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Effect of Itopride on Esophageal Motility And EFFECT OF ITOPRIDE ON ESOPHAGEAL MOTILITY AND LOWER ESOPHAGEAL SPHINCTER FUNCTION IN MAN Emidio Scarpellini, Rita Vos, Kathleen Blondeau, Veerle Boecxstaens, Ricard Farre, Antonio Gasbarrini, Jan Tack To cite this version: Emidio Scarpellini, Rita Vos, Kathleen Blondeau, Veerle Boecxstaens, Ricard Farre, et al.. EF- FECT OF ITOPRIDE ON ESOPHAGEAL MOTILITY AND LOWER ESOPHAGEAL SPHINC- TER FUNCTION IN MAN. Alimentary Pharmacology and Therapeutics, Wiley, 2010, 33 (1), pp.99. 10.1111/j.1365-2036.2010.04487.x. hal-00599484 HAL Id: hal-00599484 https://hal.archives-ouvertes.fr/hal-00599484 Submitted on 10 Jun 2011 HAL is a multi-disciplinary open access L’archive ouverte pluridisciplinaire HAL, est archive for the deposit and dissemination of sci- destinée au dépôt et à la diffusion de documents entific research documents, whether they are pub- scientifiques de niveau recherche, publiés ou non, lished or not. The documents may come from émanant des établissements d’enseignement et de teaching and research institutions in France or recherche français ou étrangers, des laboratoires abroad, or from public or private research centers. publics ou privés. Alimentary Pharmacology & Therapeutic EFFECT OF ITOPRIDE ON ESOPHAGEAL MOTILITY AND LOWER ESOPHAGEAL SPHINCTER FUNCTION IN MAN ForJournal: Alimentary Peer Pharmacology Review & Therapeutics Manuscript ID: APT-0343-2010.R1 Wiley - Manuscript type: Original Scientific Paper Date Submitted by the 26-Sep-2010 Author: Complete List of Authors: Scarpellini, Emidio; University of Leuven, Center for Gastroenterological Research Vos, Rita; University of Leuven, Center for Gastroenterological Research; K.U.Leuven, Belgium, Gastroenterology, Center for Gastroenterological Research Blondeau, Kathleen; University of Leuven, Center for Gastroenterological Research; KULeuven, Lab G-I Physiopathology Boecxstaens, Veerle; University of Leuven, Center for Gastroenterological Research Farre, Ricard; University of Leuven, Center for Gastroenterological Research Gasbarrini, Antonio; Catholic University, Internal Medicine Tack, Jan; University Hospital, Center for Gastroenterological Research GERD or GORD < Disease-based, Oesophagus < Organ-based, Keywords: Acidity (oesophageal) < Topics, Motility < Topics Page 1 of 25 Alimentary Pharmacology & Therapeutic 1 2 3 EFFECT OF ITOPRIDE ON ESOPHAGEAL MOTILITY AND LOWER ESOPHAGEAL 4 5 SPHINCTER FUNCTION IN MAN 6 7 8 9 E. Scarpellini, R. Vos, K. Blondeau, V. Boecxstaens, R. Farré, A. Gasbarrini, J. Tack 10 11 12 Department of Internal Medicine 13 14 Division of Gastroenterology 15 16 University Hospital Gasthuisberg 17 18 Catholic University of Leuven, Leuven, Belgium 19 20 For Peer Review 21 Running title: Itopride and esophageal motility in man 22 23 24 25 26 Corresponding Author: Jan Tack, M.D., Ph. D. 27 28 Department of Internal Medicine 29 30 Division of Gastroenterology 31 32 University Hospital Gasthuisberg 33 34 Herestraat 49 35 B-3000 Leuven, Belgium 36 37 Tel.: +3216344225 38 39 Fax.: +3216344419 40 41 42 Keywords: itopride, prokinetics, TLESRS, GERD. 43 44 45 46 This study was supported by a Methusalem grant from Leuven University to Prof. Jan Tack 47 48 and a Rome Foundation Fellowship to Emidio Scarpellini. Ricard Farré and Kathleen 49 Blondeau are postdoctoral research fellows from the FWO Flanders. 50 51 52 53 54 55 56 57 58 59 60 Alimentary Pharmacology & Therapeutic Page 2 of 25 Itopride and esophageal function Scarpellini et al., 2 1 2 3 SUMMARY 4 5 6 7 Introduction: Itopride is a new prokinetic agent which combines antidopaminergic and 8 9 cholinesterase inhibitory actions. Previous studies suggested that itopride improves 10 heartburn in functional dyspepsia, and decreases esophageal acid exposure in GERD. It is 11 12 unclear whether this effect is due to effects of itopride on the LES. Aims: To study the 13 14 effects of itopride on fasting and postprandial LES function in healthy subjects. Materials 15 16 and methods: twelve healthy volunteers (5 males; 32.6±2.0 years) underwent three 17 18 esophageal sleeve manometry studies after 3 days premedication with itopride 50 mg, 19 itopride 100mg or placebo t.i.d. Drug was administered after 30 minutes and a 20 For Peer Review 21 standardized meal was administered after 90 minutes, with measurements continuing to 22 23 120 minutes postprandially. Throughout the study, 10 wet swallows were administered at 24 25 30-minute intervals, and gastrointestinal symptoms were scored on 100 mm visual 26 analogue scales (VAS) at 15-minute intervals. Results: LES resting pressures, swallow- 27 28 induced relaxations and the amplitude or duration of peristaltic contractions were not 29 30 altered by both doses of itopride, at all time points. Itopride pretreatment inhibited the 31 32 meal-induced rise of transient LES relaxations (TLESRs). Conclusions: Itopride inhibits 33 34 TLESRs without significantly affecting esophageal peristaltic function or LES pressure. 