Effect of domperidone on the QTc interval in premature infants

Drugs in Focus: Domperidone

Domperidone is a peripheral dopamine-2 receptor antagonist with prokinetic and antiemetic properties. Its prokinetic effects are mainly manifest in the upper gastrointestinal (GI) tract. Currently its use is restricted to relief of nausea and vomiting in children older than 12 years for a short period of time. However, among (pediatric) gastroenterologists, domperidone is also used outside its authorized indication ("off label") for treatment of symptoms associated with gastro-esophageal reflux disease, dyspepsia, and gastroparesis. Little is known about its efficacy in the treatment of GI motility disorders in children and controversial data have emerged in the pediatric literature. As its use is off label, appropriate knowledge of its efficacy is helpful to support an "off label/on evidence" prescription. Based on this, the purpose of this review is to summarize all evidence on the efficacy of domperidone for the treatment of GI disorders in infants and children and to report an overview of its pharmacological properties and safety profile.

Review article: Functional dyspepsia and pregnancy-Effects and management in a special population

BACKGROUND

Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy.

AIMS AND METHODS

To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions.

RESULTS

Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD.

CONCLUSIONS

Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.

Embryotoxicity of silica nanoparticles in the drug delivery of domperidone in zebrafish

Domperidone is a dopamine D2 receptor inhibitor that stimulates pituitary gonadotropins. It is usually associated with synthetic GnRHa to promote spawning in fish. However, the route of administration used, intramuscular injection, can be quite stressful. Little is known about the effects of domperidone, as well as other routes. This study aims to evaluate the toxicity of domperidone encapsulated by silica nanoparticles in zebrafish embryos. The study involved four groups with three concentrations: 1. domperidone (DP) 0.0001, 0.0002 and 0.0004 mg/mL; 2. DP associated with silica nanoparticles (SiNPs) 0.0001 + 1.1, 0.0002 + 2.2 and 0.0004 + 4.4 mg/mL; 3. SiNPs 1.1, 2.2 and 4.4 mg/mL and 4. Control (E3), with four repetitions per group. Survival, teratogen and heart rate (HR) were evaluated over a period of 168 hpf. Survival was higher in DP + SiNPs treatment, HR was lower in treatment with 4.4 mg/mL of SiNPs, while treatment with 0.004 mg/mL of DP increased HR. This study demonstrated that the association of DP and SiNPs decreased the toxicity of both DP and SiNPs, demonstrating that this may be a viable alternative to reduce the possible cardiotoxic effects of DP.

QTc Interval Reference Values and Their (Non)-Maturational Factors in Neonates and Infants: A Systematic Review

QTc interval measurement is a widely used screening tool to assess the risk of cardiac diseases, arrhythmias, and is a useful biomarker for pharmacovigilance. However, the interpretation of QTc is difficult in neonates due to hemodynamic maturational changes and uncertainties on reference values. To describe trends in QTc values throughout infancy (1 year of life), and to explore the impact of (non)-maturational changes and medicines exposure, a structured systematic review (PROSPERO CRD42022302296) was performed. In term neonates, a decrease was observed over the first week of life, whereafter values increased until two months of age, followed by a progressive decrease until six months. A similar pattern with longer QTc values was observed in preterms. QTc is influenced by cord clamping, hemodynamic changes, therapeutic hypothermia, illnesses and sleep, not by sex. Cisapride, domperidone and doxapram result in QTc prolongation in neonates. Further research in this age category is needed to improve primary screening practices and QTcthresholds, earlier detection of risk factors and precision pharmacovigilance.

QTc Intervals Are Prolonged in Late Preterm and Term Neonates during Therapeutic Hypothermia but Normalize Afterwards

BACKGROUND

There are anecdotal reports on reversible QTc prolongation during therapeutic hypothermia (TH) for moderate to severe neonatal encephalopathy after asphyxia. As the QTc interval is a relevant biomarker for pharmacovigilance during medication development, a structured search and review on published neonatal QTc values to generate reference values is warranted to facilate medication development in this specific population.

