Ranitidine

Ranitidine

Systematic (IUPAC) name
N-(2-[(5-(dimethylaminomethyl)furan- 2-yl)methylthio]ethyl)- N-methyl- 2-nitroethene- 1,1-diamine
Clinical data
Trade names	Zantac
AHFS/Drugs.com	monograph
MedlinePlus	a601106
Licence data	US FDA:link
Pregnancy cat.	B1(AU) B(US)
Legal status	Pharmacy Only (S2) (AU) OTC (US) P/POM (UK)
Routes	Oral, IV
Pharmacokinetic data
Bioavailability	39 to 88%
Protein binding	15%
Metabolism	Hepatic
Half-life	2–3 hours
Excretion	30–70% Renal
Identifiers
CAS number	66357-35-5 Y
ATC code	A02BA02
PubChem	CID 657345
DrugBank	APRD00254
ChemSpider	571454 Y
UNII	884KT10YB7 Y
KEGG	D00422 Y
ChEMBL	CHEMBL512 N
Chemical data
Formula	C13H22N4O3S
Mol. mass	314.4 g/mol
SMILES	eMolecules & PubChem
InChI InChI=1S/C13H22N4O3S/c1-14-13(9-17(18)19)15-6-7-21-10-12-5-4-11(20-12)8-16(2)3/h4-5,9,14-15H,6-8,10H2,1-3H3/b13-9- Y Key:VMXUWOKSQNHOCA-LCYFTJDESA-N Y
N(what is this?)  (verify)

Ranitidine ( /rəˈnɪtɨdiːn/; trade name Zantac) is a histamine H₂-receptor antagonist that inhibits stomach acid production. It is commonly used in treatment of peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). Ranitidine is also used alongside fexofenadine and other antihistamines for the treatment of skin conditions such as hives. Ranitidine is also known to give false positives for methamphetamine on drug tests.^[1]

Medical use

Certain preparations of ranitidine are not available over the counter (OTC) in various countries. In the United States, 75 mg and 150 mg tablets are available OTC. Zantac OTC is manufactured by Boehringer Ingelheim. In Australia, packs containing 7 or 14 doses of the 150 mg tablet are available in supermarkets, small packs of 150 mg and 300 mg tablets are Schedule 2 Pharmacy Medicines. Larger doses and pack sizes still require a prescription.

Outside the United States and Canada, ranitidine is combined with bismuth (which acts as a mild antibiotic) as a citrate salt (ranitidine bismuth citrate, Tritec), to treat Helicobacter pylori infections. This combination is usually given with clarithromycin, an antibiotic.

Ranitidine's main role is in treating gastric and duodenal ulcers and gastroesophageal reflux disease. It is also used to treat pediatric reflux, where it is preferred over a PPI, because it does not induce histologically relevant hyperplastic changes in the parietal cells. Liquid formulations are available for administering to children.

Ranitidine can also be co-administered with NSAIDs to reduce the risk of ulceration. Proton pump inhibitors are more effective for the prevention of NSAID-induced ulcers.^[2]

Ranitidine can be administered preoperatively to reduce the risk of aspiration pneumonia. The drug not only increases gastric pH, but also reduces the total output of gastric juice. Ranitidine may have an antiemetic effect when administered preoperatively.

It can be administered IV in intensive care units to critically ill patients (particularly geriatric ones) to reduce the risk of gastric bleeding.

The usual dose of ranitidine is either 150 mg twice a day or 300 mg once every twenty four hours, usually at night. For ulcer treatment, a 300 mg nighttime dose is especially important - as the increase in gastric/duodenal pH promotes healing overnight when the stomach and duodenum are empty. Conversely, for treating reflux, smaller and more frequent doses are more effective.

Ranitidine used to be administered long term for reflux treatment, sometimes indefinitely. However, PPIs have taken over this role.

