The dramatic success of pharmacological acid suppression in healing peptic ulcers and managing

patients with gastroesophageal reflux disease (GERD) has been reflected in the virtual abolition
of elective surgery for ulcer disease, a reduction in nonsteroidal anti-inflammatory drug
(NSAID)-associated gastropathy and the decision by most patients with reflux symptoms to
continue medical therapy rather than undergo surgical intervention. However, a number of
challenges remain in the management of acid-related disorders. These include management of
patients with gastroesophageal symptoms who do not respond adequately to proton pump
inhibitor (PPI) therapy, treatment of patients with nonvariceal upper gastrointestinal bleeding,
prevention of stress-related mucosal bleeding, optimal treatment and prevention of NSAID-
related gastrointestinal injury, and optimal combination of antisecretory and antibiotic therapy
for the eradication of Helicobacter pylori infection. A number of new drugs are currently being
investigated to provide a significant advance on current treatments. Some of them (namely
potassium-competitive acid blockers (P-CABs) and CCK 2 -receptor antagonists) have already
reached clinical testing while some others (like the anti gastrin vaccine, H3 -receptor ligands or
gastrin-releasing peptide receptor antagonists) are still in preclinical development and need the
proof of concept in human beings. Of the current approaches to reduce acid secretion, P-CABs
and CCK 2 -receptor antagonists hold the greatest promise, with several compounds already in
clinical trials. Although the quick onset of action of P-CABs (i.e. a full effect from the fi rst
dose) is appealing, the results of phase II studies with one such agent (namely AZD0865) did not
show any advantages over esomeprazole. Thanks to their limited efficacy and the development
of tolerance it is unlikely that CCK 2 antagonists will be used alone as antisecretory compounds
but, rather, their combination with PPIs will be attempted with the aim of reducing the long-term
consequences of hypergastrinemia. While H 2 - receptor antagonists (especially soluble or over-
the counter formulations) will become the ‘antacids of the third millennium’ and will be
particularly useful for on demand symptom relief, clinicians will continue to rely on PPIs to
control acid secretion in GERD and other acid related diseases. In this connection, several new
PPI formulations have been developed and two novel drugs (namely ilaprazole and
tenatoprazole) are being studied in humans. The recently introduced immediate-release (IR)
omeprazole formulation (currently available only in the USA) quickly increases intragastric pH
and, given at bedtime, seems to achieve a better control of nocturnal acidity. IR formulations of
other PPIs (including the investigational ones) will probably be available in the future and will
enlarge our therapeutic armamentarium. Amongst the novel PPIs, tenatoprazole appears to be a
true advance in the acid suppression therapy. Its long half-life (the longest among the available
compounds) and longer duration of antisecretory action, with no difference between day and
night, will allow the drug to go beyond the intrinsic limitations of currently available PPIs.
Thanks to its favorable pharmacokinetics, the sodium salt of S-tenatoprazole is being developed
and the preliminary results indicate that this drug has the potential to address unmet clinical
needs. Although some decades have elapsed since the introduction of effective and safe
antisecretory drugs in clinical practice and their use has stood the test of time, the ongoing
research will further provide the clinician with more effective means of controlling acid
secretion.
Introduction
Gastric acid secretion is under nervous and hormonal influence [1] . This physiologic process is
controlled by a number of redundant second messenger pathways activated as a result of the
binding of gastrin, acetylcholine, histamine, and prostaglandins to the specific receptors on the
basolateral surface of parietal cells. The stimulatory effect of acetylcholine and gastrin is
mediated by an increase in cytosolic calcium, whereas that of histamine is mediated by activation
of adenylate cyclase and generation of cyclic AMP (cAMP). Strong potentiation between
histamine and either gastrin or acetylcholine reflects post receptor interaction between the
distinct pathways as well as the ability of acetylcholine and gastrin to release histamine from
mucosal enterochromaffin-like (ECL) cells [1] . Indeed, gastrin, the major circulating stimulus of
acid secretion, probably does not stimulate the parietal cells directly but acts to mobilize
histamine from the ECL cells in the oxyntic mucosa [2] . The gastrin-ECL cell pathway has been
investigated extensively in situ (gastric submucosal micro dialysis), in vitro (isolated ECL cells)
and in vivo (intact animals). Gastrin acts on CCK2 receptors to control the synthesis of ECL cell
histamine, accelerating the expression of the histamine-forming enzyme, histidine decarboxylase
(HDC), at both the transcription and the translation/post translation levels [3] . The ultimate
factor in acid secretion, however, is the stimulation of the proton pump (H+ ,K+ -ATPase) to
secrete hydrogen ions into the gastric lumen in exchange for potassium ions [1] . The recognition
that H+ ,K+ -ATPase was the fi nal step of acid secretion culminated in the development of a
class of drugs, the proton pump inhibitors (PPIs), which are targeted at inhibiting this enzyme [2]
. They represent one of the most commonly prescribed classes of drugs in both
gastroenterological and primary care settings and are considered a major advance in the
treatment of acid-related diseases. After sufficient acid secretion has occurred, a feedback system
terminates gastric acid secretion. A decrease of intragastric pH stimulates somatostatin (SST)
release from antral D cells. This peptide not only inhibits acid secretion but also blunts gastrin
release and its stimulatory effect on CCK2 receptors located on parietal and ECL cells [1, 4] .
Furthermore, acidification of the duodenum triggers secretin release, which also inhibits gastric
acid secretion [5] . The inhibitory effects of SST and endogenous prostaglandins (EPs) on acid
secretion are mediated by receptors (SST2 and EP3 , respectively) coupled by guanine
nucleotide-binding proteins to inhibition of adenylate cyclase activity. All the pathways (both
stimulatory and inhibitory) converge on and modulate the activity of the luminal enzyme (i.e. H+
,K+ -ATPase) [1, 2] . In 1973, pyridylmethyl benzimidazole sulfides were originally discovered
to be active PPIs: they were then modified to the corresponding sulfoxide timoprazole,
picoprazole and omeprazole in 1979. Omeprazole, the first clinically available PPI, has been
used in some countries for more than two decades [6] . More recently, other member of f the PPI
family including lansoprazole, pantoprazole rabeprazole and esomeprazole have been developed
and launched.
Inhibition of Acid Secretion: Where Are We?
Chemistry and Pharmacology of PPIs Chemically, all the available PPIs [7, 8]consist of a
benzimidazole ring and a pyridine ring, but vary in the specific side ring substitution ( fi g. 1 ).
They are all weak protonatable pyridines, with a pKa of about 4.0 for omeprazole and
lansoprazole, about 3.9 for pantoprazole, and about 5.0 for rabeprazole. As a result, they
accumulate specifically and selectively in the secretory canaliculus, the highly acidic space of the
parietal cell [8, 9] . Within that space, PPIs undergo an acid-catalyzed conversion to a reactive
species, the thiophilic sulfonamides, which are permanent cations ( fi g. 2 ). The rate of
conversion varies among the compounds and is inversely proportional to their pKa: rabeprazole
(4.71) 1 omeprazole (4.09) 1 lansoprazole (3.92) 1 pantoprazole (3.89). The reactive species
interacts with the external surface of the H+ ,K+ - ATPase that faces the lumen of the secretory
space of the parietal cell, resulting in disulfide bond formation with one or more key cysteines
located within the -subunit of the enzyme; this is the residue that is intimately involved in
hydrogen ion transport. This covalent inhibition of the enzyme by the thiophilic sulfonamide
results in a specific and long-lasting impairment of gastric acid secretion. The selectivity of PPIs
for the parietal cell proton pump stems from the fact that H+ ,K+ -ATPase is the only pump in
the body that generates a sufficiently steep proton gradient of more than 1: 1,000,000,
corresponding to pH 0.8–1.0 inside the canaliculus of a secreting parietal cell [10] . PPIs are the
most potent inhibitors of gastric acid secretion available [8, 10] . They are most effective when
the parietal cell is stimulated to secrete acid postprandially, a relationship that has important
clinical implications for timing of administration. Because the amount of H+ ,K+ -ATPase
present in the parietal cell is greatest after a prolonged fast, PPIs should be administered before
the first meal of the day. In most individuals, once-daily dosing is sufficient to produce the
desired level of acid inhibition, and a second dose, which is occasionally necessary, should be
administered before the evening meal [11] . During meals, neither all parietal cells nor all proton
pumps are active. Since PPIs inhibit only activated enzyme present in the canalicular membrane,
the reduction of gastric acid secretion after an initial dose will probably be suboptimal. As
inactive enzyme is recruited into the secretory canaliculus, acid secretion will resume, albeit at a
reduced level. After the second dose is given on the next day, more H+ ,K+ -ATPase will have
been recruited and subsequently inhibited, and after the third dose, additional recruitment and
further acid inhibition will probably occur [8, 11] . Once-daily PPI dosing inhibits maximal acid
output by about 66% after 5 days. Thus, the occasional use of a PPI taken on an ‘as needed’ basis
would not be expected to reliably provide adequate acid inhibition and would be unlikely to
produce a consistent or satisfactory clinical response (in contrast to the H2 -antagonists, which
have a more rapid onset of action) [8, 11] . Because of the delay in optimal acid inhibition, the
initial use of twice-daily dosing (for the first 2–3 days) may be helpful in achieving more rapid
inhibition of gastric acid secretion. In addition to their delay in onset, and because PPI-derived
sulfonamides bind covalently to H+ ,K+ -ATPase, the restoration of acid secretion will likewise
be delayed, depending upon enzyme turnover and the biological reversibility of the disulfide
bond. Maximal acid secretory capacity may not be restored for 24–48 h after discontinuing PPIs
[8, 11] .
Clinical Applications of PPIs
PPIs are effective for treatment of all acid-related disorders, i.e. peptic ulcer (PU) and eradication
of Helicobacter pylori , Zollinger-Ellison syndrome (ZES), gastroesophageal reflux disease
(GERD) and its complications, nonsteroidal anti-inflammatory drugs (NSAID)-associated
gastroduodenal ulcers as well as PU bleeding. In a landmark study, Burgetet al. [12]found a
highly significant correlation between healing and the degree of acid suppression, the duration of
acid suppression, and the length of therapy. The shape of the contour expression of these
relationships showed that healing rate increases as the duration of suppression increases and as
gastric pH increases. Being more potent and longer lasting than H2 - RAs, PPIs are therefore
more effective in healing both gastric and duodenal ulcers. And indeed, several meta analyses
[13, 14]did show that these drugs are able to heal gastroduodenal ulcer more rapidly than H2 -
RAs. Raising intragastric pH with PPIs improves antimicrobial efficacy of chemotherapeutic
agents towards H. pylori through several mechanisms [15] , thus increasing their bactericidal
effectiveness. As a consequence, the combination of a PPI and two antimicrobials (mainly
clarithromycin and amoxicillin or metronidazole) is now a well-established first-line regimen
[16, 17] , whenever eradication of the microorganism is indicated [18, 19] . Since Warren and
Marshall first described the infectious etiology of PU disease in 1984 [20, 21] , a great deal of
evidence has accumulated to suggest that H. pylori eradication therapy cures PU disease [22–
24]and can be beneficial also to other H. pylori -related diseases [25] . A recent meta-analysis
[26]clearly showed that prolonging therapy with PPIs after a PPI-based triple therapy for 7 days
is not necessary to induce ulcer healing. Both oral and intravenous PPIs have allowed for the first
time a complete control over the marked acid hypersecretion often seen in patients with ZES [27,
28]and are indeed the drugs of choice in the long-term management of ZES patients. PPIs are
effective even in patients unresponsive to H2 -RAs [29]and do not show tachyphylaxis. In
patients with reflux esophagitis the degree of mucosal healing is directly related to the proportion
of time during the 24-hour period for which the intragastric pH is maintained above 4 [30, 31] .
