Treatment of reflux esophagitis using dimethylpolysiloxane
This is a Rule 60 divisional of Serial No. 07/838,398, filed Feb. 18, 1992, now U.S. Pat. No. 5,277,902, which is a Rule 60 divisional of Serial No. 07/528,078 filed May 24, 1990, now U.S. Pat. No. 5,120,53 
    
    
     The defoaming effect of dimethylpolysiloxane is well investigated and is already used therapeutically as antiflatulent or ill preparation for sonography. 
     It has been found, surprisingly, that dimethylpolysiloxane can be employed with a particularly advantageous effect for the treatment of ulcerous disorders of the gastrointestinal tract. The defoaming effect of dimethylpolysiloxane is correlated with the other physicochemical properties film-formation and adhesion to walls. It has emerged, surprisingly, that dimethylpolysiloxane can also be administered orally over extended periods without disadvantageous effects in order to form and maintain in the oesophagus and in the gastrointestinal tract of humans a protective layer which assists the healing process when disorders of the type described are present. 
     The agent according to the invention is particularly employed for the treatment of ulcerous disorders of the gastrointestinal tract, generally of disorders of the oesophagus, of the stomach and upper small intestine, such as oesophagitis, ulcers (gastric and duodenal). It is used in the form of an orally administerable composition with a pharmaceutically acceptable diluent or carrier, e.g. in the form of chewable tablets. 
     The use according to the invention of dimethylpolysiloxane experiences an increase in its effectiveness when the agent is taken in conjunction with silica gel. 
     This results in the coating which is generated by the agent in the oesophagus and gastrointestinal tract having a gel-like structure. This layer comes very close to the physiological mucus (e.g. gastric mucus) which protects the mucous membranes of the oesophagus and gastrointestinal tract. 
     It is possible with the agent employed according to the invention specifically to coat the mucous membranes of oesophagus and gastrointestinal tract over a prolonged period by appropriate intake even for days, weeks or months, and thus protect them against the aggressive constituents of the gastrointestinal tract, such as hydrochloric acid and digestive enzymes. The protection brought about by the agent employed according to the invention effects, on the one hand, a reduction in the activity of tissue-damaging mechanisms and, on the other hand, a comparatively unimpaired regeneration of the walls associated with the cell regeneration and with the ulcer cleansing. The agent employed according to the invention additionally brings about an increase in the pH (buffering of raised acid values) in the stomach. The subjective feeling of the patient improves due to intake of the agent, the `heartburn` of the frequently hyperacid patients disappears. 
     Investigations 
     The following were investigated as a function of the dose and time: 
     1. Distribution and film-formation of dimethylpolysiloxane in the stomach. 
     2. Distribution and film-formation of dimethylpolysiloxane in the duodenum. 
     8 healthy men aged 25 and 40 years were employed as volunteer subjects (Table 1). The study was carried out as a controlled, randomized phase I study in crossover design. For the crossover design, the 8 subjects were randomized and assigned to the two dosage forms. The investigations were carried out at an interval of 7 days. 
     Two dosages were used per subject in the crossover design: 
     Dosage 1: 80 mg of dimethylpolysiloxane: (2×40 mg dimethylpolysiloxane chewable tablets) 
     Dosage 2: 160 mg of dimethylpolysiloxane: (4×40 mg dimethylpolysiloxane chewable tablets) 
     The composition of the dimethylpolysiloxane chewable tablets is shown in Table 8. 
     No other drugs were allowed to be taken immediately before and during the study. Furthermore, smoking was not permitted on the day of the investigation. 
     Control Investigations 
     A comprehensive history was taken at the initial investigation; in addition the basic physical and neurological investigations. Laboratory tests were also carried out. 
     The following gastroenterological progress investigations were carried out on all the subjects on both investigation days: 
     1. Gastroscopy with documentation of oesophagus, stomach and duodenum immediately before chewing the dimethylpolysiloxane tablets. 
     2. The same investigations, including the documentation, 30 minutes after taking the chewable tablets. 
     3. The same investigations, including the documentation, 2 hours after chewing the dimethylpolysiloxane chewable tablets. 
     The investigations were carried out twice for each subject, with each alternative dosage, at an interval of 7 days. At a second progress investigation, in addition the pH of the stomach contents was measured at each gastroscopy. 
     The subjects were not allowed to take any food or drink for at least 6 hours before each drug intake and gastroscopy. 
     To prepare for the endoscopy, each subject received 0.5 mg of atropine in 1 ml of NACL solution administered subcutaneously. The local anaesthetic given for the mouth and pharyngeal space was Wander Novescine 1% solution (oxybuprocaine-HCL). 
     The gastroscopic investigations were carried out with an Olympus type P 10  instrument. Documentation was effected by the visual findings and photography. 
    
