Functional bowel disease: malabsorption and abdominal distress after ingestion of fructose, sorbitol, and fructose-sorbitol mixtures

Twenty-five patients with functional bowel disease were given fructose, sorbitol, fructose-sorbitol mixtures, and sucrose. The occurrence of malabsorption was evaluated by means of hydrogen breath tests and the gastrointestinal symptoms, if any, were recorded. One patient could not be evaluated because of lack of H2 production. Based on a cut-off level of 10 ppm rise of H2 concentration, malabsorption was apparent in 13 patients, in 7 of which the calculated absorption capacities were below 15 g. In contrast, in patients given 50 g of sucrose, malabsorption could not be detected. Ingestion of fructose caused marked abdominal distress in patients with demonstrable malabsorption. Ingestion of sucrose in these patients gave less pronounced symptoms of abdominal distress. Malabsorption of a 5-g dose of sorbitol could be detected in 8 of 13 patients. Mixtures of 25 g of fructose and 5 g of sorbitol caused significantly increased abdominal distress, and more than additive malabsorption was found in several cases. The present study shows that pronounced gastrointestinal distress may be provoked by malabsorption of small amounts of fructose, sorbitol, and fructose-sorbitol mixtures in patients with functional bowel disease. The findings may have direct influence on the dietary guidance given to a major group of patients with functional bowel disease and may make it possible to define separate entities in this disease complex.

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.

Hydro-MRI of the small bowel: effect of contrast volume, timing of contrast administration, and data acquisition on bowel distention

OBJECTIVE

The purpose of this study was to assess oral contrast agents, volumes of the agents, and time points of data acquisition in regard to small-bowel distention and patient acceptance.

SUBJECTS AND METHODS

Six healthy volunteers underwent imaging on 16 different days. Four volumes (450, 900, 1,350, and 1,800 mL) of each of the four contrast compounds (0.2% locust bean gum plus 2.5% mannitol, VoLumen containing 2.0% sorbitol, VoLumen containing 1.4% sorbitol, and tap water) were used. Two-dimensional true fast imaging with steady-state free precession data sets were acquired at 5-minute intervals after contrast ingestion. Distention values for small-bowel segments (duodenum, proximal and distal jejunum, ileum) and occurrence of side effects were documented.

RESULTS

Analysis of bowel distention revealed significantly greater distention for all carbohydrate sugar alcohol-containing solutions compared with water but no significant difference among the three contrast agents. Sufficient duodenal distention was achieved with 900 mL of any of the contrast agents, but imaging had to be performed soon after ingestion. For MRI of the distal jejunum and ileum, a volume of 1,350 mL is preferable, and the time point of data acquisition plays a minor role. Ingestion of 1,800 mL of the carbohydrate sugar alcohol solutions led to a significantly higher rate of side effects such as abdominal cramps than did ingestion of smaller volumes.

CONCLUSION

The data indicate that sufficient contrast consumption and optimal timing of data acquisition are essential to distention of the small bowel. Oral contrast agent protocols should be adapted to the bowel region in question.

Dietary sorbitol and mannitol: food content and distinct absorption patterns between healthy individuals and patients with irritable bowel syndrome

BACKGROUND

Sorbitol and mannitol are naturally-occurring polyol isomers. Although poor absorption and induction of gastrointestinal symptoms by sorbitol are known, the properties of mannitol are poorly described. We aimed to expand data on food composition of these polyols, and to compare their absorptive capacities and symptom induction in patients with irritable bowel syndrome (IBS) and healthy individuals.

METHODS

Food samples were analysed for sorbitol and mannitol content. The degree of absorption measured by breath hydrogen production and gastrointestinal symptoms (visual analogue scales) was evaluated in a randomised, double-blinded, placebo-controlled study in 21 healthy and 20 IBS subjects after challenges with 10 g of sorbitol, mannitol or glucose.

