Olestra: assessing its potential to interact with drugs in the gastrointestinal tract

Orlistat

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Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. If you would like information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The October 1999 Formulary monographs are on zanamivir, pioglitazone, levobupivacaine, temozolomide, and insulin glargine. The DUE is on zanamivir.

An overview of interactions between micronutrients and of micronutrients with drugs, genes and immune mechanisms

The objective of the present review is to examine critically the consequences of interactions that micronutrients undergo with nutrients and non-nutrients (mainly prescribed medicines) in diets and lifestyle factors (smoking, tea and alcohol consumption). In addition, the review describes recent work on interactions between nutrients and genes, the influence of gene polymorphisms on micronutrients, the impact of immune responses on micronutrients and specific interactions of antioxidant micronutrients in disease processes to minimise potential pro-oxidant damage.

Enhancement of skin penetration of vitamin K using monoolein-based liquid crystalline systems

Application of vitamin K (vitK) to the skin has been used for suppression of pigmentation and resolution of bruising. However, there is no report concerning the extent of its penetration in the skin. In this study, we investigated the in vitro skin penetration and transdermal delivery of vitK, and whether these parameters may be enhanced by lipid-based drug delivery systems. The lipid formulation used in this study contains monoolein (MO), which is structured as a liquid crystalline phase, named hexagonal phase. The skin penetration of vitK was assessed in vitro using porcine ear skin mounted in a Franz diffusion cell. VitK (2.5%, w/w) was incorporated in either of three formulations: liquid vaseline, MO-based hexagonal phase gel (MO-vitK-water at 77.5/2.5/20, w/w/w) and MO-based nanodispersion of hexagonal phase (MO-vitK-poloxamer-water at 15/2.5/0.9/81.6, w/w/w/w). When vaseline was used, vitK was delivered mainly to the stratum corneum (SC): 9.50+/-0.97 microg/cm(2) of vitK was delivered to the SC at 12 h post-application, whereas 4.90 +/- 1.28 microg/cm(2) of vitK was delivered to the epidermis (E)+dermis (D) at the same time point. The hexagonal phase gel and the nanodispersion delivered approximately 2 times more vitK to the SC and 2.0-3.7 times more vitK to the [E+D] than the vaseline solution. The nanodispersion (but not the gel) also increased the transdermal delivery of vitK at 9 h ( approximately 3-fold increase). These results demonstrate that the topical delivery of vitK incorporated in a lipophilic vehicle is small, but it may be enhanced by MO-based systems, which might be useful to increase the effectiveness of topical vitK therapy.

Stimulation of fecal fat excretion and the disposal of protoporphyrin in a murine model for erythropoietic protoporphyria

Erythropoietic protoporphyria (EPP) is characterized by toxic accumulation of the hydrophobic compound protoporphyrin (PP). Ferrochelatase-deficient (fch/fch) mice are an animal model for human EPP. Recently, we have demonstrated that the accumulation of another hydrophobic compound, unconjugated bilirubin, could effectively be treated by stimulation of fecal fat excretion. We investigated whether stimulation of fecal fat excretion enhanced the disposal of PP in fch/fch mice. Fch/fch mice were fed for 8 wk with a high-fat diet (16 wt% fat; control) or with the high-fat diet mixed with either a nonabsorbable fat (sucrose polyester) or the intestinal lipase inhibitor orlistat. The effects of the treatments on fecal excretion of fat and PP and on hepatic PP concentrations were compared with control diets. Fecal fat excretion in fch/fch mice on a high-fat diet was higher than in mice on a low-fat diet (+149%, P < 0.05). Sucrose polyesters and orlistat increased fecal fat excretion even more, up to sixfold of control values. However, none of the different treatments affected fecal PP excretion or hepatic PP concentration. Treatment of fch/fch mice with a high-fat diet, a nonabsorbable fat diet, or with orlistat increased the fecal excretion of fat but did not increase fecal PP excretion or decrease hepatic PP concentration. The present data indicate that accumulation of PP is not amenable to stimulation of fecal fat excretion.

Authors' financial relationships with the food and beverage industry and their published positions on the fat substitute olestra

OBJECTIVES

This study examined the association between authors' published positions on the safety and efficacy in assisting with weight loss of the Procter & Gamble (P&G) fat substitute olestra and their financial relationships with the food and beverage industry.

METHODS

Journal articles about olestra, and their authors, were classified as supportive, critical, or neutral with respect to its use. Authors not known to have industry affiliations were surveyed about their financial relationships.

