Feasibility study to assess lesion repair in relapsing-remitting multiple sclerosis: A randomized controlled pilot clinical trial of domperidone add-on treatment

BACKGROUND

Identification of therapies to promote repair in multiple sclerosis is challenged by the lack of an accepted trial model and associated outcome measures. The goal of this study was to determine the feasibility of a new trial model that enrolls disease modifying therapy (DMT)-treated relapsing-remitting multiple sclerosis (RRMS) participants who have enhancing lesions on clinically indicated brain MRI, and to explore estimates of lesion repair using MRI.

METHODS

This was a single site randomized controlled clinical trial. Recruitment took place between November 2015 and January 2019, with final follow-up in February 2019. DMT-treated RRMS participants aged 18-60 years with at least one gadolinium-enhancing lesion on clinically indicated brain MRI were included. Participants were randomized 2:1 to oral domperidone add-on 10-mg three times daily for 16 weeks or no add-on treatment (control). The primary outcomes were feasibility of the model pre-defined as recruitment of 24 participants within 36 months with a 79 % completion rate, and MRI outcomes of lesion repair measured at 16 and 32 weeks using texture analysis, magnetization transfer imaging (MTI), and diffusion tensor imaging (DTI). The impact of domperidone on serum prolactin at 6 and 16 weeks was also evaluated.

RESULTS

Of 237 RRMS participants screened, 17 (14 women) were randomized: 12 to domperidone add-on and 5 to control. All completed the study. Median (range) age was 38.9 (26.7-55.9) years; EDSS was 1.5 (1.0-3.5); and disease duration was 12.9 (2.9-23.3) years. Both groups showed improvement in MRI texture and diffusion fractional anisotropy (FA) at 32 weeks, and the domperidone group demonstrated additional recovery at 16 weeks in both texture and FA. There was no significant group difference in any MRI outcome. Of the 12 domperidone participants, 7 had ≥4x higher serum prolactin than normal. There were no serious adverse events.

CONCLUSION

The recruitment target was not met and therefore the trial model was not feasible despite a full completion rate. The imaging techniques performed well, especially MRI texture analysis, suggesting the sample size being sufficient for estimating lesion repair. The main challenge of this trial model may be recruiting gadolinium-enhancing lesions in DMT-treated RRMS participants. Prolactin is safe and may hold promise as a remyelination therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02493049.

Efficacy of Wang Nam Yen herbal tea on human milk production: A randomized controlled trial

Background

Insufficient milk production is a common problem affecting breastfeeding women, in particular following Cesarean delivery. Wang Nam Yen herbal tea is a promising traditional Thai medicine used by postpartum women to stimulate milk production, as an alternative to pharmaceutical galactagogues. We aimed to compare the efficacy of Wang Nam Yen herbal tea, domperidone, and placebo, in increasing milk production in mothers who underwent Cesarean delivery.

Methods

Women who underwent uncomplicated cesarean delivery at Sunpasitthiprasong Hospital were randomized into three groups. The participants received the treatments daily for three consecutive days. The primary outcome was breast milk volume at 72 hours after delivery. Secondary outcomes were pregnancy and neonatal outcomes, adverse events, and participant satisfaction.

Results

Of the 1,450 pregnant women that underwent cesarean delivery, 120 women were enrolled. Their mean age and gestational ages were 28.7 years and 38.4 weeks, respectively. Breast milk volume at 72 hours postpartum was significantly different among the three groups (p = 0.030). The post hoc Bonferroni correction indicated a significant difference in breast milk volume between Wang Nam Yen herbal tea group and placebo control group (p = 0.007) while there was no difference between Wang Nam Yen herbal tea group and domperidone group (p = 0.806) and between domperidone group and placebo control group (p = 0.018). There was no difference in pregnancy and neonatal outcomes, adverse events, and participant satisfaction among the three groups.

Conclusion

Wang Nam Yen herbal tea was effective in augmenting breast milk production at 72 hours postpartum in mothers following cesarean delivery, and there was no evidence that herbal tea and domperidone differed in terms of augmenting breast milk production.

Trial registration

The study was approved by the institutional review board of Sunpasitthiprasong Hospital (No.061/2559) and was registered TCTR20170811003 with the Thai Clinical Trial Registry.

Rotigotine-loaded microspheres exerts the antinociceptive effect via central dopaminergic system

Rotigotine-loaded microspheres (RoMS), a sustained-release formulation with a continuous release of rotigotine for more than 7 days in vivo, have been conducted a clinical trial for the treatment of Parkinson's disease (PD). Previous work from our laboratory showed that RoMS exerted an antinociceptive effect in rat models of inflammatory pain. The purpose of this study was to investigate the mechanisms of action underlying the antinociceptive effect of RoMS. A rat model of inflammatory pain was prepared by an intraplantar injection of carrageenan. The hot plate test and the Randall-Selitto test were used to evaluate the effect of domperidone (selective D2 receptor antagonist), D2D3 shRNA, and naloxone (nonselective opioid receptor antagonist) on RoMS-mediated antinociceptive efficacy. The expressions of D2 and D3 receptors in the striatum and periaqueductal gray were measured by Western blotting. Intracerebroventricular injection of domperidone abated the antinociceptive effect of RoMS. However, intraperitoneal injection of domperidone had no significant effect on the antinociceptive action of RoMS. Intracerebroventricular injection with D2D3 shRNA significantly attenuated the expressions of D2 and D3 receptors in the striatum and the periaqueductal gray. D2 and D3 receptors silence significantly weakened RoMS-mediated antinociceptive effect. Intracerebroventricular injection of naloxone also alleviated the antinociceptive effect of RoMS. The results suggest that RoMS-mediated antinociceptive efficacy is associated with activating central dopamine D2 and D3 receptors. Opioid receptors play a role in the antinociceptive effect of RoMS.

Thromboelastography with platelet mapping: Limited predictive ability in detecting preinjury antiplatelet agent use

BACKGROUND

Preinjury antiplatelet agent (APA) use in trauma patients can increase traumatic hemorrhage and worsen outcomes. Thromboelastography with platelet mapping (TEGPM) has characterized platelet function via arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition in nontrauma settings, but limited data exist in the acute trauma population.

METHODS

A prospective observational study of adult trauma patients with suspected preinjury APA use who received TEGPM testing from 2017 to 2020 was performed. Patients on anticoagulants were excluded. Patients were grouped according to preinjury APA regimen: 81 mg or 325 mg of aspirin daily, 81 mg of aspirin and 75 mg of clopidrogrel daily, 75 mg of clopidrogrel daily, or no antiplatelet. Ability of TEGPM to detect APA use was assessed using predictive statistics and area under receiver operating characteristic curves (AUROCs).

RESULTS

A total of 824 patients were included with most patients taking 81 mg of aspirin (n = 558). Patients on no antiplatelet were younger and had higher baseline platelet counts, while patients on 75 mg of clopidrogrel were more likely to be admitted after ground level fall. All other baseline characteristics were balanced. Admission TEG values were similar between groups. Median AA inhibition was higher in patients on aspirin containing regimens (p < 0.0001). Median ADP inhibition was higher in patients on clopidogrel containing regimens and those taking 325 mg of aspirin (p < 0.0001). Arachidonic acid inhibition accurately detected preinjury APA use and aspirin use (AUROC, 0.89 and 0.84, respectively); however, ADP inhibition performed poorly (AUROC, 0.58). Neither AA nor ADP inhibition was able to discern specific APA regimens or rule out APA use entirely.

