Prostaglandins for peptic ulcer: a promise unfulfilled

Cytoprotection and healing: two unequal brethren

The promotion of the concept of cytoprotection has fostered hopes that the use of co-prescribed mucosal protective agents would revolutionize the prevention of NSAID-induced ulcers and supply the basis for novel ulcer therapy. Prostaglandins do not, however, accelerate ulcer healing when applied at doses that exert an unequivocal cytoprotective activity. Attempts have therefore been made in recent years to create new less-toxic NSAIDs, such as combined lipoxygenase/cyclo-oxygenase inhibitors, NSAIDs coupled to an NO donor and so-called COX-2 inhibitors. All these preparations do in fact exert a diminished gastrointestinal toxicity. There is however increasing evidence accumulating from studies performed in and outside our laboratories that in chromic ulcer models their increased gastrointestinal tolerance is not necessarily reflected by non-interference with ulcer healing. It is thus mandatory to distinguish between cytoprotective and healing properties of drugs interfering with the cyclo-oxygenase pathway.

Mechanisms of NSAID-induced gastrointestinal mucosal injury: a basis for preventing ulceration and symptoms from these agents

Concepts are reviewed of the effects of anti-ulcer agents in counteracting the biochemical and cellular pathology of gastrointestinal injury by non-steroidal anti-inflammatory drugs (NSAIDs). While some measure of control of NSAID-induced mucosal damage is achieved in the upper gastrointestinal tract by the currently available anti-ulcer drugs, none can effectively counteract the major biochemical changes induced by NSAIDs. Some experimental approaches, which have been developed from recent studies in laboratory animals, are considered as a possible basis towards developing improvements in preventive procedures against NSAID-induced gastrointestinal injury in man.

Antiulcerogenic effect of Hippophae rhamnoides L

The antiulcerogenic effect of a hexane extract (HRe-1) from Hippophae rhamnoides (Eleagnaceae) was tested on indomethacin- and stress-induced ulcer models. As a result HRe-1 was found to be active in preventing gastric injury.

The effect of indomethacin-induced gastric mucosal injury on 24-h intragastric acidity and plasma gastrin concentration in healthy volunteers

AIMS

To determine the influences of prostaglandin inhibition by indomethacin on 24-h intragastric acidity and plasma gastrin concentration, related to gastric mucosal injury.

METHODS

A pre- and post-treatment study design was employed in 10 Helicobacter pylori negative healthy male subjects. All subjects underwent upper gastrointestinal endoscopy at least 3 days before and after 7 days dosing with indomethacin 50 mg t.d.s. Mucosal damage was scored according to the Lanza method, and biopsies were taken for H. pylori status and assay of mucosal concentrations of prostaglandin (PG)E2 and leukotriene (LT)B4. Before and on the last day of dosing, intragastric acidity was measured by continuous 24-h pH monitoring, and plasma gastrin levels determined by radioimmunoassay in blood samples collected over the same period.

RESULTS

All subjects completed the study and no serious adverse events were reported. The mucosal injury score increased significantly from 0 (0-2) to 3.4 (0-8) (mean and range of values, P < 0.05) after dosing with indomethacin. No differences were observed in 24-h mean pH or meal stimulated plasma gastrin concentrations. Mucosal PGE2 and LTB4 were unchanged 8-10 h after the last indomethacin dose.

CONCLUSIONS

Endogenous prostaglandins do not appear to alter intragastric acidity or gastrin secretion, in contrast to the PGE analogues, whose effects must be more pharmacological than physiological.

Review article: drug development in gastroenterology--the changing view of industry

Rationalization within the pharmaceutical industry to combat escalating costs has included the close examination of research portfolios. Gastroenterology has been one of the casualties of this exercise and few companies currently retain a specific gastrointestinal research programme. Acid-peptic disease has been the victim of its own success, since the availability of a range of extremely effective drugs largely satisfies current medical needs. A safe, convenient and effective monotherapy able to eradicate Helicobacter pylori would be a commercially viable alternative to antisecretory drugs, leading to further expansion of the anti-ulcer market. The irritable bowel syndrome is probably too diverse a target for logical research: inflammatory bowel disease is probably too small a market to be attractive. Potentially effective drugs to treat these and other gastrointestinal diseases could emerge from broader research programmes, provided that companies retain the expertise and desire to develop such agents for gastrointestinal indications. Cancer of the gastrointestinal tract and associated organs undoubtedly represents a commercially attractive target, but new anti-tumour drugs are more likely to arise from generic research rather than programmes specifically directed at tumours of the gastrointestinal tract. The changing view of the pharmaceutical industry towards the development of gastrointestinal drugs is likely to have a negative impact on both fundamental and clinical research in gastroenterology.

