Mucosal coating agents and other nonantisecretory agents. Are they cytoprotective?

Topical sucralfate in the management of peristomal skin disease: an open study

Dermatoses affecting the skin around stoma sites are common and difficult to treat. We have investigated the effectiveness of topical sucralfate in the management of peristomal dermatoses in adults using an open study design. Apart from forming a physical barrier to further irritation, sucralfate binds to basic fibroblast growth factor preventing its degradation and thereby promotes healing. In eight out of nine patients with faecal or urine erosions, daily, topical sucralfate treatment was associated with healing within 4 weeks. There was limited or no response to treatment in a further nine patients with traumatic ulcers, excoriated dermatitis or pyoderma gangrenosum. Topical sucralfate represents a safe, inexpensive and effective therapeutic intervention, particularly for those patients with high output or short stomas where repeated stoma leakage may be unavoidable.

Study of the antisecretory and antiulcer mechanisms of a new indenopirydazinone derivative in rats

The present study investigates the antisecretory and antiulcer mechanisms of a new indenopyridazinone derivative previously reported to inhibit gastric acid secretion in pylorus-ligated rats and to prevent gastric ulcerations induced by indomethacin or ethanol in the same animal species. The new compound was tested on the acid hypersecretion induced by histamine, pentagastrin and bethanechol in in vivo and in vitro experimental models. Furthermore, its influence on the mucosal layer adhering the gastric wall in indomethacin-treated rats was considered. Ranitidine was selected as a reference drug. The results obtained demonstrated that the new molecule, at variance with ranitidine, exerts antiulcer activity mainly enhancing the gastric mucosal integrity and simultaneously inhibiting the gastric acid hypersecretion evoked exclusively by cholinergic pulses. Therefore, an involvement of a neuronal rather than an effectorial mechanism has been suggested. Due to these mechanisms of action it clearly differentiates from ranitidine and its possible application in the peptic disease resistant to H2-blockers could be speculated.

Short-term sucralfate administration alters potassium diclofenac absorption in healthy male volunteers

AIMS

Since patients who regularly take NSAIDS may use sucralfate because of its cytoprotective properties, we examined the influence of this compound on the pharmacokinetics of diclofenac.

METHODS

Potassium diclofenac (105 mg) was administered orally to eighteen healthy male volunteers with or without a 5-day pre-treatment with sucralfate (2000 mg twice daily). Blood samples were collected at intervals post-dose and serum concentrations of diclofenac were determined by reverse-phase h.p.l.c.

RESULTS

Pre-treatment with sucralfate significantly decreased both the AUC(0,8 h) [2265 ng h ml-1 (geometric mean) (range 1815-2827) vs 1821 ng h ml-1 (1295-2562)] and the Cmax [1135 ng ml-1 (geometric mean) (range 898-1436) 701 ng ml-1 (501-981)] with no significant delay in absorption [tmax 1.0 h (median) (range 0.5-2.0) vs 1.0 h (0.5-4.0)].

CONCLUSIONS

The short-term treatment of healthy male volunteers with sucralfate decreases potassium diclofenac bioavailability. These findings suggest that either an appropriate increase in the diclofenac intake or the use of another gastric mucosa protector must be adopted.

Gastroprotective capability of exogenous phosphatidylcholine in experimentally induced chronic gastric ulcers in rats

Phosphatidylcholine (PC) is a main component of the hydrophobic gastric mucosal barrier. Exogenously administered, it prevents acute lesions. We evaluated the gastroprotective capacity of exogenous PC in both acute (ethanol- and indomethacin-induced) and chronic (indomethacin-induced) lesions in rats. Polyunsaturated (PPC) or hydrogenated PC in different concentrations were given intragastrically, before or after the injury factor, in single or repeated doses. Mucosal lesions were significantly reduced by a single dose of PPC, given before or after the injury factor, in both acute models. In the chronic model a single dose of PPC or hydrogenated PC significantly reduced lesions evaluated 6 h after ulcer induction, whereas after 72 h no protective effect was noticed. Repeated doses of PC were ineffective. In conclusion, in acute models exogenous PC reduces lesions in a dose-dependent manner and contributes to the mucosal defense. In chronic models an incomplete and temporary protection might be due to complex pathogenesis that requires activation of all levels in the mucosal defense. Strengthening of only one level was insufficient to restrict injury.