CONCLUSION

High AA inhibition accurately detects preinjury APA use in trauma patients. High ADP inhibition after trauma is common, limiting its utility to accurately identify preinjury APA use. Further study is needed to identify assays that can reliably detect and further characterize preinjury APA use in trauma populations.

LEVEL OF EVIDENCE

Diagnostic test, level II.

The effect of different exogenous kisspeptins on sex hormones and reproductive indices of the goldfish (Carassius auratus) broodstock

Despite several studies on fish hormone therapy, finding new candidates may provide more reproductive efficiency in artificial propagation. Kisspeptins, being upstream of the hypothalamic-pituitary-gonadal axis, appear to play a key role in the reproduction process. In the present study, the effect of different variants of kisspeptide, including goldfish (Carassius auratus) kiss1 kisspeptin (Kiss1), human kisspeptin (Hkiss), and their combination (Kiss1 + H), on the reproductive indices of goldfish broodstock in comparison to Ovaprim (a typical synthetic Gnrh hormone) was investigated. Peptides (Kiss1 and Hkiss) were synthesized using a solid-phase synthesis approach. Kiss1 and Hkiss were injected at a dose of 100 μg kg-1 body weight, blood samples were taken 6 h after injection and sex hormones (E2, Dhp, and 11-Kt), gonadotropins (Lh and Fsh), cortisol and reproductive indices (fecundity, fertilization and hatching percentage) were measured. The results showed a significant increase of plasma sex hormones and gonadotropins in fish treated with kisspeptins. In addition, the cortisol and lipoprotein lipase in Kiss1, Hkiss and Kiss1 + H were remarkably increased compared to Ovaprim. In conclusion, kisspeptins could be a more suitable candidate than Ovaprim for accelerating and synchronizing oocyte maturation in the fisheries industry.

Effects of sustained hyperprolactinemia in late gestation on mammary development of gilts

The objective of this project was to determine the effects of sustained hyperprolactinemia for 7 or 20 d on mammary development in late-pregnant gilts. On day 90 of gestation, gilts were assigned to one of 3 groups to receive intramuscular (IM) injections of (1) canola oil (CTL, n = 18) until day 109 ± 1 of gestation; (2) a dopamine receptor antagonist, domperidone (0.5 mg/kg of body weight [BW]) until day 96 ± 1 of gestation (T7, n = 17); or (3) domperidone (0.5 mg/kg BW) until day 109 ± 1 of gestation (T20, n = 17). Domperidone-treated gilts also received 100 mg of domperidone per os twice daily from days 90 to 93 of gestation. Blood was sampled on days 89, 97, 104, and 110 for prolactin (PRL), insulin-like growth factor 1 (IGF1), lactose, urea, and glucose assays. Mammary glands were collected at necropsy, on day 110, for compositional and cell proliferation analyses. Abundance of mRNA for selected genes was also determined in the mammary gland and the pituitary gland. On day 97 of gestation, PRL concentrations were 3 times greater for T20 and T7 than CTL gilts and were also greater for T20 than T7 and CTL gilts on days 104 and 110 (P < 0.001). Concentrations of IGF1 in T20 and T7 gilts were elevated relative to controls on days 97 and 104 and were greater for T20 vs T7 and CTL gilts on day 110 (P < 0.05). There were no treatment effects (P > 0.1) on parenchymal or extraparenchymal tissue weights, or on epithelial proliferation as measured by immunohistochemistry for Ki-67. Treatments did not alter concentrations of dry matter (DM), fat, or DNA (P > 0.1) in parenchyma. Concentrations of RNA (P < 0.05) and protein (P < 0.10) as well as total parenchymal protein, RNA, and DNA (P < 0.05) were lower, or tended to be, in T20 than T7 or CTL gilts. Hyperprolactinemia for 20 d in late gestation increased mRNA abundance of the milk protein genes beta-casein (CSN2) and whey acidic protein (WAP) (P < 0.05) in mammary parenchyma and also decreased mRNA abundance of the long form of the prolactin receptor (PRLR-LF). Increasing PRL concentrations for 7 or 20 d in late gestation had no beneficial effects on the composition of the mammary gland, and sustained exposure to domperidone for 20 d reduced metabolic activity either by a lower expression of the long form of the PRL receptor in mammary parenchymal tissue or, most likely, by the early involution of parenchymal tissue. In conclusion, results do not support the hypothesis that a sustained hyperprolactinemia in late gestation could enhance mammary development of gilts.

Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants

BACKGROUND

Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non-pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use.

OBJECTIVES

To assess the effect of oral galactagogues for increasing milk production in non-hospitalised breastfeeding mother-term infant pairs.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Health Research and Development Network - Phillippines (HERDIN), Natural Products Alert (Napralert), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster-randomised trials but excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification.

MAIN RESULTS

Forty-one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin-releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) -47.71 to 93.71; 1 study, 20 participants; low-certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low-certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low-certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty-seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of "no significant difference" (no data and no measure of significance provided, 60 participants, very low-certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta-analysed due to substantial clinical and statistical heterogeneity (I² = 60%, 275 participants, very low-certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta-analysis was not possible due to substantial heterogeneity (I² = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low-certainty evidence). There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low-certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta-analysis because there was only one small study for each match-up, so we do not know if one galactagogue is better than another for any outcome.

AUTHORS' CONCLUSIONS

Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low-certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High-quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used.

Cardiovascular alterations in rats with Parkinsonism induced by 6-OHDA and treated with Domperidone

After Alzheimer, Parkinson disease (PD) is the most frequently occurring progressive, degenerative neurological disease. It affects both sympathetic and parasympathetic nervous systems in a variable fashion. Cardiovascular symptoms are present in almost all stages of PD and narrower heart rate variability is the earliest sign. Administration of Levodopa to PD patients has proven to provide some degree of neurological protection. This drug, however, causes side effects including nausea and vomiting, lessened by the administration of domperidone. Autopsies in PD patients led some researchers to suggest the involvement of the ventricular arrhythmia induced by domperidone. The aim of the present study was to determine the impact of the adjusted human maximal dose of domperidone, on cardiological features of Wistar rats. domperidone was administered to both 6-hydroxydopamine Parkinsonism models and regular Wistar rats. Quantitative analysis of ranges of heart beat variation showed significant abnormal distribution in both groups receiving domperidone as compared with respective sham counterparts. However, qualitative analysis of Poincaré plots showed that 6-hydroxydopamine Parkinsonism models receiving domperidone had the narrowest full range of heart beat and the worst distribution heart beat ranges as compared with all study groups corroborating with previous suggestion that domperidone administration to PD patients is likely to play a role in sudden unexpected death in this group of patients.

