Effects on 24-hour intragastric pH: a comparison of lansoprazole administered nasogastrically in apple juice and pantoprazole administered intravenously

Pharmacokinetics and Pharmacodynamics of Lansoprazole/Sodium Bicarbonate Immediate-release Capsules in Healthy Chinese Subjects: An Open, Randomized, Controlled, Crossover, Single-, and Multiple-dose Trial

Proton pump inhibitors (PPIs) differ in onset of action and bioavailability. This trial was conducted to investigate the pharmacokinetics and pharmacodynamics of an immediate-release capsule formulation containing lansoprazole 30 mg and sodium bicarbonate 1100 mg (T preparation) in healthy Chinese subjects. This was an open, single-center, randomized, single and multiple oral doses, and two-period crossover study in 30 healthy subjects. After single- and multiple-dose oral administration, blood samples were obtained and lansoprazole concentration in serum was measured for pharmacokinetic analysis. Meanwhile, the intragastric pH was monitored continuously to evaluate the pharmacodynamics of the investigational drugs. The Tmax of the T preparation was 0.5 hours, while the Tmax of the R preparation was 1.5 hours after multiple doses, which indicated that the absorption speed of the T preparation was significantly faster than that of the R preparation. The same characteristics also existed after single-dose administration. The area under the curve (AUC)ss of the T preparation was bio-equivalent to that of the R preparation under steady state. The time percentage of intragastric pH > 4.0 for the T preparation was higher than that of the R preparation after 1 hour for both single- and multiple-dose. It suggested compared with R preparation, the time percentage of intragastric pH > 4.0 met the criteria for superiority after 1 hour administration for the T preparation. In addition, no serious adverse events occurred in this study. Across this study, the T preparation was better than the R preparation at improving drug absorption and increasing intragastric pH, and had a favorable safety profile.

A systematic approach for assessing the suitability of enteral feeding tubes for the administration of controlled-release pellet formulations

Enteral nutrition plays an important role for patients who are unable to properly swallow food. In such patients, enteral feeding tubes are often used, through which food, but often also oral medications, are administered. However, this can pose the risk of tube clogging. Compared to the administration of crushed tablets, multiparticulate dosage forms are often considered easier to administer and furthermore have the advantage of enabling the administration of even controlled-release preparations. The objective of this systematic study was to identify tube- and formulation-related factors that contribute to successful administration of coated pellet formulations via a variety of commercially available feeding tube devices. The suitability of enteral feeding tubes for the administration of controlled-release pellet formulations that differed in size and type of starter core and functional coating was investigated in a stepwise approach using a novel in vitro setup. Results of the study indicate that pellet diameter and inner diameter of the feeding tube are by no means reliable parameters for estimating the tube's suitability for pellet administration, but that many other tube and formulation-related factors and combinations thereof must be considered to ensure safe and effective drug administration via enteral feeding tubes.

A new strategy for the synthesis of pyridines from N-propargylic β-enaminothiones

A new robust method for the synthesis of 2,4,5-trisubstituted pyridines with high efficiency and broad functional group tolerance is described.

Evaluation of Different Lansoprazole Formulations for Nasogastric or Orogastric Administration

Background

Critically ill patients who require treatment with proton pump inhibitors are often unable to swallow solid dosage forms and have nasogastric (NG) or orogastric (OG) tube placement. Many of these patients will need medications in a liquid dosage form for easy administration. The aim of this study was to determine which extemporaneous preparation of lansoprazole is least likely to cause NG or OG tube blockage.

Methods

Lansoprazole capsules, oral disintegrating tablets, and packets were each dissolved in apple juice, cranberry juice, orange juice, ginger ale, water, and 8.4% sodium bicarbonate (NaHCO3). The resulting suspension was individually passed through an 18-French NG tube and collected in a graduated cylinder. The tubes were then inspected for clots. The amount of drug retrieved from the cylinder was rated as none, partial, or complete. The physical consistency and pH changes of the suspension were assessed for stability at 0, 2, 5, 10, and 15 minutes.

Results

Complete drug retrieval and no clots were observed when any of the lansoprazole dosage forms were mixed with 8.4% NaHCO3or when the disintegrating tablet was mixed in any of the solutions. The pH of each admixture remained fairly constant over 15 minutes, but the packet-in-water combination showed a significant lowering in pH immediately after mixing.

Conclusion

The use of NaHCO3to make suspension for any lansoprazole formulation is associated with the least likelihood of tube blockage or pH variations. Thus, it may be the preferred delivery vehicle for NG/OG administration of lansoprazole, unless the Solutab is available.

Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression

BACKGROUND

The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications.

METHODS

The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence.

RESULTS

Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile.

CONCLUSIONS

Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .

Facile synthesis of heavily-substituted alkynylpyridines via a Sonogashira approach

A robust synthesis of highly-substituted alkynylpyridines via a Sonogashira approach is described, providing a library of functionalized pyridines for biological studies.

Off-Label Use of Gastrointestinal Medications in the Intensive Care Unit

Purpose:

Determine the level of evidence supporting off-label gastrointestinal (GI) medication use and identify the medication class and indication whereby off-label use was most common.

Materials and Methods:

This prospective, multicentered observational study evaluated all medication orders written in 37 intensive care units (ICUs) in the United States, over a 24-hour period. All medications classified as “GI” according to a national reference were identified. The class and indication whereby off-label use was most prominent were determined and the level of evidence was described.

Results:

There were 774 orders from 363 patients and 63% (489 of 774) were considered off-label. Proton pump inhibitors (PPIs) accounted for most of the off-label usage (55% [271 of 489]), followed by laxatives (16% [77 of 489]) and histamine-2-receptor antagonists (H2RAs; 15% [71 of 489]). When prescribed, 99% (271 of 274) of PPIs, 99% (71 of 72) of H2RAs, and 79% (30 of 38) of promotility agents were off-label. Stress ulcer prophylaxis (100% [309 of 309]), GI bleeding (100% [18 of 18]), and gastric motility (88% [30 of 34]) were the most common off-label indications. The most common strength of recommendation and level of evidence for off-label use was indeterminate (58% [282 of 489]) and none (57% [280 of 489]), respectively.

Conclusion:

The PPIs are the most widely used off-label medications in the ICU. Stress ulcer prophylaxis is the most common indication. The level of evidence supporting off-label GI medication use is poor.

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.

Use of clinical simulation centers in health professions schools for patient-centered research

INTRODUCTION

Professional practice assessment research performed in clinical simulation centers is a research method that also creates opportunity for multidisciplinary investigator collaboration.

METHODS

Nursing and pharmacy school clinical simulation laboratories at the University of Utah were used to conduct time-and-motion (TM) studies of medication dispensing and administration. Time data were then used to determine personnel and supply costs associated with different medication dosage forms and delivery methods. A case study from a completed research project describes the use of TM and activity-based costing analyses to assess medication preparation and administration time and cost differences related to three proton pump inhibitor dosage forms. Standardized doses were prepared by pharmacists or technicians and subsequently administered by nurses to a mannequin in the simulation center by seven different administration scenarios. Simulation scenarios were developed in a manner that held the independent variables constant, so that time and cost differences between dosage forms and administrations methods could be quantified.

RESULTS

A detailed example of one approach to use of simulation centers for TM studies and activity-based costing analyses is provided. The advantages of isolating processes of interest from the day-to-day complexity of patient care are shown. Results illustrate how simulations based on professional school simulation centers may be used to assess health care processes at the microlevel with potential for projection to the macrolevel.

CONCLUSIONS

Studies based on health professional schools simulation centers may offer a novel method of evaluating health care processes at the microlevel.

Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer

BACKGROUND AND AIMS

After successful endoscopic hemostasis in bleeding peptic ulcer, addition of proton pump inhibitors reduce the rate of recurrent bleeding by maintaining intragastric pH at neutral level. The aim of the present study was to evaluate the effect of various proton pump inhibitors given through different routes on intragastric pH over 72 h after endoscopic hemostasis in bleeding peptic ulcer.

METHODS

Ninety consecutive patients who had successful endoscopic therapy of bleeding peptic ulcer underwent 72-h continuous ambulatory intragastric pH study, were randomly assigned to receive p.o. omeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg omeprazole followed by infusion 8 mg/h for 72 h. Oral pantoprazole 80 mg bolus followed by 80 mg every 12 h for 72 h or i.v. 80 mg pantoprazole followed by infusion of 8 mg/h for 72 h. Oral rabeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg rabeprazole followed by infusion 8 mg/h for 72 h. Five patients received no treatment after successful endoscopic therapy and underwent 72-h pH study.

RESULTS

Mean 72-h intragastric pH for p.o. omeprazole was 6.56 versus 6.93 for omeprazole infusion (P = 0.48). Mean 72-h intragastric pH for p.o. pantoprazole was 6.34 versus 6.32 for pantoprazole infusion (P = 0.62). Mean 72-h intragastric pH for rabeprazole p.o. was 6.11 versus 6.18 rabeprazole i.v. (P = 0.55). Mean 72-h pH for the no proton pump inhibitor group was 2.04.

