George M. Lawson

Transdermal Nicotine for Mildly to Moderately Active Ulcerative Colitis A Randomized, Double-Blind, Placebo-Controlled Trial

Ulcerative colitis is primarily a disease of nonsmokers [1-4]. Nonsmokers who have ulcerative colitis and begin smoking may go into remission [5]. These observations led to uncontrolled trials of nicotine administered through chewing gum [6] or a transdermal patch [7]. A controlled trial of 15 to 25 mg of transdermal nicotine for active ulcerative colitis reported that 49% of patients responded to nicotine, whereas only 24% responded to placebo [8]. A subsequent controlled trial of 15 mg of transdermal nicotine used to maintain remission of ulcerative colitis reported that 45% of patients receiving nicotine had remission compared with 50% of patients receiving placebo [9]. Finally, a controlled trial [10] showed a clinical response in 32% of patients with active ulcerative colitis who received 15 to 25 mg of transdermal nicotine and in 58% of patients who received oral prednisolone. These studies suggest that transdermal nicotine may be efficacious for active ulcerative colitis, but confirmatory placebo-controlled trials are needed. We conducted a 4-week placebo-controlled trial in which transdermal nicotine, 11 to 22 mg/d, was used to treat active ulcerative colitis. Methods Study Design Our study was a randomized, double-blind, placebo-controlled trial that used the highest tolerated dosage of transdermal nicotine ( 22 mg/d) in nonsmoking patients with mildly to moderately active ulcerative colitis. To ensure that the nicotine and placebo groups were similar, patients were assigned to 1 of 16 strata on the basis of concomitant medical treatment (mesalamine, sulfasalazine, and olsalazine; oral corticosteroids; both; or neither), smoking history (persons who formerly smoked or persons who never smoked), and extent of disease (extensive or left-sided only). Eligible patients were sent to the Nicotine Research Center of the Mayo Clinic in Rochester, Minnesota, for randomization and dispensing of study medication. In each stratum, patients were randomly assigned to treatment by a computer-generated randomization sequence that was developed from SAS software (SAS Institute, Cary, North Carolina) [11]. Nicotine and placebo transdermal patches, labeled only by an identifying letter, were placed in clear plastic bags without any treatment-identifying information and were dispensed by Elan Pharmaceutical Research Corp. To the staff of the Nicotine Research Center along with a key for breaking the randomization code. The staff of the Center then dispensed study medication to the patients. The staff was not involved in patient care or assessment of disease activity, and treatment allocation was concealed from the medical personnel involved in patient care or assessment of disease activity and from the patients. Patients From April 1993 to September 1995, 66 adult patients with mildly to moderately active ulcerative colitis were referred by colleagues at the Mayo Clinic for study enrollment. Active ulcerative colitis was diagnosed by the usual symptomatic, radiographic, and endoscopic criteria [12]. The Institutional Review Board of the Mayo Clinic approved the study, and all patients gave written informed consent. Patients were classified as having never smoked or as having formerly smoked. Patients who had used products that contained nicotine within 3 months of study entry were excluded. To confirm patients self-reported abstinence from nicotine products at study entry, CO concentrations in expired air [13] and serum nicotine and plasma cotinine concentrations were measured [14, 15]. During the trial, therapy with oral 5-aminosalicylate compounds (sulfasalazine, olsalazine, and mesalamine), oral corticosteroids ( 20 mg/d), topical corticosteroids, and topical mesalamine was continued at prestudy doses if the doses had not been changed during the 2 weeks preceding study entry. Patients who were receiving corticosteroids at a dosage greater than 20 mg/d and patients who were taking cyclosporine, 6-mercaptopurine, azathioprine, or methotrexate were excluded. At the initial visit, the extent of colonic mucosal involvement was determined by using flexible sigmoidoscopy. Left-sided disease was defined as a demarcation between inflamed colonic mucosa and normal colonic mucosa (both shown by endoscopy) that was located less than 60 cm from the anal verge; in extensive disease, the demarcation extended more than 60 cm from the anal verge. Assessment of Disease Activity Each day, patients recorded the number of stools, any rectal bleeding, and any other symptoms coinciding with therapy that might represent adverse reactions. Patients were evaluated at study entry and after 4 weeks according to a previously described 13-point disease activity index that measured stool frequency, rectal bleeding, endoscopic findings, and the physician global assessment [16]. Clinical remission was defined as a disease activity index score of 0, and clinical improvement was