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Cisapride
Cisapride
Cisapride
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Cisapride
Clinical data
Trade namesPrepulsid, Propulsid
AHFS/Drugs.comFDA Professional Drug Information
MedlinePlusa694006
Pregnancy
category
  • AU: B1
Routes of
administration		By mouth (tablets), suspension
ATC code
Legal status
Legal status
  • AU: S4 (Prescription only)
  • BR: Class C1 (Other controlled substances)[1]
  • UK: POM (Prescription only)
  • US: Withdrawn
Pharmacokinetic data
Bioavailability30-40%
Protein binding97.5%
Metabolismliver CYP3A4, intestinal
Elimination half-life10 hours
Excretionkidney, bile duct
Identifiers
  • (±)-cis-4-amino-5-chloro-N-(1-[3-(4-fluorophenoxy)propyl]-3-methoxypiperidin-4-yl)-2-methoxybenzamide
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.072.423 Edit this at Wikidata
Chemical and physical data
FormulaC23H29ClFN3O4
Molar mass465.95 g·mol−1
3D model (JSmol)
  • Clc1cc(c(OC)cc1N)C(=O)NC3CCN(CCCOc2ccc(F)cc2)CC3OC
  • InChI=1S/C23H29ClFN3O4/c1-30-21-13-19(26)18(24)12-17(21)23(29)27-20-8-10-28(14-22(20)31-2)9-3-11-32-16-6-4-15(25)5-7-16/h4-7,12-13,20,22H,3,8-11,14,26H2,1-2H3,(H,27,29) checkY
  • Key:DCSUBABJRXZOMT-UHFFFAOYSA-N checkY
 ☒NcheckY (what is this?)  (verify)

Cisapride is a gastroprokinetic agent, a drug that increases motility in the upper gastrointestinal tract. It acts directly as a serotonin 5-HT4 receptor agonist and indirectly as a parasympathomimetic. Stimulation of the serotonin receptors increases acetylcholine release in the enteric nervous system. It has been sold under the trade names Prepulsid (Janssen-Ortho) and Propulsid (in the United States). It was discovered by Janssen Pharmaceuticals in 1980. In many countries, it has been either withdrawn from the market or had its indications limited due to incidence of serious cardiac side-effects.[2] Propulsid was linked to children's deaths.[3]

The commercial preparations of this drug are the racemic mixture of both enantiomers of the compound. The (+) enantiomer itself has the major pharmacologic effects and does not induce many of the detrimental side-effects of the mixture.[4]

Medical uses

[edit]

Cisapride has been used for the treatment of gastroesophageal reflux disease (GERD). There is no evidence it is effective for this use in children.[5] It also increases gastric emptying in people with diabetic gastroparesis. Evidence for its use in constipation is not clear.[6]

In many countries, it has been either withdrawn or had its indications limited because of reports of the side-effect long QT syndrome, which may cause arrhythmias. The U.S. Food and Drug Administration (FDA) issued a warning letter to doctors,[7] and cisapride was voluntarily removed from the U.S. market on July 14, 2000. Its use in Europe has also been limited.[5] It was banned in India and in the Philippines in 2011.[8]

Veterinary uses

[edit]

Cisapride is still available in the United States and Canada for use in animals, and is commonly prescribed by veterinarians to treat megacolon in cats.

Cisapride is also commonly used to treat GI stasis in rabbits, sometimes in conjunction with metoclopramide (Reglan).

Kinetics

[edit]

Oral bioavailability of cisapride is approximately 33%. It is inactivated primarily by hepatic metabolism by CYP3A4 with a half-life of 10 hours. The dose of the drug should be reduced in case of liver diseases.[9]

Pharmacology and mechanism of action

[edit]

As a prokinetic agent that increases gastrointestinal motility, cisapride acts as a selective serotonin agonist in the 5-HT4 receptor subtype. Cisapride also relieves constipation-like symptoms by indirectly stimulating the release of acetylcholine, which acts on muscarinic receptors.