RESULTS

Certain fruits and sugar-free gum contained sorbitol, whereas mannitol content was higher in certain vegetables. Similar proportions of patients with IBS (40%) and healthy subjects (33%) completely absorbed sorbitol, although more so with IBS absorbed mannitol (80% versus 43%; P = 0.02). Breath hydrogen production was similar in both groups after lactulose but was reduced in patients with IBS after both polyols. No difference in mean (SEM) hydrogen production was found in healthy controls after sorbitol [area-under-the-curve: 2766 (591) ppm 4 h(-1) ] or mannitol [2062 (468) ppm 4 h(-1) ] but, in patients with IBS, this was greater after sorbitol [1136 (204) ppm 4 h(-1) ] than mannitol [404 (154) ppm 4 h(-1) ; P = 0.002]. Overall gastrointestinal symptoms increased significantly after both polyols in patients with IBS only, although they were independent of malabsorption of either of the polyols.

CONCLUSIONS

Increased and discordant absorption of mannitol and sorbitol occurs in patients with IBS compared to that in healthy controls. Polyols induced gastrointestinal symptoms in patients with IBS independently of their absorptive patterns, suggesting that the dietary restriction of polyols may be efficacious.

Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease

Hyperkalemia in patients with renal failure is frequently treated with a cation exchange resin (sodium polystyrene sulfonate, hereafter referred to as resin) in combination with a cathartic, but the effect of such therapy on serum potassium concentration has not been established. This study evaluates the effect of four single-dose resin-cathartic regimens and placebo on 5 different test days in six patients with chronic renal failure. Dietary intake was controlled. Fecal potassium output and serum potassium concentration were measured for 12 h. Phenolphthalein alone caused an average fecal potassium output of 54 mEq. The addition of resin caused an increase in insoluble potassium output but a decrease in soluble potassium output; therefore, there was no significant effect of resin on total potassium output. Sorbitol plus resin caused less potassium output than phenolphthalein plus resin. On placebo therapy, the average serum potassium concentration increased slightly (0.4 mEq/L) during the 12-h experiment. This rise was apparently abrogated by some of the regimens that included resin; this may have been due in part to extracellular volume expansion caused by absorption of sodium released from resin. Phenolphthalein regimens were associated with a slight rise in serum potassium concentrations (similar to placebo); this may have been due to extracellular volume contraction produced by high volume and sodium-rich diarrhea and acidosis secondary to bicarbonate losses. None of the regimens reduced serum potassium concentrations, compared with baseline levels. Because single-dose resin-cathartic therapy produces no or only trivial reductions in serum potassium concentration, and because this therapy is unpleasant and occasionally is associated with serious complications, this study questions the wisdom of its use in the management of acute hyperkalemic episodes.

Sugar malabsorption in functional abdominal bloating: a pilot study on the long-term effect of dietary treatment

BACKGROUND

Functional abdominal bloating is a functional bowel disorder dominated by a feeling of abdominal fullness without sufficient criteria for another functional gastrointestinal disorder. Gas-related complaints (i.e., passage of flatus), which are present in a subgroup of these patients, might be associated with carbohydrate malabsorption.

AIM

To evaluate the presence of lactose and/or fructose plus sorbitol malabsorption, and the long-term efficacy of malabsorbed sugar-free diets, in patients with Rome II criteria of functional abdominal bloating and gas-related symptoms.

METHODS

Thirty-six consecutive patients (age, 51+/-3.1 years; sex, 12 M, 24 W) with Rome II criteria of functional abdominal bloating and gas-related symptoms were included in a pilot study. In all cases, the presence of malabsorption of both lactose (20 g) and fructose plus sorbitol (20+3.5 g) was assessed by means of hydrogen breath test. Patients with sugar malabsorption were put on a malabsorbed sugar-free diet. Follow-up visits were scheduled at both 1 and 12 months after starting the diet. Global rating scales of change as compared to the beginning of the study were used to assess symptom changes.