defined as a decrease in the disease activity index of at least 3 points (or a decrease of 2 points if the baseline disease activity index was 3). Colonic mucosal biopsy specimens were obtained at study entry and after 4 weeks, and histologic disease activity was assessed according to a previously described 5-point histologic disease activity index [17]. Endoscopic biopsy specimens were obtained from the site in the rectosigmoid colon that appeared to have the most severe inflammation. One pathologist blindly determined the histologic disease activity index scores in random order at one sitting. Histologic remission was defined as a histologic disease activity index score of 0, and histologic improvement was defined as a decrease in the histologic disease activity index of at least 1 point. Transdermal Nicotine Patch Transdermal nicotine and placebo patches (Elan Pharmaceutical Research Corp., Athlone, Ireland) were used in our study. The transdermal nicotine patches were dispensed in two sizes and doses: small (11 mg) and large (22 mg). Placebo patches identical in appearance to the nicotine patches were also dispensed in two sizes. Patients were instructed to use the small patches for 7 days and then change to the large patches for 21 days. Patients who wore the larger patch and then developed intolerable side effects that lasted 3 consecutive days were instructed to resume using the smaller patch. Patients who wore the smaller patch and then developed intolerable side effects that lasted 3 consecutive days were instructed to discontinue patch therapy. The patients were instructed to apply fresh patches to the skin of the upper torso every 24 hours. Compliance was determined by review of patient diaries and by counting the number of used and unused transdermal patches at the week 4 visit. Adverse Reactions to Nicotine Intolerable adverse reactions (such as severe contact dermatitis, lightheadedness, dizziness, nausea, or vomiting) that occurred before week 4 were reported to the study coordinator; therapy was then changed as described in the preceding paragraph. At the week 4 visit, patients were specifically asked about the following adverse reactions: skin erythema or irritation or contact dermatitis, nausea or vomiting, headaches, sleep disturbance or violent or sexual dreams, diaphoresis or sweating, lightheadedness or dizziness, and shakiness or tremor. Tachycardia and hypertension were also noted. Concentrations of Serum Nicotine, Plasma Cotinine, and Expired Air Carbon Monoxide Serum nicotine and plasma cotinine concentrations were determined in venous blood by using standard assays [14, 15]. At study entry, blood samples were collected to confirm abstinence from products that contain nicotine. At the week 4 visit, blood samples were collected at the peak time (the time of maximum concentration, which occurs approximately 8 hours after the transdermal patch is placed on the skin), and at the trough time (the time just before application of the next transdermal patch). Blood samples were processed immediately after venipuncture, and serum and plasma were stored at 20C until assays were done. Concentrations of CO in expired air were measured at study entry and at the week 4 visit by using a Vitalograph EC 50 monitor (Vitalograph, Inc., Lenexa, Kansas) [13]. The results of this assay confirmed the patients self-reported abstinence from smoking (a concentration of 8 parts per million indicates recent smoking). Statistical Analysis The baseline characteristics of the treatment groups were compared by using the rank-sum test for continuous variables and the Fisher exact test for categorical variables. We also used the Fisher exact test to compare the percentage of patients in each group who had overall clinical improvement and remission. The Cochran-Mantel-Haenszel general association statistic was used to test for a difference between treatment groups on overall clinical improvement after simultaneous adjustment for the three stratification factors. For each treatment group, the changes from baseline to week 4 in the 13-point clinical disease activity index, the components of the clinical disease activity index (stool frequency, rectal bleeding, sigmoidoscopic findings, and physician global assessment), and the histologic disease activity index were compared to a score of 0 by using the one-sample signed-rank test. The changes in these scores in the nicotine group were compared with the changes in the placebo group by using the two-sample rank-sum test. When data at the week 4 visit were missing, the last-value-carried-forward technique was used. In all cases, two-tailed tests were used; P values less than 0.05 were considered statistically significant. Results Randomization Sixty-six patients were randomly assigned to treatment, but 2 patients dropped out of the study before receiving any study medication: One decided not to participate in the study, and 1 was severely ill and required hospitalization immediately after randomization (in retrospect, this patients ulcera

