The role of mosapride and levosulpiride in gut function and glycemic control in diabetic rats

BACKGROUND AND STUDY AIMS

Gastroparesis is a well-known consequence of long-standing diabetes that presents with gastric dysmotility in the absence of gastric outlet obstruction. This study aimed to evaluate the therapeutic effects of mosapride and levosulpiride on improving gastric emptying in type 2 diabetes mellitus (T2DM) while regulating glycemic levels.

MATERIAL AND METHODS

Rats were divided into the normal control, untreated diabetic, metformin-treated (100 mg/kg/day), mosapride-treated (3 mg/kg/day), levosulpiride-treated (5 mg/kg/day), metformin (100 mg/kg/day) + mosapride (3 mg/kg/day)-treated, and metformin (100 mg/kg/day) + levosulpiride (5 mg/kg/day)-treated diabetic groups. T2DM was induced by a streptozotocin-nicotinamide model. Fourweeks from diabetes onset, the treatment was started orally daily for 2 weeks. Serum glucose, insulin, and glucagon-like peptide 1 (GLP-1) levels were measured. Gastric motility study was performed using isolated rat fundus and pylorus strip preparations. Moreover, the intestinal transit rate was measured.

RESULTS

Mosapride and levosulpiride administration showed a significant decrease in serum glucose levels with improvement of gastric motility and intestinal transit rate. Mosapride showed a significant increase in serum insulin and GLP-1 levels. Metformin with mosapride and levosulpiride co-administration showed better glycemic control and gastric emptying than either drug administered alone.

CONCLUSION

Mosapride and levosulpiride showed comparable prokinetic effects. Metformin administration with mosapride and levosulpiride showed better glycemic control and prokinetic effects. Mosapride provided better glycemic control than levosulpiride. Metformin + mosapride combination provided superior glycemic control and prokinetic effects.

Comparative Efficacy of Various Pharmacological Interventions in the Treatment of Functional Dyspepsia: A Network Meta-Analysis

BACKGROUND AND AIM

Patients with functional dyspepsia often select different pharmacological treatments. We aimed to compare and rank the efficacy of different pharmacological interventions in treating functional dyspepsia.

METHODS

We searched EMBASE, PubMed, Cochrane, Web of Science and MEDLINE from the date of database inception to March 28, 2019. A random-effects model was selected to conduct traditional meta-analysis to directly examine the efficacy of different pharmacological interventions. The consistency model was selected to conduct a network meta-analysis to evaluate the relative effects and rank probability of different pharmacological interventions.

RESULTS

We included 58 trials (15,629 participants and 21 pharmacological treatments). Network meta-analysis showed that cisapride, domperidone, itopride, and levosulpiride were better than placebo, especially in short term (< 4 weeks). And levosulpiride was significantly more effective than 15 other drugs and placebo (ORs ranging between 0.05 and 0.15). Cisapride was significantly more effective than lansoprazole (OR 0.30, 95% CrI 0.09-0.99) and tegaserod (OR 0.26, 95% CrI 0.07-0.98). The rank probability showed that levosulpiride was most likely to be rank 1 (77%), cinitapride rank 2 (17%), and cisapride rank 3 (23%).

CONCLUSIONS

Our study confirmed the effectiveness of several pharmacological treatments for ameliorating functional dyspepsia. Furthermore, levosulpiride relatively ranked the best in managing FD. Physicians should be encouraged to apply promising pharmacological interventions (e.g., levosulpiride and cisapride). However, the results should be interpreted with caution due to small study effects.

An Unusual Cause of Camptocormia

Background

Camptocormia is defined as forward flexion of the spine that manifests during walking and standing and disappears in recumbent position. The various etiologies include idiopathic Parkinson’s disease, multiple system atrophy, myopathies, degenerative joint disease, and drugs.

Case Report

A 67-year-old diabetic female presented with bradykinesia and camptocormia that started 1 year prior to presentation. Evaluation revealed levosulpiride, a dopamine receptor blocker commonly used for dyspepsia, to be the culprit.

Discussion

It is well known that dopamine receptor blockers cause parkinsonism and tardive syndromes. We report a rare and unusual presentation of camptocormia attributed to this commonly used gastrointestinal drug in the Asian population.