As a consequence, numerous studies have documented the marked efficacy of PPIs in controlling
symptoms of GERD and healing esophagitis and a large meta-analysis [32]clearly showed a
distinct advantage – either in terms of healing and symptom relief – of PPIs over H2 -RAs, a
finding confirmed in a recent Cochrane Review [33] . Gastroduodenal mucosa possesses an array
of defensive mechanisms and NSAIDs have a deleterious effect on most of them. This results in
a mucosa less able to cope with even a reduced acid load. The presence of acid appears to be a
condition sine qua non for NSAID injury, which is in fact pH-dependent. There is therefore a
strong rationale for PPI use in both treatment and prevention of NSAID-associated
gastroduodenal ulcers [34] . Unlike H2 -blockers, PPIs protect from NSAID injury not only the
duodenum, but also the stomach, where the majority of mucosal lesions are usually located [35–
38] . The goal of medical therapy for bleeding ulcers has been traditionally to sustain intragastric
pH 1 6, in order to promote platelet aggregation, clot formation and stability [39, 40] . H2 -RAs
show little benefit in patients with PU bleeding [41–43] , which reflects their inadequate pH
control and the rapid onset of tolerance (see below) . Several meta-analyses [41, 42, 44–46]have
shown that treatment with a PPI reduces the risk of re-bleeding and the requirement for surgery
after ulcer bleeding but has no benefit on overall mortality, an effect seen only with intravenous
administration of high doses to high-risk patients [47, 48] . One of these systematic reviews
[48]actually suggested a significant benefit only for patients having endoscopic high-risk
stigmata for re-bleeding. PPI therapy for ulcer bleeding has been more efficacious in Asia than
elsewhere [49] . This may be because of an enhanced pharmacodynamic effect of PPIs in Asian
patients [50, 51] . Combination of endo therapy with acid suppression is superior to monotherapy
in reducing bleeding and surgery and superior to endo therapy alone in minimizing re-bleeding
but not surgery [52] . Treatment of H. pylori infection is more effective than antisecretory no
eradicating therapy (with or without long-term maintenance antisecretory therapy) in preventing
recurrent bleeding from PU [53] . Recurrence of infection seems to be responsible for recurrence
of bleeding. Consequently, all patients with PU bleeding should be tested for H. pylori infection,
and eradication therapy be prescribed to H. pylori -positive patients.
Why Are PPIs Better Antisecretory Agents than H2 -RAs? H2 -RAs have a relatively short
duration of action and, depending on the individual agent and whether the patient is in a fed or
fasting state, suppress acid for approximately 4–8 h [54]. Consequently, multiple daily doses of
these agents are likely to be required. Furthermore, H2 - RAs produce incomplete inhibition of
postprandial gastric acid secretion. Overall, these agents inhibit acid secretion by up to 70% over
a 24-hour period [54, 55] . A further shortcoming is that tolerance to standard H2 -RAs generally
develops within 2 weeks of repeated administration, resulting in a decline in acid suppression
[56] . This can be explained by a gastrin-induced increase in ECL-derived histamine
concentrations at the H2 -receptor on the parietal cell [57]and up-regulation of both gastrin and
H2 -receptors [58] . In contrast, PPIs control both basal and food-stimulated acid secretion and
produce more complete and longer lasting acid suppression than H2 -blockers [8, 11] . Such acid
inhibition virtually abolishes the damaging peptic activity of gastric juice. In addition, tolerance
to PPIs has not been observed, an advantage presumably attributable to the fact that they act at
the fi nal step of acid production, thereby blocking the effects of any compensatory mechanisms
promoting acid secretion [11, 57] . Despite all the above limitations, there is still a place for H2 -
RAs in the era of PPIs [55] . Besides the treatment of functional dyspepsia, where they are
superior to placebo [59] , H2 -RAs are useful for heartburn relief in patients with mild forms of
GERD [60] , being better and faster than antacids [61] . OTC (low-dose) formulations are not
only able to decrease gastric and esophageal acidity but actually potentiate the antacid effect in
relieving meal-induced heartburn [62] . The appreciation that even twice-daily PPIs may not
adequately control intragastric acidity during the night and that in a significant proportion of both
healthy subjects and GERD patients a ‘nocturnal acid breakthrough’ (NAB) does occur [63]has
suggested the use of a bedtime dose of H2 -RAs to improve acid control [64] . However, long-
term use of these agents led to development of tolerance so that their effect on NAB lessened
with prolonged therapy [65] . In addition, it must be emphasized that no study in patients with
GERD has yet demonstrated that addition of H2 -RAs to twice-daily PPI therapy provides any
further benefit above that derived from PPIs alone [66, 67] . However, a paper presented at a
recent DDW in Orlando [68]showed that, besides reducing NAB [64] , ranitidine, given at
bedtime even at low doses, significantly improves nocturnal heartburn in GERD patients on PPI
therapy, already on the first day of therapy. Although the benefit lasted only a few days, these
data suggest that short-term or intermittent therapy with H2 -RAs might have a significant
impact also on GERD-related symptoms. Up to 79% of patients with GERD experience
nocturnal symptoms associated with their condition. Improvement in nocturnal symptoms
associated with reduction in gastric acidity by PPIs is well documented [69] . The clinical
importance of specifically reducing NAB, however, is controversial. In patients with GERD,
recovery of nocturnal gastric acid secretion is of little importance, if it is not accompanied by
exposure of the esophagus to acid. Nevertheless, patients with severe forms of chronic GERD,
especially those with Barrett’s esophagus, are more likely to have acid reflux during NAB [70] .
A recent report [71]has shown 1 70% of patients had improved nighttime symptoms after
addition of an H2 -RA to a twice-daily PPI regimen, thus emphasizing the clinical impact of
controlling NAB. All the above findings suggest that a hierarchy of overnight pH control does
exist [72] , beginning with a PPI given in the morning, adding an H2 -RA at bedtime,
progressing to PPI therapy twice daily and then again adding an H2 -RA at bedtime ( table 1 ).
Are Currently Available PPIs All the Same? Although there are differences among PPIs
concerning their pharmacokinetics, pharmacodynamics, influence by food and antacids as well
as potential for drug interactions [7, 73] , it is not always evident whether these often subtle
differences are clinically relevant. Several comprehensive analyses of the available clinical trials
concluded that – when used at equivalent doses in the treatment of various acid-related disorders
– all the available agents are similarly effective [7, 74, 75] . These conclusions concerning
‘clinical’ efficacy of PPIs are backed by similar results obtained in comparative
‘pharmacological’ analysis [76] . Guidance from the National Institute for Clinical Excellence
(NICE) does not differentiate between PPIs except on the grounds of price and accepted
indications [77] . The physician’s choice of one PPI over another must therefore rest with her/his
interpretation of the clinical importance of the generally small differences among PPIs, their
approval for treatment of specific clinical indications within the physician’s practice jurisdiction,
and the strength of the evidence based on the quantity and quality of the supporting clinical trials
[74] .
Is There Any Acid Peptic Disease That Is Refractory to PPIs? Nonhealing and/or delayed healing
during acid inhibition treatment depend on the extent to which acid and ‘non-acid’ factors are
causative in the particular acid peptic disease, and on the effectiveness and duration of acid
suppression. Refractoriness occurs less often with PPIs than with H2 -RAs as the former
decrease acid more effectively [78] . H2 -RA refractory disease usually responds to treatment
with PPIs. However, although rare, refractoriness to PPIs does exist [79–81] , amounting to 5–
10% in GERD and 2–8% in PU [78, 81] . Potential reasons for this less than optimal response
can be found when carefully examining the intragastric pH profiles of patients with PPI-resistant
PU [82]or GERD [83, 84] . In both cases, tracings will frequently show that PPIs fail to
adequately control intragastric acidity, especially during the night, although other
pathophysiological features should be taken into account. Increasing the PPI dose will often
offset this ‘relative’ resistance. If NAB occurs in GERD patients with predominantly nighttime
symptoms, administering an H2 -RA at bedtime would be worthwhile [70, 71] , although the
benefit of this combination may be short-lasting [65] . In any event, the reported failure of PPIs
to effectively control either intragastric (and intraesophageally) pH and symptoms clearly
unmask some limitations of currently available agents. It should be mentioned, however, that
there is a small group of patients who are ‘true’ omeprazole-resistant (defined as gastric pH ! 4
for 50% of 24 h), for whom an abnormality of the proton pump, due to mutations of cysteine 813
and 822, has been suggested [85] . Whether resistance to other PPIs exists has not been currently
studied. In addition, although successful treatment with PPIs in H2 -RA-resistant GERD patients
is the rule, few patients who showed therapeutic response to high-dose H2 -RAs after failure of
high-dose omeprazole to control gastric acidity and gastroesophageal reflux have been reported
[86] .
Shortcomings and Limitations of Current PPIs Although effective and safe, currently available
PPIs are still far from the ideal antisecretory compound. An ideal drug should allow full acid
control around the clock and dose-dependent and predictable pharmacokinetic and
pharmacodynamic properties. These properties and the consequent clinical effects should also be
reproducible in a wide range of patient populations [87] . Finally, an ideal agent will display high
oral bioavailability, a rapid onset of action and few, if any, clinically relevant interactions with
food or concomitantly administered drugs [88] . The so-called fi rst-generation PPIs
(omeprazole, pantoprazole and lansoprazole) have notable limitations. These drugs exhibit
substantial interpatient variability in pharmacokinetics or may have significant interactions with
other drugs. The time of dosing and ingestion of meals may also influence the pharmacokinetics
of these agents as well as their ability to suppress gastric acid secretion. First-generation PPIs
also have a relatively slow onset of pharmacological action and may require several doses to
achieve maximum acid suppression and symptom relief, possibly limiting their usefulness in on-
demand GERD therapy. First-generation PPIs may also fail to provide 24-hour suppression of
gastric acid, and NAB can occur even with twice-daily dosing [88] . Taking all the above
considerations into account, it is clear that there is room for improvement and a new generation
of PPIs might be able to overcome the limitations of first-generation compounds [89] . To obtain
an ideal PPI capable of achieving full inhibition of acid control with the first dose, different
avenues can be pursued. One way is to develop a compound whose favorable metabolism would
allow an enhanced delivery of the active form to the proton pump with consequent better
inhibition of acid secretion. Exploiting the stereospecific catabolism of enantiomers follows that
way. The extension of plasma half-life is a critical factor in improving the onset of action of PPIs
and thus compounds with a half-life longer than that of current PPIs may be expected to display
first-day efficacy. Such an avenue can be pursued through the synthesis of new chemical entities
with a molecular structure different from the current (i.e. substituted benzimidazole) one or
designing a prodrug that will release the PPI in the bloodstream [90] . Tenatoprazole, consisting
of one imidazopyridine ring connected to a pyridine ring by a sulfonylmethyl chain [91] ,
represents an example of a new chemical entity with an extended half-life (about 8 h compared
to 1.0–1.5 h), whereas compound D [90]is an investigational pro-PPI for very stable intravenous
formulation that displays a longer duration of action in comparison with omeprazole. Some
prodrugs synthesized recently hydrolyze under physiological conditions (pH = 7.4) to provide
PPIs with a half-life largely exceeding the 2 h and are capable of providing sustained plasma
concentration of the released PPI for a time longer than the currently used compounds [92] . The
development of potassium-competitive acid blockers (P-CABs, previously called acid pump
antagonists, APAs) is another active area of research in controlling intragastric pH. P-CABs such
as the imidazopyridines have thus far shown fast first-day onset as well as improved control of
day- and nighttime intragastric pH with twice-daily dosing when compared to a once-daily PPI
[93] . Although these drugs also target H+ ,K+ -ATPase, they act via a distinct mechanism: they
bind the extra cytoplasmatic surface and act as reversible K+ -competitive antagonists [93, 94] .
