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Ayoub M, Faris C, Tomanguillo J, Anwar N, Chela H, Daglilar E. The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study. Life (Basel) 2024; 14:526. [PMID: 38672796 PMCID: PMC11051147 DOI: 10.3390/life14040526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin. METHODS We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. RESULTS Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. CONCLUSIONS The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.
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Affiliation(s)
- Mark Ayoub
- Department of Internal Medicine, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Carol Faris
- Department of General Surgery, Marshall University, Huntington, WV 25755, USA;
| | - Julton Tomanguillo
- Department of Internal Medicine, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Nadeem Anwar
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Harleen Chela
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Ebubekir Daglilar
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
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2
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Ahmed MSO, Forde H, Smith D. Diabetic gastroparesis: clinical features, diagnosis and management. Ir J Med Sci 2023; 192:1687-1694. [PMID: 36266392 DOI: 10.1007/s11845-022-03191-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 10/09/2022] [Indexed: 11/07/2022]
Abstract
Diabetic gastroparesis carries a heavy burden on people with diabetes and the healthcare system. It remains underdiagnosed and represents challenges to treat. This article reviews the epidemiology, pathophysiology, clinical features, diagnosis and treatment of diabetic gastroparesis. The disorder is characterized by delayed gastric emptying without evidence of mechanical gastric outflow obstruction. It presents with upper gastrointestinal (GI) symptoms such as nausea, vomiting, early satiety, postprandial fullness, upper abdominal discomfort and or bloating. As the prevalence of diabetes has been growing over the last few decades, we would expect an increased incidence of delayed gastric emptying in poorly controlled diabetes and perhaps in line with the increasing use of medications that act on the GI tract such as incretin-based therapy. The disease results from multiple reversible and irreversible mechanisms. Diagnosing diabetic gastroparesis requires careful history, examination and investigations to exclude other disorders that could mimic its clinical presentation. Treatment involves a wide variety of options starting with optimization of glycaemic control, stopping any offending medications and lifestyle modifications followed by the introduction of medical therapeutics such as prokinetics. Then, surgical interventions are considered in refractory cases.
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Affiliation(s)
- Mohammed S O Ahmed
- Academic Department of Diabetes and Endocrinology, Beaumont Hospital, The Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Hannah Forde
- Academic Department of Diabetes and Endocrinology, Beaumont Hospital, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Diarmuid Smith
- Academic Department of Diabetes and Endocrinology, Beaumont Hospital, The Royal College of Surgeons in Ireland, Dublin, Ireland
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3
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Sanger GJ, Andrews PLR. Review article: An analysis of the pharmacological rationale for selecting drugs to inhibit vomiting or increase gastric emptying during treatment of gastroparesis. Aliment Pharmacol Ther 2023; 57:962-978. [PMID: 36919196 DOI: 10.1111/apt.17466] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Drugs which can inhibit nausea/vomiting and/or increase gastric emptying are used to treat gastroparesis, mostly 'off-label'. Within each category, they act at different targets and modulate different physiological mechanisms. AIMS Address the questions: In gastroparesis, why should blocking one pathway causing vomiting, be more appropriate than another? Why might increasing gastric emptying via one mechanism be more appropriate than another? METHODS Drugs used clinically were identified via consensus opinions and reviews, excluding the poorly characterised. Their pharmacology was defined, mapped to mechanisms influencing vomiting and gastric emptying, and rationale developed for therapeutic use. RESULTS Vomiting: Rationale for 5-HT3 , D2 , H1 or muscarinic antagonists, and mirtazapine, amitriptyline, nortriptyline, are poor. Arguments for inhibiting central consequences of vagal afferent transmission by NK1 antagonism are complicated by doubts over effects on nausea. Gastric emptying: Confusion emerges because of side-effects of drugs increasing gastric emptying: Metoclopramide (5-HT4 agonist, D2 and 5-HT3 antagonist; also blocks some emetic stimuli and causes tardive dyskinesia) and Erythromycin (high-efficacy motilin agonist, requiring low doses to minimise side-effects). Limited trials with selective 5-HT4 agonists indicate variable efficacy. CONCLUSIONS Several drug classes inhibiting vomiting have no scientific rationale. NK1 antagonism has rationale but complicated by limited efficacy against nausea. Studies must resolve variable efficacy of selective 5-HT4 agonists and apparent superiority over motilin agonists. Overall, lack of robust activity indicates a need for novel approaches targeting nausea (e.g., modulating gastric pacemaker or vagal activity, use of receptor agonists or new targets such as GDF15) and objective assessments of nausea.
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Affiliation(s)
- Gareth J Sanger
- Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London, UK
| | - Paul L R Andrews
- Division of Biomedical Sciences, St George's University of London, London, UK
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4
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Bassotti G, Usai Satta P, Berti G, Lai M, Villanacci V, Bellini M. Pharmacotherapeutic advances for chronic idiopathic constipation in adults. Expert Opin Pharmacother 2022; 23:2053-2078. [PMID: 36408585 DOI: 10.1080/14656566.2022.2150076] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Gabrio Bassotti
- Gastroenterology, Hepatology & Digestive Endoscopy Section, Department of Medicine and Surgery, University of Perugia
- Gastroenterology & Hepatology Unit, Perugia General Hospital, Perugia, Italy
| | | | - Ginevra Berti
- Gastrointestina Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Mariantonia Lai
- Gastroenterology Unit, University of Cagliari, Monserrato, Italy
| | | | - Massimo Bellini
- Gastrointestina Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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5
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Gastroparesis in pregnancy. Am J Obstet Gynecol 2022; 228:382-394. [PMID: 36088986 DOI: 10.1016/j.ajog.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/21/2022] [Accepted: 09/05/2022] [Indexed: 01/30/2023]
Abstract
Gastroparesis is a functional gastrointestinal disorder that more commonly affects women, with most cases being diagnosed during childbearing age. However, there is a paucity of data and guidelines to specifically highlight the epidemiology, disease course, maternal and fetal impact, and the management of existing gastroparesis during pregnancy. Apart from metoclopramide, there is no approved therapy specifically indicated for gastroparesis. More importantly, pregnant and breastfeeding women are excluded from clinical trials evaluating pharmacologic agents in the management of gastroparesis. This poses a real challenge to healthcare providers in counseling and managing patients with gastroparesis. In this systematic review, we summarize the current available literature and the knowledge gaps in the impact of pregnancy on gastroparesis and vice versa. We also highlight the efficacy and safety profiles of available pharmacologic and nonpharmacologic therapies in the management of patients with gastroparesis, with emphasis on judicious use of dietary approaches that are deemed relatively safe during pregnancy.
