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Retrospective Comparison of 'Cheno' and 'Urso' in the Medical

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Retrospective Comparison of 'Cheno' and 'Urso' in the Medical Gut: first published as 10.1136/gut.23.5.382 on 1 May 1982. Downloaded from Gut, 1982, 23, 382-389 Retrospective comparison of 'Cheno' and 'Urso' in the medical treatment of gallstones* T J MEREDITH, G V WILLIAMS,t P N MATON,t G M MURPHY, H M SAXTON, and R HERMON DOWLING§ From the Gastroenterology Unit, Departments ofMedicine and Diagnostic Radiology, Guy's Hospital and Medical School, London SUMMARY In two groups of gallstone patients ideally suited for medical treatment, the effect of six to 18 months' therapy was compared retrospectively in 52 given chenodeoxycholic acid (CDCA) and 46 given ursodeoxycholic acid (UDCA). The minimum dose (mg kg-1day-1) required to desaturate bile consistently was 10O1 for UDCA and 14.3 for CDCA. In patients completing six months' treatment, 23 of 35 (66%) taking a mean of 7.7 (±SEM 0.5) mg UDCA and 34 of 42 (81%) taking 14.7±0.2 mg CDCA showed partial or complete dissolution of gallstones. The mean dose in the UDCA-treated patients, however, was artefactually lowered by previous dose-response studies: in those who had not taken multiple doses, the mean UDCA intake in the 'responders' at six months was 9.1±0.3 mg kg-'day-'. At six months, more UDCA (five of 35 or 14.3%) than CDCA (four of 42 or 9.5%)-treated patients showed complete dissolution of gallstones, but, by one year, the situation was reversed, 20 of 41 (49%) CDCA-treated and eight of 30 (27%) UDCA-treated patients showing complete dissolution of Cumulative at one year had risen to 76% for UDCA and 89% for CDCA. gallstones. efficacy http://gut.bmj.com/ Both treatments reduced the frequency of dyspepsia and biliary colic; 37% of CDCA and 2-6% of UCDA-treated patients showed hypertransaminasaemia; diarrhoea developed in 60% of the CDCA group but in none of the UDCA group. Chenodeoxycholic acid (CDCA) and ursodeoxy- 18 months' treatment with CDCA and UDCA in on September 30, 2021 by guest. Protected copyright. cholic acid (UDCA) are both established as effec- diminishing the saturation of bile with cholesterol tive treatments for patients with cholesterol-rich and in dissolving gallstones. We also compared the gallstones.Y-10 UDCA is the more recent of the two frequency and severity of symptons (such as biliary drugs but it is not yet clear whether it will replace colic and non-specific dyspepsia) and the incidence CDCA as the medical treatment of choice for of side-effects, before and during treatment. This dissolution of gallstones. paper reports our findings. The efficacy of treatment for dissolving gallstones depends on careful selection of patients and, with Methods CDCA treatment, the best results are seen in non-obese patients given 13-15 mg kg-'day-', who PATIENTS have radiolucent (presumed cholesterol-rich) gall- Fifty-two patients treated with CDCA and 46 stones measuring less than 15 mm in diameter in treated with UDCA fulfilled the criteria listed above functioning gallbladders.'1 By deliberately selecting and were selected for the comparative study. Details patients who fulfilled these criteria, we were able to of their ages, sex ratios, and body weights are compare, retrospectively, the efficacy of six, 12, and summarised in Table 1. There were no significant differences between the groups for any of these * Presented in part at the Annual Meeting of the British Society of Gastroenterology, Edinburgh, 1978, and published in abstract form.23 variables. Obese patients, arbitrarily defined as t Present address: Freeman Hospital, Newcastle upon Tyne. more than 130% of ideal body weight, were deliber- * Present address: Royal Postgraduate Medical School, Du Cane Road, London W12. ately excluded from the comparative study because § Address for correspondence: RHD at Guy's Hospital, London SE1 9RT. they are known to be relatively resistant to CDCA Received for publication 25 September 1981 therapy. 12 382 Gut: first published as 10.1136/gut.23.5.382 on 1 May 1982. Downloaded from Retrospective comparison of 'Cheno' and 'Urso' in the medical treatment of gallstones 383 Table 1 Clinical details in two groups ofnon-obese coated capsules. Ursodeoxycholic acid (Deursil, gallstone patients all ofwhom had radiolucent stones Gipharmex Company, Milan) was supplied in 150 measuring less than 15 mm in diameter in functioning mg capsules. gallbladders UDCA CDCA Dose (n=46) (n=52) In all patients, the bile acid dose was based on body weight. Apart from the previously reported'6 studies Age (yr) 53-2±2-2 51-7±2-6 in which the minimum CDCA dose found to F: M ratio 25:1 41:1 Weight (kg) 66-8±1-5 67-2±2-6 desaturate bile (see below) was determined, all % ideal body weight 115±3.1 119±2-9 CDCA-treated patients" were given 13-15 mg kg-'day-'. The dose of UDCA varied from patient UDCA = ursodeoxycholic acid; CDCA = chenodeoxycholic acid. to patient. Eleven of the UDCA-treated patients Results are means ±SEM's. F: M = female: male. had taken part in a previous dose-response study,5 each being treated for six weeks with five, 10, and 15 RADIOLOGY BEFORE AND DURING TREATMENT mg UDCA kg-'day-'. Another five patients took Oral cholecystograms were carried out not more part in an extension of this dose-response studly each than three months before starting treatment (base- receiving 2.5, 5.0, and 10-0 mg UDCA kg- day-' line radiographs) and at six monthly intervals during (Fig. 1). The remaining 30 UDCA-treated patients therapy. 