Metoclopramide. An updated review of its pharmacological properties and clinical use

Chemotherapy and pregnancy

There are still unanswered questions concerning long-term effects of intrauterine exposure to antineoplastics. It is possible that a mechanism of follow-up such as a national registry could be formalized. Although pregnancy in the women with cancer is a rare event, it may occur more frequently in the future. The nurse must be knowledgeable concerning the issues in decision-making and confident in his or her ability to mobilize resources for the patient and family. Overall, the use of cytotoxic agents during the first trimester offers the greatest potential for spontaneous abortion and fetal malformations. In contrast, chemotherapy administered in the second and third trimesters appears to offer minimal risk. What effect this exposure will have on future generations is only speculative. It would be safer if fetal drug exposure could be avoided completely, but when this is not prudent and the mother's life is at stake, careful consideration and thoughtful guidance is appropriate for the pregnant patient with cancer.

Pharmacokinetics of metoclopramide in goats

The pharmacokinetics of a parenteral formulation of metoclopramide (monochloride monohydrate) were determined following single intravenous (i.v.) and intramuscular (i.m.) 0.5-mg/kg doses to two groups of 4 goats in a crossover design. Mean serum concentrations of metoclopramide following i.v. administration of 0.5 mg/kg declined rapidly from a peak of 277.5 ng/ml at 3 min post-dosing to 25 ng/ml at 90 min. Serum concentrations were not detectable by 120 min after drug administration. The curve of serum concentrations vs. time was characteristic of a two-compartment open model. Mean parameters from analysis of the individual i.v. data gave a biological half-life of 0.62 h and a volume of distribution of the central compartment of 1.34 l/kg. Serum concentrations of metoclopramide following i.m. administration of 0.5 mg/kg rose rapidly to a peak of 160.9 ng/ml at 15 min post-dosing and then declined in parallel with the elimination phase of the i.v. study. These data were best described by a two-compartment open model with first-order absorption. The mean biological half-life was 1.04 h. There were no adverse reactions associated with metoclopramide at the 0.5-mg/kg dose administered by either route.

The resolution, isolation, and pharmacological characterization of the enantiomers of a benzamide containing a chiral sulfoxide

Rac-ML-1035 (MDL 201,035: 4-amino-5-chloro-2-[2-(methylsulfinyl)ethoxy]-N-[2-(diethylamino)ethyl] benzamide hydrochloride) is a racemic gastroprokinetic with serotonergic (5-hydroxytryptamine, 5-HT) activity and a novel chiral sulfoxide substituent. Chromatographic and chemical methods have been developed to resolve the enantiomers of rac-ML-1035, and the absolute configuration of the (R)-enantiomer has been determined. We also report pharmacological characterization of rac-ML-1035 and its respective isomers. Radioligand binding to rat cortical membranes revealed that (R)-ML-1035 (MDL 201,226) and (S)-ML-1035 (MDL 201,227) had equivalent activity at the 5-HT3 receptor. However, in isolated tissue studies including field-stimulated guinea pig ileum, field-stimulated rat fundic strip, and nonstimulated guinea pig ileum, (S)-ML-1035 was equally potent yet had greater maximal activity than (R)-ML-1035 in eliciting or facilitating cholinergic contractions. Thus, enantiomers of rac-ML-1035 can be resolved, and the relative configuration of these isomers influences their pharmacological activity.

Normal tissue reactions in mice after combined treatment with metoclopramide and ionizing radiation

We have previously shown that metoclopramide potentiates the effect of ionizing radiation and cisplatin treatment of human squamous cell carcinomas from the head and neck region xenografted to nude mice. In the present tumor study, the dose scheduling of metoclopramide in combination with radiation was evaluated, and metoclopramide was shown to be most effective in potentiating the cytotoxic effect of radiation when administered one hour before radiation. The effect of radiation in combination with metoclopramide on normal tissue was also studied in two well-established models. Acute skin reactions to radiation exposure were studied in 129-type mice, and metoclopramide did not enhance the acute skin reaction in this in vivo model. Survival after whole body irradiation was studied in heterozygote Balb/c nu/+ mice as a measure of bone marrow toxicity. Metoclopramide was not found to affect the LD50/30 in this in vivo model. The absence of potentiation of radiation damage to normal tissue in these animal studies, makes metoclopramide an interesting possibility for future clinical evaluation.

Dopamine agonists prevent duodenal ulcer relapse. A comparative study with famotidine and cimetidine

The present study investigated both the healing rate (after four weeks) and the relapse rate (during six months) following treatment with the dopamine-like drugs bromocriptine (2.5 mg twice daily), amantadine (100 mg nocte), or with the H2 blockers cimetidine (800 mg nocte), and famotidine (40 mg nocte) in 124 patients with endoscopically proven duodenal ulcer (DU). The ulcer was completely healed in 27 (amantadine), 26 (bromocriptine), 23 (cimetidine), and in 24 (famotidine) patients. Relapse was noted in 34.7% (cimetidine) and 25% (famotidine) versus 11.7% (amantadine) and 7.7% (bromocriptine) DU patients. No significant difference was found in initial healing rates. However, the relapse rate in the cimetidine-treated group was significantly higher than in all the other test groups. Additional comparisons between all the treatment categories showed a significantly lower relapse rate with the dopamine-like agents. These important new results indicate that dopamine-like compounds are equally effective as H2 blockers in inducing DU healing and may offer a promising advantage over H2 blockers concerning their efficacy in preventing ulcer relapse in DU patients.