Review article: new insights into prostaglandins and mucosal defence

A role for prostaglandins in maintaining mucosal integrity in the gastrointestinal tract is well documented. While traditionally the effects of prostaglandins on mucosal blood flow and epithelial function have been regarded as critical in the mechanism of action of these fatty acids, recent evidence that mucosal ulceration is almost invariably associated with mucosal inflammation has caused a re-evaluation of the role of prostaglandins in mucosal defence. This review focuses on the ability of prostaglandins to exert anti-inflammatory, and therefore anti-ulcerogenic, effects in the gastrointestinal tract. These effects of prostaglandins are attributable to their ability to suppress the release of inflammatory mediators and reactive oxygen metabolites from a number of immunocytes, stromal cells and inflammatory cells. There is emerging evidence for cooperative interactions between prostaglandins and nitric oxide in maintaining mucosal integrity. Recent work on the inducible isoform of prostaglandin synthase as it pertains to mucosal defence is also reviewed.

Misoprostol inhibits gastric mucosal release of endogenous prostaglandin E2 and thromboxane B2 in healthy volunteers

Prostaglandin analogues of the E-series theoretically offer the ideal antiulcer drugs. Peptic ulcer healing with prostaglandin analogues is, however, no better than would be predicted from their ability to inhibit gastric acid secretion and they are less effective than histamine H2 receptor antagonists in preventing ulcer relapse. It could be that prostaglandin analogues inhibit gastric mucosal synthesis or release of endogenous eicosanoids, thereby abrogating their own effects. This study, therefore, examined how a single therapeutic dose (200 micrograms) of misoprostol, a synthetic analogue of prostaglandin E1, influences gastric mucosal release of endogenous prostaglandin E2 (PGE2), thromboxane B2 (TXB2), and chemotactic leukotriene B4 (LTB4) during basal conditions and in response to gastric luminal acidification (0.1 M HCl; 5 ml/min for 10 minutes). Nine healthy volunteers were studied in a single blind, cross over design. In each subject misoprostol or placebo was instilled in randomised order into the stomach, which was subsequently perfused with isotonic mannitol. Misoprostol significantly decreased basal as well as acid stimulated output of PGE2 and TXB2, without affecting output of LTB4. These data show that misoprostol inhibits gastric mucosal synthesis of prostanoids. Decreased concentrations, or even a changed profile, of native eicosanoids modulating the release of inflammatory mediators from immune cells might explain why prostaglandin analogues have a comparatively poor clinical performance in ulcer healing and prevention.

Effects of FK506, an immunosuppressive agent, on genesis of water-immersion stress-induced gastric lesions in rats

We examined the effects of FK506, an immunosuppressive agent, on the genesis of water immersion stress-induced gastric lesions in rats. Using high-performance liquid chromatography, four kinds of prostaglandins, ie, 6-keto-prostaglandin F1 alpha, prostaglandin F2 alpha, prostaglandin E2, and prostaglandin D2, were detected, and no leukotrienes were detected in gastric mucosa in rats without stress. After 6 hr of stress, gastric lesions developed with decreases in all prostaglandin contents, and the emergence of peptide leukotrienes was observed. Intramuscular administration of FK506 (0.1, 0.25, 0.5, 1.0, and 2.0 mg/kg) reduced lesion index dose-dependently. Administration of FK506 at doses over 0.25 mg/kg decreased all prostaglandin contents, but did not affect the increase in leukotriene contents. Pretreatment with famotidine or omeprazole reduced lesion index, and the protective effects were equivalent to those of 1.0 mg/kg of FK506, although FK506 did not affect gastric secretion during water-immersion stress. Water-immersion stress did not change the activities of xanthine oxidase in either stomach or serum. Polyoxyethylene-modified superoxide dismutase did not prevent gastric lesions. Water-immersion stress significantly increased myeloperoxidase activity in gastric mucosa, and FK506 reduced the increase in myeloperoxidase activity induced by stress. From our results, other factors besides gastric acid secretion and tissue eicosanoid contents, such as chemoattractant factor, might also be involved in the genesis of water-immersion stress-induced gastric lesions in rats.

Effect of nizatidine versus ranitidine on gastric intraluminal prostaglandin release in duodenal ulcer patients

The role of prostaglandins in peptic ulcer disease and their relation to Helicobacter pylori infection remain controversial. This study sought to compare the effects of oral nizatidine and ranitidine on the gastric mucosal release of prostanoids in duodenal ulcer (DU) patients and to correlate prostanoid concentrations with H. pylori status. Twenty-eight patients with DUs were randomized to receive either nizatidine or ranitidine. Nizatidine 300 mg at night elevated intraluminal PGE2 concentrations; 6-keto-PGF1 alpha concentrations also rose, but did not reach statistical significance. Ranitidine induced non-significant falls in PGE2 and 6-keto-PGE1 alpha concentrations. Patients with H. pylori infection had lower PGE2 and 6-keto-PGF1 alpha concentrations than non-infected patients, but nizatidine was equally effective in increasing prostanoid levels in both groups. These findings may be considered as favourable side effects of nizatidine with uncertain clinical significance. Further studies are needed to elucidate the synergism between prostanoids, eradication of H. pylori and nizatidine in the treatment of DU.

