Randomized controlled treatment trial of irritable bowel syndrome with a probiotic E.-coli preparation (DSM17252) compared to placebo.

BACKGROUND: Therapy trials with bacterial compounds in irritable bowel syndrome (IBS) have produced conflicting results and, so far, an E.-coli preparation has not been used. METHODS: Two hundred and ninety-eight patients with lower abdominal symptoms diagnosed as IBS were treated for 8 weeks by the compound Symbioflor-2 (Symbiopharm GmbH, Herborn, Germany), an Escherichia coli product (N = 148), or placebo (n = 150) in a double-blinded, randomized fashion. Patients were seen weekly by the physician, who assessed the presence of core IBS symptoms. Both an abdominal pain score (APS) as well as a general symptom score (GSS) were used as primary endpoints. Responders had to have complete absence of IBS core symptoms at > or = 1 visit during treatment. RESULTS: The responder rate in GSS to the drug was 27 / 148 (18.2 %) in comparison to placebo with 7 / 150 (4.67 %) (p = 0.000397). The improvement in APS was 28 / 148 (18.9 %) and 10 / 150 (6.67 %) for placebo (p = 0.001649). The response was reached from visit 3 onwards with both medication and placebo. Post-hoc analysis revealed no significant differences in efficacy of the drug between the gender and different age groups. CONCLUSION: Treatment of IBS with the probiotic Symbioflor-2 is effective and superior to placebo in reducing typical symptoms of IBS patients seen by general practitioners and by gastroenterologists.

A mixture of Escherichia coli (DSM 17252) and Enterococcus faecalis (DSM 16440) for treatment of the irritable bowel syndrome--a randomized controlled trial with primary care physicians.

Therapy trials with bacterial compounds in irritable bowel syndrome (IBS) have produced conflicting results. This study was performed in 1988 and 1989, and was re-analysed according to current IBS standards. Two hundred ninety-seven patients with lower abdominal symptoms diagnosed as IBS were treated for 8 weeks by the compound ProSymbioflor((R)) (Symbiopharm GmbH, Herborn, Germany), an autolysate of cells and cell fragments of Enterococcus faecalis and Escherichia coli, or placebo in a double-blinded, randomized fashion. Patients were seen weekly by the physician, who assessed the presence of core IBS symptoms. Responders had at least a 50% decrease in global symptom score (GSS) and in abdominal pain score (APS) reports at >/=1 visit during treatment. The responder rate in GSS to the drug was 102/149 (68.5%) in comparison to placebo with 56/148 (37.8%) (P < 0.001), the improvement in APS was 108/149 (72.5%) and 66/148 (44.6%) respectively (P = 0.001). The number-needed-to-treat was 3.27 for GSS and 3.59 for the APS report. Kaplan-Meier analysis revealed a mean response time of 4-5 weeks for active treatment and more than 8 weeks for placebo (P < 0.0001). Treatment of IBS with the bacterial lysate ProSymbioflor is effective and superior to placebo in reducing typical symptoms of IBS patients seen by general practitioners.

[Absolute bioavailability of folic acid after oral administration of a folic acid tablet formulation in healthy volunteers]. / Absolute Bioverfügbarkeit von Folsäure nach einmaliger oraler Gabe einer Folsäure-Tablettenzubereitung an gesunde Versuchspersonen.

