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Bor S, Kalkan İH, Savarino E, Rao S, Tack J, Pasricha J, Cangemi D, Schol J, Karunaratne T, Ghisa M, Ahuja NK, Lacy B. Prokinetics-safety and efficacy: The European Society of Neurogastroenterology and Motility/The American Neurogastroenterology and Motility Society expert review. Neurogastroenterol Motil 2024; 36:e14774. [PMID: 38462678 DOI: 10.1111/nmo.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Prokinetics are a class of pharmacological drugs designed to improve gastrointestinal (GI) motility, either regionally or across the whole gut. Each drug has its merits and drawbacks, and based on current evidence as high-quality studies are limited, we have no clear recommendation on one class or other. However, there remains a large unmet need for both regionally selective and/or globally acting prokinetic drugs that work primarily intraluminally and are safe and without systemic side effects. PURPOSE Here, we describe the strengths and weaknesses of six classes of prokinetic drugs, including their pharmacokinetic properties, efficacy, safety and tolerability and potential indications.
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Affiliation(s)
- Serhat Bor
- Division of Gastroenterology, School of Medicine & Ege Reflux Study Group, Ege University, Izmir, Turkey
| | - İsmail H Kalkan
- Department of Gastroenterology, School of Medicine, TOBB University of Economics and Technology, Ankara, Turkey
| | - Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Augusta, Georgia, USA
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Cangemi
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jolien Schol
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Tennekon Karunaratne
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Matteo Ghisa
- Digestive Endoscopy Unit, Division of Gastroenterology, Padua University Hospital, Padua, Italy
| | - Nitin K Ahuja
- Division of Gastroenterology, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Brian Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Comparative Efficacy of Various Pharmacological Interventions in the Treatment of Functional Dyspepsia: A Network Meta-Analysis. Dig Dis Sci 2022; 67:187-207. [PMID: 33590403 DOI: 10.1007/s10620-021-06846-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 01/10/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Patients with functional dyspepsia often select different pharmacological treatments. We aimed to compare and rank the efficacy of different pharmacological interventions in treating functional dyspepsia. METHODS We searched EMBASE, PubMed, Cochrane, Web of Science and MEDLINE from the date of database inception to March 28, 2019. A random-effects model was selected to conduct traditional meta-analysis to directly examine the efficacy of different pharmacological interventions. The consistency model was selected to conduct a network meta-analysis to evaluate the relative effects and rank probability of different pharmacological interventions. RESULTS We included 58 trials (15,629 participants and 21 pharmacological treatments). Network meta-analysis showed that cisapride, domperidone, itopride, and levosulpiride were better than placebo, especially in short term (< 4 weeks). And levosulpiride was significantly more effective than 15 other drugs and placebo (ORs ranging between 0.05 and 0.15). Cisapride was significantly more effective than lansoprazole (OR 0.30, 95% CrI 0.09-0.99) and tegaserod (OR 0.26, 95% CrI 0.07-0.98). The rank probability showed that levosulpiride was most likely to be rank 1 (77%), cinitapride rank 2 (17%), and cisapride rank 3 (23%). CONCLUSIONS Our study confirmed the effectiveness of several pharmacological treatments for ameliorating functional dyspepsia. Furthermore, levosulpiride relatively ranked the best in managing FD. Physicians should be encouraged to apply promising pharmacological interventions (e.g., levosulpiride and cisapride). However, the results should be interpreted with caution due to small study effects.
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Yamawaki H, Futagami S, Wakabayashi M, Sakasegawa N, Agawa S, Higuchi K, Kodaka Y, Iwakiri K. Management of functional dyspepsia: state of the art and emerging therapies. Ther Adv Chronic Dis 2017; 9:23-32. [PMID: 29344328 DOI: 10.1177/2040622317725479] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/31/2017] [Indexed: 12/14/2022] Open
Abstract
Patients with functional dyspepsia, defined in the 2016 Rome IV criteria as bothersome clinical dyspepsia symptoms, experience markedly reduced quality of life. Several etiologies have been associated with the disorder. In the Rome IV criteria, the brain-gut axis was acknowledged as an important factor in the etiology of functional gastrointestinal (GI) disorders. The distinct subgroups of functional dyspepsia, epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS), are treated differently: acid secretion inhibitors are recommended with patients with EPS, whereas prokinetic drugs as mosapride and acotiamide are recommended for patients with PDS. A previous study has reported that proton pump inhibitors (PPIs) and H2-blockers were equally effective in functional dyspepsia. A new drug, acotiamide, a muscarinic antagonist and cholinesterase inhibitor, has been shown to improve gastric motility in rodents and dogs, and to reduce PDS symptoms in patients in double-blind multicenter studies. The pharmacological mechanisms of acotiamide remain unknown; whether acotiamide alters gastric emptying and gastric accommodation in patients with functional dyspepsia remains an open question. Other emerging treatment options include Rikkunshito, a herbal medicine that improves gastric emptying through 5-hydroxytryptamine (5-HT)2B-mediated pharmacological action, and tricyclic antidepressants (TCAs). Different drugs are needed to accommodate the clinical symptoms and etiology in individual patients.