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6
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Huang B, Li M, Klongkumnuankarn P, Mendez RE, Gillespie JC, Stevens DL, Dewey WL, Selley DE, Zhang Y. Rational Design, Chemical Syntheses, and Biological Evaluations of Peripherally Selective Mu Opioid Receptor Ligands as Potential Opioid Induced Constipation Treatment. J Med Chem 2022; 65:4991-5003. [PMID: 35255683 PMCID: PMC10546485 DOI: 10.1021/acs.jmedchem.1c02185] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Opioid-induced constipation (OIC) is a common adverse effect of opioid analgesics. Peripherally acting μ opioid receptor antagonists (PAMORAs) can be applied in the treatment of OIC without compromising the analgesic effects. NAP, a 6β-N-4-pyridyl-substituted naltrexamine derivative, was previously identified as a potent and selective MOR antagonist mainly acting peripherally but with some CNS effects. Herein, we introduced a highly polar aromatic moiety, for example, a pyrazolyl or imidazolyl ring to decrease CNS MPO scores in order to reduce passive BBB permeability. Four compounds 2, 5, 17, and 19, when administered orally, were able to increase intestinal motility during morphine-induced constipation in the carmine red dye assays. Among them, compound 19 (p.o.) improved GI tract motility by 75% while orally administered NAP and methylnaltrexone showed no significant effects at the same dose. Thus, this compound seemed a promising agent to be further developed as an oral treatment for OIC.
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Affiliation(s)
- Boshi Huang
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
| | - Mengchu Li
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
| | - Pornprom Klongkumnuankarn
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
| | - Rolando E Mendez
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - James C Gillespie
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - David L Stevens
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - William L Dewey
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - Dana E Selley
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - Yan Zhang
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
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7
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Czerniak R, Cieslarová B, Kupčová V, Rosario M, Lock R, Dong C, Dukes G. The Effect of Hepatic Impairment on the Pharmacokinetics of Intravenously Administered Felcisetrag (TAK‐954). J Clin Pharmacol 2022; 62:1006-1017. [PMID: 35253917 PMCID: PMC9542772 DOI: 10.1002/jcph.2044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Indexed: 11/29/2022]
Abstract
Felcisetrag (formerly known as TAK‐954) is a selective serotonin receptor agonist under investigation for use in patients with postoperative gastrointestinal dysfunction. The safety, tolerability, and pharmacokinetics (PK) of intravenous (i.v.) felcisetrag have been studied, but little is known about the effect of hepatic impairment on the PK of the drug. This phase 1, non‐randomized, open‐label study compared the PK of a single 60‐minute i.v. infusion of felcisetrag between healthy individuals (n = 8) and patients with moderate (n = 10) or severe (n = 7) hepatic impairment. The primary study end points were the total and free maximum observed plasma concentration of felcisetrag at the end of infusion (Cmax), area under the concentration–time curve (AUC) from time 0 to the time of the last quantifiable concentration (AUClast), and AUC from time 0 to infinity (AUCinf). Concentration–time profiles of felcisetrag were similarly shaped between groups but revealed lower concentrations of total plasma felcisetrag with increasing severity of hepatic impairment, whereas concentrations of free felcisetrag increased. The ratios of AUClast and AUCinf for patients with severe hepatic impairment were up to 29.3% lower for total felcisetrag and up to 29.2% higher for free felcisetrag than found in healthy individuals (P < .05). Infusions were well tolerated with no discontinuations, severe adverse events, or deaths during the study. Overall, the effect of hepatic impairment on exposure to felcisetrag was minimal, suggesting that dose adjustment may be unnecessary in patients with hepatic impairment.
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Affiliation(s)
- Richard Czerniak
- Takeda Pharmaceuticals International Co.CambridgeMassachusettsUSA
| | | | - Viera Kupčová
- Third Department of Internal MedicineFaculty of MedicineUniversity HospitalComenius UniversityBratislavaSlovakia
| | - Maria Rosario
- Takeda Pharmaceuticals International Co.CambridgeMassachusettsUSA
| | | | - Cheng Dong
- Takeda Pharmaceuticals International Co.CambridgeMassachusettsUSA
| | - George Dukes
- Takeda Pharmaceuticals International Co.CambridgeMassachusettsUSA
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8
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Pusalkar S, Chowdhury SK, Czerniak R, Zhu X, Li Y, Balani SK, Ramsden D. Clinical and Nonclinical Disposition and In Vitro Drug-Drug Interaction Potential of Felcisetrag, a Highly Selective and Potent 5-HT 4 Receptor Agonist. Eur J Drug Metab Pharmacokinet 2022; 47:371-386. [PMID: 35157234 PMCID: PMC9050781 DOI: 10.1007/s13318-021-00751-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Felcisetrag (previously TAK-954 or TD-8954) is a highly selective and potent 5-HT4 receptor agonist in clinical development for prophylaxis and treatment of postoperative gastrointestinal dysfunction (POGD). The rat, dog, and human absorption, distribution, metabolism, and excretion (ADME) properties of felcisetrag were investigated. METHODS The metabolism and victim and perpetrator drug interaction potentials towards cytochrome P450s (CYP) and transporters were determined using in vitro models. The excretion, metabolite profile, and pharmacokinetics were determined during unlabeled and radiolabeled ADME studies in rat and dog for comparison with human. Due to a low clinical dose (0.5 mg) and radioactivity (~ 1.5 μCi), a combination of liquid scintillation counting and accelerator mass spectrometry was used for analysis of samples in this study. RESULTS The ADME properties, including metabolite profile, for felcisetrag are generally conserved across species. Felcisetrag is primarily cleared through renal excretion (0.443) and metabolism in humans (0.420), with intact parent as the predominant species in circulation. There are multiple metabolites, each representing < 10% of the circulating radioactivity, confirming no metabolites in safety testing (MIST) liabilities. Metabolites were also detected in animals. The potential for major CYP- and transporter-based drug-drug interaction (DDI) of felcisetrag as a victim or perpetrator is considered to be low. CONCLUSIONS Felcisetrag is primarily cleared in humans through renal excretion. Although the metabolism of felcisetrag is primarily through CYP3A, the potential for clinically relevant DDI as a victim is significantly reduced as metabolism plays a minor role in the overall clearance.
