The Therapeutics Initiative presents critically appraised summary evidence primarily from controlled drug trials. Such evidence applies to patients similar to those involved in the trails, and may not be generalizable to every patient. We are committed to evaluate the effectiveness of our educational activities using the Pharmacare/PharmaNet databases without identifying individual physicians, pharmacies or patients. The Therapeutics Initiative is funded by the BC Ministry of Health through a 5-year grant to the University of BC. The Therapeutics Initiative provides evidence based advice about drug therapy, and is not responsible for formulating or adjudicating provincial drug policies.

Click here to download a printable version of this Therapeutics Letter in Adobe Acrobat PDF format (84 KB).

Therapeutics Letter, issue 45, June - September 2002

Do Single Stereoisomer Drugs Provide Value? 

Stereoisomers are molecules with one or more “chiral” centres that allow the possibility of forms with the same chemical formula but differing spatial arrangements. Quinidine and quinine are a naturally occurring pair of stereoisomers, which have been developed for different therapeutic uses. Enantiomers are a type of stereoisomer in which the molecules have two non-superimposable mirror image forms.  As a hand fits a glove, only the “right” or “left” handed enantiomer may fit a molecular receptor at a drug’s desired site of action. A compound containing an equal proportion of each enantiomer is called a racemic mixture.

Natural compounds are often single enantiomers (e.g. levothyroxine, levodopa, l-noradrenaline). In contrast, many commercially synthesized drugs are racemic mixtures (e.g. adrenaline, warfarin, fluoxetine, omeprazole).

In principle, any of the following properties could render a single enantiomers preferable¹:

• the single form has fewer adverse effects

• the desired action of the active form is interfered with by the inactive form

• one form is more prone to adverse drug interactions

Many familiar drugs were introduced to the market as single enantiomers, e.g. paroxetine (Paxil^®) and sertraline (Zoloft^®). However, when the patent of a successful racemic drug nears expiry, it can be remarketed as a single enantiomer under a new patent.²

Are single enantiomers better?

a) Esomeprazole (Nexium^®), licensed in 2001, is the S-enantiomer of racemic S,R-omeprazole (Losec^®, Prilosec^® in the US).
Approved Indications: reduction of gastric acid secretion including reflux esophagitis, gastroesophageal reflux disease and in combination with antibiotics for eradication of H. pylori associated with peptic ulcer disease. Alternative proton pump inhibitors (PPIs) include omeprazole, pantoprazole, lansoprazole and rabeprazole.
Pharmacokinetics: Both S- and R-omeprazole are pro-drugs, which are converted within the parietal cell to the active proton pump inhibitor, which lacks a chiral centre. Both the S- and R-forms are unstable in stomach acid, but are well absorbed when taken with water.^3,4 The duration of acid suppression is determined by irreversible inhibition of the proton pump, rather than by the parent drug’s elimination half-life. Because S-omeprazole is less susceptible to small intestinal and hepatic metabolism than the R-form, at equal doses, esomeprazole achieves 70 to 90% higher steady-state serum concentrations than racemic omeprazole.^3-5 Therefore lower doses of esomeprazole can be used to produce equivalent acid suppression to omeprazole. Genetic differences in metabolism of the enantiomers are known, but have no clinically important impact.⁶
Evidence of efficacy: Published comparative trials of esomeprazole for gastroesophageal reflux disease and eradication of H. pylori used approximately 2 to 4-fold higher equivalent doses of esomeprazole than the comparator drugs.⁷
No trials have demonstrated an intrinsic therapeutic advantage of esomeprazole over other PPIs at equivalent doses.
Dose and cost: Esomeprazole is available in Canada as 20 and 40 mg tablets of multiple tiny enteric-coated granules (each tablet costs $2.20). Switching from other PPIs to an approximately equivalent dose of esomeprazole, has the potential to substantially reduce the daily cost to the patient (see Table 1). This may or may not require pill splitting. Pre-clinical experiments with dissolved esomeprazole and the product monograph suggest that cutting the tablets should not affect absorption, if the tablet fragment is taken with a glass of water on an empty stomach.^3,4,8 Pill splitting strategies are increasingly popular in Health Management Organizations and hospitals.⁹
Conclusion: Esomeprazole at equivalent doses offers no therapeutic advantage over other PPIs. It has a price advantage if the dose is adjusted to the approximate equivalent dose of alternative PPIs. This may require cutting the tablets and/or taking the dose every other day, when clinically appropriate.

Table 1.  Proton pump inhibitors: Approximate equivalent doses and cost.

# Switching from omeprazole at the same dose leads to a 70-90% increase in serum concentration

* Prices are based on average PharmaNet cost for 2001 or wholesale price plus 7%.

