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Gastric and duodenal ethanol concentrations after intake of alcoholic beverages in postprandial conditions Jari Rubbens, Danny Riethorst, Joachim Brouwers, Kris Wolfs, Erwin Adams, Jan Tack, and Patrick Augustijns Mol. Pharmaceutics, Just Accepted Manuscript • DOI: 10.1021/acs.molpharmaceut.7b00252 • Publication Date (Web): 21 Jul 2017 Downloaded from http://pubs.acs.org on July 24, 2017
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Gastric and duodenal ethanol concentrations after intake
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of alcoholic beverages in postprandial conditions
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Jari Rubbensa, Danny Riethorsta, Joachim Brouwersa, Kris Wolfsb, Erwin Adamsb, Jan Tackc, Patrick
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Augustijnsa,*
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a
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Belgium,
[email protected];
[email protected];
[email protected];
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[email protected] 8
b
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[email protected];
[email protected] KU Leuven, Drug Delivery & Disposition, Gasthuisberg O&N2, Herestraat 49 Box 921, 3000 Leuven,
KU Leuven, Pharmaceutical Analysis, Gasthuisberg O&N2, Herestraat 49 Box 923, 3000 Leuven, Belgium,
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c
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Herestraat 49 Box 701, 3000 Leuven, Belgium;
[email protected] 12
*Corresponding author at: KU Leuven, Drug Delivery & Disposition, Campus Gasthuisberg O&N 2, Box 921,
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Herestraat 49, 3000 Leuven, Belgium.
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E-mail address:
[email protected] (P. Augustijns).
KU Leuven, Translational Research Center for Gastrointestinal Disorders (TARGID), Gasthuisberg O&N1,
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ABSTRACT
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Introduction: This study determined intraluminal ethanol concentrations (stomach and duodenum)
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in fed healthy volunteers after the consumption of common alcoholic beverages (beer, wine and
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whisky). The results of this study were compared with a previous study in fasted volunteers.
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Materials and methods: Five healthy volunteers were recruited in a cross-over study. The fed state
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was simulated by ingestion of 250 mL of Nutridrink Compact® Neutral. Volunteers subsequently
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consumed two standard units of beer (Stella Artois®, 500 mL, 5.2 % ethanol), wine (Blanc du Blanc®,
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200 mL, 11 % ethanol) or whisky (Gallantry Whisky®, 80 mL, 40 % ethanol). Gastric and duodenal
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fluids were aspirated through two catheters over time and analyzed for ethanol content by head
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space gas chromatography. The capability of ethanol to permeate gastric and duodenal rat mucosa
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was examined in an Ussing chambers setup.
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Results: A similar average gastric Cmax was observed in the beer and the wine conditions: 3.3 % and
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3.7% ethanol, respectively. The gastric Cmax in the whisky condition amounted to 8.5 % ethanol.
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Lower ethanol concentrations were observed in the duodenum compared to the stomach. The
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duodenal Cmax was similar in all three conditions: 1.3 %, 1.2 % and 1.6 % ethanol for beer, wine and
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whisky, respectively. Compared to the fasted state (reported in a previous study), higher gastric
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ethanol concentrations were observed during a longer time period. In the beer and wine condition,
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similar concentrations were observed in the intestine regardless of the prandial state. After intake of
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whisky, however, the ethanol concentration was lower in the fed intestine. Alcohol was observed to
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permeate both gastric and duodenal rat mucosa.
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Conclusion: Higher intragastric ethanol concentrations were maintained for a longer period of time
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in fed compared to fasted state conditions. However, the observed concentration profiles were not
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in line with current FDA guidelines for alcohol resistance testing of formulations, stating that in vitro
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tests should investigate the impact of up to 40 % ethanol for 2 hours. The presented intraluminal
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ethanol concentrations may serve as reference data for the further development of relevant in vitro
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models to assess ethanol effects on formulation performance.
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Key words
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Alcohol
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Stomach
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Intestine
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Alcoholic beverages
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Intraluminal ethanol concentrations
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Clinical study
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1. Introduction
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The ingestion of formulations with beverages other than water can pose a concern as standardized
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clinical trials typically only study drug administration with water. (FDA, 2002) A deviating intraluminal
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fluid composition (volume, pH, temperature, osmolality and solubilizing capacity) can influence drug
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release and thus absorption and systemic exposure.
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factor as it triggers multiple changes in gastrointestinal physiology. 3
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Co-ingestion of formulations with alcoholic beverages has been proven to potentially affect drug
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release and pharmacokinetics. 4 5 In severe cases, this may result in toxic drug concentrations. 6 Both
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the US Food and Drug administration (FDA) and the European Medicine Agency (EMA) recommend
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testing new formulations in vitro for ethanol resistance.
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explored the relevance of using ethanol concentrations of 20 % and 40% for a full two hours in vitro
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(according to FDA guidelines) to predict potential in vivo ethanol induced dose dumping. Studies in
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fasted healthy volunteers revealed relatively low and rapidly declining intragastric ethanol
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concentrations after consumption of common alcoholic beverages, contrasting current guidelines.
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However, Lennernas et al. suggested that a two-hour time frame can be physiologically relevant
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given the right conditions.
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content, posture, illness, polypharmacy…) may all contribute to a strongly delayed gastric emptying
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and a prolonged contact time between formulation and ethanol in the stomach. Though formulations
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can reside for a long time in a fed stomach, this effect is also prone to inter-subject variation. Higaki
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et al., for example, observed that the onset of caffeine absorption from pellets in young healthy
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volunteers following a light meal (100 kcal) varied from 40 to 180 minutes.