Appropriate acid suppression in the treatment of acid-related conditions

Gastric acid is involved in the pathogenesis of duodenal ulcer, gastric ulcer and gastro-oesophageal reflux disease. Although levels of acid secretion may not be abnormally high in patients with these conditions, pharmacological suppression of acid secretion is associated with healing of mucosal defects and maintenance of healing in the long term. In the case of duodenal ulcer, this was demonstrated before the understanding of the importance of Helicobacter pylori infection. There is a considerable body of published work examining the pharmacological effectiveness of antisecretory drugs in suppressing gastric acid secretion, as well as their therapeutic efficacy in terms of healing ulcers or oesophageal erosions. These two parameters have been significantly correlated in each of the three conditions listed above. The purpose of this article is to review the mathematical relationships established between suppression of gastric acid secretion and healing rates of duodenal ulcer, gastric ulcer and gastro-oesophageal reflux disease.

Review article: non-steroidal, anti-inflammatory drugs--the extending scope of gastrointestinal side effects

The gastrointestinal side effects of non-steroidal, anti-inflammatory drugs extend beyond the duodenal bulb, and comprise a variety of lesions in all parts of the gut. Gastroduodenal ulceration is quantitatively dominant, although a major part of these lesions probably go unnoticed and heal spontaneously. Adaptation has been demonstrated for acetylsalicylic acid, and may be of importance for other substances as well. Non-steroidal anti-inflammatory drugs (NSAIDs) may induce relapse of inflammatory bowel disease. Permeability changes and mucosal inflammation are found in the small and large bowel in the majority of subjects taking NSAIDs, although the clinical significance is still not clear. Ulceration and perforation do, however, occur in this part of the gut as well. Treatment of NSAID-associated ulceration is similar to traditional ulcer treatment, possibly with extended treatment duration if the NSAID is continued. Prophylaxis is of some value, but is not required for every patient receiving an NSAID.

Management of gastroduodenopathy associated with use of nonsteroidal anti-inflammatory drugs

Adverse events associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are reported more frequently to the Food and Drug Administration than are those associated with any other group of drugs. The absolute risk for serious gastrointestinal events--in particular, ulcer bleeding, perforation, and death--is controversial; some investigators believe that an epidemic of NSAID-related complications is being experienced, whereas others suggest that the risks are being overemphasized. The management of patients who take NSAIDs regularly also remains controversial. Key unresolved issues include how best to identify those patients at particularly high risk for the development of ulcer complications and whether such patients should receive prophylactic therapy in an attempt to prevent such problems. In this review, we critically evaluate the currently available literature and present a management algorithm for the treatment and prevention of NSAID-associated gastroduodenopathy.

Review article: stomach wars--a mucosal defense initiative

A model is presented which attempts to unify many of the processes identified in recent years as contributing to the maintenance of mucosal integrity in the stomach. Two concepts, namely acid disposal and rapid repair of superficial injury, are highlighted as being of particular physiological significance. The mechanisms involved in protection of the normal mucosa against luminal aggressors (e.g. acid/pepsin, ethanol, aspirin) must be distinguished from the factors which influence the healing of a pre-existent ulcer. In this context, the relatively neglected topic of wound healing in the gastric mucosa is considered, and the implications for current therapeutic strategies and for the discovery of new anti-ulcer drugs are explored.

Aspects of the role of prostaglandins in gastrin histamine regulation of gastric acid secretion

There is convincing evidence from in vitro studies that prostaglandins interfere with the gastrin histamine regulation of gastric acid secretion in an opposing manner. They can inhibit the action of histamine on the parietal cell when given as single-dose treatment. Conversely, when given at high doses, they liberate endogenous histamine, probably from nonparietal cells. In in vivo experiments prostaglandins are potent inhibitors of acid secretion when studied with single-dose treatment but are capable of stimulating basal acid secretion when chronically applied to rats. Studies performed in whole animal preparations on the effect of cyclooxygenase inhibitors have not fully clarified which of these two histamine-modulating effects of prostaglandins is of prime physiologic significance but favour suppression of histamine activity with subsequent acid inhibition. It appears that somatostatin release is the mechanism through which prostaglandin can simultaneously inhibit acid secretion and release plasma gastrin. At least in the rat, the pattern of plasma gastrin and somatostatin release is, similarly to acid secretion, partly reversed during prolonged prostaglandin treatment.

