Effect of cisapride on relapse of esophagitis. A multinational, placebo-controlled trial in patients healed with an antisecretory drug. The Italian Eurocis Trialists

The effect of a prokinetic agent, cisapride, on the relapse of reflux esophagitis was investigated in a randomized, double-blind trial conducted in 443 patients whose esophagitis had previously been healed with an acid antisecretory drug. Patients received cisapride, 20 mg at night, cisapride 10 mg twice daily, or placebo for 12 months or until endoscopic relapse was confirmed endoscopically. In 88% of all patients (respectively 133, 132, and 124), endoscopic data were available at discontinuation of treatment. In comparison with placebo, the two cisapride regimens prolonged both the time to endoscopically confirmed relapse (Kaplan-Meier analysis; P = 0.001) and the time to symptomatic relapse (P = 0.012). The life-table endoscopic relapse rates at 12 months were 51% for placebo, 32% for cisapride 20 mg at night (P = 0.005), and 34% for cisapride 10 mg twice daily (P = 0.02). Patients with more severe esophagitis before healing relapsed more rapidly during maintenance therapy, regardless of the treatment regimen. Adverse events were infrequent in all three groups. These findings indicate that maintenance treatment with the prokinetic drug cisapride prevents the relapse of esophagitis after it has been healed by acid antisecretory therapy.

Effect of ranitidine and amoxicillin plus metronidazole on the eradication of Helicobacter pylori and the recurrence of duodenal ulcer

BACKGROUND

Persistent infection with Helicobacter pylori is associated with the recurrence of duodenal ulcer. Whether the efficacy of bismuth therapy in reducing the rate of recurrence of duodenal ulcer is due to its antimicrobial effects on H. pylori or to a direct protective action on the mucosa is still a matter of debate.

METHODS

To study the effect of the eradication of H. pylori on the recurrence of duodenal ulcer, we treated 104 patients with H. pylori infection and recurrent duodenal ulcer with either amoxicillin (750 mg three times daily) plus metronidazole (500 mg three times daily) or identical-appearing placebos, given orally for 12 days. All patients also received ranitidine (300 mg each night) for 6 or 10 weeks. Endoscopy was performed before treatment and periodically during follow-up for up to 12 months after healing.

RESULTS

Among the 52 patients given antibiotics, H. pylori was eradicated in 46, as compared with 1 of the 52 given placebo (89 percent vs. 2 percent, P < 0.001). After six weeks, the ulcers were healed in 48 patients given antibiotics and 39 given placebo (92 percent vs. 75 percent, P = 0.011). Side effects, mainly diarrhea, occurred in 15 percent of the patients given antibiotics. Among the patients followed up for 12 months, duodenal ulcers recurred in 4 of 50 patients given antibiotics and 42 of 49 given placebo (8 percent vs. 86 percent, P < 0.001). Ulcers recurred in 1 of 46 patients in whom H. pylori had been eradicated, as compared with 45 of 53 in whom H. pylori persisted (2 percent vs. 85 percent, P < 0.001).

CONCLUSIONS

In patients with recurrent duodenal ulcer, eradication of H. pylori by a regimen that does not have any direct action on the mucosa is followed by a marked reduction in the rate of recurrence, suggesting a causal role for H. pylori in recurrent duodenal ulcer.

Treatment of patients with advanced colorectal cancer with cisplatin, 5-fluorouracil, and leucovorin