METHODS

A structured search and literature assessment (PubMed, Embase, and Google Scholar) with 'Newborn/Infant, QT and hypothermia' was conducted (October 2021). Retrieved individual values were converted to QTc (Bazett) over postnatal age (day 1-7).

RESULTS

We retrieved 94 QTc intervals (during TH (n = 50, until day 3) or subsequent normothermia (n = 44, day 4-7)) in 33 neonates from 6 publications. The median (range) of QTc intervals during TH was 508 (430-678), and 410 (317-540) ms afterwards (difference 98 ms, or +28 ms/°C decrease). Four additional cohorts (without individual QTc intervals) confirmed the pattern and magnitude of the effect of body temperature on the QTc interval.

CONCLUSIONS

We highlighted a relevant non-maturational covariate (°C dependent TH) and generated reference values for the QTc interval in this specific neonatal subpopulation. This knowledge on QTc during TH should be considered and integrated in neonatal medication development.

Efficacy comparison between oral erythromycin versus domperidone for the treatment of feeding intolerance in preterm neonates

BACKGROUND

Domperidone and erythromycin are commonly used as prokinetic agents for feeding intolerance in preterm neonates; however, no data from a previous study have compared their efficacy. This study aimed to compare the efficacy of orally administered domperidone and erythromycin for the treatment of feeding intolerance in preterm infants.

METHODS

This retrospective cohort study included preterm neonates with a birthweight of <1800 g and gestational age <37 weeks. Data were collected from medical records at Queen Sirikit National Institute of Child Health (QSNICH) from 2006 to 2014. The primary outcome was the time to establish full enteral feeding (150 ml/kg/day) after starting oral domperidone or erythromycin for the treatment of feeding intolerance in preterm neonates. The secondary outcome was adverse effects associated with domperidone and erythromycin therapy.

RESULTS

Among the 150 preterm neonates enrolled in this study, 66 received domperidone, and 84 received erythromycin. The baseline characteristics and comorbidities were not significantly different between the two groups; however, the gestational age at birth of neonates in the domperidone group was significantly lower than that of those in the erythromycin group. The time to establish full enteral feeding did not differ between the domperidone (11 days, "IQR," [6, 17]) and erythromycin (10 days, IQR [7, 14]) groups (p = 0.622). No major adverse effects were noted. There were only three preterm infants who had elevated liver enzymes in each group, but the difference between groups was not significant.

CONCLUSION

From this study, the efficacy of oral domperidone was promising equivalent to oral erythromycin and seems to be one of the treatment options for feeding intolerance in preterm neonates. However, large randomized, controlled trials are needed to confirm the efficacy and safety of domperidone in this population.

Safety considerations when managing gastro-esophageal reflux disease in infants

Introduction: Gastro-esophageal reflux disease (GERD) in infants is worldwide diagnosed with increasing frequency, resulting in an increasing number of infants exposed to treatment. In this review, we focus on the safety of therapeutic options. Areas covered: English articles were searched from 1990 until May 2020 in PubMed and Google Scholar. Evidence suggests that non-pharmacological treatment is often effective and safe. Guidelines restrict pharmacological treatment to acid-suppressive medication, which is associated with adverse effects, often related to gastro-intestinal dysbiosis and consequences of the latter. Aluminum-free alginates have some efficacy and are not associated with relevant adverse effects. Especially in infants, GERD is often nonacid related. Prokinetics are not recommended because of lack of efficacy and numerous adverse effects. Expert opinion: Pediatric trials are underpowered regarding adverse effects. The number of infants exposed to anti-secretory agents is increasing worldwide, often without indication. Informing healthcare providers about adverse effects of acid-secretory medication may contribute to a more rational use. Acid inhibiting agents such as alginates are a drug class associated with limited efficacy and devoid of serious adverse effects. Regarding prokinetics, the risk of adverse effects outweighs the benefit. Reassurance of parents and nutritional management of GERD in infants is effective and safe.