5 mg folic acid were administered in two sessions to 9 female and 8 male healthy subjects within a balanced 2-way crossover trial either as one Folsan tablet (CAS 59-30-3, test preparation A) or as 2.5 ml of an injection solution (Folsan 2, reference preparation B). Folic acid was determined in serum and urine collected in fractions over 12 h after administration by means of a radioassay. Before each session a saturation period of 9 days duration was performed by administering 1 tablet per day containing 5 mg folic acid followed by a 4-day wash-out period. The mean predose serum level of folic acid amounted to 17.9 +/- 5.62 ng/ml before the oral and 18.2 +/- 5.73 ng/ml before the intravenous administration. The post dose serum levels were corrected with the individual predose levels. After oral administration of test preparation. A a mean peak serum concentration of 243 +/- 33.0 ng/ml (Cmax) was obtained after 2.24 +/- 0.85 h (tmax). The mean area under the corrected serum level time curve was determined with 1160 +/- 177 ng x h/ml (AUC(0-12)). 6 min after intravenous administration serum levels ranged from 559 to 1490 ng/ml. Following correction with the individual predose levels the mean area under the curve amounted to 1550 +/- 249 ng x h/ml. The individual bioavailability ratios of AUC(0-12) (A versus B) varied between 49.3% and 96.7%. The mean absolute bioavailability of folic acid was 76.2% +/- 13.8% (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Pharmacokinetics and relative bioavailability of iron and folic acid in healthy volunteers]. / Pharmakokinetik und relative Bioverfügbarkeit von Eisen und Folsäure bei gesunden Versuchspersonen.

The pharmacokinetics and the relative bioavailability of iron and of folic acid was investigated in a randomized, balanced 2-way cross-over study with 14 healthy male participants. The drugs were given in a combined preparation dragée (Ferro-Folsan) containing 100 mg of ferrous-II-sulfate x 1.5 H2O (CAS 13463-43-9) and 0.85 mg of folic acid (CAS 59-30-3). Other established preparations were used as reference drugs. All subjects had a normal iron body level and were brought to a saturated folic acid level prior to the investigation. After administration of 2 dragées of the test medication and determination of serum iron level until 9 h p.a., a relative bioavailability of 64%, compared to an equal dose of a ferrous-II-sulfate-ascorbic acid reference solution, was calculated. From the serum folate AUC (0-9 h) the relative bioavailability was evaluated with 97% for the oral formulation compared to the i.m. administration. The ratio of the cumulative renal folate excretion in the 0-9 h interval amounted to 76% for the oral compared to the i.m. administration. However, in order to understand this differing result it should be kept in mind that during the first hours following parenteral administration a greater amount of the unchanged compound is renally excreted than after oral dosing. This is presumably based upon the different rate of absorption following both administrations with a steeper absorption phase following the parenteral dose.

Tolerance and cerebrospinal fluid pharmacokinetics of intrathecally administered human natural interleukin-2: a phase I trial.

Recombinant interleukin-2 (rIL-2) is at present widely applied in the immunotherapy of various advanced cancers. As a number of side effects following the administration of rIL-2, either alone or in combination with lymphokine-activated killer (LAK-) cells, have been reported, a preparation of human leukocyte-derived and fully glycosylated interleukin-2 was used in the present study. We have recently demonstrated in cats that this natural IL-2 (nIL-2) is well tolerated and that the distribution and elimination half-lifes following intrathecal (i.th.) application are considerably longer than those after intravenous (i.v.) injection. To determine whether these long half-lifes and the good tolerance of i.th. given nIL-2 are also found in man, four patients with meningeosis neoplastica received repeated injections of human nIL-2 i.th.. Cerebrospinal fluid samples were drawn at different time intervals from either the lateral ventricle or lumbar subarachnoid space. The doses of nIL-2 ranged from 2 x 10(4) to 4 x 10(5) IU per injection. Only minor side effects were noted in one patient. The half-lifes for distribution and elimination of i.th. given nIL-2 ranged between 0.5-1.7 hours and 4.9-14.4 hours respectively. A linear relationship exists between the i.th. dose of nIL-2 and the area under the cerebrospinal fluid activity time profile curve.

[Bioavailability of folic acid following intramuscular and intravenous administration to healthy volunteers]. / Bioverfügbarkeit von Folsäure nach intramuskulärer und intervenöser Gabe an gesunde Versuchspersonen.

