A Dose-Escalation Study Demonstrates the Safety and Tolerability of Cellobiose in Healthy Subjects

The disaccharide and innovative ingredient cellobiose, consisting of two β-glucose molecules linked by a β(1→4) bond is the main component of cellulose. Cellobiose can be used within a wide variety of foodstuffs and functional foods as a low-caloric bulking agent or as a substitute for lactose. For purposes of industrial large-scale production, cellobiose is produced by an enzymatic reaction in which sucrose and glucose are converted to cellobiose and fructose. The goal of this single-arm, dose-escalation study was to evaluate the safety and tolerability of cellobiose and to determine the maximum tolerated dose of cellobiose in healthy subjects. Following a baseline period, consecutive cohorts of six subjects each consumed either single doses of 10, 15, 20 and 25 g, while 12 subjects each received multiple doses of 15 g or 20 g cellobiose (twice daily, 14 days). The main recorded parameters were stool consistency, gastrointestinal well-being (Gastrointestinal Symptom Rating Scale) and adverse events. In each highest single/multiple dosage group, some sensitive subjects experienced flatulence, borborygmus and/or transient diarrhoea. A 100% global tolerability rating makes 20 g cellobiose a tolerable dose for single use. For repeated consumption, we propose up to 15 g cellobiose twice daily (92.6% global tolerability rating). Cellobiose is a promising new ingredient with excellent tolerability.

[Efficacy analysis of fecal microbiota transplantation in the treatment of 406 cases with gastrointestinal disorders]

OBJECTIVE

To evaluate the efficacy and safety of fecal microbiota transplantation (FMT) for gastrointestinal disorders.

METHODS

Retrospective analysis of the clinical data of 406 patients who underwent FMT from May 2014 to April 2016 in the Intestinal Microenvironment Treatment Centre of Nanjing General Hospital was performed, including patients with constipation(276 cases), recurrent Clostridium Difficile infection (RCDI, 61 cases), ulcerative colitis(44 cases), irritable bowel syndrome (15 cases) and Crohn's disease(10 cases). Donors were completely unrelated, 18- to 50-year-old non-pregnant healthy adult, with healthy lifestyle and habits, without taking antibiotics, probiotics and other probiotics history within 3 months. There were three routes of FMT administration: patients received 6 days of frozen FMT by nasointestinal tube placed in the proximal jejunum under gastroscope (319 cases); patients received capsules FMT per day for 6 consecutive days (46 cases) or once 600 ml of treated fecal liquid infusion into colon and terminal ileum by colonoscopy(41 cases).

RESULTS

Clinical cure rate and improvement rate of different diseases receiving FMT were respectively as follows: RCDI was 85.2% (52/61) and 95.1%(58/61); constipation was 40.2%(111/276) and 67.4%(186/276); ulcerative colitis was 34.1%(15/44) and 68.2% (30/44); irritable bowel syndrome was 46.7% (7/15) and 73.3% (11/15) and Crohn disease was 30.0%(3/10) and 60.0%(6/10). RCDI had the best efficacy among these diseases(P<0.01). There was no significant difference between the three routes of FMT administration(P=0.829). The clinical cure rate and improvement rate of different routes were 43.3%(138/319) and 58.6% (187/319) respectively in nasogastric transplantation group, 41.5%(17/41) and 61.0%(25/41) in colonoscopy group, 37.0%(17/46) and 63.0% (29/46) in the capsule transplantation group. There was no serious adverse event during the follow-up. The most common side effects were respiratory discomfort (27.3%, 87/319) and increased venting (51.7%, 165/319) in nasogastric transplantation group. Diarrhea was the most common complication in colonoscopy group (36.6%, 15/41). The main symptoms were increased venting (50.0%, 23/46) and nausea(34.8%, 16/46) in oral capsule group. Side effect symptoms disappeared after the withdraw of nasogastric tube, or at the end of treatment, or during hospitalization for 1-3 days.

CONCLUSIONS

FMT is effective for many gastrointestinal disorders. No significant adverse event is found, while the associated mechanism should be further explored.

Comparative Effect of Repeated Ingestion of Difructose Anhydride III and Palatinose on the Induction of Gastrointestinal Symptoms in Humans

We evaluated the safety and change in fermentability from repeated ingestion of difructose anhydride III (DFAIII) in humans. A randomized controlled single-blind crossover study with thirteen subjects was conducted. Each subject ingested 5 g of DFAIII or palatinose daily for 12 days, before and after which the subject was loaded with 10 g of DFAIII and had breath hydrogen measured from 0 to 9 h (DL test) to evaluate the fermentability of DFAIII. The defecation frequency and abdominal symptom score were the same between each ingestion period. Moreover, DFAIII ingestion had no influence on blood test results. Only the breath hydrogen excretion in post-DFAIII ingestion was slightly higher at h 8 than the pre-ingestion. Consequently, repeated ingestion of DFAIII for 12 days was as safe as palatinose ingestion, especially with respect to abdominal symptoms and blood test results, and its high resistance to enterobacterial fermentation in humans was not impaired.

Safety of a dual potential prebiotic system from Mexican agave "Metlin® and Metlos®", incorporated to an infant formula for term newborn babies: a randomized controlled trial

RATIONALE

Infant formulae are being supplemented with probiotics, prebiotics, or symbiotic despite uncertainties regarding their efficacy. Mexican agave is an interesting source of fructans with particular features and with potential prebiotic effects.

MATERIAL AND METHODS

RCT in 600 healthy term babies (20 ± 7 days), allocated to receive standard infant formula (control) or infant formula added with a dual prebiotic system "Metlin® and Metlos®", from Mexican agave. Primary outcomes include stools frequency, stools consistency, gastrointestinal intolerance (frequency of abdominal distension, flatulency, regurgitations, vomiting). Secondary outcomes include changes on weight and height along the study and frequency of dermatologic problems (eczema).

RESULTS

In 66,120 days of total follow-up, there were no differences on the frequency of stools passage (Human Milk: 3.8 ± 2.4 evacuations per day; Pro + Metlin + Metlos 3.6 ± 2.0; Pro + Metlin 3.6 ± 2; only Pro 3.4 ± 2.3¸ only formula 3.4 ± 2.0; p NS). Consistency of stools was similar between human milk and prebiotics supplemented groups. Also the frequency of gastrointestinal symptoms was significantly low between these groups.

CONCLUSIONS

Fructans derivate from agave and added to infant formula are safe and well tolerated by Mexican healthy term babies.

Chicory inulin does not increase stool weight or speed up intestinal transit time in healthy male subjects

Inulin is a non-digestible oligosaccharide classified as a prebiotic, a substrate that promotes the growth of certain beneficial microorganisms in the gut. We examined the effect of a 20 g day(-1) supplement of chicory inulin on stool weight, intestinal transit time, stool frequency and consistency, selected intestinal microorganisms and enzymes, fecal pH, short chain fatty acids and ammonia produced as by-products of bacterial fermentation. Twelve healthy male volunteers consumed a well-defined, controlled diet with and without a 20 g day(-1) supplement of chicory inulin (degree of polymerization (DP) ranging for 2-60), with each treatment lasting for 3 weeks in a randomized, double-blind crossover trial. Inulin was consumed in a low fat ice cream. No differences were found in flavor or appeal between the control and inulin-containing ice creams. Inulin consumption resulted in a significant increase in total anaerobes and Lactobacillus species and a significant decrease in ammonia levels and β-glucuronidase activity. Flatulence increased significantly with the inulin treatment. No other significant differences were found in bowel function with the addition of inulin to the diet. Thus, inulin is easily incorporated into a food product and has no negative effects on food acceptability. Twenty grams of inulin was well tolerated, but had minimal effects on measures of laxation in healthy, human subjects.

Gastrointestinal tolerance to an inulin-rich soluble roasted chicory extract after consumption in healthy subjects

OBJECTIVES

We aimed to assess in healthy subjects 1) the effect of two doses of a new naturally inulin-rich soluble chicory extract (IRSCE) on overall gastrointestinal discomfort after short-term ingestion and 2) the effect on gastrointestinal symptoms of long-term consumption of IRSCE administered at a dose compatible with its future commercial use.