RESULTS

Twenty-six of 36 patients (72.2%) presented sugar malabsorption (six lactose, 12 fructose plus sorbitol, and eight both). Seventeen of the 26 (65%) patients with malabsorption had symptoms of sugar intolerance during the 3-h breath testing period. All 26 were put on malabsorbed sugar-free diets. Eighty-one per cent of patients referred clinical improvement at 1-month visit, which was maintained at 12 months in 67% of them (complete improvement in 50% and partial improvement in 16.7%).

CONCLUSIONS

Sugar malabsorption and intolerance seem to be frequent in patients with functional abdominal bloating and gas-related complaints. A malabsorbed sugar-free diet might be a long-term effective therapy in a high percentage of patients. Further controlled clinical trials are warranted.

Oral contrast agents for small bowel MRI: comparison of different additives to optimize bowel distension

The purpose of this study was to compare two osmotic carbohydrate sugar alcohols (mannitol 2.5% and sorbitol 2.5%, 2.0%, and 1.5% watery solutions) in combination with 0.2% locust bean gum (LBG) for small bowel distension for MR imaging. Small bowel distension was quantified on coronal 2D TrueFISP images by measuring the diameters of 16 small bowel loops in each of 12 healthy subjects (age range 31-55 years). Additionally, the grade of small bowel distension was rated qualitatively. Patient acceptance concerning nausea, vomiting, flatulence, and diarrhea was noted for each solution, and all results were compared by a Wilcoxon test or t test, respectively. The ingestion of water combined with LBG and either 2.5% mannitol or 2.0% sorbitol showed the best distension of the small bowel. The lowest side effect rate was observed following ingestion of sorbitol in a concentration of 2.0 and 1.5%. Based on these data, we recommend a combination of LBG and 2% sorbitol use for optimal bowel distension and minimal side effects resulting in enhanced patient acceptance.

Xylitol pediatric topical oral syrup to prevent dental caries: a double-blind randomized clinical trial of efficacy

OBJECTIVES

To evaluate the effectiveness of a xylitol pediatric topical oral syrup to reduce the incidence of dental caries among very young children and to evaluate the effect of xylitol in reducing acute otitis media in a subsequent study.

DESIGN

Double-blind randomized controlled trial.

SETTING

Communities in the Republic of the Marshall Islands.

PARTICIPANTS

One hundred eight children aged 9 to 15 months were screened, and 100 were enrolled. Intervention Children were randomized to receive xylitol topical oral syrup (administered by their parents) twice a day (2 xylitol [4.00-g] doses and 1 sorbitol dose) (Xyl-2 x group) or thrice per day (3 xylitol [2.67-g] doses) (Xyl-3x group) vs a control syrup (1 xylitol [2.67-g] dose and 2 sorbitol doses) (control group).

MAIN OUTCOME MEASURES

The primary outcome end point of the study was the number of decayed primary teeth. A secondary outcome end point was the incidence of acute otitis media for reporting in a subsequent report.

RESULTS

Ninety-four children (mean [SD] age, 15.0 [2.7] months at randomization) with at least 1 follow-up examination were included in the intent-to-treat analysis. The mean (SD) follow-up period was 10.5 (2.2) months. Fifteen of 29 of the children in the control group (51.7%) had tooth decay compared with 13 of 32 children in the Xyl-3x group (40.6%) and eight of 33 children in the Xyl-2x group (24.2%). The mean (SD) numbers of decayed teeth were 1.9 (2.4) in the control group, 1.0 (1.4) in the Xyl-3x group, and 0.6 (1.1) in the Xyl-2x group. Compared with the control group, there were significantly fewer decayed teeth in the Xyl-2x group (relative risk, 0.30; 95% confidence interval, 0.13-0.66; P = .003) and in the Xyl-3x group (0.50; 0.26-0.96; P = .04). No statistical difference was noted between the 2 xylitol treatment groups (P = .22).

CONCLUSION

Xylitol oral syrup administered topically 2 or 3 times daily at a total daily dose of 8 g was effective in preventing early childhood caries.