Relationship between gastric mucosal prostaglandin levels and healing of gastric lesions in rats

1. This study was designed to determine whether or not endogenous prostaglandins (PG) contribute to the healing of gastric ulcers induced by high concentrations of ethanol or water immersion stress. 2. Ethanol-induced gastric lesions; rats were divided into four groups: (1) the control group: untreated; (2) the indomethacin group: indomethacin (2 mg/kg) was injected intramuscularly (i.m.) once daily until the end of the experiment; (3) the ethanol group: rats were given 1 mL of 50% ethanol intragastrically; (4) the ethanol + indomethacin group: indomethacin (2 mg/kg) was injected (i.m.) once daily from 1 h after administration of 50% ethanol until the end of the experiment. 3. Water immersion stress-induced gastric lesions; rats were divided into three groups: (1) control group: untreated; (2) stress group: rats were placed in a stress cage and immersed into a water bath (23 degrees C) for 6 h; (3) stress + indomethacin group: indomethacin (2 mg/kg) was injected (i.m.) once daily for 3 consecutive days immediately after stress treatment or from 3 days after stress treatment until the end of the experiment. 4. Immediately after observation of the lesions, the fundic mucosal layer was separated from the muscle layer and mucosal PG levels were measured by high performance liquid chromatography in each group. 5. Indomethacin did not inhibit ulcer healing until 48 h after administration in the ethanol experiment, and until 3 days after administration in the water immersion experiment. In contrast, indomethacin inhibited ulcer healing thereafter in each experiment respectively. 6. Four kinds of PG, that is 6-keto-PGF1 alpha, PGF2 alpha, PGE2 and PGD2 were detected in gastric mucosa.(ABSTRACT TRUNCATED AT 250 WORDS)

Proximal duodenal prostaglandin E2 release and mucosal bicarbonate secretion are altered in patients with duodenal ulcer

Proximal duodenal mucosal bicarbonate production is impaired in patients with duodenal ulcer disease. Because prostaglandins of the E class increase human proximal duodenal bicarbonate secretion, this study tested the hypothesis that endogenous prostaglandin E2 production is defective in patients with duodenal ulcer. Ten patients, five with active and five with inactive duodenal ulcer disease, were studied along with 10 normal volunteers. The proximal 4 cm of duodenum, the bulb, was isolated and continuously perfused with 154 mmol/L NaCl. Basal bicarbonate secretion was measured for 30 minutes. The test segment was then acidified with a physiological amount of HCl (2 mmol over 5 minutes), and acid-stimulated bicarbonate secretion was measured by pH/PCO2 and back-titration for 55 more minutes. Prostaglandin E2 was measured in the effluents by a radioimmunologic assay validated by gas chromatography-mass spectrometry. Compared with the normal subjects after luminal acidification, the duodenal ulcer patients had significantly greater PGE2 release and decreased total 1-hour bicarbonate output. The peak 5-minute acid-stimulated bicarbonate responses were not significantly different between the duodenal ulcer patients and normal subjects. After luminal acidification, PGE2 output remained elevated in the duodenal ulcer patients but returned promptly to basal in the normal subjects. Furthermore, the ratio of bicarbonate secreted to the amount of PGE2 released was significantly less in the ulcer patients. These findings suggest that patients with duodenal ulcer disease have an impaired mucosal bicarbonate response to endogenous PGE2. The increased acid-stimulated PGE2 response in duodenal ulcer patients suggests a compensatory phenomenon in response to the diminished mucosal bicarbonate production.

Healing of chronic gastroduodenal ulcerations by antacids. Role of prostaglandins and epidermal growth factor

Antacids show gastroprotective action against various irritants in experimental animals and enhance the healing of chronic gastroduodenal ulcers in humans but the mechanisms of these effects are unknown. The present study was designed to determine whether prostaglandin (PG) and epidermal growth factor (EGF), which also have protective and antiulcer properties, contribute to the action of antacids on rat's stomach. It was found that Maalox 70 and its active component, Al(OH)3, enhance significantly the healing of chronic gastric and duodenal ulcers observed during 7 and 14 days after their induction. Pretreatment with indomethacin caused a significant prolongation of ulcer healing, and this was accompanied by a significant reduction in PG and EGF formation, suggesting that both factors may be involved in ulcer healing. Maalox and Al(OH)3 failed to prevent the suppression of PG by indomethacin but were equally effective in ulcer healing in rats without and with indomethacin administration, suggesting that endogenous PG may not play any important role in the healing process by these drugs. Removal of salivary glands, the major source of EGF, also prolonged ulcer healing but, again, Maalox was as effective in ulcer healing as in rats with intact salivary glands. Our findings that Maalox at pH above 3.0 binds significant amounts of EGF, enhances the binding of EGF to the ulcer area, and stimulates mucosal growth, suggest that EGF may be involved in ulcer healing; however, because antacids are also effective after sialoadenectomy, EGF does not seem to be the major factor in ulcer healing by these drugs.