METHODS

First, the effect of IRSCE was assessed on overall gastrointestinal discomfort in a double-blind, crossover study where 18 subjects received in a randomized order a morning coffee drink including 10 g of sucrose alone (control period) or with IRSCE at two doses (8.9 and 14.0 g containing 5.0 and 7.8 g of inulin, respectively) during three consecutive 6-d periods. Second, 35 subjects were followed during a randomized, double-blind protocol where they were asked to take twice a day an instant coffee drink containing IRSCE (8.1 g/d containing inulin 5.0 g/d) or sucrose 8.1 g/d during 4 wk. The effects of the treatment on flatulence, bloating, abdominal pain, stool consistency, and number were recorded.

RESULTS

In the first study a significant slight increase (P = 0.05) in overall abdominal discomfort was observed with the morning coffee drink containing 7.8 g of inulin after 1 wk of consumption. In the second study, no significant differences between the IRSCE and placebo groups were evidenced with respect to gastrointestinal symptoms during the consumption period.

CONCLUSION

Short- and long-term consumptions of IRSCE, given at a daily dose containing 5 g of inulin, are well tolerated by healthy subjects.

Are the effects of alpha-glucosidase inhibitors on cardiovascular events related to elevated levels of hydrogen gas in the gastrointestinal tract?

The major side-effect of treatment with alpha-glucosidase inhibitors, flatulence, occurs when undigested carbohydrates are fermented by colonic bacteria, resulting in gas formation. We propose that the cardiovascular benefits of alpha-glucosidase inhibitors are partly attributable to their ability to neutralise oxidative stress via increased production of H(2) in the gastrointestinal tract. Acarbose, which is an alpha-glucosidase inhibitor, markedly increased H(2) production, with a weaker effect on methane production. Our hypothesis is based on our recent discovery that H(2) acts as a unique antioxidant, and that when inhaled or taken orally as H(2)-dissolved water it ameliorates ischaemia-reperfusion injury and atherosclerosis development.

Cholesterol reduction using psyllium husks - do gastrointestinal adverse effects limit compliance? Results of a specific observational study

PURPOSE

Despite known cholesterol lowering effects the use of psyllium husk (Plantaginis ovatae testa) in Germany for hypercholesterolemia is limited compared to their use as a laxative. To investigate whether use in hypercholesterolemia is limited due to adverse effects on the gastrointestinal system, a prospective observational study was conducted.

METHODS

Sixty-two outpatients with documented hypercholesterolemia and complaints of constipation were identified from an academic clinical center. Treatment with 3.5g psyllium husk preparation administered three times daily was initiated and patients were monitored at weekly intervals. Gastrointestinal symptoms were quantified using a validated Nepean Dyspepsia Index modified to identify both upper and lower abdominal symptoms. Diaries and study medication records were used to evaluate compliance.

RESULTS

Fifty-four of 62 patients enrolled in the study completed the study protocol with 4 subjects discontinuing due to adverse reactions associated with psyllium husks. Total cholesterol was significantly decreased from 252+/-39mg/dl before treatment to 239+/-37mg/dl after 3 weeks of treatment. Similarly, low density lipoprotein (LDL)-cholesterol decreased from 174+/-34 to 162+/-31mg/dl during the study. Triglycerides and high density lipoprotein (HDL) were unchanged. Gastrointestinal symptoms were rated lower at the end than at the beginning of the study. In week 1 most of the patients reported gastrointestinal symptoms and also gastrointestinal adverse reactions, which however, showed a decrease from week 1 to weeks 2 and 3 in the diaries. Patient response to study medication was positive for patients completing the study.

CONCLUSIONS

Psyllium husk preparations may be a therapeutic option for patients with mild to moderately elevated cholesterol levels. Adverse gastrointestinal symptoms associated with the preparation appear to be transient in some of the patients. Compliance may be optimized with adequate patient counseling.

Effects of low doses of lactitol on faecal microflora, pH, short chain fatty acids and gastrointestinal symptomology

BACKGROUND

Lactitol (4-beta-D: -galactopyranosyl-D: -glucitol) is a sugar alcohol used as a sweetener. Previous studies have shown that it has a beneficial effect on intestinal microflora.

AIMS OF THE STUDY

To determine whether low doses of lactitol had beneficial effects without eliciting adverse gastrointestinal symptoms.

METHODS

Faecal bacterial populations (total anaerobes, total aerobes, enterobacteria, bifidobacteria and lactobacilli), faecal pH and faecal short chain fatty acids (SCFA) were studied in a randomized longitudinal study of 75 non-adapted healthy adults before and after consumption of low doses of lactitol. Subjects consumed 25 g tablets of milk chocolate containing 10 g sweetener as sucrose:lactitol in ratios of 10:0, 5:5 or 0:10 daily for 7 d.

RESULTS

No significant changes in faecal bacterial counts occurred in the 10:0 or 5:5 sucrose:lactitol groups. There were no significant changes in faecal anaerobes, aerobes, Enterobacteriaceae or lactobacilli during the study period in subjects consuming 0:10 sucrose:lactitol but there was a significant increase (P = 0.017) in bifidobacteria. There were no significant changes in faecal pH and SCFA for the 10:0 or 5:5 sucrose:lactitol groups but a significant decrease (P = 0.02) in faecal pH and significant increases (P = 0.001) in concentrations of propionic and butyric acids were observed in the 0:10 sucrose:lactitol group. There were few adverse symptoms of gastrointestinal intolerance to the daily consumption of 10 g lactitol.

CONCLUSIONS

The results show that low doses of lactitol can beneficially affect the faecal flora without eliciting gross symptoms of intolerance and that lactitol can be classified as a prebiotic.

Tolerability of oral xylitol solution in young children: implications for otitis media prophylaxis

OBJECTIVE

Xylitol, given as 2g orally five times-a-day, significantly reduces the incidence of acute otitis media (AOM) in children. A less frequent dosing schedule, if tolerable and efficacious, would promote the more widespread use of this treatment. We sought to determine the tolerability and acceptability in young children of oral xylitol solution at doses of 5g three times-a-day (TID) and 7.5g once daily (QD).

METHODS

The study was a 3-month randomized placebo-controlled trial of the tolerability and acceptability of oral xylitol solution in 120 children 6-36 months of age performed in the SCOR Network.

RESULTS

Study withdrawals and unscheduled medical visits for gastrointestinal complaints did not differ significantly among the study groups. The proportions of subjects in the xylitol TID group who experienced excessive gas or diarrhea at months 1, 2, and 3 were 22.7%, 10.0%, and 14.3%, respectively, and in the xylitol QD group were 27.3%, 17.4%, and 14.3%, respectively, and these did not differ from the placebo groups. The proportions who accepted the study solution easily or with only minor difficulty at 1, 2, and 3 months in the xylitol TID group were 77.3%, 90.0%, and 90.5% and in the xylitol QD group, 77.3%, 82.6%, and 90.5%, respectively.

CONCLUSIONS

Oral xylitol solution at dosages of 5g TID and 7.5g QD is well-tolerated by young children. Given the potential for xylitol as a safe, inexpensive option for AOM prophylaxis, clinical trials using these dosages of xylitol can be conducted.

Single-dose safety and pharmacokinetics of brecanavir, a novel human immunodeficiency virus protease inhibitor

Brecanavir (BCV, 640385) is a novel, potent protease inhibitor (PI) with low nanomolar 50% inhibitory concentrations against PI-resistant human immunodeficiency virus (HIV) in vitro. This phase I, double-blind, randomized, placebo-controlled, two-part single-dose study (first time with humans) was conducted to determine the safety, tolerability, and pharmacokinetics of BCV administered at 10 mg/ml in a tocopherol-polyethylene glycol succinate-polyethylene glycol 400-ethanol 50:40:10 solution. In part 1 of the study, single oral doses of BCV ranged from 25 mg to 800 mg. In part 2, single oral doses of BCV ranged from 10 mg to 300 mg and were coadministered with 100-mg oral ritonavir (RTV) soft gel capsules. Single doses of BCV and BCV/RTV were generally well tolerated. There were no severe adverse events (SAEs), and no subject was withdrawn due to BCV. The most commonly reported drug-related AEs during both parts of the study combined were gastrointestinal disturbances (similar to placebo) and headache. BCV was readily absorbed following oral administration with mean times to maximum concentration from >1 h to 2.5 h in part 1 and from 1.5 h to 3 h in part 2. Administration of BCV without RTV resulted in BCV exposures predicted to be insufficient to inhibit PI-resistant virus based on in vitro data. Coadministration of 300 mg BCV with 100 mg RTV, however, significantly increased the plasma BCV area under the concentration-time curve and maximum concentration 26-fold and 11-fold, respectively, achieving BCV concentrations predicted to inhibit PI-resistant HIV.