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Affiliation(s)
- Sandeepraj Pusalkar
- Global; Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., 35 Landsdowne Street, Cambridge, MA, 02139, USA.,Servier Pharmaceuticals, Cambridge, MA, USA
| | - Swapan K Chowdhury
- Global; Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., 35 Landsdowne Street, Cambridge, MA, 02139, USA.,Boston Pharmaceuticals, Cambridge, MA, USA
| | - Richard Czerniak
- Global; Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., 35 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Xiaochun Zhu
- Global; Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., 35 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Yuexian Li
- Global; Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., 35 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Suresh K Balani
- Global; Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., 35 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Diane Ramsden
- Global; Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., 35 Landsdowne Street, Cambridge, MA, 02139, USA. .,AstraZeneca, Waltham, MA, USA.
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9
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Chen C, Zhang L, Almansa C, Rosario M, Cwik M, Balani SK, Lock R. Evaluation of the Pharmacokinetics of Felcisetrag (TAK-954), a 5-HT 4 Receptor Agonist, in the Presence and Absence of Itraconazole, a Potent CYP3A4 Inhibitor. Clin Pharmacol Drug Dev 2022; 11:142-149. [PMID: 34989180 DOI: 10.1002/cpdd.1046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/10/2021] [Indexed: 12/12/2022]
Abstract
The 5-hydroxytryptamine type-4 receptor agonist felcisetrag (TAK-954) is being investigated for improving gastrointestinal motility in postoperative gastrointestinal dysfunction. Polypharmacy often occurs in this setting, and as in vitro data indicate, felcisetrag is primarily metabolized by cytochrome P450 (CYP) 3A4, its CYP3A4-mediated drug-drug interaction potential requires consideration. This phase 1, fixed-sequence, open-label, crossover trial (ClinicalTrials.gov identifier NCT03173170) investigated the effect of itraconazole, a potent CYP3A4 inhibitor, on felcisetrag pharmacokinetics in healthy adults. Over 2 study periods (period 1, 6 days; period 2, 9 days), participants received a single felcisetrag 0.2-mg intravenous dose (day 1, period 1; and day 4, period 2), and once-daily oral itraconazole 200-mg doses (days 1-8, period 2). For felcisetrag alone, felcisetrag total systemic exposure was lower than with itraconazole coadministration. The geometric mean ratio for area under the plasma concentration-time curve from time 0 to infinity of felcisetrag plus itraconazole: felcisetrag alone was 1.49 (90% confidence interval, 1.39-1.60). Peak exposure was similar between regimens (geometric mean ratio, 1.06; 90% confidence interval, 0.96-1.18), and both treatments were well tolerated. These data suggest limited CYP3A4-mediated drug-drug interaction inhibition for felcisetrag.
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Affiliation(s)
- Chunlin Chen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA.,Bayer Pharmaceuticals, Whippany, New Jersey, USA
| | - Liming Zhang
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Cristina Almansa
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA.,Ironwood Pharmaceuticals, Boston, Massachusetts, USA
| | - Maria Rosario
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA.,Syros Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Michael Cwik
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Suresh K Balani
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
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10
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Camilleri M. New Drugs on the Horizon for Functional and Motility Gastrointestinal Disorders. Gastroenterology 2021; 161:761-764. [PMID: 33989661 PMCID: PMC8380736 DOI: 10.1053/j.gastro.2021.04.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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11
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Camilleri M, Atieh J. New Developments in Prokinetic Therapy for Gastric Motility Disorders. Front Pharmacol 2021; 12:711500. [PMID: 34504426 PMCID: PMC8421525 DOI: 10.3389/fphar.2021.711500] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/10/2021] [Indexed: 12/13/2022] Open
Abstract
Prokinetic agents amplify and coordinate the gastrointestinal muscular contractions to facilitate the transit of intra-luminal content. Following the institution of dietary recommendations, prokinetics are the first medications whose goal is to improve gastric emptying and relieve symptoms of gastroparesis. The recommended use of metoclopramide, the only currently approved medication for gastroparesis in the United States, is for a duration of less than 3 months, due to the risk of reversible or irreversible extrapyramidal tremors. Domperidone, a dopamine D2 receptor antagonist, is available for prescription through the FDA's program for Expanded Access to Investigational Drugs. Macrolides are used off label and are associated with tachyphylaxis and variable duration of efficacy. Aprepitant relieves some symptoms of gastroparesis. There are newer agents in the pipeline targeting diverse gastric (fundic, antral and pyloric) motor functions, including novel serotonergic 5-HT4 agonists, dopaminergic D2/3 antagonists, neurokinin NK1 antagonists, and ghrelin agonist. Novel targets with potential to improve gastric motor functions include the pylorus, macrophage/inflammatory function, oxidative stress, and neurogenesis. In the current review, we discuss the use of pharmacological approaches with potential to enhance motor functions in the management of gastroparesis.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
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12
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Elfers K, Armbrecht Y, Mazzuoli-Weber G. Good to Know: Baseline Data on Feed Intake, Fecal Pellet Output and Intestinal Transit Time in Guinea Pig as a Frequently Used Model in Gastrointestinal Research. Animals (Basel) 2021; 11:1593. [PMID: 34071498 PMCID: PMC8227794 DOI: 10.3390/ani11061593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/13/2021] [Accepted: 05/26/2021] [Indexed: 12/11/2022] Open
Abstract
Guinea pigs are a traditional and frequently used species in gastrointestinal research. Comprehensive knowledge of basic parameters connected with their intestinal function, such as feed intake, fecal pellet output and gastrointestinal transit time, is important for evaluating results from basic gastrointestinal research that may be applied to practical problems in human and veterinary medicine, for example, when establishing diagnostic tools. Our study revealed that over a 24-h period, single-housed guinea pigs showed a continual but day-accentuated feeding activity, consuming 57% of the total feed during the light period, with pronounced peaks of feed intake during the beginning and end of the light period. This was mirrored by fecal pellet output during the light period and almost no defecation during the dark period, while potential coprophagy not measured in this study needs to be considered. A highly comparable feeding activity was recorded in pair-housed guinea pigs, with 60% of overall feed intake within the light period, indicating that such differences in housing conditions did not influence guinea pigs' feeding behavior. Intestinal transit time was successfully recorded by oral administration of carmine red and counted 5 h on average. Hence, this study provides important information on the basic functional parameters of guinea pigs' gastrointestinal tract physiology.