Bioavailability of Folic Acid Following Intramuscular and Intravenous Administration to Healthy Volunteers 2 mg folic acid (Folsan 2, CAS 59-30-3) were either i.m. or i.v. administered as injection solution to 15 male healthy subjects within an open balanced two-way crossover study. The concentration-time profile of folic acid was determined up to 12 h p.a. in serum and urine using a radioassay. Each change-over phase included a 9 days lasting saturation phase with once-per-day oral administration of a tablet containing 5 mg folic acid. Saturation was performed in order to guarantee filled-up endogenous folate storage compartments in the body of the subjects. After a four-day wash-out phase the subjects were confined and the basic serum level and basic renal 0-12 h folate excretion determined. On the following morning the respective dose of 2 mg folic acid was either i.m. or i.v. applied to the subjects (treatment day 14). 11 (i.m.) and 15 (i.v.) venous blood specimens were drawn up to 12 h p.a. and urine collected following the same schedule as the day before in 4 different fractions. The mean predose level of folic acid in serum was 13.2 +/- 4.85 ng/ml before the i.m. administration and 13.3 +/- 5.59 ng/ml before i.v. administration. The serum concentration data following the respective single administrations were corrected by subtraction of the individual predose values. After 0.50 +/- 0.19 h (mean tmax) the folate serum level increased by 101 +/- 27.2 ng/ml after the i.m. dose. Serum concentration decreased in the following 6-8 h approximately to the predose values.(ABSTRACT TRUNCATED AT 250 WORDS)

Interleukin-2 and blood brain barrier in cats: pharmacokinetics and tolerance following intrathecal and intravenous administration.

Single bolus doses of glycosylated human interleukin-2 (n IL-2) in the range of 2.8 x 10(3) to 2.0 x 10(6) IU/kg were administered to anesthesized cats via the cephalic vein (n = 10) or using suboccipital puncture (n = 8). CSF (cerebrospinal fluid) and blood samples were collected by repeated puncture. The n IL-2 concentration in four cats was determined on the basis of its biologic activity using 3H-thymidine incorporation into human ConA-blasts and by radioimmunoassay. In additional experiments radioactivity was determined in cerebrospinal fluid and serum after intravenous and intrathecal (i.th.) application of 5.8 x 10(3) - 3.2 x 10(3) IU/kg of 14C-acetyl-n IL-2 in regular time intervals. CSF and serum concentration time-profiles show a biexponential decline in the plasma elimination phase with half-lives of 4 min (alpha-phase) and 90 min (beta-phase) after intravenous and 20-120 min (alpha-phase) and 2-16 hours (beta-phase) after intrathecal application. There is a trend towards longer terminal elimination half-lives with increasing doses. Interleukin-2 is able to penetrate the blood brain barrier from the circulation into the cerebrospinal fluid and vice versa. Due to a slow rate of penetration and rapid elimination from blood only traces of n IL-2 (2-8 IU/ml) are detected in CSF after i.v. injection of 2 x 10(6) IU/kg, whereas concentrations between 400 and 1600 IU/ml are maintained in CSF for several hours following i.th. administration of 2-10 x 10(5) IU/kg.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of the analgesic o-carbamoylphenoxyacetic acid.

The pharmacokinetics of o-carbamoylphenoxyacetic acid was studied in 9 male healthy subjects following a single i.m. administration of 1000 mg of this compound in form of its sodium salt. Venous blood specimens were drawn up to the 10th h p.a. and the plasma concentration of o-carbamoylphenoxyacetic acid and its metabolite salicylamide were determined using a specific HPLC-assay. Following injection, o-carbamoylphenoxyacetic acid was rapidly distributed in the body since the maximal plasma concentration occurred within 0.37 +/- 0.08 h and was determined with 23.5 +/- 7.51 micrograms/ml in mean. In the following, the plasma concentration declined rapidly as well according to the mean terminal elimination half-life of 0.93 +/- 0.23 h. By contrast, plasma concentration of the metabolite salicylamide was comparatively low. Mean maximal plasma concentration amounted to only 0.18 +/- 0.03 microgram/ml and the peak concentration occurred 1.08 +/- 0.43 h after injection. The mean of the individual areas under the plasma concentration time profiles AUC(O-t) was 30.2 +/- 3.96 micrograms x h/ml for the parent compound and 0.69 +/- 0.14 microgram x h/ml for the metabolite. The relative mass portion of salicylamide vs o-carbamoylphenoxyacetic acid in systemic circulation was estimated with 0.008 comparing mean Cmax and with 0.023 comparing the mean areas AUC(O-t). A possible interpretation of these findings might be that a relatively stable ether bond exists in o-carbamoylphenoxyacetic acid which has to be cleaved during the formation of salicylamide. Due to the moderate rate of metabolic conversion, only minor quantities of salicylamide appeared in the systemic circulation. Furthermore, its peak concentration occurred at a time 2-3 times later than that of the parent compound.