The effects of licogliflozin, a dual SGLT1/2 inhibitor, on body weight in obese patients with or without diabetes

BACKGROUND

There is an unmet need for a safer and more effective treatment for obesity. This study assessed the effects of licogliflozin, a dual inhibitor of sodium-glucose co-transporter (SGLT) 1/2, on body weight, metabolic parameters and incretin hormones in patients with type 2 diabetes mellitus (T2DM) and/or obesity.

METHODS

Patients with obesity (BMI, 35-50 kg/m² ) were enrolled into a 12-week study (N = 88; licogliflozin 150 mg q.d.). Patients with T2DM were enrolled into a second, two-part study, comprising a single-dose cross-over study (N = 12; 2.5 - 300 mg) and a 14-day dosing study (N = 30; 15 mg q.d). Primary endpoints included effects on body weight, effects on glucose, safety and tolerability. Secondary endpoints included urinary glucose excretion (UGE₂₄ ) and pharmacokinetics, while exploratory endpoints assessed the effects on incretin hormones (total GLP-1, PYY_3-36 , and GIP), insulin and glucagon.

RESULTS

Treatment with licogliflozin 150 mg q.d. for 12 weeks in patients with obesity significantly reduced body weight by 5.7% vs placebo (P < 0.001) and improved metabolic parameters such as significantly reduced postprandial glucose excursion (21%; P < 0.001), reduced insulin levels (80%; P < 0.001) and increased glucagon (59%; P < 0.001). In patients with T2DM, a single dose of licogliflozin 300 mg in the morning prior to an oral glucose tolerance test (OGTT) remarkably reduced glucose excursion by 93% (P < 0.001; incremental AUC_0-4h ) and suppressed insulin by 90% (P < 0.01; incremental AUC_0-4h ). Treatment with licogliflozin 15 mg q.d. for 14 days reduced 24-hour average glucose levels by 26% (41 mg/dL; P < 0.001) and increased UGE₂₄ to 100 g (P < 0.001) in patients with T2DM. In addition, this treatment regimen significantly increased total GLP-1 by 54% (P < 0.001) and PYY_3-36 by 67% (P < 0.05) post OGTT vs placebo, while significantly reducing GIP levels by 53% (P < 0.001). Treatment with licogliflozin was generally safe and well tolerated. Diarrhea (increased numbers of loose stool) was the most common adverse event in all studies (90% with licogliflozin vs 25% with placebo in the 12-week study), while a lower incidence of flatulence, abdominal pain and abdominal distension (25%-43% with licogliflozin vs 9%-11% with placebo in the 12-week study) were among the other gastrointestinal events reported.

CONCLUSION

Licogliflozin treatment (1-84 days) leads to significant weight loss and favourable changes in a variety of metabolic parameters and incretin hormones. Dual inhibition of SGLT1/2 with licogliflozin in the gut and kidneys is an attractive strategy for treating obesity and diabetes.

Similarity of the effects of erythritol and xylitol on some risk factors of dental caries

Several sugar alcohols (polyols) have been promoted as potential sugar substitutes in caries limitation. However, differences in the effects of simple alditol-type sugar alcohol homologues on dental plaque have not been compared in clinical tests. The effects of 6-month use of erythritol (a sugar alcohol of the tetritol type), xylitol (a pentitol) and D-glucitol (sorbitol, a hexitol) were investigated in a cohort of 136 teenage subjects assigned to the respective polyol groups or to an untreated control group (n = 30-36 per group). The daily use of the polyols was 7.0 g in the form of chewable tablets, supplemented by twice-a-day use of a dentifrice containing those polyols. The use of erythritol and xylitol was associated with a statistically significant reduction (p < 0.001 in most cases) in the plaque and saliva levels of mutans streptococci. The amount of dental plaque was also significantly reduced in subjects receiving erythritol and xylitol. Such effects were not observed in other experimental groups. Chemical analyses showed D-glucitol to be a normal finding in dental plaque while xylitol was less consistently detected. Erythritol was detected in measurable amounts only in the plaque of subjects receiving this polyol. Erythritol and xylitol may exert similar effects on some risk factors of dental caries, although the biochemical mechanism of the effects may differ. These in vivo studies were supported by cultivation experiments in which xylitol, and especially erythritol, inhibited the growth of several strains of mutans streptococci.