Methylnaltrexone: MNTX

Methylnaltrexone is a peripheral opioid receptor antagonist undergoing phase III clinical trials for the treatment of opioid-induced constipation in patients with advanced medical illness who are being treated with narcotics for pain. The compound does not cross the blood-brain barrier in humans and reverses the opioid effects without interfering with pain relief. Some opioid-induced adverse events that the drug may potentially target include constipation, nausea/vomiting, cough suppression and urinary retention. Methylnaltrexone was discovered by researchers at the University of Chicago, Chicago, Illinois, USA and is in joint development with Progenics Pharmaceuticals and Wyeth Pharmaceuticals. Progenics is conducting clinical trials with three methylnaltrexone dosage forms: subcutaneous, IV and oral. Progenics plans to complete the clinical development of methylnaltrexone alone, after which potential pharmaceutical or biotechnology partners will be looked at to provide financial support and marketing expertise, particularly outside the US market. In December 2005, Progenics and Wyeth Pharmaceutical (Wyeth) entered into an exclusive, worldwide agreement for the joint development and commercialisation of methylnaltrexone for the treatment of opioid-induced side effects, including constipation and postoperative bowel dysfunction. Under the terms of the licensing agreement, Wyeth has worldwide rights to the compound and Progenics retains the option to co-promote methylnaltrexone in the US. The companies will collaborate on the worldwide development of methylnaltrexone. Under the terms of the agreement, Wyeth has made an up-front payment to Progenics and will also make additional milestone payments. Wyeth will also pay Progenics royalties on worldwide sales, and co-promotion fees within the US. Wyeth is also responsible for all future development and commercialisation costs. Wyeth will develop oral methylnaltrexone worldwide. Progenics will lead the US development of subcutaneous and intravenous methylnaltrexone, while Wyeth will lead development of these parenteral products outside the US.UR Labs licensed methylnaltrexone from the University of Chicago. In October 2001, Progenics in-licensed the methynaltrexone patent portfolio in exchange for rights to future methynaltrexone royalties. In December 2005, Progenics acquired a substantial portion of the royalty and milestone payments in exchange for 686,000 shares of Progenic's common stock and 2.6 million US dollars in cash. In April 2005, Progenics Pharmaceuticals made a public offering of 2 million shares of its common stock, pursuant to an effective shelf registration statement. Progenics intends to use the net proceeds from this offering to fund clinical trials of methylnaltrexone, to fund clinical trials of other product candidates and for other research and development programs. All primary and secondary endpoints were statistically significant in Progenic's second phase III trial of subcutaneous methylnaltrexone (0.15 mg/kg or 0.30 mg/kg). The trial was initiated in January 2004 in 133 patients with opioid-induced constipation at 27 nursing homes and hospices in the US. Enrollment was completed in September 2005 and results announced in February 2006. In March 2005, Progenics announced results from the pivotal phase III trial of subcutaneous methylnaltrexone for the reversal of opioid-induced constipation. This trial involved a total of 150 patients from 16 hospices in the US who had advanced medical illnesses and who were receiving occasional opioids. Progenics has completed a phase IIb dose-ranging study with subcutaneous methylnaltrexone for treatment of narcotic-induced constipation in patients with cancer or AIDS. Positive top-line results from a phase II clinical trial of methylnaltrexone in the management of postoperative bowel dysfunction were reported in January 2005. The endpoints of the study included restoration of bowel function and discharge eligibility. Reversal of urinary retention was a secondary endpoint in this study. Progenics plans to complete a more in-depth analysis of this phase II data and present the finding to the US FDA. Methylnaltrexone (IV) is scheduled to enter phase III clinical studies in this indication in 2006. An NDA is expected to be submitted for the intravenous formulation of methylnaltrexone in late 2007/early 2008. Progenics also plans to initiate a phase II study of methylnaltrexone in women who have undergone hysterectomies. This patient population is also at high risk for ileus. In May 2004, Progenics Pharmaceuticals completed phase I clinical trials using two different oral formulations of methylnaltrexone. Analysis of preliminary data from 61 healthy volunteers who received methylnaltrexone at three dose levels indicated that the drug was well tolerated and exhibited predictable pharmacokinetics. Based on these phase I studies, Progenics selected an oral formulation and dose levels of methylnaltrexone that will be tested in phase II clinical trials for relief of opioid-induced constipation in patients with chronic-pain. The technology licensed from UR Labs, Inc., is the subject of issued US and European patents and several related US and foreign patent applications relating to certain compositions, formulations and uses of methylnaltrexone filed by the University of Chicago. Progenics have continued to expand the patent coverage relating to methylnaltrexone with the filing of new patent applications.

Double-blind randomized evaluation of clinical and biological tolerance of polyethylene glycol 4000 versus lactulose in constipated children

OBJECTIVES

To assess the safety of a polyethylene glycol (PEG) 4000 laxative without additional salts in pediatric patients.

STUDY DESIGN

This was a 3-month multicenter, randomized, double-blind, double-dummy, lactulose-controlled, parallel study enrolling 96 ambulatory constipated children aged 6 months to 3 years, treated daily with 4-8 g PEG or 3.33 g-6.66 g lactulose. Total protein, albumin, iron, electrolytes, and vitamins B9 (folates), A and D (25OHD3) were measured in blood before and after treatment (day 84) in a central laboratory.

RESULTS

The percentage of children with at least one value out of normal range at day 84 with respect to baseline status (with or without at least one value out of normal range), i.e. the primary endpoint, was 87% and 90% in the PEG and lactulose groups, respectively, without any difference between groups. The whole blood parameters showed no qualitative or quantitative treatment-related changes. Vitamin A values were above normal range in 56% and 41% of children at baseline versus 33% and 36% at day 84 in the PEG and lactulose groups, respectively. Iron values were similarly under normal range in 47% and 51% at baseline versus 42% and 51% at day 84. Clinical tolerance was similar for both treatments except for vomiting and flatulence, which were significantly higher with lactulose. Significantly higher improvements were evidenced with PEG regarding stool consistency, appetite, fecaloma and use of additional laxatives.

CONCLUSION

This 3-month study in 96 constipated children aged 6 months to 3 years confirms the long-term tolerance of PEG 4000 in pediatrics and indicates a PEG efficacy similar to or greater than that of lactulose.

A digestive tolerance study of maltitol after occasional and regular consumption in healthy humans

AIM

We aimed to evaluate the gastro-intestinal tolerance to an indigestible bulking sweetener containing sugar alcohol using a double-blind random cross-over study.

METHOD

In order to simulate their usual pattern of consumption, 12 healthy volunteers ingested maltitol or sucrose throughout the day, either occasionally (once a week for each sugar, first period) or regularly (every day for two 9 day periods, second period). In both patterns of consumption, daily sugar doses were increased until diarrhea and/or a grade 3 (ie severe) digestive symptom occurred, at which the dose level was defined as the threshold dose (TD).

RESULTS

In the first period (occasional consumption), the mean TD was 92+/-6 g with maltitol and 106+/-4 g with sucrose (P=0.059). The mean intensity of digestive symptoms was 1.1 and 1.3, respectively (P=NS). Diarrhea appeared in six and one subjects respectively (P=0.035). In the second period (regular consumption), the mean TD was 93+/-9 g with maltitol and 113+/-7 g with sucrose (P=0.008). The mean intensity of digestive symptoms was 1.7 and 1.2, respectively (P=NS). However, diarrhea appeared in eight and three subjects, respectively (P=0.04). Maltitol and sucrose TDs between the two periods were not different.

CONCLUSIONS

Under our experimental conditions, in comparison to sucrose: (a) occasional or regular consumption of maltitol is not associated with severe digestive symptoms; (b) in both patterns of maltitol consumption, diarrhea frequency is higher, but it appeared only for very high doses of maltitol, much greater than those currently used; (c) maltitol does not lead to intestinal flora adaptation after a 9 day period of consumption.

Acarbose in the treatment of elderly patients with type 2 diabetes

AIMS

To study the effect of acarbose, an alpha-glucosidase inhibitor, on glycemic control in elderly patients with type 2 diabetes.

METHODS

Elderly patients with type 2 diabetes treated with diet alone were randomly treated in a double-blind fashion with placebo (n=99) or acarbose (n=93) for 12 months.

