Rebamipide enema therapy for left-sided ischemic colitis patients accompanied by ulcers: Open label study

Erosive and ulcerative lesions of the digestive tract: optimization of diagnosis and management tactics

Erosive and ulcerative lesions of the digestive tract are one of the most pressing problems in the clinic of internal diseases due to the extremely widespread prevalence, the presence of severe complications, often fatal, diagnostic difficulties due to the presence of a large number of asymptomatic pathologies and difficulties in the rational choice of therapy. Particularly noteworthy is the data that during the global pandemic of Covid-19 infection, it is capable, quite often, of causing the development of erosive and ulcerative lesions of the gastrointestinal tract. In this regard, it seems important to use drugs that can not only prevent the occurrence of erosive and ulcerative lesions and strictures throughout the gastrointestinal tract, but also effectively achieve epithelialization of injuries to the mucous membrane of the oral cavity, esophagus, stomach, small and large intestine. One of them is Rebamipid-CZ, which has a fairly high safety and efficacy profile. It seems important to consider the issues of optimizing the prevention and treatment of erosive and ulcerative lesions of various parts of the gastrointestinal tract of various etiologies, taking into account the possibility of using rebamipide both as part of complex therapy and in isolation.

Colon ischemia: A comprehensive review

The clinical and endoscopic features of colon ischemia (CI) are non-specific. CI is correctly identified at the time of presentation in only 9% of patients is. The true incidence is likely underestimated because many mild cases resolve spontaneously without medical treatment. Furthermore, since most cases of CI are transient, and no specific cause is detected they are often considered to be "idiopathic". In the setting of severe CI correct diagnosis and prompt recognition and therapy as well as identification of underlying causes are crucial for a favourable outcome. Although less severe, mild cases may present with similar symptoms, the prognosis and management are completely different and managed conservatively rather than with surgery. Unfortunately, data from most studies and current guidelines do not provide recommendations on the long-term management of CI or about the need for endoscopic follow-up to detect the development chronic, recurrent and/or ischemic colonic strictures. In this review, we focus on the definition of CI, its aetiology, and patterns of presentation. We highlight the pharmacological and/or endoscopic management as determined severity of disease that allow for improved outcomes. Prompt recognition and treatment using a multidisciplinary approach are essential for successful management of severe CI because mortality rates are significantly higher when the diagnosis is delayed.

Diagnostic methods and drug therapies in patients with ischemic colitis

PURPOSE

Ischemic colitis (IC) is the most prevalent ischemic injury of thegastrointestinal tract. Clinical features of IC such as acute abdominal pain, hematochezia,and diarrhea are similar to those of acute mesenteric ischemia, inflammatorybowel disease, or infectious bowel disease, and their relative ambiguity candelay diagnosis and treatment. To comprehensively detail the current state ofdiagnostic methods and available drug therapies for detecting and treating IC,this review aims to provide a concise and practical summary of thecorresponding literature.

METHODS

PubMed and Cochrane Library were searched toretrieve all published studies reporting the diagnostic methods and drugtherapies in patients with ischemic colitis. The search strategy of drugtherapy includes human and animal data.

RESULTS

Colonoscopy combined with histopathologicalbiopsy is the standard of diagnosis for the IC. Most patients respond well tothe conservative treatment, and surgical consultation is needed when conservativetreatment is ineffective. Studies of potential drug therapy have beendeveloped, including phosphodiesterase type 5 inhibitors, pentoxifylline,rebamipide, prostaglandin E1, and polydeoxyribonucleotide.

CONCLUSION

Accurate diagnoses and effective treatmentshave helped reduce the mortality rate and improve prognoses for patientsafflicted with IC, and corresponding drug therapies have been constantlyupdated as new research has emerged.