Malabsorption of fructose-sorbitol mixtures. Interactions causing abdominal distress

Hydrogen breath tests were performed on 10 healthy adults after they had ingested a mixture of sorbitol and fructose, in which these substances were present in amounts corresponding to the individual absorption capacities. A significant malabsorption of this mixture was evident in 7 of 10 subjects. The mixture caused mild to severe gastrointestinal distress in five subjects. When the carbohydrates were given separately, symptoms were absent. There was a significant correlation between the individual absorption capacities of fructose and of sorbitol. A mixture containing a similar amount of fructose, but given as sucrose, and a similar amount of sorbitol was further given to four of the seven subjects showing malabsorption of the fructose-sorbitol mixture. Malabsorption now failed to appear, and symptoms were absent. These findings are of potential importance for the understanding of the physiologic processes involved in fructose absorption and suggest that in healthy adults the presence of sorbitol interferes with fructose absorption and/or vice versa. An interaction between small amounts of fructose and sorbitol causing malabsorption and abdominal distress has not been demonstrated previously. Gastrointestinal discomfort must be suspected to occur in sensitive individuals at a rather limited daily intake of fructose- and sorbitol-containing foodstuffs.

Sorbitol malabsorption in normal volunteers and in patients with coeliac disease

Sorbitol is a hexahydroxy alcohol used as a sugar substitute in many dietetic foods and as a drug vehicle. Previous studies have suggested that sorbitol ingestion may be an additional cause of non-specific gastrointestinal distress. We evaluated sorbitol malabsorption in 30 healthy volunteers, seven patients with untreated coeliac disease and nine patients with coeliac disease on a gluten free diet, using a four hour H2 breath test. After ingestion of test solutions containing sorbitol 10 and 20 g and of four sweets (6.8 g sorbitol), 90%, 100%, and 62% of healthy volunteers, respectively had significantly raised H2 excretion, indicating malabsorption of sorbitol. Of all healthy subjects tested, 45% after 10 g, 100% after 20 g, and 50% after four sweets complained of symptoms of carbohydrate intolerance during the eight hours after sorbitol. After a 5 g dose given at concentrations of 2%, 4%, 8%, 16%, malabsorption was shown in 10%, 12%, 22%, and 43% of the healthy volunteers. Symptoms of intolerance at 5 g were experienced only at concentrations of 8% and 16%. Unlike healthy volunteers and coeliac patients on a gluten free diet, 100% of untreated coeliacs malabsorbed a 2% solution of 5 g sorbitol. These results show that malabsorption and intolerance of sorbitol may result from ingestion of doses and/or concentrations usually found in many foods and drugs; they underline the need to consider this as a possible and hitherto underestimated cause of gastrointestinal symptoms.

Sugar alcohol sweeteners as alternatives to sugar with special consideration of xylitol

INTRODUCTION

Dental caries is a diet-associated disease which continues to be a serious health problem in most industrialized and developing countries. Strategies to maximize caries prevention should automatically consider the use of sugar substitutes. It is important that public health authorities are made cognizant of the availability of new polyol-type sugar substitutes.

REVIEW SUMMARY

Clinical studies have shown that xylitol, a natural, physiologic sugar alcohol of the pentitol type, can be used as a safe and effective caries-limiting sweetener. Habitual use of xylitol-containing food and oral hygiene adjuvants has been shown to reduce the growth of dental plaque, to interfere with the growth of caries-associated bacteria, to decrease the incidence of dental caries, and to be associated with remineralization of caries lesions. Numerous public regulatory bodies have endorsed the use of xylitol as a caries-limiting agent. Other sugar alcohols that have been successfully used as sugar substitutes include D-glucitol (sorbitol), which, however, owing to its hexitol nature, normally has no strong effect on the mass and adhesiveness of bacterial plaque and on the growth of mutans streptococci. A tetritol-type alditol, erythritol, has shown potential as a non-cariogenic sugar substitute. Combinations of xylitol and erythritol may reduce the incidence of caries more effectively than either alditol alone.