Prolonged exercise decreases serum leptin concentrations

Serum leptin and free fatty acid concentrations were determined in two groups of subjects undergoing strenuous exercise: 12 men who fasted overnight and then pedaled a stationary ergometer for 2 hours, and 14 nonfasting ultramarathon runners. Blood samples were collected before exercise, immediately after cessation of exercise, and 6 to 24 hours after the end of the exercise period. Two hours of strenuous pedaling following an overnight fast significantly reduced mean leptin levels by 8.3%; free fatty acids were highly increased and correlated well with the decrease in serum leptin (r = .737, P = .01). After 6 hours of rest and refeeding, leptin concentrations recovered to preexercise levels and free fatty acid concentrations were decreased to less than preexercise levels. A similar decrease in serum leptin levels (12.3%) occurred in subjects who fasted overnight and then for a period corresponding to the cycle exercise period. The prolonged exercise of an ultramarathon significantly reduced leptin concentrations by 32% in comparison to prerace levels; free fatty acid concentrations were highly increased, but did not correlate with the change in serum leptin concentrations (r = .366, P = .20). Leptin and free fatty acid concentrations all trended toward prerace levels in blood samples collected 18 to 24 hours after cessation of racing. The results suggest that the negative energy balance of exercise can reduce serum leptin concentrations, but that the significant decrease occurs only at extremes of severity/duration of the exercise-induced negative balance. The possible physiological role of reduced leptin concentrations in response to energy balance and the role of free fatty acids in mediating the response are discussed.

A placebo-controlled trial of cyclosporine enemas for mildly to moderately active left-sided ulcerative colitis

BACKGROUND/AIMSnUncontrolled studies suggest that cyclosporine administered as an enema may be of benefit for left-sided ulcerative colitis and safer than intravenous or oral administration. The efficacy and safety of cyclosporine enemas for left-sided ulcerative colitis in a placebo-controlled trial was assessed.nnnMETHODSnSteroid and mesalamine enemas were withdrawn before the study. Forty patients were assigned to 1 of 4 strata: no concomitant therapy, oral steroids, oral salicylates, or oral steroids and salicylates. After stratification, patients were randomized to nightly treatment with 350 mg cyclosporine (n = 20) or placebo (n = 20) enemas. Clinical response was determined at baseline and 4 weeks by endoscopy, physician assessment, and a patient diary of daily symptoms. Trough blood cyclosporine levels were measured by high-performance liquid chromatography.nnnRESULTSnAt 4 weeks, 8 of 20 patients (40%) who received cyclosporine showed clinical improvement compared with 9 of 20 patients (45%) who received placebo. One patient receiving cyclosporine had reversible neutropenia attributable to sulfasalazine, and another patient receiving cyclosporine was unable to tolerate the enema vehicle. No other toxicity was noted during the trial. Blood cyclosporine levels were detectable in only two patients.nnnCONCLUSIONSnCyclosporine enemas administered in a dosage of 350 mg/day for 4 weeks are not efficacious in mildly to moderately active left-sided ulcerative colitis.

Application of serum nicotine and plasma cotinine concentrations to assessment of nicotine replacement in light, moderate, and heavy smokers undergoing transdermal therapy.