Domperidone nanocrystals with boosted oral bioavailability: fabrication, evaluation and molecular insight into the polymer-domperidone nanocrystal interaction

The aim of this study was to employ experimental and molecular modelling approaches to use molecular level interactions to rationalise the selection of suitable polymers for use in the production of stable domperidone (DOMP) nanocrystals with enhanced bioavailability. A low-energy antisolvent precipitation method was used for the preparation and screening of polymers for stable nanocrystals of DOMP. Ethyl cellulose was found to be very efficient in producing stable DOMP nanocrystals with particle size of 130 ± 3 nm. Moreover, the combination of hydroxypropyl methylcellulose and polyvinyl alcohol was also shown to be better in producing DOMP nanocrystals with smaller particle size (200 ± 3.5 nm). DOMP nanosuspension stored at 2-8 °C and at room temperature (25 °C) exhibited better stability compared to the samples stored at 40 °C. Crystallinity of the unprocessed and processed DOMP was monitored by differential scanning calorimetry and powder X-ray diffraction. DOMP nanocrystals gave enhanced dissolution rate compared to the unprocessed drug substance. DOMP nanocrystals at a dose of 10 mg/kg in rats showed enhanced bioavailability compared to the raw drug substance and marketed formulation. A significant increase in plasma concentration of 2.6 μg/mL with a significant decrease in time (1 h) to reach maximum plasma concentration was observed for DOMP nanocrystals compared to the raw DOMP. Molecular modelling studies provided underpinning knowledge at the molecular level of the DOMP-polymer nanocrystal interactions and substantiated the experimental studies. This included an understanding of the impact of polymers on the size of nanocrystals and their associated stability characteristics.

Using domperidone to induce and sustain hyperprolactinemia in late-pregnant gilts

Prolactin controls mammary development as well as the lactogenic and galactopoietic processes in sows and increasing prolactin during gestation can augment milk yield. The dopamine receptor antagonist domperidone can increase circulating prolactin concentrations in pigs, but the ideal dose to achieve sustained hyperprolactinemia remains unknown. An experiment was performed to develop a protocol for using domperidone in studies of rapid and sustained hyperprolactinemia in late-pregnant gilts. On day 90 of gestation, gilts were divided into 4 groups: (1) intramuscular (IM) injections of canola oil (3 mL, controls [CTL], n = 9), (2) IM injections with 0.1 mg/kg BW of domperidone (low [LO], n = 8), (3) IM injections with 0.5 mg/kg BW of domperidone (medium [ME], n = 11), and (4) IM injections with 1.0 mg/kg BW of domperidone (high [HI], n = 11). Injections were given daily at 8:05 from days 90 to 109 of gestation. Treated gilts also received domperidone per os (0.5 mg/kg BW) at 8:00 and 20:00 on days 89, 90, and 91 of gestation. Three jugular blood samples were collected from all gilts at 6-h intervals on days 89, 90, and 91 of gestation, then twice daily on days 92, 93, and 94. Thereafter, samples were obtained at 8:00 every other day until day 114 of gestation. Blood was sampled serially from 9 CTL and 11 HI gilts on days 89 and 94 of gestation. On day 89 of gestation, prolactin concentrations for LO, ME, and HI gilts increased within 6 h of domperidone per os (P < 0.001). From days 89 until 93 of gestation, the area under the curve (AUC) for LO, ME, and HI gilts was greater than that for CTL gilts (P < 0.001), whereas from days 89 until 114, ME and HI gilts had greater AUC than CTL and LO gilts (P < 0.05). Results demonstrate that the combination of per os treatment with IM injections of 0.5 mg/kg of domperidone in an oil emulsion leads to the rapid and sustained release of prolactin over 24 d in late-pregnant gilts. Higher doses of domperidone failed to further increase circulating prolactin levels. These findings provide a useful strategy to induce sustained hyperprolactinemia in late-pregnant gilts.

Prokinetics stimulate the increase of ghrelin in mice

OBJECTIVES

Intestinal motility is regulated by several neurotransmitters and neuropeptides including dopamine and acetylcholine as well as ghrelin. Metoclopramide and domperidone are long-standing treatment options for dysmotility, and erythromycin is suggested in selected patients. In the present study, we aimed to investigate the effects of mentioned prokinetics on ghrelin levels.

METHODS

Serum ghrelin levels were estimated by using enzyme-linked immunoassay following a single administration of domperidone, metoclopramide, or erythromycin.

RESULTS

Our results showed that both antidopaminergic and cholinergic prokinetics increase the circulating ghrelin levels. There was no significant difference between enteral and parenteral control groups. Also, statistical analysis revealed that neither prokinetic was superior to the other in regard to its ghrelin stimulating effect.

CONCLUSION

Conclusively, the present study demonstrated that the circulating levels of ghrelin increase by the administration of antidopaminergic and cholinergic prokinetics. Hence, this effect on ghrelin may partly be responsible for the motility‑stimulating actions of domperidone, metoclopramide, and erythromycin (Fig. 2, Ref. 39).

[Domperidone to promote lactation]

- Breast milk is the best diet for all newborns, especially premature newborns.- In case of insufficient production of breast milk, feeding and extraction techniques should be optimized first, preferably supported by a lactation consultant. When supportive measures fail, domperidone to promote milk production can be considered.- The risk of side effects in newborns is negligible. The risk of maternal arrhythmias associated with QTc prolongation is low as long as domperidone is prescribed in low doses (10 mg tds).- In the absence of risk factors it is not necessary to routinely perform an ECG and, therefore, general practitioners can safely prescribe domperidone.- The effect of the treatment should be evaluated after 2 weeks. In case of prolonged treatment or use of higher dosages, it is recommended to perform an ECG to exclude QTc prolongation.

Risk of Out-of-Hospital Sudden Cardiac Death in Users of Domperidone, Proton Pump Inhibitors, or Metoclopramide: A Population-Based Nested Case-Control Study

INTRODUCTION

Epidemiological studies have linked domperidone use with serious cardiac arrhythmias, including sudden cardiac death, but data on age, dose, and duration of use are limited.

OBJECTIVES

The aim of this study was to assess the risk of out-of-hospital sudden cardiac death associated with domperidone use versus proton pump inhibitors (PPIs), metoclopramide, or non-use of all three medications, and to evaluate the risk of sudden cardiac death in relation to age and domperidone dose.

METHODS

This was a population-based case-control study nested in a cohort of subjects aged ≥2 years in the Clinical Practice Research Datalink with one or more prescriptions for domperidone, any PPI, or metoclopramide from 2005 to 2011. Out-of-hospital sudden cardiac death was assessed by linkage with Hospital Episode Statistics and death certificates. Controls were matched on age, sex, and medical practice. The risk of sudden cardiac death in domperidone users versus risk in users of PPIs or metoclopramide was evaluated with multivariable conditional logistic regression; case-crossover analysis addressed possible residual confounding.

RESULTS

From the study cohort (n = 681,104), 3239 sudden cardiac death cases were matched to 12,572 controls. The adjusted odds ratio (95 % confidence interval) for sudden cardiac death with current use of domperidone alone was 1.71 (0.92-3.18) versus non-use of study medications, 1.26 (0.68-2.34) versus current PPI use, and 0.40 (0.17-0.94) current metoclopramide use. The adjusted odds ratio (95 % confidence interval) relative to exposure to no study drug for domperidone >30 mg/day (eight cases, five controls) was 3.20 (0.59-17.3) and 1.65 (0.89-3.07) for age ≥61 years (27 cases, 49 controls). The odds ratio (95 % confidence interval) was 3.17 (1.72-5.83) for within-person periods of domperidone use versus non-use in the case-crossover analysis.

CONCLUSIONS

Compared with non-use of any study drug, current domperidone use was associated with sudden cardiac death in nested case-control and case-crossover analyses, with a suggestion of higher risk in older persons and users of higher daily doses.

