Intravenous and oral lansoprazole are equivalent in suppressing stimulated acid output in patient volunteers with erosive oesophagitis

Drug-Encapsulated Cyclodextrin Nanosponges

To date, a number of nanocarriers, either inorganic or organic, have been developed to improve the delivery and therapeutic efficacy of various drugs. Drug delivery systems have attempted to overcome the undesirable pharmacokinetic problems encountered. Among the various nanomaterials that have been designed as potential nanocarriers, cyclodextrin-based polymers are of particular interest in this review.Cyclodextrins (CD) are a class of cyclic glucopyranose oligomers, obtained from starch by enzymatic action, with a characteristic toroidal shape that forms a truncated cone-shaped lipophilic cavity. The main common native cyclodextrins are named α, β, and γ which comprise six, seven, and eight glucopyranose units, respectively. Cyclodextrins have the capability to include compounds whose size and polarity are compatible with those of their cavity.Cyclodextrin-based cross-linked polymers, often referred to as "cyclodextrin nanosponges" (CDNSs), attract great attention from researchers for solving major bioavailability problems such as inadequate solubility, poor dissolution rate, and limited stability of some agents, as well as increasing their effectiveness and decreasing unwanted side effects.Registered patents about this novel system in various fields, different pharmaceutical applications, and classes of drugs encapsulated by CDNSs are detailed. The features outlined make CDNSs a promising platform for the development of innovative and advanced delivery systems.

Inhibitory effects of intravenous lansoprazole 30 mg and pantoprazole 40 mg twice daily on intragastric acidity in healthy Chinese volunteers: a randomized, open-labeled, two-way crossover study

BACKGROUND

Until now there has been no study that directly compares the effect of lansoprazole and pantoprazole administered intravenously on intragastric acidity. The aim of this study is to compare the effect of lansoprazole (30 mg) and pantoprazole (40 mg) administered intravenously on gastric acidity.

MATERIAL/METHODS

Helicobacter pylori-negative healthy volunteers were recruited in this open-label, randomized, two-way crossover, single centre study. Lansoprazole at 30 mg or pantoprazole at 40 mg was intravenously administered twice daily for 5 consecutive days with at least a 14-day washout interval. Twenty-four-hour intragastric pH was continuously monitored on days 1 and 5 of each dosing period.

RESULTS

Twenty-five volunteers completed the 2 dosing periods. The mean intragastric pH values were higher in subjects treated with lansoprazole than those with pantoprazole on both day 1 (6.41 ± 0.14 vs. 5.49 ± 0.13, P=0.0003) and day 5 (7.09 ± 0.07 vs. 6.64 ± 0.07, P=0.0002). Significantly higher percentages of time with intragastric pH >4 and pH >6 were found in the subjects treated with lansoprazole than those with pantoprazole on day 1 (pH >4, 87.12 ± 4.55% vs. 62.28 ± 4.15%, P=0.0012; pH >6, 62.12 ± 4.12% vs. 47.25 ± 3.76%, P=0.0216) and pH >6 on day 5 (76.79 ± 3.77% vs. 58.20 ± 3.77%, P=0.0025).

CONCLUSIONS

Intravenous lansoprazole produces a longer and more potent inhibitory effect on intragastric acidity than does intravenous pantoprazole.

Safety of proton pump inhibitor exposure

Proton pump (H(+)/K(+)-adenosine triphosphatase) inhibitors (PPIs) are widely used to treat patients with acid-related disorders because they are generally perceived to be safe and effective. However, as with any pharmacologic agent, they have the potential for side effects. Many studies have examined the side effects of long-term or short-term PPI exposure. We review the mechanism of action of PPIs, focusing on recently released products that might have greater risks of adverse effects than older products because of increased potency and/or duration of action. We summarize the data available on the putative adverse effects of PPI therapy and propose guidelines for clinicians who prescribe these agents to limit the potential for adverse outcomes in users of these effective therapeutic agents.

A clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers

Intravenous (IV) proton-pump inhibitors (PPIs) are potent gastric acid suppressing agents, and their use is popular in clinical practice. Both IV and oral PPIs have similarly short half-lives, and their effects on acid secretion are similar, thus their dosing and dosage intervals appear to be interchangeable. The possible exception is when sustained high pHs are required to promote clot stabilization in bleeding peptic ulcers. Continuous infusion appears to be the only form of administration that reliably achieves these high target pHs. IV PPI is indicated in the treatment of high-risk peptic ulcers, complicated gastroesophageal reflux, stress-induced ulcer prophylaxis, Zollinger-Ellison syndrome, and whenever it is impossible or impractical to give oral therapy. The widespread use of PPIs has been controversial. IV PPIs have been linked to the development of nosocomial pneumonia in the intensive care setting and to spontaneous bacterial peritonitis in cirrhotic patients. This review discusses the use of IV PPI in different clinical scenarios, its controversies, and issues of appropriate use.