From Omeprazole to Esomeprazole: Why a Chiral Switch? Rationalization within the
pharmaceutical industry to combat escalating costs has included the close examination of
research portfolios. Gastroenterology has been one of the casualties of this exercise and few
companies currently retain a specific gastrointestinal research program [95] . AstraZeneca, who
discovered the first PPI more than 20 years ago, synthesized and started the development of
esomeprazole (the magnesium salt of the S-isomer of omeprazole) in 1990, making it available
for clinical practice worldwide at the beginning of the third millennium. Taking into account that
omeprazole comprises a racemic mixture of its two optical isomers, S-omeprazole and R-
omeprazole, and that S-omeprazole is optically stable in humans with negligible inversion to the
other isomer [96] , the R&D team decided to follow the fi rst of the avenues outlined above in
order to obtain a PPI with improved acid control. By following the methodology (the so-called
‘Sharpless Epoxidation’) discovered by K. Barry Sharpless, one of the three scientists who
received the 2001 Nobel Prize in Chemistry [97] , they set up the stereoselective synthesis of
esomeprazole [98]and were able to produce the isomer on a large scale. Since all the currently
available PPIs are racemic mixtures, the stereoisomers of other molecules (namely lansoprazole,
pantoprazole, rabeprazole and the new non benzimidazole compound, tenatoprazole) have been
isolated [99]and are being extensively investigated. The Importance of Chirality in
Pharmacology Chiral molecules were one of the great discoveries of Louis Pasteur, who
observed in the mid-1800s that two distinct crystal forms of tartaric acid would rotate polarized
light in opposite directions. Pasteur correctly postulated that the two crystal forms were
enantiomers, or right- and left-handed mirror images of each other. The Greek name kheir means
‘hand’. So, chirality indeed means ‘handedness’. Enantiomers can be thought of as left and right
hands: although they are also mirror images of each other, a left hand, for example, does not fi t
into a right-handed glove. Following Louis Pasteur’s discoveries, the name was coined by the
Irish physicist William Thomson, alias Lord Kelvin. Chirality is central to life, as many of the
important molecules come in two mirror-image forms that have very different properties [100] .
The fundamental molecules of life, namely DNA and proteins, are, in fact, composed
respectively of right- and left-handed subunits only. Nature often discriminates between chiral
forms of small molecules, too, and what is a medicine on the one hand can be a poison on the
other. One example of this is thalidomide. Thalidomide, which was given to pregnant women as
a sedative and antinausea drug in the 1950s in Europe, turned out to produce debilitating birth
defects (i.e. missing limbs or phocomelia) [101] . But, in fact, only one enantiomer (i.e. the S-
isomer) of the molecule is responsible for these effects [102] . Stereoisomers are molecules that
are identical in atomic constitution and bonding, but differ in the three-dimensional arrangement
of the atoms. The stereoisomeric pairs of greatest interest are those with one or more asymmetric
(chiral) centers whose enantiomers (individual stereoisomers) are mirror images. According to an
absolute convention, known as the Sequence Rule notation, when the peripheral groups are
dimensionally arranged clockwise around the chiral center, the R (rectus) configuration is
assigned to the molecule. On the contrary, if they are arranged counterclockwise around the
chiral center, the S (sinister) configuration is allocated. Optical isomers have essentially identical
physical (except for optical rotatory) and chemical (except in a chiral environment) properties.
Such stereoisomers usually require specialized chiral techniques for their correct identification,
characterization, separation and measurement. They are often readily distinguished by biological
systems, however, and may have different pharmacokinetic properties (absorption, distribution,
biotransformation and excretion) and quantitatively or qualitatively different pharmacologic or
toxicologic effects [103–105] . Stereoisomers include not only the mirror-image enantiomers, but
also geometric ( cis/trans ) isomers and diastereoisomers (isomers of drugs with more than one
chiral center that are not mirror images of one another, fi g. 3 ). Diastereoisomers and geometric
isomers are both chemically distinct and pharmacologically different (unless they are
interconverted in vivo) and are generally readily separated without chiral techniques. Geometric
isomers and diastereoisomers therefore should, with the rare exception of cases where in vivo
interconversion occurs, be treated as separate drugs and developed accordingly [100] . When
stereoisomers are biologically distinguishable, they might seem to be different drugs [103–105] ,
yet it has been past practice to develop racemates (i.e., compounds with 50: 50 proportion of
enantiomers). The properties of the individual enantiomers have – in the past – not generally
been well studied or characterized. Whether separated enantiomers should be developed was
largely an academic question because commercial separation of racemates was difficult. Now
that technological advances (large-scale chiral separation procedures or asymmetric syntheses)
permit production of many single enantiomers on a commercial scale, it is appropriate to
consider the development of the single enantiomer characterized by the most favorable profile of
activity (eutomer) [104, 105] . Any decision to develop a drug as a single enantiomer, however,
should be made only after careful evaluation of the cost-benefit ratio, i.e. when the advantages of
the eutomer in terms of efficacy and tolerability outweigh the associated increase in production
and development costs with respect to the racemic drug [106] . Development of racemates raises
issues of acceptable manufacturing control of synthesis and impurities, adequate pharmacologic
and toxicologic assessment, proper characterization of metabolism and distribution, and
appropriate clinical evaluation [107] . From a theoretical standpoint, some stereochemical
aspects of drug therapy should be taken into account [108, 109] . For chiral drugs, one of the
entantiomers can: • be inactive (e.g. S-loxiglumide) or less active (e.g. R-warfarin), • display a
quantitatively different pharmacological effect. The presence of the inactive or less active isomer
is often responsible for the greater variability observed with racemates, • have a different
metabolic pattern, • have an antagonistic effect, • or be, actually, toxic. Since no drug is
completely devoid of adverse effects, recent interest has focused on the role of the different
properties of individual drug enantiomers in causing drug toxicity [110] . Several examples of
stereoselective toxicity are available in the literature. Vomiting, for instance, is caused merely by
the R-isomer of levamisole [111] . Myasthenia gravis symptoms were no longer observed when
the R-isomer was removed from the racemic mixture of carnitine [112] . Only the S-isomer has
been linked to the teratogenic effects of thalidomide [102] . Development of Esomeprazole In
accordance with results of clinical trials in acid-related diseases [7, 74] , where often different
but somewhat equipotent doses of the different PPIs have been used, data from experimental
pharmacological studies clearly show that – on a milligram basis – the available compounds
display the same potency and efficacy [76] . Since both R- and S-isomer of omeprazole are able
to inhibit acid secretion in isolated gastric glands to the same degree [113] , there should be no
pharmacodynamic benefit in using one stereoisomer instead of the racemate. Both enantiomers
(which are chiral sulfoxides) will give rise – within the secretory canaliculus – to the same
reactive species, sulfonamide, which is achiral ( fi g. 2 ). There is therefore no pharmacodynamic
reason why the racemate or any of its enantiomers should differentially interact with the proton
pump [9] . Although the use of a PPI enantiomer does not confer any direct advantage in vitro,
the pharmacokinetic (and pharmacodynamic) consequences of stereoselective drug metabolism
might anyway affect drug activity in vivo [114, 115] . The metabolism of substituted
benzimidazoles is to a larger or lesser extent (e.g. for rabeprazole) dependent on hepatic
cytochrome P450 (CYP) isoforms, CYP3A4 and CYP2C19 [7, 73, 116] . These heme-containing
enzymes are abundantly expressed in hepatocytes, where they exist in the smooth endoplasmic
reticulum in association with a number of accessory proteins. There, the cytochromes P450
catalyze the multistep oxidation reactions that inactivate xenobiotics by the introduction or
exposure of a functional group on their substrate. The dependence of most PPIs on metabolism
by CYP2C19 makes them susceptible to alterations in bioavailability due to genetic
polymorphisms affecting the activity of this enzyme [73, 117] . In particular, omeprazole is
transformed into three pharmacologically inactive metabolites, i.e. omeprazole sulfone and 5-
hydroxy- plus 5-O-desmethyl-omeprazole, respectively. Studies performed in healthy volunteers
[118],human liver microsomes and cDNA-expressed enzymes [119]have shown a signifi cant
stereoselectivity in the metabolism of omeprazole enantiomers. The R-isomer is almost
exclusively metabolized (98%) via CYP2C19, 94% transforming to the 5-hydroxy metabolite,
and 4% to the 5-O-desmethyl metabolite. Only 2% of the metabolism is via the CYP3A4
isoform. The S-isomer (esomeprazole) is metabolized primarily (73%) via the CYP2C19 isoform
(46% going to the 5-O-desmethyl metabolite, 27% going to the 5-hydroxy metabolite), and by
27% via the CYP3A4 isoform to the sulfone metabolite. The intrinsic clearance (CL) of S-
omeprazole is approximately one third of that of R-omeprazole, because of the considerably
lower CL for formation of the 5-hydroxy metabolite (15 vs. 43 l min/mg protein) via CYP2C19
[120] . This implies that the total metabolic clearance for S-omeprazole is lower than that for R-
omeprazole, resulting in higher plasma levels of the S-isomer in vivo ( fi g. 4 ). These data
suggest that, in vivo, S-omeprazole should undergo a lower fi rst-pass effect thus leading to
higher plasma levels and consequent better availability. Since the area under time concentration
curve correlates with secretory inhibition [121] , the S-isomer should be capable of achieving a
better acid control compared with the racemic mixture (i.e. omeprazole). The available in vivo
pharmacokinetic, pharmacodynamic and clinical data all show that this is the case [122–125] .
