Pharmacokinetics and Pharmacodynamic Effects S3
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Gut 1994; supplement 3: S 1-S4 Si Somatostatin and somatostatin analogues: effects pharmacokinetics and pharmacodynamic Gut: first published as 10.1136/gut.35.3_Suppl.S1 on 1 January 1994. Downloaded from A G Harris Abstract (amylase, trypsin, lipase). Octreotide Somatostatin is a 14 amino acid peptide increases intestinal transit time and that inhibits pancreatic exocrine and decreases endogenous fluid secretion in endocrine secretion. Its clinical applica- the jejunum and ileum, thus increasing tion has been limited by its very short half the absorption of water and electrolytes. life, necessitating continuous intravenous These pharmacological effects of the infusion. Octreotide is an 8 amino acid analogue point to its therapeutic role in a synthetic analogue of somatostatin that variety of endocrine and gastrointestinal possesses similar pharmacological effects. disorders. It has a much longer duration of action, (Gut 1994; supplement 3: SI -S4) however, and can be given subcuta- neously. Both the intravenous and sub- cutaneous routes ofinjection of octreotide The somatostatin family are well tolerated. Peak serum concentra- tions occur within 30 minutes after NATIVE MOLECULAR STRUCTURES subcutaneous administration and within Somatostatin is the name given to a family of four minutes of a three minute intra- peptides, the original member of which, venous infusion. Serum concentration somatostatin 14, a tetradecapeptide, was first increases linearly with dose. Octreotide is isolated from ovine hypothalami by Roger distributed rapidly, mainly in the plasma, Guillemin's group at the Salk Institute, in the where it is 65% protein bound. The course of an unsuccessful search for growth elimination half life is about 1.5 hours hormone releasing factor. The molecule was and about 32% of a subcutaneous dose shown to inhibit growth hormone release from is excreted in the urine as unchanged cultured pituitary cells, and for a while was octreotide. Octreotide inhibits gastro- known variously as growth hormone release enteropancreatic secretion, especially of inhibiting factor, somatotropin release inhibi- ting factor, and growth hormone release insulin, glucagon, pancreatic polypeptide, http://gut.bmj.com/ gastric inhibitory polypeptide, and inhibiting factor, until somatostatin - proposed gastrin. It also inhibits both release of by the Salk group in a note to the original thyroid stimulating hormone and article - emerged as standard. growth hormone secretion in response to The native molecule was found to have a Division Clinical exercise, insulin induced hypoglycaemia, cyclic structure joined by two intramolecular Pharmacology, and argenine stimulation. Octreotide disulphide bonds between the two cysteine Department of reduces splanchnic blood flow in healthy residues (Figure). The linear reduced on September 24, 2021 by guest. Protected copyright. Medicine, Cedars- Sinai Medical Center, volunteers and hepatic venous pressure in sequence, however, proved to have the same Los Angeles, cirrhotic patients. It can accelerate or biological activity as the cyclic form in vitro - California, USA delay gastric emptying, prolong transit that is, the cyclic form was not essential for A G Harris time at moderate to high doses, stimulate recognition by specific somatostatin receptors. Correspondence to: motility at low doses, and inhibit gall A second native form of somatostatin was Dr A G Harris, Division Clinical Pharmacology, bladder emptying. Octreotide consider- reported in 1980.2 Somatostatin 28 contains Department of Medicine, ably inhibits pentagastrin stimulated the amino acid sequence of somatostatin 14, Cedars-Sinai Medical Center, Los Angeles, gastric acid secretion and significantly extended by 14 residues at the N-terminus. California, USA. diminishes exocrine pancreatic function Though there is some evidence that somato- statin 28 may act as a precursor, it also operates as a hormone in its own right, with Human somatostatin Octreotide a slightly different spectrum of activity in different tissues. Thus somatostatin 28 suppresses growth hormone for much longer, but is less effective in suppressing gastric acid. There is virtually no somatostatin 28 in the stomach and duodenum. It has been shown, however, to be the dominant form lower down the gut.3 4 LOCALISATION Large amounts of somatostatin are found in Amino acids essential the gastrointestinal system, including the -4 for receptor binding pancreas, visceral autonomic nervous system, Amino acid composition ofsomatostatin and octreotide. endocrine cells, and gut lumen. Immuno- S2 Harmis cytochemical studies show that somatostatin is independent mechanisms29 30 and may act by localised to the D cells of the pancreas