Design, Formulation and In Vitro Evaluation of Sustained-release Tablet Formulations of Levosulpiride

OBJECTIVES

Levosulpiride is a widely used gastroprokinetic agent in the treatment of various gastric disorders; however, its short half-life and increased dosage frequency leads to non-compliance and possible adverse effects. The prime objective of the current study was to develop a sustained-release formulation of Levosulpiride incorporating bioresorbable cellulose derivatives.

MATERIALS AND METHODS

Sustained-release formulations of Levosulpiride were prepared through direct compression using various cellulose derivatives such as CMC sodium, HPC, and HPMC in different polymer-to-drug weight ratios as release-modifying polymers. The powder blends and compressed tablets were then subjected to pre-compressional and post-compressional evaluation, as well as FTIR analysis. In vitro release studies were performed for all formulations of the model drug in buffer solution of pH 6.8 at a wave length of 214 nm by a UV-visible light spectrophotometer.

RESULTS

The FTIR results confirmed that the interaction between components was physical, and from the different kinetic models data, the release profile was best expressed by the Higuchi model because the results showed high linearity. The results also showed formulation F9 to be the ideal one among the developed formulations, exhibiting sustained- release behavior.

CONCLUSION

Levosulpiride sustained-release matrices were prepared successfully using CMC sodium, HPC, and HPMC as the release-retarding polymer/carrier.

Development and characterisation of levosulpiride-loaded suppositories with improved bioavailability in vivo

The purpose of this study was to develop and characterize levosulpiride loaded liquid suppository with improved bioavailability. The content of levosulpiride-loaded liquid suppositories were optimized in a series of experiments using various weight ratios of P188, P407, Tween 80, and drug. The suppositories were liquid at room temperature, however, when rectally administered, they became gel at body temperature. Their rheological properties and release characteristics were determined in vitro while pharmacokinetic study was performed after its rectal administration in rats and compared with drug suspension. Poloxamer 188 and Twee 80 decreased the gelation temperature and gelation time, but increased the gel strength and mucoadhesive force of liquid suppositories. Liquid suppository composed of [Levosulpiride/P 188/P 407/Tween 80 (1/15/17/3%)] with a gelation temperature of about 30.7 °C remained liquid at 25 °C, but converted to gel at 30-36.5 °C, resulting in easy administration and rapid gelation inside the body. This liquid suppository gave a considerably increased dissolution rate reflected in a meaningfully higher plasma concentration and 7.1-fold AUC values of levosulpiride in rats as compared to the drug suspension. Hence, liquid suppository system could be used for enhanced bioavailability of levosulpiride-loaded pharmaceutical products.

Pregnancy outcomes in women reporting ingestion of levosulpiride in early pregnancy

This study aimed to evaluate pregnancy outcomes of women who were inadvertently exposed to levosulpiride in early pregnancy. All 162 consecutive singleton pregnant women counselled through the Korean Motherisk Program, Cheil General Hospital, between April 2001 and April 2014, on teratogenic risk after inadvertent exposure to levosulpiride in early pregnancy were enrolled in this study. The women were exposed to levosulpiride at median 4.8 gestational weeks. The rate of miscarriage was not significantly different between groups (9.2% in those exposed and 5.5% in the non-exposed; p = .084). The rate of major malformations was not significantly different between exposed (2.7%) and non-exposed pregnancies (4.4%) (p = .481). All other pregnancy outcomes between the two groups were comparable (p > .05). Our data suggest that levosulpiride causes no significant adverse effects on pregnancy outcomes and therefore may be not a major teratogen.