Autopsy diagnosis versus clinical diagnosis, particularly in malignant disease. Comparison of two periods: 1961-70 and 1978-87.

We present a comparison of autopsy records in the Institute of Pathology of Münster University during 1961-70 with those from 1978-87. The study was based on 11,716 autopsy cases in which reliable documentation of clinical diagnosis could be adequately correlated and compared with the respective autopsy diagnoses. In the decade 1961-70, 34% of the clinical diagnoses were correct, 15% were nearly correct and 23%, incorrect (24% had to be supplemented without relevance to therapy or prognosis, 4% side diagnoses). In the decade 1978-87, 50% of the clinical diagnoses were correct, 15% nearly correct and 18% incorrect (17% supplemented). With respect to malignant tumours, in 1961-70 clinical diagnoses were correct in 37% of cases and incorrect for 26%; in 1978-87, 47% were correct and 15% incorrect. This comparison covered all major tumour locations. The difference in incorrect clinical diagnoses between the two periods is statistically significant. With respect to infectious diseases, the concordance between clinical and autopsy diagnoses is even poorer. Lues (syphilis) is now rarely recognized in clinical diagnoses, even though it may be fatal; 50% of tuberculosis patients die from miliary tuberculosis without a correct diagnosis. Endocarditis in all its forms was underdiagnosed clinically in 75% of cases. These data provide substantial arguments in favour of autopsy control of clinical diagnosis, also including histological findings in biopsy specimens.

Concentrations of isosorbide dinitrate, isosorbide-2-mononitrate and isosorbide-5-mononitrate in human vascular and muscle tissue under steady-state conditions.

The concentrations of isosorbide dinitrate (ISDN), isosorbide-5-mononitrate (IS-5-MN) and isosorbide-2-mononitrate (IS-2-MN) were determined in plasma (PL), saphenous vein wall (SV) and pectoral muscle (PM) from 8 patients undergoing coronary bypass surgery. The patients were pretreated for 2 days with ISDN 240 mg per day (standard release formulation) in 4 doses of 40 mg and one dose of 80 mg. The plasma and tissue samples were obtained during the operation, 10-12 h after the last dose. Isosorbide-2-mononitrate and isosorbide-5-mononitrate were present in plasma and tissues in the same concentration ranges with molar concentration ratios of 0.88 (IS-2-MN: PM/PL), 0.85 (IS-5-MN: PM/PL), 0.99 (IS-2-MN: SV/PL) and 1.06 (IS-5-MN: SV/PL). Mean ISDN concentrations in tissue were considerably higher than in plasma; the molar concentration ratios were 4.9 (SM/PL) and 7.21 (SV/PL). The accumulation of ISDN in vessel walls may contribute to its greater vascular action compared to the mononitrates, but it may also facilitate the development of tolerance during long-term treatment.

Kinetics of drug binding to human serum albumin: allosteric and competitive inhibition at the benzodiazepine binding site by free fatty acids of various chain lengths.