Based on in vitro studies that have demonstrated synergy between 5-fluorouracil (5-FU), leucovorin (LV), and cisplatin (CDDP) against human colon cancer cell lines, a clinical trial was initiated to determine the effects of this combination in patients with advanced unresectable colorectal carcinoma. Fifty-nine patients were enrolled in the study and 12 of them had received prior conventional 5-FU chemotherapy. Treatment consisted of 4 weekly courses of high-dose LV (200 mg/m2) administered by intravenous (IV) bolus, followed by 5-FU (550 mg/m2) and CDDP (20 mg/m2) each administered as a 2-hour infusion on 4 consecutive days. After a median of 5.5 treatment cycles, objective tumor response was seen in 20 of 59 patients (34%) (this included 3 complete remissions). The response rate in the 47 previously untreated patients was 38% (95% confidence limits, 26% to 53%). Stable disease occurred in 16 (27%) patients, whereas the tumor progressed in 23 (39%) patients. The median survival time was 11.5 months, with 15% of the patients alive at 2 years. The regimen was well tolerated and the primary side effects were mild and reversible gastrointestinal symptoms and myelosuppression. There was no episode of life-threatening toxicity. Eastern Cooperative Oncology Group (ECOG) Grade III adverse reactions that required 25% dose reductions occurred in only 14% of the patients. The results of this trial suggest that 5-FU, LV, and CDDP is an active, safe, and well-tolerated combination regimen in patients with advanced colorectal cancer.

A comparison of two doses of nizatidine versus placebo in the treatment of reflux oesophagitis

Three-hundred and twenty-five patients with endoscopically verified oesophagitis entered a double-blind, randomized multicentre study that compared 300 mg nizatidine b.d., 300 mg nocte and placebo. The 6- and 12-week treatment responses were studied. Healing was defined as complete epithelialization of all oesophageal lesions. The healing rates were 40% in the 300 mg nizatidine b.d. group, 30% in the 300 mg nocte group and 26% in the placebo group at 6 weeks. The corresponding figures after 12 weeks of treatment were 50%, 44% and 34%, respectively. The healing rates were significantly different (P less than 0.05) between the high-dose nizatidine group and placebo only, both at 6 and 12 weeks. Despite a trend at both 6 and 12 weeks in favour of 300 mg nizatidine nocte compared to placebo, this was not significantly different. The most important factor for the outcome, apart from the treatment group, was the pre-entry severity of oesophagitis. The differences observed between treatment groups in healing rates, symptomatic relief, and antacid consumption appear to result mainly from the patients with moderate and severe oesophagitis upon entry. Nizatidine (300 mg) b.d. appeared to be safe and effective in the treatment of reflux oesophagitis.

Diagnosis and tactical approach to surgery for early gastric carcinoma: a retrospective analysis of the past 16 years in an Austrian general hospital

In principle, many authors advocate a radical surgical approach for early gastric cancer (gastrectomy on principle). Our own experience with subtotal gastrectomy (including N1 + N2 lymphadenectomy; limited resection even without groups 11, 12) shows that this method yields comparable results. With an operative mortality of 2%, the survival rate was 84.3% after 5 years and 70.5% after 10 years, instead of the predicted values of 82.8% and 63.4%, respectively. Applied to the same age group without gastric carcinoma, this yields a 5-year survival rate of 101.8% and thus almost reaches Japanese standards.

Rioprostil in the short-term treatment of duodenal ulcer: a multicentre double-blind trial vs. cimetidine

The efficacy and safety of the new prostaglandin E1 (PGE1) synthetic analogue, rioprostil, 300 micrograms b.d. and cimetidine, 400 mg b.d., on duodenal ulcer healing are compared in an international, multicentre, double-blind study. A total of 257 patients have entered the study; 243 are considered eligible for efficacy analysis and 207 for safety analysis. After 4 and 6 weeks of treatment, the endoscopic healing rates do not significantly differ between the two groups, being 55% and 83% respectively with rioprostil vs. 60% and 78% respectively with cimetidine. The major adverse effect attributable to rioprostil is diarrhoea, which was documented in 11% of patients compared with 1% of patients taking cimetidine. However, central nervous system complaints are twice as frequent in the cimetidine group. Monitoring of clinical laboratory tests show no significant abnormalities when compared with the baseline values during the administration of either drug. This study documents that rioprostil, at the dosage of 300 micrograms b.d., is as effective and safe as cimetidine in the short-term therapy of duodenal ulcer.