Atrial natriuretic factor inhibits metoclopramide stimulated aldosterone release in man

1. Atrial natriuretic factor (ANF) has an inhibitory effect on angiotensin II and ACTH stimulated aldosterone secretion in man. The selectivity of this aldosterone suppressing effect of ANF is unclear in man. The present study investigated the effect of ANF on the increase in plasma aldosterone due to metoclopramide in man. 2. Eight normal male volunteers were studied on three occasions. Metoclopramide (10 mg slow i.v.) was given on all study days and each volunteer was randomised to receive 45 min infusion of either 5% D-glucose (placebo) or ANF (99-126) 3 or 15 pmol kg-1 min-1. 3. Metoclopramide increased plasma aldosterone to approximately 170% of baseline levels (P less than 0.01). Concomitant infusion of ANF 3 pmol kg-1 min-1 and 15 pmol kg-1 min-1 significantly attenuated this rise in plasma aldosterone to approximately 130% (P less than 0.05) and 110% (P less than 0.01) of baseline values respectively. 4. It is suggested, in the light of previous findings, that the inhibitory effect of ANF represents a non-selective action of ANF on aldosterone release.

Ondansetron. Therapeutic use as an antiemetic

Ondansetron (GR 38032F) is a highly selective 5-HT3 receptor antagonist, one of a new class of compounds which may have several therapeutic applications. Animal and clinical studies show that ondansetron reduces the 24-hour incidence and severity of nausea and vomiting induced by cytotoxic drugs, including cisplatin, and by single exposure, high dose radiation. Ondansetron is more effective than high dose metoclopramide in the 24 hours following chemotherapy, and preliminary clinical evidence suggests that it is equally effective in the following 4 days. It is also more effective than the 'moderate' doses of metoclopramide used to suppress emesis following radiotherapy. The antiemetic efficacy of ondansetron is enhanced by dexamethasone in cisplatin-treated patients. Importantly, extrapyramidal effects have not been reported with ondansetron. Further comparisons are required with standard combination antiemetic therapy to complement the data presently available. Thus, ondansetron is a promising new agent for prophylaxis against nausea and vomiting in chemotherapy and radiotherapy. It may be particularly useful in young and elderly patients who are more susceptible to extrapyramidal symptoms induced by high dose metoclopramide. With its improved tolerability and clinical response profiles, ondansetron represents an important advance in a difficult area of therapeutics.

Kinetics of intravenous metoclopramide in patients with hepatic cirrhosis

The pharmacokinetics of metoclopramide has been studied after acute IV administration to 12 patients with hepatic cirrhosis (6 with and 6 without ascites) and 6 control subjects. The elimination half-life was significantly longer in patients (11.4 h and 9.9 h in those with and without ascites, respectively, vs 6.4 h in controls). Total plasma clearance was significantly lower in patients (0.29 and 0.36 l.kg-1.h-1 vs 0.52 l.kg-1.h-1 in controls). The differences between patients with and without ascites did not reach statistical significance. Reduction of functional hepatic blood flow in cirrhotic patients is the probable cause of the observed alteration in metoclopramide kinetics.

Metoclopramide, domperidone and dopamine in man: actions and interactions

The effects of oral doses of the dopamine antagonist antiemetics metoclopramide and domperidone on baseline and dopamine stimulated renal function and systemic haemodynamics were assessed in a placebo controlled crossover study in 9 healthy volunteers. Metoclopramide did not change baseline ERPF, GFR or FF over 2 h post dosing but it significantly reduced baseline UNaV, UKV, urine flow, urinary dopamine excretion, supine and erect diastolic blood pressure and supine systolic blood pressure. Domperidone and placebo did not cause these effects. Metoclopramide caused a marked rise and domperidone a small fall in plasma aldosterone concentration (PAC) but placebo was without effect. Neither antiemetic altered plasma renin activity (PRA) but a small fall occurred with placebo. Two hours after pretreatment with placebo dopamine (2 micrograms/kg/min) increased effective renal plasma flow (ERPF), glomerular filtration rate (GFR), sodium excretion rate (UNaV), urine flow rate, urinary dopamine excretion rate, supine systolic blood pressure and supine and erect pulse rate and decreased the potassium excretion rate (UKV), filtration fraction (FF) and supine diastolic blood pressure. Metoclopramide pretreatment, did not attenuate the dopamine induced rise in ERPF, GFR, urine flow, urinary dopamine excretion or supine systolic blood pressure but it did attenuate the rise in pulse rate, the fall in diastolic pressure, and the antikaliuretic effect of dopamine leading to a net kaliuresis when compared to placebo. Domperidone was similar to placebo. Neither metoclopramide nor domperidone given orally caused clinically important antagonism of the renal haemodynamic effects of dopamine. However the effects of metoclopramide on blood pressure and electrolyte excretion may have clinical importance.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of metoclopramide in patients with liver cirrhosis

The pharmacokinetics of metoclopramide were investigated after intravenous and oral administration in eight patients with severe alcoholic cirrhosis and in eight healthy volunteers. As a consequence of a 50% lower clearance (0.16 +/- 0.07 vs 0.34 +/- 0.09 l h-1 kg-1, plasma drug concentrations and the half-life of metoclopramide were greater in patients following both routes of drug administration. Volume of distribution (3.1 +/- 0.8 vs 3.4 +/- 1.2 l kg-1) and absolute bioavailability (79 +/- 19 vs 84 +/- 15%) were similar in the two groups. The adverse effects of metoclopramide observed in patients with marked hepatic impairment are likely to result from increased accumulation of the drug as a result of impaired clearance. Consequently a reduction in dose of 50% is recommended in patients with severe liver cirrhosis.

Pharmacology of antimigraine drugs

The drugs used in migraine therapy can be divided into two groups: agents that abort an established migraine attack and agents used prophylactically to reduce the number of migraine attacks. Both groups have drugs that are specific for migrainous headaches and that are non-specific, and are used to treat the accompanying headache (analgesics), vomiting (anti-emetics), anxiety (sedatives and anxiolytics), or depression (antidepressants). The main drugs with specific action on migraine include ergot alkaloids (ergotamine, dihydroergotamine), agonists (sumatriptan) or partial agonists (methysergide) at a specific subtype of 5-HT1-like receptors, beta-adrenoceptor antagonists (propranolol, metoprolol), calcium antagonists (flunarizine) and anti-inflammatory agents (indomethacin). The pharmacological basis of therapeutic action of several of these drugs is not well understood. In the case of the ergot alkaloids and 5-HT1-like receptor agonists, however, it is likely that the antimigraine effect is related to the potent and rather selective constriction of the large arteries and arteriovenous anastomoses in the scalp and dural regions. In addition, these drugs inhibit plasma extravasation into the dura in response to trigeminal ganglion stimulation, but it is possible that this effect is related to the selective vasoconstriction in the extracerebral vascular bed. The selectivity of the pharmacological effects of these antimigraine drugs (constriction of the extracerebral arteries and arteriovenous anastomoses, poor penetration into the central nervous system and the absence of an antinociceptive effect even after intrathecal administration) strongly suggests that excessive dilatation in the extracerebral cranial vasculature, probably initiated by a neuronal event, is an integral part of the pathophysiology of migraine.