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Affiliation(s)
- Hiroshi Yamawaki
- Department of Internal Medicine, Division of Gastroenterology, Nihon Ika Daigaku, Bunkyo-ku, Tokyo, Japan
| | - Seiji Futagami
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Mako Wakabayashi
- Department of Internal Medicine, Division of Gastroenterology, Nihon Ika Daigaku, Bunkyo-ku, Tokyo, Japan
| | - Noriko Sakasegawa
- Department of Internal Medicine, Division of Gastroenterology, Nihon Ika Daigaku, Bunkyo-ku, Tokyo, Japan
| | - Shuhei Agawa
- Department of Internal Medicine, Division of Gastroenterology, Nihon Ika Daigaku, Bunkyo-ku, Tokyo, Japan
| | - Kazutoshi Higuchi
- Department of Internal Medicine, Division of Gastroenterology, Nihon Ika Daigaku, Bunkyo-ku, Tokyo, Japan
| | - Yasuhiro Kodaka
- Department of Internal Medicine, Division of Gastroenterology, Nihon Ika Daigaku, Bunkyo-ku, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Internal Medicine, Division of Gastroenterology, Nihon Ika Daigaku, Bunkyo-ku, Tokyo, Japan
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Madisch A, Vinson BR, Abdel-Aziz H, Kelber O, Nieber K, Kraft K, Storr M. Modulation of gastrointestinal motility beyond metoclopramide and domperidone : Pharmacological and clinical evidence for phytotherapy in functional gastrointestinal disorders. Wien Med Wochenschr 2017; 167:160-168. [PMID: 28424994 PMCID: PMC5409921 DOI: 10.1007/s10354-017-0557-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 02/27/2017] [Indexed: 12/11/2022]
Abstract
The prokinetic cisapride, an important therapeutic option in functional gastrointestinal (GI) disorders, was withdrawn from the market 15 years ago due to rare severe side effects. Likewise in 2014, the use of metoclopramide (MCP) and domperidone in functional GI disorders (FGID) was restricted, consequently leaving a therapeutic gap in clinical practice. A systematic review revealed that the herbal medicinal product (HMP) STW 5 presents a therapeutic option equivalent to MCP and cisapride. STW 5 is the only HMP for which efficacy has been shown in randomized controlled clinical trials (RCTs) in functional dyspepsia and irritable bowel syndrome, based on its multitarget effect on numerous etiological factors. Due to an outstanding favorable safety profile, STW 5 allows an effective and safe use in FGID without a limitation of the duration of the treatment.
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Affiliation(s)
- Ahmed Madisch
- Gastroenterologie, Interventionelle Endoskopie, Diabetologie, KRH Klinikum Siloah, Hannover, Germany
| | - Bettina R Vinson
- Medical and Clinical Affairs Phytomedicines, Innovation and Development, Phytomedicines Supply and Development Center, Bayer Consumer Health, Steigerwald Arzneimittelwerk GmbH, Darmstadt, Germany
| | - Heba Abdel-Aziz
- Medical and Clinical Affairs Phytomedicines, Innovation and Development, Phytomedicines Supply and Development Center, Bayer Consumer Health, Steigerwald Arzneimittelwerk GmbH, Darmstadt, Germany
| | - Olaf Kelber
- Scientific Strategy Phytomedicines, Innovation and Development, Phytomedicines Supply and Development Center, Bayer Consumer Health, Steigerwald Arzneimittelwerk GmbH, Darmstadt, Germany
| | - Karen Nieber
- Institut für Pharmazie, Universität Leipzig, Leipzig, Germany
| | - Karin Kraft
- Lehrstuhl für Naturheilkunde, Zentrum für Innere Medizin, Universitätsmedizin Rostock, Rostock, Germany
| | - Martin Storr
- Zentrum für Endoskopie, Oßwaldstraße 1, 82319, Starnberg, Germany.