The stereoselective metabolism of lansoprazole [126– 128] , pantoprazole [129, 130]and
rabeprazole [131]has also been studied and consistently revealed significant quantitative
differences between isomers. The stereoisomers of some of these PPIs are being extensively
studied. In particular a new modified release formulation of the R-isomer of lansoprazole
(compound marked TAK390MR) is now in phase III development [132]and 7 clinical trials in
GERD (registered at www.clinicaltrials. gov) are ongoing in the USA [133] . Actually, the Food
and Drug Administration (FDA) granted the permission to move directly to phase III without
going through phase II based on the results of the phase I studies. This R isomer was selected
either because of its higher plasma concentrations [126]and lower clearance [127]and because –
besides being the most potent inhibitor of CYP2C19 enzyme – S-lansoprazole also inhibits
CY2C9 and CYP2D6 activities [134] . These properties make the S-isomer an unsuitable drug
for the treatment of acid-related diseases for its large drug interaction potential. By the way,
NSAIDs – amongst other drugs – represent one of the most important substrates of CYP2C9
[135] . Being NSAID-associated symptoms and mucosal lesions are one of the clinical
indications of PPIs, the use of S-lansoprazole concomitantly with NSAIDs would need great
caution or be actually contraindicated. While chirality with the elegance of its underlying
concepts is certainly fascinating, the demonstration that chiral switching provides superior
clinical benefits (either in terms of efficacy, safety or economy) is difficult. Although
esomeprazole is considered by some [124, 125, 136]a true therapeutic advantage and a cost-
effective treatment for acid-related diseases [137] , others [138–140]have questioned its
superiority over other PPIs, including omeprazole. Chiral switching is a rational but undesirable
response of manufacturers to patent expiration. When patents on commercially successful drugs
approach their expiry dates, the development of a stereoisomer enables companies to maintain
market share and high prices despite generic competition. Indeed, the zealously guarded patent
monopoly system provides the same exclusivity and market protection to an enantiomer of an
existing product as it does to a new chemical entity. This makes the development and marketing
of stereoisomers of existing racemates more commercially attractive than the high costs,
uncertainties and risks of developing genuine innovative compounds [141] . It would be
desirable and in some ways ethical to explore from the very beginning the pharmacokinetics and
pharmacodynamics of enantiomers and start the development of the more attractive isomer
(eutomer) right away. Inhibition of Acid Secretion: Where Are We Going? Unmet Needs in Acid
Suppression The dramatic success of pharmacological acid suppression in healing ulcers and
managing patients with GERD has been reflected in the virtual abolition of elective surgery for
ulcer disease [142] , a reduction in NSAID associated gastropathy [143] , and the decision by
most patients with reflux symptoms to continue medical therapy rather than undergo surgical
intervention. However, a number of challenges remain in the management of acid-related
disorders. These include management of patients with gastroesophageal symptoms who do not
respond adequately to PPI therapy, treatment of patients with nonvariceal upper gastrointestinal
(GI) bleeding, prevention of stress-related mucosal bleeding, optimal treatment and prevention of
NSAID-related GI injury, and optimal combination of antisecretory and antibiotic therapy for the
eradication of H. pylori infection [144, 145] . As outlined before, PPIs have a number of
shortcomings, which stem from their pharmacology. However, there is increasing evidence of
both inappropriate prescribing and inappropriate use of these drugs. An expanding proportion of
patients have indeed poor indication to acid suppression. Not uncommonly, empiric therapy in
nonexplorer and functional dyspepsia is based upon PPI therapy, standard or high dose for 2–4
weeks. If symptom resolution is limited and patient dissatisfaction continues, often the dose is
doubled. Upon sudden arrest of such therapy because of insufficient symptom relief, rebound
acid secretion may reactivate GERD-like/dyspeptic symptoms leading to a vicious circle [144] .
There is a staggering lack of clear instructions in practice concerning empirical therapy. That
PPIs are often taken inappropriately is revealed by a US survey [146]showing that only 27% of
GERD patients dosed their PPI correctly (i.e. up to 60 min before any meal of the day) and only
9.7% dosed it optimally (i.e. 15–60 min before the first meal of the day). Furthermore, in a study
of 1,046 primary care physicians across the USA [147] , only 36% of them did give their patients
advice on when and how to take their medication. Although a proper education can improve PPI
use and effectiveness, currently available drugs have their own shortcomings. To overcome these
limitations, novel formulations of currently available PPIs [92, 148]and novel PPIs [149]are
being developed. In addition, new avenues (i.e., competitive blockade of proton pump at K+
exchange sites [93]or blockade of CCK2 , e.g. gastrin receptors on the parietal and ECL cells
[150] ) are being explored. In this section, the new PPI formulations currently under
development or recently introduced in clinical practice as well as the novel acid-lowering drugs,
which have already reached clinical testing, will be discussed. New PPI Formulations Some
interesting new PPI formulations have recently been patented by AstraZeneca [92] . An enteric-
coated, extended-release dosage form of a PPI provided an extended plasma concentration
profile of the drug for a period of up to 12 h. This pharmacokinetic profi le is obtained with a
formulation comprising a core material of a hydrophilic or hydrophobic matrix containing the
PPI protected by enteric coating. An additional patent describes a multilayered tablet capable of
releasing the PPI in discrete pulses, separated in time (2 pulses of drug release at least 0.5 h
apart). The dosage form, which has one fraction with instant release of the drug and at least
another fraction with a pulsed delayed release, is intended for once-daily administration [92] .
The bioavailability and pharmacokinetic profile of these formulations have not yet been studied
in humans and it is presently unknown whether they will assure a better and longer lasting
control of intragastric pH compared with the currently available PPI formulations. A
Micropump™ technology, which permits either extended or both delayed and extended delivery
of drugs to the small intestine, has been developed by Flamel Technologies (Vénissieux, France)
and applied in cooperation with TAP Pharmaceutical Products Inc. (Lake Forest, Ill., USA) (a
joint venture between two global pharmaceutical leaders, Abbott and Takeda Pharmaceutical Co.
Ltd) to lansoprazole [151] . This technology consists of a multiple-dose system containing
5,000–10,000 microparticles per capsule or tablet. The 200- to 500- m diameter-sized
microparticles are released in the stomach and then pass into the small intestine, where each
microparticle, operating as a miniature delivery system, releases the compound by osmotic
pressure at an adjustable rate and over an extended period of time. The design of the
Micropump™ microparticles allows an extended transit time in the small intestine with a plasma
mean residence time extended up to 24 h. Thanks to the microparticles’ size, these formulations
are easy to swallow, well tolerated and taste masking. Another proprietary controlled-release
formulation (the so-called ChroNAB delivery technology) has been developed by AGI
Therapeutics Ltd (Dublin, Ireland) and applied to currently available PPIs in order to modify
their pharmacokinetics allowing for a better acid control, especially during the night when the
NAB occurs [152] . One such formulation, namely AGI 010, is currently undergoing clinical
testing. Currently available PPIs are orally administered as gastro protected preparations. The
different enteric coatings, which are necessary to protect the acid-labile PPI from acid
degradation within the stomach, have the potential disadvantage of delaying PPI absorption and,
as a consequence, the available PPI formulations are considered delayed-release (DR)
preparations. DR oral dosage forms are supplied as enteric-coated granules encapsulated in a
gelatine shell (e.g. omeprazole capsules and lansoprazole capsules) or as enteric-coated tablets
(e.g. pantoprazole tablets, rabeprazole tablets and omeprazole multiple-unit pellet system
[MUPS]). An alternative oral formulation of lansoprazole – the lansoprazole orally disintegrating
tablet (ODT) – has recently been developed and introduced into clinical practice. It is easy to
swallow and can be taken orally with or without water. This feature greatly improves compliance
when patients are away from home (and water is not readily available) and in those patients with
odynophagia or dysphagia as well as swallowing disorders. In addition, when this formulation is
dispersed in water, it provides a less expensive alternative to intravenous PPIs for patients with
nasogastric or gastric tubes in ICU or long-term care settings [153] . Some studies (reviewed by
Horn and Howden [154] ) have evaluated PPI absorption from intact nonencapsulated
omeprazole or lansoprazole as well as their suspension in sodium bicarbonate (8.4%) solution.
Although, with exception of the so-called simplified omeprazole suspension (SOS) whose
bioavailability was impaired, the other ‘extemporary’ formulations allowed a proper PPI
absorption, predisintegrated lansoprazole ODT would represent the most appropriate choice for
administration via nasogastric or gastrostomy tube. Most PPI tablets (e.g. rabeprazole) are
formulated as an enteric-coated, single-unit system, that is, a tablet with a gastric acid-resistant
layer only on its outer surface. There is a risk that the enteric coat of such tablets can become
damaged during gastric emptying. As PPIs are acid-labile, a small crack or damage to a single-
unit system may, therefore, affect the entire dose. Multiple-unit systems have been developed to
overcome this problem [155] . Common formulations of multiple-unit systems include both
capsules and tables containing enteric-coated granules. The very small size and multiple coatings
of these granules mean that they are less likely to be damaged during gastric emptying, and
absorption issues are therefore minimized. If a granule is damaged and a crack develops on the
surface, only a small portion of active substance is likely to be affected. The lansoprazole
capsule and omeprazole MUPS are examples of multiple unit systems. While enteric coating of
oral formulations is beneficial for ensuring that PPI agents are effectively delivered, it does mean
that the individual dose administration unit, be it a tablet or a granule-containing capsule, is
relatively large. The lansoprazole ODT contains much smaller microgranules than lansoprazole
capsules (330 vs. 1,100 g). The tablet disintegrates rapidly (within 30 s) in the mouth without
water. Unlike the granules in lansoprazole capsules, which have a core, a lansoprazole layer and
a gastro resistant enteric coating, each lansoprazole ODT microgranule comprises seven layers
( fi g. 5 ). The active lansoprazole layer surrounds an inert core, followed by an inert under the
coating layer that improves stability in high humidity. Three enteric-coating layers prevent
dissolution in the stomach, improve stability, reduce damage during compression and neutralize
the taste of the microgranule. An outer layer increases the hardness of the tablet [156, 157] .
When lansoprazole ODT disintegrates in the mouth the microgranules are swallowed with the
patient’s saliva. The enteric-coated microgranules dissolve in the neutral condition of the small
intestine and lansoprazole is absorbed into the bloodstream. However, absorption kinetics still
depends on the enteric coating; the oral pharmacokinetics of lansoprazole after dosing with the
ODT is essentially identical to that observed after dosing with capsules of enteric coated granules
[158] . The bioequivalence between these two formulations will translate into a similar
pharmacodynamics and clinical efficacy. And indeed, despite that the formulation was preferred
by a higher proportion of patients, no significant difference in symptom relief between
lansoprazole ODT and other PPIs (namely esomeprazole) was found in NERD [159] .
Conversely from lansoprazole ODT, the recently FDA-approved immediate-release (IR)
omeprazole formulation displays a different pharmacokinetics and pharmacodynamics compared
with the standard, DR preparation [148] . This formulation consists of pure, non enteric-coated
omeprazole powder (40 or 20 mg per unit dose) along with 1,680 mg of sodium bicarbonate
(containing 460 mg of sodium). It is flavored with peach and peppermint and is designed be
constituted with water to be drunk. Besides sachets, capsules containing 40 or 20 mg of
omeprazole are also available, while a chewable tablet formulation has been developed and an
NDA (new drug application) already submitted to FDA [160] . It is important to distinguish IR
omeprazole (IR-OME) formulation from the SOS (see above) . While IR-OME has no form of
enteric coating, SOS is prepared by opening standard capsules of DR omeprazole (DR-OME),
dropping the granular contents into 8.4% sodium bicarbonate solution and agitating the mixture
until the enteric coating of the granules disintegrates and a suspension formed. Due to the
impaired absorption of omeprazole from this extemporary preparation [154] , a lower than
expected antisecretory effect can be predicted. The pharmacokinetics of IR-OME has been
studied in healthy volunteers given 40 mg of both formulations in a crossover fashion [161] .
While the AUC was not significantly different, the Cmax was higher and the Tmax shorter with
the IR formulation ( fi g. 6 ). As with the DR capsules, both Cmax and AUC but not Tmax
increased between 1 and 7 days of once-daily dosing with IR-OME, indicating an increase of
bioavailability over time. In a crossover trial, the effect of both formulations on intragastric
acidity was investigated in healthy volunteers. Within the first 30 min, DR-OME had no
measurable activity on intragastric pH, whereas the IR formulation caused an immediate increase
in pH. From 4 to 6 h after ingestion, there was a 27% reduction from baseline in intragastric
activity with DR-OME and 65% decrease with the IR formulation ( fi g. 6 ) [162] . Therefore,
the antisecretory effect of IR-OME was quicker than that observed with the classical DR
formulation while the duration of the acid-lowering activity was similar. The early increase in
intragastric pH is likely due to the neutralizing capacity of sodium bicarbonate, which also
accelerates and enhances absorption of omeprazole whose increased bioavailability translates
into a more profound acid suppression. As already discussed, NAB is a common physiological
event, observed in approximately 70% of both healthy subjects and GERD patients treated with
up to twice daily administration of DR PPIs, regardless of whether the PPI is administered in the
morning, prior to dinner, or at bedtime [163] . Bedtime dosing with 40 mg of IROME suspension
provides better control of nocturnal gastric acidity than once-daily dosing with all DR PPIs ( fi g.