Serum gastrin and blood glucose levels during halothane-nitrous oxide anaesthesia and strabismus surgery in children

The purpose of this study was to determine whether serum gastrin levels are increased by reflexogenic stimuli applied to the extrinsic muscles of the eye. Serum gastrin and blood glucose concentrations were measured in ten normal children aged between 5 and 12 yr during general anaesthesia with halothane and nitrous oxide and during strabismus surgery. Fasting basal concentrations of gastrin (33.6 +/- 14.8 pg.ml-1) and of glucose (4.43 +/- 0.72 mmol.L-1) were in the normal range of values for children. Intravenous atropine (0.01 mg.kg-1), general anaesthesia with halothane in nitrous oxide and oxygen by mask for three minutes, tracheal intubation, extraocular muscle stimulation and surgical stress did not cause any variation in the mean serum gastrin concentration. On the contrary, tracheal intubation and surgical stress increased blood glucose concentrations (P less than 0.05). There was no difference in the serum gastrin levels after extraocular muscle stimulation between children with positive or negative oculocardiac reflexes (44.5 +/- 16.7 pg.ml-1 vs 38 +/- 14.7 pg.ml-1, respectively). The incidence of vomiting predischarge was 60 per cent. Serum gastrin levels did not differ between children who vomited and children who did not (44.3 +/- 18.5 pg.ml-1 vs 47.1 +/- 16.9 pg.ml-1, respectively). Vomiting after strabismus surgery cannot be attributed to high gastrin serum levels. Consequently, it is unlikely that vomiting after strabismus surgery is linked to an "oculogastric reflex" with the vagus nerve as the efferent pathway.

Determination of ML-1035 enantiomers in plasma by chiral high-performance liquid chromatography

ML-1035, is a gastroprokinetic agent structurally related to metoclopramide. Because ML-1035 contains an asymmetric chiral sulphoxide moiety, a chiral HPLC method has been developed to separate and quantitate its R- and S-enantiomers in plasma. The ML-1035 enantiomers present in plasma are extracted with dichloroethane under alkaline conditions, the extract evaporated to dryness and reconstituted in the mobile phase. Samples are chromatographed on a Chiralcel OD HPLC column with hexane-absolute ethanol (1% TEA) (1:1, v/v) as the mobile phase. The enantiomers of the unchanged drug are determined by fluorescence measurement (ex: 310 nm, em: 350 nm). The method provides a linear response for both enantiomers over a concentration range of 25 (limit of determination) to 2500 ng ml-1 with correlation coefficients of 0.9987 or greater. The inter-assay precision is 9.5% or less and the accuracy ranges from 93.9 to 103.4% of the theoretical value. The method is used to determine the plasma concentrations of the R- and S-enantiomers following oral and intravenous administration of R- or S-enantiomers to dogs. The method is also adapted to measure enantiomer levels from in vitro reaction mixtures so that the possibility of metabolic inversion may be assessed. The data suggest that no significant level of inversion between the enantiomers occurred either in vivo or in vitro.

Column-switching liquid chromatographic determination of ML-1035 sulphoxide and its sulphone and sulphide metabolites in rat urine

A fully automated column-switching LC assay has been developed for the simultaneous determination of a gastroprokinetic agent, ML-1035 sulphoxide, and its sulphone and sulphide metabolites in rat urine. ML-1035 Sulphoxide is a metoclopramide analogue. The method involved direct injection of a diluted urine sample into a CN extraction column for sample clean-up. Polar urine components, including proteins, were flushed to waste. The retained compounds were then eluted onto a C8 analytical column for further separation and analysis by fluorescence detection. After the subsequent washing and re-equilibration with a sequence of three solvent mixtures, the extraction column was ready for the next injection. The recovery of the compounds from the extraction column was 85-90%. The limit of quantitation for all compounds of interest was 25 ng ml-1 or lower, using a 100 microliters specimen of urine. Good inter-day precision (2.1-10.0%), accuracy (0.3-18.0%), and linearity were obtained for all compounds over a range of 25-1000 ng ml-1. The applicability of the LC method was validated with urine samples from rats that had received ML-1035 sulphoxide.

Fetal and maternal placental and nonplacental clearances of metoclopramide in chronically instrumented pregnant sheep

The placental and nonplacental clearances of metoclopramide were studied in nine chronically instrumented, near-term pregnant sheep using a two-compartment open model. Metoclopramide was administered to the ewe and fetus on separate occasions as an initial iv bolus loading dose followed by a constant-rate infusion, with steady-state maternal and fetal plasma concentrations being obtained by 45 min. Following the maternal infusions, metoclopramide reached average steady-state concentrations of 50.0 +/- 20.2 ng/mL in the ewe and 27.1 +/- 8.6 ng/mL in the fetus, with a mean fetal-to-maternal concentration ratio of 0.57 +/- 0.14. The ability of the fetus to eliminate metoclopramide by nonplacental routes appears to be responsible for this ratio being less than unity, rather than differential protein binding and ion-trapping effects. Mean steady-state concentrations were 13.8 +/- 4.5 and 253.7 +/- 92.1 ng/mL in the ewe and fetus, respectively, after fetal drug administration. Metoclopramide was bound significantly less to fetal (39.5 +/- 8.9%) than to maternal (49.5 +/- 7.9%) plasma proteins, with values similar to that reported for humans (approximately 40%). Clearance of metoclopramide across the placenta from the fetus to the ewe (6.2 +/- 2.4 L/h/kg) was significantly greater than that in the reverse direction (4.3 +/- 1.3 L/h/kg) and accounted for approximately 80% of total fetal drug elimination. This may be explained by the higher percentage of fetal cardiac output to the placenta and the flow-limited transfer of this compound.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of metoclopramide on portal blood flow in patients with liver cirrhosis, measured by the pulsed Doppler system