Awareness of, and Compliance with, Domperidone Revised Labeling After a Risk-Minimization Activity in Europe

BACKGROUND AND OBJECTIVE

Risk-minimization measures (RMM), including label revisions were implemented in Europe for domperidone because of evidence of increased incidence of cardiac arrhythmia and sudden cardiac death. In accordance with the guideline on good pharmacovigilance practices, the European Medicines Agency Pharmacovigilance Risk Assessment Committee requested to conduct two studies to evaluate the effectiveness of these risk minimization measures.

METHODS

In Belgium, France, Germany, Spain, and the UK, surveys were conducted to assess physicians' knowledge on the updated domperidone labeling information, and a drug-utilization study (DUS) was conducted using healthcare databases to assess domperidone prescribing patterns before and after the RMM. Four DUS sensitivity analyses (scenarios) evaluated uncertainty regarding domperidone treatment duration and indication.

RESULTS

Among 1805 physicians participating in the survey, most were aware of the approved indication (nausea and vomiting, 80%), treatment duration (≤ 7 days, 70%), and maximum adult daily dose (10 mg three times daily, 84%). Only 33% selected the on-label indication from a list of indications for which they would prescribe domperidone. Awareness was low for medications contraindicated for concomitant use (26%) and contraindicated conditions (4%). In the DUS, under the optimistic scenario, a large improvement in labeling compliance from pre- to post-implementation period was observed in France (27% vs. 69%), while Belgium, Germany, Spain, and the UK showed small improvements (< 10%). In the other scenarios, there was little to no improvement in compliance with the revised labeling from the pre- to post-implementation periods in most countries.

CONCLUSIONS

The survey findings documented that most physicians in all five countries were aware of the main aspects of the revised labeling. Results of the DUS were inconclusive regarding the effect of the RMM and compliance with the revised labeling for all countries except France.

A meta-analysis on the cardiac safety profile of domperidone compared to metoclopramide

BACKGROUND

This meta-analysis aimed to assess the cardiac safety profile of domperidone treatment for the risk of cardiovascular (CV) event and QT prolongation.

METHODS

Data from nine studies involving 101,155 patients were used for the analysis of CV event risk, while data from eight studies involving 390 patients were used for the analysis of QT prolongation risk.

RESULTS

Meta-analysis findings suggested a significant increase in CV risk under domperidone as compared to no treatment for domperidone doses of >30 mg/day (OR: 3.14, 95% CI, 1.191 to 8.304, p = 0.021), no significant increase in QT prolongation event rates with domperidone (3.54%, 95% CI, 1.73% to 7.10%) and a significantly lower CV risk for domperidone than for metoclopramide (OR: 0.63, 95% CI, 0.58 to 0.70, p < 0.001).

CONCLUSIONS

The present meta-analysis indicates that domperidone treatment may not be associated with an overall CV event risk increase at doses ≤30 mg/day and does not result in QT prolongation.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.

Drug-Induced QT Interval Prolongation in Children: Are the Kids Alright?

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Domperidone-Associated QT Interval Prolongation in Non-oncologic Pediatric Patients: A Review of the Literature

BACKGROUND

Domperidone is a prokinetic agent used to treat pediatric gastroesophageal reflux disease. Health Canada has issued warnings about an increased risk of domperidone-associated ventricular arrhythmias and sudden cardiac death. However, the supporting data referred only to adult patients; therefore, extrapolating the safety risks to pediatric patients is difficult.

OBJECTIVE

To summarize and evaluate the evidence for domperidone-associated QT interval prolongation, ventricular arrhythmias, and sudden cardiac death to determine the safety of this drug for pediatric patients.

