Cisapride does not alter gastric volume or pH in patients undergoing ambulatory surgery

Dynamic in vitro gastric digestion of skimmed milk using the NERDT, an advanced human biomimetic digestion system

The main objective of this study was to assess the ability of the NEar Real Digestive Tract (NERDT), a computer-controlled biomimetic in vitro digestion system that considers the biomechanics of the stomach, to reproduce physiologically relevant features of skimmed milk gastric digestion. A second objective was to evaluate the influence of pepsin on the gastric coagulation and emptying of milk proteins from experiments performed with and without pepsin. A mass balance model over the stomach, assuming a perfectly stirred reactor behaviour, has been developed. The results show that the NERDT can adequately reproduce the targeted kinetics of gastric acidification and emptying, with a sieving effect that naturally leads to a delayed emptying of caseins. Milk coagulated earlier and more chyme was emptied towards the end of the experiments in the presence of pepsin than without, hence illustrating the key influence of pepsin on the gastric coagulation of caseins and subsequent hydrolysis and emptying of dairy particles. Overall, this study shows that the NERDT can be adequately controlled to achieve desired gastric digestion conditions, and appears to be a very useful tool to further improve the knowledge of the gastric digestion behaviour of complex foods such as milk.

Efficient Evaluation of In Vivo Performance in Human for Generic Formulation by Novel Dissolution-Absorption Prediction (DAP) Workflow

PURPOSE

The pharmaceutical bioequivalence of generic medicines must be confirmed with corresponding original drugs. Although the in vitro dissolution tests are required, results of the mandatory in vitro study do not necessarily reflect the in vivo performance after oral administration. Then, we have tried to develop the novel "Dissolution-Absorption Prediction (DAP) workflow" to evaluate the in vivo performance of generic medicines.

METHODS

The DAP workflow consists of an "In vitro two-cell connected dissolution (TCCD) system" mimicking the changes in the luminal pH associated with gastrointestinal transit of medicines, "Evaluation of pharmacokinetics of active pharmaceutical ingredient (API)" and "Prediction of plasma concentration-time profile". TCCD system-evaluated dissolution kinetics of APIs from generic formulations and pharmacokinetic parameters based on human data regarding the original drugs were used to calculate the plasma concentration-time profiles of APIs after the oral administration of generic medicines.

RESULTS

The mandatory in vitro dissolution tests indicated that the dissolution properties of valsartan (BCS class II) and fexofenadine (BCS class III/IV) in generic formulations did not coincide with those in the corresponding original formulations. The TCCD system provided the very similar dissolution kinetics for the generic and original formulations for the two APIs. Plasma concentration-time profiles evaluated utilizing the dissolution profiles obtained by the TCCD system were in good agreement with the observed profiles for both the generic and original formulations for each API.

CONCLUSIONS

The DAP workflow would be valuable for estimating the in vivo performance of generic formulation and deducing their bioequivalence with the original formulation.

Exploration of Neusilin® US2 as an Acceptable Filler in HPMC Matrix Systems-Comparison of Pharmacopoeial and Dynamic Biorelevant Dissolution Study

Modern pharmaceutical technology still seeks new excipients and investigates the further use in already known ones. An example is magnesium aluminometasilicate Neusilin^® US2 (NEU), a commonly used inert filler with unique properties that are usable in various pharmaceutical fields of interest. We aimed to explore its application in hypromellose matrix systems (HPMC content 10–30%) compared to the traditionally used microcrystalline cellulose (MCC) PH 102. The properties of powder mixtures and directly compressed tablets containing individual fillers NEU or MCC, or their blend with ratios of 1.5:1, 1:1, and 0.5:1 were investigated. Besides the routine pharmaceutical testing, we have enriched the matrices’ evaluation with a biorelevant dynamic dissolution study and advanced statistical analysis. Under the USP apparatus 2 dissolution test, NEU, individually, did not provide advantages compared to MCC. The primary limitations were the burst effect increase followed by faster drug release at the 10–20% HPMC concentrations. However, the biorelevant dynamic dissolution study did not confirm these findings and showed similarities in dissolution profiles. It indicates the limitations of pharmacopoeial methods in matrix tablet development. Surprisingly, the NEU/MCC blend matrices at the same HPMC concentration showed technologically advantageous properties. Besides improved flowability, tablet hardness, and a positive impact on the in vitro drug dissolution profile toward zero-order kinetics, the USP 2 dissolution data of the samples N75M50 and N50M50 showed a similarity to those obtained from the dynamic biorelevant apparatus with multi-compartment structure. This finding demonstrates the more predictable in vivo behaviour of the developed matrix systems in human organisms.

In vivo models to evaluate ingestible devices: Present status and current trends

Evaluation of orally ingestible devices is critical to optimize their performance early in development. Using animals as a pre-clinical tool can provide useful information on functionality, yet it is important to recognize that animal gastrointestinal physiology, pathophysiology and anatomy can differ to that in humans and that the most suitable species needs to be selected to inform the evaluation. There has been a move towards in vitro and in silico models rather than animal models in line with the 3Rs (Replacement, Reduction and Refinement) as well as the better control and reproducibility associated with these systems. However, there are still instances where animal models provide the greatest understanding. This paper provides an overview of key aspects of human gastrointestinal anatomy and physiology and compares parameters to those reported in animal species. The value of each species can be determined based upon the parameter of interest from the ingested device when considering the use of pre-clinical animal testing.

