Ranitidine

Ranitidine, sold under the trade name Zantac among others, is a medication which decreases stomach acid production.[2] It is commonly used in treatment of peptic ulcer disease, gastroesophageal reflux disease, and Zollinger–Ellison syndrome.[2] There is also tentative evidence of benefit for hives.[4] It can be taken by mouth, by injection into a muscle, or into a vein.[2]

Ranitidine
Clinical data
Pronunciation/rəˈnɪtɪdiːn/
Trade namesZantac, others
Other namesDimethyl [(5-{[(2-{[1-(methylamino)-2-nitroethenyl]amino}ethyl)sulfanyl]methyl}furan-2-yl)methyl]amine, ranitidine hydrochloride (JAN JP)
AHFS/Drugs.comMonograph
MedlinePlusa601106
License data
Pregnancy
category
  • AU: B1 [1]
  • US: B (No risk in non-human studies) [1]
    Routes of
    administration    		By mouth, IV
    Drug classH2 receptor blocker
    ATC code
    Legal status
    Legal status
    Pharmacokinetic data
    Bioavailability50% (by mouth)[2]
    Protein binding15%
    MetabolismLiver: FMOs, including FMO3; other enzymes
    Onset of action55–65 minutes (150 mg dose)[3]
    55–115 minutes (75 mg dose)[3]
    Elimination half-life2–3 hours
    Excretion30–70% Kidney
    Identifiers
    CAS Number
    PubChem CID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    CompTox Dashboard (EPA)
    ECHA InfoCard100.060.283
    Chemical and physical data
    FormulaC13H22N4O3S
    Molar mass314.40 g·mol−1
    3D model (JSmol)
     NY (what is this?)  (verify)

    Common side effects include headaches and pain or burning if given by injection.[2] Serious side effects may include liver problems, a slow heart rate, pneumonia, and the potential of masking stomach cancer.[2] It is also linked to an increased risk of Clostridium difficile colitis.[5] It is generally safe in pregnancy.[2] Ranitidine is an H2 histamine receptor antagonist that works by blocking histamine and thus decreasing the amount of acid released by cells of the stomach.[2]

    Ranitidine was discovered in 1976, and came into commercial use in 1981.[6] It is on the World Health Organization's List of Essential Medicines, the safest and most effective medicines needed in a health system.[7] It is available as a generic medication.[2] The 2015 wholesale price in the developing world was about US$0.01–0.05 per pill.[8] In the United States it is about $0.05 per dose.[2] In 2016, it was the 50th most prescribed medication in the United States with more than 15 million prescriptions.[9] In September 2019, the toxin N-nitrosodimethylamine was discovered to occur in ranitidine from a number of manufacturers, resulting in distribution stops and recalls.[10][11][12][13]

    Medical uses
    • Relief of heartburn
    • Short-term and maintenance therapy of gastric and duodenal ulcers
    • Ranitidine can also be given with nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce the risk of ulceration. Proton-pump inhibitors (PPIs) are more effective for the prevention of NSAID-induced ulcers.[14]
    • Pathologic gastrointestinal (GI) hypersecretory conditions such as Zollinger–Ellison syndrome
    • Gastroesophageal reflux disease (GERD)
    • Erosive esophagitis
    • Part of a multidrug regimen for Helicobacter pylori eradication to reduce the risk of duodenal ulcer recurrence
    • Recurrent postoperative ulcer
    • Upper GI bleeding
    • Prevention of acid-aspiration pneumonitis during surgery: ranitidine can be administered preoperatively to reduce the risk of aspiration pneumonia. The drug increases gastric pH, but generally has no effect on gastric volume. In a 2009 meta-analysis comparing the net benefit of proton pump inhibitors and ranitidine to reduce the risk of aspiration before anesthesia, ranitidine was found to be more effective than proton pump inhibitors in reducing the volume of gastric secretions.[15] Ranitidine may have an antiemetic effect when administered preoperatively.
    • Prevention of stress-induced ulcers in critically ill patients[16]
    • Used together with diphenhydramine as secondary treatment for anaphylaxis; after first-line epinephrine.[17][18]

    Preparations

    Certain preparations of ranitidine are available over the counter (OTC) in various countries. In the United States, 75- and 150-mg tablets are available OTC. Since 2017, Zantac is marketed in the U.S. by Sanofi.[19][20] In Australia and the UK, packs containing seven 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 require a prescription.

    Dosing

    For ulcer treatment, a night-time 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, proton-pump inhibitors (PPIs) have taken over this role. In addition, a fairly rapid tachyphylaxis can develop within six weeks of initiation of treatment, further limiting its potential for long-term use.[21]

    People with Zollinger–Ellison syndrome have been given very high doses without any harm.[22]

    Contraindication

    Ranitidine is contraindicated for patients known to have hypersensitivity to the drug.