Factors associated with domperidone use as a galactogogue at an Australian tertiary teaching hospital

BACKGROUND

Insufficient milk supply is 1 of the most commonly reported reasons for discontinuation of infant breastfeeding. Although domperidone is often used to improve milk supply, knowledge of factors associated with the use of domperidone in clinical practice is scarce.

OBJECTIVE

This study aimed to examine factors associated with the use of domperidone as a galactogogue at the Women's and Children's Hospital (WCH), Adelaide.

METHODS

A retrospective cohort study was conducted, involving women who delivered live-born singletons (N = 21 914) at the WCH between January 2004 and December 2008. Women dispensed domperidone were identified using WCH pharmacy dispensing records. Maternal and infant clinical data were obtained from the WCH Perinatal Statistics Collection. Relationships between maternal/infant demographic and clinical variables and the use of domperidone were examined through univariate and multivariate logistic regression analyses.

RESULTS

Key factors associated with an increased likelihood of women receiving domperidone were increasing maternal age (adjusted odds ratio [aOR] = 1.04; 95% confidence interval [CI], 1.03-1.06), maternal obesity (aOR = 1.41; 95% CI, 1.16-1.77), primiparity (aOR = 1.94; 95% CI, 1.63-2.30), delivery by cesarean section (aOR = 1.31; 95% CI, 1.10-1.55), preterm birth (aOR = 3.54; 95% CI, 2.79-4.50), and neonatal hospitalization (aOR = 2.51; 95% CI, 2.01-3.14). In addition, statistically significant trends were observed between increasing socioeconomic status and year of delivery and an increased likelihood of women receiving domperidone (all Ps < .004).

CONCLUSION

These findings are of clinical importance as they not only reinforce previous findings regarding risk factors for women experiencing lactation difficulties but also highlight the need for improved research regarding the rational and efficacious use of domperidone to improve breastfeeding outcomes.

Co-processed chitin-mannitol as a new excipient for Oro-dispersible tablets

This study describes the preparation, characterization and performance of a novel excipient for use in oro-dispersible tablets (ODT). The excipient (Cop–CM) consists of chitin and mannitol. The excipient with optimal physicochemical properties was obtained at a chitin: mannitol ratio of 2:8 (w/w) and produced by roll compaction (RC). Differential scanning calorimetry (DSC), Fourier transform-Infrared (FT-IR), X-ray powder diffraction (XRPD) and scanning electron microscope (SEM) techniques were used to characterize Cop–CM, in addition to characterization of its powder and ODT dosage form. The effect of particle size distribution of Cop–CM was investigated and found to have no significant influence on the overall tablet physical properties. The compressibility parameter (a) for Cop–CM was calculated from a Kawakita plot and found to be higher (0.661) than that of mannitol (0.576) due to the presence of the highly compressible chitin (0.818). Montelukast sodium and domperidone ODTs produced, using Cop–CM, displayed excellent physicochemical properties. The exceptional binding, fast wetting and superdisintegration properties of Cop–CM, in comparison with commercially available co-processed ODT excipients, results in a unique multifunctional base which can successfully be used in the formulation of oro-dispersible and fast immediate release tablets.

Effect of piperine, a major component of black pepper, on the pharmacokinetics of domperidone in rats

The present study was aimed to investigate the effect of piperine, a major active ingredient of black pepper, on the pharmacokinetics of domperidone in rats. Animals were given oral (p.o.) or intraperitoneal (i.p.) domperidone (20 mg/kg) alone or together with piperine (20 mg/kg, p.o.). Plasma samples were collected at 0.25, 0.5, 1.0, 2.0, 3.0, 4.0, 6.0, 8.0, 10.0 and 12 hours after drug administration. The concentration of domperidone in the plasma was measured using a HPLC method. The concomitant administration of piperine with oral or intraperitoneal domperidone resulted in a significant (P<0.05) increase in the maximum plasma concentration (Cmax), the mean area under the plasma concentration-time curve (AUC), and the elimination half-life (t1/2) of domperidone as compared to those obtained for domperidone alone. These results suggest that an important pharmacokinetic interaction may occur if piperine is administered concurrently with domperidone.

[Role of psychological correction in the combination treatment of patients with gastroesophageal reflux disease]

AIM

To evaluate the efficiency of psychotherapeutic methods on the clinical course of gastroesophageal reflux disease (GERD), quality of life (QL), esophagogastroduodenoscopic findings and 24-hour pH monitoring readings in patients with this condition.

SUBJECTS AND METHODS

Sixty patients with GERD were divided into equal groups according to performed therapy: standard drug treatment or its combination with psychotherapeutic methods. The investigators estimated the degree of esophageal mucosal damage by esophagogastroduodenoscopy, esophageal acidity by 24-hour pH monitoring, and the magnitude of clinical manifestations by the Likert scale and assessed QL by the SF-36 questionnaire. The psychoemotional health component was analyzed using the clinical questionnaire for the identification and evaluation of neurotic states (CQIENS), the Leonhard-Shmichek characterological questionnaire, and the individual typological questionnaire.

RESULTS

The patients with GERD were found to have individual personal traits and a definite psychological response. Incorporation of psychotherapeutic methods into the combination therapy was ascertained to have an additional therapeutic effect against the clinical manifestations of GERD, psychological responses in the patients, and QL indicators. There was a direct relationship between the psychological component of QL and the data of the CQIENS questionnaire. The most significant correlation was found between the CQIENS anxiety scores and the psychological component of QL (r = 0.73; p = 0.00004). Correlation analysis in the patients with GERD showed a relationship between the CQIENS anxiety scores and the clinical index (r = -0.68; p = 0.0001).

CONCLUSION

The use of psychotherapeutic methods in addition to standard drug therapy improves both the physical and psychological states in patients with GERD and has some impact on a reduction in the magnitude of clinical symptomatology. This may contribute to the prompter recovery of patients and create prerequisites for improving their QL.

Effects of dopamine 2 receptor antagonist on sex steroid levels, oocyte maturation and spawning performances in Waigieu seaperch (Psammoperca waigiensis)

The present study has investigated the effects of domperidone (DOM), a dopamine 2 receptor antagonist, on plasma steroid hormone levels and reproductive performances of a female tropical marine finfish, Waigieu seaperch (Psammoperca waigiensis), with potential for cultivation in Vietnam. We showed that oral treatment of DOM during early stage of the reproductive cycle had no significant effects on the maturation and reproductive performances of the female fish, while plasma steroid hormone (testosterone (T), 11-ketotestosterone (11-KT), 17β-estradiol (E2) and progesterone (P)) levels were modulated based on month, DOM dose and the individual hormones measured. Overall, these findings suggest that DOM may not be needed for the induction of maturation and spawning of this species under aquaculture conditions. The data in the present study are significant in highlighting practical efforts for reducing drug use, production costs and for a sustainable aquaculture in a developing country such as Vietnam.

[Comparative data of prokinetics in treatment of gastroesophageal reflux disease in patients with diabetes]

The purpose is to evaluate the effectiveness of itopride (IP) and domperidone (DP) in the treatment of patients with gastroesophageal reflux disease (GERD), in combination with diabetes mellitus (DM) type 1 and 2.