'Functioning' gallbladders were defined as were given 8-10 mg kg-'day-'. With both treat- those which opacified well after contrast material ments, the bile acid capsules were taken with meals and contracted in response to a fatty meal. Gall- in two or three divided doses throughout the day. stone size was based on the maximum diameter of Bile lipid composition was measured after six weeks' the largest stone measured on standardised chole- treatment on each dose. At the end of the six to 18 cystogram films (ignoring the small error which week dose-response studies, UDCA treatment was results from magnification on the radiographs). continued at the lowest dose which had been found During treatment, partial gallstone dissolution to produce desaturation of fasting duodenal bile was defined as an unequivocal reduction in gallstone with cholesterol (see below). The following criteria size and/or number as agreed by three observers were used to compare the doses of the two bile http://gut.bmj.com/ (one radiologist and two physicians). Complete acids: gallstone dissolution was accepted only if two 1 The minimum dose of CDCA or UDCA during consecutive cholecystograms, three months apart, which fasting duodenal bile became unsaturated in showed no evidence of gallstones remaining on erect cholesterol (arbitrarily defined as a post-treatment films taken with fluoroscopic control, as well as saturation index of less than 1.0 according to the supine, prone, and after fatty meal films. limits of cholesterol solubility in bile as determined and Holzbach and In by Hegardt Dam,'3 others14). on September 30, 2021 by guest. Protected copyright. BILE ACID THERAPY the case of the UDCA-treated patients, no correc- Source tion was made for the reduced equilibrium Chenodeoxycholic acid (Chendol, Weddel Pharma- cholesterol solubility known to occur in vitro in ceuticals, London) was supplied in 125 mg gelatin- UDCA-rich bile.'5 Fig. 1 Effect doses ofdifferent Saturation of UDCA on the cholesterol index 1.0 saturation index infasting bile- (H+D) rich duodenalfiuid according to the solubility criteria'3 of Hegardt and Dam (H+D), in individual patients. 0. 5 0 10 1 1 1 16l 4 8 12 16 Dose UDCA mg kg dayf Gut: first published as 10.1136/gut.23.5.382 on 1 May 1982. Downloaded from 384 Meredith, Williams, Maton, Murphy, Saxton, and Dowling 2 The minimum bile acid dose required to produce nomial equation described by Thomas and unsaturated bile, as defined above, in all patients. Hofmann17 and the cholesterol solubility criteria 3 The mean bile acid dose required to produce described above. gallstone dissolution (either partial or complete) after six and 12 months' treatment. EFFICACY OF TREATMENT IN PRODUCING PARTIAL In the case of the 16 UDCA-treated patients who OR COMPLETE GALLSTONE DISSOLUTION took part in the bile-lipid, dose-response studies, the The efficacy of treatment was assessed by comparing dose required to produce gallstone dissolution was results for partial or complete gallstone dissolution calculated by multiplying the daily dose (mg UDCA after six, 12, and 18 months' CDCA and UDCA kg-') by the number of weeks at that dose level and therapy. taking the mean over the six or 12 month period when the cholecystogram first became normal. To FOLLOW-UP: SYMPTOMS AND SIDE-EFFECTS exclude the possibility that the varying initial dose During treatment, the patients were assessed as could have biased the results, the mean UDCA dose outpatients every one to two months. Fasting serum found to produce complete gallstone dissolution was lipids and liver 'function' tests (see below) were calculated separately for the responders who took checked at each visit and the frequency and severity part in the dose-response studies over the first six to of symptoms associated with gallstones, and of 18 weeks and for those who took constant UDCA side-effects attributable to therapy, were noted. In doses throughout (Table 2). particular, the presence or absence of diarrhoea, We, and others, have previously shown that there dyspepsia, and pain suggestive of biliary colic were is a significant linear relationship between biliary recorded. Diarrhoea was arbitrarily defined as two cholesterol saturation index and the dose of or more loose motions per day in patients who had CDCA16 and UDCA5 expressed in mg kg-'day-'.
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