DATA SOURCES

Two databases (MEDLINE [1946 to August 2015] and Embase [1980 to August 2015]) were searched with the following Medical Subject Headings and keywords: "domperidone", "arrhythmias, cardiac", "death, sudden, cardiac", "electrocardiography", "heart diseases", "long QT syndrome", "tachycardia, ventricular", "torsades de pointes", and "ventricular fibrillation". The search was limited to studies conducted in humans under 18 years of age and published in English.

STUDY SELECTION AND DATA EXTRACTION

Original research included in this review reported on the cardiac-related safety of domperidone in nononcologic patients under 18 years of age.

DATA SYNTHESIS

Of the 5 studies meeting the inclusion criteria (n = 137 patients), one reported a statistically significant change in the corrected QT (QTc) interval, but the clinical significance was unclear. Most of the studies reported rare occurrences of pathological QTc intervals in a limited number of patients. However, confounding factors (e.g., abnormal electrolyte level or concurrent medications) were not consistently considered. Potential bias might have been alleviated by blinding of electrocardiogram (ECG) assessors; however, this was not consistently implemented. The designs of the included studies did not allow assessment of causality. The results should be interpreted with caution.

CONCLUSIONS

Although the available evidence is limited, pathological QTc intervals were noted among a small number of infants, which supports the possibility of domperidone-associated risk of prolonged QTc interval. Because of the potential severity of QT interval prolongation, individual assessment and routine ECG monitoring should be implemented for patients receiving domperidone.

Domperidone for Treatment of Low Milk Supply in Breast Pump-Dependent Mothers of Hospitalized Premature Infants: A Clinical Protocol

Mothers of hospitalized premature infants who choose to provide breast milk are at increased risk of an inadequate breast milk supply. When nonpharmacologic interventions to increase milk supply fail, clinicians are faced with limited options. There is no current evidence to support the use of herbal galactogogues in this population and a black box warning for metoclopramide for potential serious side effects. Thus, domperidone was the only known, effective option for treatment of low milk supply in this population. With a thorough review of the literature on domperidone and coordination with the obstetrical, neonatal, lactation, and pharmacology teams, a domperidone treatment protocol for mothers of hospitalized premature infants with insufficient milk supply was developed at our institution and is presented in this article. A comprehensive understanding of domperidone for use as a galactogogue with a standard treatment protocol will facilitate safer prescribing practices and minimize potential adverse reactions in mothers and their hospitalized premature infants.

Effects of Domperidone on QT Interval in Children with Gastroesophageal Reflux Disease

BACKGROUND

Domperidone has been widely used in children with gastroesophageal reflux disease (GERD). Studies on the effects of domperidone on corrected QT interval (QTc) in young children are limited. Our aim was to study the effect of domperidone on the repolarization abnormalities assessed by electrocardiogram (ECG) in young children.

METHODS

ECG was performed in children <2 years of age before and after taking domperidone orally 0.3 mg/kg three times/day for at least a 1 week period. Each ECG was reviewed and QT, RR, and Tpeak to Tend intervals (TpTe) were measured to calculate the QTc and TpTe/QT ratio.

RESULTS

A total of 22 patients (12 male) with a median age of 8.5 months (1-24 months) were enrolled. Most patients (59.1%) were under 1 year of age. The median baseline QTc (410 milliseconds, 350-450 milliseconds) was not significantly different from the QTc after taking domperidone (410 milliseconds, 320-560 milliseconds), p = 0.159. Only two patients showed a QTc increase ≥450 milliseconds. The baseline TpTe interval and TpTe/QT (105 milliseconds, 60-170 milliseconds and 0.27 milliseconds, 0.15-0.43 milliseconds) were significantly greater than the TpTe interval and TpTe/QT in children after taking domperidone (90 milliseconds, 60-140 milliseconds and 0.22 milliseconds, 0.15-0.29 milliseconds), p = 0.001 and 0.004, respectively.

CONCLUSIONS

Our data demonstrate that domperidone treatment over a short-term period in children <2 years of age did not lengthen QTc significantly; however, QTc increased ≥450 milliseconds in two patients with concomitant lansoprazole. Routine baseline and follow-up ECG may not be necessary in each individual case receiving only domperidone.