    Adverse effects

    The following adverse effects have been reported as events in clinical trials:

    Central nervous system

    Rare reports have been made of malaise, dizziness, somnolence, insomnia, and vertigo. In severely ill, elderly patients, cases of reversible mental confusion, agitation, depression, and hallucinations have been reported.[23] Ranitidine causes fewer CNS adverse reactions and drug interactions compared with cimetidine.

    Cardiovascular

    Arrhythmias such as tachycardia, bradycardia, atrioventricular block, and premature ventricular beats have also been reported.[23]

    Gastrointestinal

    All drugs in its class have the potential to cause vitamin B12 deficiency secondary to a reduction in food-bound vitamin B12 absorption.[24] Elderly patients taking H2 receptor antagonists are more likely to require B12 supplementation than those not taking such drugs.[25] H2 blockers may also reduce the absorption of drugs (azole antifungals, calcium carbonate) that require an acidic stomach.[26] In addition, multiple studies suggest the use of H2 receptor antagonists such as raniditine may increase the risk of infectious diarrhoea, including traveller's diarrhoea and salmonellosis.[27][28][29][30][31] A 2005 study found that by suppressing acid-mediated breakdown of proteins, ranitidine may lead to an elevated risk of developing food or drug allergies, due to undigested proteins then passing into the gastrointestinal tract, where sensitisation occurs. Patients who take these agents develop higher levels of immunoglobulin E against food, whether they had prior antibodies or not.[32] Even months after discontinuation, an elevated level of IgE in six percent of patients was still found in the study.

    Liver

    Cholestatic hepatitis, liver failure, hepatitis, and jaundice have been noted, and require immediate discontinuation of the drug.[23] Blood tests can reveal an increase in liver enzymes or eosinophilia, although in rare instances, severe cases of hepatotoxicity may require a liver biopsy.[33]

    Lungs

    Ranitidine and other histamine H2 receptor antagonists may increase the risk of pneumonia in hospitalized patients.[34] They may also increase the risk of community-acquired pneumonia in adults and children.[35]

    Blood

    Thrombocytopenia is a rare but known side effect. Drug-induced thrombocytopenia usually takes weeks or months to appear, but may appear within 12 hours of drug intake in a sensitized individual. Typically, the platelet count falls to 80% of normal, and thrombocytopenia may be associated with neutropenia and anemia.[36]

    Skin

    Rash, including rare cases of erythema multiforme, and rare cases of hair loss and vasculitis have been seen.[23]

    Precautions

    Relief of symptoms due to the use of ranitidine does not exclude the presence of a gastric malignancy. In addition, with kidney or liver impairment, ranitidine must be used with caution. Ranitidine should be avoided in patients with porphyria, as it may precipitate an attack.[37][38]

    Pregnancy

    This drug is rated pregnancy category B in the United States.[1]

    Lactation

    Ranitidine enters breast milk, with peak concentrations seen at 5.5 hours after the dose in breast milk. Caution should be exercised when prescribed to nursing women.[39]

    Children

    In children, the use of gastric acid inhibitors has been associated with an increased risk for development of acute gastroenteritis and community-acquired pneumonia.[40] A cohort analysis including over 11,000 neonates reported an association of H2 blocker use and an increased incidence of necrotizing enterocolitis in very-low-birth-weight (VLBW) neonates.[41] In addition, about a sixfold increase in mortality, necrotizing enterocolitis, and infection (such as sepsis, pneumonia, urinary tract infection) was reported in patients receiving ranitidine in a cohort analysis of 274 VLBW neonates.[42]

    Drug tests

    Ranitidine may return a false positive result with some commercial kits for testing for drugs of abuse.[43]

    Cancer-causing impurities
    See also: Valsartan § recalls, and Angiotensin II receptor blocker § recalls

    In September 2019, the U.S. Food and Drug Administration (FDA) learned that some ranitidine medicines, including some products sold under the brand name Zantac, contained a nitrosamine impurity called N-nitrosodimethylamine (NDMA), classified as a probable human carcinogen, at low levels.[11][44] Health Canada announced that it was assessing NDMA in ranitidine[10] and requested that manufacturers stop the distribution of ranitidine products in Canada until the NDMA levels in the products are found to be safe.[45] Health Canada announced that ranitidine drugs were being recalled by Sandoz Canada, Apotex Inc., Pro Doc Limitée, Sanis Health Inc., and Sivem Pharmaceuticals ULC.[45] The European Medicines Agency (EMA) started an EU-wide review of ranitidine medicines at the request of the European Commission.[12][46]

