Domperidone

There are few data on the efficacy of domperidone as a prokinetic agent in critical care patients. Cisapride

Cisapride stimulates gastrointestinal motility, from the lower esophagus to the colon, by increasing acetylcholine release in the myenteric plexus. This leads to faster gastric emptying and reduced gut transit time.

Pharmacokinetics

There is no parenteral preparation of cisapride, but it can be administered rectally or as a nasogastric suspension. It is absorbed quickly and is highly plasma protein bound. There is high first-pass hepatic metabolism with about half the metabolites excreted by the kidney. The elimination half-life is about 10 h and may be prolonged in renal or hepatic impairment.

Adverse effects and drug interactions

The most likely adverse effects are those related to increased gastrointestinal motility such as abdominal cramps and diarrhea; consequently cisapride is contraindicated in patients with mechanical obstruction or bowel perforation. Enhancement of motility is impaired by the concurrent use of antimuscarinic agents.

Because of its effects on gastric emptying, uptake of drugs which are primarily absorbed in the stomach may be reduced, but those absorbed mainly in the small bowel can be increased.

There have been rare reports of a prolonged QT interval and ventricular arrhythmias in patients taking other medications or with risk factors for arrhythmias such as hypokalemia or hypomagnesemia.

Some drugs inhibit cisapride metabolism and may increase the incidence of QT-interval prolongation. Therefore it is recommended that cisapride should not be used concurrently with erythromycin, clarithromycin, fluconazole, ketoconazole, itraconazole, and miconazole. Cimetidine also inhibits cisapride metabolism.

Use in critical care

Use of cisapride for treatment of postoperative ileus may improve intestinal motility in some patients, but its effects are variable.

Randomized controlled studies of the effect of cisapride in critical care patients have confirmed a significant improvement in gastric emptying compared with controls

(Spapen etal 1995; Heylandeta/ 1996). However, further studies are required to investigate the efficacy of cisapride in promoting the establishment of full enteral feeding.

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