Physiological and psychological response to a three-month mental strain period in students

Biochemical and immunological parameters, physical and mental performance, subjective complaints and behavioural characteristics were compared before and after 14 final examinations undertaken by 64 students during a three-month examination period. A decrease in cholesterol, triglycerides, HDL-cholesterol, physical performance and an increase in LDL/HDL cholesterol quotient, lactate level, mental performance were accompanied by a lower frequency of mental complaints and higher frequency of physical complaints. From the multidimensional variance and discriminant analysis 17 of the 44 variables discriminated between the state prior to and after the examination period. The results are interpreted in terms of the psychophysiological adaptation to adequate mental stress.

Combined therapy with cisapride and cimetidine in severe reflux oesophagitis: a double blind controlled trial

Combined treatment with cimetidine 1 g daily and cisapride 40 mg daily in patients with endoscopically diagnosed severe reflux oesophagitis was compared with single drug therapy (cimetidine and placebo). At the end of the six to 12 weeks treatment, 11 (46%) of the 24 patients under single drug therapy were endoscopically healed and three were improved. In contrast, 16 (70%) of the 23 patients under combined therapy were healed and all of the remainder were improved (p = 0.025). The severity of diurnal and nocturnal heartburn, decreased significantly more (p less than 0.05) on cimetidine + cisapride than on cimetidine + placebo. The combined treatment was well tolerated. These results suggest that combined therapy with cisapride and cimetidine may be useful in patients with severe reflux oesophagitis.

The efficacy of antimicrobial treatment in Campylobacter pylori-associated gastritis and duodenal ulcer

The efficacy of various antimicrobial and anti-ulcer agents on the elimination of Campylobacter pylori in duodenal ulcer patients was investigated. Ranitidine, cimetidine, pirenzepine, aluminium phosphate gel as well as combinations of H2-receptor antagonists or pirenzepine + penicillin V, ciprofloxacin, ofloxacin, phenyl-mercuryborate or rifampicin had no influence on C. pylori in vivo. Short term elimination of C. pylori was achieved in 3/15 patients treated with ranitidine + bacampicillin and in 1/5 treated with cimetidine + metronidazole. This elimination was accompanied by a significant reduction of polymorphonuclear infiltration of the antral mucosa. Development of bacterial resistance was observed in patients with additional quinolones, metronidazole and rifampicin but not in patients treated with betalactam antibiotics.

A comparison of roxatidine acetate 150 mg once daily and 75 mg twice daily in duodenal ulcer healing

A randomised multicentre, double-blind study of the efficacy and safety of roxatidine acetate 150 mg at bedtime or 75 mg twice a day was conducted in 300 outpatients with endoscopically confirmed duodenal ulcers. After 14 days' treatment with roxatidine acetate substantial reductions in ulcer sizes had been obtained, in addition to healing rates of 87 to 89%, with no significant differences between the dosage regimens. There were graded reductions in day and night-time assessment of epigastric pain for both treatment groups and no differences in the mean numbers of antacid tablets consumed. In addition, cigarette smoking did not influence the healing rates produced by either treatment schedule. 11 patients reported 12 mild adverse reactions, with gastrointestinal symptoms the most frequent, and no clinically significant alterations in laboratory values. The present data suggests that a single bedtime dose of roxatidine acetate 150 mg produces effective duodenal ulcer healing and pain relief equivalent to that produced by a twice daily dosage regimen.

[Treatment of duodenal ulcer with famotidine]

In a prospective double blind study the efficacy and safety of the new H2-receptor antagonist famotidine was compared with ranitidine. 48 patients with endoscopically proven duodenal ulcer were randomly allocated to receive famotidine 40 mg once at night, 20 mg bid, 40 mg bid or ranitidine 150 mg bid. After 4 weeks of treatment the ulcers of 7/12, 10/12, 9/12 and 6/12 patients were healed; the corresponding rates after 8 weeks were 9/12, 12/12, 11/12 and 10/12. Statistically there was no significant difference between the various groups. Adverse events of any clinical importance were not observed. These data indicate, that famotidine is as effective and as safe as ranitidine for the treatment of acute duodenal ulcer.

