Erythromycin and other macrolides as prokinetic agents

Isolation, sequence, and bioactivity of chicken motilin

Motilin was isolated from acid extracts of the small intestine of chickens by a combination of gel filtration chromatography, ion-exchange, and reverse-phase HPLC. The purification was monitored using a radioreceptor assay. The sequence of chicken motilin is FVPFFTQSDIQKMQEK-ERNKGQ. Although the six residues differing from porcine motilin (4, 7-10, and 12) are mostly in the pharmacophore of porcine motilin, the affinity of chicken motilin and of the (1-14) fragment of chicken motilin for the motilin receptor of rabbit antral smooth muscle is not much reduced (pKds of 8.90 and 8.45), compared with the affinity of [Nle13]porcine motilin (pKd 9.12). With smooth muscle tissue of the chicken, however, receptors could not be demonstrated with binding studies. In the tissue bath chicken motilin induced a dose-dependent tonic contraction, which was most pronounced with muscle strips prepared from chicken jejunum. This response was blocked by the Ca2+ antagonist verapamil, but atropine, TTX, L-NNA, guanethidine, prazosin, and yohimbine had no effect. The pEC50 for chicken motilin in the chicken jejunum was 7.41. Motilins from other species had lower potencies, and [Phe3, Leu13]porcine motilin, an antagonist in the rabbit, was an agonist in the chicken. The motilin agonists erythromycin A and EM-523 were almost without effect. Tested against rabbit duodenum, chicken motilin had a smaller potency than mammalian motilins. Thus, chicken motilin and the chicken motilin receptor differ from their mammalian counterparts.

Heterogeneity of motilin receptors in the gastrointestinal tract of the rabbit

Motilin, a 22-amino acid peptide synthesized in endocrine cells of intestinal mucosa, stimulates GI smooth muscle contractility. To elucidate the mode of action of motilin, we attempted to determine whether motilin receptors are localized on nerve cells or on smooth muscle cells of the GI tract. Mucosa-free tissues from rabbit antrum and duodenum were homogenized separately with a Polytron prior to differential centrifugation to obtain synaptosome or plasma membrane-enriched fractions, as determined by the distribution of [3H]saxitoxin (SAX) binding (neural membranes) and 5' nucleotidase (5'N) activity (smooth muscle plasma membranes). Motilin binding was evaluated by the displacement of [125I]motilin by motilin (1-22) on the various membrane fractions. In the antrum, motilin binding was highly correlated with SAX binding (r = 0.81, p < 0.0005), and also significantly with 5'N activity (r = 0.54, p < 0.05). In the duodenum, motilin binding correlated significantly with 5'N activity (r = 0.67, p < 0.005), but not with SAX binding (r = -0.11, NS). Receptor affinity, for the motilin antagonist MOT(1-12)[CH2NH]10-11, for motilin(1-22), and for the motilin agonist erythromycin lactobionate was significantly (p < 0.001, p < 0.001, and p < 0.05, respectively) higher in SAX-enriched fractions from the antrum than in 5'N-enriched fractions from the duodenum. Therefore, in the rabbit: 1) motilin receptors appear to be predominantly located on nerve tissues in the antrum and restricted to smooth muscle cells in the duodenum, and 2) antral receptors and duodenal receptors displayed different pharmacological characteristics, probably corresponding to two specific and heterogeneous motilin receptor subtypes.

Antagonistic properties of [Phe3,Leu13]porcine motilin

We describe the antagonistic properties due to the replacement of Pro3 by phenylalanine in porcine motilin. The analogue, [Phe3,Leu13] porcine motilin (OHM-11526), displaces iodinated [Nle13]porcine motilin bound to a homogenate of rabbit antral smooth muscle tissue. The dissociation constant (pKd) was 9.26 +/- 0.04, versus 9.11 +/- 0.01 for motilin and 8.24 +/- 0.06 for ANQ-11125, the (1-14) fragment of OHM-11526. The Hill coefficient was close to one and Schild plot analysis confirmed the competitive nature of the interaction. In the tissue bath OHM-11526 was unable to induce contractions of segments of rabbit duodenum. At a concentration of 10(-6) M, OHM-11526 was unable to induce contractions of segments of rabbit duodenum. At a concentration of 10(-6) M, OHM-11526 inhibited the effect of maximally effective doses of porcine motilin and of the erythromycin derivative, EM-523, but was without effect on contractions induced by acetylcholine, substance P and serotonin. Increasing doses of OHM-11526 shifted the dose-response curves of motilin and EM-523 to the right, but caused a depression of the maximal response as well. From the motilin curves, and assuming a dual competitive and non-competitive interaction, the pA2 was 7.79 +/- 0.08, the pD'2 6.91 +/- 0.08. The EM-523 curves yielded comparable data (pA2 = 8.10 +/- 0.12 and pD'2 = 7.06 +/- 0.13). OHM-11526 also blocked the motilin responses observed with smooth muscle strips from the rabbit and human antrum. However, in a preparation of the chicken small intestine, OHM-11526 was a full agonist with a potency (pD2 = 6.84) comparable to that of porcine motilin (pD2 = 6.71). Our data confirm the interaction of motilides with the motilin receptor. Due to its increased affinity for the motilin receptor, OHM-11526 will be a valuable took for studying the physiology of motilin and the pharmacology of motilin and motilides.