CONCLUSION

There was no significant difference among various proton pump inhibitors given through different routes on raising intragastric pH above 6 for 72 h after successful endoscopic hemostasis in bleeding peptic ulcer.

Relative potency of proton-pump inhibitors-comparison of effects on intragastric pH

AIM

Comparative potency of proton-pump inhibitors (PPIs) is an important clinical issue. Most available trials have compared the different PPIs at one or a few selected specific dosages, making it difficult to derive quantitative equivalence dosages. Here we derived PPI dose equivalents based on a comprehensive assessment of dose-dependent effects on intragastric pH.

METHODS

All available clinical studies reporting the effects of PPIs on mean 24-h intragastric pH were sought from electronic databases including Medline. Studies included were restricted to those targeting the Caucasian population, and healthy volunteers or gastroesophageal reflux disease (GERD) patients. The dose-effect relationships for mean 24-h intragastric pH and for percentage of time with pH > 4 in 24 h were analyzed for each PPI using pharmacodynamic modeling with NONMEM and a model integrating all available data.

RESULTS

Fifty-seven studies fulfilled the inclusion criteria. Based on the mean 24-h gastric pH, the relative potencies of the five PPIs compared to omeprazole were 0.23, 0.90, 1.00, 1.60, and 1.82 for pantoprazole, lansoprazole, omeprazole, esomeprazole, and rabeprazole, respectively. Compared with healthy volunteers, patients with GERD needed a 1.9-fold higher dose and Helicobacter pylori-positive individuals needed only about 20% of the dose to achieve a given increase in mean 24-h intragastric pH.

CONCLUSION

The present meta-analysis provides quantitative estimates on clinical potency of individual PPIs that may be helpful when switching between PPIs and for assessing the cost-effectiveness of specific PPIs. However, our estimates must be viewed with caution because only a limited dose range has been tested and not exactly the same study conditions were applied for the different substances.

Comparison of the enteral and intravenous lansoprazole pharmacodynamic responses in critically ill patients

BACKGROUND

While proton pump inhibitors are frequently administered in the intensive care unit, the pharmacodynamic response of acid suppression between the enteral and intravenous (IV) route is unknown.

AIM

To compare the pharmacodynamic response between enteral and IV lansoprazole in intensive care unit patients requiring stress ulcer prophylaxis therapy.

METHODS

Adult mechanically ventilated patients were randomized to receive 72 h of daily enteral [lansoprazole oral disintegrating tablet (LODT) 30 mg mixed in 10 mL of water via a nasal gastric tube] or IV lansoprazole (30 mg over 30 min) therapy. Serial blood samples were collected after the first and third dose and analysed for pharmacokinetic parameters. Pharmacodynamic determination of intragastric pHmetry began prior to the first dose and continued for 72 h using a single channel pH microelectrode.

RESULTS

Nineteen intensive care unit patients were randomized [LODT (n = 10); IV-L (n = 9)]. LODT bioavailability was 76%. LODT maintained gastric pH > 4 longer than IV-L at both 24 h (7.4 vs. 5.9 h; P = 0.039) and 72 h (10.4 and 8.9 h; P = 0.046) and resulted in a greater average pH over the first 24 h (3.67 vs. 2.89; P = 0.03).

CONCLUSION

Despite a lower bioavailability, enteral lansoprazole suppresses acid in intensive care unit patients to a greater extent than IV lansoprazole.

Intravenous pantoprazole utilization in a level 1 trauma center

BACKGROUND

In recent years there has been a rapid increase in the use of proton pump inhibitors. Our institution has recently had several shortages of IV pantoprazole, each lasting 7-10 days. The purpose of our study was to evaluate in-patient usage of IV pantoprazole. We hypothesized that hospitalized patients with upper gastrointestinal bleeding (GIB) or risk for stress ulcers inappropriately received IV pantoprazole based on current literature.

METHODS

This was a retrospective study of 165 consecutive in-patients identified as receiving pantoprazole from December 2004 to March 2005. Only patients receiving IV pantoprazole were included (n = 78). Data collected included demographics, indication and dosing of pantoprazole, admitting team (surgery vs. medicine), and risk factors for stress ulcers.

RESULTS

Our study population had a mean age of 54 +/- 17 years and 62% were male. Overall, 45% (35/78) of patients receiving IV pantoprazole had an appropriate indication, and 19% (15/78) received the correct dose. Of the 78 patients, 43 (55%) were treated with pantoprazole for stress ulcer prophylaxis (SUP), and 35 (45%) patients were treated for GIB. We found that none of the 43 patients treated for SUP had an appropriate indication for pantoprazole, but all of the patients with GIB (35) had an appropriate indication. Of the 35 patients treated for GIB with pantoprazole, only 40% (14/35) received the correct dose. In all cases of incorrect dosing, the patients were underdosed.