See also

[edit]

References

[edit]

Further reading

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Cisapride

View on Grokipedia
from Grokipedia
Cisapride is a synthetic derivative and gastrointestinal that functions as a selective serotonin 5-HT4 receptor , enhancing motility in the upper by stimulating release in the without significantly affecting gastric, biliary, or pancreatic secretions. Marketed primarily under the brand name Propulsid, it was approved for oral use to treat nocturnal associated with (GERD) and used off-label for conditions such as and chronic , typically administered 15 minutes before meals and at bedtime in doses of 10 mg four times daily for adults. With a of C23H29ClFN3O4 and a molecular weight of 465.9 g/mol, cisapride exhibits a of 6–12 hours and is primarily metabolized by the cytochrome P450 3A4 in the liver. Developed in the 1980s and first approved by the U.S. (FDA) in 1993, cisapride gained widespread use as an alternative to metoclopramide for disorders due to its favorable side-effect profile at the time, including common but mild effects like , , and . However, post-marketing surveillance revealed serious risks of cardiac arrhythmias, including prolongation, , and sudden death, particularly in patients with predisposing factors or those taking interacting medications such as erythromycin, , or even , which inhibit and elevate cisapride plasma levels. In response, the FDA issued multiple warnings starting in 1998, restricted distribution to an program in 2000, and ultimately withdrew cisapride from the U.S. market on July 14, 2000, following reports of over 270 cardiac adverse events, including 70 fatalities. Although cisapride remains available in limited compassionate-use programs as of 2025 and is still marketed in some countries under strict controls, its global withdrawal or restriction highlights key lessons in , emphasizing the importance of monitoring drug interactions and post-approval safety for serotonergic agents. Subsequent has confirmed that the drug's prokinetic benefits were offset by its cardiac , leading to the development of safer alternatives like (later also withdrawn) and for similar indications.

Uses

Human medicine

Cisapride was primarily indicated in human medicine for the symptomatic relief of (GERD), particularly nighttime , and for diabetic , where it enhanced gastric emptying and gastrointestinal to alleviate delayed emptying and reflux-related symptoms. The drug acted as a , promoting in the , , and intestines without directly affecting secretion, making it suitable for patients unresponsive to antacids or lifestyle modifications. The typical adult dosage for GERD and was 10 mg orally four times daily, administered at least 15 minutes before meals and at to optimize effects, with potential escalation to 20 mg per dose if response was inadequate after initial . Pediatric use was limited, with dosing of 0.2–0.3 mg/kg three or four times daily (total approximately 0.8 mg/kg/day) in protocols for children, though restricted due to insufficient data, particularly for those under 12 years. Clinical trials in adults demonstrated cisapride's efficacy in GERD, with placebo-controlled studies showing improved esophageal healing rates of 55–90% after 6–16 weeks of 10 mg four times daily and reduced reflux symptoms, including enhanced esophageal normalization and fewer reflux episodes in assessments. For diabetic , trials indicated accelerated gastric emptying and short-term symptom relief, such as reduced and , though benefits were less consistent for idiopathic beyond initial treatment periods. While short-term symptom improvements were observed in some studies for chronic constipation, no proven long-term benefits were established, with broader evaluations showing inconsistent or non-sustained effects. Specific limitations included ineffectiveness in pediatric GERD, as randomized controlled trials and meta-analyses found a significant reduction in reflux index but no significant symptom resolution compared to in children. Additionally, cisapride was not advised for long-term therapy due to its safety profile, with efficacy confined to short-term symptom management in approved indications.