CONCLUSIONS

Partial sugar substitution with polyols is an important dietary tool in the prevention of dental caries that should be used to enhance existing fluoride-based caries prevention programmes. The most effective method of conveying this information to the public is through a proper health claim for these alditols in food labelling. The present review summarizes clinical and biochemical aspects of the above three dietary polyols and emphasizes the role of sugar substitution as a potential health-promoting strategy.

Two-dimensional contrast echocardiography. II. Transpulmonary studies

A method using contrast two-dimensional echocardiography for left ventricular chamber and myocardial opacification from a right-sided pulmonary capillary wedge position is described. A total of 152 studies were carried out in nine mongrel dogs. Four different catheters with different catheter tip cross-sectional areas (varying from 0.75 to 2.3 mm2) were used. In addition, catheter position (six different positions in the pulmonary circulation), pressure of injection and type of echo contrast agent (hand-agitated and sonicated) were studied. In all 152 studies, two independent observers agreed that echo contrast was seen in the left ventricular chamber after a pulmonary capillary wedge injection of 8 cc of echo contrast agent followed by a flush injection of 8 cc saline solution. In 71% of the studies, the two independent observers agreed about the degree of opacification on a qualitative scale of 0 to 3+. Time from injection from the catheter tip to the appearance of echo contrast in the left atrium was 6.2 +/- 4.8 seconds for sonicated Renografin-76 and 2.8 +/- 0.6 seconds for sonicated sorbitol 70% (p less than 0.05). Correlation for the disappearance rate of echo contrast as determined for the region in the mid left ventricular chamber and thermodilution cardiac output was fair (r = -0.78; n = 14). In 24 studies, it was not possible to demonstrate the appearance of echo contrast in the myocardium. Peak videointensity of 10 duplicate injections showed a mean percent error of 10.4 +/- 2.1% for sonicated Renografin-76 and 1.4 +/- 0.8% for sonicated sorbitol 70%.(ABSTRACT TRUNCATED AT 250 WORDS)

Dose-finding study of luseogliflozin in Japanese patients with type 2 diabetes mellitus: a 12-week, randomized, double-blind, placebo-controlled, phase II study

OBJECTIVES

Luseogliflozin is a selective sodium glucose cotransporter 2 inhibitor under development for the treatment of type 2 diabetes mellitus (T2DM). This phase II study was conducted to confirm the efficacy and safety of luseogliflozin monotherapy at doses of up to 10 mg in Japanese patients with T2DM.

PATIENTS AND METHODS

Patients with hemoglobin A1c (HbA1c) of 6.9-10.5% on diet therapy were randomized in a double-blind manner to treatment with 1, 2.5, 5, or 10 mg luseogliflozin or placebo for 12 weeks (n = 56, 56, 54, 58, and 58, respectively).

TRIAL REGISTRATION

Japan Pharmaceutical Information Center (identifier: Japic CTI-101191).

MAIN OUTCOME MEASURES

The primary endpoint was the change in HbA1c from baseline to the end of treatment. Other endpoints included fasting plasma glucose (FPG), postprandial plasma glucose (PPG) and body weight. Adverse events were recorded throughout the study.

RESULTS

HbA1c decreased significantly at the end of treatment in the 1, 2.5, 5, and 10 mg luseogliflozin groups compared with placebo (-0.29, -0.39, -0.46, and -0.43%, respectively, versus +0.22%; all P < 0.001), as did FPG and PPG (all P < 0.001). Body weight also decreased significantly in all luseogliflozin groups compared with placebo (all P < 0.001). The incidence rates of adverse events (40.0-50.0%) were not significantly different among the five groups. The overall incidence of hypoglycemia was low. Limitations of this study include the short study duration and the relatively small sample size.

CONCLUSIONS

In Japanese patients with T2DM, luseogliflozin was well tolerated, improved glycemic control, and reduced body weight over 12 weeks of treatment at all tested doses. Doses of ≥2.5 mg achieved similar improvements in glycemic control.