Adverse effects reported in the use of gastroesophageal reflux disease treatments in children: a 10 years literature review

Gastroesophageal reflux (GER) is commonly observed in children, particularly during the first year of life. Pharmacological therapy is mostly reserved for symptomatic infants diagnosed with GER disease (GERD), usually as defined in a recent consensus statement. The purpose of the present article was to review the reported adverse effects of pharmacological agents used in the treatment of paediatric GERD. We conducted this review using the electronic journal database Pubmed and Cochrane database systematic reviews using the latest 10-year period (1 January 2003 to 31 December 2012). Our search strategy included the following keywords: omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole, rantidine, cimetidine, famotidine, nizatidine, domperidone, metoclopramide, betanechol, erythromycin, baclofen, alginate. We used Pubmed's own filter of: 'child: birth-18 years'. All full articles were reviewed and we only included randomized controlled trials retrieved from our search. We addressed a summary of our search on a drug-by-drug basis with regard to its mechanism of action and clinical applications, and reviewed all of the adverse effects reported and the safety profile of each drug. Adverse effects have been reported in at least 23% of patients treated with histamine H2 receptor antagonists (H2 RAs) and 34% of those treated with proton pump inhibitors (PPIs), and mostly include headaches, diarrhoea, nausea (H2 RAs and PPIs) and constipation (PPIs). Acid suppression may place immune-deficient infants and children, or those with indwelling catheters, at risk for the development of lower respiratory tract infections and nosocomial sepsis. Prokinetic agents have many adverse effects, without major benefits to support their routine use.

Guidelines for feeding very low birth weight infants

Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.

[Knowledge and practice of Brazilian pediatricians concerning gastroesophageal reflux disease in infants]

OBJECTIVE

To assess the knowledge and practice of pediatricians about infants with physiological reflux and gastroesophageal reflux disease.

METHODS

140 pediatricians were interviewed during two scientific events in 2009 and 2010. The questions referred to two clinical cases of infants. One with symptoms of infant regurgitation (physiological reflux) and another with gastroesophageal reflux disease.

RESULTS

Among 140 pediatricians, 11.4% (n=16) and 62.1% (n=87) would require investigation tests, respectively for infant regurgitation (physiological reflux) and gastroesophageal reflux disease. A series of upper gastrointestinal exams would be the first requested with a higher frequency. Medication would be prescribed by 18.6% (n=26) in the case of physiological reflux and 87.1% (n=122) in the case of gastroesophageal reflux disease. Prokinetic drugs would be prescribed more frequently than gastric acid secretion inhibitors. Sleeping position would be recommended by 94.2% (n=132) and 92.9% (n=130) of the respondents, respectively for the case of physiological reflux and gastroesophageal reflux disease; however, about half of the respondents would recommend the prone position. Only 10 (7.1%) of the pediatricians would exclude the cow's milk protein from the infants' diet.

CONCLUSIONS

Approaches different from the international guidelines are often considered appropriate, especially when recommending a different position other than the supine and prescription of medication. In turn, the interviews enable us to infer the right capacity of the pediatricians to distinguish physiologic reflux and gastroesophageal reflux disease correctly.

Cardiac safety concerns for domperidone, an antiemetic and prokinetic, and galactogogue medicine

INTRODUCTION

Domperidone is a dopamine D2-receptor antagonist developed as an antiemetic and prokinetic agent. Oral domperidone is not approved in the United States, but it is used in many countries to treat nausea and vomiting, gastroparesis and as a galactogogue (to promote lactation). The US Food and Drug Administration (FDA) have issued a warning about the cardiac safety of domperidone.

AREAS COVERED

The authors undertook a review of the cardiac safety of oral domperidone.