7 ) [164, 165]and also decreases NAB more effectively than with dosing of DR-OME 20 mg b.d.
and lansoprazole 30 mg b.d. or pantoprazole 40 mg b.d. Nighttime control of gastric acidity with
IR-OME suspension is comparable with that achieved by twice-daily dosing of DR esomeprazole
20 mg [164, 165] . Being easy to administer through a nasogastric tube, IR-OME was also
studied for its ability to control intragastric pH in critically ill patients [166, 167] . A
randomized, double-blind trial [168]found this formulation more effective than intravenous
cimetidine (the only FDA-approved drug for this indication) in maintaining gastric pH 1 4 and
similarly effective in preventing upper GI bleeding without increasing the incidence of
pneumonia. Several studies [162]have shown that antacids do not have a major effect on the
absorption or disposition of DR PPIs. On the contrary, addition of sodium bicarbonate to
uncoated omeprazole clearly affects its pharmacokinetics and pharmacodynamics. The putative
mechanism of action to explain these observations is as follows [162] . Following ingestion of
IR-OME as an oral suspension, the sodium bicarbonate causes a prompt rise in intragastric pH.
While this serves the primary function of protecting the uncoated omeprazole from acid
degradation within the stomach, it may also provide a temporary stimulus to gastrin release from
antral G cells. Sodium bicarbonate solution has previously been shown to raise circulating
gastrin levels within 30 min of oral ingestion [169, 170] . The rise in circulating gastrin may
stimulate the parietal cell mass and promote the insertion of functioning molecules of H+ ,K+ -
ATPase into the secretory canaliculi. Since the peak plasma concentration of omeprazole occurs
around 30 min after ingestion of IROME, this allows for the rapid uptake of circulating
omeprazole by activated parietal cells leading to irreversible inhibition of a large proportion of
available proton pumps. This sequence of events may explain both the rapidity of onset of the
antisecretory effect and its prolonged duration. Novel PPIs Several new PPIs have been
synthesized since the discovery of omeprazole. The majority of them are still in preclinical
development or have been abandoned. This is for instance the case of leminoprazole [171] ,
whose development has been interrupted despite the interesting pharmacological profi le
showing also a peculiar mucosal protective activity of the drug [172, 173] . Only two drugs are
actively being studied in humans, namely ilaprazole and tenatoprazole, and will be reviewed in
detail. Ilaprazole (compound marked IY-81149, fi g. 8 ) is a benzimidazole compound
synthesized at Il-Yang (South Korea) and presently developed by TAP Pharmaceutical Products
Inc. (Lake Forest, Ill., USA). Although the drug is already on the market in South Korea, phase
II clinical trials will start soon in the USA. Studies performed on rabbit isolated parietal cells
[174]have shown that ilaprazole irreversibly inhibits H+ ,K+ -ATPase and aminopyrine
accumulation in a dose dependent manner with a potency comparable to that of omeprazole. In
vivo investigations [174–176]evaluated the antisecretory activity of the compound, which proved
to be 2–3 times stronger than that of omeprazole. In a model of experimentally-induced
esophagitis in the rat [176],both ilaprazole and omeprazole prevented the development of
esophagitis and reduced gastric acid secretion in a dose-dependent manner. The antisecretory
activity of this novel PPI was confirmed in GERD patients where the drug, at 10 and 20 mg
daily, provided a greater and prolonged suppression of acid secretion compared to omeprazole
[177] . Since a half-life of 3.6 h (i.e. longer than that of omeprazole) has been reported in healthy
volunteers [178] , the improved pharmacodynamic activity could reflect the improved
pharmacokinetics of the drug. It should be pointed out, however, that ilaprazole displays an
inhibitory effect on cytochrome P450 enzymes, as revealed by its dose-dependent ability to
prolong hexobarbital-induced sleeping time in mice [175] . Tenatoprazole (compound also
marked TU-199) has been developed by Mitsubishi Pharma in Japan [91]and is now under active
development by Negma-Gild (France). Conversely from all the other PPIs, this compound is not
a benzimidazole derivative, consisting of one imidazopyridine ring connected to a pyridine ring
by a sulfonylmethyl chain ( fi g. 8 ). It represents therefore a new chemical entity. In vitro
studies, performed in hog and dog gastric microsomes, have shown that tenatoprazole displays
an inhibitory action on proton pump comparable to that of omeprazole and lansoprazole [179] .
The inhibitory activity of this novel compound on gastric H+ ,K+ - ATPase has been thoroughly
characterized by George Sachs’ team [180, 181] . Like the other PPIs, tenatoprazole is a prodrug
(pKa = 4.04), which is converted to the active sulfonamide or sulfenic acid by acid in the
secretory canaliculus of the stimulated parietal cell of the stomach. This active species binds to
luminally accessible cysteines of the gastric H+ ,K+ -ATPase resulting in disulfide formation
and acid secretion inhibition. Tenatoprazole binds at the catalytic subunit of the gastric acid
pump with a stoichiometry of 2.6 nmol/mg of the enzyme in vitro. In vivo, maximum binding of
tenatoprazole was 2.9 nmol/ mg of the enzyme at 2 h after intravenous administration. The
binding sites of tenatoprazole were at cysteine 813 and cysteine 822 as shown by tryptic and
thermolysin digestion of the ATPase labeled by tenatoprazole. Both of these sites are located in
the proton transport pathway, though cysteine 822 is found deeper in the TM5/6 membrane
domain than cysteine 813. Decay of tenatoprazole binding on the gastric enzyme consisted of
two components. One was relatively fast, with a half-life 3.9 h due to reversal of binding at
cysteine 813 and the other was a plateau phase corresponding to ATPase turnover reflecting
binding at cysteine 822 that also results in sustained inhibition in the presence of reducing agents
in vitro ( fi g. 9 ). The in vivo antisecretory potency of tenatoprazole, evaluated in different
animal models (Shay rat preparation, acute fistula rats and Heidenhain pouch dogs), proved to be
2–4 times higher than that observed with omeprazole. As a consequence, the healing activity of
the compound on experimentally-induced gastric and duodenal ulcers appeared similarly higher
[179] . Conversely from omeprazole, which delays gastric emptying [182] , tenatoprazole was
unable to affect emptying rate [183] . In addition, experiments carried out in dogs with gastric fi
stula revealed an elevation of intragastric pH lasting longer (by 20%) than that observed with
omeprazole or lansoprazole [184] . Pharmacokinetic studies, performed in Japanese subjects,
showed a 7-fold longer half-life (7.6 and 13.7 h after single and repeated administration of 20
mg, respectively), compared to the other PPIs. As a consequence, the area under the
concentration-time curves, that reflect tissue exposure, was about 20-fold higher after single oral
administration of 20 and 40 mg of the drug (24.50 and 67.76 mg h/ml, respectively) [185] .
These pharmacokinetic properties translated into a long-lasting antisecretory action. Indeed,
inhibition of basal and tetragastrinstimulated acid output in healthy volunteers was still
significant 2 days after tenatoprazole administration. Intragastric pH recordings, performed after
repeated administration of a dose as low as 10 mg of the drug, did show that the time spent above
pH 3 and pH 4 reached 96.7 and 88.0%, respectively. The most interesting finding was the
prolonged effect of tenatoprazole during nighttime, since the % of pH holding time above 3 and
4 was almost identical during this period compared to daytime (94.7 vs. 98.3% and 86.3 vs.
89.3%, respectively) [185] . The compound was originally discovered by Mitsubishi Pharma and
was therefore first studied in Japanese subjects. Pharmacokinetic (and consequently
pharmacodynamic) differences between East Asians and Caucasians are well known, being
mainly due to genetic polymorphism of several phase I enzymes such as CYP2D6 and the
CYP2C subfamily [186] . Since the pharmacokinetics and pharmacodynamics of PPIs depend on
CYP2C19 genotype status, CYP2C19 genotype-dependent differences in pharmacokinetics and
pharmacodynamics of PPIs influence the cure rates for the GERD and H. pylori infection by PPI-
based therapies [187] . Pharmacokinetics of tenatoprazole was thus re-investigated in H. pylori -
negative healthy Caucasian subjects in a randomized, double-blind, dose-ranging study (10–80
mg, either single and repeated administration). A linear correlation between tenatoprazole dose
and AUC was found, thus showing a linear pharmacokinetic pattern ( fi g. 10 ). The long half-life
of tenatoprazole was confirmed for every dose, reaching 8.7 8 2.6 h for repeated administration
of 40 mg [188] . A comparison of pharmacokinetic parameters between Asian and European
subjects is shown in table 2 . Pharmacodynamic studies on the same subjects showed an increase
of intragastric pH with tenatoprazole 40 mg daily for 7 days significantly higher (p ! 0.05) than
that observed with the same regimen of esomeprazole, the median pH being 4.6 8 0.9 and 4.2 8
0.8, respectively [189] . In addition, the time spent above pH 4 during nighttime after
tenatoprazole administration was significantly longer than that observed with esomeprazole
( table 3 ). The intragastric pH during the night was similarly higher (4.7 8 1.1 units with
tenatoprazole and 3.6 8 1.4 units with esomeprazole, p ! 0.01) [189] . The better control of
intragastric acidity achieved with tenatoprazole during the night was already evident from the
first 24 h of dosing [190] . A recent pharmacodynamic and pharmacokinetic investigation
[191]confirmed and extended previous data showing the prolonged duration of acid suppression
with tenatoprazole ( fi g. 11 ). The proportion of healthy volunteers spending at least 16 h above
pH 4 in the 24-hour period was remarkably higher with tenatoprazole than with esomeprazole
(81.5 vs. 34.5%, p ! 0.001), while the proportion of subjects with NAB was lower (73.1 vs.
93.1%, p = 0.06), although the difference fell short of statistical significance. Even 3 days after
treatment was discontinued, mean 24 h pH, and percentage of time at pH 1 3 and pH 1 4 were
significantly higher with tenatoprazole, indicating a sustained control of intragastric acidity with
this novel PPI compared to esomeprazole. After 7 days of repeated dosing the maximal plasma
concentration of tenatoprazole was almost 6 times higher than that of esomeprazole, while AUC
was 32 times higher. A significant correlation between AUC and percentage of time intragastric
pH 1 4 was observed with tenatoprazole not only during but also after stopping treatment [191] .
All these data clearly show that – compared to the existing PPIs – tenatoprazole has a longer
half-life and a longer duration of the antisecretory action, in agreement with the current
knowledge according to which the antisecretory effect is proportional to the AUC [121, 192] .
Although these properties should theoretically translate into a better therapeutic efficacy, no
randomized clinical trials in acid-related diseases are available as yet. It is worth mentioning,
however, that a preliminary analysis of a phase II dose-ranging (10, 20 and 40 mg daily)
Canadian study, performed in patients with reflux esophagitis (grade A–C according to Los
Angeles classification), demonstrated that this novel PPI effectively heals mucosal lesions
regardless of the dose [Alan B. Thomson, pers. commun.]. After 4 weeks of treatment with
whatever dose of tenatoprazole, the healing rate was larger than that reported with esomeprazole
(40 mg daily) in published clinical trials. Like the other PPIs, tenatoprazole is a racemic mixture
of two stereoisomers which derive from the chiral nature of the sulfur atom of the sulfi nyl group
[193] . As a consequence, in order to exploit the features of stereoselective catabolism, the S-
isomer was selected for further development [194] . As expected, the in vitro binding of both
Sand R-tenatoprazole to hog gastric H+ ,K+ -ATPase was virtually the same and overlapped that
observed with the racemate [181] . Similarly, there was no difference in binding reversibility
kinetics amongst the different forms of this PPI [181] . Preliminary experiments in laboratory
animals did confirm the antisecretory and ulcer healing activity of S-tenatoprazole and did point
out that this isomer is more effective than R-tenatoprazole [Ficheux et al., unpubl. observations].