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Affiliation(s)
- Kristin Elfers
- Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, 30173 Hannover, Germany; (Y.A.); (G.M.-W.)
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13
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Chedid V, Brandler J, Arndt K, Vijayvargiya P, Wang XJ, Burton D, Harmsen WS, Siegelman J, Chen C, Chen Y, Almansa C, Dukes G, Camilleri M. Randomised study: effects of the 5-HT 4 receptor agonist felcisetrag vs placebo on gut transit in patients with gastroparesis. Aliment Pharmacol Ther 2021; 53:1010-1020. [PMID: 33711180 PMCID: PMC8251541 DOI: 10.1111/apt.16304] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/27/2020] [Accepted: 02/09/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastroparesis is defined by delayed gastric emptying with associated symptoms in the absence of mechanical obstruction. AIM To evaluate pharmacokinetics and pharmacodynamics of felcisetrag, a highly selective 5-HT4 receptor agonist, on total gut transit in patients with documented delayed gastric emptying of solids. METHODS Single-centre, placebo-controlled study of 36 participants receiving placebo, 0.1mg, 0.3mg or 1.0mg of felcisetrag I.V. infusion, daily, for 3 days. At baseline, each participant completed a 4h, 99m Tc-egg meal (300 kcal, 30% fat) gastric emptying test. Following infusion (Day 2), gastric, small bowel and colonic transit of solids were measured over 48h (same meal plus 111 In-charcoal delivered in methacrylate-coated capsule). Samples were collected for pharmacokinetics. The primary endpoint was gastric emptying T1/2 . Statistical analysis used baseline parameters as covariates (ANCOVA). RESULTS Patients (22 idiopathic, 14 diabetic gastroparesis) were randomised to felcisetrag (0.1 mg, n = 10; 0.3 mg, n = 9; 1.0 mg, n = 7) or placebo (n = 10). Compared to placebo, felcisetrag significantly accelerated gastric emptying T1/2 , colonic filling at 6h, and 10% small bowel transit time (overall P < 0.01; all three doses individually Bonferroni corrected P < 0.05) for all three measurements. Ascending colon emptying (T1/2 ) was significantly accelerated (all doses), and colonic transit at 48 hours was accelerated with 0.1 mg and 0.3 mg felcisetrag compared to placebo. Pharmacokinetic results were dose proportional. Felcisetrag was well tolerated with no clinically significant findings from clinical laboratory, vital signs or ECG. CONCLUSION I.V. felcisetrag significantly accelerated gastric, small bowel and colonic transit in patients with gastroparesis, and should be further evaluated for short-term treatment of gastric and intestinal motility disorders. ClinicalTrials.gov #NCT03281577.
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Affiliation(s)
- Victor Chedid
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | - Justin Brandler
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | - Kayla Arndt
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | - Priya Vijayvargiya
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | - Xiao Jing Wang
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | - Duane Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | - W. Scott Harmsen
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | | | - Chunlin Chen
- Takeda Pharmaceuticals International CoCambridgeMAUSA
| | - Yinzhong Chen
- Takeda Pharmaceuticals International CoCambridgeMAUSA
| | | | - George Dukes
- Takeda Pharmaceuticals International CoCambridgeMAUSA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER)Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
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Mazzotta E, Villalobos-Hernandez EC, Fiorda-Diaz J, Harzman A, Christofi FL. Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols. Front Pharmacol 2020; 11:583422. [PMID: 33390950 PMCID: PMC7774512 DOI: 10.3389/fphar.2020.583422] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022] Open
Abstract
Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.
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Affiliation(s)
- Elvio Mazzotta
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | | | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alan Harzman
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Fievos L. Christofi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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15
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Das R, Wille L, Zhang L, Chen C, Winchester W, Selimkhanov J, Wykosky J, Apgar JF, Burke JM, Rogge M, Hua F, Vakilynejad M. A quantitative systems pharmacology model of colonic motility with applications in drug development. J Pharmacokinet Pharmacodyn 2019; 46:485-498. [DOI: 10.1007/s10928-019-09651-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 08/09/2019] [Indexed: 12/17/2022]
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16
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Jeong EJ, Chung SY, Hong HN, Oh SW, Sim JY. The novel, potent and highly selective 5-HT 4 receptor agonist YH12852 significantly improves both upper and lower gastrointestinal motility. Br J Pharmacol 2018; 175:485-500. [PMID: 29139561 DOI: 10.1111/bph.14096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 10/27/2017] [Accepted: 10/31/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE 5-HT4 receptor agonists have been shown to be effective at treating various gastrointestinal tract disorders. However, a lack of selectivity against off-targets has been a limiting factor for their clinical use. EXPERIMENTAL APPROACH The binding affinity and selectivity of YH12852 for human 5-HT4(a) receptor in CHO-K1 cells were evaluated using radioligand binding assays, and agonistic activity was assessed using a β-lactamase reporter system. Contractile activity and propulsive motility were measured in the guinea pig isolated distal colon. Its prokinetic effect on the gastrointestinal tract was evaluated in guinea pigs, dogs and monkeys. Its tissue distribution was evaluated in rats. KEY RESULTS YH12852 exhibited high affinity and potency for human recombinant 5-HT4(a) receptor with high selectivity over other 5-HT and non-5-HT receptors, ion channels, enzymes and transporters. YH12852 induced contractions and increased propulsive motility in guinea pig isolated colon. These effects were abolished by the 5-HT4 receptor antagonist GR113808. YH12852 increased defecation more effectively than prucalopride in guinea pigs and dogs and improved gastric emptying more effectively than mosapride in guinea pigs, dogs and monkeys. YH12852 was highly distributed to the gastrointestinal tract as the target organ. CONCLUSION AND IMPLICATIONS The high in vitro potency and selectivity of YH12852 for 5-HT4 receptor translated into potent in vivo efficacy with good tolerability. YH12852 significantly improved both upper and lower bowel motility in the animal models tested and has the potential to address considerable unmet needs in patients with functional constipation, gastroparesis or both.