MATERIALS AND METHODS

40 patients were examined with GERD and type 1 diabetes and 50 patients with GERD and type 2 diabetes. Each group of patients with GERD, DM 1 and 2 has been divided into: the basic subgroup receiving IG 50 mg 3 tid and control--DP 10 mg tid. Patients were also administered omeprazole. Both subgroups were strictly randomized to key indicators, except for therapy. Baseline and after 2 and 4 weeks, all patients were examined to identify complaints, endoscopy and pH-metric changes, gastric motility was studied by electrogastroenterographic method (PEGEG).

RESULTS

In the subgroups of patients with GERD + DM 1 and GERD + DM 2, received treatment with IG complaints on heartburn, regurgitation, odynophagia relieved significantly earlier then in the subgroups treated with DP. After 4 weeks of therapy, decreasing in the number of gastroesophageal refluxes, number of patients with erosive esophagitis B level, and normalization of the motility of the stomach were significantly higher in the groups of GERD + DM 1 and GERD + DM 2 received treatment with IG when compared with the subgroup of PD. There were no side effects of prokinetics.

CONCLUSION

IG was more effective then DP in the treatment of GERD in patients with diabetes, and may be recommended for inclusion in the scheme of treatment of this comorbidity.

Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants

BACKGROUND

Breastmilk remains the optimal form of enteral nutrition for term and preterm infants until up to six months postnatal age. Mothers of preterm infants who have not established suck feeds must express their breastmilk and often have difficulty in maintaining sufficient volume for their infants' needs (Donath 2008). In preterm infants, donor breastmilk reduced the occurrence of necrotising enterocolitis, when compared with formula feeds (McGuire 2003). Also, case-control studies have suggested that breastmilk is associated with an improvement in feeding tolerance, a reduction in significant gastrointestinal infective events (Beeby 1992) and a reduction in late-onset sepsis (Schanler 1999) when compared with formula feeds in preterm hospitalised infants.

OBJECTIVES

To assess the effect of medication given for at least seven days to mothers of preterm infants whose breastmilk is insufficient for their infants' needs on the outcomes of expressed milk volume and duration of breastfeeding.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of breastmilk-augmenting medications (compared with placebo or with other augmenting medications) in mothers with preterm hospitalised infants whose breastmilk volumes failed to meet their infants' requirements. We did not include trials with a cluster-randomised or cross-over design.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed studies for inclusion, assessed risk of bias, and extracted data. Any differences were resolved by consensus. Data were checked for accuracy.

MAIN RESULTS

Two trials (involving 59 mothers) that examined the use of domperidone in a total of 59 mother-infant pairs met the inclusion criteria. Meta-analysis of these trials showed a modest increase in expressed breastmilk (EBM) of 99.49 mL/day (95% confidence intervals -1.94 to 200.92; random-effects, T² 3511.62, I² 63%) in mothers given domperidone. Both trials gave the same dose of domperidone (10 mg three times per day) with a duration of seven days in the smaller trial and 14 days in the larger.Neither trial showed significant improvements in longer-term outcomes of breastfeeding in a preterm population and no adverse effects were reported.

AUTHORS' CONCLUSIONS

Two studies with a total of 59 mothers suggest modest improvements in short-term EBM volumes when a medication is used after insufficient EBM occurs in mothers following preterm delivery. In both studies, the medication was commenced ≧14 days post delivery and following insufficient EBM supply with other lactation supports.Currently, no studies support prophylactic use of a galactagogue medication at any gestation. Use of any galactagogue medication has only been examined at more than 14 days post delivery and after full lactation support has been given. Further trials should examine larger groups of preterm mothers and consider breastfeeding outcomes over a longer period.

[Proposed alternative to standard apomorphine challenge test]

Subcutaneous apomorphine injection is used as a rescue treatment in the off periods in moderate and advanced Parkinson's disease and also when required to assess the dopaminergic response. It is not recommended as a diagnostic tool in Parkinson's disease because it has more side effects and is less specific than chronic response to levodopa. To calculate the dosage, an apomorphine challenge test is performed, generally taking quite time and testing several doses. We propose an alternative apomorphine challenge test, with a single injection and a higher initial dosage of 2-4 mg, as well as to schedule treatment according to the obtained response at that dosage. This procedure saves time and also allows a better planning of medical attention.

Effects of domperidone on augmentation of lactation following cesarean delivery at full term

OBJECTIVE

To evaluate the effects of domperidone on breast milk production in women who underwent cesarean at full term.

METHODS

Women who underwent uncomplicated full-term cesarean were randomly assigned to receive domperidone or placebo for 4 consecutive days post partum. Breast milk was collected twice daily via electric breast pump. Baseline milk production was determined by measuring the volume of milk collected on the 1st postpartum day, before initiation of study medication (day 0). The daily volume of milk collected was compared between groups. Adverse treatment-related effects were recorded.

RESULTS

The study was completed by 22 women in the domperidone group and 23 in the placebo group. Compared with day 0, mean increases in milk volume per participant collected on days 1, 2, 3, and 4 were significantly higher in the domperidone (13.6 ± 23.2 mL, 68.5 ± 71.9 mL, 144.5 ± 122.3 mL, and 191.3 ± 136.1 mL) than in the placebo (2.5 ± 4.6 mL, 24.5 ± 26.5 mL, 72.1 ± 55.6 mL, and 91.4 ± 60.3 mL) group. Minor adverse effects were reported by 7 women in the domperidone group.

CONCLUSION

Postpartum treatment with domperidone can augment breast milk production after full-term cesarean, with minimal adverse effects.

Combination of PPI with a prokinetic drug in gastroesophageal reflux disease

AIM

to evaluate the efficacy of combination of PPI with prokinetic drug compared to PPI mono therapy in GERD patients with high frequency scale for the symptoms of GERD (FSSG) score.

METHODS

sixty dyspeptic patients having heartburn and/or regurgitation were recruited during the period of July 2010-April 2011 in this double blind clinical trial. By randomization, they were divided into two groups; group A was given omeprazole 2 x 20 mg and domperidone 3 x 10 mg for 2 weeks, while another group was only given omeprazole 2 x 20 mg. The FSSG score was performed before treatment and after 2 weeks of treatment.

RESULTS

there were 20 (33%) males and 40 (67%) females. The mean total score of FSSG was 25.3 ± 8.2 at pretest, and 19.3 ± 9.7 at posttest, with improvement of 6.1 ± 4.9. The FSSG score in group A after treatment (19.3 ± 11.3) was significantly lower than before treatment (26.7 ± 8.9, p<0.001) as well as in group B (from 23.9 ± 7.3 to 19,3 ± 7.9, p<0.001). The mean improvement score in group A was 7.5 ± 5.9, while in the group B was of 4.6 ± 3.3, and this difference was statistically significant (p=0.02)

CONCLUSION

combination of omeprazole with domperidone in GERD patients with high FSSG score is more superior compared to omeprazole monotherapy.

Acute and chronic stress and the inflammatory response in hyperprolactinemic rats

BACKGROUND/AIM

Prolactin (PRL), a hormone produced by the pituitary gland, has multiple physiological functions, including immunoregulation. PRL can also be secreted in response to stressful stimuli. During stress, PRL has been suggested to oppose the immunosuppressive effects of inflammatory mediators. Therefore, the aim of the present study was to analyze the effects of short- and long-term hyperprolactinemia on the inflammatory response in rats subjected to acute or chronic cold stress.