The effect of metoclopramide on portal blood flow, the maximal diameter of the portal vein, and some cardiovascular haemodynamic variables was studied in 10 patients with cirrhosis of the liver and portal hypertension. Portal vein haemodynamics were studied by the pulsed Doppler system. Within 15 min of intravenous administration of 20 mg metoclopramide, portal blood velocity and portal blood flow decreased significantly, from 11.2 +/- 1.1 to 10.8 +/- 1.2 cm/sec and from 769.0 +/- 87.7 to 707.9 +/- 84.2 ml/min, respectively (p less than 0.001). Within about 30 min portal blood velocity and portal blood flow returned to basal values (p greater than 0.05). The maximal diameter of the portal vein, systolic and diastolic blood pressure, and heart rate remained unchanged. These results support the hypothesis that metoclopramide, which raises lower oesophageal sphincter pressure and reduces intravariceal blood flow, significantly decreases the portal blood flow in cirrhotic patients with portal hypertension.

Gastric fluid volume and pH in elective surgical patients: triple prophylaxis is not superior to ranitidine alone

The effect of oral ranitidine alone was compared with sequentially administered ranitidine, metoclopramide, and sodium citrate on gastric fluid volume and pH in 196 healthy, elective surgical inpatients, each of whom was randomly assigned to one of four groups. Patients in all groups received oral ranitidine 150 mg 2-3 hr before the scheduled time of surgery. Those in Group 1 also received oral metoclopramide 10 mg one hour before surgery, and sodium citrate 0.3 M 30 ml on call to the operating room; Group 2 received sodium citrate but no metoclopramide; Group 3 received metoclopramide but no sodium citrate; Group 4 received ranitidine alone. Following induction of anaesthesia a #18 Salem sump tube was passed into the stomach and all available gastric fluid was aspirated. Volumes were recorded and pH measured. In all groups mean pH was greater than 5.8, although at least one patient in each group had pH less than 2.5. Mean volumes were significantly greater in patients who received citrate (Groups 1 and 2: 22 and 19 ml) than in those in those who did not (Groups 3 and 4: 10 and 8 ml). One patient in Group 2 and one in Group 3 had pH less than 2.5 with volume greater than 25 ml. Our results do not demonstrate any advantage of double or triple prophylaxis over ranitidine alone. The practical difficulty of correctly administering two or even three medications, each at different but exact preoperative intervals, is emphasized.

A novel water-soluble dopamine-2 antagonist with anticholinesterase activity in gastrointestinal motor activity. Comparison with domperidone and neostigmine

A novel water-soluble dopamine-2 antagonist, N-[4-[2-(dimethylamino) ethoxy]benzyl]-3,4-dimethoxybenzamide hydrochloride (HSR-803) was synthesized and assayed for its gastrointestinal smooth muscle stimulating activity in vivo and in vitro. In the in vivo study, gastrointestinal contractile activity was measured by means of chronically implanted force transducers in conscious dogs; it was found that HSR-803 at 3.0 mg/kg IV probably stimulated gastric contractile force twice during the digestive state and significantly antagonized dopamine-(1.0 mg/kg per hour) inhibited gastric contractions in doses of 0.3, 1, and 3 mg/kg IV. With a background IV infusion of HSR-803 at 3 mg/kg per hour, the contraction-stimulating activity of acetylcholine (0.05 mg/kg per minute) was greatly enhanced while the response to bethanechol was not changed. As a result, HSR-803 was found to have a strong anticholinesterase activity besides the antidopamine-2 activity; i.e., the anticholinesterase activity of HSR-803 at 3 mg/kg per hour was equivalent to that of neostigmine at 10 micrograms/kg per hour, and dopamine-2 antagonistic activity of HSR-803 was similar to that of domperidone on a weight basis. No symptom suggesting actions on the central nervous system was noticed in HSR-803 up to 10 mg/kg IV in conscious dogs. In the in vitro study, HSR-803 inhibited cholinesterase dose-dependently, and IC50 was 2.9 x 10(-6) mol/L, while those of neostigmine and domperidone were 2.3 x 10(-8) mol/L and 1.7 x 10(-5) mol/L, respectively. In conclusion, HSR-803 stimulates endogenous acetylcholine release by antagonizing the dopamine-2 receptor on the postsynaptic cholinergic neurons, and the anticholinesterase activity of HSR-803 may cause the released acetylcholine to accumulate at cholinergic receptor sites. Thus, HSR-803 is potentially capable of enhancing cholinergic activity in the gastrointestinal region.

Therapeutic management of nausea and vomiting

1. The aim of this study is to review the mechanisms implicated in nausea and vomiting and the treatment of these symptoms. 2. Metoclopramide, a benzamide, is the drug most frequently used to alleviate or abolish the majority of nausea and vomiting of different origin. Domperidone, which scarcely penetrates the central nervous system (CNS), is less used. 3. The treatment of vomiting induced by cytotoxic drugs is necessary to use a combination (two or more) of antiemetic drugs (metoclopramide, glucocorticoids, antihistamines, butyrophenones, anticholinergics, cannabinoids). Recently, antagonists of serotonergic (5-HT) receptors of the subtype 5-HT3 appear to possess interesting antiemetic properties and they have a promising future in this field. 4. Antagonists of dopamine receptors (benzamides, phenotiazines, butyrophenones and domperidone) induce adverse reactions in CNS (mainly extrapyramidal disorders), which are scarce with metoclopramide and practically absent with domperidone. These disorders must not suppress antiemetic therapy when it is needed.