A careful pharmacokinetic and structural study by George Sachs’ team [181]showed that the oral
bioavailability of S-tenatoprazole sodium salt hydrate is almost twice that of S-tenatoprazole-free
form ( fi g. 12 ). The difference in bioavailability can be explained by the better solubility of the
sodium salt due to its peculiar crystal structure. The crystal form of S-tenatoprazole sodium salt
hydrate is indeed quite different from that of S-tenatoprazole-free form. In the crystal of S-
tenatoprazole sodium salt hydrate there is a loose packing structure of molecules, which results
in rapid water access and hence greater solubility. The pharmacokinetics of S-tenatoprazole
sodium was then studied in healthy volunteers and proved to be linear with a dose-related
increase in both Cmax and AUC [Ficheux et al., unpubl. observations]. The antisecretory effect
of this stereoisomer (80 mg orally once a day over 1 week) was investigated in H. pylori -
negative healthy subjects. On day 7, intragastric pH was markedly increased and remained over 5
or above throughout most of the 24-hour recording period, both during day- and nighttime
[Galmiche, pers. commun.]. Some pharmacodynamic and healing studies with S-tenatoprazole
sodium have already been planned and will start in the near future. In summary, the available
studies point out both pharmacokinetic and pharmacodynamic advantages of tenatoprazole over
esomeprazole. Since this last compound provides – amongst the members of the class – the most
effective control of intragastric pH whatever the parameter considered [195] , it is conceivable
that tenatoprazole could similarly be better than the other existing PPIs. Tenatoprazole (as well
as its S-isomer) then appears a promising PPI for the treatment of acid-related diseases, where it
has the potential to address unmet clinical needs. Potassium-Competitive Acid Blockers The next
generation of drugs which suppress gastric acidity will most likely be P-CABs which are K+ -
competitive inhibitors of the ATPase [93] . While the PPIs have a unique mechanism of action
based on their chemistry, P-CABs have a structural specificity for their target, the K+ -binding
region of the H+ ,K+ -ATPase. Although it can also be activated by NH4 + in vitro, the proton
pump is highly selective for K+ [196] . In common with many other cells, the level of K+ in the
parietal cell is higher than that in the plasma. The higher intracellular K+ level is dependent on
H+ ,K+ -ATPase. This enzyme, located on the basolateral membrane of the cell, exchanges
intracellular H+ for extracellular K+ [10] . The level of K+ within the cell is also regulated by
K+ channels, which allow ion movement across the basolateral membrane ( fi g. 13 ). These
channels have a particularly important role in generating negative cell membrane potential.
Given the importance of the cation for enzyme function, agents that compete with the binding of
K+ have the potential to block acid secretion. P-CABs inhibit H+ ,K+ -ATPase by binding
ionically to the enzyme and thus prevent its activation by the K+ cation. Since these molecules
are larger than K+ , it is likely that they compete by preventing the access of the cation to its
binding site rather than occupying the ion-binding site directly. P-CABs, despite sharing the
same mechanism of action, represent a heterogeneous class of drugs. Indeed, they belong to four
different chemical classes, namely imidazopyridines, pyrimidines, imidazonaphthyridines and
quinolones [93, 94] . The prototype P-CAB, SCH28080, was developed by Schering-Plough
more than 20 years ago. In a study published in 1982, this compound was shown to inhibit
gastric acid secretion in humans [197] , although its mechanism of action was not fully
understood at the time. Subsequently, SCH28080 was shown to block gastric H+ ,K+ -ATPase
by competing with K+ [198] . The development of SCH28080 was discontinued because of
hepatic toxicity. Since then, several other compounds with this peculiar mechanism of action
have been synthesized and studied, but only few did reach clinical development. Four
representative members of the P-CAB class have been studied in humans with the aim of finding
a suitable drug for the treatment of acid-related diseases ( table 4 , fi g. 14 ). Despite a number of
papers presented at the recent DDW (Chicago 2005) and UEGW (Copenhagen 2005) and two
clinical trials on GERD (registered at www.clinicaltrials.gov) that were successfully completed,
AZD0865 was discontinued [199] . The same holds true for CS526. However, a follow-up
compound of soraprazan is currently in phase I [200] . Therefore, there are still three molecules
under active development. P-CABs are lipophilic, weak bases that have high pKa values and are
stable at low pH. This combination of properties allows them to concentrate in acidic
environments. For example, the concentration of a P-CAB with a pKa of 6.0 would theoretically
be expected to be 100,000- fold higher in the parietal cell canaliculus (pH = 1) than in the plasma
(pH = 7.4). The concentration of P-CABs in the gastric mucosa is demonstrated by in vitro and
in vivo studies with AZD0865 and revaprazan [201, 202] . On entering an acidic environment, P-
CABs are instantly protonated and it is in this form that it is thought to bind to and inhibit the
enzyme. The protonated form of a P-CAB inhibits H+ ,K+ -ATPase by binding ionically to it, as
illustrated by the recovery of enzymatic activity after washout of AZD0865 and revaprazan [201,
202] . This family of compounds binds to the outward-facing conformation of the pump on the
luminal side and do not require its activation. This would suggest that these agents will produce
more rapid acid inhibition and will be able to elevate gastric pH to a higher level than PPIs. Both
animal and human studies have shown that PCABs achieve rapidly peak plasma concentrations
after oral administration. This is partly due to their stability at low pH allowing their
administration as IR formulations. All the compounds studied to date exhibit a linear
pharmacokinetic pattern [93] . The rapid absorption of PCABs is mirrored by a fast onset of acid
inhibition. In healthy volunteers, a single oral dose of pumaprazole (an imidazopyridine
compound marked BY841) [203]or revaprazan [204]increased intragastric pH to about 6 within
30–60 min, whereas high doses of AZD0865 resulted in over 95% inhibition of acid secretion
within 1 h after oral dosing [205] . Both the degree [206]and the duration [205]of the
antisecretory action are dose-dependent. As for PPIs [207] , the pH-rising effect of P-CABs
seems to be increased in the presence of H. pylori infection [208] . Animal studies have shown a
close correlation between maximum inhibition of acid output and the logarithm of Cmax [93] ,
thus suggesting that the duration of action of P-CABs will depend on their half-life. One
drawback of these agents is the need for twice-daily dosing since they inhibit the pump only for
the duration of their presence in the blood; however, since these compounds are acid-stable, their
plasma half-life may be readily prolonged with extended-release formulations [92] . The main
differences between P-CABs and PPIs are summarized in table 5 . It is evident that P-CABs offer
a more rapid elevation in intragastric pH than a PPI (and similar to that achieved by an H2 -RA)
while maintaining the same degree of antisecretory action, whose duration is dependent on half-
life and can easily be prolonged by appropriate formulations. Whether these favorable
pharmacodynamic properties will translate into clinical benefits is unknown. Results of phase III
clinical trials with one of such compound (namely revaprazan) are eagerly awaited. New H2 -
Receptor Antagonists As already discussed, despite all the intrinsic limitations, there is still a
place for H2 -RAs in the era of PPIs. A recent survey of Castell’s team [71]found that the
majority of GERD patients report a persistent improvement of nighttime symptoms from bedtime
H2 -RA use and suggested that a possible clinically important tolerance does occur in a small
number of patients. In this connection a fast-dissolving oral tablet containing a fixed dose
combination of a PPI and an H2 -RA (product marked OX 17) has been developed by Orexo AB
(Uppsala, Sweden) and phase II clinical trials with this formulation are presently Fig. 15.
Chemical structure of the novel H2 -receptor antagonists ebrotidine and lafutidine. Besides S-
and R-isomers, cis - and trans -isomers of lafutidine have also been isolated. P-CABs PPIs Acts
directly on the H+,K+-ATPase enzyme Requires transformation to the active form Super-
concentrates in parietal cell acid space (100,000-fold higher than in plasma) Concentrate in
parietal cell acid space (1,000-fold higher than in plasma) P-CABs binds competitively to the
potassium binding site of H+,K+-ATPase Sulfenamide binds covalently to H+,K+-ATPase
Duration of effect related to half-life of drug in plasma Duration of effect related to half-life of
the sulfenamide-enzyme complex Full effect from first dose Full effect after repeated doses
Table 5. P-CABs and PPIs: main differences in the mechanism of action on the way in Europe
[209] . A combination of H2 -RA with the novel PPI tenatoprazole has also been patented [210] .
Although the last decade has been dominated by the growing use of PPIs, several new H2 -RAs
have been synthesized. While the majority of them have been discontinued, few molecules
reached clinical development and two (namely ebrotidine and lafutidine, fi g. 15 ) have actually
been marketed. These drugs belong to a new generation of H2 -RAs which combine the
antisecretory effect with a mucosal-protective activity. Ebrotidine has been developed by the
Ferrer group in Spain [211] . The drug is able to displace 3 H-thiotidinespecifi c binding to H2 -
receptors with an affinity (Ki 127.5 nmol/l) significantly (p ! 0.05) higher than that of ranitidine
(Ki 190.0 nmol/l) and cimetidine (Ki 246.1 nmol/l) [212] . Its antisecretory efficacy is similar to
that of ranitidine and 10 times higher than that of cimetidine [211] . The mucosal-protective
properties of ebrotidine, possibly due to enhanced mucosal synthesis of both endogenous
prostaglandins (PGs) and nitric oxide (NO) [213, 214] , stem from its ability to improve the
physicochemical characteristics of mucus gel (i.e. increase in mucus gel dimension, viscosity,
hydrophobicity and hydrogen ion retardation capacity). Improvements in mucus gel-protective
qualities with ebrotidine are directly related to the ability of the drug to enhance the synthesis
and secretion of sulfo- and sialomucins and phospholipids of gastric mucus and to promote
mucin macromolecular assembly [215] . This drug also exhibits an inhibitory activity against H.
pylori that is synergistic with a number of antibacterial agents; it inhibits the urease enzyme and
the proteolytic and mucolytic activities of H. pylori , and counteracts the inhibitory effects of H.
pylori lipopolysaccharide. Although ebrotidine proved to be as effective as ranitidine for the
treatment of patients with PU or erosive refl ux esophagitis [211] , it achieved a significantly
better ulcer healing rate (94 vs. 86%, p ! 0.05) than ranitidine treatment in smokers [216] .
Unfortunately, the drug was prematurely withdrawn from the Spanish market because of serious
hepatotoxicity [217–219] . Another peculiar H2 -RA endowed with both antisecretory and
mucosal-protective activities is lafutidine . This drug, originally developed by Fujirebio Inc.
