A double-blind fluoroscopic study of cisapride on gastrointestinal motility in patients with functional dyspepsia

DA-9701: A New Multi-Acting Drug for the Treatment of Functional Dyspepsia

Motilitone^® (DA-9701) is a new herbal drug that was launched for the treatment of functional dyspepsia in December 2011 in Korea. The heterogeneous symptom pattern and multiple causes of functional dyspepsia have resulted in multiple drug target strategies for its treatment. DA-9701, a compound consisting of a combination of Corydalis Tuber and Pharbitidis Semen, has being developed for treatment of functional dyspepsia. It has multiple mechanisms of action such as fundus relaxation, visceral analgesia, and prokinetic effects. Furthermore, it was found to significantly enhance meal-induced gastric accommodation and increase gastric compliance in dogs. DA-9701 also showed an analgesic effect in rats with colorectal distension induced visceral hypersensitivity and an antinociceptive effect in beagle dogs with gastric distension-induced nociception. The pharmacological effects of DA-9701 also include conventional effects, such as enhanced gastric emptying and gastrointestinal transit. The safety profi le of DA-9701 is also preferable to that of other treatments.

WITHDRAWN: Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that £450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Correlations among electrogastrogram, gastric dysmotility, and duodenal dysmotility in patients with functional dyspepsia

AIM

The aim of this study was to assess gastric slow waves, antral and duodenal motility simultaneously, and determine the correlation among all these measures in patients with functional dyspepsia.

METHODS

Thirty-one patients with functional dyspepsia were assessed for severity of upper gastrointestinal symptoms with the electrogastrography (EGG) and antroduodenal manometry. The EGG and manometry were recorded for 3 to 4 hours in the fasting state and for 2 hours after a solid meal. Computerized spectral analysis methods were used to compute various EGG parameters.

RESULTS

The EGG was abnormal in 71.0% of patients. The abnormalities included normal slow waves lower than 70% in the fasting state (51.6% of patients) and in the fed state (48.4% of patients), a decrease in dominant power in 28.9% of patients. Antral motility was abnormal in 80.6% of patients and duodenal motility was abnormal in 74.2% of patients. For the EGG and antral motility, 19 of 31 patients had both abnormal EGG and abnormal antral motility; 2 of 31 patients had both normal EGG and normal antral motility. For the EGG and duodenal motility, these values were 16/31 and 2/31, respectively. By both EGG and antroduodenal manometry, abnormal gastric motor function was found in 93.5% of patients. However, quantitative one-to-one correlation between any of the EGG parameters and the antroduodenal dysmotility was not noted. The patients showed high symptom scores particularly to upper abdominal pain, nausea, and belch. No one-to-one correlation was noted between the symptom scores and any of the EGG or motility parameters.

CONCLUSIONS

More than two-thirds of patients with functional dyspepsia have abnormalities in the EGG and antral/duodenal motility. The sensitivity of these 2 different methods is essentially the same. EGG and antroduodenal manometry can complement each other in demonstrating gastric motor dysfunction in patients with functional dyspepsia.

Rhythmic and spatial abnormalities of gastric slow waves in patients with functional dyspepsia

OBJECTIVE

The objectives of this study were to assess differences in gastric slow waves measured by a newly approved multichannel electrogastrogram (EGG) device between patients with functional dyspepsia (FD) and healthy controls.

MATERIALS AND METHODS

Gastric myoelectrical activity was measured by multichannel EGG for 1 hour preprandially and for 2 hours postprandially in 72 FD patients and 16 healthy volunteers. Computerized spectral analysis methods were used to compute various EGG parameters.

RESULTS

(1) Multichannel EGG was abnormal in 83.3% of patients. (2) The regularity of the gastric slow wave was significantly lower in the FD patients in both fasting and fed states; the lowest regularity was seen in channel 3. (3) There was a significantly higher incidence of arrhythmia and tachygastria in FD patients. The highest percentage of arrhythmia and tachygastria were both seen in channel 3. (4) The FD patients showed a significantly lower percentage of slow wave coupling among the 4-channel EGGs in the fed state. (5) The postprandial-preprandial power ratio was significantly less in FD patients. (6) These patients had high symptom scores particularly to nausea, upper abdominal pain, and bloating. However, no significant correlation was noted between the EGG parameters and the symptoms.

CONCLUSIONS

Gastric myoelectrical activity is impaired in most patients with FD. The impairment is reflected as a decreased percentage of normal slow waves and an excessive amount of arrhythmia as well as an abnormal spatial distribution of EGG parameters among the 4 channels, suggesting an impaired coordination of gastric slow waves.

Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that pound450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H(2) antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that 450 million pounds is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptom scores either individual or global symptom assessments and also quality of life scores and adverse effects.

MAIN RESULTS

A total of 11796 citations were obtained. 157 trials were retrieved and 98 trials fulfilled our eligibility criteria. However, subsequent data extraction was not possible in 31 trials. The final 67 trials were included in the meta-analysis. Prokinetics (14 trials with dichotomous outcomes generating 1053 patients; relative risk reduction [RRR] = 48%; 95% confidence intervals [CI] = 27% to 63%), H2RAs (11 trials generating 2,164 patients; RRR = 22%; 95% CI = 7% to 35%) and PPIs (8 trials generating 3,293 patients; RRR = 14%; 95% CI = 5% to 22%) were significantly more effective than placebo. Bismuth salts (6 trials generating 311 patients; RRR = 40%; 95% CI = -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial generating 109 patients; RRR = -2%; 95% CI = -36% to 24%) and sucralfate (two trials generating 246 patients; RRR = 29%; 95% CI = -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic and H2RA results could be due to publication bias.