Evidence for the presence of both D-1 and D-2 dopamine receptors in human esophagus

Clinical and pharmacological evidence suggested that dopamine is involved in the control of esophageal motility. The present study was designed to determine whether or not dopamine receptors are present in human esophagus. With this aim we measured adenylate cyclase activity as a biochemical index of dopamine receptor function in esophageal specimens taken from five patients during surgery for upper esophageal carcinoma. The selective D-1 agonist fenoldopam stimulated cAMP formation in the lower esophageal sphincter, but not in the esophageal body; this effect was prevented by the selective D-1 antagonist SCH 23390 and by d-butaclamol. Bromocriptine, a selective D-2 stimulator, inhibited adenylate cyclase activity in the lower esophageal sphincter, an effect blocked by the D-2 antagonist (-)sulpiride. No effects of bromocriptine were found in the esophageal body. These data indicate that both D-1 and D-2 receptors are present in the lower esophageal sphincter, but not in esophageal body and emphasize the role of dopamine in the regulation of esophageal function.

The use of place conditioning in studying the neuropharmacology of drug reinforcement

The place conditioning paradigm has proven successful in identifying the neural mechanisms of drug reinforcement. Two classes of drugs, opiates and psychomotor stimulants, have received the most study, and in each case an important role for DA neurons of the mesolimbic system has been established. Moreover, both receptor subtypes, D1 and D2, appear to be involved. Despite this progress, the substrates of drug reward are not completely understood. First, a role for DA has not been established for all stimulants: DA receptor blockade failed to affect conditioned place preferences produced by the stimulants methylphenidate, nomifensine, or bupropion. Second, preliminary evidence suggests that intact serotonergic transmission is important in morphine place conditioning, but a similar consistent finding has not been observed with amphetamine place conditioning. Further study may reveal an interesting dissociation of serotonin's role in the rewarding effects of psychomotor stimulants and opiates. Finally, the role of the opiate receptor subtype kappa is not known; also, the significance of the several anatomical sites that support opiate place conditioning remains unclear.

The effects of selective dopamine D1 or D2 receptor antagonists on the establishment of agonist-induced place conditioning in rats

The ability of the dopamine D1 antagonist, SCH 23390 (0.01, 0.1, 1.0, 2.0 mg/kg) or the D2 antagonist, metoclopramide (1.0, 10.0, 20.0 mg/kg), to block the establishment of place conditioning with either the nonselective dopamine agonist, amphetamine (2.0 mg/kg), the D1 agonist, SKF 38393 (10.0 mg/kg), or the D2 agonist, quinpirole (1.0 mg/kg), was evaluated in rats. The experimental protocol consisted of three phases. During the preexposure phase, rats explored two distinctive compartments joined by a small tunnel. During the 8-day conditioning phase, rats were pretreated with either saline, SCH 23390 or metoclopramide; 1 hr later the animals were treated with an agonist and confined to one compartment for 30 min. On alternate days, rats received saline and were placed in the opposite compartment. Test days occurred over the remaining 3 days during which drug-free animals were allowed access to both compartments. A significant increase or decrease in the amount of time spent in the drug-paired environment was indicative of a place preference or aversion, respectively. SCH 23390 and metoclopramide were effective in blocking amphetamine-induced place preference and SKF 38393-induced place aversion. At lower doses, the D1 and D2 antagonist blocked the place preference induced by quinpirole, however, higher doses were not effective. In general, these data suggest that both receptor subtypes participate in the establishment of place conditioning with amphetamine, SKF 38393 or quinpirole.

An automated high-performance liquid chromatographic trace enrichment method for the determination of metoclopramide in serum and its application to a bioequivalence human volunteer study

An automated trace enrichment method for metoclopramide is described. Serum was injected on to a short column packed with PLRP-S 100A (a polymeric reversed-phase material). The unwanted components were washed off with borate buffer (pH 9.8) before switching to a Spherisorb ODS column for the separation. The limit of detection in serum samples was 2 ng/ml. The method was used in a pharmacokinetic study to compare the biovailability of two formulations of the drug.

Review article: a role for gastrointestinal prokinetic agents in the treatment of reflux oesophagitis?

Gastro-oesophageal reflux disease may result from a host of factors. Medical therapy has largely been aimed at neutralizing acid or decreasing acid production but improvement of upper-gastrointestinal motility may prove to be a valuable treatment modality as well. This paper reviews the current state of knowledge of the pathogenesis of reflux disease and concentrates upon promotility treatment with domperidone, metoclopramide and cisapride.

Metoclopramide utilization review

Utilization review of metoclopramide conducted at the Ambulatory Care Center at the Veterans Administration Medical Clinic in Boise, Idaho, revealed that a substantial proportion of prescriptions were written for indications that were considered inappropriate. After further evaluation, it was found that the medical literature supported metoclopramide use for one of the indications that had been considered inappropriate.

Studies on D1 and D2 dopamine receptor involvement in conditioned taste aversions

This series of studies investigated the ability of compounds selective for either the D1 or D2 dopamine receptor to induce a conditioned taste aversion (CTA) in thirsty rats. Neither the D1 antagonist SCH23390 (0.12-0.60 mg/kg) nor the D2 antagonist haloperidol (0.125-0.375 mg/kg) were able to induce CTAs to a saccharin solution. In contrast, the D1 agonist SKF38393 produced a dose-dependent taste aversion which was stereoselective to the (R-) enantiomer. The aversion to (R,S)-SKF38393 was not blocked by pretreatment with either SCH23390 or haloperidol, suggesting that the aversion is not mediated through stimulation of either dopamine receptor subtype. The D2 dopamine receptor agonist quinpirole was also found to produce a dose-dependent CTA. This aversion was blocked by injections of haloperidol and was attenuated following injections of domperidone, suggesting involvement of peripheral dopamine receptors in the aversion. Pretreatment with SCH23390 failed to affect the quinpirole-induced CTA, providing additional evidence that the D1 and D2 dopamine receptor subtypes can function independently of one another in the control of behavior. Finally, it does not appear that the area postrema is importantly involved in these taste aversions since lesions of this brain region did not affect the CTAs induced by either SKF38393 or quinpirole.