RESULTS

Supportive authors were significantly more likely than critical or neutral authors to have financial relationships with P&G (80% vs 11% and 21%, respectively; P <.0001). All authors disclosing an affiliation with P&G were supportive.

CONCLUSIONS

Because authors' published opinions were associated with their financial relationships, obtaining noncommercial funding may be more essential to maintaining objectivity than disclosing personal financial interests.

Postmarketing Surveillance of New Food Ingredients: Results from the Program with the Fat Replacer Olestra

Market introduction of savory snacks containing olestra offered an opportunity to evaluate the safety of olestra in a free-living population and thereby compare the outcome to the previously established safety profile determined in clinical trials in which subjects were required to eat predetermined amounts at prescribed intervals. Therefore, a multifaceted postmarketing surveillance program was designed to evaluate consumer experience and safety of olestra in the marketplace. Customer comments were solicited through toll-free telephone numbers. Collected data were evaluated by both internal and external medical experts. About 10% of toll-free telephone calls reported health effects, most of which were gastrointestinal (GI) in nature. Clinical studies were designed and conducted to determine potential GI effects under the range of consumption patterns reported by toll-free calls. Health effects reported were those found commonly in the general population and analyses of the data found no biological reason to conclude that serious or meaningful health effects were the result of olestra consumption.

Orlistat--a novel weight loss therapy

OBJECTIVE

To review the pharmacology, pharmacokinetics, clinical safety and efficacy, drug interactions, and therapeutic issues related to the use of orlistat for treatment of obesity.

DATA SOURCES

English-language articles were identified from MEDLINE (1966-July 2000), Roche Laboratories, organizational guidelines, National Institutes of Health and Food and Drug Administration Web sites, and Doctor's Guide online. Key words included obesity, orlistat, and lipase inhibitors. References were also identified from reference sections of published articles.

STUDY SELECTION AND DATA EXTRACTION

Prospective, randomized, double-blind, placebo-controlled, human trials were selected for review and discussion.

DATA SYNTHESIS

Orlistat is the first agent in the lipase inhibitor class of antiobesity drugs. Orlistat is minimally absorbed and has been shown to reduce body weight by inhibiting absorption (by approximately 30%) of ingested dietary fat. Safety and efficacy have been established in one- and two-year double-blind, placebo-controlled trials; adverse effects were primarily, and almost exclusively, gastrointestinal. Due to its ability to block fat absorption, orlistat also has the capability to inhibit absorption of fat-soluble vitamins. Therefore, a daily multiple vitamin is recommended while taking orlistat.

CONCLUSIONS

By inhibiting fat absorption, orlistat offers a new treatment modality for weight loss and maintenance. Preliminary data from clinical trials suggest that orlistat may be beneficial in patients with comorbid conditions related to obesity, such as diabetes and hyperlipidemia. However, further studies during postmarketing surveillance are needed to fully establish orlistats long-term benefits and safety. Orlistat should be considered a useful adjunctive therapy for weight loss and maintenance in obese patients (i.e., body mass index > or = 30 kg/m2 or > or = 27 kg/m2 if other risk factors are present) committed to lifestyle changes including diet, exercise, and behavioral modification.

Drug, meal and formulation interactions influencing drug absorption after oral administration. Clinical implications

Drug-drug, drug-formulation and drug-meal interactions are of clinical concern for orally administered drugs that possess a narrow therapeutic index. This review presents the current status of information regarding interactions which may influence the gastrointestinal (GI) absorption of orally administered drugs. Absorption interactions have been classified on the basis of rate-limiting processes. These processes are put in the context of drug and formulation physicochemical properties and oral input influences on variable GI physiology. Interaction categorisation makes use of a biopharmaceutical classification system based on drug aqueous solubility and membrane permeability and their contributions towards absorption variability. Overlaying this classification it is important to be aware of the effect that the magnitudes of drug dosage and volume of fluid administration can have on interactions involving a solubility rate limits. GI regional differences in membrane permeability are fundamental to the rational development of extended release dosage forms as well as to predicting interaction effects on absorption from immediate release dosage forms. The effect of meals on the regional-dependent intestinal elimination of drugs and their involvement in drug absorption interactions is also discussed. Although the clinical significance of such interactions is certainly dependent on the narrowness of the drug therapeutic index, clinical aspects of absorption delays and therapeutic failures resulting from various interactions are also important.