[Campylobacter pylori, gastritis and peptic ulcer]

In the course of routine gastroduodenoscopic examination of 218 patients bioptic mucosal specimens were examined bacteriologically for the presence of Campylobacter (C.) pylori. The organism was isolated from 52 out of 53 patients (98%) with duodenal ulcer, 7 out of 9 with gastric ulcer (78%), 24 out of 31 with mucosal erosions (77%), 10 out of 10 with duodenitis (100%), 16 out of 16 with chronic active gastritis (100%) and from 40 out of 73 patients (55%) with inactive chronic gastritis. By contrast, all specimens from 26 patients with endoscopically and histologically normal mucosa were negative for this bacterium. The rate of elimination of C. pylori from mucosal specimens was investigated as a first step towards studying the influence of antibiotic therapy upon healing of gastric and duodenal ulcers. For this purpose 30 patients with duodenal ulcers were treated either with ranitidine alone (15) or together with bacampicillin (15), which was shown to be highly active in studies with ampicillin in vitro. After 4 weeks the organism was still found in specimens from all patients treated with ranitidine alone, but also in 12 out of 15 patients given combined therapy. This result demonstrates that systemic antimicrobial chemotherapy with bacampicillin is insufficient to eradicate C. pylori from the stomach and the duodenum.

Effects of low and high dose oral cimetidine on hormone serum levels in patients with peptic ulcers

Luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (hPRL) and testosterone (T) were assayed in a total of 131 patients with peptic ulcer. Initial oral treatment was performed with 1000 mg cimetidine per day for 6 to 12 weeks. After healing was confirmed endoscopically, the patients were switched to a maintenance dose of 400 mg per day cimetidine for 3 years. Serum hormone levels before and during the two regimens were estimated in 48 male, 22 postmenopausal and 5 premenopausal subjects. Comparison between the two cimetidine doses was possible in 76 male, 44 postmenopausal and 6 premenopausal patients. In all patients hormone parameters assayed before therapy were within the normal ranges. FSH was noted to increase significantly in all but the premenopausal group but remained within the normal range. In contrast, hPRL declined significantly in all groups of subjects except for premenopausal females during cimetidine treatment. LH and T did not change during treatment and no differences of hormone serum levels were noted between the two regimens. Present data combine to suggest that an initial treatment with 1000 mg of cimetidine per day did not provoke hyperprolactinemia, and a switch from an initial high dose to a maintenance dose of 400 mg per day did not cause further changes in hormone serum levels. Changes of LH, FSH, hPRL and T recorded in the present study are too small to be considered responsible for possible endocrine disorders observed during cimetidine therapy.

[3-year long-term therapy of recurrent duodenal ulcer with 400 mg cimetidine nocte]

253 patients were treated for 3 years with 400 mg cimetidine at night to prevent relapses of recently healed duodenal ulcers. The efficacy of maintenance treatment was evaluated on a life table basis. In contrast to previous studies not the first but the third symptomatic relapse was taken as the major criterium of treatment failure, an assumption, that better represents the everyday practical situation. Further endpoints for the life table calculation were: the wish of the patient to stop treatment after the first or second recurrence, the failure of a first or second recurrence to heal within 12 weeks and side effects. At 1, 2 and 3 years 5 +/- 2.4%, 16 +/- 4.6% and 20 +/- 5.2% respectively had to be considered as treatment failures. 4 patients presented with a bleeding relapse, none of which necessitated emergency operation. There were no irreversible side effects. This study demonstrates that treatment of recurrent duodenal ulcers with 400 mg cimetidine at night for 3 years is safe and improves considerably the quality of life of the majority of patients. The authors suggest that drug maintenance treatment should be offered before surgery is recommended.