Gross and histologic effects of topical misoprostol on canine gastric mucosa

This study reports the histological effects of topical misoprostol, a synthetic PGE1 analog, administered in varying dosages on the resting canine gastric mucosa. Misoprostol did not macroscopically or microscopically damage the mucosa but its presumed permeability effects on the gastric vasculature induced marked edema of the mucosa and submucosa. Consistent features included increased thickness of both layers, dilated interglandular regions of the lamina propria, marked subepithelial edema, reduced depth and width of gastric foveolae, vasodilation of the vascular channels, reduced height of surface epithelial cells, swelling of their basolateral intercellular spaces, and increased amounts of surface adherent mucus. It is speculated that the mucosal edema, in addition to an increased mucus layer, may be important in the mechanism of gastric cytoprotection by increasing the distance of penetration or absorption for a mucosal-damaging agent, diluting its concentration, and disseminating any focal accumulations of red blood cells.

Gastric mucosal protection with beta-phenylethylamine (PEA) and other sympathomimetic amines against absolute ethanol in the rat

The purpose of this study was to investigate the potential of beta-phenylethylamine (PEA), an amphetamine-like compound present in the blood during high stress situations, to protect rat gastric mucosa against absolute ethanol. F-344 rats were pretreated with PEA in saline at several dose levels and at various times prior to oral administration of 1 ml absolute ethanol. PEA at dose levels of 50 and 100 mg/kg significantly reduced the severity of alcohol-induced lesions following oral, but not parenteral, treatment. The duration of protection with PEA was approximately 90 min, with maximum protection observed when PEA was administered 15-30 min before alcohol. Pretreatment with indomethacin did not prevent or reduce the protection induced by PEA. Other sympathomimetic amines such as isoproterenol and ephedrin were similarly cytoprotective against absolute ethanol while amphetamine, phenylephrine, and epinephrine proved ineffective. These results add further support to the role of the sympathetic nervous system in regulating gastric mucosal protection in the rat.

Effect of repeated colloidal bismuth subcitrate treatment on the response of the rat gastric mucosa to the presence of luminal ethanol

The purpose of this study was to determine the effects of repeated colloidal bismuth subcitrate administration on the cellular populations of the fundic region of the rat stomach and to investigate the effect of such treatment, after initial ethanol damage, on the gastric response to a second challenge by ethanol. The administration of 240 mg of colloidal bismuth subcitrate per kilogram body weight, at 12 hour intervals, for 14 days, resulted in an increase in the density of the mucosal epithelial cells, but a decreased rate of epithelial cell division in the neck region. Comparison with placebo treated animals showed that the repeated administration of colloidal bismuth subcitrate after an initial ethanol challenge, decreased the degree of damage induced by a second ethanol challenge, enhanced the rate of tissue repair and prevented the establishment of persistent erosions.

Na+/H+ ion-exchange property of postmortem human gastric mucus. The effects of Campylobacter pylori infection and sucralfate

The effect of Campylobacter pylori infection and sucralfate treatment on the ion-exchange property of human gastric mucus from 17 human postmortem stomachs was investigated in an in vitro chamber. Of the 10 stomachs not infected with C. pylori mucus from 4 stomachs had a 'normal' Na+/H+ exchange capacity, whereas 6 were without a Na+/H+ exchange capacity. The Na+/H+ exchange capacity of the seven stomachs infected with C. pylori was half that of the four 'normal' uninfected stomachs. Sucralfate significantly improved the Na+/H+ exchange capacity of mucus from C. pylori-infected stomachs and from the uninfected stomachs without Na+/H+ exchange. This study shows that impairment of the Na+/H+ exchange capacity of gastric mucus is associated with C. pylori infection and that sucralfate improves the Na+/H+ exchange capacity of gastric mucus.

