Double-blind, randomized, parallel-group study on the efficacy and safety of oral granisetron and oral ondansetron in the prophylaxis of nausea and vomiting in patients receiving hyperfractionated total body irradiation.

The efficacy and safety of granisetron and ondansetron for the prophylaxis of nausea and vomiting resulting from hyperfractionated total body irradiation (TBI) were assessed. Thirty-four patients randomly received double-blind, oral granisetron (2 mg, 1 h before first daily fraction of radiation) or ondansetron (8 mg, 1.5 h prior to each fraction of TBI). Ninety patients who received the same TBI regimen prior to bone marrow transplantation (BMT), but no 5-HT3-receptor antagonist, were identified and comprised the historical control group. By design, this study was only powered to show a difference between each of the active treatment groups and the historical control group. Significantly more patients given granisetron (33.3%) or ondansetron (26.7%) had zero emetic episodes over 4 days, the primary efficacy end point, than those in the historical control group (0%) (P < 0.01; intent-to-treat). Secondary efficacy end points were also evaluated. During the first 24 h, significantly more patients taking granisetron (61.1%) or ondansetron (46.7%) had zero emetic episodes than patients in the historical control group (6.7%) (P < 0.01). Complete emetic control (no emesis or rescue antiemetic) over 4 days was more frequent in patients taking granisetron (27.8%) or ondansetron (26.7%) compared with the historical control group (0%) (P < 0.01). Significantly fewer patients taking granisetron (18/18), but not those taking ondansetron (12/15), experienced more than five emetic episodes during the 4 days of the study compared with the historical control group (40/90; P < 0.01). Oral granisetron and ondansetron are safe and effective for the prevention of nausea and vomiting resulting from TBI.

Antiemetic efficacy of single-dose oral granisetron (1 mg vs 2 mg) with moderately emetogenic chemotherapy.

PURPOSE: To compare the efficacy of oral granisetron, 1 mg and 2 mg, administered as one dose in patients who receive moderately emetogenic chemotherapy. PATIENTS AND METHODS: Chemotherapy-naïve patients, scheduled to receive intravenous cyclophosphamide (500 to 1200 mg/m2) or carboplatin (> or = 300 mg/m2), were stratified by dexamethasone/methylprednisolone use (+ DEX, n = 92) or nonuse (- DEX, n = 5). Patients were randomized to one dose of either 1 mg (n = 48) or 2 mg (n = 49) of granisetron administered 60 minutes before chemotherapy. Known important prognostic variables (gender, age, alcohol) were well balanced between groups. RESULTS: Using the most rigorous criterion of total control (no emetic episodes, no nausea, no rescue therapy during the first 24 hours), response rates were 54.2% (26/48) and 57.1% (28/49) in patients receiving 1 mg and 2 mg of granisetron, respectively (95% confidence interval, -0.17, 0.23). Total control rates in patients who received 1 mg and 2 mg of granisetron + DEX were also comparable: 57.8% (26/45) and 55.3% (26/47), respectively. Response rates were similar for the parameters of nausea, emesis, and complete response (no emetic episodes, no more than mild nausea, no antiemetic rescue). Among all patients, one (2.1%) who received 1 mg of granisetron and three (6.1%) who received 2 mg experienced severe nausea. The proportions of 1- and 2-mg-treated patients who received rescue therapy within the first 24 hours were 31.3% (15/48) and 34.7% (17/49), respectively. Reported adverse experiences were generally mild in severity. DISCUSSION: The results of this trial demonstrate good control of emesis with a single 1-mg dose of oral granisetron, with efficacy that compares favorably with that of a 2-mg dose.

Linear pharmacokinetic behavior of ropinirole during multiple dosing in patients with Parkinson's disease.

The objectives of this study were to measure the pharmacokinetics of ropinirole at steady state when the drug is used as an adjunct to L-dopa and evaluate the long-term tolerability of ropinirole in this indication. Twenty-four patients who were taking L-dopa for Parkinson's disease and experiencing a lack of symptomatic control were recruited. Patients received open-label adjunctive treatment with ropinirole for up to 2 years. The starting dose was 0.5 mg bid, which could be titrated to a maximum of 6.0 mg tid. Ropinirole demonstrated approximately dose-linear pharmacokinetics at steady state; corresponding values were higher during tid than bid dosing. A reduction in mean L-dopa dose was maintained throughout the trial. The combination of L-dopa and ropinirole was generally well tolerated, with only 1 patient withdrawing from treatment because of adverse events. Thus, ropinirole shows approximately linear steady-state pharmacokinetics and a good safety profile when administered with L-dopa.

Oral granisetron for the prevention of acute late onset nausea and vomiting in patients treated with moderately emetogenic chemotherapy.