Maintenance treatment with cimetidine in peptic ulcer disease for up to 4 years

A multinational maintenance trial was conducted in 1842 peptic ulcer patients to investigate the efficacy and safety of continuous cimetidine maintenance therapy for up to 4 years. Patients with healed ulcers entered maintenance treatment with a 400-mg bedtime dose of cimetidine. Symptomatic ulcer relapse occurred in 17.2% of patients during the 1st year of treatment, in 9.6% during the 2nd year, and in 8.8% during the 3rd year. In addition to life-table analysis, the monthly prevalence of active ulceration over the 3-year period was examined. The average monthly prevalence rates were 2.1%, 1.8%, and 1.5% for the three successive yearly periods of continued cimetidine treatment. The adverse reactions observed in this study were not different from those previously reported with cimetidine. Moreover, there was a progressive decrease in the incidence of adverse events over the 4 years, thus establishing the long-term safety of continuous cimetidine treatment. It is concluded from this study that cimetidine maintenance treatment not only continues to be effective and safe beyond 1 year but also may reduce the risk of relapse over time.

Famotidine: proven once-a-day treatment for gastric ulcer

An 8-week, double-blind, randomized, placebo-controlled, multinational (n = 14), multicenter (n = 44) trial was conducted to determine whether famotidine speeds healing and relief of symptoms in patients with benign gastric ulcer. Of the 336 patients who entered the trial, 167 received 40 mg of famotidine in the evening, and 169 received placebo. At 4, 6, and 8 weeks after entry, ulcers had healed in a significantly (P less than 0.01) higher percentage of famotidine-treated patients than in those treated with placebo (47%, 65%, 80% versus 31%, 46%, 54%, respectively). Famotidine was also superior to placebo in relieving ulcer symptoms; the proportion of patients receiving additional antacid therapy was significantly lower in the famotidine group. The findings show that the new H2-receptor antagonist famotidine, administered as a single evening dose, significantly speeds the healing of benign gastric ulcers and that it is a safe and highly effective treatment of gastric ulceration. The convenient dosage regimen of famotidine (one tablet in the evening) should improve patient compliance, which, in turn, may result in faster healing of ulcers and a lower incidence of ulcer complications.

Nizatidine versus ranitidine in the prevention of duodenal ulcer relapse. Six-month interim results of a European multicentre study

Nizatidine, a new H2-receptor antagonist, was compared with ranitidine in a double-blind, randomized, multicentre trial for the prevention of duodenal ulcer relapse. This is the interim analysis of 197 patients admitted to the study by 1 September 1985, having finished a 6-month treatment period by 1 March 1986. At night, 96 and 101 patients received 150 mg nizatidine and 150 mg ranitidine, respectively. Both groups were well matched for demographic data, duration and severity of ulcer disease. Calculating cumulative relapse rates by the life-table method of Cutler and Ederer, 18% on nizatidine and 13% on ranitidine had experienced a symptomatic or asymptomatic recurrence. The difference is not statistically significant. The symptomatic response was identical in both groups, 3/4 of the patients in both groups being free of any symptom over all 6 months. During maintenance treatment, 24% of the patients on nizatidine and 32% of those on ranitidine reported new symptoms, listed as 'adverse events'. However, none of these events was likely to be drug related. There was no difference between the two groups concerning the percentage change of laboratory variables from baseline to endpoint.

300 mg nizatidine at night versus 300 mg ranitidine at night in patients with duodenal ulcer. A multicentre trial in Europe