35 These observations support further studies with itopride in GERD. 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 3 of 25 Alimentary Pharmacology & Therapeutic Itopride and esophageal function Scarpellini et al., 3 1 2 3 INTRODUCTION 4 5 6 7 8 9 Itopride is a novel prokinetic agent acting both as a dopamine D2 receptor antagonist and 10 as an acetylcholine esterase inhibitor. Both animal (1-3) and human studies (5,6) have 11 12 shown the ability of the drug to accelerate delayed gastric emptying, associated with anti- 13 14 emetic properties. In a phase 2 controlled trial, itopride was superior to placebo in relieving 15 16 symptoms of functional dyspepsia (6). In a phase 3 program, this superiority was not 17 18 confirmed, and comparison of both studies suggested that the presence of heartburn, 19 which was excluded in the phase 3 program, was a predictor of response in the phase 2 20 For Peer Review 21 studies (7). Heartburn is a typical symptom of gastro-esophageal reflux disease (GERD) 22 23 (8), and a pilot study in GERD patients confirmed the ability of itopride to decrease 24 25 esophageal acid exposure (9). The mechanisms underlying a potential beneficial effect of 26 itopride in GERD remain to be elucidated. 27 28 29 30 The pathophysiology of GERD is multifactorial and involves several well-known 31 32 mechanisms such as failure of the anti-reflux barrier, impaired esophageal clearance, the 33 34 presence of caustic factors in the refluxate (acid and/or non-acid) and defective 35 esophageal mucosal resistance (10). The influence of itopride on the anti-reflux barrier has 36 37 not been studied. Among the dysfunctions of the anti-reflux barrier, transient lower 38 39 oesophageal sphincter relaxations (TLESRs) are the major mechanism underlying gastro- 40 41 oesophageal reflux events in normal subjects, and in the majority of GERD patients. 42 (10,11) TLESRs are controlled by a vago–vagal reflex pathway, triggered by activation of 43 44 stretch receptors of the proximal stomach, and organized in the brain stem, leading to 45 46 transient relaxation of the lower esophageal sphincter (LES) (12). Pharmacological 47 48 inhibition of TLESRs is considered a relevant target for the control of GERD (10). Several 49 pharmacological agents, including atropine, morphine, GABA-B agonists, cholecystokinin 50 51 1 receptor antagonists and nitric oxide synthase inhibitors, have been shown to inhibit the 52 53 occurrence of transient lower oesophageal sphincter relaxations (12,13). 54 55 56 57 The aim of the present study was to investigate the effect of itopride on oesophageal and 58 lower oesophageal sphincter function in healthy subjects, with a focus on the occurrence 59 60 of TLESRS. Alimentary Pharmacology & Therapeutic Page 4 of 25 Itopride and esophageal function Scarpellini et al., 4 1 2 3 MATERIALS AND METHODS 4 5 6 7 8 9 Subjects 10 11 12 Studies were performed in 12 healthy volunteers (five men and seven women; mean age, 13 14 2 15 32.6±2.0 years; range, 23–41 years) with a mean body mass index of 22.2±0.9 kg/m . 16 17 None of the subjects had symptoms or a history of gastrointestinal disease or upper 18 19 gastrointestinal surgery, nor were they taking any medication. Written informed consent 20 For Peer Review 21 22 was obtained from each subject and the study protocol had been approved previously by 23 24 the Ethics Committee of the University Hospital. 25 26 27 28 29 30 Study design 31 32 33 34 All subjects underwent the studies after 3 days premedication with itopride 50 mg, itopride 35 100mg or matching placebo t.i.d. in a double-blind randomised cross-over design. 36 37 Treatment periods occurred at least one week apart. On each day of measurements, 38 39 subjects were studied after an overnight fast of at least 12 hours. A summary of the 40 41 protocol is shown in Figure 1. Together with a stationary manometry probe, a pH assembly 42 was passed through the nose under topical anesthaesia and positioned with the pH 43 44 electrode at 5 cm above the LES. After placement of the assembly, the subjects remained 45 46 in a sitting position for a habituation period of 20 minutes. This period allowed baseline 47 48 assessment of esophageal peristalsis and LES function. Ten wet swallows of 5 ml of water 49 were administered at 1-minute interval and followed by ingestion of itoprode or placebo 50 51 according to the double-blind, randomized cross-over design. During the 30 min after 52 53 administration of the drug oesophageal and lower oesophageal sphincter pressure and 54 55 oesophageal pH were continuously monitored. Sixty minutes after drug administration the 56 57 subjects ingested a mixed liquid meal (400 mL, 600 kcal, 13% proteins, 48% 58 carbohydrates, 39% lipids; Nutridrink®, Nutricia, Bornem, Belgium) and recordings 59 60 continued for 2 hours after the meal. Throughout the study, 10 wet swallows of 5 ml of water were administered at 30-minute intervals.
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