Development and validation of a high throughput UPLC-MS/MS method for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma

A high throughput ultra pressure liquid chromatography–mass spectrometry (UPLC–MS/MS) method with good sensitivity and selectivity has been developed and validated for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma using lansoprazole as internal standard (IS). The extraction method based on liquid–liquid extraction technique was used to extract the analytes and IS from of 50 µL of human plasma using methyl tert-butyl ether:ethyl acetate (80:20, v/v), which offers a high recovery. Chromatographic separation of analytes and IS was achieved on a Hypersil gold C₁₈ column using gradient mobile phase consisting of 2 mM ammonium formate/acetonitrile. The flow rate was set at 0.5 mL/min to elute all the analytes and IS within 1.00 min runtime. Detection of target compounds was performed on a triple quadruple mass spectrometer by multiple reaction monitoring (MRM) mode via positive electrospray ionization (ESI). Method validation results demonstrated that the developed method has good precision and accuracy over the concentration ranges of 0.1–2000 ng/mL for each analyte. Stability of compounds was established in a battery of stability studies, i.e., bench top, autosampler, dry extract and long-term storage stability as well as freeze-thaw cycles. The validated method has been successfully applied to analyze human plasma samples for application in pharmacokinetic studies.

Quality by design in the chiral separation strategy for the determination of enantiomeric impurities: development of a capillary electrophoresis method based on dual cyclodextrin systems for the analysis of levosulpiride

Quality by design (QbD) concepts, in accordance with International Conference on Harmonisation Pharmaceutical Development guideline Q8(R2), represent an innovative strategy for the development of analytical methods. In this paper QbD principles have been comprehensively applied in the set-up of a capillary electrophoresis method aimed to quantify enantiomeric impurities. The test compound was the chiral drug substance levosulpiride (S-SUL) and the developed method was intended to be used for routine analysis of the pharmaceutical product. The target of analytical QbD approach is to establish a design space (DS) of critical process parameters (CPPs) where the critical quality attributes (CQAs) of the method have been assured to fulfil the desired requirements with a selected probability. QbD can improve the understanding of the enantioseparation process, including both the electrophoretic behavior of enantiomers and their separation, therefore enabling its control. The CQAs were represented by enantioresolution and analysis time. The scouting phase made it possible to select a separation system made by sulfated-β-cyclodextrin and a neutral cyclodextrin, operating in reverse polarity mode. The type of neutral cyclodextrin was included among other CPPs, both instrumental and related to background electrolyte composition, which were evaluated in a screening phase by an asymmetric screening matrix. Response surface methodology was carried out by a Doehlert design and allowed the contour plots to be drawn, highlighting significant interactions between some of the CPPs. DS was defined by applying Monte-Carlo simulations, and corresponded to the following intervals: sulfated-β-cyclodextrin concentration, 9-12 mM; methyl-β-cyclodextrin concentration, 29-38 mM; Britton-Robinson buffer pH, 3.24-3.50; voltage, 12-14 kV. Robustness of the method was examined by a Plackett-Burman matrix and the obtained results, together with system repeatability data, led to define a method control strategy. The method was validated and was finally applied to determine the enantiomeric purity of S-SUL in pharmaceutical dosage forms.

Pharmacokinetics of levosulpiride after single and multiple intramuscular administrations in healthy Chinese volunteers

The main purpose of this study was to evaluate the pharmacokinetics of levosulpiride in humans after single and multiple intramuscular injections. Six males and six females received single dose of either 25 mg or 50 mg levosulpiride, or multiple doses of 25 mg every 12 h for 5 consecutive days. In the single 25 mg study, the mean peak plasma concentration (C_max) was 441 ng/mL, the mean area under the concentration–time curve from 0 to 36 h (AUC_0–36) was 1724 ng h/mL, and the mean elimination half-life (t_1/2) was 7.0 h. In the single 50 mg study, the mean C_max was 823 ng/mL, the mean AUC_0–36 was 3748 ng·h/mL, and the mean t_1/2 was 6.8 h. After multiple doses of 25 mg levosulpiride, the average plasma concentration (C_av) was 136 ng/mL, the fluctuation index (DF) was 3.60, and the accumulation ratio (R) was 1.2. Levosulpiride injections appeared to be well tolerated by the subjects, and can be used for successive administration.

