A prospective randomized trial of mosapride vs. placebo in constipation-predominant irritable bowel syndrome

Deglycosylated Azithromycin Targets Transgelin to Enhance Intestinal Smooth Muscle Function

Azithromycin (AZM) has been widely used as an antibacterial drug for many years. It has also been used to treat delayed gastric emptying. However, it exerts several side effects. We found that deglycosylated AZM (Deg-AZM or CP0119), an AZM metabolite, is a positively strong intestinal agonist that may result in the intestinal mobility experienced by patients after AZM administration. We confirmed that Deg-AZM can function strongly on intestinal peristalsis and identified transgelin as its potential molecular target. Furthermore, our pharmacological studies showed that the binding of Deg-AZM to transgelin enhanced the contractility of intestinal smooth muscle cells by facilitating the assembly of actin filaments into tight bundles and stress fibers. Specifically, Deg-AZM promoted intestinal peristaltic activity in wild-type mice but not in transgelin (-/-) mice. Moreover, Deg-AZM did not exert antibacterial activity and did not disrupt intestinal flora. Thus, Deg-AZM may become a potential drug for slow-transit constipation treatment.

Management Options for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is associated with diverse pathophysiologic mechanisms. These mechanisms include increased abnormal colonic motility or transit, intestinal or colorectal sensation, increased colonic bile acid concentration, and superficial colonic mucosal inflammation, as well as epithelial barrier dysfunction, neurohormonal up-regulation, and activation of secretory processes in the epithelial layer. Novel approaches to treatment include lifestyle modification, changes in diet, probiotics, and pharmacotherapy directed to the motility, sensation, and intraluminal milieu of patients with IBS. Despite recent advances, there is a need for development of new treatments to relieve pain in IBS without deleterious central or other adverse effects.

Pharmacotherapy for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a disorder of the brain-gut axis; the pathophysiological mechanisms include altered colonic motility, bile acid metabolism, neurohormonal regulation, immune dysfunction, alterations in the epithelial barrier and secretory properties of the gut. This article reviews the mechanisms, efficacy, and safety of current pharmacotherapy, and medications that are in phase III trials for the treatment of IBS. There remains a significant unmet need for effective treatments-particularly for the pain component of IBS-although the introduction of drugs directed at secretion, motility and a non-absorbable antibiotic provide options for the bowel dysfunction in IBS.

New Options in Constipation Management

Constipation is common in the general population and for those on opioids and/or who are suffering from advanced cancer. Self-management consists of dietary changes, exercise, and laxatives. However, responses to self-management efforts are often inadequate to relieve the subjective and objective experience of constipation. Multiple new anti-constipating medications have recently been tested in randomized trials and the following are available commercially: probiotics, prucalopride, lubiprostone, linaclotide, elobixibat, antidepressants, methylnaltrexone, alvimopan, and naloxegol. This review will discuss the evidence-based benefits of these medications and outline an approach to managing constipation.

Effective Constipation Treatment Changes More Than Bowel Frequency: A Systematic Review and Meta-Analysis

BACKGROUND/AIMS

The marketing of newer agents for treatment of constipation and irritable bowel syndrome with constipation (IBS-C) emphasize improvements in abdominal pain. However, it is not clear whether this observation reflects a unique visceral analgesic effect of these agents or is a general feature of effective laxation. We sought to determine the relationship between improvements in bowel frequency and decreases in abdominal pain in clinical trials of patients with constipation or IBS-C.

METHODS

We searched "PubMed" and "Embase" databanks for clinical trials in patients with constipation or IBS-C, targeting publications that provided detailed data on bowel movement frequency and pain intensity before and after an intervention. We abstracted the results and performed meta-analytic and meta-regression analyses.

RESULTS

Twenty-seven trials (16 constipation and 11 IBS) met entry criteria. Baseline weekly bowel movement frequency was low with 2.35 (2.07-2.64) with differences between constipation (2.00 [1.62-2.38]) and IBS-C (2.77 [2.40-3.14]; Q = 8.18; P = 0.002). Studies reported moderate pain levels (2.12 [1.81-2.42]) with comparable baseline levels in constipation (2.02 [1.63-2.42]) and IBS-C (2.35 [2.10-2.60]; Q = 1.92; P = 0.167). Treatments increased bowel frequency by 2.17 [1.88-2.47] and lowered pain ratings by 0.58 [0.49-0.68]. Meta-regression demonstrated a significant correlation between treatment-induced increases in bowel frequency and decreased pain ratings.

CONCLUSIONS

Our analysis suggests that reduction of abdominal pain observed in clinical trials of constipation and IBS-C is associated with laxation, and may not require specific drug mechanisms, thus arguing against a unique advantage of newer agents over traditional laxatives in the treatment of constipation and IBS-C.

Curative effect of mosapride vs prucalopride in treatment of chronic constipation in elderly patients

AIM: To compare the curative effect between mosapride and prucalopride in the treatment of chronic constipation in elderly patients.

METHODS: From February 2013 to September 2014, 123 elderly patients with chronic constipation at our department were randomly assigned to orally receive either mosapride (control group, n = 61) or prucalopride (observation group, n = 62). The efficacy, time to first defecation, and time to improvement of difficult defecation were compared between the two groups. Moreover, the scores for common symptoms (defecation frequency, stool properties, defecation difficulty and defecation time) and adverse reactions were also recorded.

RESULTS: The total effective rate in the observation group was 83.61% (59/62), significantly higher than that of the control group [83.61% (51/61), P < 0.05]. Compared with the control group, the time to first defecation and time to improvement of difficult defecation were shortened, and common symptom scores decreased in the observation group (P < 0.05). Main adverse reactions included diarrhea, nausea and abdominal pain, and the duration of these adverse reactions was shorter. There was no statistical significance in the incidence of adverse reactions between the two groups (P > 0.05).

CONCLUSION: Prucalopride has a better curative effect than mosapride in the treatment of elderly patients with chronic constipation in terms of improved symptoms and tolerable adverse reactions.

Emerging Pharmacologic Therapies for Constipation-predominant Irritable Bowel Syndrome and Chronic Constipation

Irritable bowel syndrome with constipation and chronic functional constipation are common digestive disorders that negatively impact quality of life and account for billions of dollars in health care costs. Related to the heterogeneity of pathogenesis that underlie these disorders and the failure of symptoms to reliably predict underlying pathophysiology, traditional therapies provide relief to only a subset of affected individuals. The evidence surrounding new and emerging pharmacologic treatments, which include both luminally and systemically acting drugs, is discussed here. These include agents such as lubiprostone, bile acid modulations, guanylate cyclase-C receptor agonists, serotonin receptor modulators and herbal therapies.

What's New in the Toolbox for Constipation and Fecal Incontinence?

Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut-brain-microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.