[220] , is currently marketed by UCB and Taiho Pharmaceutical in Japan. This compound
showed a potent and long-lasting inhibition of tiotidine binding and histamine-induced cyclic-
3 ,5 -adenosine monophosphate production in Chinese hamster ovary cells expressing human H2
-receptors [221] . Animal experiments [222]have pointed out that lafutidine has a potent and
long-lasting antisecretory effect, a finding confirmed by human investigations [223] showing that
this drug inhibits acid secretion more strongly than conventional H2 -RAs. Conversely from
ranitidine and famotidine, lafutidine increases both day and nighttime intragastric pH in H. pylori
-negative subjects [224] , and conversely from omeprazole (and other PPIs) its efficacy is not
influenced by the CYP2C19 genotype status [223] . When used in combination with antibiotics
(namely clarithromycin and amoxicillin) it achieves an eradication rate which is comparable to
that of the same PPI-based triple therapy [225] . A recent crossover study [226]in healthy
volunteers did show that a single dose (10 mg) of this novel H2 -RA is able to increase
intragastric pH more quickly than a single dose (20 mg) of rabeprazole, the fastest amongst the
available PPIs [227] . Both in fasting conditions and in the postprandial state, the duration of the
antisecretory action was longer than that of the PPI since the drug maintained the pH over a
given threshold for a sustained period of time ( fi g. 16 ). Its terminal half-life (3.30 8 0.39 and
3.79 8 1.02 h in fasting and fed conditions, respectively [228] ) is longer than that of cimetidine,
ranitidine and nizatidine [55, 229]and shorter than that of roxatidine, but not dissimilar from that
of famotidine [55] . Conversely from other H2 -RAs [230] , lafutidine does increase SST release,
which may contribute to its antisecretory effect [231] . Similarly, the observed rise in calcitonin
gene-related peptide (CGRP) levels after drug administration could account for both its acid-
lowering and cytoprotective activities [232] . Lafutidine displays mucosal protection against a
variety of noxious agents, and structure-activity relationships revealed that the presence of
furfurylsulfi nyl, pyridyl and amide moiety ( fi g. 15 ) are chemically important for the
gastroprotective activity. The mucosal-protective effect of lafutidine is attenuated by
pretreatment with the antagonist of CGRP (CGRP8-37) and the blocker of NO production (NG -
nitro-L -arginine), as well as chemical ablation of capsaicin-sensitive sensory neurons,
suggesting that this action appears through capsaicin-sensitive afferent neurons and is mediated
by CGRP and NO [233] . Interestingly enough, lafutidine also exhibits a protective activity
against the experimentally-induced mucosal lesions in digestive tissues other than the stomach,
i.e. acid induced reflux esophagitis [234] , indomethacin-induced small intestinal lesions
[235]and colonic inflammation induced by dextran sulfate sodium [236] . Finally, this H2 - RA
inhibits H. pylori -induced IL-8 release from gastric epithelial cells and impairs cellular adhesion
of the microorganism, protecting in this way against the mucosal inflammation associated with
the infection [238] . Provided lafutidine is available worldwide, it will represent a quick and
strong means of inhibiting acid secretion which is particularly suitable for on-demand use in
PUD and GERD, where it could also be useful to control NAB. It could also be particularly
effective in the prevention and treatment of NSAID-associated GI lesions. In this setting, its
marked and long-lasting antisecretory activity, coupled with the mucosal-protective properties,
will probably allow the drug to go beyond the intrinsic limitations of conventional H2 -RAs,
which only protects the duodenum [35, 37] . In this connection, the use of lafutidine and its
isomers [238]in the prevention or treatment of inflammatory enteropathy has recently been
patented [239] . According to R&D Focus, some other H 2-receptor antagonists are being
developed. Among them, CP-66,948 developed by Pfizer Inc. (Groton, Conn., USA), a
compound [2-(N-pentyl-N-guanidino)-4-(2-methylimidazol4-yl)thiazole] possessing both
antisecretory and mucosa protective properties [240]entered phase I trials. Preliminary results
have shown that a single oral bedtime dose (50 mg) of CP-66,948 produced the same inhibition
of acid secretion achieved by 150 mg of ranitidine. However, no further development is currently
reported. A similar compound (TRM 115 by Terumo Co., Tokyo, Japan) was recently
discontinued after completing phase I studies. Gastrin (CCK2 ) Antagonists Gastrin is a major
endocrine regulator of gastric acid secretion and its release stimulates an estimated mean of 90%
of postprandial secretion [1] . This hormonal peptide is produced by the antral G cells in
response to food proteins and their digestion by-products as well as upon stimulation by gastrin-
releasing peptides from postganglionic fibers of the vagus nerve [241] . Besides its central role in
the regulation of acid secretion, gastrin also affects GI motility [242]and stimulates epithelial cell
proliferation throughout the GI tract [243] . Gastrin displays a structural similarity with
cholecystokinin (CCK), another GI peptide released by lipids from the upper small bowel I cells
[244] . Both peptides share indeed the same C-terminal pentapeptide amide sequence although
they differ in sulfation at the sixth (gastrin) and seventh (CCK) tyrosyl residues [241, 244] . As a
consequence, they both bind to the same receptors located on parietal cells, and CCK also
stimulates acid secretion both in vitro and in vivo. CCK however stimulates fundic D cells to
produce SST, which in turn inhibits both gastrin release and acid secretion [244] . Receptors for
CCK are a family of G protein-coupled receptors, which were fi rst characterized on pancreatic
acinar cells and identified as CCK type A receptors (now called CCK1 ), with the subsequent
discovery in the same year of a second receptor with a different pharmacology in the brain, i.e.
CCK type B receptors (now CCK2 ) 1 [244, 245] . These two types of CCK receptors could be
pharmacologically distinguished on the basis of their affinity for the agonists CCK and gastrin
and by recently developed subtype-specific antagonists. CCK1 receptors are highly selective
(500- to 1,000-fold) for sulfated analogs of CCK, whereas CCK2 receptors have similarly high
affinity for both sulfated and nonsulfated peptide analogs of CCK and gastrin peptides [245, 246]
. However, although binding the same receptors, gastrin is mainly a peripheral ligand, while
CCK is considered a brain-gut peptide thanks to its effects on the CNS. Formerly, the gastrin
receptor mediating acid secretion in the stomach was thought to constitute a third type of high-
affinity receptor on the basis of its location, small differences in affinity for CCK and gastrin-like
peptides, and the reversal in relative affinity for receptor subtype-selective antagonists in canine
gastric glands. Subsequent cloning of gastrin receptors from canine stomach and CCK2 receptors
from canine brain revealed their molecular identity, leading to the classification of gastrin
receptors as CCK2 receptors [245] . These receptor subtypes have been found not only on
parietal cells [246]but also on ECL cells [247] , fundic D cells [248]and the vagus nerve [246] .
The known targets for gastrin-mediated acid secretion are histamine-releasing ECL cells and
acid-secreting parietal cells, which both possess a CCK2 receptor [249] . The current concept of
gastrin regulation of acid secretion involves a complex but incompletely delineated mechanism.
The feedback loop is constituted by at least three key elements: the G cell, the ECL cell, and the
parietal cell, and their products gastrin, histamine and hydrochloric acid, respectively. Gastrin
has a direct secretory effect on both parietal cells and ECL cells, although the latter effect is
probably far more significant. The peptide mediates histamine release from ECL cells via
activation of its CCK2 receptors. The initial signal transduction events involve a transient rise in
intracellular calcium, followed by histamine granule exocytosis [249] . This process occurs
maximally within 5 min. Thereafter, extracellular calcium influx and histidine decarboxylase
(HDC) activation are presumed to play a role in subsequent histamine release [249] . The
released histamine is a potent stimulant of acid secretion, exerting a direct stimulatory effect on
the H2 - receptor of the parietal cell. The parietal cell secretory product, hydrochloric acid,
causes antral inhibition of gastrin release from the G cell, probably via a SST-regulated
mechanism. It also seems probable that SST by a direct action on ECL cells is able to inhibit
histamine release, since the direct effect of paracrine peptide on parietal cells is not pronounced
in vitro [4] . Indeed, ECL cells have been reported to express SST receptors, suggesting a dual
regulation of the ECL cell by both gastrin and SST [250] . Whilst gastrin appears to be a major
stimulant for histamine release, there is also significant evidence for the role of other gut
neurotransmitters, namely acetylcholine, vasoactive intestinal peptide, PYY and corticotropin
generelated peptide (CGRP) in this process [251] . Given the important physiological role of
gastrin in the stimulation of gastric acid secretion, selective CCK2 - receptor antagonists offer a
potential approach to regulate acid production. High-affinity nonpeptide antagonists for both
types of CCK receptors were synthesized more than 15 years ago. Their availability has
stimulated a broad array of investigations into the physiologic actions of CCK-like peptides
[252] , including gastrin [253] . At least 12 chemical classes of CCK-receptor antagonists have
been described [254] . Amongst them, several ligands with high affinity for CCK2 receptors
have been identified and characterized by binding and pharmacodynamic studies [246] .
However, only few have been tested in humans for their effect on acid secretion or their
anxiolytic activity2 . The 5 compounds, whose antisecretory effect was studied in clinical trials,
will be reviewed in detail. They belong to amino acid (i.e. spiroglumide and itriglumide) or
benzodiazepine (i.e. L-365,260, YF476 and Z-360) derivatives ( fi g. 17 ). Amongst the amino
acid derivatives, proglumide, which has long been used as an antiulcer drug [256] , was
considered the prototype CCK antagonist [257] . Its low potency and specifi city (the compound
binds to both types of receptors) stimulated the synthesis of glutaramic acid derivatives, the most
interesting ones being lorglumide and loxiglumide (as selective CCK1 -receptor antagonists) and
spiroglumide and itriglumide (as CCK2 -receptor antagonists). These compounds (developed at
Rotta Research Laboratorium, Milan, Italy) are active after oral administration and able to
antagonize the effects of both endogenous and exogenous peptides (i.e. CCK and gastrin) [258,
259] . Animal studies [260, 261]have shown that spiroglumide (compound marked CR-2194) is a
selective CCK2 antagonist, capable of inhibiting dose-dependently pentagastrin- but not
carbachol- or histamine-stimulated acid secretion. Studies performed on healthy volunteers [262]
confirmed the inhibitory activity against gastrin-induced acid secretion and also showed its
ability to inhibit postprandial gastric secretion. Despite these promising results, the development
of spiroglumide was ended because more potent and selective derivatives became available.
Itriglumide (compound marked CR-2945) is a follow up selective antagonist endowed with a
good oral bioavailability [263] . After intraduodenal administration, the drug proved to be more
potent as an antisecretory compound than either ranitidine or omeprazole [263] . Its healing
activity of experimentally-induced gastric and duodenal ulcer was comparable to that of
ranitidine. The pharmacodynamics and pharmacokinetics of itriglumide were recently studied in
humans, where the compound inhibited gastrin-stimulated acid secretion in a dose-dependent
manner ( fi g. 18 ). The pharmacokinetics proved to be linear in the dose range of 30–600 mg
and drug was well tolerated at any dose level [264] . Itriglumide therefore appears to be a
promising CCK2 antagonist that deserves further clinical investigations in acid- and
gastrinrelated disorders. The other major chemical class of CCK2 antagonists has exploited a
benzodiazepine template present in asperlicin, which was initially discovered in a natural product
screen for CCK receptor antagonists. The structurally related benzodiazepines L-365,260 and
YF-476 are selective antagonists of the CCK2 receptor subtype. Their in vitro pharmacological
profi les have been characterized using the human CCK2 receptor expressed in Chinese hamster
ovary cells. Conversely from other benzodiazepine derivatives (L-740,093 and YM022), which
display an insurmountable antagonism, L-365,260 (developed at Merck Research Laboratories,
West Point, Pa., USA) behaves as a competitive antagonist [265] . Animal experiments [266–
270]have shown that this compound inhibits pentagastrin-stimulated acid secretion and that
higher doses also affect basal gastric secretion as well as the response to other secretagogues.