    
     Results 
     1. Change in the stomach pH 
     Table 2 summarizes the changes in pH based on the pH at the investigation immediately before medication and 2 hours after medication. 
     The dimethylpolysiloxane administration leads to a distinct increase in the pH, i.e. a distinct shift from strongly acid in the direction of the alkaline range, irrespective of the number of chewable tablets administered. Despite the small number of subjects, this difference is significant at the 5% level. 
     Subject 7 was removed from the calculation because he had a duodenal cap greatly deformed by scarring and, moreover, the pH was already near the alkaline range (pH 6.05 or 6.83). 
     2. Film formation 
     Table 3 summarizes the individual results in Tables 4 to 7. The aim of the study was to demonstrate that the dimethylpolysiloxane remained in the stomach or duodenum in the observed period of 2 hours after administration of chewable tablets. The results are unambiguous. Administration of only 2 tablets of dimethylpolysiloxane (80 mg) leads to a reaction in all the subjects. This is even more evident due to administration of 4 tablets of dimethylpolysiloxane (160 mg). 
     At 360 mg, a relatively large amount of milky secretion was evident as observation parameter on the gastric mucous membrane in 7 of 8 subjects. 
     The individual findings (and the summary findings) are set out in Tables 4 to 7. 
     Evaluation of the visual findings and of the photographic documentation allows the summary assessment to be made that dimethylpolysiloxane chewable tablets and dimethylpolysiloxane are able to form an adhesive film on the gastric mucous membrane and in the proximal part of the duodenum. 
     
                       TABLE 1                                                     
______________________________________                                    
Anamnestic data on the subjects in the dimethylpolysiloxane study         
       Mean  SD      Min     Max   Median                                 
______________________________________                                    
Age      32.15   4.51    25    40    31.5 years                           
Height   179.75  7.31    170   191   181  cm                              
Weight   78      7.68    63    90    77   kg                              
Systol. blood                                                             
         116     9.99    101   130   114.5                                
                                          mmHg                            
pressure                                                                  
Diast. blood                                                              
         78.62   8.44    62    90    81   mmHg                            
pressure                                                                  
Pulse    63.5    10.94   53    88    60.5 min                             
______________________________________                                    
 
    
     
                       TABLE 8                                                     
______________________________________                                    
40 mg dimethylpolysiloxane chewable tablets                               
______________________________________                                    
Composition per tablet:                                                   
I.   1)    Dimethylpolysiloxane DAB9                                      
                                  40.000                                  
                                        mg                                
     2)    Highly disperse silica DAB9                                    
                                  12.555                                  
                                        mg                                
     3)    Peppermint oil DAB9    0.300 mg                                
           Aniseed oil DAB9       0.033 mg                                
     4)    Microcrystalline cellulose DAB9                                
                                  200.000                                 
                                        mg                                
II.  5)    Mannitol DAB9          338.111                                 
                                        mg                                
     6)    Saccharin sodium DAB9  0.667 mg                                
     7)    Carboxymethylcellulose sodium DAB9                             
                                  1.667 mg                                
III. 9)    Magnesium stearate DAB9                                        
                                  3.333 mg                                
     10)   Maize starch DAB9      3.333 mg                                
______________________________________                                    
 DAB9 is the abbreviation for Deutches Arznel Buch (German Pharmaceutical 
 Handbook) 9th Edition.                                                   
 
    
     
