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Intestinal Motility Disorders Medication

  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Dec 29, 2015
 

Medication Summary

Drugs used in the management of intestinal motility disorders include cholinergic agonists, prokinetic agents, opioid antagonists, antidiarrheals, and antibiotics. The agents that are most useful in the treatment of these disorders are neostigmine,[32] bethanechol, metoclopramide, cisapride, and loperamide. Neostigmine appears to increase antral and intestinal motor activity in patients with hypomotility, including intestinal dysmotility.[32]

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Cholinergic Agonists

Class Summary

Excessive parasympathetic suppression appears to be involved in the genesis of intestinal pseudo-obstruction. Cholinergic agents may allow early resolution of pseudo-obstruction and obviate surgery.

Neostigmine (Prostigmin)

 

Neostigmine inhibits destruction of acetylcholine by acetylcholinesterase, which facilitates transmission of impulses across myoneural junction.

Bethanechol (Urecholine)

 

Bethanechol is a synthetic muscarinic stimulant. It should never be administered intravenously (IV) or intramuscularly (IM).

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Prokinetic Agents

Class Summary

Prokinetics are promotility agents, proposed for use with severe constipation-predominant symptoms.

Tegaserod (Zelnorm)

 

Tegaserod was temporarily withdrawn from the US market in March 2007; however, as of July 27, 2007, restricted use of tegaserod is now permitted via a treatment investigational new drug (IND) protocol. This protocol allows tegaserod treatment of irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Its use is further restricted to those in critical need who have no known or preexisting heart disease. (See the FDA MedWatch Product Safety Alert.)

Tegaserod is used for short-term treatment of women with IBS in which constipation is the predominant symptom. It is also indicated to treat CIC. Tegaserod is a serotonin type 4 receptor partial agonist with no affinity for 5-HT3 receptors. It may trigger peristaltic reflex via 5-HT4 activation, which enhances basal motor activity and normalizes impaired gastrointestinal (GI) motility. Research studies have shown inhibitory activity of the drug on visceral activity in the GI tract.

Metoclopramide (Reglan, Metozolv)

 

Metoclopramide is characterized by remarkable coordination of gastric and duodenal motility.

Cisapride (Propulsid)

 

Cisapride indirectly improves GI motility by promoting acetylcholine release from postganglionic nerve endings in the myenteric plexus. It was withdrawn from the US market on July 14, 2000, but the manufacturer will make it available to certain patients meeting clinical eligibility criteria for a limited-access protocol only.

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Opioid Reversal Agents

Class Summary

Consider using a peripherally selective opioid antagonist to treat constipation in patients who have advanced illness requiring chronic opioid analgesia and are unresponsive to laxatives.

Methylnaltrexone (Relistor)

 

Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist. It selectively displaces opioids from mu-opioid receptors outside the central nervous system (CNS), including those located in the GI tract, thereby decreasing constipating effects. Methylnaltrexone is indicated for opioid-induced constipation in patients with advanced illness who are receiving palliative care and whose response to laxatives has not been sufficient. It is available as a 12-mg/0.6-mL injectable solution for subcutaneous use.

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Antidiarrheals

Class Summary

Antidiarrheal agents inhibit peristalsis and slow intestinal motility.

Loperamide (Imodium)

 

Loperamide inhibits peristalsis by acting directly on the muscles of the intestinal wall, thereby slowing intestinal motility. It prolongs movement of electrolytes and fluid through the bowel and increases viscosity and loss of fluids and electrolytes.

Diphenoxylate and atropine (Lomotil)

 

Diphenoxylate and atropine is an antidiarrheal drug combination wherein diphenoxylate is chemically related to the narcotic analgesic meperidine. It acts on intestinal muscles to inhibit peristalsis and slow intestinal motility. It prolongs the movement of electrolytes and fluid through the bowel and increases viscosity and loss of fluids and electrolytes. A subtherapeutic dose of anticholinergic atropine sulfate is added to discourage overdosage, in which case diphenoxylate may clinically mimic the effects of codeine.

Difenoxin and atropine (Motofen)

 

Difenoxin and atropine is an antidiarrheal drug combination wherein diphenoxylate is chemically related to the narcotic analgesic meperidine. Difenoxin is the active metabolite of diphenoxylate, and it is active at one fifth the dose of diphenoxylate.

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Antibiotics

Class Summary

Erythromycin is a prokinetic agent for the stomach. It is indicated in patients with gastroparesis.

Erythromycin (E.E.S., Erythrocin, Ery-Tab)

 

Erythromycin is a macrolide antibiotic that duplicates the action of motilin and is responsible for migrating motor complex activity by binding to and activating motilin receptors. IV administration enhances the emptying rate of liquids and solids. The effect can be seen with oral erythromycin. The enteric-coated form may be better tolerated.

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Contributor Information and Disclosures
Author

Nafisa K Kuwajerwala, MD Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Breast Disease

Disclosure: Nothing to disclose.

Coauthor(s)

Vivek V Gumaste, MD Associate Professor of Medicine, Mount Sinai School of Medicine of New York University; Adjunct Clinical Assistant, Mount Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center at Elmhurst; Program Director of GI Fellowship (Independent Program); Regional Director of Gastroenterology, Queens Health Network

Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association

Disclosure: Nothing to disclose.

Luigi Santacroce, MD Assistant Professor, Medical School, State University at Bari, Italy

Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD Fellow in Bariatric/Advanced Laparoscopic Surgery, University of Missouri Healthcare

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Silvia Gagliardi, MD Consulting Staff, Department of Surgery, Medical Center Vita, Italy

Disclosure: Nothing to disclose.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Shivkumar Prabhu, MD Consulting Staff, Department of Internal Medicine, St John Detroit Riverview Hospital

Disclosure: Nothing to disclose.

Daniel Schafer Department of Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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