[Digestive stress hemorrhage. Physiopathology and prevention]

Lesions of the gastroduodenal mucosa are seen very early on in virtually 100% of patients suffering from organ failure. Bleeding, even if it is only occult, defines acute stress-induced gastrointestinal tract bleeding (SGIB). The rates of SGIB vary according to the inclusion criteria: 13 to 100% microscopic SGIB, 2.3 to 9.5% haemorrhage with blood transfusion and/or shock. Gastrointestinal bleeding does not really influence the death rate of patients with SGIB (0 to 5% increase). Damage to the gastric mucosa may be due to an intraluminal aggression, and/or decreased mucosal and mural defence mechanisms. H+ ions and bile salts are mostly responsible for the former. Physiological quantities of H+ ions may be sufficient, as their abnormal diffusion into the gastric mucosa will reduce the mucosal pH (pHm), which is itself sensitive to microcirculatory modifications and systemic acidosis. There is a good correlation between bleeding and pHm. Bile salts are involved because of the usual increase in frequency and volume of gastric biliary reflux due to stress. Surfactant, mucosal alkaline layer and the microcirculation are all involved in gastric protection. The PGE2 synthetized by the gastric mucosa have a favourable influence on these 3 mechanisms. Changes in microcirculation and hypoxia are the predominant factors involved in stress-induced mucosal damage. The prevention of SGIB relies on the treatment of risk factors, a reduction of intraluminal aggression, and the support and/or stimulation of gastric defence mechanisms. Antacids and anti-H2 drugs aim to neutralize most of the H+ ions, being more efficient than placebo in increasing gastric pH greater than 4, although anti-H2 agents are responsible of a greater number of failures. The non-homogenous character of the patient groups studied and the diagnostic methods, as well as the increasing lack of placebo groups in the published studies make the interpretation of the results rather risky. Antacids and anti-H2 drugs are more efficient than placebo, and equally efficient, in preventing overt SGIB. Efficiency is increased by giving anti-H2 drugs continuously, and antacids hourly. Other agents are thought to protect mucosal cells, probably increasing mucosal defences. Amongst them are the prostaglandins, the most interesting of which are still being investigated, and sucralfate. The latter molecule is as efficient as antacids and anti-H2 drugs, and does not alter gastric pH, so reducing the number of nosocomial pneumonias. Its reduced cost and easy administration make it, at the present time, the treatment of choice of SGIB. The few rare contraindications of sucralfate will justify the infusion of anti-H2 drugs in those patients at risk.

The pathophysiological and pharmacological basis of peptic ulcer therapy

Both genetic and nongenetic factors predispose to ulcer diathesis. At the mucosal level ulcers result from an imbalance between aggressive factors and mucosal defense. Ulcer therapy reduces aggressive forces, bolsters defense, or both. Gastric acid, the major aggressive factor, may have its secretion inhibited or it may be partially neutralized by antacids. H2 receptor antagonists competitively block histamine occupancy of H2 receptors on parietal cells, thereby preventing stimulation of adenylate cyclase, cAMP rises, and activation of protein kinase and H+/K+ATPase. Prostaglandins inhibit acid secretion largely by preventing histamine-induced cAMP rises. Proton pump inhibitors bind H+/K+ATPase. Antimuscarinics inhibit acetylcholine receptors on the parietal cell, thereby blocking Ca2+ entry and subsequent activation of protein kinase and the proton pump. Mucosal defense is enhanced by certain prostaglandins, colloidal bismuth subcitrate and sucralfate. Prostaglandins stimulate secretion of bicarbonate and mucus, among other effects. Colloidal bismuth and sucralfate bind to proteins in the ulcer base and stimulate bicarbonate and mucus secretion, partially, in the case of sucralfate, by increasing endogenous prostanoid synthesis. Sucralfate also binds pepsin and bile acids. Colloidal bismuth temporarily eradicates mucosal colonization by Campylobacter pylori, another putative agent in ulcer diathesis.