EXPERT OPINION

The data from preclinical studies are unambiguous in identifying domperidone as able to produce marked hERG channel inhibition and action potential prolongation at clinically relevant concentrations. The compound's propensity to augment instability of action potential duration and action potential triangulation are also indicative of proarrhythmic potential. Domperidone should not be administered to subjects with pre-existing QT prolongation/LQTS, subjects receiving drugs that inhibit CYP3A4, subjects with electrolyte abnormalities or with other risk factors for QT-prolongation. With these provisos, it is possible that domperidone may be used as a galactogogue without direct risk to healthy breast feeding women, but more safety information should be sought in this situation. Also, more safety information is required regarding risk to breast feeding infants before domperidone is routinely used in gastroparesis or gastroesphageal reflux in children.

Effect of Chenxiang Huaqi Capsules on interstitial cells of Cajal and myenteric plexus in the intestine of diabetic rats

AIM: To explore the protection of Chenxiang Huaqi Capsules against the impairment of interstitial cells of Cajal (ICC) and myenteric plexus in the intestine of diabetic rats.

METHODS: Healthy male SD rats were randomly divided into three groups: control group, diabetes mellitus (DM) group, and DM + Chinese herb group (DM + CH group). DM was induced in rats by a single intraperitoneal injection of streptozotocin (STZ, 60 mg/kg). The DM + CH group was given herb 15.75 g/(kg•d), while the DM group and control group were given equal volumes of distilled water. Four weeks after intervention, all rats were given Indian ink by lavage for determining the small intestinal transit rate. The expression of c-Kit, synaptophysin, and PGP9.5 was studied by immunohistochemistry and quantified using an image analyzer.

RESULTS: Four weeks after treatment, the small intestine transit rate was increased obviously in the DM + CH group compared to the DM group (71.26 ± 5.22 vs 45.52 ± 6.42, P < 0.01), but was still lower than that in the control group (71.26 ± 5.22 vs 80.40 ± 7.33, P < 0.05). The total area and mean optical density value of c-Kit-positive products in the myenteric plexus were significantly increased in the DM + CH group compared to the DM group (443.28 ± 24.40 vs 358.83 ± 35.03, P < 0.01; 0.16 ± 0.02 vs 0.13 ± 0.02, P < 0.01), but were still lower than those in the control group (443.28 ± 24.40 vs 557.28 ± 42.35, P < 0.01; 0.16 ± 0.02 vs 0.18 ± 0.02, P < 0.05). Similar results were also obtained for synaptophsin- and PGP9.5-positive products.

CONCLUSION: Chenxiang Huaqi Capsules may improve intestinal motility by partially reversing abnormal changes in the intestinal ICC and expression of c-Kit, synaptophysin and PGP9.5 in diabetic rats.

Pharmacokinetic interaction between domperidone and ketoconazole leads to QT prolongation in healthy volunteers: a randomized, placebo-controlled, double-blind, crossover study

AIMS

To assess the steady-state pharmacokinetic and QT(c) effects of domperidone and ketoconazole, given alone and together.

METHODS

A randomized, placebo-controlled, double-blind, crossover study was carried out. Healthy subjects (14 men, 10 women; age 18-39 years; mean weight 73.5kg, range 53.8-98.8kg; 23 Europid, 1 Afro-Caribbean) received orally, for 7 days each, placebo, domperidone 10mg, four doses daily, at 4h intervals, ketoconazole 200mg 12-hourly and domperidone and ketoconazole together. The washout period was 15 days. Pharmacokinetics and serial 12-lead ECGs were assessed on day 7, and serial ECGs on day -1 and at follow-up. Two subjects withdrew before the third treatment period, so data were available for 22-24 subjects. RESULTS Ketoconazole tripled domperidone concentrations at steady-state. Domperidone, ketoconazole and their combination significantly increased QT(c) F in men. Overall adjusted mean differences from placebo were 4.20 (95% CI 0.77, 7.63), 9.24 (95% CI 5.85, 12.63) and 15.90 (95% CI 12.47, 19.33) ms, respectively. In women, QT(c) F was not significantly different from placebo on either domperidone or ketoconazole alone, or in combination. However, QT(c) was positively correlated with plasma drug concentrations, in both men and women. ΔQT(c) F increased by about 2ms per 10ngml(-1) rise in domperidone concentration, and per 1µgml(-1) rise in ketoconazole concentration.