Effect of erythromycin on gastric motility in mechanically ventilated critically ill patients: a double-blind, randomized, placebo-controlled study

OBJECTIVE

To document the action of erythromycin on gastric emptying and motility in mechanically ventilated patients.

DESIGN

Crossover, double-blind, randomized, placebo-controlled study.

SETTING

General intensive care unit in a university hospital.

PATIENTS

Ten patients, mechanically ventilated, in a stable hemodynamic condition.

INTERVENTIONS

Erythromycin (200 mg i.v. over 30 mins) and placebo were infused at mid-morning, on two consecutive days, in a random order. Pressure changes in the gastric antrum were recorded by means of a multi-lumen manometric tube (perfused catheter technique) over a period of 300 mins, beginning with the institution of the erythromycin or placebo infusion. Gastric emptying was simultaneously assessed by the kinetics of the absorption of acetaminophen delivered into the stomach (1 g with 20 mL of water) immediately before the infusion.

MEASUREMENTS AND MAIN RESULTS

Motility was quantified by determining the number of contractions, the amplitude of contractions, and the Motility Index (Motility Index = natural logarithm [sum of amplitude x number of contractions] + 1). Comparison between placebo and erythromycin was made for the first hour after the infusion and for the whole recording session. The maximal acetaminophen concentration, the time to reach the peak acetaminophen concentration, and the area under the concentration-time curve at 60 mins were obtained from serial determinations of plasma acetaminophen concentrations. Compared with placebo, the mean number of contractions (104 +/- 34 vs. 5 +/- 8; p = .003), the mean amplitude of contractions (52 +/- 16 vs. 20 +/- 17 mm Hg; p = .005), and the Motility Index (13.06 +/- 0.95 vs. 4.45 +/- 3.54; p = .004) were significantly increased during the first hour after erythromycin infusion compared with placebo. Number of contractions (p = .017) and Motility Index (p < .001) after erythromycin infusion remained significantly higher when values throughout the whole recording session were considered. The following data were noted after erythromycin was infused: a) the time to reach the peak acetaminophen concentration was shorter (32 +/- 8 vs. 171 +/- 93 mins; p = .007); b) the maximal acetaminophen concentration was higher (22.09 +/- 6.23 vs. 5.38 +/- 3.80 micrograms/mL; p = .007); and c) the area under the concentration-time curve at 60 mins increased markedly (730 +/- 269 vs. 72 +/- 42 micrograms/min/mL; p = .002) as compared with placebo.

CONCLUSION

In mechanically ventilated patients, intravenous erythromycin (200 mg over 30 mins) increases indices of antral motility and accelerates gastric emptying as assessed by the kinetics of acetaminophen absorption.

Erythromycin enhances fasting and postprandial proximal gastric tone in humans

BACKGROUND & AIMS

Low doses of erythromycin induce antral contractions and accelerate gastric emptying. However, the effect of erythromycin on the proximal stomach remains unknown. The aim of this study was to assess the effect and mechanism(s) of action of erythromycin on proximal gastric tone in humans.

METHODS

Gastric tone was measured using an electronic barostat in two groups of 6 subjects both in the fasting state and after a 200-kcal meal. On different occasions, subjects received saline, atropine alone (6 micrograms.kg-1.h-1 for 30 minutes), erythromycin alone (1.5 mg/kg in the fasting state and 1.5 and 3.0 mg/kg in the postprandial state), and erythromycin plus atropine.

RESULTS

Low-dose (1.5 mg/kg) erythromycin enhanced fasting gastric tone, but only the 3.0-mg/kg dose reduced the duration of meal-induced relaxation (37 +/- 14 vs. 105 +/- 20 minutes; P < 0.01). Atropine did not change the fasting or postprandial gastric tone as well as the erythromycin-induced responses. Plasma motilin levels were unaffected by erythromycin infusion. No correlation was observed between gastric tone and plasma motilin or erythromycin levels.

