolated and vascular function was assessed by wire myography. Aged dams had increased phospho-eIF2α and CHOP expression, reduced fetal weight, reduced litter size, and impaired uterine artery relaxation. In the aged dams, TUDCA treatment reduced phospho-eIF2α and CHOP expression, reduced blood pressure, improved fetal body weight, and tended to improve uterine artery function compared to control-treated aged dams. In conclusion, our data illustrate the role of ER stress, as well as TUDCA as a potential therapeutic that may benefit pregnancy outcomes in advanced maternal age.

Primary biliary cholangitis in pregnancy: A systematic review with meta-analysis

BACKGROUND

The outcomes and disease associations in pregnant women with primary biliary cholangitis (PBC) have not been largely explored. This study aimed to determine the level of evidence associated with maternal and fetal outcomes and other disease associations in female patients with PBC.

DATA SOURCES

A comprehensive literature search was conducted. Maternal and fetal outcomes were obtained from patients with a previous, current or subsequent diagnosis of PBC. A random-effects model was employed, using odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Eleven studies, with 2179 female PBC patients were included. Pregnant women with PBC were significantly more likely to have a miscarriage (OR = 1.27, 95% CI: 1.02-1.58; P = 0.03), and a history of abortion (OR = 1.50, 95% CI: 1.09-2.07; P = 0.01), with absent heterogeneity (I2 = 0%). PBC pregnant women were significantly more likely to deliver via vaginal birth (OR = 1.69, 95% CI: 1.33-2.14; P < 0.001) with low level heterogeneity (I2 < 0.001%). Patients had a statistically significant increased likelihood of lifetime smoking (OR = 1.95, 95% CI: 1.17-3.23; P = 0.01). Egger's regression revealed no evidence of publication bias.

CONCLUSIONS

This meta-analysis provides pooled evidence that a PBC pregnancy is associated with fetal morbidity and maternal lifestyle associations that may influence pregnancy outcomes. More studies are needed to establish disease associations that may directly affect pregnancy outcomes. These data are essential for clinicians managing these patients before, during or after pregnancy.

Outcome of pregnancy in patients with primary sclerosing cholangitis

BACKGROUND

Data on the clinical course of primary sclerosing cholangitis (PSC) during pregnancy remain scarce. Herein, we assessed the maternal and fetal outcomes of pregnancy in this condition.

METHODS

We reviewed 104 consecutive female outpatients with PSC using a structured questionnaire. The outcomes were assessed both before and after the diagnosis of PSC.

RESULTS

In total, 62 patients (60%) reported 126 pregnancies. Of these, 25 patients reported 44 pregnancies occurring after the diagnosis of PSC. There were two (5%) pregnancies in progress, and among the completed pregnancies there were 34 (80%) live births, six (14%) miscarriages, one (2%) stillbirth, and one (2%) termination. The median neonatal APGAR score was 10, the median body weight was 3375 g and the median body length was 55 cm. In three pregnancies, there was a flare-up of inflammatory bowel disease. In 45 patients, 82 pregnancies occurred before PSC was diagnosed with comparable maternal and fetal outcomes. Out of 42 pregnancies following PSC diagnosis, in 29 UDCA was continued. There was no difference in the fetal outcomes between the UDCA and non-UDCA groups.

CONCLUSIONS

Pregnancy in patients with PSC seems to be well tolerated, but should be closely monitored by an obstetrician and an experienced hepatologist.

Ursodeoxycholic acid improves pregnancy outcome in patients with intrahepatic cholestasis during pregnancy: A protocol for systematic review and meta-analysis

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is a common complication in the third trimester of pregnancy, which may result in premature delivery, fetal distress, stillbirth, and other adverse pregnancy outcomes. Ursodeoxycholic acid (UDCA) is a first-line treatment for ICP and has been controversial in improving adverse pregnancy outcomes. The purpose of this protocol is to systematically evaluate the effect of UDCA on pregnancy outcomes in patients with intrahepatic cholestasis during pregnancy.

METHODS

To search the databases PubMed, Embase, Web of Science, the Cochrane Library, CNKI, WanFang, VIP, CBMDIsc by computer, then to include randomized controlled clinical studies on UDCA for treatment of intrahepatic cholestasis during pregnancy from the establishment of the database to October 1, 2020. Two researchers independently extract and evaluate the data of the included studies, and meta-analysis is conducted on the included literatures using RevMan5.3 software.

RESULTS

This protocol evaluates the outcome of UDCA in improving ICP by incidence of postpartum hemorrhage in pregnant women preterm birth rates meconium contamination rate in amniotic fluid incidence of fetal distress scale of newborns scoring <7 in 5-min Apgar incidence of neonatal admission to neonatal intensive care unit.

CONCLUSION

This protocol will provide an evidence-based basis for clinical use of UDCA in the treatment of intrahepatic cholestasis during pregnancy.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval was not required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605 / OSF.IO / BE67H.

Liver disease in pregnancy

Development of liver diseases during pregnancy is not uncommon. They are caused by either a disorder that is unique to pregnancy or an acute or chronic liver disease that already exists or coincidentally develops as a comorbidity of pregnancy. Liver diseases unique to pregnancy include hyperemesis gravidarum; hypertensive disorders of pregnancy, such as pre-eclampsia/eclampsia; hemolysis, elevated liver enzymes, and low platelet count syndrome; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Chronic liver diseases that affect pregnancy, or are affected by pregnancy, mainly include autoimmune liver diseases and non-alcoholic fatty liver disease. Prompt diagnosis and management of liver diseases in pregnancy, while very challenging, is extremely important, as they might cause adverse maternal and fetal outcomes. Therefore, a multidisciplinary, collaborative approach involving both hepatologists and obstetricians is required. In this review article, the up-to-date epidemiology, etiology, clinical features, and outcomes of liver diseases in pregnancy are discussed, to promote a deeper understanding among physicians, and subsequently improved outcomes.

Effect of ursodeoxycholic acid therapy due to pregnant intrahepatic cholestasis on chemerin and irisin levels

The purpose of the work was to assess changes in chemerin and irisin levels in women with diagnosed intrahepatic cholestasis of pregnant women treated with ursodeoxycholic acid. The study group consisted of 50 patients with diagnosed and confirmed intrahepatic cholestasis of pregnant women at 24-25 weeks of pregnancy treatment by ursodeoxycholic acid (UDCA). The study also included a group of 40 pregnant women, without concomitant intrahepatic cholestasis of pregnancy (ICP). In the pregnant ICP group, whole blood was collected 4 times: before the first dose of drug, 4 and 8 weeks after the first dose, and day after delivery. It was observed that statistically significant differences in the concentration of irisine occur between the time before starting treatment and the 8-week therapy and 1 day after delivery. The Pearson correlation analysis (r's) showed two statistically significant relationships (p < .05). The first of these can be found between the concentration of irisine and chemerin in the group of nonpregnant women and the second in the group of patients with intrahepatic pregnant cholestasis before the first dose of UDCA. A significant relationship between irisin and chemerin concentrations was confirmed in the group of pregnant ICP patients during UDCA acid therapy and among healthy pregnant women.