The antiemetic profile of zacopride

The antiemetic activity of zacopride against a variety of emetogenic agents has been determined in dogs. Zacopride was highly effective in inhibiting emesis due to a wide range of cancer chemotherapeutic agents, particularly cisplatin. It was well absorbed orally since the dose of zacopride required to inhibit cisplatin-induced emesis in dogs by 90% was 28 micrograms kg-1 both by i.v. and p.o. routes. Further, zacopride (1 mg kg-1 p.o.), administered after the onset of cisplatin-induced emesis, reduced the number of subsequent emetic episodes by 91%. Zacopride at 0.1, 1, or 3.16 mg kg-1 p.o. or i.v., reduced the number of emetic episodes due to dacarbazine, mechlorethamine, adriamycin, actinomycin D, or peptide YY by 100, 100, 86, 96 and 79%, respectively. However, zacopride was not effective in inhibiting emesis due to either apomorphine, copper sulphate, protoveratrine A, histamine, or pilocarpine. No adverse effects attributed to zacopride were observed. Zacopride is thus a unique and potent antiemetic agent as it selectively inhibits the emetic response to cancer chemotherapy agents and peptide YY.

Metoclopramide reversal of decreased gastrointestinal myoelectric and contractile activity in a model of canine postoperative ileus

Postoperative ileus is characterized by decreased gastrointestinal myoelectric activity and motility. Metoclopramide was used to treat experimentally induced postoperative ileus in six dogs. Contractile activity was monitored by extraluminal strain gages on the pyloric antrum and proximal segment of the duodenum, and myoelectric activity was measured by recording bipolar electromyograms (EMGs) at the pyloric antrum, pyloric canal, proximal segment of the duodenum, proximal and distal parts of the jejunum, and ileum. Measurements were obtained from animals without ileus (baseline) and those with ileus that were either untreated or treated with metoclopramide. Adynamic ileus was induced by rubbing a 50 cm segment of jejunum with a dry sponge for 5 minutes and exposing the bowel to the air for 30 minutes. Treated dogs received metoclopramide (0.4 mg/kg 4 times daily [QID] intravenously [IV]), whereas untreated dogs received a saline placebo, starting 1 hour after celiotomy closure. Recordings were made for 26 hours after induction of ileus. The phases of the migrating myoelectric complex (MMC) were identified and motility index values were determined. During ileus, the MMC phase II duration was increased at the duodenum and phase III duration was decreased at the antrum, pylorus, duodenum, and proximal segment of the jejunum (p less than 0.05). Motility index values were decreased at the antrum and duodenum during ileus (p less than 0.05). Treatment with metoclopramide reversed the MMC phase III inhibition at the antrum and pylorus, and partially reversed the inhibition at the duodenum and jejunum (p less than 0.05). Motility index values were restored to preoperative baseline values with metoclopramide treatment (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Blockade of acquisition of one-way conditioned avoidance responding by haloperidol and metoclopramide but not by thioridazine or clozapine: implications for screening new antipsychotic drugs

The classical neuroleptic drugs haloperidol and pimozide have a strong disruptive effect on the acquisition of conditioned avoidance responding (CAR), yet have relatively little impact on the performance of previously acquired responses. Separate experiments compared the effects of haloperidol, two atypical neuroleptics, thioridazine and clozapine, and a substituted benzamide, metoclopramide, on one-way avoidance by rats. Thioridazine (10-50 mg/kg) and clozapine (1.25-10.0 mg/kg) disrupted both acquisition and performance of CAR. In contrast, haloperidol (0.075-0.150 mg/kg) and metoclopramide (5.0-7.5 mg/kg) completely blocked the acquisition of CAR, yet initially produced only a slight disruption in the performance of a previously acquired response. The ineffectiveness of the atypical neuroleptics in producing a complete disruption of acquisition of CAR may be due to the anticholinergic properties of these drugs. Alternatively, the differences between metoclopramide and the atypical neuroleptics may be due to a preferential effect of metoclopramide on striatal or amygdaloid dopamine neurotransmission. These results suggest that caution should be exercised in using CAR as an animal model for assessing the antipsychotic potential of new pharmacological agents.

Differential interactions of traditional and novel antiemetics with dopamine D2 and 5-hydroxytryptamine3 receptors

The affinities of 11 drugs for both dopamine D2 and 5-hydroxytryptamine3 (5-HT3) receptor sites were determined in brain membranes. The five "traditional" antiemetics (chlorpromazine, prochlorperazine, droperidol, fluphenazine, and domperidone) displayed high affinity (less than 20 nM) for dopamine D2 receptors in corpus striatum but were inactive at 5-HT3 receptors. In contrast, five recently developed 5-HT3 antagonists (BRL 43694, ICS 205-930, zacopride, Lilly 278584, and MDL 72222) displayed nanomolar affinity for the 5-HT3 site but were inactive (greater than 10,000 nM) at the dopamine D2 receptor. Metoclopramide was unique among these agents in that it was similarly potent at dopamine D2 (240 +/- 60 nM) and 5-HT3 (120 +/- 30 nM) receptors.

The influence of dopamine agonists and antagonists on indomethacin lesions in stomach and small intestine in rats

Dopamine agents (saline in control groups) were coadministered with indomethacin by either single or repeated application. The ulcerogenic effect (erosions and/or ulcers) of repeated given indomethacin on gastric mucosa differed clearly from that on intestinal mucosa. The effect on intestinal mucosa was markedly greater than after a single dose. The effects of dopamine agents appeared to be more consistent. Domperidone and haloperidol, given as single or repeated doses, strongly aggravated both the gastric and intestinal lesions. Bromocriptine and amantadine had a protective effect. The adverse effects of both dopamine antagonists (increased after repeated administration) were strongly inhibited by the simultaneous administration of either bromocriptine or amantadine. The involvement of the dopamine system (central or peripheral) in the mechanisms that maintain gastric (probably related to cytoprotection also) and intestinal mucosa integrity is therefore suggested.