Biopharmaceutical characterization of rebamipide: The role of mucus binding in regional-dependent intestinal permeability

In this study, we aimed to elucidate biopharmaceutical characteristics of the anti-ulcer drug rebamipide, with special emphasis on the influence of gastrointestinal (GI) mucus on rebamipide segmental-dependent permeability and absorption. Experimental studies and physiologically-based pharmacokinetic (GastroPlus^TM) simulations were used to elucidate segmental-dependent absorption and pharmacokinetic (PK) profile, accounting for various drug properties, including solubility/dissolution limitations, regional-dependent drug affinity to mucus and membrane permeability, as well as physiological factors such as regional-pH differences along the intestine, thickness and types of mucus, transit time and surface areas. Low permeability and extensive binding to GI mucus were the key modeling features, and accounting for these resulted in good fitting between the predicted and in-vivo PK profiles, validating the ability of the model to pinpoint the underlying mechanisms of rebamipide limited oral bioavailability. Furthermore, the simulations indicated regional-dependent intestinal permeability of rebamipide, with absorption rank order of jejunum>ileum>duodenum>colon, mainly attributable to segmental mucus differences. Food effect simulations indicated somewhat decreased rebamipide absorption in the fed state, in corroboration with previous reports. Since this anti-ulcer drug is currently examined for additional indications, this work provides important input for future development of rebamipide.

Pharmacological and clinical feature of rebamipide: new therapeutic targets

Rebamipide is a cytoprotector developed in Japan where it has been successfully used for the treatment of stomach diseases for 30 years. Initially discovered effects of the drug included the induction of prostaglandins and the elimination of free oxygen radicals. Recent studies discovered new therapeutic targets of the drug, its new forms that made possible using rebamipid for the treatment of such diseases as NSAID enteropathy, ulcerative colitis, radiation colitis, pouchitis, enteropathy with impaired membrane digestion. It is used in endoscopy, ophthalmology, chemotherapy, rheumatology. The aim of this review is to present current information about the pharmacological and clinical feature of rebamipide and to study its therapeutic potential.

Diagnosis and management of ischemic colitis

The clinical presentation and outcome of ischemic colitis have a wide spectrum. Impaired perfusion of blood to the bowel from a variety of causes is the underlying pathophysiology. The presence of diarrhea, abdominal pain, and mild lower gastrointestinal bleeding should prompt consideration of ischemic colitis as a cause. Although many laboratory tests and radiographic images may suggest the diagnosis, endoscopic visualization of the colonic mucosa with histologic analysis of biopsies is the gold standard for identification of colonic ischemia. Many cases are transient and resolve without any complications. Medical therapy for chronic ischemia has been anecdotally proven but not carefully studied. Complications of ischemic colitis can include bowel perforation, peritonitis, persistent bleeding, protein-losing colonpathy, and symptomatic intestinal strictures. Surgical resection of the affected segment should be considered early to minimize adverse outcomes. This review describes the etiology, pathophysiology, clinical features, diagnostic approach, and management of ischemic colitis.

Systematic review of the management of ischaemic colitis

AIM

The study reviews the literature related to ischaemic colitis (IC) to establish an evidence base for its management and to identify factors predicting severity and mortality.

METHOD

A systematic review of the English language literature was conducted according to recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE, Embase and Cochrane Library databases were searched using the keyword search 'ischaemic colitis OR colon ischaemia OR colonic ischaemia OR management ischaemic colitis'. IC is often misdiagnosed so only studies where the diagnosis was supported by histopathology in every case were included. Critical appraisal was performed of included studies using predefined quality assessment checklists and narrative data synthesis.

RESULTS

In all, 2610 publications were identified. Of these, eight retrospective case series and three case controlled studies describing 1049 patients were included. Medical management was used in 80.3% patients of whom 6.2% died. Surgery was required in 19.6% of whom 39.3% died. The overall mortality of IC was 12.7%. Lack of rectal bleeding, peritonism and renal dysfunction were commonly quoted predictors of severity; however, right sided IC appeared to be the most significant predictor of outcome.

CONCLUSION

Most patients with IC can be managed conservatively. Right sided IC may be the most significant predictor of severity.

Predictors of severity in ischaemic colitis

PURPOSE

Ischaemic colitis (IC) is an inadequate perfusion leading to potentially life-threatening colonic inflammation. The aim was to identify patient characteristics that predict severity in biopsy-confirmed IC.