and gut affecting calcium transport through the cell mucosa, particularly in the gastric fundus, membrane.3' Because somatostatin inhibits antrum, and duodenum.5 6D cells are situated many aspects of cellular function, including Gut: first published as 10.1136/gut.35.3_Suppl.S1 on 1 January 1994. Downloaded from in the lower third of the crypts, from where endocrine secretion, muscular contraction, they extend cytoplasmic processes along the and cellular growth, it must antagonise a basal membranes to the basal pole of variety of intracellular signalling programmes. neighbouring glands.7 Thus somatostatin is The dephosphorylation processes crucial for well placed to exercise paracrine control of secretory activity intimately participate in other endocrine cells in the gut, for example, inhibition by somatostatin at the molecular those responsible for the synthesis and release level. After binding to its receptor, somato- of gastrin. The D cells also have microvilli in statin probably acts as a dephosphorylator to direct contact with the lumen, thus providing a inhibit secretory processes, but whether the pathway by which changes in gut content can hormone also interacts with DNA to affect influence somatostatin production, either into transcription is disputed. the lumen or into the circulation. In addition, Because of its many diverse physiological the gut is innervated by extrinsic and intrinsic effects, native somatostatin has been investi- somatostatin containing neurones, with the gated for the treatment of acromegaly and gut intrinsic neurones being present in both the endocrine tumours. Despite its many potential submucosal and myenteric plexuses. uses, however, the clinical applications of somatostatin were limited by a very short half life of two to three minutes, necessitating con- ACTIONS tinuous intravenous infusion and resulting in These anatomical considerations explain how rebound hypersecretion of hormones after somatostatin can have multiple endocrine, infusion. paracrine, and exocrine functions, in addition to its central growth hormone release inhibit- ing effect. The first description of its gastro- OCTREOTIDE intestinal action was published within a year of Octreotide (Sandostatin) is an 8 amino acid the original paper.8 Somatostatin has long synthetic peptide analogue engineered to recognised inhibitory effects on pancreatic overcome the limitations of native somato- endocrine and exocrine secretion - that is, on statin.32 Octreotide retains the Phe-Trp-Lys- insulin, glucagon, and pancreatic polypep- Thr portion of the native molecule (with the tide9 10 and also on pancreatic enzyme and tryptophan residue in the D configuration), bicarbonate responses to cholecystokinin and which is believed to constitute the essential secretin,l-13 recently reviewed by Layer et al. 14 pharmacophore22 23 and to be critical for gut It also inhibits the secretion of a wide variety of specificity.33 Octreotide has greater pharmaco- http://gut.bmj.com/ stimulatory gastrointestinal hormones,'5 and logical activity than the native molecule (being decreases gastrointestinal motility and blood at least 20 times more potent in suppressing flow.118 growth hormone secretion in vivo), is more selective for the inhibition of growth hormone than of insulin, and has a much enhanced STRUCTURE-FUNCTION RELATIONS duration of action (an elimination half life of The action of native somatostatin is brief and 113 minutes compared with the to two three on September 24, 2021 by guest. Protected copyright. rapid, and is followed by rebound secretion, all minutes of somatostatin).32 The synthetic of which suggests that it inhibits release rather molecule is sufficiently stable even to retain than synthesis, perhaps by depressing exocyto- some activity on oral administration, the oral sis. 19 dose required to inhibit growth hormone secre- Somatostatin receptors have been identified tion by 50% being 125 ,ug/kg after one hour.34 in the exocrine pancreas, on islet cells secreting As octreotide is incompletely absorbed insulin, glucagon and somatostatin,20 and on after oral administration, investigation of its gastric cells.2' Binding of somatostatin to its pharmacokinetic profile used intravenous and receptor is accounted for primarily by the 4 subcutaneous injection. Both routes of injec- amino acids in positions 7 to 10.22 23 In the late tion are well tolerated and the incidence of side 1970s analogues were synthesised that were effects is low. Moreover, bioavailability is more specific in some respects than the native similar by both routes of administration. Peak peptide, for example, more effective in inhibit- serum concentrations occur within 30 minutes ing insulin than glucagon, and vice versa,24 25 after subcutaneous administration and within while the structural requirements