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Ang D, Talley NJ, Simren M, Janssen P, Boeckxstaens G, Tack J. Review article: endpoints used in functional dyspepsia drug therapy trials. Aliment Pharmacol Ther 2011; 33:634-49. [PMID: 21223343 DOI: 10.1111/j.1365-2036.2010.04566.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The measurement of patient-reported outcomes (PRO) in treatment trials for functional gastrointestinal disorders is a matter of controversy. AIM To focus on instruments and endpoints that have been used to evaluate the efficacy of therapeutic agents in functional dyspepsia (FD) trials, also considering the newly defined Rome III FD criteria. METHODS A Medline search was conducted to identify relevant studies pertaining to FD treatment, with particular emphasis on the studies to date which have used validated outcome measures. RESULTS Currently available outcome measures are heterogeneous across studies. They include global binary endpoints, analogue or categorical scoring scales, uni- or multi-dimensional disease specific questionnaires, global outcome evaluations and quality of life questionnaires. Across the available outcome measures, substantial heterogeneity is found, not only in the type of endpoint measure, but also in the number and types of symptoms that are considered to be part of the FD symptom complex. Especially based on content validity, none of the existing questionnaires or endpoints can be considered sufficiently validated to be recommended unequivocally as the primary outcome measure for FD trials according to the Rome III criteria. On the other hand, existing well-validated multi-dimensional questionnaires that include many non-FD symptoms can be narrowed down to evaluate only the cardinal symptoms according to Rome III. CONCLUSIONS There is an urgent need to develop Rome III-based patient-reported outcomes for functional dyspepsia. Well-validated multi-dimensional questionnaires may serve as a guidance for this purpose, and could also be considered for use in ongoing clinical trials.
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Affiliation(s)
- D Ang
- Center for Gastroenterological Research, Department of Pathophysiology, Division of Gastroenterology, University Hospital Gasthuisberg, Herestraat 49, Leuven, Belgium
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Moayyedi P, Shelly S, Deeks JJ, Delaney B, Innes M, Forman D. WITHDRAWN: Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev 2011; 2011:CD001960. [PMID: 21328253 PMCID: PMC10734254 DOI: 10.1002/14651858.cd001960.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Paul Moayyedi
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street WestRoom 4W8EHamiltonOntarioCanadaL8N 3Z5
| | - Soo Shelly
- The General Infirmary at LeedsGastroenterology Unit, Centre for Digestive DiseasesGreat George StreetLeedsUKLS1 3EX
| | - Jonathan J Deeks
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Brendan Delaney
- King's College LondonDivision of Health and Social Care Research7th Floor Capital House42 Weston StreetLondonUKSE1 3QD
| | - Michael Innes
- The University of BirminghamDepartment of Primary Care and General PracticeThe Medical SchoolEdgbastonBirminghamUKB15 2TT
| | - David Forman
- International Agency for Research on Cancer150 cours Albert‐ThomasLyonFrance69372
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7
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Abstract
Dyspepsia is a common term used for a heterogeneous group of abdominal symptoms. Functional dyspepsia (FD) is the focus of this review. The 2006 Rome III criteria defined FD and its subgroups, postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). FD is a very common condition with a high prevalence throughout the world, adversely affecting the quality of life of patients. The pathophysiology of FD has been under investigation during the past two decades. Multiple mechanisms such as abnormal gastric emptying, visceral hypersensitivity, impaired gastric accommodation, and central nervous system factors are likely involved. Several tests are available for the assessment of various physiologic functions possibly involved in the pathogenesis of FD, and some of these could be used in clinical practice, helping to understand the abnormalities underlining patients' complaints. Currently, the possibilities of pharmacological therapy for FD are still limited, however, experience of using prokinetics, tricyclic antidepressants, selective serotonin-reuptake inhibitors (SSRIs), proton-pump inhibitors (PPIs), and several alternative techniques has been accumulated. The different combinations of alterations in physiologic gastrointestinal and central nervous system functions result in the very heterogeneous nature of FD so combined approaches to these patients could be beneficial in challenging cases.