CONCLUSIONS

Erythromycin enhances fasting and postprandial proximal gastric tone in humans by a mechanism that does not seem to involve endogenous motilin release or a cholinergic pathway.

From motilin to motilides: a new direction in gastrointestinal endocrinology

Investigation into gastrointestinal irritation from the use of erythromycin lead to the discovery of the gastrointestinal motor effect of this antibiotic. Erythromycin and gastrointestinal peptide motilin share many similar gastrokinetic activities, and studies indicate that erythromycin mimics the effect of motilin through motilin receptor agonism. Since erythromycin is readily available for clinical use, it may offer an alternative therapeutic approach to gastroparesis and related conditions. Several analogs of erythromycin without antimicrobial activity are also shown to possess similar motor effects, thus termed "motilides". A growing number of motilides may expand our knowledge on gastrointestinal peptides.

Review article: functional dyspepsia--should treatment be targeted on disturbed physiology?

In patients who present with chronic unexplained upper abdominal pain or discomfort (functional dyspepsia), therapy should ideally be targeted on correcting the individual's disturbed pathophysiology. Here, putative mechanisms implicated in functional dyspepsia and potential approaches to therapy are critically reviewed in order to determine if targeting treatment is of value. Pharmacological therapies reviewed include those that aim to correct disordered gastric emptying (e.g. cisapride, dopaminergic receptor antagonists, macrolides), reduce visceral hypersensitivity (e.g. somatostatin analogues, cholecystokinin antagonists, opioid agonists, serotonin type 3 receptor antagonists), reduce gastric acid secretion (e.g. H2-blockers, acid pump inhibitors), cure Helicobacter pylori infection, enhance muscosal defence (e.g. sucralfate, bismuth) or modify central nervous system processes. It is concluded that the imperfectly understood pathophysiology of functional dyspepsia contributes to the paucity of established efficacious therapies.

Gastric but not duodenal motor effects of oral erythromycin are dose related

There has been increasing interest in the potential use of erythromycin as a prokinetic agent, despite limited data on the effect of oral administration on gastrointestinal motility. We have now evaluated, in 15 conscious pigs fitted with strain gauges, the response of (i) basal gastric motility and (ii) gastric motility during inhibition with intraduodenal triglycerides infusion to increasing doses of oral erythromycin. In the basal state, erythromycin led to dose-dependent increases in both the amplitude (10-30 mg kg-1) and the frequency (10-55 mg kg-1) of gastric contractions. The corpus was more responsive than the antrum, with an increase in amplitude at lower doses. The amplitude of the duodenal contractions was also improved but not in a dose-dependent manner. Gastroduodenal coordination was unchanged regardless of the dose of erythromycin. Following inhibition of gastric motility, a dose of erythromycin below 45 mg kg-1 increased both the amplitude of gastric contractions and the gastroduodenal coordination, although individual doses produced smaller increases in amplitude than in the basal state. These results suggest that erythromycin has a different mechanism of action in the stomach compared with the duodenum. The reduced effectiveness of large doses of erythromycin has important therapeutic implications.

Transduction mechanism of motilin and motilides in rabbit duodenal smooth muscle

The present study was undertaken to explore motilin's transduction pathway in the rabbit. Guanine nucleotides inhibited 125I-motilin binding in rabbit antral tissue and increased the dissociation of motilin from its receptor. Motilin, the motilin agonist erythromycin A enol ether (EM-201) and carbachol (taken as control) increased the production of inositol phosphates in rabbit duodenal smooth muscle strips labeled with myo-[2-3H]inositol. The effect of carbachol was blocked by atropine. Dose-response curves revealed that 50% of this effect was obtained with 3.9 nM motilin, 170 nM EM-201, 0.54 microM carbachol. Chromatographic separation of the inositol phosphate metabolites showed significant increases in the levels of [3H]inositol bisphosphate and of [3H]inositol trisphosphate. The three substances were without effect upon the metabolism of cAMP, nor did they modulate the rise in cAMP induced by GTP. We propose that motilin's transduction pathway uses a G protein that causes an increase in inositol trisphosphate which is rapidly metabolized, and which may release calcium from intracellular stores.

Motilin receptor: a model for development of prokinetics

Erythromycin and related macrolides act as smooth muscle and neural receptors to contract rabbit duodenum and induce phase III migrating motor complex (MMC) activity in intact dogs. A recently developed motilin antagonist confirms that motility effects of erythromycin are mediated by motilin receptors. Despite species, organ, and tissue heterogeneity of motilin receptors, binding experiments with rodent antral smooth muscle tissue provide a good model for the development of this new class of prokinetics.