CONCLUSIONS

Pantoprazole is not being prescribed appropriately for stress ulcer prophylaxis in our patient population. Even in patients appropriately receiving pantoprazole the majority were prescribed an incorrect dose. Appropriate indications and dosing of pantoprazole could eliminate the shortages seen at our institution.

Oral rabeprazole vs. intravenous pantoprazole: a comparison of the effect on intragastric pH in healthy subjects

BACKGROUND

Intravenous pantoprazole is often administered inappropriately to hospitalized patients who can take oral medications.

AIM

To compare the antisecretory effects of oral rabeprazole and intravenous pantoprazole in healthy subjects.

METHODS

In a double-blind, double-dummy, two-way crossover study, 38 Helicobacter pylori-negative volunteers were randomized to oral rabeprazole 20 mg or intravenous pantoprazole 40 mg daily for 3 days followed, after a 14-day washout period by the comparator treatment. Intragastric pH was recorded continuously for 24 h at baseline and on days 1 and 3 of each treatment period.

RESULTS

The mean (95% CI) percentage of the 24-h recording with gastric pH >4 was higher with rabeprazole than with pantoprazole on day 1: 37.7% (30.6-44.8%) vs. 23.9% (20.0-27.8). The mean percentage times with pH >3 and >4 for all intervals assessed were greater and the median 24-h intragastric pH values were higher with rabeprazole than with pantoprazole on days 1 and 3. The mean acidity index was lower with rabeprazole on days 1 and 3.

CONCLUSIONS

Oral rabeprazole 20 mg produced greater acid suppression than intravenous pantoprazole 40 mg. Therefore, it may be an appropriate and effective alternative in patients who can take oral medication.

Effect of frequent dosing of an oral proton pump inhibitor on intragastric pH

BACKGROUND

Treatment with a continuous i.v. proton pump inhibitor is presumed to promote clot formation and stability by sustaining intragastric pH > or = 6.

AIM

We postulated that very frequent oral dosing of proton pump inhibitors should simulate i.v. infusion and achieve similar pH control.

METHODS

Twenty healthy volunteers were stratified by Helicobacter pylori status (10 positive; 10 negative) and had determination of CYP2C19 status. After an overnight fast, an intragastric pH probe was placed. Subjects received 120 mg of lansoprazole at 8 am and 30 mg every 3 h until 8 pm. Intragastric pH was measured over 24 h, and lansoprazole plasma concentrations were determined at five time points.

RESULTS

Intragastric pH was > or = 6 for 41% (95% CI: 30-53%) of the 15-h period from 8 am-11 pm and 46% (95% CI: 35-56%) of the 24-h period (8-8 am). The mean proportion of patients with pH > or = 6 was not significantly different in H. pylori-positive vs. negative patients. Only 25% of subjects sustained pH > or = 6 for at least 60% of the 15-h period, and 35% had a sustained pH > or = 6 for at least 60% of the 24-h period.

CONCLUSIONS

A dose of 120 mg of oral lansoprazole followed by standard 30 mg doses of lansoprazole every 3 h did not reliably sustain pH at the desired level of 6.

What is potent acid inhibition, and how can it be achieved?

The clinical response to antisecretory treatment correlates directly with the degree of inhibition of acid secretion achieved. Acid inhibition able to maintain the intragastric pH at a value greater than 4 for at least 16 h/day seems to heal even the most refractory acid-related diseases. It has also been shown that the degree of inhibition of acid secretion in response to antisecretory treatment depends on the genetic characteristics of the patient and on the presence of Helicobacter pylori infection. A possible definition of potent (or profound) acid inhibition is, therefore, the achievement of the aforementioned level of control of acid secretion regardless of patient characteristics or of the presence of H. pylori infection. Antisecretory drugs differ in their ability to reach potent acid inhibition. As far as the comparative efficacy of different drugs for inhibiting acid secretion is concerned, proton pump inhibitors are more efficient in inhibiting gastric acid secretion than histamine (H2) receptor antagonists. Among the different proton pump inhibitors, esomeprazole 40 mg/day exhibits greater antisecretory potency than the others at standard doses. Rabeprazole 20 mg/day and lansoprazole 30 mg/day exhibit a more rapid onset of action than omeprazole 20 mg/day or pantoprazole 40 mg/day.