Thanks to its antisecretory activity, the drug proved to be capable of preventing aspirin-
associated gastric damage and cysteamine-induced duodenal ulcer. In humans, L-325,260
confirmed its selectivity towards CCK2 receptors being able to inhibit pentagastrin-stimulated
acid secretion [271]but not fat-induced gallbladder emptying [272] . The drug does not inhibit –
at the clinically tested doses – basal acid secretion and has poor bioavailability. Its development
as an antisecretory compound is therefore unlikely. Nevertheless, since L-325,260 crosses the
blood-brain barrier [273] , reaching and binding central CCK2 receptors, it represents a useful
tool to assess the physiology and pathophysiology of CCK in the CNS. A placebo-controlled trial
in patients with panic disorders [274]gave however disappointing results. A back-up compound
(L-368,935) with more water solubility [275]and less CNS penetration [276]and thus more
suitable for peripheral receptor blockade has entered phase I in the USA. YF-476 is a potent and
orally active CCK2 antagonist synthesized at Ferring Research Institute (Southampton, UK)
[277]and co-developed with Yamanouchi Pharmaceutical Co. (Tsukuba, Japan). In vitro and
vivo experiments [278, 279]have confirmed its high selectivity by showing that its affi nity for
the rat brain CCK2 receptors is 4,100 times higher than that for rat pancreatic CCK1 receptors
and that the drug is able to inhibit pentagastrinbut not histamine-stimulated acid secretion in rats
and dogs. In dogs with gastric fistula its antisecretory activity was found to be 7 and 40 times
more potent than that of famotidine and omeprazole, respectively [279] . The potent and long-
lasting antisecretory effect of YF-476 was confirmed in human studies after single administration
of the drug [280] , which also found a linear pharmacokinetics with a half-life of 7.1 h after oral
administration of 100 mg. However, the effect of repeated (7 days) doses of this compound on
intragastric pH was disappointing, with the 200-mg daily dose giving a significant inhibition of
acid secretion only in the postprandial period [281] . The adaptation of the antisecretory effect of
YF-476 after short-term administration is unlikely to be due to endogenous gastrin increase
[282]and might reflect up-regulation of gastrin (CCK2 ) and/or histamine receptors. According
to R&D Focus, a third benzodiazepine derivative, presently in a phase I study in UK, is the
compound marked Z-360 , developed at Zeria Pharmaceutical Co., Japan. Preclinical studies
[283]have shown a very high (615-fold) selectivity toward human CCK2 receptors compared to
CCK1 ones. The drug dose-dependently inhibited pentagastrin- but not histamine- or carbachol
stimulated acid secretion with a potency 50 times higher than that of L-365,260. In Pavlov pouch
dogs, postprandial acid secretion was inhibited by 70% by Z-360 while other CCK 2 antagonists
(namely L- 365,260 and YM 022) proved to be ineffective [284] . Being CCK2 receptors
expressed in the regenerative mucosa adjacent to the ulcer margin they can mediate the gastrin-
enhanced cell proliferation underlying ulcer healing [285] . Therefore, despite their acid-
lowering activity, CCK2 antagonists might delay mucosal healing. Because of this concern and
because of the development of tolerance (see above), it is unlikely that these compounds will be
used as antiulcer drugs. Similarly, it is difficult to imagine these agents as an alternative to PPIs
in GERD. On the contrary, their use together with long-term acid suppression would prevent the
consequences of PPI-induced hypergastrinemia (e.g. ECL cell hyperplasia or gastrindriven GI
malignancies) [286–289] . As a matter of fact, a preclinical study using the benzodiazepine
CCK2 -receptor antagonist Z-360 seems to confirm this hypothesis. Rats were given repeated
doses of Z-360, omeprazole or a combination of the two compounds for 4 weeks. Although both
drugs caused hypergastrinemia, omeprazole but not Z-360 caused ECL hyperplasia. In addition,
Z360 significantly reduced omeprazole-induced hyperplasia [283] , thus suggesting that CCK2-
receptor blockade could prevent ECL cell proliferation stimulated by long-term treatment with
PPIs. In this connection, several patents concerning this particular application of CCK2
antagonists have been granted to the James Black Foundation [290] . An additional logic use of
this class of drugs is the treatment of GI and pancreatic cancer. Indeed, it is becoming
increasingly apparent that gastrin and gastrin (CCK2 ) receptors are expressed in a number of
tumor sites (GI and non-GI) throughout the body [291] . It is noteworthy that in these neoplastic
cells posttranslational processing of gastrin is not as well developed as in endocrine cells and
other less completely processed forms of gastrin, such as glycine-extended gastrin, may also
have a role [292] . Despite being attractive from a theoretical point of view, targeting CCK2
receptors in cancer however has not provided optimal beneficial effects, as yet [293] .
Antigastrin Vaccine G-17DT is an immunoconjugate of the amino-terminal sequence of gastrin
17 (G-17) linked by means of a spacer peptide to diphtheria toxoid ( fi g. 19 ) [294] . It has been
developed by Aphton Corp. (Miami, Fla., USA), originally labeled as Gastrimmune™ and later
known as Insegia™. Given as an intramuscular vaccination, it has been shown to induce the
formation of antibodies that can neutralize not only G-17 but also its precursor glycine-extended
G-17, which also stimulates the growth of human gastric and possibly other GI cancers [295] .
These anti gastrin antibodies can inhibit the proliferation of pancreatic cancer cell lines. In a
phase II study of 30 patients with pancreatic cancer, 67% of them were shown to mount an
immune response to the vaccine. Eighty-two percent of patients given the highest dose of the
vaccine (250 g) achieved a response. There was indeed a significant difference between the
median survival times noted for patients who produced an immune response and for those who
did not [296] . While preliminary, these results are promising and three phase III clinical trials
(registered at www.clinicaltrials.gov) with G-17DT, alone or in combination with chemotherapy,
are ongoing [297] . In addition to the treatment of GI and pancreatic cancer, the use of G-17DT
has been proposed for the management of GERD. Indeed, besides stimulating acid secretion, G-
17 also affects lower esophageal sphincter function. Indeed, continuous intravenous infusion of
this peptide to healthy volunteers significantly increases gastroesophageal reflux and the number
of transient lower esophageal sphincter relaxations associated with reflux [298] . Active
immunization against G-17 should not only neutralize its acidstimulating properties but also
reduce postprandial gastroesophageal refl ux. Animal studies [299–301]have indeed shown that
this antigastrin vaccine strongly inhibits gastric acid secretion. Therefore, G-17DT would
represent a reliable mean of achieving acid suppression while avoiding hypergastrinemia. A
phase II clinical trial in GERD has been started although not currently recruiting patients [302] .
Aphton has also patented the use of G-17DT together with antisecretory agents for the treatment
of GERD [303] . Combination therapy is claimed to be a more effective method of controlling
gastric acid secretion since two independent mechanisms will operate. In addition, the gastrin
immunogen will block PPI-induced hypergastrinemia, thus reducing mucosal hyperplasia [290] .
Conclusions and Perspectives for the Future The discovery of gastrin by John Edkins
[304]initiated the scientific examination of the regulation of gastric acid secretion and led to
elucidation of the pathogenic basis of PU and its subsequent cure. During the course of the
century after this breakthrough, the identification of the cellular regulators of acid secretion
culminated in the development of novel pharmacotherapeutic agents, namely H2 -RAs and PPIs,
which allowed the effective and safe treatment not only of PU but also of GERD and other acid-
related disorders. Although antisecretory therapy has advanced dramatically since the
introduction of cimetidine in the mid-1970s, there are several identifiable unmet needs especially
in the management of GERD, where an antisecretory therapy with rapid onset of action and
sustained antisecretory effect would be desirable. This is also true in the management and
prevention of nonvariceal upper GI bleeding and may be increasingly important in patients
taking NSAIDs. A number of new drugs are currently being investigated to provide a signifi cant
advance on current treatments. Some of them (namely P-CABs and CCK2-receptor antagonists)
have already reached clinical testing while some others (like the antigastrin vaccine, H3-receptor
ligands or gastrin-releasing peptide (GRP) receptor antagonists) are still in preclinical
development and need the proof of concept in human beings. An increasing body of evidence
suggests that H3 -receptors are involved in the regulation of acid secretion as well as mucosal
protection [for review, see 150]and several potent and selective H3 -receptor agonists and
antagonists have been synthesized [305] . None of these compounds has however been tested in
humans, as yet. Similarly, although endogenous GRP is involved in the regulation of acid
secretion, GRP antagonists (like, for instance, BIM-26226 or BW2258U89) have been used in
men only as a pharmacological tool to gain new insights into the physiological role of the peptide
rather than as antisecretory drugs [150] . However, the potential therapeutic applications of these
antagonists would be limited by the fact that blockade of GRP receptors also affects other GI
functions, such as pancreatic secretion, gallbladder contraction and gastric as well as intestinal
motility [306] . Of the current approaches to reduce acid secretion, PCABs and CCK2 -receptor
antagonists hold the greatest promise, with several compounds already in clinical trials. Although
the quick onset of action of P-CABs (i.e. a full effect from the fi rst dose) is appealing, the results
of phase II studies with one such agent (namely AZD0865) did not show any advantages over
esomeprazole (Sohtell et al., pers. commun.). Furthermore, the development of this class of
drugs, which started in the early of 1990s, has been very slow, with many compounds abandoned
over the years for lack of efficacy or safety reasons. The results of clinical trials with soraprazan
are therefore eagerly awaited to understand whether such agents will have a role in the future
management of acid-related disorders. Thanks to their limited efficacy and the development of
tolerance, it is unlikely that CCK2 antagonists will be used alone as antisecretory compounds
but, rather, their combination with PPIs will be attempted with the aim of reducing the long-term
consequences of hypergastrinemia [288, 289] . This combination would be particularly useful in
patients with ZES, where the elevated gastrin levels [307]may also be associated with reduced
absorption of sodium and water in the gut as well as with the increased occurrence of carcinoids
[308] . While H2 -receptor antagonists (especially soluble or OTC formulations) will become the
‘antacids of the third millennium’ and will be particularly useful for on-demand symptom relief,
clinicians will continue to rely on PPIs to control acid secretion in GERD and other acid related
diseases. In this connection, new formulations, novel compounds and better acid-suppressing
regimens are welcome. The recently introduced IR-OME formulation (currently available only in
the USA) quickly increases intragastric pH and, given at bedtime, seems to achieve a better
control of nocturnal acidity. IR formulations of other PPIs (including the investigational ones)
will probably be available in the future and will enlarge our therapeutic armamentarium. As far
as the novel PPIs are concerned, tenatoprazole appears to be a true advance in the acid
suppression therapy. Its long half-life (the longest among the available compounds) and long
duration of antisecretory action, with no difference between day and night, will allow the drug to
go beyond the intrinsic limitations of currently available compounds. Thanks to its favorable
pharmacokinetics, the sodium salt of S-tenatoprazole is being developed and the preliminary
results indicate that this drug has the potential to address unmet clinical needs. Although some
decades have elapsed from the introduction of an effective and safe antisecretory drug in the
clinical practice and the therapeutic use of acid suppression has stood the test of time, a large
number of basic and clinical publications on the topic appear every year in the medical literature.
All this ongoing research clearly shows that the final chapter on the pharmacological treatment
of acid-related diseases has not yet been written. Acknowledgements We are indebted to Prof.
Marcello Tonini (Chairman, Department of Physiological and Pharmacological Sciences,
University of Pavia, Italy) for the critical reading of the manuscript and his useful suggestions.
We would also like to thank Dr. Elena Losi (Department of Pharmaceutical Chemistry,
University of Parma) for the invaluable help with the molecular structures of investigational new
drugs.