Veterinary medicine

Cisapride is employed in primarily as an off-label to treat gastrointestinal disorders in companion animals and horses, where its use persists despite restrictions in human applications. It is also used off-label in dogs for conditions like gastroesophageal reflux, , and , with dosing typically 2.5–5 mg orally two to three times daily for small breeds. In cats, it serves as a key treatment for idiopathic chronic and , conditions characterized by impaired colonic propulsion leading to obstipation. Veterinary guidelines highlight its role in stimulating colonic contraction to alleviate these issues, often as part of a multimodal approach including dietary modifications and laxatives. Typical dosing protocols for cats involve of compounded suspensions at 2.5 mg per (for those under 5 kg body weight) to 5 mg per (for those over 5 kg) every 8 to 12 hours, adjusted based on pharmacokinetic studies showing effective plasma concentrations at these intervals. In rabbits experiencing gastrointestinal stasis—a common involving reduced gut —cisapride is frequently combined with metoclopramide to enhance overall , with doses around 0.5 mg/kg orally every 8 to 12 hours; however, a 2021 experimental study found that cisapride did not significantly enhance gastric emptying or gastrointestinal transit, including when combined with opioids like that induce stasis. For horses, cisapride is used supportively in managing postoperative following surgery, administered at 0.1 mg/kg intramuscularly every 6 to 8 hours for prophylaxis, promoting the restoration of small intestinal . Evidence from veterinary studies supports these applications: in cats with , cisapride has demonstrated increased colonic and improved defecation frequency in clinical trials, establishing it as the only reliably safe and effective therapy for chronic cases. A prospective study in horses undergoing surgery found that cisapride prophylaxis prevented idiopathic postoperative in 22 cases, with minimal side effects and rapid return to normal gut function. In rabbits, it is still used clinically despite mixed experimental results on transit enhancement. Since its withdrawal from the human market in due to cardiac risks, cisapride is not FDA-approved for veterinary use or but remains widely prescribed off-label through formulations, which are essential for precise dosing in small animals and included on the FDA's bulk drug substances list for urgent non-food-producing animal needs as of 2025. pharmacies prepare oral liquids, tablets, or suspensions tailored to species-specific requirements, ensuring availability for conditions like feline where no approved alternatives exist.

Pharmacology

Pharmacodynamics

Cisapride is a selective agonist of the serotonin 5-HT4 receptor, primarily acting within the to stimulate the release of from postganglionic neurons in the . This enhanced activity promotes coordinated peristaltic contractions and increases the tone of gastrointestinal , thereby improving throughout the upper and lower . Unlike non-selective agents, cisapride's action is localized to the gut due to its limited penetration of the blood-brain barrier. The drug binds with high affinity to 5-HT4 receptors on both cells and enteric neurons, facilitating excitatory with weak at other serotonin receptor subtypes, such as 5-HT3, which helps avoid broader systemic or effects. This receptor specificity results in accelerated gastric emptying; for instance, in healthy subjects, cisapride has been shown to increase the rate from approximately 20% to 31%. Physiologically, cisapride enhances esophageal clearance by boosting the and of peristaltic waves, accelerates small intestinal transit to reduce stagnation, and facilitates colonic to aid , all without directly influencing secretion or pancreatic enzyme release. These effects stem from its prokinetic properties, which coordinate segmental and propulsive patterns across the gut. In contrast to dopamine antagonists like metoclopramide, which exert central effects through D2 receptor blockade, cisapride provides more comprehensive gastrointestinal motility enhancement from the to the colon without antidopaminergic activity or associated extrapyramidal side effects.

