Motilin receptor: a model for development of prokinetics

Prokinetics in diabetic gastroparesis

Within the last 50 years, diabetic gastroparesis has become a well recognized complication of type 1 and type 2 diabetes. It is a syndrome characterized by abnormal gastric function, resulting in delayed emptying of the stomach in the absence of any evident mechanical obstruction, predominantly manifested by early satiety, postprandial fullness, nausea, vomiting, and weight loss. The past five years have shown significant advances in its pathophysiology and in new diagnostic tests. Prokinetic medications remain the therapeutic focus for improving clinical symptoms of gastroparesis through enhanced gastric emptying. This article summarizes the present knowledge of prokinetics, with emphasis on medications currently available, as well as drugs under clinical investigation, including some agents in advanced clinical trials that are likely to be used in the treatment of diabetic gastroparesis in the future. These include the ghrelin agonists and newer 5-HT4 agonists devoid of cardiac side effects.

Pharmacotherapy of gastroparesis

Gastroparesis is a relatively common and often disabling condition that is characterized by a broad range of clinical presentation ranging from dyspeptic symptoms to nausea, vomiting, abdominal pain, malnutrition, frequent hospitalizations and incapacitation. The treatment of gastroparetic symptoms can be challenging to the gastroenterologist and the intensity of therapy varies with the physician's knowledge. Hence the determination that a patient is refractory to 'standard medical therapy' is an assessment that is subspeciality-based and could differ around the world depending on medications available. In this article, we review the use of available prokinetics, antiemetic agents, the approach for analgesia in the context of gastroparesis, and also discuss potential and evolving pharmacotherapies. The progress has been relatively limited as far as availability of new medications for gastroparesis is concerned; however, active research in developing newer prokinetics holds great promise for the future of management of this challenging entity.

Evaluation of promotility agents to limit the gut bioavailability of extended-release acetaminophen

BACKGROUND

Erythromycin and neostigmine have both been shown to act as gastrointestinal promotility agents.

OBJECTIVES

The purpose of this study was to determine whether either erythromycin or neostigmine, administered parenterally, would result in lower serum levels of a recently ingested drug, when compared with placebo.

METHODS

Ten volunteers ingested 1300 mg of extended-release acetaminophen on each of three occasions. They were then given an intravenous dose of erythromycin (200 mg), neostigmine (2 mg), or placebo. Each volunteer received all three treatments in a counterbalanced fashion, each separated from the next by at least two weeks. Blood for serum acetaminophen concentration was drawn at 1, 2, 4, 6 and 8 h after treatment, and the serum acetaminophen elimination curves were compared for the three treatments.

RESULTS

The elimination phase of the curves did not differ among the treatments as a result of administration of the prokinetic agents.

CONCLUSIONS

Under the present conditions, administration of erythromycin and neostigmine as prokinetic agents failed to alter the kinetics of an ingested dose of sustained-release acetaminophen.

Interaction of the growth hormone-releasing peptides ghrelin and growth hormone-releasing peptide-6 with the motilin receptor in the rabbit gastric antrum

The structural relationship between the motilin and the growth hormone secretagogue receptor (GHS-R), and between their respective ligands, motilin and ghrelin, prompted us to investigate whether ghrelin and the GHS-R agonist growth hormone-releasing peptide-6 (GHRP-6), could interact with the motilin receptor. The interaction was evaluated in the rabbit gastric antrum with binding studies on membrane preparations and with contraction studies on muscle strips in the presence of selective antagonists under conditions of electrical field stimulation (EFS) or not. Binding studies indicated that the affinity (pK(d)) for the motilin receptor was in the order of ghrelin (4.23 +/- 0.07) < GHRP-6 (5.54 +/- 0.08) < motilin (9.13 +/- 0.03). The interaction of ghrelin with the motilin receptor requires the octanoyl group. Motilin induced smooth muscle contractile responses but ghrelin and GHRP-6 were ineffective. EFS elicited on- and off-responses that were increased by motilin already at 10(-9) M, but not by 10(-5) M ghrelin. In contrast, GHRP-6 also enhanced the on- and off-responses. The motilin antagonist Phe-cyclo[Lys-Tyr(3-tBu)-betaAla-] trifluoroacetate (GM-109) blocked the effect of GHRP-6 on the off-responses but not on the on-responses. Under nonadrenergic noncholinergic conditions, the effects of motilin and GHRP-6 on the on-responses were abolished; those on the off-responses were preserved. All responses were blocked by neurokinin (NK)(1) and NK(2) antagonists. In conclusion, ghrelin is unable to induce contractions via the motilin receptor. However, GHRP-6 enhances neural contractile responses, partially via interaction with the motilin receptor on noncholinergic nerves with tachykinins as mediator, and partially via another receptor that may be a GHS-R subtype on cholinergic nerves that corelease tachykinins.

The motilin pharmacophore in CHO cells expressing the human motilin receptor

We performed a structure-activity study with the human motilin receptor, which was recently cloned from thyroid tissue. N-terminal fragments, Ala-analogs of motilin, and motilides were tested in a cell line that expresses the cloned human motilin receptor and apoaequorin. Full potency to induce calcium fluxes was obtained with N-terminal fragments of 14 amino acids. Motilin fragments 1-14 in which residues 1 (Phe), 4 (Ile), and 7 (Tyr) were replaced by Ala showed the largest reduction in potency. Only motilides with an enol configuration had markedly higher potencies compared to erythromycin A. The potencies to induce Ca(2+) fluxes correlated strongly with rabbit binding and contractility data, suggesting that the cloned receptor is indeed the motilin receptor, responsible for contractile effects. Conservation of the motilin pharmacophore in evolution indicates an important physiological role of motilin.