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8
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Hiyama T, Yoshihara M, Matsuo K, Kusunoki H, Kamada T, Ito M, Tanaka S, Chayama K, Haruma K. Treatment of functional dyspepsia with serotonin agonists: a meta-analysis of randomized controlled trials. J Gastroenterol Hepatol 2007; 22:1566-70. [PMID: 17845684 DOI: 10.1111/j.1440-1746.2006.04723.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Functional dyspepsia (FD) is often treated with serotonin agonists; however, the efficacy of such agents has recently been questioned. The aim of this study was to perform a meta-analysis of randomized controlled trials (RCTs) comparing serotonin agonists with other types of prokinetics in patients with FD. METHODS Included studies were RCTs that compared serotonin agonists, including cisapride and mosapride, with dopamine antagonists, including metoclopramide and domperidone, and an opiate agonist, trimebutine, in patients with FD. Studies were identified by searching the Medline database (January 1951 - January 2005) and Cochrane Library (Issue 4, 2004), and by manual searches. The difference in the probability of patients' responses between the serotonin agonists and control agents was used as a summary statistic for the treatment effect. Meta-regression analysis was used to detect sources of heterogeneity. RESULTS Five studies were identified. In total, 467 subjects were assigned to a serotonin agonist arm, and 322 subjects were assigned to a control arm. In the overall analysis, the summary statistic was 0.019 (95% confidence interval [CI]: -0.055 to 0.093; P = 0.612), indicating that the patients' responses to serotonin agonists were similar to those to control agents. However, in the stratified meta-analysis of cisapride and mosapride, mosapride had a 6.7% greater probability of producing a response compared with control agents (summary statistic: 0.067; 95% CI: 0.010-0.124; P = 0.021), whereas no significant effect was observed with cisapride. CONCLUSION The data suggest that mosapride may be more effective than cisapride for the treatment of FD. Although FD is a chronic condition, efficacy was assessed over short periods in the studies used for the present meta-analysis. Long-term RCTs are needed to confirm the effect.
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Affiliation(s)
- Toru Hiyama
- Health Service Center, Hiroshima University, Higashihiroshima, Japan.
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9
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Moayyedi P, Soo S, Deeks J, Delaney B, Innes M, Forman D. Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev 2006:CD001960. [PMID: 17054151 DOI: 10.1002/14651858.cd001960.pub3] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- P Moayyedi
- McMaster University, Department of Medicine, Gastroenterology Division, HSC-3N51d, 1200 Main Street West, Hamilton, Ontario, Canada.
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10
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Burger DM, Wiestner T, Hubler M, Binder H, Keiser M, Arnold S. Effect of Anticholinergics (Atropine, Glycopyrrolate) and Prokinetics (Metoclopramide, Cisapride) on Gastric Motility in Beagles and Labrador Retrievers. ACTA ACUST UNITED AC 2006; 53:97-107. [PMID: 16466463 DOI: 10.1111/j.1439-0442.2006.00787.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The effect of atropine, glycopyrrolate, metoclopramide and cisapride on the antral motility was investigated in eight dogs (four Beagles and four Labradors) using passive telemetry. Both anticholinergics induced a pronounced and lasting reduction of the intensity and frequency of the contractions. A definite dose-related inhibition of the antral motility was seen in Beagles, similar for both active substances. Low doses of atropine (0.02 mg/kg BW i.m.) and glycopyrrolate (0.005 mg/kg BW i.m.) completely inhibited the gastric motility for at least 30 min, whereas higher doses (0.04 or 0.01 mg/kg BW) caused a cessation of activity for more than 3 h. In Labradors, the effects of both active substances were not so dose related and the effect of glycopyrrolate lasted at least 6 h, whereas the effect of atropine gradually decreased after 3 h. A distinct breed difference regarding the effect of the two prokinetics on the antral motility was also observed. In Beagles, the prokinetics, at a low dose (metoclopramide 0.3 mg/kg BW, cisapride 0.2 mg/kg BW), resulted in a significant increase in the amplitude integral. Higher doses (metoclopramide 0.6 mg/kg BW, cisapride 0.5 mg/kg BW) also increased the integrals of the pressure profiles, but significantly less than with the lower doses. In Labradors, both medications, mainly at higher doses, resulted in an increase of the contraction amplitudes. The low dose had no (cisapride) or only a transient effect (metoclopramide). The frequency of the antral contractions was not at all influenced by cisapride, and only in Beagles metoclopramide resulted in a dose-related increase. It is not clear if the different results in Labradors and Beagles are because of breed or body weight.