Inappropriate use of intravenous pantoprazole: extent of the problem and successful solutions

BACKGROUND & AIMS

Indications for intravenous proton pump inhibitors (IV PPI) include upper gastrointestinal bleeding (UGIB) from peptic ulcer disease with high-risk stigmata and patients receiving nothing by mouth (NPO). The objectives were to assess the extent of errors in indications for IV PPI use and to determine whether multidisciplinary interventions could improve IV PPI use and costs.

METHODS

Part 1: Patients prescribed IV PPI during a period of 4 months were divided into 2 settings, UGIB or non-UGIB. The setting-specific appropriateness of the IV PPI indication and dosing regimen was determined. Part 2: Patients prescribed IV PPI before and after multidisciplinary interventions (educating physicians, a computerized dose template, pharmacists altering IV PPI orders in non-UGIB patients who were not NPO, and recommending a GI consult when a continuous infusion was ordered) were studied. Incidence of prescribing errors, IV PPI costs, and potential confounders were compared.

RESULTS

Part 1: Only 50% of UGIB (n = 145) patients received IV PPI for an appropriate indication. Both indication and dosing regimen were appropriate in 21%. In the non-UGIB group (n = 95), 33% were truly NPO; 51% had a correct dosing frequency. Part 2: The postintervention (n = 105) group (vs the preintervention group, n = 113) showed a significant absolute reduction in the degree of inappropriate indication in the UGIB (26%; 95% confidence interval [CI], 10%-42%; P < .0001) and in the non-UGIB (41%; 95% CI, 24%-58%; P < .0001) subgroups. However, a greater improvement in underspending than overspending meant that overall costs were unchanged.

CONCLUSIONS

IV PPI was frequently prescribed inappropriately and incorrectly; simple maneuvers resulted in reductions in errors.

Comparative study and optimisation of the administration mode of three proton pump inhibitors by nasogastric tube

Patients in intensive care often develop stress-induced ulcers. As a preventive measure, proton pump inhibitors (PPIs) are administered by nasogastric tube. However, some PPIs can block the tube. The aim of this study was to compare the behaviour of three PPIs (omeprazole, lanzoprazole and esomeprazole) during the transit of the granules through the tube and to optimise their modes of administration. For each IPP, the experiment was designed to study the influence of four variables: the tube material (silicone or polyurethane), the solvent used to dilute the granules (water or apple juice), the mode of administration (in two or three doses) and the rinse volume (10 or 20 ml). We counted the granules before transit and at the tube outlet, and assayed the active drug ingredient by UV spectrometry. The assay showed complete transit of esomeprazole through the tube, but average losses of omeprazole and lanzoprazole of 39 and 33%, respectively, were observed. No significant improvement was obtained by the variables 'diluent' and 'mode of administration'. The variable 'rinse' had a significant influence. For lanzoprazole, a polyurethane tube allowed recovery of on average 86% of the active ingredient. Esomeprazole is thus the choice PPI for the treatment of patients by nasogastric tube. Using a polyurethane tube and a rinse volume of 20 ml, the administration of lanzoprazole by tube can be considered. Use of omeprazole is not recommended because none of the modes of administration tested ensured that a sufficient concentration of active ingredient reached the stomach.

Comparison of the pharmacokinetics of lansoprazole 15- and 30-mg sachets for suspension versus intact capsules

OBJECTIVE

The pharmacokinetic profiles of single doses of lansoprazole 15- and 30-mg sachets for suspension were compared with those of corresponding doses of lansoprazole oral capsules.

METHODS

Healthy adult male and female subjects were randomized (1:1 ratio) into 2 Phase 1, open-label, single-dose, 2-sequence, 2-period complete crossover studies. In the first study, each subject received 1 lansoprazole 15-mg sachet mixed with water and 1 lansoprazole 15-mg oral capsule; in the second study, each subject received 1 lansoprazole 30-mg sachet mixed with water and 1 lansoprazole 30-mg oral capsule. Administration of the 2 formulations was separated by a washout period of > or =7 days. Blood samples were collected before and after each administration to assess the pharmacokinetic parameters of lansoprazole and bioequivalence between suspension and capsule.