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Affiliation(s)
- Eun Jeong Jeong
- Yuhan R&D Institute, Yongin-si, Gyeonggi-do, Republic of Korea
| | - Soo Yong Chung
- Yuhan R&D Institute, Yongin-si, Gyeonggi-do, Republic of Korea
| | - Han Na Hong
- Yuhan R&D Institute, Yongin-si, Gyeonggi-do, Republic of Korea
| | - Se-Woong Oh
- Yuhan R&D Institute, Yongin-si, Gyeonggi-do, Republic of Korea
| | - Jae Young Sim
- Yuhan R&D Institute, Yongin-si, Gyeonggi-do, Republic of Korea
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17
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Sanger GJ, Pasricha PJ. Investigational drug therapies for the treatment of gastroparesis. Expert Opin Investig Drugs 2017; 26:331-342. [PMID: 28127997 DOI: 10.1080/13543784.2017.1288214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Gastroparesis is defined by nausea, vomiting, pain, early satiety and bloating, and characterized by delayed gastric emptying without obvious structural abnormalities. Metoclopramide is widely used, increasing gastric emptying and inhibiting nausea and vomiting. Other drugs are available in certain countries and some are used 'off-label' because they increase gastric emptying or inhibit emesis. However, correlation between gastroparesis symptoms and rates of gastric emptying is poor. For anti-emetic drugs, dose-ranging and Phase III trials in gastroparesis are lacking. Areas covered: Gastric motility may still be disordered, leading to nausea, even though gastric emptying is unchanged. One hypothesis is that interstitial cells of Cajal (ICC) are damaged by diabetes leading to gastric dysrhythmia and nausea. Novel approaches to treatment of nausea also include the use of ghrelin receptor agonists, highlighting a link between appetite and nausea. Expert opinion: There is an urgent need to diversify away from historical drug targets. In particular, there is a need to control nausea by regulating ICC functions and/or by facilitating appetite via ghrelin receptor agonists. It is also important to note that different upper gastrointestinal disorders (gastroparesis, chronic unexplained nausea and vomiting, functional dyspepsia) are difficult to distinguish apart, suggesting wider therapeutic opportunity.
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Affiliation(s)
- Gareth J Sanger
- a Professor of Neuropharmacology , Blizard Institute and the National Centre for Bowel Research, Barts The London School of Medicine and Dentistry, Queen Mary University of London , London , UK
| | - Pankaj Jay Pasricha
- b Vice Chair of Medicine for Innovation and Commercialization , Johns Hopkins University School of Medicine, Director, Johns Hopkins Center for Neurogastroenterology, Professor of Medicine and Neurosciences, Professor of Innovation Management, Johns Hopkins Carey School of Business , Baltimore , MD , USA
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18
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Dalziel JE, Young W, Bercik P, Spencer NJ, Ryan LJ, Dunstan KE, Lloyd-West CM, Gopal PK, Haggarty NW, Roy NC. Tracking gastrointestinal transit of solids in aged rats as pharmacological models of chronic dysmotility. Neurogastroenterol Motil 2016; 28:1241-51. [PMID: 27028044 DOI: 10.1111/nmo.12824] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/24/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dysmotility in the gastrointestinal (GI) tract often leads to impaired transit of luminal contents leading to symptoms of diarrhea or constipation. The aim of this research was to develop a technique using high resolution X-ray imaging to study pharmacologically induced aged rat models of chronic GI dysmotility that mimic accelerated transit (diarrhea) or constipation. The 5-hydroxytryptamine type 4 (5-HT4 ) receptor agonist prucalopride was used to accelerate transit, and the opioid agonist loperamide was used to delay transit. METHODS Male rats (18 months) were given 0, 1, 2, or 4 mg/kg/day prucalopride or loperamide (in dimethyl sulfoxide, DMSO) for 7 days by continuous 7-day dosing. To determine the GI region-specific effect, transit of six metallic beads was tracked over 12 h using high resolution X-ray imaging. An established rating scale was used to classify GI bead location in vivo and the distance beads had propagated from the caecum was confirmed postmortem. KEY RESULTS Loperamide (1 mg/kg) slowed stomach emptying and GI transit at 9 and 12 h. Prucalopride (4 mg/kg) did not significantly alter GI transit scores, but at a dose of 4 mg/kg beads had moved significantly more distal than the caecum in 12 h compared to controls. CONCLUSIONS & INFERENCES We report a novel high-resolution, non-invasive, X-ray imaging technique that provides new insights into GI transit rates in live rats. The results demonstrate that loperamide slowed overall transit in aged rats, while prucalopride increased stomach emptying and accelerates colonic transit.
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Affiliation(s)
- J E Dalziel
- Food Nutrition & Health Team, Food & Bio-based Products Group, AgResearch, Palmerston North, New Zealand
| | - W Young
- Food Nutrition & Health Team, Food & Bio-based Products Group, AgResearch, Palmerston North, New Zealand
| | - P Bercik
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - N J Spencer
- School of Medicine, Flinders University, Adelaide, SA, Australia
| | - L J Ryan
- Food Nutrition & Health Team, Food & Bio-based Products Group, AgResearch, Palmerston North, New Zealand
| | - K E Dunstan
- Food Nutrition & Health Team, Food & Bio-based Products Group, AgResearch, Palmerston North, New Zealand
| | - C M Lloyd-West
- Bioinformatics Mathematics and Statistics, AgResearch, Palmerston North, New Zealand
| | - P K Gopal
- Fonterra Co-operative Group, Palmerston North, New Zealand
| | - N W Haggarty
- Fonterra Co-operative Group, Palmerston North, New Zealand
| | - N C Roy
- Food Nutrition & Health Team, Food & Bio-based Products Group, AgResearch, Palmerston North, New Zealand.,Riddet Institute, Massey University, Palmerston North, New Zealand.,Gravida: National Centre for Growth and Development, The University of Auckland, Auckland, New Zealand
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19
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Abstract