                       TABLE 2                                                     
______________________________________                                    
Change in the pH values in the stomach on                                 
medication with dimethylpolysiloxane                                      
       Sub;. No.                                                          
       1    2      3      4    5    6    7    8                           
______________________________________                                    
Before med.                                                               
         1.80   1.96   1.92 1.98 1.51 2.11 6.03 1.69                      
30 min after                                                              
         2.06   --     --   --   --   --   --   --                        
med.                                                                      
2 hours after                                                             
         2.15   2.04   4.48 7.49 3.84 2.32 6.83 2.67                      
med.                                                                      
No. of Tab.                                                               
         2      4      4    2    2    2    4    2                         
______________________________________                                    
 
    
     A positive influence on the pH by the medication is confirmed by the sign test (p&lt;0.05, two-sided). However, no influence of the number of tablets on the increase in the pH can be established. 
     Subject 7 had a deformed duodenal cap due to scarring, without stenosis, was not included in the calculation because of the high pH values. 
     
                       TABLE 3                                                     
______________________________________                                    
Positive reaction on administration of dimethyl-                          
polysiloxane chewable tablets                                             
______________________________________                                    
2 dimethylpolysiloxane tablets                                            
Subjects with                                                             
positive reaction*                                                        
                  no reaction                                             
                            n                                             
______________________________________                                    
8                 0         8                                             
______________________________________                                    
4 dimethylpolysiloxane tablets                                            
Subjects with                                                             
positive reaction**                                                       
                  no reaction                                             
                            n                                             
______________________________________                                    
8                 0         8                                             
______________________________________                                    
 *The reaction was minimal milky secretion in 5 of 8 subjects             
 **The reaction was minimal milky secretion in 1 of 8 subjects, otherwise 
 always a relatively large amount of milky secretion                      
 
    
     
                       TABLE 4                                                     
______________________________________                                    
Findings at the first investigation                                       
             No. of                                                       
       Time* tabl.   Finding                                              
______________________________________                                    
Subject No. 1                                                             
         1       4       Signs of antral gastritis. Other-                
                         wise duodenum, stomach and                       
                         oesophagus macroscopically                       
                         normal.                                          
Subject No. 1                                                             
         2       4       Gastric juice in the fundus;                     
                         milky, cloudy and flocculent.                    
Subject No. 1                                                             
         3       4       Only minimal residues in the                     
                         fundus. Otherwise empty as far                   
                         as the deep duodenum.                            
Subject No. 2                                                             
         1       2       Signs of slight antral                           
                         gastritis. Otherwise                             
                         duodenum, stomach and                            
                         oesophagus macroscopically                       
                         normal.                                          
Subject No. 2                                                             
         2       2       Gastric juice in the fundus;                     
                         milky, cloudy and flocculent                     
Subject No. 2                                                             
         3       2       Still milky substance in the                     
                         fundus. Duodenum and antrum                      
                         empty.                                           
Subject No. 3                                                             
         1       2       Small hiatus hernia with reflux                  
                         of grade 0-1. Otherwise                          
                         duodenum, stomach and                            
                         oesophagus macroscopically                       
                         normal.                                          
Subject No. 3                                                             
         2       2       Gastric juice in the fundus;                     
                         milky, cloudy and flocculent                     
Subject No. 3                                                             
         3       2       Minute residues of milky,                        
                         flocculent deposits. Fundus with                 
                         a film-like coating over large                   
                         areas. Duodenum empty.                           
Subject No. 4                                                             
         1       4       Duodenum, stomach and                            
                         oesophagus macroscopically                       
                         normal.                                          
Subject No. 4                                                             
         2       4       Gastric juice in the fundus;                     
                         milky, cloudy and flocculent                     
Subject No. 4                                                             
         3       4       Slightly cloudy, milky gastric                   
                         juice. Otherwise duodenum,                       
                         stomach, oesophagus normal.                      
Subject No. 5                                                             
         1       4       Small hiatus hernia with reflux                  
                         oesophagitis (grade 0-1). Other-                 
                         wise duodenum, stomach and                       
                         oesophagus macroscopically                       
                         normal.                                          
Subject No. 5                                                             
         2       4       Antrum with scabby-milky                         
                         coating in the fundus. Very                      
                         cloudy, milky fluid.                             
Subject No. 5                                                             
         3       4       Residues of milky flakes in the                  
                         fundus. A few plaques in the                     
                         antrum. Duodenum empty.                          
Subject No. 6                                                             
         1       4       Duodenum, stomach and                            
                         oesophagus normal.                               
Subject No. 6                                                             
         2       4       A few whitish, milky spots in                    
                         the antrum. Otherwise cloudy,                    
                         milky coating in the fundus.                     
Subject No. 6                                                             
         3       4       Very cloudy, milky fluid                         
                         deposited on the fundus. A few                   
                         plaques in the antrum.                           
                         Duodenum empty.                                  
Subject No. 7                                                             
         1       2       Deformed duodenal cap due to                     
                         scarring, without stenosis.                      
                         Stomach and oesophagus normal.                   
Subject No. 7                                                             
         2       2       Low-viscosity, milky deposits                    
                         in the fundus. Antrum, duodenum                  
                         empty.                                           
Subject No. 7                                                             
         3       2       Minimal spots of milky deposits                  
                         in the stomach fundus. Other-                    
                         wise duodenum and antrum                         
                         empty.                                           
Subject No. 8                                                             
         1       2       Duodenum, stomach and                            
                         oesophagus normal.                               
Subject No. 8                                                             
         2       2       Low-viscosity but cloudy, milky                  
                         secretion in the fundus, film-like               
                         coating. Antrum, duodenum                        
                         empty.                                           
Subject No. 8                                                             
         3       2       Low-viscosity milky secretion                    
                         as film-like coating. Secretion                  
                         cloudy. Antrum, duodenum                         
                         empty.                                           
______________________________________                                    
 *Time 1 = immediately before medication                                  
  Time 2 = 1/2 hour after medication                                      
 Time 3 = 2 hours after medication                                        
 