METHODS

Inflammatory edema was induced by carrageenan in male rats, and hyperprolactinemia was induced by injections of the dopamine receptor antagonist domperidone. The volume of inflammatory edema was measured by plethysmography after carrageenan injection. Additionally, the effects of hyperprolactinemia on body weight and serum corticosterone levels were evaluated.

RESULTS AND CONCLUSION

Five days of domperidone-induced hyperprolactinemia increased the volume of inflammatory edema. No differences in serum corticosterone levels were observed between groups. No significant differences were found among 30 days domperidone-induced hyperprolactinemic animals subjected to acute stress and the inflammatory response observed in chronic hyperprolactinemic animals subjected to chronic stress. The results suggest that short-term hyperprolactinemia has pro-inflammatory effects. Because such an effect was not observed in long-term hyperprolactinemic animals, PRL-induced tolerance seems likely. We suggest that short-term hyperprolactinemia may act as a protective factor in rats subjected to acute stress. These data suggest that hyperprolactinemia and stress interact differentially according to the time period.

[Use of the prokinetic domperidine in patients in the early postoperative period]

The work focuses on the comparison of influence of domperidone and metoclopramide on rehabilitation of motor-evacuation function of stomach and small intestine in 82 patients with post-surgical flatulent distention. For group 1 (n=50) - metoclopramide was administered intravenously from the 1st postoperative day, 10 mg 3 times a day. For group 2 (n=32) - domperidone was used from the 1st postoperative day (motilium suspension), 20 ml 4 times a day. The results of gastrointestinal tract capacity rehabilitation were evaluated using the data of peripheral electrogastroenterography, enteral balance, a complex of radial diagnostics methods. Application of domperidone in patients with post-surgical flatulent distention resulted in quicker gastrointestinal tract motor resolution.

Feasibility of xanthan gum-sodium alginate as a transdermal drug delivery system for domperidone

The present investigation comprises the formulation and in vitro evaluation of domperidone loaded transdermal drug delivery system (TDDS) for controlled release. The polymer membranes were prepared using xanthan gum (XG) and sodium alginate (SA) by varying the blends compositions viz., 10:0, 8:2, 6:4, 5:5, 4:6, 2:8, and 0:10 (XG/SA, wt/wt, %). The drug loaded membranes were evaluated for thickness, content uniformity, tensile behaviours, and in vitro drug release studies. Domperidone was found to be compatible with the prepared formulation as revealed by Fourier transform infrared (FTIR) spectroscopy studies. In vitro release studies were carried out in open glass diffusion cell for a period of 8 h and it showed controlled release of drug from the XG/SA matrix. The present study concludes that, the prepared transdermal films can be used to achieve controlled release of drug and improved bioavailability.

[Clinical observation on transcutaneous electrical acupoint stimulation for treatment of functional dyspepsia]

OBJECTIVE

To compare the therapeutic effects of transcutaneous electrical point stimulation and medication on functional dyspepsia.

METHODS

Two hundred and fifty cases were randomly divided into an observation group and a control group, 125 cases in each group. The observation group was treated with transcutaneous electrical acupoint stimulation and oral administration of placebo, transcutaneous electrical stimulated at Zusanli (ST 36), Liangmen (ST 21), Taichong (LR 3) etc. The control group was treated with oral administration of Mosapride citrate dispersible tablets, Domperidone and Omeprazole and the placebo treatment of transcutaneous electrical acupoint stimulation, the stimulated position was 3-4 cm to the selected points of the observation group, the amount of the stimulation did not reach the treatment amount. The symptom score, the plasma motilin (MTL) concentration and the somatostatin (SS) concentration were observed before and after treatment of 3 courses.

RESULTS

All symptom scores after treatment were lower than that before treatment in the two groups, the scores of the upper abdominal pain, acid regurgitation, belching and abdominal distention in the observation group were significantly lower than that in the control group (P < 0.05, P < 0.01); the treatments of both two groups can increase the plasma MTL concentration and decrease the SS concentration (both P < 0.001), and the plasma MTL concentration in the observation group was significantly higher than that in the control group (P < 0.01), and the SS concentration was significantly lower than that in the control group (P < 0.05).

CONCLUSION

Transcutaneous electrical point stimulation can more reduce the symptoms of upper abdominal pain, acid regurgitation, belching and abdominal distention, etc. in the functional dyspepsia patients than medication treatment, and can increase the concentration of the plasma MTL and decrease the SS concentration, thus to improve the gastrointestinal motility.

[How to raise efficacy of gastroesophageal reflux disease treatment]

AIM

To specify dysfunction of the stomach and duodenum in gastroesophageal reflux disease (GRD) to offer more effective pathogenetic pharmacotherapy of GRD.

MATERIAL AND METHODS

Fibroesophagogastroduodenoscopy with further assessment of esophageal mucosa condition by Savary-Miller, intragastric pH-metry, dynamic gastroscintigraphy and electrogastrography were made in 150 GRD patients.

RESULTS

GRD patients were found to have significant disturbances of a motor-evacuatory function of the gastroduodenal complex. Addition of domperidon and mebeverin to routine combined treatment of GRD raises clinical efficacy of GRD treatment and promotes recovery of gastric and duodenal function though therapeutic efficacy of the above drugs depended on concomitant pathology.

CONCLUSION

Domperidon and mebeverin addition to combined treatment of GRD makes this treatment more effective.

Population pharmacokinetics of domperidone in preterm neonates

PURPOSE

A population pharmacokinetic analysis was performed to define domperidone pharmacokinetic parameters in preterm neonates, as no pharmacokinetic data are available in this population.

METHODS

An oral domperidone solution was administered (0.75 mg/kg per day) in 32 preterm neonates (64 samples). Domperidone plasma concentration was measured by high-performance liquid chromatography (HPLC) assay, and a one-compartment model with first-order absorption was fitted to the data using NONMEM version V level 1.1.

RESULTS

The mean peak and trough plasma concentration values of domperidone were, respectively, 25.3 +/- 20.5 ng/ml and 15.4 +/- 11.4 ng/ml (mean +/- standard deviation). The pharmacokinetic parameters (interindividual variability%) were clearance (Cl/F) = 0.92 L/h (51.6%), volume of distribution (Vd/F) = 0.405 L (68%), and absorption constant rate (Ka) = 0.0843 h(-1) (55.8%). The clearance is not lower than values reported in adults. No influence of covariates (postnatal age, prematurity, weight, gender) on domperidone pharmacokinetic parameters was found.

CONCLUSION

This pilot study designed with a limited sampling strategy showed that domperidone plasma concentrations were consistent with those reported in adults, suggesting that domperidone dosage regimen currently used in preterm neonates is suitable.

Dose-effect study of domperidone as a galactagogue in preterm mothers with insufficient milk supply, and its transfer into milk

AIMS

To investigate the possibility of a dose-response relationship for the use of domperidone in treating insufficient milk supply in mothers of preterm infants, and to quantify the exposure of the breastfed infant to domperidone.

METHODS

Six preterm mothers received domperidone (30 mg daily or 60 mg daily) in a double-blind, randomized, crossover trial. Milk production and serum prolactin were measured before and during the trial, and domperidone concentration in milk was measured during drug treatment.