RESULTS

After 12 months of therapy, there was a statistically significant difference in the change in glycated haemoglobin (HbA(1c)) (-0.6%) in the acarbose group versus placebo, as well as in the incremental post-prandial glucose values (-2.1 mmol h/l) and mean fasting plasma glucose (-0.7 mmol/l). Although there was no effect of acarbose on insulin release, there was a clear effect of acarbose to decrease relative insulin resistance (-0.8) (HOMA method). In addition, acarbose was generally well tolerated and safe in the elderly; most discontinuations were due to gastrointestinal side effects such as flatulence and diarrhea. There were no cases of hypoglycemia reported, and no clinically relevant changes in laboratory abnormalities or vital signs during the study.

CONCLUSIONS

Acarbose improves the glycemic profile and insulin sensitivity in elderly patients with type 2 diabetes who are inadequately controlled on diet alone.

The solution was the problem

There are increasing numbers of adults living in the community who require enteral tube feeding. While there is significant evidence of the importance of this treatment, there are side effects which can cause difficulties for patients, their carer tabers and health professionals. Gastrointestinal complications are the most common side effects with feed formula being cited as the main culprit, often without investigating other potential causes. Many patients requiring aggressive nutrition support also require concurrent drug therapy to manage underlying disease. Drugs are often given via tubes in liquid form. These elixirs often contain large quantities of sorbitol, which will increase the osmolar concentration. There is a lack of awareness from primary health-care professionals about the difficulties that can arise when giving medications to patients receiving enteral feeding which may affect patient care and the nutritional outcomes.

Effect of different probiotic preparations on anti-helicobacter pylori therapy-related side effects: a parallel group, triple blind, placebo-controlled study

OBJECTIVES

Several studies show that probiotics may prevent side effects during therapy against Helicobacter pylori (H. pylori). Other reports indicate competitive interaction between some probiotics and H. pylori. We compared efficacy of two different probiotics and one probiotic combination with placebo for preventing anti-H. pylori therapy-related side effects and for improving the eradication rate.

METHODS

A total of 85 H. pylori positive, asymptomatic patients were randomized in four groups to receive probiotic or placebo both during and for 7 days after a 1-wk triple therapy scheme (rabeprazole 20 mg b.id., clarithromycin 500 mg b.i.d., and tinidazole 500 mg b.i.d.). Group I (n = 21) received Lactobacillus GG; group II (n = 22), Saccharomyces boulardii; group III (n = 21), a combination of Lactobacillus spp. and biphidobacteria; and group IV (n = 21), placebo. Subjects filled in weekly symptom questionnaires for 4 wk. Blinded investigators collected and analyzed data. H. pylori status was rechecked after 5-7 wk.

RESULTS

Side effects occurred mainly during the eradication week. None of them caused therapy discontinuation. In all probiotic-supplemented groups, there was a significantly lower incidence of diarrhea and taste disturbance during the eradication week with respect to the placebo group. Overall assessment of tolerability was significantly better in the actively treated patients than in the placebo group. No differences in the incidence of side effects between the probiotic groups were observed. The H. pylori eradication rate was almost identical between the probiotic and placebo groups.

CONCLUSIONS

All the probiotics used were superior to placebo for side effect prevention, but were not associated with better compliance with antibiotic therapy. The effect of probiotic supplementation on side effects during anti-H. pylori regimens seemed to be independent of the probiotic species used.

Inhibition of gastric emptying by acarbose is correlated with GLP-1 response and accompanied by CCK release

We investigated the effect of acarbose, an alpha-glucosidase and pancreatic alpha-amylase inhibitor, on gastric emptying of solid meals of varying nutrient composition and plasma responses of gut hormones. Gastric emptying was determined with scintigraphy in healthy subjects, and all studies were performed with and without 100 mg of acarbose, in random order, at least 1 wk apart. Acarbose did not alter the emptying of a carbohydrate-free meal, but it delayed emptying of a mixed meal and a carbohydrate-free meal given 2 h after sucrose ingestion. In meal groups with carbohydrates, acarbose attenuated responses of plasma insulin and glucose-dependent insulinotropic polypeptide (GIP) while augmenting responses of CCK, glucagon-like peptide-1 (GLP-1), and peptide YY (PYY). With mixed meal + acarbose, area under the curve (AUC) of gastric emptying was positively correlated with integrated plasma response of GLP-1 (r = 0.68, P < 0.02). With the carbohydrate-free meal after sucrose and acarbose ingestion, AUC of gastric emptying was negatively correlated with integrated plasma response of GIP, implying that prior alteration of carbohydrate absorption modifies gastric emptying of a meal. The results demonstrate that acarbose delays gastric emptying of solid meals and augments release of CCK, GLP-1, and PYY mainly by retarding/inhibiting carbohydrate absorption. Augmented GLP-1 release by acarbose appears to play a major role in the inhibition of gastric emptying of a mixed meal, whereas CCK and PYY may have contributory roles.

The efficacy of acarbose in type 2 diabetes mellitus in Jamaica

The efficacy and tolerability of acarbose was studied in type 2 diabetic patients eating a typical Jamaican diet. The study was an open label parallel group study without placebo control. Of the 51 subjects recruited, five (9.8%) did not complete the study and were excluded from further analysis. Six (13%) of the remaining 46 had adverse side effects and did not complete the protocol. Of the remaining 40 (Gp A), acarbose was added to their previous regime of diet alone (n = 15), [Gp B], oral hypoglycaemic agents, OHAs (n = 17), [Gp C], or insulin (n = 8), Gp D]. In addition, during the run-in period all subjects had one session each with a dietitian and a diabetes educator. Over a 3-month period, significant reductions in average glucose (mmol) were observed in Gp B 10.5 +/- 1.1 to 8.4 +/- 0.9 (p < 0.027) and, from 11.0 +/- 1.0 to 8.7 +/- 0.7 (p < 0.01) in Gp C. Similarly, total glycosylated haemoglobin fell from 14.8 +/- 1.1% to 12.2 +/- 1.0% (p < 0.016) in Gp B, from 14.9 +/- 1.1 to 11.9 +/- 1.1% (p < 0.002) in Gp C, and from 14.1 +/- 1.4 to 11.8 +/- 1.4 (p < 0.02) in Gp D. Twenty-three per cent (23%) of the patients experienced flatulence; 7.5%, changes in bowel habits and 5%, abdominal cramps and discomfort. Acarbose is effective as monotherapy and as combination therapy with oral hypoglycaemic agents or insulin. Side effects were common, but tolerable.

Optimal dosage interval for depot somatostatin analogue therapy in acromegaly requires individual titration

BACKGROUND

The recent introduction of the depot somatostatin analogues octreotide LAR and lanreotide represent major advances in the medical treatment of acromegaly. However, it is uncertain whether the recommended dose intervals of 4 weeks and 10-14 days, respectively, are applicable to all patients.

AIMS

To determine the optimum intervals between depot injections of either octreotide LAR and lanreotide for the suppression of serum GH and IGF-I in patients with acromegaly. Twenty-seven patients with acromegaly were randomly allocated to receive either three injections at 4 week intervals of octreotide LAR (n = 18) or five injections at 14 day intervals of lanreotide (n = 11); two patients participated in both arms. Prior to the first injection, at 4 and 6 weeks after the last injection of LAR, and at 10, 14 and 21 days after the last injection of lanreotide, serum mean GH and IGF-I levels were measured.

RESULTS

In the LAR-treated group, at 4 and 6 weeks after the third injection 13 patients (72%) and 12 patients (67%), respectively, had a mean GH < 5 mU/l. IGF-I was normalized in 12 and 11 patients at these times. In the lanreotide-treated group, five (45%), four (36%) and three (27%) patients, respectively, had a GH < 5 mU/l at 10, 14 and 21 days after the last injection and eight, six and five patients had a normal serum IGF-I.

CONCLUSION

There is marked variability in individual patient responses to depot somatostatin analogues. The establishment of optimal drug intervals requires careful assessment. For octreotide LAR many patients may be as adequately controlled with 6 weekly injections as with 4 weekly injections. It is important to measure serum GH profiles at intervals after initiating therapy with these drugs to individualize doses for each patient and hence minimize cost.