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Affiliation(s)
- D M Burger
- Department of Reproduction, Vetsuisse-Faculty, University of Zurich, CH-8057 Zurich, Switzerland
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11
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Abstract
Functional dyspepsia (FD) refers to unexplained pain or discomfort in the upper abdomen and is commonly seen in gastroenterology practice. The underlying pathophysiologic mechanisms associated with FD are unclear, although traditionally, delayed gastric emptying, visceral hypersensitivity to acid or mechanical distention, and impaired gastric accommodation have been implicated as putative physiologic disturbances. It also remains uncertain whether FD and irritable bowel syndrome are different presentations of the same disorder. Recent data on pathophysiologic mechanisms of FD have focused on postprandial motor disturbances (accelerated gastric emptying, antral-fundic incoordination, and abnormal phasic contractions), alterations of neurohormonal mechanisms in response to a meal, and previous acute infection. Pharmacologic therapies for FD may be guided by these novel mechanisms, as current available therapeutic options are limited. Novel prokinetics and gastric accommodation modulators, visceral analgesics, and agents targeting the neurohormonal response to food ingestion are the next therapeutic frontiers in FD. This review summarizes traditional knowledge and more recent advances in the pathophysiology of FD and potential therapeutic opportunities.
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Affiliation(s)
- Noel R Fajardo
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Plummer 6-56, 200 First Street SW, Rochester, MN 55905, USA
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12
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Otaka M, Jin M, Odashima M, Matsuhashi T, Wada I, Horikawa Y, Komatsu K, Ohba R, Oyake J, Hatakeyama N, Watanabe S. New strategy of therapy for functional dyspepsia using famotidine, mosapride and amitriptyline. Aliment Pharmacol Ther 2005; 21 Suppl 2:42-6. [PMID: 15943846 DOI: 10.1111/j.1365-2036.2005.02473.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In functional gastrointestinal (GI) disorders including functional dyspepsia (FD) and irritable bowel syndrome (IBS), there might be no small extent of contributions of psychosomatic factors. As a therapy for IBS patients, the effectiveness of antidepressants has been reported. AIM In this study, we evaluated the efficacy of H2-receptor antagonist (famotidine) and 5-HT4 receptor agonist (mosapride citrate). In addition, the effect of antidepressants was assessed as the second-step therapy. METHODS Patients complaining upper GI symptoms were diagnosed as FD excluding organic diseases. Randomized patients received 20 mg/day of famotidine or 15 mg/day of mosapride citrate for 4 weeks and the efficacy was compared between the two groups based on a 10-point visual analogue scale. When symptoms were not relieved (score improvement 0-2 points), patients received amitriptyline (30 mg/day) or no medication for 4 weeks randomly. Patients who had depression in psychological test (SDS) were omitted. RESULTS As the first-step therapy, both famotidine and mosapride showed beneficial effects regardless of FD subtypes, age and gender. The efficacy of these two drugs in relieving FD symptoms was not significantly different. In patients who failed in the first-step therapy, amitriptyline showed beneficial effects. CONCLUSIONS These findings might be clinically important in view of the efficient relief of symptoms in FD patients.
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Affiliation(s)
- M Otaka
- Department of Internal Medicine, Akita University School of Medicine, Hondu, Akita, Japan.
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13
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Moayyedi P, Soo S, Deeks J, Delaney B, Innes M, Forman D. Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev 2004:CD001960. [PMID: 15495023 DOI: 10.1002/14651858.cd001960.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- P Moayyedi
- Department of Medicine, Gastroenterology Division, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada, L8N 3Z5
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Cremonini F, Delgado-Aros S, Talley NJ. Functional dyspepsia: drugs for new (and old) therapeutic targets. Best Pract Res Clin Gastroenterol 2004; 18:717-33. [PMID: 15324710 DOI: 10.1016/j.bpg.2004.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The therapeutic management of functional dyspepsia remains a major challenge for the gastroenterologist. Current therapies available are based on putative underlying pathophysiologic mechanisms, including gastric acid sensitivity, slow gastric emptying and Helicobacter pylori infection, but only a small proportion of patients achieve symptomatic benefit from these therapeutic approaches. Relatively novel mechanistic concepts under testing include impaired gastric accomodation, visceral hypersensitivity, and central nervous system dysfunction. Serotonergic modulators (e.g. the 5-HT4 agonist tegaserod, the 5-HT3 antagonist alosetron and the 5-HT1P agonist sumatriptan), CCK-1 antagonists (e.g. dexloxiglumide), opioid agonists (e.g. asimadoline), N-methyl-D-aspartate (NMDA) receptor antagonists (e.g dextromethorphan), neurokinin antagonists (e.g. talnetant), capsaicin-like agents and antidepressants are among the agents currently under investigation. It seems unlikely, however, that targeting a single mechanism with an individual drug will result in complete symptom remission in most cases.