BACKGROUND Upper gastrointestinal disorders typically present with common symptoms. The most relevant non-mucosal diseases are gastroparesis, functional dyspepsia and rumination syndrome. The literature pertaining to these 3 conditions was reviewed. KEY MESSAGES Gastroparesis is characterized by delayed gastric emptying in the absence of mechanical obstruction of the stomach. The cardinal symptoms include postprandial fullness (early satiety), nausea, vomiting and bloating. The most frequently encountered causes of these symptoms are mechanical obstruction (pyloric stenosis), iatrogenic disease, gastroparesis, functional dyspepsia, cyclical vomiting and rumination syndrome. The most common causes of gastroparesis are neuropathic disorders such as diabetes, idiopathic, post-vagotomy and scleroderma among myopathic disorders. Principles of management of gastroparesis include exclusion of mechanical obstruction with imaging and iatrogenic causes with careful medication and past surgical history. Prokinetics and anti-emetics are the mainstays of treatment. Functional dyspepsia is characterized by the same symptoms as gastroparesis; in addition to delayed gastric emptying, pathophysiological abnormalities include accelerated gastric emptying, impaired gastric accommodation and gastric or duodenal hypersensitivity to distension and nutrients. Novel treatments include tricyclic antidepressants in patients with normal gastric emptying, acotiamide (acetyl cholinesterase inhibitor) and 5-HT1A receptor agonists such as buspirone. Rumination syndrome is characterized by repetitive regurgitation of gastric contents occurring within minutes after a meal. Episodes often persist for 1-2 h after the meal, and the regurgitant consists of partially digested food that is recognizable in its taste. Regurgitation is typically effortless or preceded by a sensation of belching. This has been summarized as a 'meal in, meal out, day in, day out' behavior for weeks or months, differentiating rumination from gastroparesis. Patients often have a background of psychological disorder or a prior eating disorder. Treatment is based on behavioral modification. CONCLUSION Precise identification of the cause and pathophysiology of upper gastrointestinal symptoms is essential for optimal management.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minn., USA
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20
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Lefebvre RA, Van Colen I, Pauwelyn V, De Maeyer JH. Synergistic effect between 5-HT4 receptor agonist and phosphodiesterase 4-inhibitor in releasing acetylcholine in pig gastric circular muscle in vitro. Eur J Pharmacol 2016; 781:76-82. [PMID: 27060014 DOI: 10.1016/j.ejphar.2016.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 01/14/2023]
Abstract
5-HT4 receptor agonists have a gastroprokinetic effect by facilitating acetylcholine release from cholinergic nerves innervating gastrointestinal smooth muscle. The role of phosphodiesterase (PDE) 4 in the signal transduction pathway of the 5-HT4 receptors located on the cholinergic neurons towards the circular muscle layer in pig stomach was investigated by analysis of acetylcholine release. Circular muscle strips were prepared from pig proximal stomach and tritium outflow, induced by electrical field stimulation, was studied as a marker for acetylcholine release after incubation with [(3)H]-choline. The PDE4-inhibitor roflumilast concentration-dependently (0.1-1µM) enhanced the facilitating effect of a submaximally effective concentration of the 5-HT4 receptor agonist prucalopride (0.01µM) on electrically induced acetylcholine release. Roflumilast (0.3µM) enhanced acetylcholine release per se but in the combined presence of roflumilast and prucalopride, acetylcholine release was enhanced more than the sum of the effect of the 2 compounds alone. The 5-HT4 receptor agonist velusetrag concentration-dependently (0.01-0.1µM) enhanced acetylcholine release; the effect of the minimally effective concentration (0.01µM) was significantly enhanced by 1µM of the PDE4-inhibitor rolipram, again to a level higher than the sum of the effect of the 2 compounds alone. The synergistic effect between 5-HT4 receptor agonists and PDE4-inhibitors demonstrates that the intracellular pathway of the 5-HT4 receptors located on cholinergic neurons towards pig gastric circular muscle is controlled by PDE4. Combining a 5-HT4 receptor agonist with a PDE4-inhibitor might thus enhance its gastroprokinetic effect.
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Affiliation(s)
- Romain A Lefebvre
- Heymans Institute of Pharmacology, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium.
| | - Inge Van Colen
- Heymans Institute of Pharmacology, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium
| | - Vicky Pauwelyn
- Heymans Institute of Pharmacology, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium
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21
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Valentin N, Acosta A, Camilleri M. Early investigational therapeutics for gastrointestinal motility disorders: from animal studies to Phase II trials. Expert Opin Investig Drugs 2016; 24:769-79. [PMID: 25971881 DOI: 10.1517/13543784.2015.1025132] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The most common gastrointestinal disorders that include evidence of dysmotility include: gastroparesis, the lower functional gastrointestinal disorders associated with altered bowel function (such as chronic [functional] diarrhea, chronic idiopathic constipation) and opioid-induced constipation. These conditions, which are grouped as gastrointestinal motility and functional disorders, are characterized by abnormal motor, sensory or secretory functions that alter bowel function and result in a significant disease burden, since currently available treatments do not completely alleviate symptoms. New drugs are being developed for these disorders, targeting mechanisms involved in the pathophysiology of these diseases, specifically, motor function, intestinal secretion and bile acid modulation. AREAS COVERED The article provides a brief overview of motility disorders and the drugs approved and currently available for these indications. It also provides an evaluation of the efficacy, safety and possible mechanisms of the drugs currently under investigation for the treatment of gastroparesis, chronic diarrhea, chronic idiopathic constipation and opioid-induced constipation, based on animal to Phase II studies. Medications with complete Phase III trials are excluded from this discussion. EXPERT OPINION Treatment of gastrointestinal motility disorders requires the understanding of the pathophysiological mechanisms, biomarkers to identify subgroups of these disorders and robust pharmacological studies from animal to Phase II studies. These are prerequisites for the development of efficacious medications and individualizing therapy in order to enhance the treatment of these patients.
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Affiliation(s)
- Nelson Valentin
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic , 200 First St. S.W., Charlton Bldg, Rm. 8-110, Rochester, MN 55905 , USA +1 507 266 2305 ;
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22
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Current developments in pharmacological therapeutics for chronic constipation. Acta Pharm Sin B 2015; 5:300-9. [PMID: 26579459 PMCID: PMC4629408 DOI: 10.1016/j.apsb.2015.05.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/20/2015] [Accepted: 02/26/2015] [Indexed: 12/11/2022] Open
Abstract
Chronic constipation is a common gastrointestinal disease severely affecting the patient׳s quality of life. The traditional treatment of constipation is the use of laxatives. Recently, several new drugs including lubiprostone, linaclotide and prucalopride have been approved for treatment of chronic constipation. However, a significant unmet medical need still remains, particularly among those patients achieving poor results by current therapies. The 5-HT4 receptor modulators velusetrag and naronapride, the guanylate cyclase C agonist plecanatide and the ileal bile acid transporter inhibitor elobixibat are recognized as the most promising drugs under investigation. Herein, we give a comprehensive review on the pharmacological therapeutics for the treatment of chronic constipation, with the purpose of reflecting the drug development trends in this field.