As part of a clinical trial investigating the level of nicotine replacement with different doses of transdermal therapy for smoking cessation, peak and trough serum nicotine and plasma cotinine concentrations were measured in 70 subjects while they were actively smoking (baseline) and daily for 6 consecutive inpatient days while they were receiving transdermal nicotine. Subjects were randomly assigned to a daily 24‐hour patch delivering a transdermal nicotine dose of 0, 11, 22, or 44 mg and stratified by self‐reported smoking rate as either light (10–15 cigarettes per day), moderate (16–30 cigarettes per day), or heavy (>30 cigarettes per day). Steady‐state concentrations of nicotine and cotinine were attained in 1 and 3 days, respectively, at all doses and were independent of baseline smoking rate. Mean percentage replacement of nicotine was calculated by dividing steady‐state peak nicotine or cotinine concentrations by their respective baseline concentrations. Significant underreplacement occurred in subjects receiving the 11 mg/day patch regardless of baseline smoking rate. Underreplacement also occurred in moderate and heavy smokers receiving 22 mg/day and in light smokers at this same dose. Complete replacement occurred only in subjects receiving the 44 mg/day patch. These results have several implications for transdermal nicotine therapy. First, with the higher nicotine and cotinine levels observed with heavier smoking, it is inherent that one size does not fit all, and there is a need to consider more individualization of dosage for nicotine patch therapy. Second, there is substantial underreplacement with the 22 mg/day dose in moderate to heavy smokers and in some light smokers. Third, even with twice the usual dose (i.e., 44 mg/day), there was no accumulation of either nicotine or cotinine. Plasma cotinine levels after achievement of steady state (i.e., after 3 days of patch therapy) can be collected at any time and used to calculate percent replacement using baseline levels.

Serum nicotine and cotinine levels during nicotine-patch therapy

We related serum nicotine and cotinine levels while subjects were smoking their usual numbers of cigarettes to levels while wearing a nicotine patch under carefully controlled, smoke‐free conditions in a clinical research center. Twenty‐four volunteers who needed intensive treatment for severe nicotine dependence were admitted to the clinical research center and were treated with a 22 mg transdermal nicotine patch each day and an intensive smoking‐cessation program. Serum nicotine and cotinine levels, withdrawal symptoms, and hours and quality of sleep were noted. The steady‐state serum nicotine and cotinine levels produced with the nicotine patch were lower than those observed when the subjects were smoking. Mean nicotine and cotinine levels were inversely related to mean withdrawal scores for the first 6 days. A fixed dose of transdermal nicotine will not be effective for all smokers. Individualization of therapy should be based on objective biologic measures such as serum cotinine and subjective assessment of withdrawal relief.

Concentration and separation of hypoglycemic drugs using solid-phase extraction-capillary electrophoresis

Solid-phase extraction-capillary electrophoresis (SPE-CE) is a technique whereby very dilute analytes may be selectively extracted from a sample matrix and concentrated on-line for analysis. This study describes the first phase in the development of a method exploiting this technique for the direct analysis of hypoglycemic drugs in urine. Effective separation and detection of six sulfonylurea drug standards at concentrations below the detection limit of conventional capillary electrophoretic techniques is shown to be attainable. Since surfactant interfered with the on-line concentration process, non-MEKC (micellar electrokinetic chromatography) separation conditions were defined. Using 250 mM borate/5 mM phosphate at pH 8.4, all drugs in a mixture at 285 ng/ml were effectively extracted, concentrated from an injected volume of 2.5 microliters, non-selectively desorbed with an organic-based elution buffer and electrophoretically resolved. Sample loading was found to be linear in the 0.12-1.9 microliters range and drugs in a volume of up to 190 microliters could be concentrated and detected with a sensitivity of approximately 5 ng/ml. Not only was resolution of the desorbed material uncompromised by the presence of the SPE-tip, but separation of glipizide and glyburide was observed despite the fact that these drugs were unresolved under the same separation conditions by standard capillary zone electrophoresis (CZE). From these results, it is clear that SPE-CE not only increases the sensitivity for detection but that selectivity may be altered due to chromatographic processes occurring on the solid-phase resin.

Nicotine tartrate liquid enemas for mildly to moderately active left-sided ulcerative colitis unresponsive to first-line therapy: a pilot study.

Background: Ulcerative colitis is predominantly a disease of non‐smokers, and transdermal nicotine is therapeutic but often results in side‐effects. Administration of nicotine as a liquid rectal enema results in less systemic nicotine absorption.

Application of urine nicotine and cotinine excretion rates to assessment of nicotine replacement in light, moderate, and heavy smokers undergoing transdermal therapy.