    In September 2019, Sandoz issued a "precautionary distribution stop" of all medicines containing ranitidine.[47][48] followed a few days later by a recall of ranitidine hydrochloride capsules in the United States.[49][50][51] The Italian Medicines Agency, AIFA, recalled all ranitidine that uses an active pharmaceutical ingredient (API) from Saraca Laboratories.[52][53][54] The German Pharmacists Committee (AMK) published a list of recalled products.[55] The Therapeutic Goods Administration (TGA) in Australia published a list of recalled products.[56]

    In September 2019, Apotex recalled all over-the-counter (OTC) ranitidine tablets sold in the United States at Walmart, Rite Aid, and Walgreens.[57][58] Subsequently, Walmart, Rite Aid, Walgreens, and CVS pulled Zantac and some generics from their shelves.[59][60][61][62][63]

    In October 2019, the U.S. Food and Drug Administration (FDA) observed that a third-party laboratory was using higher temperatures in its tests to look for nitrosamine impurities. The NDMA was generated by the added heat but the higher temperatures were recommended for using a gas chromatography–mass spectrometry (GC/MS) method to test for NDMA in valsartan and angiotensin II receptor blockers (ARBs).[64] The FDA stated that it recommends using a liquid chromatography-high resolution mass spectrometry (LC-HRMS) testing protocol to test samples of ranitidine.[65] Its LC-HRMS testing method does not use elevated temperatures and has shown the presence of much lower levels of NDMA in ranitidine medicines than reported by the third-party laboratory. International regulators using similar LC-MS testing methods have also shown the presence of low levels of NDMA in ranitidine samples.[13] The FDA provided additional guidance about using another liquid chromatography-mass spectrometry (LC-MS) method based on a triple-quadrupole MS platform.[13][66]

    In October 2019, Sanofi recalled all over-the-counter Zantac in the United States and Canada,[67][68][13] Perrigo issued a worldwide recall of ranitidine,[69][13], Dr. Reddy's issued a recall of all ranitidine products in the United States,[70][13] and Novitium Pharma recalled all ranitidine hydrochloride capsules in the United States.[71][13]

    In November 2019, the FDA stated that their tests have found levels of NDMA in ranitidine and nizatidine that are similar to the levels you would expect to be exposed to if you ate common foods like grilled or smoked meats.[72][73] They also stated that their simulated gastric fluid (SGF) model tests and their simulated intestinal fluid (SIF) model tests indicate that NDMA is not formed when exposed to acid in the stomach with a normal diet.[72][73] The FDA advised companies to recall their ranitidine if testing shows levels of NDMA above the acceptable daily intake (96 nanograms per day or 0.32 parts per million for ranitidine).[13] At the same time, they indicated that some levels of NDMA found in medicines still exceed what the FDA considers acceptable for these medicines.[72][73]

    In November 2019, Aurobindo Pharma, Amneal Pharmaceuticals, American Health Packaging, Golden State Medical Supply, and Precision Dose recalled some lots of ranitidine tablets, capsules, and syrup.[74][75][76][77][78]

    In December 2019, the FDA asked manufacturers of ranitidine and nizatidine products to expand their testing for NDMA to include all lots of the medication before making them available to consumers.[79]

    Pharmacology

    Mechanism of action

    Ranitidine is a competitive, reversible inhibitor of the action of histamine at the histamine H2 receptors found in gastric parietal cells. This results in decreased gastric acid secretion and gastric volume, and reduced hydrogen ion concentration.

    Pharmacokinetics

    Absorption: Oral: 50%

    Protein binding: 15%

    Metabolism: N-oxide is the principal metabolite.

    Half-life elimination: With normal renal function, ranitidine taken orally has a half-life of 2.5–3.0 hours. If taken intravenously, the half-life is generally 2.0–2.5 hours in a patient with normal creatinine clearance.

    Excretion: The primary route of excretion is the urine. In addition, about 30% of the orally administered dose is collected in the urine as non-absorbed drug in 24 hours.

    Elderly

    In the elderly population, the plasma half-life of ranitidine is prolonged to 3–4 hours secondary to decreased kidney function causing decreased clearance.[23]

    Children

    In general, studies of pediatric patients (aged one month to 16 years) have shown no significant differences in pharmacokinetic parameter values in comparison to healthy adults, when correction is made for body weight.[23]

    History
    Zantac (ranitidine) 300-mg tablets

    Ranitidine was first prepared as AH19065 by John Bradshaw in the summer of 1977 in the Ware research laboratories of Allen & Hanburys, part of the Glaxo organization.[80][81] 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.

    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 10 times the activity of cimetidine. Ranitidine has 10% of 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.[82]

    Ranitidine was introduced in 1981, and was the world's biggest-selling prescription drug by 1987. It was largely 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 with 50% of those given ranitidine. In addition, the omeprazole group reported earlier relief of heartburn symptoms.[83][84]

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