Effects of zinc L-carnosine on gastric mucosal and cell damage caused by ethanol in rats. Correlation with endogenous prostaglandin E2

The effects of zinc L-carnosine on ethanol-induced damage and the correlation of these effects with endogenous prostaglandin E2 were evaluated in rat gastric mucosa in vivo and in vitro. When given either intragastrically or intraperitoneally, zinc L-carnosine (10 or 30 mg/kg) prevented gross visible damage to gastric mucosa caused by ethanol without affecting the mucosal prostaglandin E2 level. This protective effect of zinc L-carnosine was not inhibited by indomethacin. Histological assessment showed that zinc L-carnosine inhibited deep mucosal necrosis, as did 16,16-dimethyl prostaglandin E2. Zinc L-carnosine (10(-6) or 10(-5) M) inhibited the damage caused by ethanol to gastric cells isolated from rat gastric mucosa in vitro; this effect was not inhibited by indomethacin. The results suggested that zinc L-carnosine protects the gastric mucosa and enhances cellular resistance to ethanol without the mediation of endogenous prostaglandins.

Acid and barriers. Current research and future developments for peptic ulcer therapy

Medical therapy for peptic ulcer disease has been targeted at inhibiting acid secretion based on the belief that ulcers occur due to an imbalance between aggressive and protective factors. New antisecretory agents are unlikely to show any dramatic improvement over the success and safety of histamine H2 receptor antagonists or the recently introduced H+K+ATPase proton pump antagonist omeprazole. The development of specific muscarinic M3 and gastrin receptor antagonists will provide useful agents to suppress acid and pepsinogen secretion by alternative means and may prevent the associated hypergastrinaemia seen with anti-secretory therapy. Enhancement of mucosal defence by site protective agents will be based on a better understanding of the vascular and immune factors involved in maintaining mucosal integrity and the growth factors that regulate wound healing. Molecular techniques are likely to produce the 'model anti-ulcer' agent which will effectively inhibit acid secretion and also enhance wound healing thus providing a cure for this chronic disease.

The role of mucosal prostaglandin levels in healing of water immersion-induced gastric ulcers in rats

This study was designed to clarify the recovery time course of water immersion stress ulcers. Rats were divided into two groups: the control group and the cetraxate group. In the cetraxate group, 6 h after water immersion stress, cetraxate (300 mg/kg) was administered intragastrically twice a day until the end of the experiment. Ulcer indices were observed immediately, 1, 3, 7, 14, and 21 days after water immersion stress in each group. Changes in gastric mucosal prostaglandin (PG) levels were measured by means of high-performance liquid chromatography. In the control group ulcer healing was not observed within 1 day after stress. Gastric lesions had decreased significantly after 3 days, but 21 days were required for total healing. Accelerated ulcer healing was observed in the cetraxate group. Four kinds of PGs were detected in gastric mucosa: 6-keto-PGF1 alpha, PGF2 alpha, PGE2, and PGD2. Recovery of PG levels differed from each other. Fourteen days were required for full recovery of PGD2 and 6-keto-PGF1 alpha. In contrast, 7 days were required for recovery of PGF2 alpha and PGE2. Cetraxate accelerated the recovery of gastric mucosal PGD2 and 6-keto-PGF1 alpha levels, especially the former. These results suggest that PGs, especially PGD2, are linked with the healing processes of stress ulcers.

Use of microbleeding and an ultrathin endoscope to assess gastric mucosal protection by famotidine

We have developed an ultrathin endoscope for repeated endoscopy in unsedated subjects and used it with assessment of bleeding rates to investigate aspirin-induced gastric mucosal injury and its prevention by famotidine. Compared with placebo, 900 mg of aspirin b.i.d. taken for 48 h caused significant endoscopic injury (median grade 3.5, interquartile range 2-4, modified Lanza scale, p less than 0.01), with an increase in mucosal bleeding from 2.0 (geometric mean; 95% confidence limits, 1.1-3.9) microliters/12 min, to 8.3 (2.4-28.8) microliters/12 min (p less than 0.05). Famotidine (20 mg b.i.d.) raised intragastric pH and reduced endoscopic antral injury (median 1.5, interquartile range 0.5-2, p less than 0.05) and bleeding [3.1 (1.2-8.3) microliters/12 min, p less than 0.01] to levels not significantly different from placebo [1 (0-1) and 2.0 (1.1-3.9) microliters/12 min, respectively]. By contrast, 2 mg of famotidine b.i.d. had no significant effect on intragastric pH endoscopic injury or bleeding rates. The two assessments of gastric mucosal injury correlated strongly (r = 0.71, p less than 0.01). The reduction in bleeding with famotidine tended to be higher, the greater the intragastric pH (r = 0.66, p = 0.057). Ultrathin endoscopy is a simple technique that validates gastric mucosal bleeding as a measure of acute gastric mucosal injury in humans. Acid suppression is an effective method of ameliorating this injury.