The inhibition of dansylsarcosine (DS) binding at the benzodiazepine binding site of human serum albumin has been studied in the presence of saturated and unsaturated free fatty acids (FFA) of various chain lengths (C6-C20, C18:1, C18:2). In order to determine the mechanism of displacement, velocity constants for association (k2) and dissociation (k-2) and binding constants (KA and KA') have been measured using the stopped-flow method. The inhibitory effect of FFA on DS binding kinetics at site II is dependent of their structure. With increasing amounts of FFA the association velocity constant of DS binding decreases from 520 s-1 (fatty acid free albumin) by a factor of 3-10 and affinity decreases according to FFA chain length. Inhibition is strongest in the presence of caprylic, capric and lauric acid (C8-C12) i.e. with more than one mole FFA per mole albumin, DS association could no longer be measured. Short chain caproic and the long chain FFA C14-C20 showed only a less inhibitory effect since in the presence of a twofold excess k2 ranged between 100 and 200 s-1. Dissociation velocity of DS from the benzodiazepine binding site could be measured in relationship to FFA chain length using ibuprofene, another drug binding at site II. Dissociation velocity constants k-2 remained constant up to 2 moles FFA per mole albumin (k-2 = 16-18 s-1). A rise in k-2 to 70 s(-1) was seen, however, when 2-4 moles capric, lauric, myristic and palmitic (C10-C16) acid were bound, whereas no change was observed when increasing concentrations of caproic, caprylic, stearic and arachic acid.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug input rate from the GI-tract. Michaelis-Menten kinetics and the bioavailability of slow release verapamil and nifedipine.

We present evidence, from studies with slow release verapamil and nifedipine, for Michaelis-Menten metabolism during first pass through the liver. Drug input rate from the GI-tract after an oral dose appears to be a determinant of bioavailability. Highest oral bioavailabilities are observed with standard release formulations at high dosage. The bioavailability of slow release formulations with a zero order release kinetic is lower than standard release formulations and related to the dissolution rate in vitro. In addition, (a) the presence of non-linear absorption kinetics offers a further explanation for the considerable inter-patient variability in AUC since the ability of drug to cross the liver is a function of the concentrations attained in portal blood which will be dependent on dissolution conditions prevailing in the GI-tract, (b) depending on the choice of the dose and dosage interval of the conventional release formulation used for comparison and as a consequence of Michaelis-Menten first pass metabolism it is possible to obtain relative bioavailability data showing superiority, equivalence or bioavailability loss with the slow release form. This may explain the discrepancies in bioavailability data for slow release drugs reported in the literature, (c) 'true' estimates of relative bioavailability of a slow release formulation can only be achieved if steady state conditions are present, and the dose and dosage interval of the slow and conventional release formulation are the same, (d) since a slower dissolution rate is 'ipso facto' associated with a lower bioavailability, slow release formulations of verapamil and nifedipine cannot be classified as being 'inferior' or of poorer quality on the basis of bioavailability alone.

[A model study of bioequivalence of dissolved nifedipine from soft gelatin capsules]. / Eine Modelluntersuchung zur Bioäquivalenz von gelöstem Nifedipin aus Weichgelatinekapseln.

Oral absorption of nifedipine determined from plasma concentrations was studied in 20 healthy subjects aged 19 to 40 years following application of a single soft gelatin capsule as a generic preparation (P) and a reference preparation (R) containing 10 mg nifedipine. Nifedipine was measurable in plasma 15 min after application and maximal concentrations occurred after 0.44 and 0.64 h (mean), respectively. Maximal concentrations Cmax varied between 46.4 and 251.0 ng/ml (median 100.7, mean 112.6) after P and between 35.5 and 279.7 ng.h/ml (median 115.8, mean 125.2) after R. Mean areas under the curves (AUC0-infinity) were 173.6 (median 151.4 P) and 188.6 ng.h/ml (median 163.1, R). The minor differences in the AUC values and Cmax values were not statistically significant. The shorter tmax after the generic preparation (p less than 0.05) is clinically unimportant. Since the bioavailability of P is 97% the two preparations are bioequivalent.