    
     
                       TABLE 5                                                     
______________________________________                                    
Findings at the second investigation                                      
(after 7 days)                                                            
             No. of                                                       
       Time* Tabl.   Finding                                              
______________________________________                                    
Subject No. 1                                                             
         1       2       Duodenum, stomach, oesophagus                    
                         normal, distinct macroscopic                     
                         improvement in antral gastritis.                 
                         pH 1.80                                          
Subject No. 1                                                             
         2       2       Distinctly less milky secretion                  
                         and film coating. Otherwise                      
                         finding unchanged. pH 2.06                       
Subject No. 1                                                             
         3       2       Minimal milky secretion in the                   
                         fundus. Duodenum, stomach                        
                         normal. pH 2.15                                  
Subject No. 2                                                             
         1       4       Continuing signs of slight antral                
                         gastritis. Otherwise duodenum,                   
                         stomach and oesophagus normal.                   
                         pH 1.96                                          
Subject No. 2                                                             
         2       4       Large amount of high-viscosity                   
                         milky secretion in the fundus.                   
                         Otherwise antrum empty.                          
Subject No. 2                                                             
         3       4       Large amount of high-viscosity                   
                         milky secretion in the fundus.                   
                         Antrum, duodenum empty.                          
                         pH 2.04                                          
Subject No. 3                                                             
         1       4       Small hiatus hernia with reflux                  
                         of grade 0-1. Otherwise                          
                         duodenum, stomach and                            
                         oesophagus macroscopically                       
                         normal. pH 1.92                                  
Subject No. 3                                                             
         2       4       Large amount of high-viscosity                   
                         milky secretion in the antrum and                
                         fundus, duodenum empty.                          
Subject No. 3                                                             
         3       4       Large amount of residues of                      
                         milky coating and secretion in                   
                         the antrum and fundus.                           
                         Duodenum empty. pH 4.48                          
Subject No. 4                                                             
         1       2       Duodenum, stomach and                            
                         oesophagus macroscopically                       
                         normal. pH 1.98                                  
Subject No. 4                                                             
         2       2       Minimal milky secretion in the                   
                         fundus. Duodenum, antrum                         
                         empty.                                           
Subject No. 4                                                             
         3       2       Only residues of cloudy,                         
                         milky secretion in fundus.                       
                         Duodenum and antrum otherwise                    
                         empty. pH 7.49                                   
Subject No. 5                                                             
         1       2       Small hiatus hernia with reflux                  
                         oesophagitis (grade 0-1). pH 1.51                
Subject No. 5                                                             
         2       2       Minimal milky secretion in the                   
                         corpus and in the antrum.                        
                         Duodenum empty.                                  
Subject No. 5                                                             
         3       2       Little cloudy secretion in the                   
                         fundus. Antrum, duodenum                         
                         empty. pH 3.84                                   
Subject No. 6                                                             
         1       2       Duodenum, stomach and                            
                         oesophagus normal. pH 2.11                       
Subject No. 6                                                             
         2       2       Little milky, cloudy secretion                   
                         in the fundus and corpus.                        
Subject No. 6                                                             
         3       2       Minimal secretion in the                         
                         duodenum and in the stomach.                     
                         pH 2.32                                          
Subject No. 7                                                             
         1       4       Deformed duodenal cap due to                     
                         scarring, without stenosis.                      
                         Stomach and oesophagus normal.                   
                         pH 6.03                                          
Subject No. 7                                                             
         2       4       Little milky cloudy secretion                    
                         in the fundus. Antrum                            
                         duodenum empty.                                  
Subject No. 7                                                             
         3       4       Minimal secretion in the fundus                  
                         without the milky cloudiness.                    
                         Duodenum, antrum empty.                          
                         pH 6.83                                          
Subject No. 8                                                             
         1       4       Duodenum, stomach and                            
                         oesophagus normal. pH 1.69                       
Subject No. 8                                                             
         2       4       Minimal, milky secretion as                      
                         film-like coating. Tablets                       
                         unchewed in the corpus.                          
                         Duodenum empty.                                  
Subject No. 8                                                             
         3       4       Now large amount of cloudy,                      
                         milky secretion as film-like                     
                         coating in the fundus. Corpus,                   
                         duodenum, antrum empty.                          
                         pH 2.67                                          
______________________________________                                    
 *Time 1 = immediately before medication                                  
 Time 2 = 1/2 hour after medication                                       
 Time 3 = 2 hours after medication                                        
 