Treatment of peptic ulcer disease in the arthritic patient

Dyspepsia associated with arthritis and non-steroidal anti-inflammatory drugs (NSAIDs) is a common clinical problem. Up to 80% of deaths attributable to peptic ulceration may be associated with NSAID usage. The problem is foremost in the elderly population, in which there has been an increase both in the incidence of peptic ulcers and in the use of NSAIDs. Although the development of duodenal ulceration is not clearly associated with NSAIDs, it is accepted that these drugs increase the risk of gastric ulceration and the occurrence of peptic ulcer complications. Asymptomatic peptic ulceration is common, and patients taking NSAIDs are often asymptomatic prior to presentation with life-threatening complications. The key principle in management of this problem is prevention through careful selection of patients for NSAID use, adequate treatment of peptic ulceration and maintenance of remission. A variety of effective drugs are available for the treatment of peptic ulcers, including H2-receptor antagonists, pirenzepine, sucralfate and colloidal bismuth subcitrate. However, it is recognised that peptic ulceration is a chronic disease with a relapsing-remitting course, often with asymptomatic ulcer episodes. The knowledge that current ulcer-healing strategies do not significantly alter this natural history has lead to increasing efforts to prevent relapse with effective 'maintenance' therapy.

Effects of four orally administered analogues of prostaglandin E1 and E2 on glucose tolerance and on the secretion of pancreatic and gastrointestinal hormones in man

Oral glucose tolerance tests (75 g, 300 ml) were performed in 12 healthy volunteers, with prior administration of placebo, misoprostol (400 micrograms), rioprostil (300 micrograms), enprostil (70 micrograms), or nocloprost (200 micrograms), in a double-blind, randomized manner. None of the drugs significantly affected glucose tolerance, although with misoprostal some volunteers displayed an impaired glucose tolerance. Nocloprost was without effect on gastric inhibitory polypeptide (GIP) and did not influence insulin or C-peptide concentrations. Misoprostol and rioprostil reduced integrated incremental responses of GIP by 57% (P less than or equal to 0.001) and 45% (P less than or equal to 0.01), respectively, and both gave rise to an initial (approximately 10 min) delay of insulin and C-peptide responses, without a significant overall reduction in integrated incremental responses. Enprostil almost totally inhibited the GIP response (by 94%; P less than or equal to 0.001), delayed initial insulin and C-peptide responses, but reduced the integrated incremental C-peptide response (which corresponds to the overall release of insulin) by only 14% (P less than or equal to 0.05). Enprostil more substantially reduced the integrated incremental response of insulin by 36% (P less than or equal to 0.01), and also reduced the ratio of insulin and C-peptide incremental responses (P less than or equal to 0.001). In conclusion, prostaglandin E analogues which caused a reduction in GIP responses, and thereby disrupting the enteroinsular axis to varying degrees, delayed the time-course of insulin secretion without a significant impact on glucose tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

Prostaglandins and the gastric epithelium: effects of misoprostol on gastric epithelial cell proliferation in the dog

The effects of the methyl ester analogue of prostaglandin E1, misoprostol, on gastric epithelial cell proliferation were investigated in six dogs given 300 micrograms/kg/day of misoprostol orally for 11 weeks and in six control dogs given placebo for 11 weeks. Misoprostol treatment resulted in a 36% increase in stomach weight (p less than 0.01) and a 30% increase in the length (measured as the cell column count from the base/neck junction to the surface) of the fundic gastric glands (p less than 0.01). This mucosal hyperplasia was predominantly caused by enlargement of the foveolar region of the gland, with little change occurring in the neck or in the isthmus. The hyperplasia was the result of an increased number of mitotic (p less than 0.01) and DNA synthesising cells (p less than 0.05) in each gastric gland, which resulted in a significant increase in the gland cell production rate, from 22.5 to 42.6 cells per gland per day (p less than 0.05).

Ulcers, nonsteroidal antiinflammatory drugs, and related matters

This overview is intended to provide perspectives drawn from the proceedings of the Ulcer-Epidemiology Symposium reported in this supplement. This meeting was designed to review the epidemiology and risk factors underlying the development of acid/peptic diseases and to highlight the natural history and therapy of these disorders. These topics served as a focus for the meeting. A second goal was to consider the topics in the context of ulcer complications resulting from use of nonsteroidal antiinflammatory drugs. Although nonsteroidal antiinflammatory drugs are well known to cause gastric damage and ulcers and to lead to complications of preexisting peptic ulcers, the frequency and severity of the clinical problems resulting from their use and the efficacy of different modalities for prevention and treatment have only recently begun to be the subjects of careful analysis.