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Key Words
- 5-HT, serotonin
- 5-HT4 receptor
- CC, chronic constipation
- CDCA, chenodeoxycholic acid
- CFTR, cystic fibrosis transmembrane conductance regulator
- CIC, chronic idiopathic constipation
- CaCC, calcium-activated chloride channel
- Chronic constipation
- ClC-2, chloride channel protein 2
- ENaC, epithelial sodium channel
- GC-C, guanylate cyclase C
- GI, gastrointestinal
- IBAT, the ileal bile acid transporter (also known as apical sodium-dependent bile acid transporter)
- IBS-C, irritable bowel syndrome with constipation
- IPAN, intrinsic primary afferent neurons
- LGP, lubricating gut pill
- NHE3, sodium-hydrogen exchanger 3
- OIC, opioid-induced constipation
- PKGII, protein kinase II
- Prokinetic agent
- Prosecretory agent
- SBMs, spontaneous bowel movements
- TGR5, the G-protein-coupled bile acid receptor
- hERG, human ether-à-go-go–related gene
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van Zanten ARH, van der Meer YG, Venhuizen WA, Heyland DK. Still a Place for Metoclopramide as a Prokinetic Drug in Critically Ill Patients? JPEN J Parenter Enteral Nutr 2015; 39:763-6. [PMID: 25567783 DOI: 10.1177/0148607114567711] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/20/2014] [Indexed: 12/26/2022]
Affiliation(s)
| | - Y Gert van der Meer
- Department of Hospital Pharmacy, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Willem A Venhuizen
- Department of Hospital Pharmacy, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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van der Meer YG, Venhuizen WA, Heyland DK, van Zanten ARH. Should we stop prescribing metoclopramide as a prokinetic drug in critically ill patients? Crit Care 2014; 18:502. [PMID: 25672546 PMCID: PMC4331179 DOI: 10.1186/s13054-014-0502-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Regulatory agencies in North America and Europe recently re-evaluated the safety of metoclopramide. This re-evaluation resulted in recommendations and restrictions in order to minimise the risk of neurological and other adverse reactions associated with the use of metoclopramide. In the ICU, off-label prescription of metoclopramide is common. We have reviewed the evidence for safety, effectiveness and dosing of metoclopramide in critically ill patients. Furthermore, tachyphylaxis is addressed and alternatives are summarised. Finally, recommendations are presented not to abandon use of metoclopramide in ICU patients, because metoclopramide is considered effective in enhancing gastric emptying and facilitating early enteral nutrition.
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Affiliation(s)
- Y Gert van der Meer
- />Department of Hospital Pharmacy, Gelderse Vallei Hospital, Willy Brandtlaan 10, Ede, 6716 RP the Netherlands
| | - Willem A Venhuizen
- />Department of Hospital Pharmacy, Gelderse Vallei Hospital, Willy Brandtlaan 10, Ede, 6716 RP the Netherlands
| | - Daren K Heyland
- />Clinical Evaluation Research Unit, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7 Canada
| | - Arthur RH van Zanten
- />Department of Intensive Care, Gelderse Vallei Hospital, Willy Brandtlaan 10, Ede, 6716 RP the Netherlands
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Mozaffari S, Didari T, Nikfar S, Abdollahi M. Phase II drugs under clinical investigation for the treatment of chronic constipation. Expert Opin Investig Drugs 2014; 23:1485-97. [PMID: 24960333 DOI: 10.1517/13543784.2014.932770] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Chronic constipation (CC) is a common gastrointestinal (GI) motility disorder that significantly impairs the quality of life in affected subjects. As almost half of the patients suffering from CC are not satisfied with currently available medicines, there is a need to develop new molecules with better effectiveness and tolerability. AREAS COVERED The authors include all experimental and clinical trials (up to Phase II) about new investigational drugs for the treatment of CC. The article identifies nine new agents: mitemcinal, TD-8954, YKP10811, itopride, RM-131, KWA-0711, elobixibat, velusetrag, and naronapride. All nine agents have shown prokinetic effects in different stages of the development. The mechanisms of new developing drugs include: the activation of 5-hydroxytryptamine type-4 (5-HT4), ghrelin and motilin receptors, antagonizing dopamine type-2 (D2) receptors, inhibition of ileal bile acid reabsorption and acetylcholine esterase, as well as water absorption from the GI tract. EXPERT OPINION At this current point in time, new generations of 5-HT4 receptor agonists (velusetrag, noranopride and YKP10811) are hoped to progress, further in the future, due to better efficiency and safety. However, it is not possible to make a concise conclusion at this current time due to a lack of evidence. Further clinical trials with a longer duration and a larger sample size are warranted.
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Affiliation(s)
- Shilan Mozaffari
- Tehran University of Medical Sciences, Department of Toxicology and Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences Research Center , Tehran , Iran ,
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26
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Izzo AA. Novel insights which may translate into treatments for irritable bowel syndrome. Front Pharmacol 2013; 4:160. [PMID: 24427135 PMCID: PMC3875871 DOI: 10.3389/fphar.2013.00160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/06/2013] [Indexed: 12/12/2022] Open
Affiliation(s)
- Angelo A Izzo
- Department of Pharmacy, University of Naples Federico II Naples, Italy
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Constella™(EU)-Linzess™(USA): the last milestone in the long journey of the peptide linaclotide and its implications for the future of peptide drugs. Future Med Chem 2013; 5:291-300. [PMID: 23464519 DOI: 10.4155/fmc.13.5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are highly prevalent gastrointestinal disorders associated with health, economical and social problems. Recently, after a long journey of preclinical studies and clinical trials, linaclotide, a first-in-class GC-C receptor peptide agonist, has received the approval in the USA and Europe for the treatment of IBS-C and CIC. This article provides an overview of clinical, economic and biological aspects of IBS-C and CIC and covers the current and emerging therapeutic agents for treating these conditions. Particularly, the pharmacodynamic and pharmacokinetic properties of linaclotide, a small, disulfide-rich peptide, and its implications in the future of peptide drug discovery and development are discussed.
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McKinnell RM, Armstrong SR, Beattie DT, Fatheree PR, Long DD, Marquess DG, Shaw JP, Vickery RG. Discovery of TD-8954, a clinical stage 5-HT(4) receptor agonist with gastrointestinal prokinetic properties. Bioorg Med Chem Lett 2013; 23:4210-5. [PMID: 23756062 DOI: 10.1016/j.bmcl.2013.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 05/01/2013] [Accepted: 05/07/2013] [Indexed: 01/26/2023]
Abstract
The discovery of a series of 5-HT4 receptor agonists based on a novel 2-alkylbenzimidazole aromatic core is described. Optimization of the 2-substituent of the benzimidazole ring led to a series of agonists with subnanomolar binding affinity and moderate-to-high intrinsic activity relative to that of 5-HT. Consistent with our previously described multivalent design approach to this target, subsequent optimization of the linker and secondary binding group regions of the series afforded compound 18 (TD-8954), a potent and selective 5-HT4 receptor agonist in vitro with demonstrated prokinetic activity in multiple species.