A comparative study of the effects of four motor-stimulating agents on canine jejunal spike bursts. The use of a computer program to analyze spike burst spread

The intestinal myoelectric effects of four motor-stimulating drugs were compared in conscious dogs. Dogs were fed a standardized 400-kcal meal, and the myoelectric activity was monitored before and after drug administration. Graded doses of metoclopramide, cisapride, bethanechol, and cholecystokinin (CCK) were compared by means of a computer program to identify spike bursts and determine their frequency, duration, and length of migration. Bethanechol and CCK produced the greatest increase in myoelectric activity in terms of spike burst frequency and duration but the least in terms of length of spike burst spread. Metoclopramide had minimal measurable myoelectric effects. Cisapride had the greatest effect on the length of spike burst migration but little effect on spike burst frequency and duration. The results suggest that cisapride is a more efficient prokinetic agent than bethanechol, CCK, or metoclopramide. The greater length of spike burst spread caused by cisapride was associated with a more rapid rate of transit along the monitored segment of bowel when compared with control. This confirms the correlation between length of spike burst spread and propulsive efficiency.

Comparison of the effect of cisapride and metoclopramide on morphine-induced delay in gastric emptying

1. The effects of metoclopramide or cisapride on morphine-induced delay in gastric emptying in patients before surgery were compared. 2. Forty patients were allocated randomly to receive one of four premedications i.m.: placebo only, morphine 10 mg alone, morphine 10 mg with metoclopramide 10 mg and morphine 10 mg with cisapride 10 mg. Gastric emptying after each premedication was assessed indirectly from the rate of absorption of oral paracetamol. 3. Cisapride 10 mg reversed the delay in gastric emptying due to morphine. Its effects were significantly greater than those of metoclopramide 10 mg.

Humoral effects of metoclopramide and domperidone in normal subjects and in hypertensive patients

To evaluate whether, in humans, metoclopramide (MCP), a DA2 antagonist which readily crosses the brain-blood barrier, can stimulate plasma aldosterone (ALD) through hypophyseal-adrenal axis activation in addition to its direct adrenal antidopaminergic activity, we have investigated the effects of MCP and domperidone (DMP), a specific antagonist of peripheral DA2 receptors, on plasma ALD, adrenocorticotropin (ACTH), cortisol and prolactin (PRL) in 15 subjects. Ten controls and 5 uncomplicated essential hypertensive patients, in whom the dopaminergic tone is hypothesized to be reduced, received, according to a single-blind randomized procedure, MCP (10 mg iv) or DMP (10 mg iv) and, after an interval of at least 1 week, the reverse treatment. MCP and DMP similarly increased PRL (p less than 0.001), while only MCP significantly increased plasma ALD (p less than 0.01), ACTH (p less than 0.02) and cortisol (p less than 0.02) both in normotensives and in hypertensives, without any difference between them. These data confirm that, in spite of similar DA2 antagonistic potency of the two drugs, only MCP is able to increase plasma ALD. Since MCP significantly increased also ACTH levels we cannot exclude an involvement of this hormone on MCP-induced ALD release. Finally, the similar PRL and ALD response in normotensives and hypertensives does not support the hypothesis of a reduced dopaminergic system activity in essential hypertensives.

The inhibitory effect of metoclopramide on plasma cholinesterase activity

The in vitro effect of metoclopramide on plasma cholinesterase (PCHE) activity was studied to investigate a mechanism for metoclopramide-induced prolongation of succinylcholine action. The mean PCHE of the control samples was 0.86 +/- 0.02 unit.ml-1. PCHE activity in the presence of metoclopramide, at concentrations of 0.05, 0.10, 0.50, 1.0, 2.5 and 5.0 micrograms.ml-1, was reduced to 0.78 +/- 0.02, 0.69 +/- 0.04, 0.50 +/- 0.03, 0.39 +/- 0.02, 0.24 +/- 0.01 and 0.15 +/- 0.01 unit.ml-1, respectively. Our data demonstrated that PCHE activity was significantly depressed by metoclopramide at all concentrations studied (p less than 0.001). Our data also show that the concentration of metoclopramide required to inhibit 50 per cent of PCHE activity (I50) was 0.8 micrograms.ml-1 (2.4 x 10(-6) M). We recommend caution when succinylcholine and or ester type local anaesthetics are administered to patients who are also receiving metoclopramide, especially in high doses.

Metoclopramide pharmacokinetics in pregnant and nonpregnant sheep

The pharmacokinetics of metoclopramide was studied in chronically instrumented pregnant and nonpregnant sheep. Metoclopramide was administered to the ewe by intravenous bolus injections (on a crossover basis) of 10, 20, and 40 mg, with an additional 80-mg dose to the nonpregnant animals. Transfer of the drug to the fetus was rapid with significant concentrations in fetal plasma 1 min after maternal dosing. The ratio of fetal-to-maternal area under the plasma concentration-time curves averaged 0.74, indicating significant fetal exposure to the drug. Maternal metoclopramide administration resulted in minimal fetal effects, with no change in arterial pressure, heart rate, or arterial pH or PCO2, and only a small (approximately 1.8 mmHg) transient decline in PO2. Plasma concentrations in maternal and fetal plasma in most animals were best described by a biexponential equation with rapid distribution and elimination phases. The terminal elimination half-lives in maternal and fetal plasma averaged 71.3 and 86.8 min, respectively, with fetal half-life being significantly longer. The number of fetuses present had no consistent effects on either maternal or fetal pharmacokinetic parameters. Total body clearance and volume of distribution averaged 3.5 L/h/kg and 5.8 L/kg, respectively, in the pregnant ewe, and 4.5 L/h/kg and 6.9 L/kg, respectively, in the nonpregnant animals. The terminal elimination half-life in the nonpregnant ewes averaged 67.5 min. Pharmacokinetic parameters were compared in the pregnant and nonpregnant ewes at the 10-, 20-, and 40-mg doses, and no significant differences were observed in the distribution or elimination rate constants, elimination half-life, or volume of distribution.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacotherapy and the neurobehavioural sequelae of traumatic brain injury