    
     
                       TABLE 6                                                     
______________________________________                                    
Summary of the findings in the dimethylpolysiloxane study                 
              No. of                                                      
                    Frequency of occurrence                               
              subj. 2T    4T     t2  t3  t 2 + 3                          
______________________________________                                    
Signs of antral gastritis                                                 
                2                                                         
Antral gastritis macroscop.                                               
                1                                                         
improved                                                                  
Duodenum and antrum                                                       
                6       6     4        4   6                              
empty                                                                     
Duodenum empty  3             3    1   2                                  
Corpus empty    1             1        1                                  
Minimal/little milky                                                      
                6       5     1    2   2   2                              
secretion                                                                 
Minimal/residues of spots                                                 
                4       2     2    1   3                                  
of milky deposits                                                         
A few plaques in the antrum                                               
                2       0     2    0   2                                  
Milky, cloudy, flocculent                                                 
                4       2     2    2       2                              
gastric juice                                                             
Milky deposits  5       3     2    2   1   2                              
Large amount of high-                                                     
                3       0     3    1   1   1                              
viscosity milky secretion                                                 
Large amount of residues of                                               
                1       0     1        1                                  
milky coating and secretion                                               
______________________________________                                    
 Abbreviations:                                                           
 No. of subj. = number of subjects;                                       
 T = tablets;                                                             
 t = time                                                                 
 
    
     