RESULTS

Thirty-six subjects (19 males, 17 females) with a mean (SD) age of 32.0 (9.6) years and mean (SD) body weight of 68.6 (10.5) kg received lansoprazole 15 mg. Thirty-six subjects (22 males, 14 females) with a mean (SD) age of 38.0 (8.3) years and mean (SD) body weight of 75.1 (9.7) kg received lansoprazole 30 mg. The pharmacokinetic parameters of the 15- and 30-mg lansoprazole sachets for suspension were similar to those of the corresponding doses of the oral capsules. The mean (SD) values for C(max) and AUC from time 0 to infinity (AUC(0-infinity) for the lansoprazole 15-mg sachet (591.9 [242.3] ng/mL and 1614 [2065] ng.h/mL, respectively) did not differ significantly from those for the lansoprazole 15-mg capsules (578.6 [275.2] ng/mL and 1620 [2290] ng.h/mL, respectively). These parameters also did not differ significantly between the lansoprazole 30-mg sachet and 30-mg capsule: mean (SD) C(max), 1103 (428.3) and 1077 (465.6) ng/mL, respectively; mean (SD) AUC(0-infinity), 2655 (1338) and 2669 (1311) ng.h/mL, respectively. The 90% Cls for C(max) and AUC(0-infinity) ratios were contained within the 0.80 to 1.25 equivalence range, supporting bioequivalence.

CONCLUSIONS

These findings suggest that the 15- and 30-mg lansoprazole sachets for suspension are bioequivalent to the corresponding doses of oral capsules. The sachet for suspension may provide an alternative route of administration to patients who have difficulty swallowing solid oral formulations.

Use of intravenous proton pump inhibitors in community practice: an explanation for the shortage?

BACKGROUND

Since 2001, one intravenous proton pump inhibitor (pantoprazole) has been available in the United States. A drug shortage bulletin was issued for this agent in 2003.

AIM

To evaluate the patterns of use of intravenous proton pump inhibitors (IV PPIs) in routine clinical practice.

METHODS

Prospective evaluation of IV PPI use in two community-based teaching hospitals. A computerized pharmacy ordering system was used to identify all patients for whom an IV PPI was ordered. Trained investigators obtained clinical data from patient records and these data were mapped to establish clinical criteria for the use of IV PPIs.

RESULTS

Intravenous PPIs were prescribed in 238 patients over a 30-day period and a total of 1,631 doses were prescribed. Primary care providers prescribed 46% of prescriptions. Fifty-six percent of patients who received IV PPIs had no acceptable indication for their use. Of the 126 (81%) patients who were started on PPIs for the first time during their hospital stay, 102 were discharged on a PPI.

CONCLUSIONS

Intravenous PPIs are widely used for poor indications, which may contribute to the shortage of these agents.

Evaluation of the pharmacokinetics and pharmacodynamics of intravenous lansoprazole

AIM

To compare the pharmacokinetics and pharmacodynamics of lansoprazole 30 mg administered intravenously in 0.9% NaCl or in polyethylene glycol, or orally.

METHODS

Twenty-nine subjects received lansoprazole orally on days 1-7 and intravenous lansoprazole in NaCl on days 8-14. Blood samples were collected on days 1, 7, 8 and 14. Fasting basal acid output and pentagastrin-stimulated maximal acid output were determined on days -1, 8, 9 and 15. Thirty-six different subjects received one of four regimen sequences: intravenous lansoprazole in NaCl, intravenous in polyethylene glycol, per orally, or intravenous placebo, each for 5 days. Twenty-four hour intragastric pH was recorded on days 1 and 5.

RESULTS

Intravenous and per oral lansoprazole for 7 days produced equivalent basal acid output and maximal acid output suppression. Pharmacokinetics and mean pH values with intravenous lansoprazole in NaCl or polyethylene glycol were equivalent. Both produced mean pH and percentages of time pH above 3, 4, 5 and 6 that were significantly greater than did per orally.

CONCLUSIONS

Intravenous lansoprazole inhibits acid secretion as effectively in NaCl as in polyethylene glycol, and its onset of action is faster than per oral lansoprazole.

Review article: approaches to the long-term management of adults with GERD-proton pump inhibitor therapy, laparoscopic fundoplication or endoscopic therapy?

The goals of gastro-oesophageal reflux disease (GERD) treatment are to control symptoms, heal the injured oesophageal mucosa, and prevent complications. Pharmacological therapy is effective in producing acute symptom relief and mucosal healing, as well as the long-term maintenance of remission. Proton pump inhibitors are the mainstay of GERD therapy. However, the need for daily administration, failure to provide complete symptom relief and costs of these agents may limit their use in some patients, prompting a consideration of alternative treatment strategies. Laparoscopic fundoplication may achieve symptom relief and healing of the oesophagitis in these individuals, but its invasiveness, cost and inherent surgical risks have created an interest in endoscopic therapies for GERD, with several emerging during the past few years. These interventions may either be viewed as an alternative therapy or as 'bridge' therapy, with patients still choosing to be treated with acid anti-secretory drugs or fundoplication if the endoscopic procedure fails to provide adequate symptom relief or if symptoms recur. Patient selection is critical for the success of fundoplication as well as endoscopic procedures, with ideal candidates being those with well-established endoscopically documented GERD, abnormal pH monitoring, normal oesophageal motility studies, and who have experienced at least partial symptom relief with proton pump inhibitor therapy. Hiatal hernia is not a contra-indication to fundoplication, while endoscopic intervention is best suited for those with a hiatal hernia of less than 3 cm in length. The long-term efficacy, cost-effectiveness, and impact of endoscopic procedures on extra-oesophageal manifestations of GERD and risk for GERD-related complications has not been determined.