In some patients with severe reflux, up to 600 mg of ranitidine can be administered daily, usually in 4 lots of 150 mg. Such a high dose was not unusual in the past, but nowadays a once-a-day PPI is used instead - both for convenience and because they are more effective in raising gastric pH. Patients with Zollinger-Ellison syndrome have been given doses of 6000 mg per day without any harm.

Adverse effects

Ranitidine appears to decrease mucosal perfusion in patients with acute renal or cardiac failure and increases their risk of death.^[3] All drugs in its class decrease gastric intrinsic factor secretion which can significantly reduce absorption of protein-bound vitamin B12 in humans.^[4] Elderly patients taking H2 receptor antagonists are more likely to require vitamin B12 supplementation than those not taking such drugs.^[5] H2 blockers may also reduce the absorption of drugs (azole antifungals, calcium carbonate) that require an acidic stomach.^[6]

Ranitidine and other histamine H2 receptor antagonists may increase the risk of pneumonia in hospitalized patients.^[7] They may also increase the risk of community-acquired pneumonia in adults and children.^[8] Multiple studies suggest that use of H2 receptor antagonists such as raniditine may increase the risk of infectious diarrhea, including traveller's diarrhea and salmonella.^{[9][10][11][12][13]}

H2 antagonists may increase the risk of developing food allergies. Patients who take these agents develop higher levels of IgE against food, whether they had prior antibodies or not.^[14] Even months after discontinuation there was still an elevated level of IgE in 6% of patients in this study.

History and development

Zantac (ranitidine) 300 mg tablets

Ranitidine was first prepared as AH19065 by John Bradshaw in the summer of 1976 in the Ware research laboratories of Allen_&_Hanburys Ltd, part of the Glaxo organization ^[15],^[16]. Its development was a response to the first in class histamine H₂-receptor antagonist, cimetidine, developed by Sir James Black at Smith, Kline and French, and launched in the United Kingdom as Tagamet in November 1976. Both companies would eventually become merged as GlaxoSmithKline following a sequence of mergers and acquisitions starting with the integration of Allen & Hanbury's Ltd and Glaxo to form Glaxo Group Research in 1979, and ultimately with the merger of Glaxo Wellcome and SmithKline Beecham in 2000. Ranitidine was the result of a rational drug-design process using what was by then a fairly refined model of the histamine H₂-receptor and quantitative structure-activity relationships (QSAR).

Glaxo refined the model further by replacing the imidazole-ring of cimetidine with a furan-ring with a nitrogen-containing substituent, and in doing so developed ranitidine. Ranitidine was found to have a far-improved tolerability profile (i.e. fewer adverse drug reactions), longer-lasting action, and ten times the activity of cimetidine. Ranitidine has 10% the affinity that cimetidine has to CYP450 so it causes fewer side effects, but other H₂ blockers famotidine and nizatidine have no CYP450 significant interactions.^[17]

Ranitidine was introduced in 1981 and was the world's biggest-selling prescription drug by 1988. It has since largely been superseded by the even more effective proton pump inhibitors, with omeprazole becoming the biggest-selling drug for many years. When omeprazole and ranitidine were compared in a study of 144 people with severe inflammation and erosions or ulcers of the esophagus, 85% of those treated with omeprazole healed within eight weeks, compared to 50% of those given ranitidine. In addition, the omeprazole group reported earlier relief of heartburn symptoms.^[18]

