Lorna Kemble Pregnancy and Birth

2525 Cholestyramine and other lipid reducers

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Pharmacology and toxicology

Cholestyramine is an anion-cxchangc resin which is not absorbed systemically. It binds bile acids, producing an insoluble complex

which is excreted in the stool. This leads to a reduction of cholesterol and the low-density (LD) lipoproteins in the serum. Cholestyramine is used in pregnancy for the treatment of obstetric cholestasis to relieve the itching. Ursodeoxycholic acid is, however, more effective than cholestyramine in intrahepatic cholestasis of pregnancy (see ursodeoxycholic acid; Kondrackiene 2005). There is at least a theoretical risk for the fetus because, in addition to bile acids, cholestyramine also binds other lipophile substances - such as fat-soluble vitamins and medications. One case report concerning the gestational use of cholestyramine has described severe intracranial hemorrhage in a fetus; vitamin K deficiency was suspccted (Sadler 1995).

Individual case studies argue against teratogenic properties (Landon 1987).

Other lipid reducers, such as acipimox, colestipol, i-sitosterin, eze-timibe xantinol and inositol nicotinate, and probucol, have not been sufficiently studied for pregnancy effects. Little systemic absorption of colestipol is believed to occur. As with the related agent cholestyra mine, colestipol can bind and impede the absorption of a variety of nutrients, including Lhe fat-soluble vitamins.

For these medications, too, there have not, as yet, been indications of specific teratogenic effects.

Recommendation. Cholestyramine - and, as a second choice, colestipol -may be used for intrahepatic cholestasis of pregnancy or when the use of a lipid reducer is strongly indicated. If used, sufficient supplementation of fat-soluble vitamins should be considered. These vitamins must be taken at a different time than the medication. Acipimox, i-sitosterin, ezetimibe, xantinol and inositol nicotinate, and probucol should not be used in pregnancy. However, their (inadvertent) use does not require either an interruption of the pregnancy or invasive diagnostic procedures.