Patients (859) from six countries were randomized into an endoscopically controlled double-blind trial. The objective of this study was to compare the efficacy and safety of nizatidine 300 mg nocte with ranitidine 300 mg nocte in the therapy of duodenal ulceration. Patients fulfilling the entry criteria and completing the protocol numbered 777 (388 nizatidine, 389 ranitidine). Endoscopy was performed on entry and at 4-week intervals (up to 8 weeks) until the ulcer healed, except in Germany where endoscopy was also performed after 14 days. Both groups appeared well matched for population demographics, duodenal ulcer history, previous therapy and pre-study symptomatology. Overall healing rates in the nizatidine group compared favourably with the ranitidine group at 4 weeks (nizatidine 81%, ranitidine 80%) and 8 weeks (nizatidine 92%, ranitidine 93%). Data from Germany alone showed similar ulcer healing rates after 2 weeks therapy (nizatidine 60%, ranitidine 64%). Although there were no differences between or within the treatment groups, overall ulcer healing was significantly impaired (p less than 0.05 or less) in patients with a large ulcer (greater than 15 mm), a family history of peptic ulcer disease, verified disease or greater than 5 years duration, or heavy smokers (greater than 20 cigarettes/day). Age did not influence healing. Overall healing rates were significantly influenced by country of patient origin, being higher in Germany, and lower in Belgium (p less than 0.001). After 2 weeks therapy, about 60% of the nizatidine and ranitidine treated patients were pain free, while 4 weeks therapy was associated with relief of all symptoms in 72% of patients and relief of night pain in more than 90%. Antacid consumption reduced at a similar rapid rate during the study. Events were reported equally in both treatment groups, events compatible with peptic ulcer disease predominating. Events associated with study termination appeared related to documented disease or protocol violations. Monitoring of laboratory data suggested no significant haematological or biochemical abnormalities in the nizatidine group. Nizatidine 300 mg nocte appears to be as effective as ranitidine 300 mg nocte in both ulcer healing and symptomatic response.

[Therapy of duodenal ulcer and pyloric ulcer with 800 mg cimetidine nightly]

The efficacy of cimetidine 400 mg b.i.d. as compared with a single evening dose 800 mg was evaluated in a single-blind multicentre trial involving 86 patients with endoscopically proven duodenal or pyloric ulcer. After four weeks of treatment the healing rates were 64.4% (29/45) with 400 mg cimetidine twice daily and 78% (32/41) with 800 mg nocte; after eight weeks the corresponding rates were 77.7% (35/45) and 85.3% (35/41). Administration of 800 mg cimetidine every evening is, consequently, at least as effective as a twice-daily regimen. In the second half of the treatment period it was significantly more effective in reducing pain and antacid consumption. The single noctural dose takes the pathogenetic importance of overnight gastric acidity into consideration, entails a simplification of therapy and may improve patient compliance. It should, therefore, take preference over the conventional twice-daily regimen.

[Parameters of acral vasomotor activity--sensory arousal variables in psychological stress]

By means of complex methods in 65 test persons from a large number of parameters the photopulse amplitude and the rheographic quotient at the finger apart from the heart rate and the blood pressure were established as very sensitive demand variables under psychic stress. The temporary and formal criteria of the volume pulse curves are less well suitable for this purpose. In the different reaction patterns the inclusion of sensitive biosignals of the acral vasomotricity is an information gain for the demand diagnostics under psychic stress.

[Famotidine versus placebo in prevention of the recurrence of duodenal ulcer disease. A multicenter study in Germany, Austria and Italy]

The aim of this study was to gain experience concerning efficacy and safety of famotidine, the new H2-receptor antagonist, for the maintenance of duodenal ulcer disease. 344 patients whose acute duodenal ulceration had recently been healed under famotidine or ranitidine were recruited for a year maintenance treatment with 20 mg bedtime dose of famotidine or placebo. 167 patients were treated with famotidine over 6 and 52 over 12 months. The corresponding numbers in the placebo control were 177 and 21. A life table method of analyses showed that the ulcer relapse rate was consistently and significantly (p less than 0.01) lower on famotidine than on placebo after 6 months (26% [43/167] versus 55% [98/177]). Of the 52 patients treated with 20 mg famotidine at night for further 6 months 7 (14%) developed an ulcer relapse. Of the 21 patients treated for further 6 months with placebo 5 (24%) showed an acute ulcer crater at endoscopy. Famotidine was well tolerated in the longterm therapy. The results confirm the efficacy and safety of famotidine in the prevention of duodenal ulcer relapse for at least 6 months.