[Postprandial delay of drug absorption in a gitoformate model]. / Postprandiale Resorptionsverzögerung von Pharmaka am Modell des Gitoformat.

Oral absorption of gitoformate (Dynocard), a non-renal-dependent cardiac glycoside, was investigated in 8 healthy subjects aged 23-45 years. Plasma concentration-time profiles were obtained once following a 12-h period of fasting, then after intake of a standard high protein meal. The half-life of absorption t1/2a, Cmax and tmax, half-life of elimination t1/2z, and area under the curve (AUC) were compared to evaluate the influence on the bioavailability of gitoformate. t1/2a in the fasting condition (0.36 +/- 0.43 h) is increased when gitoformate is applied after a high protein meal 1.12 +/- 1.12 h). Correspondingly, fasting maximum concentrations are already achieved after 1.4 +/- 1.2 h, but only after 4.8 +/- 1.8 h following the intake of a standard meal. Comparison of AUC (0-168 h) showed that the bioavailability was reduced by 25% after meals.

[Concentration-time profile of isosorbide dinitrate and its metabolites in plasma following percutaneous resorption of a transdermal therapeutic system]. / Konzentrations-Zeit-Profil von Isosorbiddinitrat und seinen Metaboliten im Plasma nach perkutaner Resorption aus einem transdermalen therapeutischen System.

Percutaneous absorption of isosorbide dinitrate (ISDN), determined from plasma concentrations of ISDN and its metabolites isosorbide 2-mononitrate (IS-2-MN) and isosorbide 5-mononitrate (IS-5-MN), was studied in 8 healthy subjects aged 19 to 25 years following application of a single plaster containing 40 mg ISDN to the hairless skin on the left side of the chest for 72 h. ISDN and mononitrates were measurable in plasma 2 h after application and maximal concentrations for ISDN and mononitrates occurred after 12-16 h and 16 h, respectively. Mean areas under the curves values corrected for the body surface (BS) (AUC0-72 h.BS of 1074, 815 and 3584 nmol.m2.h/l for ISDN, IS-2-MN and IS-5-MN are equivalent to area ratios of 1, 0.8 and 3.3. ISDN metabolism following transdermal application is less extensive than after oral application. The molar nitrate concentration including metabolites, however, is comparatively low reaching approximately 60-80 nmol/l.

[Bioequivalence of generic drugs and substitution: example of depot verapamil]. / Bioäquivalenz von Generika und Substitution: Beispiel retardiertes Verapamil.

Following oral administration of 240 mg Verapamil-HCl as Isoptin RR, Veramex SR 240 and durasoptin SR 240, plasma concentration time curves of Verapamil and ECG changes were determined in 14 healthy subjects. There was a linear correlation between maximal plasma concentration and prolongation of PQ-intervals of the ECG. No hysteresis was observed when the changes in PQ-interval were plotted against plasma concentration. Comparison of concentration and effect profiles showed that the three formulations were not equivalent and a change in therapy from one to the other cannot be recommended.

[Bioavailability of delayed-action and non-delayed-action preparations of isosorbide-5-nitrate]. / Bioverfügbarkeit von retardierten und nicht-retardierten Isosorbid-5-nitrat-Präparaten.

In a randomized crossover study on twelve healthy test subjects, the plasma concentration of isosorbide-5-nitrate (IS-5-N) after oral administration of 40 mg IS-5-N daily from two standard preparations (two tablets Ismo 20 or Corangin 20) and two sustained release preparations with 40 mg or 60 mg IS-5-N (one tablet Corangin 40 or Corangin 60) once a day was determined. The concentrations were measured in the first and in the third dose interval (24 hours). The respective pharmacokinetic parameters (AUC, Cmax and tmax) of the first and the third day only differed slightly. The two standard formulations proved to be bioequivalent. With the two sustained release preparations, maximum plasma concentrations attained after five to six hours were measured which were lower by roughly the factor 2. The sustained release preparations showed a low loss of bioavailability of 13-19% as compared to the nonretarded standard formulations.