Effects of inulin on faecal bifidobacteria in human subjects

A controlled study with eight healthy free-living subjects was carried out, in which energy intake was adjusted to the individual energy requirements. On administration of inulin, blood lipids, the faecal microflora, short-chain fatty acids and accompanying gastrointestinal symptoms were characterized in order to investigate the long-term effect of inulin. During the run-in phase (8 d), subjects received a typical Western diet providing 45% energy as fat and 40% energy as carbohydrate. Subsequently, the subjects consumed a fat-reduced diet which provided 30% energy as fat and 55% energy as carbohydrate for a period of 64 d using inulin as a fat replacer. The amounts of inulin consumed by the subjects (up to 34 g/d) were based on individual energy requirements with the aim to keep the diet isoenergetic with that used in the run-in period. To assess the effects of inulin administration, a control study (run-in and intervention) was carried out in which subjects consumed the same diet but devoid of inulin during the whole course of the study. To investigate the effect of inulin on faecal flora composition total bacteria and bifidobacteria in the faeces were enumerated by in situ hybridization with 16S rRNA targeted oligonucleotide probes. Inulin significantly increased bifidobacteria from 9.8 to 11.0 log10/g dry faeces and caused a moderate increase in gastrointestinal symptoms such as flatulence and bloatedness, whereas blood lipids and short-chain fatty acids remained essentially unaffected.

Integrated modelling of the clinical pharmacokinetics of SDZ HTF 919, a novel selective 5-HT4 receptor agonist, following oral and intravenous administration

AIMS

The purpose of the present study was to assess the pharmacokinetics of the novel selective 5-HT4 receptor agonist SDZ HTF 919 (HTF) including food effect, absolute bioavailability, interoccasion and intersubject variabilities.

METHODS

In the randomized, open-label, three treatment, four period crossover study, HTF was administered to 12 young healthy male subjects as a 12 mg tablet (twice under fasted and once under fed conditions) and a 3 mg intravenous (i.v.) infusion over 40 min (fasted). Pharmacokinetic parameters were obtained by noncompartmental methods. A more comprehensive pharmacokinetic characterization was achieved by integrated modelling of oral (p.o.) and i.v. data. To describe the absorption phase a Weibull function and a classical first order input function were compared.

RESULTS

Noncompartmental pharmacokinetic analysis revealed a rapid absorption (tmax 1.3 h, fasted), an absolute bioavailability of 11+/-3%, a biphasic disposition phase with a terminal half-life of 11+/-5 h, a clearance of 77+/-15 l h-1, and a volume of distribution at steady state of 368+/-223 l. The coefficients of interoccasion and interindividual variability in Cmax and AUC ranged between 17 and 28%. Food intake caused a delay (tmax 2.0 h) and decrease in absorption with consequently lower systemic exposure ( approximately 5% absolute bioavailability). Integrated p.o./i.v. pharmacokinetic modelling with a Weibull input function allowed accurate description of individual profiles. Modelling of the data from the p.o. dosing improved the description of the terminal phase by inclusion of the i. v. data and additionally provided quantitative characterization of the absorption phase.

CONCLUSIONS

The pharmacokinetics of HTF could be well described by an integrated modelling approach for both p.o. and i.v. data. The derived model will provide guidance in the design of future studies.

Human gastrointestinal tolerance to D-tagatose

D-Tagatose is a stereoisomer of D-fructose which is poorly absorbed in the small intestine and may, therefore, have potential as a reduced calorie bulk sweetener. However, one of the major limitations is the use of malabsorbed sugars is that their consumption may be associated with gastric discomfort. This is due to the osmotic impact of the sugar molecules remaining in the gut lumen for a prolonged period. We have performed a series of studies in which gastrointestinal symptoms have been recorded after the consumption of 29 or 30 g of D-tagatose. Nausea and diarrhea were reported with an incidence of 15.1 and 31.5%, respectively, in 73 healthy young male subjects in a screening study. Increased flatulence after D-tagatose was frequently reported in all the studies and the flatulence did not decline during a 15-day period with intake of 30 g in one dose daily. In most cases, symptoms were reported as light or moderate. However, the results suggest that 30 g taken at one time may be above the dose which should be recommended for ordinary use.

Transitory laxative threshold of trehalose and lactulose in healthy women

The transitory laxative threshold of a partially digestible disaccharide, trehalose, and an undigestible disaccharide, lactulose, was estimated by the dose-response relation between the test substance and the prevalence of diarrhea in 20 healthy female subjects. The subjects ingested several indicated amounts of trehalose or lactulose once daily 2 to 3 h after a meal. The intake of the test substance was stopped at the dose level that caused diarrhea or when the dose reached the maximal level. A record of physical conditions, gastrointestinal symptoms, and fecal conditions was made by all subjects before and after each ingestion of the test substance. Half the subjects experienced no diarrhea even with the ingestion of the maximal dose level (60 g) of trehalose in this study, and the ingestion of up to 40 g of lactulose caused diarrhea in 75% of all subjects. Abdominal symptoms such as flatus, distension, and borborygmus appeared at high prevalence with lactulose and trehalose ingestion, and the effect of lactulose was significantly stronger than that of trehalose at the same dose level (p < 0.05). The quantity of trehalose and lactulose that induced diarrhea differed greatly from person to person. The transitory laxative threshold was estimated as 0.65 g/kg body weight for trehalose and 0.26 g/kg body weight for lactulose by using the regression equation between the dose levels of the test substances and the cumulative incidence of diarrhea. These results suggest that it would be quite acceptable to administer trehalose up to 33 g and lactulose up to 13 g in a person weighing 50 kg.

Lack of pharmacokinetic interaction between tiagabine and erythromycin

This study was conducted to investigate the effects on the pharmacokinetics of tiagabine at steady state when coadministered with therapeutic doses of erythromycin. Tiagabine doses of 4 mg twice daily and erythromycin doses of 500 mg twice daily were administered for 4 days in an open-label, crossover, two-period interaction trial in 13 healthy volunteers. No statistically significant differences in maximum plasma concentration (Cmax), area under the concentration-time curve (AUC tau), or half-life (t1/2) of tiagabine were observed when tiagabine was administered alone or in combination with erythromycin. A statistically significant treatment effect was observed for time to maximum concentration (tmax; 0.72 after tiagabine alone versus 0.56 hours after administration with erythromycin). No statistically significant differences were seen between men and women except in tmax and t1/2; these differences were thought to be of no clinical significance. The decrease in tmax seen in women in this study is interpreted as a differential effect of erythromycin on gastric emptying of females and not as an interaction between tiagabine and erythromycin. No changes in laboratory parameters or vital signs were attributable to trial medication. The most common treatment-emergent adverse events that were possibly related to trial medication were central nervous system effects (e.g., headache, dizziness); all adverse events were transient, the majority were rated mild in severity, and did not require additional action. Coadministration of erythromycin in healthy subjects does not significantly affect the pharmacokinetics of tiagabine at the doses tested.

The influence of ispaghula husk on bowel habit

Frequency of defaecation, faecal form, straining at the start and end of defaecation, feelings of incomplete evacuation of faeces and urgency of defaecation were recorded in 69 healthy volunteers during three distinct 28-day study phases: pre-treatment, treatment with ispaghula husk and post-treatment. During treatment there was a significant increase (P < 0.001) in stool frequency and significant decreases in straining at the start (P < 0.001) and end (P < 0.001) of defaecation and in feelings of incomplete evacuation (P < 0.001). There was evidence of a beneficial residual effect after treatment had stopped. There are indications that ispaghula husk (Fybogel Orange) is of benefit in relieving constipation symptoms in apparently healthy people.

Beneficial effects of acarbose on familiar hypertriglyceridemias

Elevated serum triglyceride levels may be related to the following clinical features: increased blood coagulation and viscosity, increased serum fibrinogen levels, decreased fibrinolysis, and for serum levels over 1000 mg/dl, a strong increase of acute pancreatitis rate. Pharmacological choice among the numerous drugs to treat hypertriglyceridemias is currently debated. Our study was aimed to assess the therapeutic efficacy of acarbose in the treatment of non-diabetic subjects, affected by familiar hypertriglyceridemia (FH). We studied 18 non-diabetic patients (10 males, 8 females; mean age 57.61+/-6.85 years) without family history of diabetes mellitus affected by familiar hypertriglyceridemia. The study protocol planned a treatment period of 20 weeks, divided into five 4-week courses and made up as follows: diet plus acarbose therapy (4 weeks); diet therapy alone (4 weeks) alternatively. In the second and fourth 4-week courses diet plus acarbose were administered, while diet therapy alone was administered in the first, third, and fifth 4-week courses. Acarbose doses consisted of 50 mg (1/2 pill) twice daily. Mean serum triglyceride levels, after first month of dietary treatment, underwent a significant reduction from 481.5 +/- 67.1 mg/dl to 389.5 +/- 62.7 mg/dl, even if they did not reach the optimal levels to keep on the dietary therapy alone. After the first month of treatment with acarbose associated to diet, we observed a further reduction of serum triglycerides levels (p = 0.02). When diet alone was administered, mean triglyceride serum levels underwent a significant enhancement (p = 0.003). Restarting for the second time the association treatment, we observed a noteworthy reduction of mean serum triglyceride levels (p = 0.0001). Acarbose acts on the pathogenesis of FH, lowering the production of endogenous triglycerides. Our data suggested that acarbose can be considered a valid therapeutic tool in the treatment of familiar hypertriglyceridemias, also in non-diabetic patients.