RESULTS

For milk production, two of the mothers were 'nonresponders', whereas the other four were 'responders' and showed a significant increase in milk production from 8.7 +/- 3.1 g h(-1) in the run-in phase (mean +/- SEM), 23.6 +/- 3.9 g h(-1) for the 30-mg dose (P = 0.0217) and 29.4 +/- 6.6 g h(-1) for the 60-mg dose (P = 0.0047). In all participants, serum prolactin was significantly increased for both doses, but the response was not dose dependent. Median (interquartile range) domperidone concentrations in milk over a dose interval at steady-state were 0.28 microg l(-1) (0.24-0.43) and 0.49 microg l(-1) (0.33-0.72) for the 30-mg and 60-mg doses, respectively. The mean relative infant dose was 0.012% at 30 mg daily and 0.009% at 60 mg daily.

CONCLUSION

In one-third of mothers, domperidone did not increase milk production. In the remainder, milk production increased at both domperidone doses, and there was a trend for a dose-response relationship. The amount of domperidone that transfers into milk was extremely low, and infant exposure via breastfeeding was not considered to be significant.

Bioeqivalence assessment of two domperidone 1 tablet formulations

A randomized, single-dose, crossover study was conducted to assess the bioavailability of two domperidone (CAS 57808-66-9) tablet formulations, Domperidone (test) and a commercially available original preparation (reference) under fasting conditions. A 10 mg dose of each formulation was administered to 36 healthy male volunteers with a one-week washout period, 17 blood samples were collected over 48 h, plasma concentrations of domperidone were analyzed by a locally validated LC-MS-MS assay, and the pharmacokinetic parameters were determined by the standard non-compartmental method. Mean +/- SD maximum concentration (C(max)), time to reach maximum concentration (T(max)), areas under the curve (AUC(0 --> t and AUC(0 --> infininty)), and elimination constant (K(el)) were 17.13 +/- 9.62 and 17.67 +/- 7.97 ng/ml, 0.87 +/- 0.58, and 0.89 +/- 0.33 h, 73.12 +/- 43.37 and 71.45 +/- 35.41 ng x h/ml, 90.32 +/- 48.55 and 87.08 +/- 40.29 ng x h/ml, and 0.069 +/- 0.046 and 0.068 +/- 0.048 h(-1) for the test and reference formulation, respectively. The parametric 90% confidence intervals on the mean difference between log-transformed values of the two formulations were within the acceptable bioequivalence range for AUC(0 --> t) (87.84% to 109.60%), AUC(0 --> infinity) (89.05% to 111.67%) and C(max) (83.28% to 107.50%). ANOVA revealed significant subject's effect for AU4C(0 --> t), AUC((0 -->infinity), C(max), and t1/2 with a ratio of the inter-subject to intra-subject coefficient of variation of 2.10, 1.55, 1.10, and 1.02, respectively. The results indicate that the two formulations are equivalent in relation to the extent and rate of absorption and confirm the previously reported marked intra-individual variations in the pharmacokinetics of domperidone.

Comparison of pramipexole with and without domperidone co-administration on alertness, autonomic, and endocrine functions in healthy volunteers

AIMS

To investigate the effects of the D2-receptor agonist pramipexole with and without the co-administration of the peripherally acting D2-receptor antagonist domperidone on measures of alertness, autonomic and endocrine function.

METHODS

Sixteen male volunteers participated in four weekly sessions of pramipexole 0.5 mg, domperidone 40 mg, their combination, and placebo administered according to a balanced, double-blind design. Alertness (visual analogue scales (VAS), critical flicker fusion frequency, pupillographic sleepiness test), autonomic (pupil diameter, light and darkness reflexes, blood pressure, heart rate, salivation, temperature) and endocrine (prolactin, thyroid-stimulating hormone (TSH), growth hormone (GH)) functions were assessed. Data were analyzed with anova with multiple comparisons.

RESULTS

The pre-post treatment changes in VAS alertness were reduced by pramipexole with and without domperidone (mean difference from placebo (95% confidence interval), mm): pramipexole -15.75 (-23.38, -8.13), combination -11.84 (-20.77, -2.91). Treatment condition significantly affected pupil diameter measured in different ways (resting pupil diameter (F(3,45) = 8.39, P < 0.001), initial diameter of the light reflex response (F(3,42) = 3.78, P < 0.05), and light (F(3,45) = 5.21, P < 0.005) and dark (F(3,45) = 3.36, P < 0.05) diameters of the darkness reflex response). Pramipexole without domperidone consistently increased pupil diameter on all measures (P < 0.05), whereas with domperidone only the increase in resting and dark diameters reached significance. Pramipexole reduced light reflex amplitude and increased latency, whereas the combination affected latency only. Concentrations of prolactin and TSH were increased by domperidone. Pramipexole reduced prolactin and increased GH concentrations.

CONCLUSIONS

The attenuation of the central pupillary effects of pramipexole by domperidone indicates that domperidone had access to some central D2-receptors.

Effects of pergolide on severe sleep bruxism in a patient experiencing oral implant failure

In the patient described in this study, oral implants failed as a probable consequence of severe, polysomnographically confirmed sleep bruxism. As this patient had the wish to be re-implanted after this failure, we decided to try diminishing the frequency of bruxism and duration first. To that end, two management strategies were used. Their efficacy was evaluated polysomnographically, yielding a total of six overnight recordings. Of the selected management strategies, the administration of low doses of the dopamine D1/D2 receptor agonist pergolide finally resulted in a substantial and lasting reduction in the bruxism outcome measures under study. This result supports the previous suggestion that central neurochemicals like dopamine may be involved in the modulation of sleep bruxism. The case report also illustrates the importance of an extensive history taking (questionnaires as well as oral) and clinical examination of oral implant patients for the presence of severe bruxism before the implant procedure is started. In case of doubt, polysomnography may be considered to definitively confirm or rule out the presence of severe sleep bruxism.

Bioequivalence study of a sustained release fixed dose combination capsule containing esomeprazole and domperidone in healthy subjects

OBJECTIVE

The study was designed to determine the relative bioavailability of two sustained release fixed dose combination (FDC) products of two manufacturers containing esomeprazole (CAS 326602-80-6) 40 mg and domperidone (CAS 57808-66-9) 30 mg in 24 healthy male volunteers. The pharmacokinetics of esomeprazole and domperidone individually after oral administration of tablet formulation has been extensively evaluated in adult volunteers. However, no published data are available regarding the combined pharmacokinetics and bioavailability of this particular FDC.

METHOD

The study was designed as a randomized, balanced, open-label, 2-period cross-over study. Each subject was randomized at the beginning of the study to receive either a single dose of the Test FDC or Reference FDC during Period I. Following a 7-day wash-out period, all subjects received the alternate formulation during Period II.

RESULTS

No statistically significant differences were obtained between the two products with respect to the mean concentration-time profiles or in the pharmacokinetic parameters, including area under the serum concentration-time curve from the present study. The relative extent of absorption as assessed by the AUC ratio (Test/Reference) and C(max), the average value was found to be 1.00 +/- .09 with 90% confidence limits (C.L.) of 0.82-1.18.

CONCLUSION

These findings clearly indicate that the two products are bioequivalent in terms of rate and extent of drug absorption. Both preparations were well tolerated with no adverse reactions throughout the study.

