What are the alternatives to Cisapride (prokinetic agent) for treating gastrointestinal conditions?

From the Guidelines

Alternatives to cisapride for treating gastrointestinal motility disorders include prucalopride, metoclopramide, domperidone, erythromycin, and mosapride, with prucalopride being a preferred option due to its minimal cardiac effects and efficacy in chronic constipation, as noted in a study published in Gut in 2020 1. When considering alternatives to cisapride, it's essential to weigh the benefits and risks of each option.

• Prucalopride (1-2mg once daily) is a selective 5-HT4 receptor agonist with minimal cardiac effects, making it a safer choice for patients with cardiovascular concerns, as highlighted in the study published in Gut in 2020 1.
• Metoclopramide (5-10mg three times daily before meals) works by blocking dopamine receptors and is useful for gastroparesis and GERD but carries a risk of extrapyramidal side effects with long-term use, as noted in the study published in Diabetes Care in 2024 1.
• Domperidone (10-20mg three to four times daily) offers similar efficacy with fewer central nervous system effects since it doesn't cross the blood-brain barrier as readily, though it may cause QT prolongation, as mentioned in the study published in Gut in 2020 1.
• Erythromycin (50-250mg three times daily) acts as a motilin receptor agonist and is particularly effective for diabetic gastroparesis but may cause antibiotic resistance with prolonged use, as highlighted in the study published in Diabetes Care in 2024 1.
• Mosapride (5mg three times daily before meals), another 5-HT4 agonist, is used for functional dyspepsia and GERD with a favorable safety profile, as noted in the study published in Gut in 2020 1. Non-pharmacological approaches, such as dietary modifications, smaller frequent meals, and avoiding fatty foods, can also be beneficial in managing gastrointestinal motility disorders, as suggested in the study published in Diabetes Care in 2024 1. The choice of agent depends on the specific condition being treated, patient comorbidities, and potential drug interactions, as cisapride was withdrawn from many markets due to cardiac arrhythmia risks, as mentioned in the study published in Gut in 2020 1.

From the FDA Drug Label

Prucalopride, a selective serotonin type 4 (5-HT4) receptor agonist, is a gastrointestinal (GI) prokinetic agent that stimulates colonic peristalsis (high-amplitude propagating contractions [HAPCs]), which increases bowel motility The alternative to Cisapride is prucalopride, a prokinetic agent that stimulates colonic peristalsis and increases bowel motility.

• Key points:
  • Prucalopride is a selective serotonin type 4 (5-HT4) receptor agonist
  • It stimulates colonic peristalsis and increases bowel motility
  • Prucalopride is used to treat gastrointestinal conditions such as chronic idiopathic constipation (CIC) 2 2 2

From the Research

Alternatives to Cisapride

Cisapride, a prokinetic agent, has been used to treat various gastrointestinal disorders, but its use has been limited due to the risk of ventricular arrhythmias and other adverse effects 3. Several alternatives to cisapride are available, including:

• Metoclopramide: Although metoclopramide has been associated with more central nervous system adverse effects than cisapride, it is still a viable option for treating motility disorders 4.
• Domperidone: Domperidone is another prokinetic agent that can be used to treat gastrointestinal disorders, but its long-term use may not result in persistently enhanced gastric emptying like cisapride 5.
• Azithromycin: Azithromycin is an alternative to clarithromycin, which should be avoided when taking cisapride due to the risk of increased plasma concentrations of cisapride 3.
• Citalopram, paroxetine, and sertraline: These antidepressants are alternatives to nefazodone and fluvoxamine, which should be avoided when taking cisapride due to the risk of increased plasma concentrations of cisapride 3.
• Famotidine, nizatidine, ranitidine, or proton pump inhibitors: These medications are alternatives to cimetidine, which should be avoided when taking cisapride due to the risk of increased plasma concentrations of cisapride 3.
• Montelukast: Montelukast is an alternative to zileuton, which should be avoided when taking cisapride due to the risk of increased plasma concentrations of cisapride 3.

Gastrointestinal Prokinetic Drugs

Other gastrointestinal prokinetic drugs that can be used as alternatives to cisapride include:

• Mosapride: Although not mentioned in the provided studies, mosapride is another prokinetic agent that can be used to treat gastrointestinal disorders.
• Levosulpiride: Levosulpiride is a prokinetic agent that can be used to treat gastrointestinal disorders, but its use may be limited due to the risk of adverse effects.

Treatment of Gastrointestinal Conditions

The treatment of gastrointestinal conditions with cisapride or its alternatives depends on the specific condition being treated. For example:

• Gastro-oesophageal reflux disease: Cisapride or its alternatives can be used to treat gastro-oesophageal reflux disease, but the effectiveness of cisapride in reducing symptoms of gastro-oesophageal reflux in children is unclear 6.
• Functional dyspepsia: Cisapride or its alternatives can be used to treat functional dyspepsia, and cisapride has been shown to be effective in improving symptoms in patients with functional dyspepsia 5, 4.
• Gastroparesis: Cisapride or its alternatives can be used to treat gastroparesis, and cisapride has been shown to improve gastric emptying rates and symptoms in patients with gastroparesis 5, 4.