^ assumes cutting tablets to halves or quarters when possible to minimize cost.

b) Levofloxacin (Levaquin^®), licensed in 1998, is the pure L-form of the racemic mixture, ofloxacin (see Therapeutics Letter #26). The L-form contains the antimicrobial activity; the D-form is pharmacologically inert. Brand name racemic ofloxacin (Floxin^®, same manufacturer) was similarly priced, offering no cost advantage. Generic ofloxacin is now available and less expensive at comparable doses (800 mg ofloxacin contains 400 mg levofloxacin) (see Table 2). Since once-daily levofloxacin has been proven effective, ofloxacin could be prescribed similarly.
Clinically important resistance of S. pneumoniae to levofloxacin (thus also ofloxacin) is now documented in Canada.¹⁰

Table 2.  Prices of ofloxacin and levofloxacin.

* Prices are based on average PharmaNet cost for 2001.

Enantiomeric drugs under development

a) S-citalopram (escitalopram): The S-enantiomer of racemic citalopram (Celexa^®), is about 30-fold more potent an inhibitor at the serotonin transporter in vitro than its R-counterpart.¹¹ Current knowledge provides no reason to expect a clinically significant advantage over the racemate.¹² Both the antidepressant effect and adverse events (nausea, diarrhea, insomnia, dry mouth, ejaculatory disorder) were similar for S-citalopram at 10 or 20 mg/day and racemic citalopram at 40 mg/day in one 8-week DBRCT.¹³
b) R-fluoxetine: Both enantiomers of fluoxetine (Prozac^®, generic) have a relatively long elimination half-life (> 2 days). The longer-lived demethylated active metabolite of S-fluoxetine is more potent than its R-desmethylfluoxetine counterpart. Interestingly, drug development of both enantiomers for different indications is underway (R-fluoxetine for depression and S-fluoxetine for migraine).¹ There is no evidence yet that either single enantiomer is preferable to racemic fluoxetine.
c) R-salbutamol (R-albuterol in the US): The active enantiomer of racemic salbutamol (Ventolin^®) has been licensed in the US since 1999. Despite a significantly higher price than racemic salbutamol, it offers no demonstrated clinical advantage.¹⁴

Conclusions

The concept that a single enantiomer of a chiral drug may be preferable to a racemic mixture is intellectually appealing. However, in most instances this strategy has not been demonstrated to confer any clinical advantage.

References

1. Tucker GT. Chiral switches. Lancet 2000; 355: 1085-7.
2. Anon. First launches for Cipralex. SCRIP 2002; No. 2756: 21.
3. Andersson T, Hassan-Alin M, Hasselgren G et al. Pharmacokinetic studies with esomeprazole, the (S)-isomer of omeprazole. Clin Pharmacokinet 2001; 40: 411-26.
4. Andersson T, Rohss K, Bredberg E,Hassan-Alin M. Pharmacokinetics and pharmacodynamics of esomeprazole, the S-isomer of omeprazole. Aliment Pharmacol Ther 2001; 15: 1563-9.
5. Lind T, Rydberg L, Kyleback A et al. Esomeprazole provides improved acid control vs. omeprazole in patients with symptoms of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2000; 14: 861-7.
6. http://www.nexium-us.com/moa/moa.asp (“Nexium Story” icon, accessed September 29, 2002).
7. US FDA, NDA 21-153, Medical Review, p 4-8. http://www.fda.gov./cder/approval/index.htm Nexium, Medical Review(s), Part 1, accessed September 29, 2002).
8. Nexium Product Monograph. Compendium of Pharmaceuticals and Specialties. 2002:1116-1117.
9. Landers SJ. 11 pills score as candidates for splitting. Amednews.com. Sept. 23/30, 2002. Accessed September 29, 2002. http://www.ama-assn.org/sci-pubs/amnews/pick_02/hlsa0923.htm
10. Davidson R, Cavalcanti R, Brunton JL et al. Resistance to levofloxacin and failure of treatment of pneumococcal pneumonia. N Engl J Med 2002; 346: 747-50.
11. Owens MJ, Knight DL, Nemeroff CB. Second-generation SSRI’s: human monoamine transporter binding profile of escitalopram and R-fluoxetine. Biol Psychiatry 2001; 50: 345-50.
12. von Moltke LL, Greenblatt DJ, Giancarlo GM. Escitalopram and its metabolites in vitro: cytochromes mediating biotransformation, inhibitory effects, and comparison to R-citalopram. Drug Metab Dispos 2001; 29: 1102-9.
13. Burke WJ, Gergel I, Bose A. Fixed-dose trial of the single isomer SSRI escitalopram in depressed outpatients. J Clin Psychiatry 2002; 63: 331-6.
14. Slattery D, Wong SW, Colin AA. Levalbuterol hydrochloride. Pediatric Pulmonology 2002; 33:151-7.

Please send feedback!

Back to Therapeutics Letter.

Back to the Therapeutics Initiative Home Page.

©Therapeutics Initiative. Last updated: September 29, 2002.