Evaluation of a charcoal-sorbitol mixture as an antidote for oral aspirin overdose

The preparation of charcoal in a 70% sorbitol solution results in a suspension that is more palatable and less gritty than an aqueous slurry of charcoal. Although the charcoal-sorbitol mixture may be slightly less effective in reducing the extent of aspirin absorption compared with a charcoal slurry, it may prove to be of particular value in those cases where acceptance of a charcoal slurry presents a problem.

Parenteral nutrition in the critically ill: use of a medium chain triglyceride emulsion

OBJECTIVES

The study investigated the use of an intravenous lipid emulsion containing medium chain triglycerides (MCTs) in critically ill patients, and compared the effects with those of a conventional long chain triglyceride (LCT) preparation.

DESIGN

Patients received a parenteral nutrition regime including either 500 ml 20% Lipofundin MCT/LCT (1/1) per day, or 500 ml 20% Lipofundin S (LCT) infused over 8 h each evening.

SETTING

The patients were receiving treatment, including assisted ventilation, in the Intensive Care Unit of a large teaching hospital. All patients on this unit for at least 3 days and who were likely to receive parenteral nutrition for at least a week were considered, unless they had severe renal or liver disease, or trauma/major surgery in the previous 3 days. Because ICU patients are a heterogenous group, subjects were randomised within clinical groups to receive either lipid. There were 24 patients entered into the study and the data on 20 matched patients is reported.

MEASUREMENTS AND RESULTS

Blood specimens were collected pre-TPN, daily at 0800 and after 5 h lipid infusion on days 1 and 6. Urine collections (24 h) were also performed. There were no apparent adverse effects due to the new MCT/LCT emulsion. Plasma ketone and glycerol concentrations were higher during MCT/LCT infusion, but 8 h post infusion plasma levels of ketones, triglycerides, non-esterified fatty acids and glucose were similar. Urinary carnitine excretion was high in all patients and was not significantly different between the groups. Nitrogen balance was less negative in patients receiving MCT/LCT on days 6 and 9.

CONCLUSION

MCTs are rapidly hydrolysed and oxidised to fatty acids and ketones which can be readily utilised. This study indicates that intravenous lipid emulsion containing MCT are safe in critically ill patients and may have advantages over LCT. The number and range of patients studied was, however, small and larger studies are needed.

A novel method for the detection of sticking of tablets

The purpose of this work was to develop an instrumented upper punch to measure the adhesion force which occurs when the punch detaches itself from the upper surface of the tablet after compression. A specially designed adhesion force sensor instrumented with semiconductor strain gauges was inserted into an upper punch with a 25-mm punch face diameter suitable for a Korsch EK II eccentric press. Sorbitol, microencapsulated acetylsalicylic acid (ASA), and a formulation of a new active ingredient resulted in characteristic pull-off signals, providing a quantitative measure of the adhesion force. With "sticking-free" substances such as microcrystalline cellulose, tension signals could not be obtained; only Starch 1500 showed small adhesion force signals that indicated a sticking tendency. The compression force had a specific influence on the extent of the adhesion force; increasing the compression force caused an increase (sorbitol) or a decrease (ASA) of the adhesion force signals due to the plastic and elastic behavior of the substances. Depending on running time, ASA showed an increase in the adhesion force, reaching a plateau after 150 tablets. The addition of lubricants such as magnesium stearate resulted in smaller adhesion forces. The instrumented upper punch is a new helpful tool for the quantification of sticking and a valuable instrument in the development of formulations.