REVIEWERS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Abnormal gastric slow waves in patients with functional dyspepsia assessed by multichannel electrogastrography

The aim of this study was to utilize multichannel electrogastrography to investigate whether patients with functional dyspepsia had impaired propagation or coordination of gastric slow waves in the fasting state compared with healthy controls. The study was performed in 10 patients with functional dyspepsia and 11 healthy subjects. Gastric myoelectrical activity was measured by using surface electrogastrography with a specially designed four-channel device. The study was performed for 30 min or more in the fasting state. Special computer programs were developed for the computation of the propagation and coupling of the gastric slow wave. It was found that, compared with the healthy controls, the patients showed a significantly lower percentage of slow wave propagation (58.0 +/- 8.9 vs. 89.9 +/- 2.6%, P < 0.002) and a significantly lower percentage of slow wave coupling (46.9 +/- 4.4 vs. 61.5 +/- 6.9%, P < 0.04). In addition, the patients showed inconsistencies in the frequency and regularity of the gastric slow wave among the four-channel electrogastrograms (EGGs). It was concluded that patients with functional dyspepsia have impaired slow wave propagation and coupling. Multichannel EGG has more information than single-channel EGG for the detection of gastric myoelectrical abnormalities.

The effect of cisapride on dyspepsia symptoms and the electrogastrogram in patients with non-ulcer dyspepsia

BACKGROUND

The electrogastrogram (EGG), which records gastric myoelectrical activity, is abnormal in one-third of adult patients with non-ulcer dyspepsia (NUD).

AIM

To observe the effects of cisapride on EGG in adults with NUD.

METHODS

Twenty-seven NUD patients who had undergone a pre- and post-prandial EGG were entered into an open study. All patients completed a dyspepsia symptom questionnaire and were then treated with cisapride 10 mg t.d.s. The dyspepsia questionnaire was repeated in all those completing 4 weeks of treatment. Those with an initial abnormal EGG (< 70% of slow wave activity at 2-4 cycles per minute) had a repeat EGG at the end of the study.

RESULTS

Treatment with cisapride was associated with a significant improvement in the post-prandial EGG (P = 0.007). After 4 weeks of treatment, 7 of 13 abnormal EGGs normalized. Symptom scores improved significantly in the 13 patients with an abnormal EGG who completed treatment (P < 0.0003), but not in NUD patients with a normal EGG (P = 0.48).

CONCLUSION

In this open study, treatment of NUD with cisapride was associated with significant symptom improvement in patients with an abnormal pre-treatment EGG, but not those with a normal EGG, with a significant improvement of the post-prandial EGG.

Clinical economics review: functional (non-ulcer) dyspepsia

Dyspepsia is common within the general population and it imposes a significant burden on health-care resources. Calculation of the economic implications of functional dyspepsia is constrained by the fact that it is only possible to make this diagnosis in a minority of individuals with the disorder, because many do not seek medical attention and investigation is not appropriate for all who do. Studies which attempt to assess the effectiveness or cost-effectiveness of therapy may be further constrained by the fact that there is now good evidence that many patients with dyspepsia seek medical attention not so much because of the severity of symptoms, but because they fear that the symptoms signal the presence of some serious underlying disease. In this situation, effective well-founded reassurance that no serious disease is present is an important outcome of medical intervention and one which should be included in an economic appraisal of dyspepsia management. For obvious reasons, it is sensible to compare the cost-effectiveness of various clinical management strategies applicable in dyspepsia. Decision-tree analyses are currently fashionable but suffer from the major defect that there is no theoretical basis from which patient satisfaction with treatment options can be assessed. It is suggested that for disorders such as functional dyspepsia, which are non-lethal and non-progressive, recommendations about acceptable clinical management strategies require that account be taken of patient satisfaction with the strategies being reviewed. Cost-effectiveness calculations which take no account of this aspect of outcome are of limited relevance to clinical practice.

Cisapride. An updated review of its pharmacology and therapeutic efficacy as a prokinetic agent in gastrointestinal motility disorders

Cisapride is an orally administered prokinetic agent which facilitates or restores motility throughout the length of the gastrointestinal tract. It is a substituted piperidinyl benzamide, chemically related to metoclopramide, but unlike metoclopramide, cisapride is largely devoid of central depressant or antidopaminergic effects. In placebo-controlled trials, cisapride improved healing rates and symptoms in both adults and children with reflux oesophagitis. Maintenance therapy with cisapride at half the healing dose is effective in reducing the incidence of relapse. Symptoms are also alleviated in patients with functional dyspepsia, and gastric emptying and symptoms are improved in most patients with gastroparesis, an effect which is sustained during long term administration. However, the efficacy of cisapride in end-stage gastroparesis remains less clear. Cisapride increases stool frequency in patients with chronic constipation, and limited data suggest that the drug may also be beneficial in treating chronic intestinal pseudo-obstruction and irritable bowel syndrome. Cisapride demonstrated efficacy comparable with or superior to that of metoclopramide, and was at least as effective as cimetidine and ranitidine in patients with reflux disease. In patients with functional dyspepsia, cisapride has shown at least equal efficacy to domperidone, metoclopramide and ranitidine, and superior efficacy to cimetidine in the small comparative trials conducted to date. Adverse effects in patients receiving cisapride are generally transient and mild, with abdominal cramping, borborygmi, diarrhoea or loose stools most frequently reported. Central nervous system adverse effects are rare. Thus, with its favourable tolerability profile and demonstrated efficacy in a variety of gastrointestinal motility disorders, the position of cisapride as a valuable agent in the management of patients with gastrointestinal motility disorders is strengthening. However, larger well-controlled comparative trials of the drug with other agents are necessary before the relative position of cisapride in therapy can be categorically defined.