METHODS

A retrospective study of consecutive patients admitted with a robust diagnosis of IC over a 5-year period was performed. As IC is often misdiagnosed, strict inclusion criteria including supporting histopathology, exclusion of inflammatory bowel disease, absence of recent antibiotics or negative stool sampling with testing for Clostridium difficile were adhered to. Due to differing pathophysiology involved, patients suffering IC due to injury to colonic perfusion from vascular procedures or tumours were also excluded. Patients were divided by outcomes into a severe IC group including those that needed surgery or suffered mortality and a non-severe IC group that included patients managed medically with good evolution during their index admission. Patient characteristics were analysed to identify statistically significant predictors of severity (p < 0.05).

RESULTS

Thirty-two patients (11 males, 21 females; mean age 72.5) met the inclusion criteria. Medical management was adopted in 23 patients with a single mortality (4.3%). Nine patients were managed surgically with two mortalities (22.2%), giving an overall mortality of 9.4% and a severe IC group consisting of ten patients. Significant prognostic predictors of severity included: right-sided IC (p = 0.0002), guarding (p = 0.001), lack of bleeding per rectum (p = 0.005) and chronic constipation (p = 0.02).

CONCLUSIONS

The majority of patients with IC can be managed conservatively. Right-sided IC, guarding, lack of bleeding per rectum and chronic constipation are associated with severe IC.

Preliminary studies on the effect of rebamipide against the trypsin and egg-albumin induced experimental model of asthma

The present investigation was carried out to study the effect of rebamipide in experimentally induced bronchial asthma in mice. Trypsin and egg-albumin induced chronic model of asthma was used and various parameters were measured on the 35th day. The asthmatic control group showed lower level of haemoglobin saturation with oxygen, tidal volume, airflow rate and higher respiratory rate, serum bicarbonate level, eosinophil count in bronchoalveolar lavage fluid and histamine level compared to the normal control group. Dexamethasone and rebamipide treated groups showed the return of all the above parameters towards normal values. Histopathological examination of lungs showed more prominent alveolar and muscular layer destruction in the asthmatic control group than in dexamethasone and rebamipide treated groups. Rebamipide showed a beneficial effect and might be used for the treatment of bronchial asthma.

Rebamipide promotes healing of colonic ulceration through enhanced epithelial restitution

AIM: To investigate the efficacy of rebamipide in a rat model of colitis and restitution of intestinal epithelial cells in vitro.

METHODS: Acute colitis was induced with trinitrobenzene sulfonic acid (TNBS) in male Wistar rats. Rats received intrarectal rebamipide treatment daily starting on day 7 and were sacrificed on day 14 after TNBS administration. The distal colon was removed to evaluate the various parameters of inflammation. Moreover, wound healing assays were used to determine the enhanced restitution of rat intestinal epithelial (RIE) cells treated with rebamipide.

RESULTS: Intracolonic administration of rebamipide accelerated TNBS-induced ulcer healing. Increases in the wet weight of the colon after TNBS administration were significantly inhibited by rebamipide. The wound assay revealed that rebamipide enhanced the migration of RIE cells through phosphorylation of extracellular signal-regulated kinase (ERK) and activation of Rho kinase.

CONCLUSION: Rebamipide enema healed intestinal injury by enhancing restitution of RIE cells, via ERK activation. Rebamipide might be a novel therapeutic approach for inflammatory bowel disease.

Wound healing of intestinal epithelial cells

The intestinal epithelial cells (IECs) form a selective permeability barrier separating luminal content from underlying tissues. Upon injury, the intestinal epithelium undergoes a wound healing process. Intestinal wound healing is dependent on the balance of three cellular events; restitution, proliferation, and differentiation of epithelial cells adjacent to the wounded area. Previous studies have shown that various regulatory peptides, including growth factors and cytokines, modulate intestinal epithelial wound healing. Recent studies have revealed that novel factors, which include toll-like receptors (TLRs), regulatory peptides, particular dietary factors, and some gastroprotective agents, also modulate intestinal epithelial wound repair. Among these factors, the activation of TLRs by commensal bacteria is suggested to play an essential role in the maintenance of gut homeostasis. Recent studies suggest that mutations and dysregulation of TLRs could be major contributing factors in the predisposition and perpetuation of inflammatory bowel disease. Additionally, studies have shown that specific signaling pathways are involved in IEC wound repair. In this review, we summarize the function of IECs, the process of intestinal epithelial wound healing, and the functions and mechanisms of the various factors that contribute to gut homeostasis and intestinal epithelial wound healing.