Recent advances in clinical neuropharmacology are likely to improve the treatment and rehabilitation of traumatic brain injury (TBI) patients. Treatment may be directed to alleviate specific symptoms, to improve function in certain areas, or even to enhance the cortical recovery process. The author reviews pertinent issues in clinical neuropharmacology for the following drug classes: stimulants, other dopamine agonists, antidepressants, lithium, cholinergics, neuroleptics, anticonvulsants, beta-blockers, calcium channel blockers, nootropes, opiates and neuropeptides. Since the relevant research literature in TBI is so sparse, information and recommendations are extrapolated from some other patient groups, especially developmentally handicapped children and adults, and patients with dementia.

Population analysis of the pharmacokinetic variability of high-dose metoclopramide in cancer patients

Metoclopramide infusions are used to prevent nausea and vomiting in cancer patients during chemotherapy. 47 patients received metoclopramide during 109 chemotherapeutic treatments as a loading (dose range = 0.55 to 4.5 mg/kg over 15 minutes) and maintenance (dose range = 0.57 to 4.8 mg/kg over 8 hours) infusion. During and up to 24 hours after the end of the maintenance infusion between 4 and 10 blood samples were collected per treatment. Metoclopramide was analysed in plasma by liquid chromatography. Pharmacokinetic and demographic data of 83 treatments were analysed by the NONMEM program using a linear 2-compartment model. It was found that bodyweight and serum alkaline phosphatase activity explain some of the interindividual variability in clearance (CL). The typical pharmacokinetic parameters for an average individual (70kg, alkaline phosphatase = 100 IU/L) were: CL = 20 L/h; volume of distribution at steady state (Vdss) = 190L; terminal half-life = 8h. The interindividual variabilities in clearance, volume of central compartment and Vdss were 50%, 35% and 35%, respectively. The residual variability in plasma concentrations was estimated as 13%.

Determination of metoclopramide and its glucuronide and sulphate conjugates in human biological fluids (plasma, urine and bile) by ion-pair high-performance liquid chromatography

Metoclopramide was determined in human biological fluids (plasma, urine and bile) by reversed-phase ion-pair high-performance liquid chromatography using a newly introduced cyanopropyl column. The method is precise, selective and sensitive: the mean recoveries of metoclopramide from plasma, urine and bile were 74.4, 99.1 and 85.9%, respectively; the mean within- and between-run coefficients of variation were, respectively, 0.8 and 8.5% for plasma and 2.0 and 8.2% for urine at the drug concentration of 100 ng/ml, and 2.3 and 11.2% for bile at the concentration of 20 ng/ml; the lower detection limit was 2 ng/ml for 1 ml of each biological fluid. Enzymic hydrolysis of a urine or bile specimen was used in the identification of metoclopramide, as well as its glucuronide and sulphate conjugates, from the human samples. A preliminary study on metoclopramide determinations from plasma and urine samples of a healthy subject and from bile samples of a patient demonstrated the clinical applicability of the method for therapeutic monitoring and pharmacokinetic studies.

Evidence that 5-hydroxytryptamine3 receptors mediate cytotoxic drug and radiation-evoked emesis

The involvement of 5-hydroxytryptamine (5-HT) 5-HT3 receptors in the mechanisms of severe emesis evoked by cytotoxic drugs or by total body irradiation have been studied in ferrets. Anti-emetic compounds tested were domperidone (a dopamine antagonist), metoclopramide (a gastric motility stimulant and dopamine antagonist at conventional doses, a 5-HT3 receptor antagonist at higher doses) and BRL 24924 (a potent gastric motility stimulant and a 5-HT3 receptor antagonist). Domperidone or metoclopramide prevented apomorphine-evoked emesis, whereas BRL 24924 did not. Similar doses of domperidone did not prevent emesis evoked by cis-platin or by total body irradiation, whereas metoclopramide or BRL 24924 greatly reduced or prevented these types of emesis. Metoclopramide and BRL 24924 also prevented emesis evoked by a combination of doxorubicin and cyclophosphamide. These results are discussed in terms of a fundamental role for 5-HT3 receptors in the mechanisms mediating severely emetogenic cancer treatment therapies.

Effects of acute thioridazine, metoclopramide and SCH 23390 on the basal activity of A9 and A10 dopamine cells

Extracellular single-unit recording techniques were employed to examine the effects of various dopamine (DA) antagonists on the basal activity of spontaneously active DA cells. Metoclopramide and thioridazine were both effective in reversing apomorphine-induced suppression of A9 and A10 DA cells. SCH 23390 produced only a partial reversal of this suppression. When the antagonists were given without any pretreatment, thioridazine preferentially increased the firing rate of A10 DA cells, and was relatively ineffective in altering A9 activity. Metoclopramide, on the other hand, increased the activity of most A9 DA cells, but was less effective in doing so with A10 cells. SCH 23390 did not significantly affect the basal activity of either cell subpopulation. These data support the hypothesis that the so-called 'atypical' antipsychotic drugs act preferentially on the A10 DA system. Taken together with previous results, they also suggest that the acute effects of DA antagonists on DA cell subpopulations coincide with their chronic effects.

The effect of GR38032F, novel 5-HT3-receptor antagonist on gastric emptying in the guinea-pig

The effects of GR38032F a novel, selective and potent 5-hydroxytryptamine (5-HT3)-receptor antagonist on gastric emptying in the guinea-pig were investigated and compared to those of metoclopramide and haloperidol. Both GR38032F and metoclopramide increased gastric emptying in a dose-dependent manner. In contrast, haloperidol was ineffective. GR38032F was about 200 times more potent than metoclopramide in enhancing gastric emptying over the 2 h period studied.