Dynamic In Vitro Gastric Digestion of Sheep Milk: Influence of Homogenization and Heat Treatment

Milk is commonly exposed to processing including homogenization and thermal treatment before consumption, and this processing could have an impact on its digestion behavior in the stomach. In this study, we investigated the in vitro gastric digestion behavior of differently processed sheep milks. The samples were raw, pasteurized (75 °C/15 s), homogenized (200/20 bar at 65 °C)-pasteurized, and homogenized-heated (95 °C/5 min) milks. The digestion was performed using a dynamic in vitro gastric digestion system, the human gastric simulator with simulated gastric fluid without gastric lipase. The pH, structure, and composition of the milks in the stomach and the emptied digesta, and the rate of protein hydrolysis were examined. Curds formed from homogenized and heated milk had much looser and more fragmented structures than those formed from unhomogenized milk; this accelerated the curd breakdown, protein digestion and promoted the release of protein, fat, and calcium from the curds into the digesta. Coalescence and flocculation of fat globules were observed during gastric digestion, and most of the fat globules were incorporated into the emptied protein/peptide particles in the homogenized milks. The study provides a better understanding of the gastric emptying and digestion of processed sheep milk under in vitro gastric conditions.

Designing a dynamic dissolution method: a review of instrumental options and corresponding physiology of stomach and small intestine

Development of new pharmaceutical compounds and dosage forms often requires in vitro dissolution testing with the closest similarity to the human gastrointestinal (GI) tract. To create such conditions, one needs a suitable dissolution apparatus and the appropriate data on the human GI physiology. This review discusses technological approaches applicable in biorelevant dissolutions as well as the physiology of stomach and small intestine in both fasted and fed state, that is, volumes of contents, transit times for water/food and various solid oral dosage forms, pH, osmolality, surface tension, buffer capacity, and concentrations of bile salts, phospholipids, enzymes, and Ca(2+) ions. The information is aimed to provide clear suggestions on how these conditions should be set in a dynamic biorelevant dissolution test.

Human Gastrointestinal Juices Intended for Use in In Vitro Digestion Models

The aim of this study was to characterise the individual human gastric and duodenal juices to be used in in vitro model digestion and to examine the storage stability of the enzymes. Gastroduodenal juices were aspirated, and individual variations in enzymatic activities as well as total volumes, pH, bile acids, protein and bilirubin concentrations were recorded. Individual pepsin activity in the gastric juice varied by a factor of 10, while individual total proteolytic activity in the duodenal juice varied by a factor of 5. The duodenal amylase activity varied from 0 to 52.6 U/ml, and the bile acid concentration varied from 0.9 to 4.5 mM. Pooled gastric and duodenal juices from 18 volunteers were characterised according to pepsin activity (26.7 U/ml), total proteolytic activity (14.8 U/ml), lipase activity (951.0 U/ml), amylase activity (26.8 U/ml) and bile acids (4.5 mM). Stability of the main enzymes in two frozen batches of either gastric or duodenal juice was studied for 6 months. Pepsin activity decreased rapidly and adjusting the pH of gastric juice to 4 did not protect the pepsin from degradation. Lipase activity remained stable for 4 months, however decreased rapidly thereafter even after the addition of protease inhibitors. Glycerol only marginally stabilised the survival of the enzymatic activities. These results of compositional variations in the individual gastrointestinal juices and the effect of storage conditions on enzyme activities are useful for the design of in vitro models enabling human digestive juices to simulate physiological digestion.

Cisapride does not prevent postoperative vomiting in children

The peripherally acting prokinetic drug cisapride can overcome opioid-induced gastrointestinal paresis and may thereby eliminate a stimulus for postoperative vomiting. We conducted a prospective, randomized, double-blinded, controlled trial of 96 children undergoing inguinal surgery to determine whether cisapride would reduce the incidence of postoperative vomiting after general anesthesia supplemented with morphine. Group C1 patients (n = 38) received cisapride 0.3 mg/kg orally 1 h before surgery and placebo 6 h later, Group C2 (n = 28) received cisapride both before and after surgery, and Group P (n = 30) received placebo. Mean age (5.0 +/- 2.7 yr) and weight (21.0 +/- 8.6 kg), median pain scores and parent satisfaction scores, and incidence of rescue analgesic administration were similar across groups. Contrary to our hypothesis, incidences of postoperative vomiting in the hospital (32% vs 20%, P = 0.33) and at home (53% vs 46%, P = 0.33) did not vary by treatment group (with [C1 and C2] and without [P] cisapride, respectively). There was a trend toward more severe postoperative vomiting (three or more episodes) in children who received cisapride versus those who did not, both in hospital (6% vs 0%, P = 0.3) and at home (22% vs 8%) (P = 0.13). We conclude that cisapride does not prevent postoperative vomiting in this patient population and speculate that factors other than reduced gastrointestinal motility associated with general anesthesia and opioids are more important determinants of postoperative vomiting.

IMPLICATIONS

Cisapride does not prevent postoperative vomiting in children and may increase its severity.

Pre-operative oral erythromycin reduces residual gastric volume and acidity

We investigated whether low-dose erythromycin (200 mg) given as an oral premedicant altered the residual gastric volume and its acidity in fasted patients at induction of anaesthesia in a single-blinded study. Sixty patients were allocated randomly to receive either an erythromycin tablet (200 mg) or nothing with 10 ml water 3 h before induction of anaesthesia, and another 60 patients 1 h before induction of anaesthesia. Oral erythromycin significantly reduced residual gastric volume when it was given approximately 3 h (P<0.05; 95% CI for median difference: 0.1-17 ml) or 1 h (P<0.0005; 95% CI for median difference: 6-24 ml) before induction of anaesthesia. Erythromycin significantly reduced gastric acidity when it was given 1 h before induction of anaesthesia (P<0.02; 95% CI for median pH difference: 0.1-1.7). In contrast, when given 3 h before induction of anaesthesia, erythromycin did not significantly alter acidity.