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Armstrong SR, Campbell CB, Richardson CL, Vickery RG, Tsuruda PR, Long DD, Hegde SS, Beattie DT. The in vivo pharmacodynamics of the novel opioid receptor antagonist, TD-1211, in models of opioid-induced gastrointestinal and CNS activity. Naunyn Schmiedebergs Arch Pharmacol 2013; 386:471-8. [PMID: 23512167 DOI: 10.1007/s00210-013-0844-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 02/18/2013] [Indexed: 12/25/2022]
Abstract
The in vivo preclinical pharmacodynamic profile of TD-1211, a selective opioid receptor antagonist currently under development for the treatment of opioid-induced constipation, was compared to that of the clinically studied opioid antagonists, naltrexone, alvimopan, and ADL 08-0011 (the primary active metabolite of alvimopan). The oral activity of TD-1211 was evaluated in models of gastrointestinal (GI) and central nervous system (CNS) function in the rat and dog. Oral administration of TD-1211, naltrexone, and ADL 08-0011 reversed loperamide-induced inhibition of gastric emptying and castor oil-induced diarrhea in rats and nonproductive GI circular smooth muscle contractility in dogs. Alvimopan was only efficacious in the castor oil model. Oral administration of naltrexone and ADL 08-0011, but not TD-1211 or alvimopan, was associated with a CNS withdrawal response in morphine-dependent mice, inhibition of morphine-induced anti-nociception in rat and dog hot plate tests, and hypothermia and sedation in dogs. It is concluded that TD-1211 has potent in vivo GI activity, consistent with opioid receptor antagonism, but has no significant CNS activity. The data from these studies support the clinical development of TD-1211 as a novel treatment for opioid-induced GI dysfunction.
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Affiliation(s)
- Scott R Armstrong
- Theravance, Inc., 901 Gateway Boulevard, South San Francisco, CA 94080, USA.
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De Ponti F. Drug development for the irritable bowel syndrome: current challenges and future perspectives. Front Pharmacol 2013; 4:7. [PMID: 23378837 PMCID: PMC3561631 DOI: 10.3389/fphar.2013.00007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/10/2013] [Indexed: 12/15/2022] Open
Abstract
Medications are frequently used for the treatment of patients with the irritable bowel syndrome (IBS), although their actual benefit is often debated. In fact, the recent progress in our understanding of the pathophysiology of IBS, accompanied by a large number of preclinical and clinical studies of new drugs, has not been matched by a significant improvement of the armamentarium of medications available to treat IBS. The aim of this review is to outline the current challenges in drug development for IBS, taking advantage of what we have learnt through the Rome process (Rome I, Rome II, and Rome III). The key questions that will be addressed are: (a) do we still believe in the "magic bullet," i.e., a very selective drug displaying a single receptor mechanism capable of controlling IBS symptoms? (b) IBS is a "functional disorder" where complex neuroimmune and brain-gut interactions occur and minimal inflammation is often documented: do we need to target gut motility, visceral sensitivity, or minimal inflammation? (c) are there validated biomarkers (accepted by regulatory agencies) for studies of sensation and motility with experimental medications in humans? (d) do animal models have predictive and translational value? (e) in the era of personalized medicine, does pharmacogenomics applied to these medications already play a role? Finally, this review will briefly outline medications currently used or in development for IBS. It is anticipated that a more focused interaction between basic science investigators, pharmacologists, and clinicians will lead to better treatment of IBS.
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Affiliation(s)
- Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of BolognaBologna, Italy
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Nirogi R, Kandikere V, Bhyrapuneni G, Saralaya R, Ajjala DR, Aleti RR, Rasheed MA. In-vivo rat striatal 5-HT4 receptor occupancy using non-radiolabelled SB207145. J Pharm Pharmacol 2013; 65:704-12. [DOI: 10.1111/jphp.12030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 12/19/2012] [Indexed: 12/18/2022]
Abstract
Abstract
Objectives
The objective of the current investigation was to develop a simple, rapid method for determining in-vivo 5-hydroxytryptamine type 4 receptor (5-HT4R) occupancy in rat brain using non-radiolabelled SB207145 as a tracer for accelerating the drug discovery process.
Methods
In-vivo tracer optimization studies for tracer dose, survival intervals and brain distribution profile were carried out in rats. The tracer was pharmacologically validated using potent well-characterized 5-HT4R ligands. The brain regional concentrations of tracer (SB207145); plasma and brain concentrations of 5-HT4R ligands were quantified using high-performance liquid chromatography coupled with a tandem mass spectrometric detector (LC-MS/MS).
Key findings
SB207145 showed a higher specific binding in striatum (1.96 ng/g) and lower binding in cerebellum (0.66 ng/g), which is consistent with findings of other published 5-HT4R expression studies. Pretreatment with potent 5-HT4 ligands dose-dependently reduced striatal SB207145 concentration and the effective dose to achieve 50% receptor occupancy (ED50) values were 4.8, 2.0, 7.4, 9.9, 3.8 and 0.02 mg/kg for GR113808, piboserod, prucalopride, RS67333, TD8954 and PF04995274, respectively.
Conclusions
Results from the mass spectrometry approach to determine 5-HT4R occupancy in rat brain are comparable with those reported using radiolabelled scintillation spectroscopy methods. In conclusion, the LC-MS/MS characterization permits use of tracer at a preclinical stage in high-throughput fashion as well as characterization of target expression.
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Affiliation(s)
- Ramakrishna Nirogi
- Pharmacokinetics and Drug Metabolism, Suven Life Sciences Ltd, Hyderabad, India
- Department of Medicinal Chemistry, Discovery Research, Suven Life Sciences Ltd, Hyderabad, India
| | | | | | - Ramanatha Saralaya
- Pharmacokinetics and Drug Metabolism, Suven Life Sciences Ltd, Hyderabad, India
| | | | | | - Mohammed Abdul Rasheed
- Department of Medicinal Chemistry, Discovery Research, Suven Life Sciences Ltd, Hyderabad, India
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