Acarbose in NIDDM patients with poor control on conventional oral agents. A 24-week placebo-controlled study

OBJECTIVE

To determine the efficacy of acarbose, compared with placebo, on the metabolic control of NIDDM patients inadequately controlled on maximal doses of conventional oral agents.

RESEARCH DESIGN AND METHODS

In this three-center double-blind study, 90 Chinese NIDDM patients with persistent poor glycemic control despite maximal doses of sulfonylurea and metformin were randomly assigned to receive additional treatment with acarbose 100 mg thrice daily or placebo for 24 weeks, after 6 weeks of dietary reinforcement. Efficacy was assessed by changes in HbA1c, fasting and 1-h postprandial plasma glucose and insulin levels, and fasting lipid levels.

RESULTS

Acarbose treatment was associated with significantly greater reductions in HbA1c (-0.5 +/- 0.2% vs. placebo 0.1 +/- 0.2% [means +/- SEM], P = 0.038), 1-h postprandial glucose (-2.3 +/- 0.4 mmol/l vs. placebo 0.7 +/- 0.4 mmol/l, P < 0.001) and body weight (-0.54 +/- 0.32 kg vs. placebo 0.42 +/- 0.29 kg, P < 0.05). There was no significant difference between the two groups regarding changes in fasting plasma glucose and lipids or fasting and postprandial insulin levels. Flatulence was the most common side effect (acarbose vs. placebo: 28/45 vs. 11/44, P < 0.05). One patient on acarbose had asymptomatic elevations in serum transaminases that normalized in 4 weeks after acarbose withdrawal. Another patient on acarbose developed severe hypoglycemia; glycemic control was subsequently maintained on half the baseline dosage of sulfonylurea.

CONCLUSIONS

In NIDDM patients inadequately controlled on conventional oral agents, acarbose in moderate doses resulted in beneficial effects on glycemic control, especially postprandial glycemia, and mean body weight. Additional use of acarbose can be considered as a useful alternative in such patients if they are reluctant to accept insulin therapy.

An Asian multicenter clinical trial to assess the efficacy and tolerability of acarbose compared with placebo in type 2 diabetic patients previously treated with diet. Asian Acarbose Study Group

OBJECTIVE

To assess the efficacy, safety, and tolerability of acarbose versus placebo during a 24-week treatment period in Asian type 2 diabetic patients with dietary failure.

RESEARCH DESIGN AND METHODS

After a 6-week screening period, 126 multiethnic Asian type 2 diabetic patients (64 men, 62 women; mean age +/- SD, 53.4 +/- 10 years) were randomized to receive acarbose (n = 63) or placebo (n = 63). The dosage was increased from 50 mg t.i.d. at week 0 to 100 mg t.i.d. at week 4. Patients were then followed up at weeks 10, 16, and 24. At each visit, body weight, blood pressure, and metabolic indexes were measured. At weeks 0 and 24, fasting plasma glucose and insulin were measured before and 1 h after the administration of an individually tailored breakfast.

RESULTS

Using the intention-to-treat analysis, there were greater reductions in (mean [95% CI]) HbA1c (-0.70 [-1.00 to -0.39] vs. -0.27% [-0.54 to 0]; P = 0.04), fasting plasma glucose (-0.37 [-0.75 to 0.02] vs. 0.41 mmol/l [-0.08 to 0.90]; P = 0.017) and 1-h plasma glucose (-0.77 [-1.44 to -0.10] vs. 0.65 mmol/l [-0.07 to 1.36]; P = 0.05) in the acarbose group compared with the placebo group. With acarbose treatment, 78% of patients achieved an HbAlc < 8% compared with 56% in the placebo group (P = 0.003). There was a greater reduction in body weight (-1.31 [-2.46 to -0.15] vs. 0.16 kg [-3.36 to 0.10]; P = 0.02) and higher incidence of flatulence (56 vs. 37%; P = 0.032) in the acarbose than in the placebo group. Using baseline HbA1c and race as covariates, there were no significant interethnic differences in treatment responses (P = 0.232 for treatment-race interaction; P < 0.001 for treatment effect). The dropout rates were similar between the two groups (acarbose, 11 of 63; placebo, 6 of 63). There were no significant laboratory adverse events in either group.

CONCLUSIONS

In this multicenter study involving six ethnic groups, acarbose 100 mg t.i.d. was an effective, safe, and generally well-tolerated therapy in Asian type 2 diabetic patients with dietary failure. In some patients with troublesome gastrointestinal symptoms, a lower dosage may be necessary.

High dose gabapentin in refractory partial epilepsy: clinical observations in 50 patients

Fifty patients with refractory partial seizures took part in a prospective, observational study of adjuvant gabapentin (GBP) in increasing doses. Thirty-three were started on 400 mg GBP daily with further weekly increments of 400 mg until seizures came under control for at least 6 months or to the limit of tolerability. A further 17 patients, not fully controlled on low dose GBP, followed the same regimen. All patients took the drug three times daily. Comparisons were made with seizure numbers during a 3-month baseline during which antiepileptic medication remained unchanged. Overall, 24 of the 50 patients documented a seizure reduction of 50% or more. Fifteen did so at or below 2400 mg GBP daily. Three of these patients became seizure-free. The remaining nine appeared to respond to higher daily doses of GBP (1:2800 mg; 3:3600 mg; 1:4000 mg; 1:4800 mg; 3:6000 mg), with two becoming seizure-free. Side-effects most commonly reported included tiredness, dizziness, headache and diplopia. On GBP doses exceeding 3600 mg daily, three patients developed flatulence and diarrhoea and two more had myoclonic jerks. Mean circulating GBP concentrations (mg/l) at each 1200 mg dose level were as follows: 1200 mg-4.1; 2400 mg-8.6; 3600 mg 13.2; 4800 mg 15.5; 6000 mg-17.2. In six patients, including three taking 6000 mg daily, GBP concentrations continued to rise linearly at each dosage increment. Although limited, our results do not support the suggestion that GBP absorption is saturable. High dose GBP may be effective in controlling seizures in patients with refractory partial epilepsy.

The effect of cisapride in maintaining symptomatic remission in patients with gastro-oesophageal reflux disease

BACKGROUND

Successful treatment of gastro-oesophageal reflux disease (GORD) has traditionally been assessed as healing of reflux oesophagitis, which may not be relevant in patients with moderate disease. In these patients symptom relief and patient satisfaction with therapy are of fundamental importance. Cisapride has well-documented prokinetic effects and may be well suited for long-term therapy of GORD, but its effectiveness in purely symptomatic treatment is unknown. We therefore compared two dosage regimens of cisapride with placebo over a period of 6 months in patients with evidence of gastrooesophageal reflux, initially treated with antisecretory medication, with regard to maintaining symptom relief and satisfaction with treatment.

METHODS

Five hundred and thirty-five patients with reflux oesophagitis grade 1 (n = 293) or 2 (n = 124) or with no reflux oesophagitis but pathologic 24-h pH-metry (n = 118) achieved satisfactory symptom relief with an H2-receptor antagonist or proton pump inhibitor within 4-8 weeks. In a double-blind randomized, parallel-group study, they were then treated with cisapride, 20 mg at night or 20 mg twice daily, or placebo and followed up for a maximum period of 6 months. Relapse was defined as dissatisfaction with therapy or an average consumption of more than two antacid tablets a day.

RESULTS

Median time to relapse was 63 days for cisapride, 20 mg twice daily; 59 days for cisapride, 20 mg at night; and 49 days for placebo. Time to relapse was not significantly different (P = 0.09). Presence and grade of oesophagitis at base line, type of therapy before randomization, and pattern of non-reflux symptoms at base line did not influence these findings significantly.

CONCLUSION

The study indicates that cisapride is of limited value in maintenance therapy of GORD in patients in whom symptom relief has been accomplished with potent antisecretory medication. This 'step-down' approach to therapy seems disadvantageous in the long-term therapy of GORD.