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Affiliation(s)
- Filippo Cremonini
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic College of Medicine, Charlton 8-138, 200 First Street SW, Rochester MN 55905, USA
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Berman DA, Porter RS, Graber M. The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial. J Emerg Med 2003; 25:239-44. [PMID: 14585449 DOI: 10.1016/s0736-4679(03)00196-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The "GI Cocktail" is a mixture of medications often given in the Emergency Department (ED) for dyspepsia symptoms. Several combinations are used, but the most effective has not yet been determined. This study compared three combinations commonly given for dyspepsia. The study was a prospective, randomized, double-blinded trial comparing antacid (group 1); antacid + Donnatal (group 2); antacid + Donnatal + viscous lidocaine (group 3) for acute treatment of dyspepsia in the ED. Patients were randomly assigned to receive one of the three medication combinations. Patients rated their discomfort on a Visual Analog Scale (VAS) immediately before receiving the medication and 30 min later. Change in VAS was the primary study endpoint. A 13-mm difference in VAS was considered clinically significant. VAS change in the three groups was compared using multivariable regression, controlling for pretreatment VAS, study drug, previous antacid use, and gastrointestinal (GI) history. One hundred twenty patients were enrolled between July and December 2000. One hundred thirteen subjects (113) completed the protocol: Group 1 (N = 38); Group 2 (N = 37); Group 3 (N = 38). There was no statistically significant difference between the groups in terms of age, gender, GI history, previous antacid use, or initial degree of pain. Group 1 had a 25 +/- 27 mm mean (+/- SD), decrease in pain; Group 2, 23 +/- 22 mm decrease; and Group 3, 24 +/- 26 mm decrease. There was no statistically significant difference in pain relief between the three groups on univariate analysis or multivariable regression. In conclusion, the addition of Donnatal or Donnatal + lidocaine to an antacid did not relieve dyspepsia better than plain antacid. The "GI Cocktail" concoction may not be necessary.
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Affiliation(s)
- Dean A Berman
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
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Moayyedi P, Soo S, Deeks J, Forman D, Harris A, Innes M, Delaney B. Systematic review: Antacids, H2-receptor antagonists, prokinetics, bismuth and sucralfate therapy for non-ulcer dyspepsia. Aliment Pharmacol Ther 2003; 17:1215-27. [PMID: 12755835 DOI: 10.1046/j.1365-2036.2003.01575.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Evidence for the effectiveness of antacids, histamine-2 receptor antagonists, bismuth salts, sucralfate and prokinetic therapy in non-ulcer dyspepsia is conflicting. AIM To conduct a systematic review evaluating these therapies in non-ulcer dyspepsia. METHODS Electronic searches were performed using the Cochrane Controlled Trials Register, Medline, EMBASE, Cinahl and SIGLE until September 2002. Dyspepsia outcomes were dichotomized into cured/improved vs. same/worse. RESULTS Prokinetics [14 trials, 1053 patients; relative risk reduction (RRR), 48%; 95% confidence interval (95% CI), 27-63%] and histamine-2 receptor antagonists (11 trials, 2164 patients; RRR, 22%; 95% CI, 7-35%) were significantly more effective than placebo. Bismuth salts (RRR, 40%; 95% CI, - 3% to 65%) were superior to placebo, but this was of marginal statistical significance. Antacids and sucralfate were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic and histamine-2 receptor antagonist results could be due to publication bias. CONCLUSIONS The meta-analyses suggest that histamine-2 receptor antagonists and prokinetics are superior to placebo. These data are difficult to interpret, however, as funnel plot asymmetry suggests that the magnitude of the effect could be due to publication bias or other heterogeneity-related issues.
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Affiliation(s)
- P Moayyedi
- Gastroenterology Unit, City Hospital NHS Trust, Birmingham, UK.
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Abeygunasekera S, Talley NJ. Management of dyspepsia. COMPREHENSIVE THERAPY 2003; 28:182-9. [PMID: 12360630 DOI: 10.1007/s12019-002-0027-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Proper management of uninvestigated dyspepsia is a challenging task for any clinician. Efficient and cost-effective management of such patients requires careful history taking and awareness of the available options.
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Affiliation(s)
- Shehan Abeygunasekera
- Department of Medicine, University of Sydney, Nepean Hospital, PO Box 63, Penrith, NSW 2751, Australia
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Abstract
Dyspepsia, defined as pain or discomfort centered in the upper abdomen, affects an estimated 25% of the U.S. population each year; accounts for up to 5% of all visits to primary care physicians, and generates over $1.3 billion in prescription drug costs annually. In the majority of patients evaluated, no clear cause of symptoms can be identified, and the condition is termed functional or nonulcer dyspepsia (NUD). The pathophysiology of NUD remains unclear, but disturbances in gastrointestinal motility or sensation are often found. Clinically, NUD can be subdivided into dysmotility-like (in which discomfort, fullness, bloating, early satiety, or nausea [but not pain] predominate) or ulcer-like (in which epigastric pain is predominant). In ulcer-like NUD, antisecretory therapy is useful, but in dysmotility-like NUD, acid suppression is not superior to placebo. Cisapride accelerates gastric emptying and enhances gastric accommodation but probably does not blunt perception. Although cisapride relieves symptoms of dyspepsia without the adverse central nervous system effects often associated with metoclopramide, its cardiac toxicity has led to disuse. Antidepressants are of uncertain efficacy but are widely used. New prokinetics and other enteric neuromodulating agents are being tested in NUD and are likely to find an important place in clinical practice in the future.