Sucralfate for prevention of naproxen-induced mucosal lesions in the proximal and distal gastrointestinal tract

To study the protective effect of Sucralfate on Naproxen-induced mucosal lesions, 16 healthy, male volunteers were given Naproxen 500 mg b.i.d. together with Sucralfate 2 g b.i.d. or placebo in a double-blind, crossover study. Drug periods were 1 week, with a 3-week wash out in between. Mucosal lesions in stomach and duodenum were assessed by upper endoscopy before and after each drug period, using a visual analogue with separate scoring of mid- and distal duodenal lesions. 51Cr-EDTA absorption tests were performed to demonstrate possible changes in distal gut permeability. In addition, subjective symptoms were registered. Both drug periods induced significant lesions in the stomach and duodenum. Statistically speaking, fewer changes were found in the stomach and duodenal bulb after Sucralfate co-administration, whereas no significant reduction of lesions was seen in the distal duodenum. The 51Cr-EDTA absorption was increased in both periods, indicating deleterious effects to distal parts of the gut, but our results did not demonstrate Sucralfate-mediated protection from these changes. Symptoms were modest, and equal in the two periods. We conclude that Sucralfate may offer protection in the gastric and proximal duodenal mucosa, but no such protective effect was seen distally to the duodenal bulb.

Combined esophageal and gastric pH-metry in healthy volunteers. Influence of cable through LES and effect of misoprostol

In order to evaluate whether combined esophageal and gastric pH-metry is feasible without interference due to the transcardial cable, four 24-hr ambulatory esophageal pH-metries were carried out in seven healthy volunteers in a randomized order. In two studies only one glass electrode was used. It was placed 5 cm above the lower esophageal sphincter. In the two other studies an additional electrode was placed in the corpus region 10 cm below the lower esophageal sphincter. In order to obtain a wide range of pH values, misoprostol (400 micrograms) was given at 9 AM and 9:15 PM in two studies. In the two other studies placebo was given. Misoprostol exerted only a weak and short-lasting effect on gastric acidity. The four measuring conditions did not differ with respect to medians of esophageal reflux time and duration of single reflux episodes, Kendall's coefficient of concordance yielded a high reproducibility for both variables (P less than 0.0025). Thus, combined esophageal and gastric pH-metry is feasible and highly reproducible.

Rioprostil vs. ranitidine in duodenal ulcer healing: a double-blind multicentre trial

A total of 156 patients with endoscopically proven duodenal ulcers are randomized in a double-blind, multicentre trial comparing rioprostil, 300 micrograms b.d., with ranitidine, 150 mg b.d. With rioprostil, the cumulative healing rate by endoscopy is 73% at 4 weeks, and 87% at 6 weeks. With ranitidine it is 79% and 92%, respectively. There is no difference in the occurrence of pain after the two types of treatment, and the side effects are comparable in the two groups. These results show that rioprostil is probably as effective and safe as ranitidine in the treatment of duodenal ulcer.

Comparison of the gastrointestinal side effects of naproxen formulated as plain tablets, enteric-coated tablets, or enteric-coated granules in capsules

We studied the gastrointestinal side effects of three formulations of naproxen in 18 healthy male volunteers. In a Latin-square design crossover study, the subjects received 500 mg naproxen twice daily for 7 days as plain tablets, enteric-coated tablets, or enteric-coated granules in capsules. The 51Cr-EDTA absorption test was performed before and at the end of each drug period, to evaluate changes in the distal gut. The test dose was instilled distally in the duodenum to prevent lesions in the stomach from interfering with the evaluation. Upper endoscopy was performed at the same intervals, scoring changes in the middle and distal duodenum separately from findings in the stomach and duodenal bulb. The nature and severity of adverse effects were recorded for each treatment period. Non-parametric methods were used for statistical evaluation. All drugs induced a significant increase in 51Cr-EDTA absorption, but we did not detect any difference between the three formulations. All formulations were associated with a significant increase in all the endoscopic findings monitored. Enteric-coated tablets induced significantly less lesions than enteric-coated granules in the stomach and duodenal bulb, and an advantage over plain tablets was indicated. No difference was seen in the middle and distal duodenum. The proximal endoscopic scores were not correlated to those found in the middle and distal duodenum. Evaluation of the small and large bowel should probably be included in clinical studies of NSAIDs, but our findings suggest that the importance of transfer of mucosal lesions to the distal gut by enteric coating may have been overemphasized.

Side effects of anti-ulcer prostaglandins: an overview of the worldwide clinical experience

Anti-ulcer prostaglandins (PG)--misoprostol, enprostil and rioprostil--have been given to more than 5000 patients in short-term studies on gastric and duodenal ulcer. Analysis of these studies shows the drugs to be safe. Their side effects appear to be dose-dependent and mainly restricted to the gastrointestinal system, the major syndromes being diarrhoea and abdominal pain. The clinical relevance of PG-related unwanted effects, though in average exceeding that of H2-blockers, seems to be sufficiently low. In terms of safety efficacy, however, they appear inferior to H2-antagonists, so their routine use in preference to the latter compounds is still premature.

