Cisapride for children with intractable constipation: an interim verdict!

Cisapride for intestinal constipation

BACKGROUND

Cisapride is a propulsive agent, withdrawn from most of the world's health institutes because of its recorded fatalities in addition to serious side effects such as severe arrhythmias. However it is widely available in third world countries and can be easily purchased through the Internet.  We did a systematic review to assess its efficacy and safety in relieving constipation.

OBJECTIVES

The primary objective is to assess Cisapride's role and safety as a prokinetic drug in the management of constipation and constipation predominant Irritable bowel syndrome (C-IBS).The secondary objective is to assess Cisapride's efficacy in improving symptoms of constipation and IBS.

SEARCH STRATEGY

Cochrane methodology was followed to find available RCTs that assessed the efficacy of cisapride. Electronic databases searched November 2009:Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library 2009 issue 4MEDLINE (from 1966)EMBASE (from 1980)

SELECTION CRITERIA

All RCTs comparing cisapride to placebo or to active comparators were included. We included patients of all ages who had functional constipation or C-IBS.

DATA COLLECTION AND ANALYSIS

Eight RCTs were included, comparing cisapride to a placebo on patients with constipation or C-IBS. The studies were pooled and analysed and a combined effect was calculated using meta-analysis.

MAIN RESULTS

8 trials included in the review for a total 424 patients who were randomised to Cisapride or placebo, of which 157 were children and 284 were female. Intervention duration was 8 to 12 weeks. Dosage of Cisapride in the adult and children trials were 5mg TDS and 0.2mg/kg/dose TDS respectively.Cisapride showed significant benefit in investigators' assessment of clinical improvement (OR: 0.45, P=0.03), likelihood of passing daily stools (OR: 0.22, P<0.001), passage of normal stools (OR: 0.06, P<0.001) and total gastrointestinal transit time (MD: -19.47, P<0.00001). However Cisapride showed no benefit in global improvement of symptoms (MD: 0.11, P=0.99), abdominal pain (MD: 1.94, P=0.56), stool frequency: weekly (MD: 3.36, P=0.11), visual analogue scale (MD: -0.23, P=0.66), stool consistency (MD: 0.32, P=0.50), bloating (MD: 3.93, P=0.44), persistent bloating(OR: 1.11, P=0.83), 'feeling of incomplete evacuation' (MD: -3.80, P=0.08), straining (MD -0.95, p=0.19).

AUTHORS' CONCLUSIONS

No clear benefit can be demonstrated with cisapride. We do not feel that cisapride can be justifiably used for chronic constipation or irritable bowel disease given its side effects of arrhythmia and associated 175 recorded deaths.

Cisapride for the treatment of constipation in children: A double-blind study

OBJECTIVE

To determine whether cisapride is effective in the treatment of children with constipation.

STUDY DESIGN

Double-blind, placebo-controlled study in which children with chronic constipation were randomly assigned to treatment with cisapride or placebo for 12 weeks.

RESULTS

Forty children were enrolled, and 36 completed the therapy. Treatment successes occurred in 13 of 17 (76%) subjects in the cisapride group and 8 of 19 (37%) subjects in the placebo group (P <.03). The odds ratio for response after cisapride administration was 8.2 times higher (95% CI 1.3 to 49.4). During cisapride therapy, there was a significant improvement in number of spontaneous bowel movements per week (from 0.9 +/- 0.1 to 4.1 +/- 1.1), and there was a significant decrease in number of fecal soiling episodes per day (1.8 +/- 0.5 to 0.08 +/- 0.4), percent with encopresis (82% vs 23%), number of laxative doses per week (from 10.3 +/- 2.6 to 0.8 +/- 0.6), percent using laxatives (77% to 24%), and total gastrointestinal transit time (from 115.0 +/- 3.7 hours to 77.0 +/- 11.1 hours). With placebo, there were no significant changes in the number of spontaneous bowel movements (from 1.0 +/- 0.8 to 2.2 +/- 0.6), percent with encopresis (74% vs 47%), or total gastrointestinal transit time (from 112.5 +/- 4.9 hours to 95.4 +/- 9.8 hours); but there was a significant decrease in number of fecal soiling episodes per day (from 1.3 +/- 0.4 to 0.4 +/- 0.2) and number of laxative doses used per week (from 11.5 +/- 2.9 to 2.05 +/- 0.7). The final number of spontaneous bowel movements, fecal soiling episodes, laxatives used, or percent patients with encopresis was not different when patients receiving cisapride were compared with those receiving placebo.

CONCLUSION

Cisapride was effective in the treatment of children with constipation.

[Management of chronic constipation in the infant]

Constipation is a common symptom of various pathologies with dysfunction of the intestinal motricity which largely differ in their expression and severity. However chronic idiopathic constipation is by far the most frequent condition. Only constipations associated with symptoms such as poor nutritional status, failure to thrive, signs of upper intestinal tract obstruction (gross abdominal distention), or showing resistance to the usual therapeutic approach, justify investigations looking for an organic disease, mainly Hirschsprung disease. Treatment of chronic idiopathic constipation requires, first to evacuate the fecal mass, then to prevent its reconstitution mainly by dietetic measures, regular large hydration, stool modifying therapy, daily bowel habit, and regular physical activities; in addition it is important that clear and reassuring explanations be given to the parents.