PURPOSE: To demonstrate the efficacy of oral granisetron 1 mg twice daily for the prevention of late onset nausea and vomiting after moderately emetogenic chemotherapy that includes cyclophosphamide, carboplatin, or doxorubicin. METHODS: Prior to chemotherapy, patients were stratified by gender and randomized to receive oral granisetron (1 mg tablet twice daily) or prochlorperazine (10 mg sustained release capsule twice daily). Study agents were administered 1 h prior to and 12 h after chemotherapy. Antiemetics were administered for seven consecutive days. Efficacy variables were assessed 48 and 72 h after administration of chemotherapy, and included no emesis, no nausea, no moderate or severe nausea, and no antiemetic rescue. Safety analysis included all patients who received medication. RESULTS: A total of 230 patients were included in the intent-to-treat analysis; 119 patients received granisetron and 111 patients received prochlorperazine. Females, and all patients combined, who received granisetron had significantly higher no-emesis rates at 48 h (p =.010 and p =.016, respectively) than patients who received prochlorperazine. No-nausea rates at 48 h were numerically higher for all patients combined and females who received granisetron rather than prochlorperazine. Response rates for no nausea or mild nausea were also numerically higher in females treated with granisetron, compared to prochlorperazine, at 48 h. Significantly more patients (p <.001) and females (p <.001) in the granisetron group than in the prochlorperazine group did not require rescue antiemetics at 48 h. At 72 h, efficacy results were comparable for granisetron and prochlorperazine. CONCLUSION: Oral granisetron is well tolerated and more effective than prochlorperazine in preventing nausea and vomiting for up to 48 h following treatment with moderately emetogenic chemotherapy.

Famotidine increases plasma alcohol concentration in healthy subjects.

The effect of famotidine on plasma alcohol concentration was studied in 24 healthy male subjects who demonstrated high apparent ethanol first-pass metabolism after oral (p.o.) and intravenous (i.v.) ethanol administration (i.e. AUC(po) < or = 40% of AUC(i.v.), where AUC is area under the plasma ethanol concentration-time curve). Six of the original 30 subjects screened (20%) did not demonstrate high first-pass metabolism and were excluded. In a randomized open crossover study, oral ethanol pharmacokinetics were assessed after breakfast in the morning following a 3-day regimen of famotidine, 40 mg/day, and following a no-drug control period. Famotidine increased the area under the plasma ethanol concentration-time curve (AUC0-t) by 29% (7.1 vs 5.5 mg.h/dL, P = 0.006) and maximal plasma concentration (Cmax) by 23% (9.2 vs 7.5 mg/dL, P = 0.013). The changes in ethanol AUC0-t and Cmax may have been associated with changes in gastric emptying, as they were inversely correlated with changes in the time at which maximal plasma concentration was attained. There was considerable intra-individual variation in ethanol AUC and Cmax. As a result, regression to the mean is a potentially confounding problem in ethanol pharmacokinetic studies when subjects are selected on the basis of having low AUC(po), and properly controlled randomized studies of substantial size are required to detect modest drug effects. Small effects on ethanol pharmacokinetics have now been demonstrated with all four of the major H2-receptor antagonists, but these effects are seen only under specific experimental conditions and appear to be unimportant clinically.

Safety and immunogenicity of a recombinant protein influenza A vaccine in adult human volunteers and protective efficacy against wild-type H1N1 virus challenge.

A recombinant influenza A vaccine (D protein), comprising a carboxy-terminal sequence from the hemagglutinin HA2 subunit of A/Puerto Rico/8/34 virus (H1N1, A/PR/34) fused to 81 amino-terminal residues of the NS1 nonstructural protein, has previously protected mice against influenza A challenge by inducing H1N1/H2N2 cross-reactive cytotoxic T cells (CTL) without hemagglutination-inhibiting (HI) or neutralizing antibody. In our dose-escalating study, the vaccine was safe in humans and induced both IgG and T cell proliferative responses to D protein but little antibody to A/PR/34 or A/Kawasaki/8/86 (H1N1, A/KW/86) viruses. Among an additional group of A/KW/86-seronegative volunteers immunized with 500 micrograms of D protein, none had a rise in serum HI or neutralizing antibody to A/KW/86, 20% had minimal IgG responses to A/KW/86 by EIA, and a minority had any increase in A/KW/86-specific CTL activity. However, viral shedding and clinical illness score were reduced in vaccines relative to A/KW/86-seronegative unimmunized controls after intranasal challenge with wild-type A/KW/86. D protein immunization conferred significant protective immunity not currently explained by any of the immune parameters measured.

Assessment of an implantable ileostomy sphincter.