As part of a clinical trial investigating the level of nicotine replacement with different doses of transdermal therapy for smoking cessation, urine excretion rates of nicotine and cotinine were measured in 70 subjects while they were actively smoking (baseline) and for 6 consecutive inpatient days while they were receiving transdermal nicotine therapy. Subjects were stratified according to baseline smoking rate as light (10–15 cigarettes per day), moderate (16–30 cigarettes per day), or heavy (>30 cigarettes per day) smokers and randomly assigned to a daily 24‐hour patch delivering a transdermal nicotine dose of 0, 11, 22, or 44 mg. Steady‐state excretion rates of nicotine and cotinine were attained in 2 and 3 days, respectively, at all doses and were independent of smoking rate. Percentage replacement of nicotine was calculated by dividing steady‐state nicotine or cotinine excretion rates by their respective baseline excretion rates. Significant underreplacement occurred with the 11‐mg/day dose, particularly in moderate and heavy smokers (<50%). At a dose of 22 mg/day, nicotine replacement was still <100% in the majority of subjects. Only at a dose of 44 mg/day did mean replacement exceed 100% regardless of baseline smoking rate.

Pharmacokinetics of nicotine tartrate after single-dose liquid enema, oral, and intravenous administration.

Ulcerative colitis is predominantly a disease of nonsmokers, and transdermal nicotine is therapeutic but often results in adverse reactions. Colonic administration of nicotine tartrate as a liquid enema could decrease systemic nicotine absorption and adverse reactions. The purpose of the current study was to determine the bioavailability and pharmacokinetic parameters of nicotine after administration by hydrophilic liquid enema (acidic and basic), hydrophobic liquid enema (acidic and basic), and by oral and intravenous routes. Thirty healthy volunteers received 45 μg nicotine base/kg (as nicotine tartrate) in one of five formulations (each n = 6): hydrophilic acidic liquid enema, hydrophilic basic liquid enema, hydrophobic acidic liquid enema, hydrophobic basic liquid enema, and oral solution. All participants also received 15 μg nicotine base/kg (as nicotine tartrate) intravenously during a separate study period. Serum concentrations of nicotine were determined by gas chromatography with mass spectrometry. The mean (± SD) bioavailabilities of nicotine after administration in the liquid enema formulations (hydrophilic acidic 17 ± 18%, hydrophilic basic 16 ± 16%, hydrophobic acidic 25 ± 17%, hydrophobic basic 15 ± 12%) were similar to the bioavailability of nicotine after administration by oral solution (20 ± 25%). The bioavailabilities of nicotine for all five nonintravenous formulations were significantly less than for intravenous nicotine (100%). Serum concentrations of nicotine did not predict adverse reactions. Nicotine tartrate administered as either a liquid enema or as an oral solution had low bioavailability and was well tolerated. The therapeutic potential of nicotine tartrate liquid enemas, which can potentially limit toxicity by local (colonic) delivery of high doses of nicotine should be investigated in patients with left‐sided ulcerative colitis.

Measurement of colonic tissue cyclosporine concentration in children with severe ulcerative colitis

Summary Recent studies suggest that cyclosporine may be an alternative to colectomy in children with severe ulcerative colitis who fail traditional therapy with bowel rest and high-dose corticosteroids. We report the clinical course of two such children. Patient I received oral cyclosporine at 15 mg/kg/day for 1 week followed by 8 mg/kg/day for 6 weeks. Clinical remission occurred within 5 days and has been sustained for 24 weeks after azathioprine was substituted for cyclosporine. Patient 2 received oral cyclosporine at 7–8 mg/kg/day for 7 days after which colectomy was performed due to lack of clinical improvement. Blood cyclosporine levels for patient 1 ranged from 95 to 406 ng/ml and for patient 2 from 36 to 65 ng/ml. Sigmoid colonic tissue cyclosporine concentrations for patients 1 and 2 were 10,058 and 3,205 ng/g, respectively. The patient who responded had significantly higher blood and colonic tissue cyclosporine concentrations than the patient who did not respond. Further studies with larger numbers of patients are needed to determine if there is a correlation between blood and colonic tissue cyclosporine concentrations and clinical response.