References

1. ^ Poklis, A; Hall KV, Still J, Binder SR (March 1991). "Ranitidine interference with the monoclonal EMIT d.a.u. amphetamine/methamphetamine immunoassay". Journal of analytical toxicology 15 (2): 101–103. PMID 2051743. http://www.ncbi.nlm.nih.gov/pubmed/2051743. Retrieved 13 July 2011. 
2. ^ "Reflux Remedies: ranitidine". PharmaSight OTC Health. PharmaSight.org. http://pharmasight.org/overthecounter/2011/11/15/reflux-remedies-ranitidine-zantac/. Retrieved 16 November 2011. 
3. ^ Jakob SM, Parviainen I, Ruokonen E, et al. (2005). "Lack of effect of ranitidine on gastric luminal pH and mucosal PCO2 during the first day in the ICU". Acta Anaesthesiol Scand 49 (3): 390–396. doi:10.1111/j.1399-6576.2005.00651.x. 
4. ^ Salom IL, Silvis SE, Doscherholmen A. (1982). "Effect of cimetidine on the absorption of vitamin B12". Scand J Gastroenterol 17 (1): 129–131. doi:10.3109/00365528209181056. PMID 7134827. 
5. ^ Mitchell SL, Rockwood K. (2001). "The association between antiulcer medication and initiation of cobalamin replacement in older persons". J Clin Epidemiol 54 (5): 531–534. doi:10.1016/S0895-4356(00)00340-1. 
6. ^ "Reflux Remedies: ranitidine". PharmaSight OTC Health. PharmaSight.org. http://pharmasight.org/overthecounter/2011/11/15/reflux-remedies-ranitidine-zantac/. Retrieved 16 November 2011. 
7. ^ Mallow S, Rebuck JA, Osler T, et al. (2004). "Do proton pump inhibitors increase the incidence of nosocomial pneumonia and related infectious complications when compared with histamine-2 receptor antagonists in critically ill trauma patients?". Curr Surg 61 (5): 452–458. doi:10.1016/j.cursur.2004.03.014. PMID 15475094. 
8. ^ Canani RB, Cirillo P, Roggero P, et al. (2006). "Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children". Pediatrics 117 (5): e817––820. doi:10.1542/peds.2005-1655. 
9. ^ Cobelens FGJ, Leentvarr-Kuijpers A, Kleijnen J, Coutinho RA. (1998). "Incidence and risk factors of diarrhoea in Dutch travellers: Consequences for priorities in pre-travel health advice". Trop Med Intern Health 3: 896–903. 
10. ^ Neal KR, Briji SO, Slack RCB, et al. (1994). "Recent treatment with H2-antagonists and antibiotics and gastric surgery as risk factors for Salmonella infection". Br Med J 308: 176. 
11. ^ Neal KR, Scott HM, Slack RC, Logan RF. (1996). "Omeprazole as a risk factor for campylobacter gastroenteritis: Case-control study". BMJ 312: 414–415. 
12. ^ Wickramasinghe LSP, Basu SK. (1984). "Salmonellosis during treatment with ranitidine". Br Med J 289 (6454): 1272. doi:10.1136/bmj.289.6454.1272. 
13. ^ Ruddell WS, Axon AT, Findlay JM, et al. (1980). "Effect of cimetidine on gastric bacterial flora". Lancet i: 672–674. 
14. ^ Untersmayr E, Bakos N, Scholl I, et al. (2005). "Anti-ulcer drugs promote IgE formation toward dietary antigens in adult patients". Faseb J 19 (6): 656–658. 
15. ^ Lednicer, Daniel (Editor). "Chronicles of Drug Discovery". ACS Professional Reference Books, Volume 3, pages 45-81 1993. ISBN 0-8412-2733-0.
16. ^ US patent US4128658, "Aminoalkyl furan derivatives", 1978
17. ^ Laurence Brunton, John Lazo, Keith Parker (August 2005). Goodman & Gilman's The Pharmacological Basis of Therapeutics (11 ed.). McGraw-Hill. p. 972. doi:10.1036/0071422803. ISBN 0071422803. http://mhprofessional.com/product.php?isbn=0071422803. 
18. ^ Pelot, Daniel, (M.D.). "Digestive System : New Drug for Heartburn". The New Book of Knowledge : Medicine & Health, Grolier : Danbury, Connecticut. 1990. p.262. ISBN 0-7172-8244-9. Library of Congress 82-645223

External links

• Reflux Remedies: ranitidine (Zantac)
• Consumer information on Zantac from the manufacturer
• Zantac official website GlaxoSmithKline
• Zantac OTC official website Boehringer Ingelheim