The efficacy and safety of miglitol therapy compared with glibenclamide in patients with NIDDM inadequately controlled by diet alone

OBJECTIVE

To compare the therapeutic effects of the alpha-glucosidase inhibitor miglitol (BAY m 1099), the sulfonylurea glibenclamide, and placebo on parameters of metabolic control and safety in patients with NIDDM that is inadequately controlled by diet alone.

RESEARCH DESIGN AND METHODS

After a 4-week placebo run-in period, 201 patients in 18 centers in 4 countries were randomized in a double-blind manner to miglitol (50 mg t.i.d., followed by 100 mg t.i.d.), glibenclamide (3.5 mg q.d/b.i.d.), or placebo for 24 weeks. Efficacy criteria were changes from baseline of HbA1c, fasting and postprandial blood glucose and insulin levels, body weight, and serum triglycerides.

RESULTS

Efficacy was assessed in 119 patients who completed the full protocol, and the results were similar to those obtained in 186 patients who fulfilled the validity criteria for analysis. Compared with placebo, mean baseline-adjusted HbA1c decreased by 0.75% (P = 0.0021) and 1.01% (P = 0.0001) in the miglitol and glibenclamide treatment groups, respectively. Blood glucose decreased slightly in the fasting state and considerably in the postprandial state in both treatment groups but not in the placebo group. Fasting insulin levels increased slightly (NS) in all treatment groups; however, postprandial insulin levels decreased with miglitol, while increasing markedly with glibenclamide (P = 0.0001 between all treatment groups). Gastrointestinal side effects (flatulence and diarrhea) occurred mostly in the miglitol-treated patients, while some glibenclamide-treated patients had symptoms suggestive of hypoglycemia.

CONCLUSIONS

Miglitol monotherapy is effective and safe in NIDDM patients. Compared with glibenclamide, it reduced HbA1c less effectively and caused more gastrointestinal side effects. On the other hand, glibenclamide, unlike miglitol, tended to cause hypoglycemia, hyperinsulinemia, and weight gain, which are not desirable in patients with NIDDM.

Effect of processing on flatus producing oligosaccharides in cowpea (Vigna unguiculata) and the tropical African yam bean (Sphenostylis stenocarpa)

The effect of dehulling, soaking and soaking/cooking on sucrose, raffinose and stachyose in mature dry seeds of nine varieties of cowpea (Vigna unguiculata) and one variety of tropical African yam bean (Sphenostylis stenocarpa) were investigated. The results showed a progressive decrease in sucrose, raffinose, and stachyose contents. Soaking for 12 hours and cooking for 30 min eliminated most of the sucrose, raffinose and stachyose. The sugar contents in whole raw cowpea were sucrose 0.73-4.58%, raffinose 0.71-6.86% and stachyose 2.38-3.87%, and for tropical African yam bean sucrose 4.08%, raffinose 1.08% and stachyose 4.14% while the seeds soaked for 12 hours and cooked for 30 min had for cowpea sucrose 0.03-0.81%, raffinose 0.04-0.20% and stachyose 0.12-0.72%, and tropical African yam bean sucrose 0.70%, raffinose 0.40% and stachyose 0.41%.

Dose-related gastrointestinal response to the ingestion of either isomalt, lactitol or maltitol in milk chocolate

OBJECTIVES

To determine whether there were differences between different polyols (sugar alcohols) in terms of their ability to stimulate intolerance symptoms when consumed in milk chocolate. Also to discover whether symptomatology can be related to the dose of polyol ingested.

DESIGN

The study was of a randomised double-blind cross-over design.

SUBJECTS

59 healthy volunteers aged 18-24 years were recruited from the student population of the University of Salford. All subjects successfully completed the trial.

INTERVENTIONS

Subjects ingested 100 g milk chocolate containing 40 g bulk sweetner as either sucrose, isomalt, lactitol or maltitol or a mixture (10:30 w/w) of sucrose and isomalt, sucrose and lactitol or sucrose and maltitol. Each bar was taken as breakfast on one day with following products consumed at 1-week intervals. Subjects reported the incidence and severity of the symptoms of flatulence, borborygms, colic, motion frequency and loose stools.

RESULTS

The ingestion of 30 g or 40 g lactitol resulted in a significant increase in the incidence and severity of all symptoms examined compared to reactions after the consumption of standard sucrose-containing chocolate (P <0.01). Similarly, 40 g isomalt led to an increased incidence of all symptoms, including mild laxation (P <0.01), but unlike lactitol none was rated as being severe. A reduction in isomalt to 30 g was marked by increased tolerance with evidence of only mild borborygms (P <0.01), mild flatulence, colic, and laxation (P <0.05), with no increase in motion frequency (P <0.35). Ingestion of 40 g maltitol caused less intolerance than 40 g isomalt, with evidence of only flatulence, borborygms and colic (P <0.01), symptoms being rated as only mild. A reduction to 30 g led to a decrease in all symptoms except mild flatulence. Maltitol did not have any laxative effect when ingested at either 30 g (P = 0.32) or 40 g (P = 0.13) per day.

CONCLUSIONS

This work has shown that there are significant differences in the reporting of gastrointestinal symptomatology following the consumption of isomalt, lactitol and maltitol incorporated into milk chocolate. However, with all three polyols the incidence and severity of symptomatology was dose dependent.

A randomized, double-blind placebo controlled cross-over study to investigate the effects of RW94 on the absorption of dietary fat in healthy volunteers

RW94 is a permitted additive in the food industry, which precipitates fatty acids in vitro. In vivo, this could result in reduced fatty acid absorption by the body, and may, therefore, influence the amount of fat excreted in the faeces. An investigation into the effects of RW94 on bodily fat absorption and excretion was undertaken. The safety, tolerability and efficacy of the product was compared with placebo in a group of 12 healthy volunteers, randomly assigned to receive either RW94 or placebo for a period of four days when dietary fat intake was controlled. After a 10-day washout period, the randomly assigned groups were crossed over to receive placebo and RW94, respectively, for a second 4-day period, when fat intake was similarly controlled. Five grams of RW94 administered orally 30 min after each meal resulted in a statistically significant increase in the amount of excreted faecal lipids compared with placebo (p < 0.05). Following high fat intake, total blood cholesterol was predictably raised in both placebo and RW94 groups, but was less markedly raised with RW94 than placebo. All subjects lost body weight during the study, but the loss while consuming RW94 was significantly greater (p < 0.05) than while consuming placebo. All subjects found the treatments acceptable, though an increased incidence of flatulence, rumbling stomach and abdominal discomfort was noted with RW94 compared with placebo. RW94 was comparable with placebo in respect of safety.

The tolerability and pharmacokinetics of N-butyl-deoxynojirimycin in patients with advanced HIV disease (ACTG 100). The AIDS Clinical Trials Group (ACTG) of the National Institute of Allergy and Infectious Diseases

Twenty-nine patients were enrolled in a phase I dose-escalating tolerance trial of N-butyl-deoxynojirimycin, an alpha-glucosidase I inhibitor that inhibits human immunodeficiency virus (HIV)-1 replication by altering glycosylation of gp120. Dosing was begun at 8 mg/kg/day and subsequent doses were 16, 32, 48, and 64 mg/kg/day. The maximum tolerated dose was not achieved because of slow accrual and because the study was stopped after the finding of cataracts in initial long-range rat toxicology studies. These cataracts were later shown to be transient and not found in other animals. The most common side effects were gastrointestinal, with diarrhea and flatulence occurring in most subjects, which seemed to partially improve on a modified diet that excluded complex carbohydrates. Grade III elevations in liver function tests were seen in two patients. Grade III leukopenia and neutropenia were seen in seven patients, but were only severe enough in two to require discontinuation. No significant trends in CD4 cell counts or HIV-1 p24 levels were noted.

Breath hydrogen after ingestion of the bulk sweeteners sorbitol, isomalt and sucrose in chocolate

The effect of eating chocolate containing sugar alcohols as sweetening agents on colonic fermentation has been investigated by monitoring breath H2 levels. Levels were compared with those occurring after the consumption of normal, sugar-containing chocolate. Ten healthy volunteers aged 19 to 21 years ingested equal amounts of either sorbitol, isomalt or sucrose incorporated into standard chocolate bars. Breath H2 levels after consumption of chocolate containing either sorbitol or isomalt were significantly higher than those after consumption of chocolate containing sucrose (P < 0.001). After consumption of chocolate containing sorbitol, double the mean estimated volume of breath H2 was produced over 6 h compared with that produced after eating chocolate containing isomalt. Taken together with results relating to the incidence of intolerance symptoms, these findings demonstrate that sorbitol is associated with greater colonic fermentation compared with isomalt.