Pharmacokinetics

Cisapride is rapidly absorbed from the following , with an absolute of approximately 40-50% attributable to extensive first-pass in the liver. Peak plasma concentrations are typically achieved within 1 to 2 hours after dosing. The drug exhibits high of about 97.5-98%, primarily to , which limits its free fraction in circulation. Its is approximately 2.4 L/kg, reflecting extensive tissue distribution, including penetration into the to support its prokinetic effects. Cisapride undergoes extensive hepatic metabolism, predominantly via the 3A4 enzyme, with minor contributions from CYP2A6. The primary , norcisapride, is formed through oxidative N-dealkylation and accounts for 41-45% of the administered dose; this retains prokinetic activity, with approximately 15% of the potency of the parent compound. Other minor metabolites include hydroxylated derivatives. Elimination of cisapride occurs mainly through biliary secretion and fecal excretion of metabolites, with approximately 60-70% of the dose recovered in feces over several days. Renal excretion is minimal, with less than 5% of the unchanged appearing in and about 35-50% of the dose as metabolites. The terminal elimination in healthy adults is 7-10 hours, which can be prolonged in cases of hepatic impairment due to reduced metabolic clearance. In special populations, dose adjustments are recommended for patients with hepatic disease to account for extended and potential accumulation, while no significant modifications are needed for those with renal impairment given the drug's low renal clearance. In elderly individuals, the elimination may be prolonged (up to 20 hours in some cases), leading to higher steady-state concentrations, though standard dosing is generally maintained with monitoring.

Clinical safety

Adverse effects

Cisapride is associated with serious cardiac adverse effects primarily due to its blockade of the human ether-a-go-go-related gene (hERG) potassium channel, which prolongs the QT interval on electrocardiograms and increases the risk of torsades de pointes, ventricular arrhythmias, and sudden death. Post-marketing surveillance identified 341 cases of heart rhythm abnormalities linked to cisapride use as of December 1999, including 80 deaths, with many occurring in pediatric patients. The incidence of such serious cardiac events is estimated to be low, on the order of 1.28 hospitalizations per 1,000 person-years of use, though rare severe outcomes like sudden death were reported based on pharmacoepidemiological data. Common non-cardiac adverse effects occur in a dose-dependent manner and include , , , and , with gastrointestinal symptoms such as and reported more frequently at higher doses. effects like and have also been noted in clinical use. Rare adverse effects encompass , seizures, elevated liver enzymes, and reactions such as . Risk factors for cardiac adverse effects include congenital , , and concurrent use of other QT-prolonging drugs, which can exacerbate hERG blockade and risk. Due to these risks, electrocardiographic monitoring, including a baseline 12-lead ECG, is recommended prior to initiating cisapride in any remaining approved or investigational uses to assess and exclude at-risk patients. A 2025 meta-analysis of cisapride use in diabetic found a generally acceptable safety profile in this specific context, though cardiac risks remain a concern in limited applications.

Contraindications and drug interactions

Cisapride is absolutely contraindicated in patients with known prolonged , ventricular arrhythmias, congenital , or uncorrected electrolyte imbalances such as or hypomagnesemia, as these conditions heighten the risk of serious cardiac arrhythmias including and sudden death. It is also contraindicated in individuals with severe hepatic impairment, given the 's reliance on hepatic metabolism via the 3A4 () enzyme for clearance, which can lead to accumulation and exacerbated . Additionally, cisapride should not be used in cases of gastrointestinal hemorrhage, mechanical obstruction, , or known to the , where enhanced could worsen outcomes. Relative contraindications apply to patients with a history of cardiac disease, as well as elderly or pediatric populations, where cisapride use requires close monitoring for QT prolongation due to age-related variations in cardiac sensitivity and metabolism. In such cases, baseline assessment of cardiac function is essential to identify subclinical risks. Major drug interactions with cisapride primarily involve inhibitors like , erythromycin, and , which block the enzyme responsible for its metabolism, resulting in elevated plasma concentrations—typically a 2- to 3-fold increase in area under the curve (AUC) for moderate inhibitors such as —and a substantially amplified risk of QT prolongation. , a potent inhibitor, can cause even greater elevations, up to an 8-fold AUC increase. Additive QT prolongation may occur with antiarrhythmics such as quinidine, , or , and certain antipsychotics, compounding arrhythmogenic potential through independent effects on cardiac . Concomitant use with , which inhibits intestinal , or other should be strictly avoided to prevent these pharmacokinetic alterations. As noted in the pharmacokinetics section, cisapride's hepatic metabolism underscores these interaction risks. To manage potential issues, a baseline electrocardiogram (ECG) and serum electrolyte evaluation are recommended before starting , with ongoing monitoring in at-risk groups; alternative s are advised for contraindicated patients to avoid cardiac complications like QT prolongation, a primary .