Localization of motilin binding sites in subcellular fractions from rabbit antral and colonic smooth muscle tissue

BACKGROUND AND AIM

Motilin stimulates gastrointestinal motility, but in vitro studies reveal a direct smooth muscle effect, whereas in vivo studies reveal a neurally mediated effect. The aim of the present study was to determine if motilin binds to microsomes (smooth muscle) and/or synaptosomes (neurons).

METHODS

Subcellular fractions were prepared from tissue of rabbit gastric antrum and colon by differential centrifugation and density gradient centrifugation and characterized by determining motilin binding and the presence of membrane markers.

RESULTS

The purified microsomal fraction, enriched in the smooth muscle marker 5'-nucleotidase, was found to have the highest specific motilin binding in both antrum and colon. In the antrum, but not in the colon, the mitochondrial fraction also showed enrichment of [3H]-saxitoxin binding (marker for synaptosomes) and motilin binding, although the latter was much lower than in the microsomal fraction. Two receptor binding sites were characterized in both the antral mitochondrial/synaptosomal and colonic microsomal fraction (antrum: pKd,1 9.89+/-0.19, pKd,2 8.18+/-0.11, colon: pKd,1 9.72+/-0.31, pKd,2 8.39+/-0.58).

CONCLUSION

Motilin binding is predominantly associated with smooth muscle membranes in both antrum and colon of the rabbit. In both organs two motilin binding sites are present with comparable affinities, but the density in the colon is much higher for both sites. Whether they represent neural and smooth muscle receptors will require studies with isolated smooth muscle cells and neurons.

Anxiolytic effect of motilin and reversal with GM-109, a motilin antagonist, in mice

There have been few reports on the effects of the brain-gut peptide motilin on the central nervous system (CNS). We administered motilin intracerebroventricularly to mice and investigated the effect of motilin on anxiety using an elevated plus-maze. Motilin produced a significant decrease in anxiety with an inverted U-shaped dose response. To determine whether the anxiolytic effect of motilin was mediated via motilin receptors in the brain, the effect of GM-109, a novel motilin receptor antagonist, was investigated. GM-109 showed a significant and dose-dependent antagonism on the motilin-induced anxiolytic effect. GM-109 administered alone had no effect on anxiety. These results suggest that motilin receptors are present in the brain and may have a role in anxiety and emotion.

Immuno-electron microscopic study of differential localization of motilin and serotonin in the rabbit duodenal epithelium

A guinea pig antibody against rabbit motilin was generated to study the localization of motilin-containing cells in the rabbit small intestine with special reference to the co-localization of motilin and serotonin. A pre- and post-embedding technique for immuno-electron microscopy was used; duodenal sections were stained with either motilin or serotonin in the pre-embedding DAB-nickel reaction, followed by subsequent staining of ultrathin sections of positive cells with either motilin or serotonin in the post-embedding immunogold reaction. Samples were divided into four groups: 1) pre-motilin, post-motilin, 2) pre-motilin, post-serotonin, 3) pre-serotonin, post-serotonin, and 4) pre-serotonin, post-motilin. Motilin-containing cells in the rabbit duodenum were characterized by round granules (395.3 +/- 66.1 nm in diameter) with medium electron density, located basally or in the perinuclear cytoplasm. In contrast, serotonin-containing cells were characterized by round to pleomorphic secretory granules (344.5 +/- 90.5 nm in diameter with electron dense cores and prominent halos. In motilin-containing cells, massive aggregations of immunogold particles reacted to motilin occurred over secretory granules. A few immunogold particles scattered diffusely over the cytoplasm reacted to serotonin; however, this reaction appeared to be background staining because the density was not changed if the section was treated by preabsorption. In serotonin-containing cells, immunogold particles reacted to serotonin were aggregated over the secretory granules and a large number of gold particles were scattered diffusely at the extragranular cytoplasm; however, very few or no immunogold particles were observed within the cells which reacted to motilin. Results of the present study indicate that motilin and serotonin are not co-localized in the epithelial endocrine cells of the rabbit intestine.

Cisapride reduces neonatal postoperative ileus: randomised placebo controlled trial

AIM

To assess the efficacy of cisapride in reducing ileus persisting to the tenth postoperative day after neonatal abdominal surgery.

METHODS

A prospective, randomised, double blind trial comparing rectal cisapride (1.4-2.3 mg/kg/day) with placebo over seven days was undertaken in 33 neonates.

RESULTS

Seven of 12 (58%) patients receiving placebo and eight of 11 (73%) receiving cisapride achieved a first sustained feed during treatment. Of those receiving cisapride, the first sustained feed occurred at 2.3 days (SEM 0.6) compared with 4.7 days (SEM 0.8) with placebo. By the seventh day the mean daily net enteral balance was 69 (SEM 18) ml/kg in the cisapride subgroup and 17 (SEM 8) ml/kg for those receiving placebo. Stool was passed on 6.3 (SEM 0.4) treatment days in the cisapride subgroup compared with 4.1 (SEM 1.0) treatment days in the placebo subgroup.

CONCLUSION

Cisapride is effective in neonates with a prolonged ileus after abdominal surgery.

Therapeutic strategies for motility disorders. Medications, nutrition, biofeedback, and hypnotherapy

Gastrointestinal motility is regulated by a complex balance of inhibitory and excitatory neuronal, humoral, and mechanical factors. The goal in the management of motility disorders is to maintain adequate nutrition while decreasing symptoms. This can be accomplished by medications and support of nutrition and biofeedback; the application of these therapeutic strategies to patients with gut motility disorders is reviewed.