Challenges in drug development for functional gastrointestinal disorders. Part I: functional dyspepsia

Routine assessment of gastrointestinal symptom using a validated questionnaire in the clinical setting to assess the probability of organic or functional gastrointestinal diseases

BACKGROUND

Patients presenting with gastrointestinal symptoms can be challenging in terms of determining etiology and management strategies. Identifying likely organic pathology is important since it can be treated and may result in further, long-term harm to the patient if not treated. Currently, organic pathology is often identified via invasive procedures such as endoscopy or referral to a medical imaging service. We report on an approach that offers a first step at identifying patients with an organic gastrointestinal disease based on the SAGIS, a validated symptom questionnaire.

METHODS

8,922 patients referred to a tertiary care hospital were classified as having either functional gastrointestinal disease or an organic gastrointestinal disease. A model was developed to distinguish organic from functional symptoms on one random split half of the sample and validated on the other half. The incremental benefit of including psychological conditions and extra-gastrointestinal conditions was also evaluated.

KEY RESULTS

Functional gastrointestinal patients scored higher on average than organic patients on all dimensions of the SAGIS and reported higher rates of psychological and extra-gastrointestinal conditions. All five dimensions of the SAGIS provided statistically independent discrimination of organic from functional diagnoses with good overall discrimination (AUC = 0.75). However, there was no noticeable incremental benefit of adding either psychological or extra-gastrointestinal conditions. Model performance was highly reproducible.

CONCLUSIONS AND INFERENCES

The proposed algorithm for identifying likely organic gastrointestinal disease applied to symptoms as recorded in the SAGIS questionnaire provides a useful tool for the clinician in deciding what or if further diagnostic testing is required.

Development and validation of a high throughput UPLC-MS/MS method for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma

A high throughput ultra pressure liquid chromatography–mass spectrometry (UPLC–MS/MS) method with good sensitivity and selectivity has been developed and validated for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma using lansoprazole as internal standard (IS). The extraction method based on liquid–liquid extraction technique was used to extract the analytes and IS from of 50 µL of human plasma using methyl tert-butyl ether:ethyl acetate (80:20, v/v), which offers a high recovery. Chromatographic separation of analytes and IS was achieved on a Hypersil gold C₁₈ column using gradient mobile phase consisting of 2 mM ammonium formate/acetonitrile. The flow rate was set at 0.5 mL/min to elute all the analytes and IS within 1.00 min runtime. Detection of target compounds was performed on a triple quadruple mass spectrometer by multiple reaction monitoring (MRM) mode via positive electrospray ionization (ESI). Method validation results demonstrated that the developed method has good precision and accuracy over the concentration ranges of 0.1–2000 ng/mL for each analyte. Stability of compounds was established in a battery of stability studies, i.e., bench top, autosampler, dry extract and long-term storage stability as well as freeze-thaw cycles. The validated method has been successfully applied to analyze human plasma samples for application in pharmacokinetic studies.

Effectiveness and safety of levosulpiride in the treatment of dysmotility-like functional dyspepsia

The objective of this study was to assess the effectiveness and safety of levosulpiride in patients with dysmotility-like functional dyspepsia including nonerosive reflux esophagitis in conditions of daily practice. The study was conducted as a prospective, open-label, multicenter design in 342 patients with dysmotility-like functional dyspepsia (n=279) and nonerosive reflux disease (n=63), who received levosulpiride 25 mg 3 times daily orally for 4 weeks. Individual symptoms (pain/discomfort, fullness, bloating, early satiety, pyrosis, regurgitation, and nausea/vomiting) and a global symptom score were assessed at 15, 30, and 60 days after starting treatment. Adverse events also were recorded. There were 151 men and 191 women (mean age 38.8 years) who referred dyspeptic symptoms for a mean of 10.2 (10.7) months. A total of 66.4% patients were treated with 75 mg/day levosulpiride and 33.6% with 50 mg/day. At the 15-day visit, a decrease greater than 50% in the global symptom score was observed. The frequency and intensity of individual symptoms showed a statistically significant decrease (p<0.001) at all visits compared with baseline. At the 30-day visit, all symptoms had almost disappeared, a trend that was maintained until the last visit. Treatment with levosulpiride was well tolerated and only 40 adverse events were recorded (galactorrhea 26.7%, somnolence 17.8%, fatigue 11.1%, headache 11.5%) and no patient had to abandon the study due to side effects. In conclusion, levosulpiride is an effective and safe drug in the treatment of dysmotility-like functional dyspepsia and non-erosive reflux disease.

Gastric emptying of solids is slower in functional dyspepsia unrelated to Helicobacter pylori infection in female children and teenagers

AIM

To evaluate gastric emptying of solids in children and adolescents with functional dyspepsia with and without Helicobacter pylori infection.

PATIENTS AND METHODS

The study included 27 female patients (mean age 13.38 +/- 2.81 y) with functional dyspepsia according to Rome II criteria who were selected after upper gastrointestinal endoscopy found no major mucosal abnormality. Fragments were collected from the esophagus, gastric antrum, and gastric body for histological examination and rapid urease test. H. pylori infection was diagnosed according to the rapid urease test and histological appearance. The histological appearance of the gastric mucosa was evaluated according to modified Sydney criteria. A C-octanoic breath test was performed after a test meal (2 slices of toasted bread, 10 g margarine, and 1 egg with 100 microL of the tracer dipped in the yolk) with 13 points of air collection in 4 hours.

RESULTS

Infection with H. pylori was observed in 12 of 27 patients (44.4%). The gastric emptying half-time was shorter in infected patients than in uninfected patients (mean +/- SD 153.4 +/- 20.0 min vs 179.2 +/- 32.2 min; P = 0.019), as was the lag phase (106.3 +/- 22.6 vs 126.6 +/- 22.7 min; P = 0.038). There was no relationship between gastric emptying (half-time and lag phase) and degree of histological abnormality. Vomiting and nausea were associated with slower gastric emptying in patients without H. pylori gastritis more often than in infected patients.

CONCLUSIONS

The study suggests that delayed gastric emptying can play an important role in a subgroup of dyspeptic patients, particularly those without H. pylori infection who have nausea and vomiting.