Lansoprazole for long-term maintenance therapy of erosive esophagitis: double-blind comparison with ranitidine

In a study evaluating the efficacy and safety of lansoprazole to prevent the relapse of erosive esophagitis (EE), 206 of 241 patients (85%) healed after open-label treatment with lansoprazole 30 mg once daily for 8 weeks and received double-blind maintenance treatment with lansoprazole 15 mg once daily or ranitidine 150 mg twice daily for up to 1 year. At 1 year, 67% of lansoprazole-treated and 13% of ranitidine-treated patients remained healed (P<0.001). Lansoprazole-treated patients experienced significantly greater symptom relief (P<0.001), and, if asymptomatic at entry into the maintenance phase, remained asymptomatic for significantly longer than ranitidine-treated patients (P<0.001). Symptom status correlated with healing (P=0.001), supporting the symptom-directed management of EE. Both treatments were well tolerated and no unexpected events occurred. Daily therapy with lansoprazole to prevent the relapse of EE is effective, well tolerated, and superior to ranitidine in the maintenance of healing and symptom relief.

The role of proton pump inhibitors in the treatment of Zollinger-Ellison syndrome

Zollinger-Ellison syndrome is characterised by refractory peptic ulcer disease, diarrhoea and gastric acid hypersecretion associated with a gastrin-secreting tumour. The incidence is unknown, but, in the US, the frequency is 0.1-3.0 million people. Zollinger-Ellison syndrome is associated with multiple endocrine neoplasia type 1 in 25-35% of the cases. The diagnosis of Zollinger-Ellison syndrome is suggested when plasma gastrin is > 1000 pg/ml and the basal acid output is > 15 mEq/h or when associated with a pH < 2. The treatment is focused on controlling gastric acid hypersecretion and localisation of the tumour and its metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered at high dosages. This review focuses on the role of the proton pump inhibitors in the management of gastric acid hypersecretion in Zollinger-Ellison syndrome.

Lansoprazole regimens that sustain intragastric pH > 6.0: an evaluation of intermittent oral and continuous intravenous infusion dosages

BACKGROUND

Orally and intravenously administered proton pump inhibitors have been shown to reduce rebleeding rates, surgery and transfusion requirement.

AIM

To compare lansoprazole intravenous and orally disintegrating tablet (Prevacid SoluTab) regimens with a pantoprazole intravenously administered regimen in sustaining intragastric pH >6.0.

METHODS

Two similarly designed three-way, randomized crossover studies each enrolled 36 Helicobacter pylori-negative healthy volunteers. Study 1 regimens included intravenously administered bolus followed by 24-h continuous infusion (lansoprazole 90 mg, 6 mg/h; lansoprazole 120 mg, 6 mg/h; pantoprazole 80 mg, 8 mg/h). Study 2 regimens included intravenous bolus followed by lansoprazole orally disintegrating tablet or intravenous continuous infusion for 24 h (lansoprazole 90 mg, lansoprazole orally disintegrating tablet 60 mg every 6 h; lansoprazole 120 mg, 9 mg/h; pantoprazole 80 mg, 8 mg/h). Percentage of time pH >6.0 was assessed with 24-h intragastric pH monitoring.

RESULTS

All regimens produced comparable gastric acid suppression. In both studies, regimens superior to pantoprazole included lansoprazole 90 mg, 6-mg/h; lansoprazole 90 mg, lansoprazole orally disintegrating tablet 60 mg q.d.s. and lansoprazole 120 mg, 9 mg/h (P < or = 0.013). The lansoprazole 120-mg, 6-mg/h regimen (P = 0.082) was not superior to pantoprazole in percentage of time intragastric pH >6.0. Mild reaction at the intravenous injection site was the most frequently reported adverse event.

CONCLUSIONS

The intravenous bolus and continuously infused lansoprazole or intravenous bolus and intermittent lansoprazole orally disintegrating tablet regimens are as effective as intravenous pantoprazole in sustaining intragastric pH >6.0.