Oral esomeprazole vs. intravenous pantoprazole: a comparison of the effect on intragastric pH in healthy subjects

BACKGROUND

Intravenous (IV) proton-pump inhibitor therapy is used in patients who cannot take oral medications or require greater acid suppression. Oral esomeprazole produces greater acid suppression than oral pantoprazole; however, no comparative data exist for oral esomeprazole and i.v. pantoprazole.

AIM

To compare acid suppression (time with pH>3.0, 4.0, 5.0 and 6.0) produced by standard doses of oral esomeprazole and i.v. pantoprazole in healthy subjects.

METHODS

A randomized, two-way crossover study in 30 subjects receiving oral esomeprazole (40 mg o.d.) or i.v. pantoprazole (40 mg o.d.) for 5 days followed by a 2-week washout period before the second 5-day drug administration period using the crossover drug regimen.

RESULTS

Oral esomeprazole produced greater acid suppression than i.v. pantoprazole on day 1 [pH>3.0 (56.9%, 35.8%; P<0.001), pH>4.0 (43.4%, 25.0%; P<0.001) and pH>5.0 (28.7%, 15.6%; P<0.001)] and on day 5 [pH>3.0 (70.4%, 45.9%; P<0.001), pH>4.0 (59.2%, 33.9%; P<0.001), pH>5.0 (45.5%, 23.9%; P<0.001) and pH>6.0 (19.6%, 12.6%; P=0.045)]. The adverse event profiles indicated both treatments to be safe and well tolerated.

CONCLUSIONS

In healthy subjects, esomeprazole, 40 mg o.d. dispersed in water, produces greater acid suppression than pantoprazole 40 mg i.v. o.d. after 1 and 5 days of medication.

A Pharmacy-Managed Intravenous to Enteral Proton-Pump Inhibitor Conversion Program

This article describes a pharmacy-managed, intravenous (IV) to enteral proton-pump inhibitor (PPI) program at a 377-bed tertiary care, teaching community hospital. IV pantoprazole was not restricted by indication, service, or patient location. Pharmacy converted any eligible patient prescribed an IV PPI to either pantoprazole tablets or lansoprazole capsules, packets, or enteral suspension according to protocol. Over a four-month evaluation period, 113 patients (mean age of 66 years) were prescribed IV PPIs for primarily suspected or documented GI bleeding. Gastroenterology specialists initiated 85% of IV PPI therapy. The most common dosage of IV PPI was 40 mg, once or twice daily with a median duration of 3 to 4 days. Continuous infusion IV PPI therapy was used for only two patients, both with GI bleeding. IV pantoprazole was converted to an enteral PPI in 73 of 113 patients in dosages of pantoprazole 40 mg or lansoprazole 30 or 60 mg administered once (32%) or twice (68%) daily. Pharmacists initiated 34% of the conversions. The total PPI expenditure was $6200 during the evaluation period. Daily acquisition cost savings, based on nominal pricing, ranged from approximately $5 to $25. Initial evaluation of the conversion program resulted in protocol revision and education of the medical staff, in an effort to minimize days of IV PPI use and encourage transition to enteral therapy. The protocol conversion dosage of lansoprazole 60 mg twice daily was changed to 30 mg twice daily and enteral pantoprazole tablets were deleted from the protocol (all IV PPI is converted to lansoprazole, 30 mg twice daily). Although IV pantoprazole remained on the hospital formulary, the medical staff were educated about the relative effectiveness of IV and enteral PPI therapy and the use of histamine-2 receptor antagonists for various indications. Prescribers of IV pantoprazole are now required to document the rationale for use. The Pharmacy and Therapeutics Committee will continue to explore the role IV PPI therapy, based on efficacy, safety, and cost.

Comparative pharmacokinetics and safety of lansoprazole oral capsules and orally disintegrating tablets in healthy subjects

BACKGROUND

Many individuals with acid-related gastrointestinal disorders have difficulty in swallowing oral agents.