Development and Validation of a UPLC Method by the QbD-Approach for the Estimation of Rabeprazole and Levosulpiride from Capsules

Statistical experimental design was used to optimize the chromatographic separations of two pharmaceutical compounds from their respective potential impurities. A fractional factorial design was utilized to study the effects of pH, organic solvent in mobile phases A&B, and flow rate on the resolution of Rabeprazole and Rabeprazole Sulfone, which had closely eluting peaks. A desirability function applied to the optimized conditions predicted the peak resolution between 2.2 and 2.7 for the Rabeprazole & Rabeprazole Sulfone impurity. The chromatographic method employed an Acquity UPLC, BEH C18 column (100 × 2.1 mm i.d., 1.7 μm particle size) with the mobile phase consisting of a phosphate buffer, pH 6.5, and acetonitrile in a gradient program. The flow rate and injection volumes were 0.45 mL/min & 5 μl, respectively, and detection was done at 254 nm. The chromatographic method was validated for linearity, accuracy, precision, specificity, and ruggedness according to ICH guidelines. The results clearly showed that the quality by design concept could be effectively applied to optimize a UPLC chromatographic method with fewer trials and error-free experimentation.

Electrogastrography associated with symptomatic changes after prokinetic drug treatment for functional dyspepsia

AIM: To evaluate the effect of prokinetic drugs on electrogastrography (EGG) parameters according to symptomatic changes in patients with functional dyspepsia (FD).

METHODS: Seventy-four patients with FD were prospectively enrolled in this study between December 2006 and December 2010. We surveyed the patients using a questionnaire on dyspeptic symptoms before and after an 8-wk course of prokinetic drug treatment. We also measured cutaneous pre-prandial and post-prandial EGG recordings including percentage of gastric waves (normogastria, bradygastria, tachygastria), dominant frequency (DF), dominant power (DP), dominant frequency instability coefficient (DFIC), dominant power instability coefficient (DPIC), and the ratio of post-prandial to fasting in DP before and after the 8-wk course of prokinetic drug treatment.

RESULTS: Fifty-two patients (70%) achieved symptomatic improvement after prokinetic drug treatment. Patients who had normal gastric slow waves showed symptom improvement group after treatment. Post-prandial DF showed a downward trend in the symptom improvement group, especially in the itopride group. Post-prandial DP was increased regardless of symptom improvement, especially in the itopride group and mosapride group. Post-prandial DFIC and DPIC in the symptom improvement group were significantly increased after the treatment. The EGG power ratio was increased after treatment in the symptom improvement group (0.50 ± 0.70 vs 0.93 ± 1.77, P = 0.002), especially in the itopride and levosulpiride groups.

CONCLUSION: Prokinetics could improve the symptoms of FD by regulating gastric myoelectrical activity, and EGG could be a useful tool in evaluating the effects of various prokinetics.

Levosulpiride in somatoform disorders: A double-blind, placebo-controlled cross-over study

Reliable data on the psychopharmacotherapy of somatoform disorders (SDs) are scanty because of patients' poor psychopathological awareness and compliance, the need for combination treatment, and the lack of suitable instruments for clinical diagnosis and assessment. The aim of the present study was to investigate the efficacy and tolerability of low doses of levosulpiride in the treatment of SDs. Seventy-four patients with SDs diagnosed according to ICD-10 and DSM-IIIR criteria by means of the Comprehensive International Schedule for Somatoform Disorders-Somatoform Disorders Schedule (CISSD-SDS) were treated for 4 weeks either with levosulpiride (50 mg b.i.d.) or placebo, under double-blind, cross-over conditions. The clinical evaluation was performed using CISSD-SDS. Side-effects were evaluated using the Simpson and Angus Extrapyramidal Side Effects Scale (EPSE) and specific check-lists for anticholinergic and endocrine side effects. Levosulpiride significantly reduced the number of SD symptoms compared to placebo ( P =0.007) after 4 weeks of treatment. Eighty per cent of positive responses were observed during treatment with levosulpiride in the placebo-levosulpiride sequence; on the other hand, only 44% of positive responses were found during treatment with active compound in the levosulpiride-placebo sequence ( P <0.002). Levosulpiride also determined a more evident reduction of the total number of SD symptoms compared to placebo ( P <0.001). There were no differences in endocrine and anticholinergic side effects between levosulpiride and placebo. In the levosulpiride group, a higher percentage of patients (13.4 vs. 2.8%; P =0.029) showed signs of extrapyramidal system involvement compared to placebo. Levosulpiride appears to be a well-tolerated and effective drug for the treatment for SDs.