Prokinetics

Prokinetics include the drugs, domperidone, metoclopramide and cisapride.

Mode of action

Prokinetics claim to restore gastric motility and to increase the tone in the LOS by enhancing acetylcholine release in the group of nerves that control upper GI motility. These actions are said to speed up gastric emptying and reduce reflux into the oesophagus.

Efficacy

Prokinetics are indicated for relief of symptoms associated with GORD, non-ulcer dyspepsia, symptomatic relief of delayed gastric emptying associated with diabetes and various neurological diseases, and for chronic or excessive regurgitation of food in infants. However, the clinical efficacy of domperidone and metoclopramide in treating GORD has not been confirmed.

Dosing

For GORD, the usual dosage is one tablet 3 or 4 times daily for 12 weeks.

Adverse effects

Side effects may include:

  • Abdominal cramps
  • Diarrhoea
  • Headache
  • Convulsions (rarely)
  • Serious cardiac arrhythmias including ventricular tachycardia, ventricular fibrillation and torsade de pointes (rarely).

Precautions

Prokinetic agents are contraindicated in pregnancy and in cases of GI obstruction or perforation. They should be used with caution in patients with renal or hepatic impairment, in the elderly and in nursing mothers. Interactions may occur with CNS depressant drugs, anticholinergics and oral anticoagulants.

Cisapride is metabolised by cytochrome P450 3A4 enzymes, therefore certain concomitant medications* that increase cisapride blood levels by inhibiting the enzyme should be avoided.

*These drugs include clarithromycin, erythromycin, troleandomycin, nefazodone, fluconazole, itraconazole, ketoconazole, indinavir, and ritonavir.

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