History and availability

Development and approval

Cisapride was developed by Janssen Pharmaceutica in the late as a non-dopaminergic intended to address limitations of metoclopramide, which was associated with side effects due to its antagonism. The compound, a substituted derivative, was first synthesized around 1979 as part of efforts to enhance gastrointestinal motility through serotonergic mechanisms. In preclinical research, cisapride was identified as a selective 5-HT4 receptor agonist that promoted release in the , leading to enhanced gastrointestinal transit in animal models such as pigs and rats without inducing effects observed with dopaminergic agents. These studies demonstrated its prokinetic activity across the upper and lower , supporting its potential for treating disorders. Phase III clinical trials conducted in the late 1980s evaluated cisapride's efficacy for , showing significant symptom relief and esophageal healing compared to , with dosages of 10 mg four times daily over 8-12 weeks. These trials established its role in improving esophageal clearance and reducing reflux episodes. Following successful outcomes, cisapride received regulatory approval in in 1988 under the trade name Prepulsid for motility-related gastrointestinal disorders. In the United States, it was approved by the FDA in 1993 as Propulsid specifically for the symptomatic relief of nocturnal due to GERD in adults. Initially marketed for nocturnal associated with GERD and , cisapride demonstrated clinical benefits in accelerating gastric emptying and alleviating symptoms in these conditions during early post-approval use. By the late , it had achieved substantial , with millions of prescriptions issued annually and peak global sales exceeding $300 million. The original , filed in 1979 and granted in 1980, expired in the early , though market dynamics were influenced by emerging safety considerations.

Market withdrawal and current status

Post-marketing surveillance in the 1990s revealed serious cardiac risks associated with cisapride, including prolongation leading to potentially fatal arrhythmias such as . In response, the U.S. (FDA) issued a black box warning in June 1998, contraindicating its use in patients with cardiac conditions or those on interacting medications, following reports of 38 deaths and approximately 145 cases of serious cardiac arrhythmias since its approval. By early 2000, the cumulative reports had risen to 341 instances of heart rhythm abnormalities, including 80 fatalities, prompting further regulatory action. Janssen Pharmaceutica voluntarily withdrew cisapride (marketed as Propulsid) from the U.S. market on July 14, 2000, after determining that the risks outweighed benefits for its approved indications. Similar restrictions followed internationally: it was banned for human use in the in 2000 and in in 2011 due to cardiac risks. In the , cisapride's marketing authorizations were suspended in 2000, with access limited to compassionate use programs under strict medical supervision for patients lacking alternatives. As of 2025, cisapride remains unavailable for general use in most countries, including the U.S., where it is accessible only through an FDA-approved (IND) limited-access program for refractory gastrointestinal motility disorders in patients who have failed other therapies. Veterinary use continues in the U.S. and , where it is compounded by pharmacies for off-label treatment of conditions like and gastroesophageal reflux in dogs and cats, without the human market restrictions. The withdrawal shifted clinical practice toward safer prokinetic alternatives, such as (a selective 5-HT4 agonist approved for chronic idiopathic constipation) and (a with lower cardiac risk in many regions), which promote gastrointestinal motility with reduced potential. Janssen faced numerous lawsuits in the early alleging inadequate warnings about cardiac risks; a notable 2001 Mississippi jury awarded $100 million in compensatory damages to 10 plaintiffs, though subsequent settlements, including a 2004 class-action agreement for up to $90 million to settle claims alleging over 300 deaths and 16,000 injuries, resolved many claims. Despite ongoing research into safer analogs, no resurgence in broad human approvals has occurred.

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