The effect of feeding xanthan gum on colonic function in man: correlation with in vitro determinants of bacterial breakdown

Xanthan gum (15 g/d) was given for 10 d to eighteen normal volunteers. In vivo measurements of stool output, transit time, frequency of defaecation and flatulence were compared with a preceding control period of 10 d. At the end of the control and test periods fresh faecal homogenate from each subject was anaerobically incubated with xanthan gum and control solutions to assess the ability of the bacteria to break down the gum. Xanthan gum was found to be a highly efficient laxative agent causing significant increases in stool output (P < 0.01), frequency of defaecation (P < 0.05) and flatulence (P < 0.01) whilst having variable effects on transit time. Before feeding xanthan gum, faecal samples from twelve of the eighteen subjects could reduce the viscosity of the gum in vitro. This rose to sixteen of the eighteen with significantly greater amounts (P < 0.05) of hydrogen and short-chain fatty acids also being produced, indicating bacterial adaptation in the presence of the substrate. Correlations between the in vivo and in vitro findings did not substantiate claims that the in vivo effect of a given polysaccharide can be predicted from its fermentation characteristics in vitro.

Comparative studies of gastrointestinal tolerance and acceptability of milk chocolate containing either sucrose, isomalt or sorbitol in healthy consumers and type II diabetics

The objective was to compare reaction of adult consumers of confectionery to milk chocolate made with either isomalt, sucrose or sorbitol. Test chocolate was eaten by subjects at home during 7 days in amounts chosen by them up to a maximum of 100 g per day. In a double-blind crossover trial isomalt chocolate was associated in healthy consumers (n = 58) with increased motion frequency, wind and flatulence compared with sucrose chocolate. However, the intensity of these gastrointestinal effects was predominantly slight and insufficient to affect acceptability. In separate crossover trials, reactions of Type II diabetic consumers to eating isomalt chocolate (n = 53) or sorbitol chocolate (n = 51) were compared to reactions when eating no chocolate. Both isomalt and sorbitol chocolate were associated with higher incidence of wind and flatulence than for no chocolate, but only sorbitol chocolate increased motion frequency. Again intensity of gastrointestinal effects was slight. It is concluded that isomalt has potential use in both regular and diabetic chocolate.

Safety profile of acarbose, an alpha-glucosidase inhibitor

Acarbose, an alpha-glucosidase inhibitor, delays absorption of carbohydrate in the gut, thereby lowering postprandial glucose levels. Safety data on this drug have been gathered in a series of studies on animals and in extensive clinical trials in humans. Although an initial long term feeding study in rats showed an excess of renal tumours at very high dosages of acarbose (up to 300 mg/kg bodyweight daily), further evaluation with similar studies in rats, hamsters, and dogs indicated that the problem was related to carbohydrate malabsorption. With adequate glucose intake and in gavage studies, no difference in tumour incidence between placebo- and acarbose-treated groups was seen. From 1976 to 1989, safety data on acarbose were obtained in approximately 8800 patients in 2 separate groups of clinical trials, the Bayer International Clinical Data Pool and the American phase III trials. Almost all adverse experiences, as reported by 56 to 76% of patients on acarbose vs 32 to 37% of patients on placebo, were related to the digestive system and included diarrhoea, flatulence, bloating and nausea. Most symptoms were of mild to moderate intensity and tended to improve with time. In the American trials a small but significant increase in liver transaminases was seen, 3.8% in acarbose-treated patients vs 0.9% in controls together with a 1% increase in anaemia in the acarbose group. Overall, acarbose was well tolerated and the adverse experience profile was clinically acceptable.

Diarrhea in diabetics: the role of sorbitol

Diabetics often consume dietetic foods with sorbitol as the sweetener. Sorbitol, in amounts as little as 10 g. may produce diarrhea in healthy individuals. Sorbitol intolerance was studied in 12 diabetics and 23 nondiabetics. Similar numbers of diabetics (n = 10, 83.3%) and nondiabetics (n = 18, 78.3%) were found intolerant as judged by a greater than or equal to 20 ppm rise in postprandial breath hydrogen levels. Six diabetics (50%) and 13 nondiabetics (56.5%) developed abdominal symptoms after sorbitol ingestion. Subsequently, 100 diabetics and 100 nondiabetics were interviewed to determine the relationship between regular sorbitol consumption and abdominal symptoms. The interview revealed that (1) most individuals consuming sorbitol were unaware of its presence in their diet and (2) diarrhea was significantly (p less than 0.001) more prevalent in diabetics consuming sorbitol than diabetics not consuming it. We conclude that (1) many diabetics are intolerant to sorbitol and (2) regular sorbitol consumption may explain the "idiopathic" diarrhea in some diabetics.

Cost-effective treatment of constipation in the elderly: a randomized double-blind comparison of sorbitol and lactulose

PURPOSE

The purpose of this study was to evaluate the use of sorbitol as an inexpensive alternative to lactulose for treating constipation in the elderly.

PATIENTS AND METHODS

Thirty men aged 65 to 86 with chronic constipation were studied in a randomized, double-blind, cross-over trial in which lactulose and 70% sorbitol (0 to 60 mL daily) were each given for 4 weeks preceded by a 2-week washout period.

RESULTS

The average number of bowel movements per week was 6.71 with sorbitol and 7.02 with lactulose (95% confidence interval of the difference: -0.43 to 1.06), and the average number of days per week with bowel movements was 5.23 with sorbitol and 5.31 with lactulose (95% confidence interval of the difference: -0.32 to 0.48). Eleven patients stated a preference for sorbitol, 12 for lactulose, and seven had no preference. On a visual analogue scale measuring severity of constipation (0 to 100 mm), the average score for sorbitol was 35.6 mm versus 37.1 mm for lactulose (95% confidence interval of the difference: -6.4 to 9.3). The sorbitol and lactulose treatment periods were also similar in percent of bowel movements recorded as "normal," frequency and severity of symptoms such as bloating, cramping, and excessive flatulence, and overall health status as assessed by a previously validated five-category questionnaire. There were no significant differences between sorbitol and lactulose in any outcome measured except nausea, which was increased with lactulose (p less than 0.05).

CONCLUSION

These results support the hypothesis that sorbitol and lactulose have no clinically significant differences in laxative effect. Sorbitol can be recommended as a cost-effective alternative to lactulose for the treatment of constipation in the elderly.

Gaseous response to ingestion of a poorly absorbed fructo-oligosaccharide sweetener

Fructo-oligosaccharides are naturally occurring sweet substances that are poorly absorbed and have the potential to be clinically useful nonnutritive sweeteners. Because most nonabsorbed carbohydrates are fermented yielding gas, we assessed flatulent symptoms and H2 excretion during ingestion of fructo-oligosaccharide (5 g tid) for 12 d. Ten subjects had significantly greater flatulence while taking the oligosaccharide than did five subjects taking sucrose (5 g tid). Breath H2 after 10 g fructo-oligosaccharide was similar to that of 10 g lactulose, suggesting near total malabsorption of the fructo-oligosaccharide. Although previous studies found a marked diminution in breath H2 after prolonged exposure to lactulose, breath H2 response increased by 50% after a 12-d period on the oligosaccharide and gaseous symptoms did not improve. We conclude that adaptation of colonic bacteria to carbohydrate malabsorption is variable and may depend upon quantity or nature of the carbohydrate.

Sorbitol intolerance in adults

Sorbitol is a commonly used sugar substitute in "sugar-free" food products. Although sorbitol intolerance manifested by abdominal pain, bloating, and diarrhea has been observed in children, it has not been well documented in adults. Forty-two healthy adults (23 whites, 19 nonwhites) participated in this study. After ingestion of 10 g of sorbitol solution, end expiratory breath samples were collected at 15-min intervals for 4 h and analyzed for H2 concentration. Clinical sorbitol intolerance was detected in 43% of the whites and 55% of the nonwhites, the difference not being statistically significant. However, severe clinical sorbitol intolerance was significantly more prevalent in nonwhites (32%) as compared to whites (4%). There was a good correlation between the severity of symptoms and the amount of hydrogen exhaled. Dietetic foods, many of them containing sorbitol, are very popular with diabetics and "weight watchers." Based on our observations, we believe that a large number of adults could be suffering from sorbitol-induced nonspecific abdominal symptoms and diarrhea. These symptoms could lead to an extensive diagnostic work-up and lifelong diagnosis of irritable bowel syndrome.