CONCLUSIONS

Ketoconazole tripled the plasma concentrations of domperidone. Domperidone and ketoconazole increased QT(c) F in men, whether given together or separately. The effect of domperidone alone was below the level of clinical importance. The negative result in women is unexplained.

Effects of domperidone on QTc interval in infants

AIM

To prospectively evaluate the effects of oral domperidone on the QTc interval in infants.

METHODS

Infants (0-1 year) with a diagnosis of gastro-oesophageal reflux (GOR) disease were included. A 12-lead electrocardiography (ECG) was performed in all infants at baseline and 1 h after the intake of domperidone after 7-14 days; the corrected QTc interval was calculated by one investigator (MV) according to Bazett's formula.

RESULTS

Forty-five infants were enrolled in this study. The mean gestational age was of 38.6 weeks (35.5-42.0), and the mean age at the start of domperidone was 75.3 days (19-218 days). No statistically significant difference in corrected QTc was observed between baseline and the second ECG (0.389 ± 0.02 vs. 0.397 ± 0.31; p 0.130)). A trend was observed regarding gender: Although there was no difference in QTc change in girls (p 0.622), there was a strong trend in boys (p 0.051). Two infants (both boys) had a clinically significant QTc prolongation (> 460 msec) without symptoms. The Spearman correlation test showed no relation between the QTc change and age (r: -0.05822; p 0.7284). There was no relation between domperidone dosage and QTc change.

CONCLUSION

Overall, the group-analysis showed no statistical significant difference in QTc duration induced by domperidone. However, 2/45 (4.4%) infants had a prolonged QTc interval (> 460 msec) induced by domperidone. As a consequence, QTc measurement should be recommended in routine in infants when domperidone is started.

Domperidone treatment for gastroparesis: demographic and pharmacogenetic characterization of clinical efficacy and side-effects

BACKGROUND

Domperidone is a useful alternative to metoclopramide for treatment of gastroparesis due to better tolerability. Effectiveness and side-effects from domperidone may be influenced by patient-related factors including polymorphisms in genes encoding drug-metabolizing enzymes, drug transporters, and domperidone targets.

AIMS

The aim of this study was to determine if demographic and pharmacogenetic parameters of patients receiving domperidone are associated with response to treatment or side-effects.

METHODS

Patients treated with domperidone for gastroparesis provided saliva samples from which DNA was extracted. Fourteen single-nucleotide polymorphisms (SNPs) in seven candidate genes (ABCB1, CYP2D6, DRD2, KCNE1, KCNE2, KCNH2, KCNQ1) were used for genotyping. SNP microarrays were used to assess single-nucleotide polymorphisms in the ADRA1A, ADRA1B, and ADRA1D loci.

RESULTS

Forty-eight patients treated with domperidone participated in the study. DNA was successfully obtained from each patient. Age was associated with effectiveness of domperidone (p=0.0088). Genetic polymorphism in KCNH2 was associated with effectiveness of domperidone (p=0.041). The efficacious dose was associated with polymorphism in ABCB1 gene (p=0.0277). The side-effects of domperidone were significantly associated with the SNPs in the promoter region of ADRA1D gene.

CONCLUSIONS

Genetic characteristics associated with response to domperidone therapy included polymorphisms in the drug transporter gene ABCB1, the potassium channel KCNH2 gene, and α1D--adrenoceptor ADRA1D gene. Age was associated with a beneficial response to domperidone. If verified in a larger population, this information might be used to help determine which patients with gastroparesis might respond to domperidone and avoid treatment in those who might develop side-effects.