Effect of nonabsorbed amounts of a fructose-sorbitol mixture on small intestinal transit in healthy volunteers

Although malabsorption of small amounts of fructose-sorbitol mixtures occurs frequently in healthy humans, insights into their effects on gastrointestinal motility are poor. The present study addresses the hypothesis that malabsorption of a fructose-sorbitol challenge changes the small intestinal transit rate. Eleven healthy volunteers participated in a double-blind crossover investigation. In random order, the subjects ingested 30 g glucose or a mixture of 25 g fructose and 5 g sorbitol as 10% solutions. As a radiolabeled marker, (99m)Tc-diethylenetriaminepentaacetic acid was added to each test solution. Breath hydrogen and methane concentrations and gastrointestinal progress of the radiolabeled marker were followed for the next 6-hr period. Malabsorption of small amounts of the fructose-sorbitol mixture was evident in all subjects. The area under the gastric radioactivity-time curve after ingestion of glucose did not differ from that after ingestion of the fructose-sorbitol mixture (P = 0.7897). However, the mouth-to-cecum transit of the radiolabeled marker was faster (P = 0.0033) and the percentage content of the marker in colon was higher after ingestion of the fructose-sorbitol mixture than after ingestion of glucose (P = 0.0128). In healthy humans, malabsorption of small amounts of a fructose-sorbitol mixture accelerates small bowel transit.

Gastrointestinal transit times of cathartics combined with charcoal

Oral activated charcoal usually is administered in toxic ingestions along with a cathartic. A study was done in volunteers to determine the rapidity of gastrointestinal transit when activated charcoal was administered with various cathartics. A control of activated charcoal was compared to the gastrointestinal transit times of activated charcoal plus the cathartics magnesium citrate, magnesium sulfate, or sorbitol. Activated charcoal alone produced a mean transit time of 23.5 hours; magnesium citrate catharsis occurred in 4.2 hours, magnesium sulfate catharsis occurred in 9.3 hours, and sorbitol catharsis occurred in 0.9 hours. Sorbitol clearly was the most rapidly acting cathartic.

Effect of xylitol and sorbitol in chewing-gums on mutans streptococci, plaque pH and mineral loss of enamel

Seventeen subjects with more than 3 x 10(5) mutans streptococci per millilitre of saliva completed this randomised, cross-over study. Four different chewing-gums, containing: (1) 70% xylitol, (2) 35% xylitol + 35% sorbitol, (3) 17.5% xylitol + 52.5% sorbitol, and (4) 70% sorbitol, were tested. The participants used 12 pieces of each gum per day for 25 days. During the four experimental periods, they wore a removable palatinal plate containing two demineralised enamel samples, and brushed their teeth with a non-fluoridated toothpaste. The results showed that an increased concentration of xylitol in the gum resulted in a lower number of mutans streptococci in both saliva and dental plaque, although the decreases were only significant in the saliva samples (p < 0.01). The pH drop in plaque, measured in vivo after a 1-min mouthrinse with a 10% sorbitol solution, was least pronounced after the 70% xylitol gum and most pronounced after the 70% sorbitol gum period (p < 0.01). No significant differences were found after a mouthrinse with a 10% sucrose solution. All demineralised enamel samples lost mineral during the experimental periods. However, the lesion depth as well as the mineral loss values, assessed microradiographically, did not differ significantly between the four chewing-gums.

Sorbitol catharsis does not enhance efficacy of charcoal in a simulated acetaminophen overdose

The use of a 70% sorbitol solution has recently been advocated as an adjunct to activated charcoal. This results in rapid and profuse catharsis that could possibly cause fluid and electrolyte imbalance. An investigation was undertaken to determine if sorbitol catharsis enhanced the antidotal efficacy of activated charcoal. Eight healthy volunteers participated in a randomized, crossover trial. Subjects ingested 3 g of acetaminophen followed by either no intervention, 50 g of plain activated charcoal at one hour, or 50 g activated charcoal-sorbitol solution at one hour. Serial acetaminophen levels were determined at intervals over eight hours and side effects noted. Both interventions significantly reduced the area under the curve versus control (P less than .05). The addition of sorbitol did not enhance the efficacy of activated charcoal but did increase the side effects noted. Sorbitol has not been proven effective in enhancing drug removal and has side effects that can be significant in a poisoned patient. Current data do not warrant its use, and further investigations should be carried out with other ingested drugs.