AIM

To compare the bio-availability of a single dose of lansoprazole orally disintegrating tablet with that of an intact capsule.

METHODS

One hundred and twenty healthy subjects participated in two prospective, Phase I, open-label, two-period cross-over studies to receive lansoprazole, 15 mg or 30 mg. Within each study, subjects were randomized into two parallel cohorts consisting of 30 subjects per regimen, dispensed in opposing sequence over two periods separated by a 7-day washout period. Blood samples were collected on day 1 of both periods to determine the pharmacokinetic parameters.

RESULTS

Tmax occurred at 1.8 and 2.0 h with the 15-mg and 30-mg tablets, respectively. Dose proportional increases in Cmax, AUCt and AUC infinity were observed in the 15-mg and 30-mg groups. The terminal elimination half-lives (t1/2) were identical in both dose groups (1.18 h). Lansoprazole administered as the orally disintegrating tablet was bio-equivalent to the intact capsule formulation with respect to Cmax, AUCt and AUC infinity.

CONCLUSIONS

Lansoprazole orally disintegrating tablets, 15 mg and 30 mg, are bio-equivalent to the respective dose administered as the intact capsule. This novel dosage formulation represents an option for patients who have difficulty in swallowing oral agents.

A comparison of simplified lansoprazole suspension administered nasogastrically and pantoprazole administered intravenously: effects on 24-h intragastric pH

AIM

To compare the 24-h intragastric pH effects of simplified lansoprazole suspension, 30 mg, administered nasogastrically, with pantoprazole, 40 mg, administered intravenously.

METHODS

Thirty-six healthy adults were enrolled and given simplified lansoprazole suspension, 30 mg (nasogastrically), or pantoprazole, 40 mg (intravenously), once daily for five consecutive days in a cross-over fashion. Intragastric pH was monitored at baseline and on Days 1 and 5 of each treatment period. The pharmacokinetic parameters of lansoprazole and pantoprazole were also determined on Days 1 and 5.

RESULTS

No statistically significant changes in pharmacokinetic parameters occurred between Days 1 and 5 with either regimen, except for pantoprazole Cmax. On Days 1 and 5, significantly higher mean 24-h intragastric pH values were observed with 30 mg simplified lansoprazole suspension compared with 40 mg intravenous pantoprazole (Day 1, 3.13 vs. 2.67; Day 5, 3.95 vs. 3.61, respectively; P < 0.05). Additionally, 30 mg simplified lansoprazole suspension produced significantly (P < 0.05) higher percentages of time intragastric pH was above 3, 4, 5 or 6 as compared with 40 mg intravenous pantoprazole throughout Days 1 and 5.

CONCLUSIONS

A 30 mg dose of simplified lansoprazole suspension administered nasogastrically was consistently more effective at controlling intragastric pH than pantoprazole, 40 mg, administered intravenously.

Lansoprazole: pharmacokinetics, pharmacodynamics and clinical uses

Lansoprazole (Prevacid, TAP Pharmaceuticals, Inc.) is a substituted benzimidazole that inhibits gastric acid secretion. This agent is approved for the short-term treatment of erosive reflux oesophagitis, active gastric ulcer, active duodenal ulcer and the treatment of non-steroidal anti-inflammatory drug (NSAID)-induced gastric and duodenal ulcers. It is also approved for the long-term treatment of healed reflux oesophagitis, healed duodenal ulcer, the treatment of hypersecretory conditions such as Zollinger-Ellison syndrome and the eradication of Helicobacter pylori as a component of triple therapy with lansoprazole, clarithromycin and amoxicillin, or dual therapy with lansoprazole and amoxicillin. Its mechanism of action is to selectively inhibit the membrane enzyme H+/K+ ATPase in gastric parietal cells. In clinical trials, lansoprazole is more effective than placebo or histamine (H2)-receptor antagonists in the treatment of reflux oesophagitis. Lansoprazole administered at a dose of 30 mg daily produced faster relief of symptoms and superior healing rates in patients with gastric or duodenal ulcers or reflux oesophagitis than H2-receptor antagonists. A daily dose of 30 mg lansoprazole reduced epigastric pain faster than omeprazole 20 mg daily in patients with peptic ulcer disease but healing rates at 4 and 8 weeks were similar with both agents at these dosages. Lansoprazole was more effective than H2-receptor antagonists in patients with Zollinger-Ellison syndrome and produced similar treatment outcome to omeprazole. Lansoprazole in combination with clarithromycin and amoxicillin produced similar rates of eradication of H. pylori. In clinical trials, lansoprazole is well-tolerated and has a low frequency of side effects similar to that of H2-receptor antagonists or omeprazole.