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Affiliation(s)
- N J Talley
- Department of Medicine, Nepean Hospital, Kingswood, Australia.
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Flockhart DA, Desta Z, Mahal SK. Selection of drugs to treat gastro-oesophageal reflux disease: the role of drug interactions. Clin Pharmacokinet 2000; 39:295-309. [PMID: 11069215 DOI: 10.2165/00003088-200039040-00005] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Gastro-oesophageal reflux disease is probably the most common acid-peptic disease in Western countries, and the successful treatment of mild to moderate disease with pharmacotherapy has become commonplace. A large number of effective drugs are now available, and so the decision-making process for physicians increasingly relies on considerations other than pure efficacy. Cost, adverse effects and drug interactions have therefore become important, particularly in the most vulnerable patients - children, the elderly and patients who are ill and are taking medications that may influence the efficacy of antireflux therapy. Important drug interactions with antacids include the prevention of the absorption of antibacterials such as tetracycline, azithromycin and quinolones. H2 antagonists, proton pump inhibitors and prokinetic agents undergo metabolism by the cytochrome P450 (CYP) system present in the liver and gastrointestinal tract. Cimetidine is an inhibitor of CYP3A and it may cause significant interactions with drugs of narrow therapeutic range and low bioavailability that are metabolised by these enzymes. The gastroparietal proton pump inhibitors lansoprazole, omeprazole and pantoprazole are all primarily metabolised by a genetically polymorphic enzyme, CYP2C19, that is absent from approximately 3% of Caucasians and 20% of Asians. These drugs may also interact with CYP3A, but to a lesser extent. Interactions with prokinetic agents carry the greatest potential for harm. Metoclopramide is a dopamine antagonist that may cause extrapyramidal effects when administered alone at high concentrations, or when coadministered with antipsychotic agents such as haloperidol or phenothiazines. Cisapride is clearly able to prolong the electrocardiographic QT interval and cause lethal ventricular arrhythmias when its metabolism is slowed by interaction with inhibitors of CYP3A, such as erythromycin, ketoconazole or itraconazole.
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Affiliation(s)
- D A Flockhart
- Division of Clinical Pharmacology, Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA.
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Lu CL, Chang FY, Chen TS, Chen CY, Jiun KL, Lee SD. Helicobacter pylori colonization does not influence the symptomatic response to prokinetic agents in patients with functional dyspepsia. J Gastroenterol Hepatol 1998; 13:500-4. [PMID: 9641648 DOI: 10.1111/j.1440-1746.1998.tb00676.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Functional dyspepsia (FD) is very common, but the pathogenesis of Helicobacter pylori leading to FD is still debated. The aim of this study was first to evaluate the impact of H. pylori colonization on the efficacy of Paspertase (a metoclopramide plus exogenous enzymes regimen for FD patients) and, second, to compare the prevalence of H. pylori infection in FD patients with the general population. Seventy-four consecutive FD patients were enrolled undergoing Paspertase treatment. The symptomatic response was evaluated according to 1-4 scales of six main dyspeptic symptoms (i.e. epigastric pain/discomfort, early satiety, heartburn, nausea/vomiting, abdominal fullness/bloating, and belching). Nine hundred and seventy healthy subjects undergoing a paid physical check-up were included to study the status of H. pylori colonization. The demographic data and basal symptom scores between 43 H. pylori-positive and 31 H. pylori-negative patients were not significantly different. Total and individual symptom scores improved significantly after 4 weeks of Paspertase therapy (P < 0.05), irrespective of H. pylori infection. The prevalences of H. pylori were very similar in FD patients and the general population (58.1 vs 58.0%, NS). In conclusion, these observations suggest that H. pylori colonization is not significant in FD patients of Taiwan while a short-term prokinetic medication is effective for these patients, irrespective of H. pylori status.