Influence of prostaglandins, omeprazole, and indomethacin on healing of experimental gastric ulcers in the rat

We investigated whether the trophic actions of prostaglandins, omeprazole, and indomethacin on gastric mucosa lead to accelerated healing of gastric ulcers in the rat. Cryoulcers were produced in the corpus area and treated with 16,16-dimethyl prostaglandin E2 (5 or 100 micrograms/kg b.i.d., intragastrically), omeprazole (40 mumol/kg once daily, subcutaneously), indomethacin (2 mg/kg b.i.d., subcutaneously), or placebo. At the end of the treatment, plasma gastrin, cell labeling index (autoradiography with [3H]thymidine), and the size and depth of mucosal defects were measured. Compared with placebo, omeprazole accelerated ulcer healing as indicated by a smaller ulcer area [1.1 +/- 0.2 vs. 4.8 +/- 1.2 mm2 (mean +/- SEM)] and smaller ulcer depth (383 +/- 31 vs. 488 +/- 41 microns) after 10 days of treatment. Prostaglandins did not affect ulcer healing despite thickening of gastric corpus mucosa. Indomethacin delayed ulcer healing and reduced the labeling index. Omeprazole induced a marked hypergastrinemia (208 +/- 12 vs. 66 +/- 12 pmol/L on day 5, and 469 +/- 23 vs. 58 +/- 16 pmol/L on day 10). The results indicate that abolishment of acid secretion by omeprazole accelerates healing. Trophic actions and "cytoprotective" effects by prostaglandins are not relevant for ulcer healing in this model.

Effects of zinc acexamate on gastric mucosal production of prostaglandin E2 in normal and stressed rats

Changes in PGE2 levels induced by zinc acexamate (ZAC) at gastricmucosal level were assessed in a rat model. Experiments were performed in normal rats and rats subjected to cold-restraint stress and in experimental conditions in which prostaglandins (PGs) synthesis was inhibited by prior administration of indomethacin. Gastric injuries after different treatments were quantified macro and microscopically. Total amount of PGE2 and mucus material recovered from gastric mucosa were increased after ZAC treatment. Indomethacin aggravated gastric damage secondary to stress and inhibited PGE2 and mucus increase appearing after ZAC treatment. These data confirm the relation between PGE2, mucus production and gastric protection. ZAC 200 mg/kg was able to reduce the gastric damage induced by stress. This decrease was also evident in the group receiving indomethacin before ZAC administration. These experiments indicate that ZAC exhibits its antiulcer action by increasing prostaglandins but other mechanisms independent of PGs synthesis are also involved.

The effect of dietary fatty acids on the gastric production of prostaglandins and aspirin-induced injury

We have investigated in man the effect of dietary supplementation with evening primrose oil (linoleic acid 72%, gamma-linolenic acid 9%) on gastric immunoreactive PGE2 release and aspirin-induced mucosal injury. Twenty healthy volunteers received in a randomized crossover evening primrose oil (2 g b.d.) and olive oil (control) for 2 weeks each. During the last 48 hours of each period, five doses of aspirin 900 mg were taken. In gastric washings on day 7, evening primrose oil had enhanced immunoreactive PGE2 release from a mean of 38 ng/30 min (olive oil) to 80 ng/30 min (P less than 0.05). This, however, was not able to protect against aspirin-induced gastric blood loss which rose from a mean (95% confidence limits) of 1.3 (0.7-2.1) microliters 10 min-1 (evening primrose oil day 7) to 9.4 (5.4-16.5) microliters 10 min-1 (day 14). Although not effective against aspirin, similar dietary supplementation might assist in preventing peptic ulcer recurrence.

A multicentre comparison of trimoprostil and cimetidine in the treatment of duodenal ulcer. U.K. Trimoprostil Study Collaborative Group

Trimoprostil is a new synthetic prostaglandin E2 analogue that inhibits acid secretion and has mucosal protective properties. It was compared with cimetidine to assess its effectiveness in the short-term treatment of duodenal ulcer. Seven centres recruited 107 patients, who were randomized to receive either 3 mg trimoprostil daily (n = 54) or 1 g cimetidine daily (n = 53) for 4 weeks, the drugs being taken in four divided doses. Of patients completing treatment, 23 of 40 (58%) healed with trimoprostil, compared with 47 of 53 (89%) with cimetidine (p less than 0.001). Both drugs relieved daytime and nighttime pain, but cimetidine was significantly quicker. Eight patients taking trimoprostil were withdrawn because of pain, nausea, and vomiting, but none taking cimetidine; diarrhoea did not occur with trimoprostil. There were no clinically significant changes in haematology or in biochemistry studies. In conclusion, trimoprostil was not as effective as cimetidine in the treatment of duodenal ulcer.

Future trends in the management of peptic ulcer disease

Future trends in the short- and long-term management of peptic ulcer disease are considered. The present state of development of pharmacologic agents for the short-term healing of duodenal and gastric ulcer is impressive, and high rates of healing with rapid symptom relief can be safely achieved with several agents. The problem of ulcer recurrence has not been solved, although new work concerning the role of Campylobacter pylori holds promise. The mortality of acute gastrointestinal haemorrhage remains unacceptably high, especially in the elderly. Therapeutic endoscopy may be effective in decreasing the death rate from bleeding.