[Modern attitude towards management of laryngopharyngeal form of gastroesophageal reflux disease. Lithuanian clinical practice guidelines for adults]

The aim of this article is to introduce Lithuanian clinical practice guidelines for the management of laryngopharyngeal form of gastroesophageal reflux disease for standardization of the diagnosis and treatment of the disease and prevention of its complications. Composed guidelines provide recommendations for primary care physicians as well as otorhinolaryngologists and gastroenterologists for the management of adults with uncomplicated laryngopharyngeal form of gastroesophageal reflux disease. Committee composed of experts from Lithuanian Otorhinolaryngological and Gastroenterological Societies developed guidelines based on a comprehensive review of the evidence-based literature related to laryngopharyngeal form of gastroesophageal reflux disease and guidelines of other countries. The guidelines provide description of each medicine groups with emphasis on proton pump inhibitors as the most effective drugs for the treatment of laryngopharyngeal form of gastroesophageal reflux disease. Indications for empirical treatment with proton pump inhibitors are described, as well as duration of treatment, doses, optimal regimen of use, and assessment of treatment efficacy. The therapy should begin with the application of proton pump inhibitors twice daily, before meal for three months. Combined therapy for nonresponders is described. Algorithm for stopping the medication is recommended. These recommendations may provide an efficient and economical approach to the management of this problem.

Domperidone and sudden death

(1) Domperidone, a "hidden" neuroleptic, is widely used as an oral antiemetic yet its efficacy has not been adequately documented. (2) In a case-control study domperidone was associated with an estimated relative risk of sudden cardiac death of 3.8 (95% confidence interval 1.5-9.7). (3) QT interval prolongation has been reported in an infant on domperidone, with normalisation after domperidone withdrawal. Serious cardiac arrhythmias led to the market withdrawal of the intravenous form of domperidone in the 1980s. (4) In practice, these data represent an additional reason not to use domperidone, or other antiemetics, for mild and transient health problems. Special care is required when other risk factors for QT interval prolongation are present.

Influence of acid suppressants on gastric emptying: cross-over analysis in healthy volunteers

BACKGROUND

Gastric emptying plays an important role in gastroesophageal reflux disease. Acid suppressants such as H2 receptor antagonists and/or proton pump inhibitors are often used in patients with gastroesophageal reflux disease. However, it remains controversial whether H2 receptor antagonists and proton pump inhibitors delay or accelerate gastric emptying. Here, the influence of acid suppressants on gastric emptying was evaluated via a cross-over study using the [13C]-labeled acetate breath test.

METHODS

Twenty normal male subjects without gastroesophageal reflux disease symptoms were enrolled. Gastric emptying was investigated five times in every subject by the [13C]-labeled acetate breath test with oral administration of the vehicle, domperidone, and three acid suppressants: ranitidine, famotidine and rabeprazole. Gastric emptying was estimated by the values of T(max-calc), T(1/2) and %dose/2 h calculated from the 13CO2 breath excretion curve.

RESULTS

Using the T(max-calc) values, rabeprazole, ranitidine and famotidine did not influence gastric emptying time in comparison with vehicle administration. Using the T(1/2) and %dose/2 h values, rabeprazole tended to delay gastric emptying. Domperidone produced a statistically significant acceleration of gastric emptying for all three variables (P < 0.05).

CONCLUSION

Oral dosage of the H2 receptor antagonists, ranitidine and famotidine, has no significant effect on gastric emptying. However, rabeprazole may delay gastric emptying more strongly than H2 receptor antagonists.

Quantitative study of salivary secretion in Parkinson's disease

We examined basal and reflex salivary flow rate and composition in 46 patients with Parkinson's disease (PD), both in off and on conditions, compared to 13 age-matched controls without underlying disease or treatment affecting autonomic function. Whole saliva was collected 12 hours after withdrawal of dopaminergic drugs and at the peak of levodopa-induced motor improvement. Twenty-three of the 46 PD patients had received domperidone a week before the study. Basal salivary flow rate was significantly lower in PD patients in the off state compared to controls (P<0.005). Levodopa increased salivary flow rate (P<0.05) both in the domperidone-pretreated and untreated groups. Citric acid stimulated salivary flow rate in both the off and on states in PD patients. This effect was higher in the domperidone-pretreated patients. Salivary concentration of sodium, chloride, and amylase was higher in PD patients than in controls and was not affected by levodopa or domperidone treatment. Levodopa stimulates both basal and reflex salivary flow rate in PD. The mechanism appears to be central, as the effect is not blocked by domperidone. Domperidone may have a peripheral effect that potentiates reflex salivary secretion. Salivary composition is abnormal in PD and is not affected by levodopa treatment.

Antiemetics for children with gastroenteritis: off-label but still on in clinical practice

Antiemetics are not included for treatment of vomiting associated with acute gastroenteritis (AGE) in children by standard guidelines. We performed a survey to determine antiemetic prescribing rates by Italian pediatricians. A structured questionnaire was distributed at a pediatric national conference. The majority of responders reported prescribing antiemetics for pediatric gastroenteritis. Although there is insufficient evidence to justify their use, the use of antiemetics is widely present among pediatricians.

Helicobacter pylori eradication versus prokinetics in the treatment of functional dyspepsia: a randomized, double-blind study

BACKGROUND

This randomized, double-blind study compared the efficacy of Helicobacter pylori eradication against prokinetics in H. pylori-infected functional dyspepsia patients.

METHODS

Patients with moderately severe or severe dyspepsia fulfilling the Rome II criteria were randomized to either H. pylori eradication for 1 week and 6 weeks of placebo prokinetics or 6 weeks of prokinetics and placebo H. pylori eradication in the first week. Symptoms were assessed at baseline and at 6 and 12 months using the Glasgow Dyspepsia Severity Score (GDSS). Global response to treatment was assessed at 12 months.

RESULTS

Altogether 130 patients were enrolled (H. pylori eradication, 71; prokinetics, 59). The mean baseline GDSS was 9.3 for the H. pylori eradication group and 8.9 for the prokinetic group. At 6 months, the score was 3.6 and 4.1, respectively, and it remained at 3.5 and 3.8, respectively, at 12 months. With H. pylori eradication, 31.0% had complete symptom resolution (GDSS 0 or 1) at 12 months compared with 23.7% with prokinetics (a nonsignificant difference). At 12 months, global symptomatic improvement was seen in 62.0% of the H. pylori eradication group compared with 67.8% of the prokinetics group.

CONCLUSIONS

Both H. pylori eradication and prokinetic therapy resulted in symptom improvement in two-thirds of dyspeptic patients at 1 year. More patients tended to achieve complete symptom relief with H. pylori eradication.

Nursing the adopted infant

BACKGROUND

Breast feeding is commonly accepted as the preferred method of infant nutrition for various reasons, both nutritional and emotional. For some who have become parents by adoption, there is a strong desire to induce lactation for adoptive nursing.

METHODS

Information regarding adoptive nursing was initially obtained for the author's personal experience from searching the internet and speaking with other adoptive mothers. The medical literature was also searched through OVID/MEDLINE using pertinent terms, including induced lactation, adoptive nursing, domperidone, and metoclopramide.

RESULTS

Use of physiologic and pharmacologic methods can help an adoptive mother bring in a milk supply. The quantity may not be sufficient to entirely meet an infant's nutritional needs. However, for many the emotional benefits remain. There is some controversy surrounding the use of domperidone and metoclopramide for induced lactation. Herbals such as fenugreek have not been researched. Physicians can help their patients understand the current tools available to assist them with this unique endeavor.