                       TABLE 7                                                     
______________________________________                                    
Findings in the dimethylpolysiloxane study                                
            Subj.         No. of  Investigation                           
            No.  Date     tabl.   time                                    
______________________________________                                    
Signs of antral gastritis                                                 
              1      March 15       1                                     
Antral gastritis macro-                                                   
              1      March 22       1                                     
scop. improved                                                            
Signs of antral gastritis                                                 
              2      March 15       1                                     
              2      March 22       1                                     
Small hiatus hernia                                                       
              3      March 15       1                                     
              3      March 22       1                                     
              5      March 15       1                                     
              5      March 22       1                                     
Deformed duodenal cap                                                     
              7      March 15       1                                     
due to scarring, without                                                  
              7      March 22       1                                     
stenosis.                                                                 
Duodenum and antrum                                                       
              2      March 15 2     3                                     
empty         3      March 15 2     3                                     
              4      March 22 2     2 and 3                               
              5      March 22 2     2 and 3                               
              7      March 15 2     2 and 3                               
              8      March 15 2     2 and 3                               
              2      March 22 4     2 and 3                               
              4      March 15 4     3                                     
              7      March 22 4     2 and 3                               
              8      March 22 4     3                                     
Duodenum empty                                                            
              5      March 15 4     3                                     
              6      March 15 4     3                                     
              8      March 22 4     2                                     
Corpus empty  8      March 22 4     3                                     
Minimal milky secretion                                                   
              8      March 22 4     2                                     
(tablets unchewed in the                                                  
corpus)                                                                   
Minimal milky secretion                                                   
              1      March 22 2     2 and 3                               
in the fundus 4      March 22 2     2 and 3                               
              5      March 22 2     3                                     
              6      March 22 2     2                                     
Minimal milky secretion                                                   
              5      March 22 2     2                                     
in the corpus and antrum                                                  
              6      March 22 2     2                                     
Fundus with minimal                                                       
              7      March 15 2     3                                     
spots of milky deposits                                                   
              1      March 15 4     3                                     
Little milky secretion in                                                 
              7      March 22 4     2                                     
the fundus                                                                
Stomach with minimal                                                      
              7      March 15 2     3                                     
spots of milky deposits                                                   
Minimal secretion in the                                                  
              6      March 22 2     3                                     
duodenum and antrum                                                       
Minimal secretion in the                                                  
              7      March 22 4     3                                     
fundus without milky                                                      
cloudiness                                                                
A few whitish spots in                                                    
              6      March 15 4     2                                     
the antrum                                                                
Minute residues of                                                        
              3      March 15 2     3                                     
milky, flocculent                                                         
deposits                                                                  
Residues of milky flakes                                                  
              5      March 15 4     3                                     
in the fundus                                                             
A few plaques in the                                                      
              5      March 15 4     3                                     
antrum        6      March 15 4     3                                     
Milky, cloudy, floccu-                                                    
              2      March 15 2     2 and 3                               
lent gastric juice in the                                                 
              3      March 15 2     2                                     
fundus                                                                    
              1      March 15 4     2                                     
              4      March 15 4     2 and 3                               
Low-viscosity, milky                                                      
              7      March 15 2     2                                     
deposits in the fundus                                                    
              8      March 15 2     2 and 3                               
Fundus with film-like                                                     
              3      March 15 2     3                                     
coating over large area                                                   
Antrum and fundus with                                                    
              5      March 15 4     2                                     
scabby-milky coating                                                      
Fundus with cloudy,                                                       
              6      March 15 4     2 and 3                               
milky coating                                                             
Large amount of high-                                                     
              2      March 22 4     2 and 3                               
viscosity milky secretion                                                 
              3      March 22 4     2                                     
in the fundus                                                             
Large amount of high-                                                     
              3      March 22 4     2                                     
viscosity milky secretion                                                 
in the antrum                                                             
Large amount of cloudy,                                                   
              8      March 22 4     3                                     
milky secretion as film-                                                  
like coating in the                                                       
fundus                                                                    
Large amount of                                                           
              3      March 22 4     3                                     
residues of milky coating                                                 
and secretion in the                                                      
fundus.                                                                   
Large amount of                                                           
              3      March 22 4     3                                     
residues of milky coating                                                 
and secretion in the                                                      
antrum                                                                    
______________________________________                                    
 
    
     Dimethylpolysiloxane is obtained by hydrolysis and polycondensation of dichlorodimethylsilane and chlorotrimethylsilane. The various types differ in the nominal viscosity which is expressed by the number with the substance name. 
     The degree of polymerization (n=20 to 400) is such that the kinematic viscosity ranges from 20 to 1,000 mm 2 .s -1  (20 to 1,000 cSt). 
     The structural formula of dimethylpolysiloxane is: ##STR2## 
     S 184 silicone antifoam agent from Wacker Chemie was used to prepare the chewable tablets in the tests described hereinbefore. Equivalent results are also achieved with dimethylpolysiloxane or silicone oils with a kinematic viscosity in the range from 10.0 to 10,000 mm 2 .s -1 , in particular 300 to 3,000 mm 2 .s -1 . 
     Aerosil 2000 was employed as highly disperse silica.