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Affiliation(s)
- C L Lu
- Department of Medicine, Veterans General Hospital-Taipei and National Yang-Ming University, School of Medicine, Taiwan, ROC
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21
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Talley NJ, Lam SK, Goh KL, Fock KM. Management guidelines for uninvestigated and functional dyspepsia in the Asia-Pacific region: First Asian Pacific Working Party on Functional Dyspepsia. J Gastroenterol Hepatol 1998; 13:335-53. [PMID: 9641295 DOI: 10.1111/j.1440-1746.1998.tb00644.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Dyspepsia is most optimally defined as pain or discomfort centred in the upper abdomen. The symptom complex may be caused by peptic ulcer disease, gastro-oesophageal reflux, or gastric cancer but is most often due to functional (or non-ulcer) dyspepsia. While upper endoscopy is the method of choice to determine the underlying cause of dyspepsia, it is expensive. A more pragmatic approach is needed in the Asia Pacific region where health services are limited. A detailed treatment algorithm is given for managing patients presenting with new-onset dyspepsia and documented functional dyspepsia after endoscopy, and evidence to support this approach is reviewed. Prompt endoscopy is recommended for patients with alarm features. In patients without alarm features, treatment for 2-4 weeks with an empirical anti-secretory or prokinetic agent, followed by investigation using non-invasive Helicobacter pylori testing and treatment for patients who do not respond or relapse, is recommended. Trials of management strategies are now needed to establish the efficacy and cost-effectiveness of the approaches recommended.
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Affiliation(s)
- N J Talley
- Department of Medicine, University of Sydney, Nepean Hospital, New South Wales, Australia.
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Cutts TF, Abell TL, Karas JG, Kuns J. Symptom improvement from prokinetic therapy corresponds to improved quality of life in patients with severe dyspepsia. Dig Dis Sci 1996; 41:1369-78. [PMID: 8689913 DOI: 10.1007/bf02088561] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Prokinetic therapy has been shown to improve patients' symptoms associated with gastrointestinal motility disorders and quality of life. This study investigated the correlation between clinical improvement and quality of life after 12 months of treatment with cisapride or domperidone in patients with severe dyspepsia. Psychological and quality-of-life measures were assessed at baseline and after 12 months of therapy using three patient-administered, standardized questionnaires: the Minnesota Multiphasic Personality Inventory, the Millon Behavioral Health Inventory, and the Sickness Impact Profile. Changes in clinical symptoms were correlated with changes in these measures. Twenty-seven patients with symptoms of severe dyspepsia were treated with cisapride or domperidone (60-80 mg/day) for 12 months. Symptoms and quality-of-life measures were improved at the end of therapy. There were significant correlations between improvement in clinical symptoms and improvement in quality of life parameters. Patients with more marked symptom improvement had more significant improvements in quality of life measures. We conclude that prokinetic therapy improved symptoms and quality of life. Standardized questionnaires can be used to quantify response to prokinetic therapy and to individualize treatment regimens for patients with dyspepsia who have specific psychologic or behavioral characteristics.
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Affiliation(s)
- T F Cutts
- Department of Medicine, Gastroenterology Division, University of Tennessee, Memphis, USA
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Abstract
In patients who present with chronic unexplained upper abdominal pain or discomfort (functional dyspepsia), therapy should ideally be targeted on correcting the individual's disturbed pathophysiology. Here, putative mechanisms implicated in functional dyspepsia and potential approaches to therapy are critically reviewed in order to determine if targeting treatment is of value. Pharmacological therapies reviewed include those that aim to correct disordered gastric emptying (e.g. cisapride, dopaminergic receptor antagonists, macrolides), reduce visceral hypersensitivity (e.g. somatostatin analogues, cholecystokinin antagonists, opioid agonists, serotonin type 3 receptor antagonists), reduce gastric acid secretion (e.g. H2-blockers, acid pump inhibitors), cure Helicobacter pylori infection, enhance muscosal defence (e.g. sucralfate, bismuth) or modify central nervous system processes. It is concluded that the imperfectly understood pathophysiology of functional dyspepsia contributes to the paucity of established efficacious therapies.
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Affiliation(s)
- N J Talley
- University of Sydney, Nepean Hospital, Penrith, NSW, Australia
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Wiseman LR, Faulds D. Cisapride. An updated review of its pharmacology and therapeutic efficacy as a prokinetic agent in gastrointestinal motility disorders. Drugs 1994; 47:116-52. [PMID: 7510617 DOI: 10.2165/00003495-199447010-00008] [Citation(s) in RCA: 175] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- L R Wiseman
- Adis International Limited, Auckland, New Zealand
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