A totally implanted, intermittently inflatable, silicone rubber cuff, reservoir, and control mechanism were evaluated for use as an artificial sphincter in 18 female beagle dogs that had undergone ileostomy. The dogs were divided into daily 8-hour occlusion, test, and always open, control, groups. Animals were evaluated daily for continence and peristomal irritation. Quantitative aerobic and anaerobic cultures, measurements of ileal accommodation, net fluxes of H2O, Na, K, and taurocholate, fecal fat loss, and urinary excretion of oral 58Co X B12 plus mucosal suction biopsies were done at 4, 12, 24, and 36 weeks. Eight hours of daily occlusion caused dependable continence without causing damage to the underlying or upstream mucosa and significantly reduced the incidence of peristomal erosion (6.8 +/- 0.8 days/dog-days X 100 versus 50.7 +/- 7 days/dog-days X 100 [+/- SEM] [p less than 0.001]). Occlusion also promoted anaerobic bacterial growth (9.00 +/- 0.41 logs versus 6.70 +/- 0.58 logs [p less than 0.001]). Test animals showed significant capacitance accommodation of the terminal ileum without incurring defects in ileal absorptive or secretory function. Gangrenous herniation of small bowel through an aperture formed by an intestinal loop adhering to the capsule surrounding the cuff, device failure, and fibrotic obstruction occurred sporadically as late as 29 weeks after implantation. The artifical sphincter was effective and was physiologically well tolerated, but its specific liabilities require further address.

Immunoperoxidase staining for CEA in ulcerative colitis.

Immunoperoxidase staining allows detection of small amounts of antigens in tissues, and can be applied to formalin-fixed, paraffin-embedded specimens several years old. We utilized this technique to stain for carcinoembryonic antigen (CEA) in 11 specimens of colon from 10 patients with ulcerative colitis. We compared the degree of epithelial abnormality in these mucosal specimens with the extent of immunoperoxidase staining for CEA. CEA staining was also compared with the duration of colitis, extent of colonic involvement, the indication for colectomy, and the medical therapy before colectomy. We found that neither cytoplasmic nor cell surface CEA staining correlated with the degree of epithelial alteration. Similarly, CEA staining did not correlate with any of the clinical parameters evaluated. We conclude that immunoperoxidase staining for CEA is not useful in assessing the degree of dysplasia in mucosal specimens from patients with ulcerative colitis. There seems to be no clinically relevant role for anti-CEA staining in ulcerative colitis.

A solitary juvenile polyp with hyperplastic and adenomatous glands.

This report describes a 21-year-old man with chronic rectal bleeding, who was found to have a solitary juvenile polyp containing hyperplastic and adenomatous glands. This admixture of glandular elements has not been clearly recognized previously. The significance of this finding is uncertain at this time. Since adenomatous polyps are considered premalignant lesions, and juvenile polyps have been associated with colon cancer, we recommend that juvenile polyps with adenomatous glands also be regarded as premalignant lesions.

Prophylaxis of upper gastrointestinal hemorrhage in patients requiring mechanical ventilation.

Because approximately 20% of patients receiving mechanical ventilation have upper gastrointestinal bleeding, these patients were prophylatically treated with either antacids, cimetidine, or a placebo in a double-blind randomized fashion. The authors did not titrate gastric acidity because it is a time-consuming process that requires a nasogastric tube. When gastrointestinal bleeding developed in 9 of the 36 patients entered in the study, the treatment code was broken to assess the efficacy of prophylaxis and the frequency of complications. In the antacid group, 5 of the 11 patients were unable to ingest and tolerate their antacids (p less than 0.05 when compared to the control and cimetidine groups). Gastrointestinal bleeding did not occur in any of the six subjects receiving antacids but did occur in one of the 11 subjects receiving cimetidine, in 5 of the 14 control patients, and in 3 of the 5 patients who were unable to tolerate antacids. These differences were not significant. When groups were rearranged, though, there was a significant difference between them. Only 1 of 17 patients receiving medication (antacids or cimetidine) bled, whereas 8 of 19 patients receiving no medications bled (p less than 0.01). The average number of risk factors was not significantly different in the treatment groups. The authors conclude that prophylactic therapy (cimetidine or antacids) given without titration is associated with a lower frequency of upper gastrointestinal hemorrhage than when no medication is given. The authors also conclude that more subjects are able to tolerate cimetidine than antacids.

Crohn's disease associated with Takayasu's arteritis.

In a young woman with Takayasu's arteritis, standard roentgenographic studies suggested a diagnosis of Crohn's ileocolitis. Mesenteric angiography was performed and revealed specific abnormalities diagnostic of Crohn's disease, namely, the zoning sign in the cecum with a hypervascular inner layer and a hypovascular outer layer, and paraintestinal inflammatory neovasculature adjacent to the ascending colon. In addition, several helpful but nonspecific findings were demonstrated, and these features are reviewed. This patient represents another example of large vessel lesions associated with inflammatory bowel disease.