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reported postprandial gastric residence times of an indigestible capsule in a range between 69 and
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583 min (meals between 500 and 1000 kcal). 11 Whenever a formulation is retained in the stomach,
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ethanol effects on drug release may be more likely, provided that sufficiently high ethanol
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concentrations are present. In the stomach of fasted volunteers, ethanol concentrations quickly
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Food co-ingestion is another complicating
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In a previous manuscript, this group
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Several factors (food calories, beverage calories, beverage alcohol
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Weitschies et al.
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decline, irrespective of the type and volume of alcoholic beverages ingested. 9 In a fed volunteer, the
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delayed gastric emptying may help in retaining some alcohol in the stomach, though no studies have
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been performed on this matter yet. It should be noted that postprandial gastric transit times are
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expected to be shorter for (alcoholic) liquids then for indigestible solids.
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gastric emptying of a liquid along the stomach road (or magenstrasse), dilution of the alcoholic
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beverage with (liquid) food, and gastric absorption of ethanol may reduce gastric ethanol
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preservation. 13 Although the stomach is not considered the main absorptive organ, several authors
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suggested it can be considered a mere lipophilic barrier through which some molecules can be
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passively absorbed. The absorption of ethanol through the gastric mucosa has been observed
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multiple times, though literature reports several methods resulting in various extents of alcohol
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absorption. 14151617
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Considering the need for relevant in vitro tools to test for alcohol-induced dose-dumping and the
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currently unpredictable fate of ethanol in a fed stomach, we complemented our previous study on
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ethanol concentrations in the gastrointestinal tract of healthy volunteers.
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previous reports, that study included the advantage of commercially available beverages (as opposed
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to artificial drinks) which were consumed orally (as opposed to through an instillation tube). The
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present study used a similar approach to assess ethanol concentrations in the stomach and
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duodenum of volunteers after the consumption of various alcoholic beverages, but this time in
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postprandial conditions. Furthermore, the apparent permeability of the gastric and intestinal rat
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mucosa for ethanol was investigated.
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In addition, accelerated
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In comparison with
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2. Materials and methods 2.1. Chemicals
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Ethanol absolute AnalaR NORMAPUR was purchased from VWR Chemicals (Heverlee, Belgium).
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Sodium carbonate (Na2CO3) and sodium hydroxide pellets were purchased from Merck (Darmstadt,
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Germany). Magnesium chloride hexahydrate was bought from Applichem (Darmstadt, Germany).
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Disodium hydrogen phosphate dehydrate, sodium dihydrogen phosphate, potassium chloride and
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sodium hydrogen carbonate were retrieved from Chemlab (Zedelgem, Belgium). Sodium chloride,
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sodium acetate trihydrate, acetic acid and methanol were obtained from VWR (Leuven, Belgium).
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Sodium fluorescein was retrieved from UCB (Leuven, Belgium). Glucose and calcium chloride
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dihydrate were obtained from Sigma-Aldrich (St. Louis, MO). Water was purified by using a Maxima
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system (Elga Ltd., High Wycombe Bucks, UK). Krebs buffer (KB) was prepared by dissolving 1.25 mM
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CaCl2, 1.1 mM MgCl2, 5 mM KCl, 1.15 mM Na2HPO4, 0.3 mM NaH2PO4, 25 mM NaHCO3, 110 mM NaCl
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and 25 mM glucose in purified water. This solution was sparged with carbogen O2/CO2 (95%/5%) and
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adjusted to pH 7.4 with 1M HCl.
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2.2. Administered beverages
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Gallantry whisky (40 % alcohol) and Blanc du Blanc wine (11 % alcohol) were purchased from Aldi
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market (Leuven, Belgium); Stella Artois beer (5.2 % alcohol) was purchased from Carrefour market
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(Leuven, Belgium). Alcoholic beverage characteristics (pH, osmolality and caloric value) are reported
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in Table 1.
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simulate intake of a standard meal. A liquid meal was selected in order to avoid clogging of the
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catheters used to aspirate the gastrointestinal fluids. Volunteers consumed 250 mL of Nutridrink®
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with a total energy content of 600 kcal providing 61% of the calories in an FDA standard breakfast.
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Nutridrink® Compact Neutral (Sorgente B.V., Houten, The Netherlands) was used to
2.3. In vivo study
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Five healthy volunteers (1 female and 4 males) were enrolled in a cross-over study. Studies were
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performed at the University Hospitals Leuven and were approved by the Committee of Medical
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Ethics (ML10920). Candidate volunteers with gastrointestinal diseases, hepatitis B or C or HIV were
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excluded. All volunteers gave written informed consent prior to participation. After 12 h of fasting,
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two double-lumen catheters (Salem Sump Tube 14 Ch, external diameter 4.7 mm; Covidien, Dublin,
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Ireland) were introduced trough nose or mouth, and positioned into the stomach and the
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duodenum, respectively. Positioning was checked by fluoroscopy. Volunteers were asked to drink
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250 mL Nutridrink® Compact Neutral to simulate a fed state. Thirty minutes later, volunteers were
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asked to drink two standard consumptions of beer, wine or whisky in a cross-over design. One
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standard consumption was defined as 250 mL beer, 100 mL wine and 40 mL whisky. Volunteers
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finished drinking beer within 20 min and wine or whisky within 15 min. Subsequently, gastric and
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duodenal fluids were collected for 3 hours. Immediately after aspiration, samples were prepared for
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analysis (see section 2.4).
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Based on the gastric and duodenal ethanol concentrations over time, the AUC0-3h was calculated
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using the linear trapezoidal method and presented as mean (+S.E.M.). This AUC0-3h was compared to
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the AUC0-3h obtained in a previous study in which five volunteers consumed the same alcoholic
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beverages in a fasted state.9 A non-parametric unpaired Mann-Whitney-U test was applied as not all
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five volunteers participated in both studies. Statistical significance of the food effect was accepted if
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p