Comparison of the effects of intravenously and orally administered esomeprazole on acid output in patients with symptoms of gastro-oesophageal reflux disease

BACKGROUND

Intravenous esomeprazole may be beneficial for patients who cannot take oral medications.

AIM

To compare intravenous esomeprazole with oral esomeprazole for effects on maximal acid output during pentagastrin stimulation in patients with gastro-oesophageal reflux disease symptoms.

METHODS

In four separate open-label, randomized, two-way crossover studies, adult patients were administered esomeprazole 20 or 40 mg once daily either orally or intravenously (by 15-min infusion or 3-min injection) for 10 days and switched to the other formulation with no washout period. Basal acid output and maximal acid output were measured on days 11, 13 and 21.

RESULTS

In the four studies (total of 183 patients), least-squares mean maximal acid output ranged from 3.0 to 4.1 mmol/h after intravenous esomeprazole 40 or 20 mg and from 2.2 to 3.3 mmol/h after oral esomeprazole 20 or 40 mg. Differences between formulations were small and not statistically significant but did not meet the prospectively defined criterion for non-inferiority of the intravenous formulation. Median basal acid output values ranged from 0.04 to 0.27 mmol/h after intravenous administration and from 0.05 to 0.25 mmol/h after oral esomeprazole.

CONCLUSIONS

Intravenous esomeprazole is an acceptable alternative to the oral formulation for treatment of up to 10 days of duration.

Proton pump inhibitor formulary considerations in the acutely ill. Part 2: Clinical efficacy, safety, and economics

OBJECTIVE

To review, using an evidence-based approach, the clinical efficacy, safety, and cost-effectiveness of proton pump inhibitors (PPIs) for treatment of common acid peptic disorders in the acutely ill and provide clinicians with guidance when making hospital formulary decisions with this class of agents.

DATA SOURCES

MEDLINE (1966-May 2005) and the Cochrane Library databases were searched using the key words proton pump inhibitor, acid suppression, peptic ulcer disease, gastrointestinal bleeding, stress ulcer prophylaxis, critical care, safety, and cost-effectiveness. Bibliographies of cited references were reviewed, and a manual search of abstracts from recent gastroenterology, critical care, and surgery scientific meetings was completed.

STUDY SELECTION AND DATA EXTRACTION

All articles identified from the data sources were evaluated, and all information deemed relevant was included for this review.

DATA SYNTHESIS

PPIs have become a mainstay for acute acid suppression in hospitalized patients. Various commercially available PPI products are available either enterally or parenterally for administration to patients unable to swallow a tablet or capsule. The results of studies comparing the clinical efficacy of different PPI dosage forms and routes of administration, safety considerations, and cost-effectiveness analyses are among the factors to consider when making formulary decisions for this class of drugs.

CONCLUSIONS

While the introduction of new PPI products has expanded the therapeutic options for acid suppression in acutely ill patients, a number of unresolved questions remain surrounding the interchangeability of these products, the clinical significance of one PPI formulation over the other, and how oral/enteral therapy should be used as step-down therapy after parenteral therapy.

Proton pump inhibitors for acid suppression in the intensive care unit: Formulary considerations

PURPOSE

The rationale for limiting the proton pump inhibitor (PPI) products included in an institutional formulary, factors to consider when making formulary decisions about PPI products, the results and limitations of cost-effectiveness analyses of PPI therapy in critically ill patients, the role of clinical practice guidelines in improving PPI use in the intensive care setting, and how these guidelines can be developed are discussed.

SUMMARY

Therapeutic interchange may make it possible to limit the number of PPI products included in the formulary and reduce costs without compromising the efficacy or safety of drug therapy. The results of studies comparing the pharmacokinetics, pharmacodynamics, and efficacy of different PPI dosage forms and routes of administration; practical considerations; safety; and costs are among the factors to consider when making formulary decisions. Some of the newer oral PPI products offer advantages over older ones in improved palatability and ease of preparation, storage, and administration. The cost-effectiveness of intravenous (i.v.) PPIs for preventing the recurrence of peptic ulcer bleeding has been demonstrated, but the cost-effectiveness of oral therapy for this indication and both oral and i.v. therapy for preventing stress-related mucosal bleeding has not been well established.

CONCLUSION

Intravenous PPIs are cost-effective for patients at risk for the recurrence of peptic ulcer bleeding. The introduction of new oral PPI products that can be administered as a suspension has expanded the therapeutic options for critically ill patients. The use of clinical practice guidelines can optimize the use of PPIs in the intensive care setting.