Ethanol concentrations in the human gastrointestinal tract after intake of
alcoholic beverages

Jari Rubbens, Joachim Brouwers, Kris Wolfs, Erwin Adams, Jan Tack,
Patrick Augustijns

PII: S0928-0987(16)30039-2
DOI: doi: 10.1016/j.ejps.2016.02.009
Reference: PHASCI 3486

To appear in:

Received date: 8 December 2015

Revised date: 19 January 2016
Accepted date: 14 February 2016

Please cite this article as: Rubbens, Jari, Brouwers, Joachim, Wolfs, Kris, Adams, Erwin,
Tack, Jan, Augustijns, Patrick, Ethanol concentrations in the human gastrointestinal
tract after intake of alcoholic beverages, (2016), doi: 10.1016/j.ejps.2016.02.009

This is a PDF le of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its nal form. Please note that during the production process
errors may be discovered which could aect the content, and all legal disclaimers that
apply to the journal pertain.
 ACCEPTED MANUSCRIPT
1

Ethanol concentrations in the human gastrointestinal tract

after intake of alcoholic beverages.

T
Jari Rubbensa, Joachim Brouwersa, Kris Wolfsb, Erwin Adamsb, Jan Tackc, Patrick Augustijnsa,*

IP
a
KU Leuven, Drug Delivery & Disposition, Gasthuisberg O&N2, Herestraat 49 Box 921, 3000 Leuven,

R
Belgium, jari.rubbens@kuleuven.be; joachim.brouwers@kuleuven.be; patrick.augustijns@kuleuven.be

SC
b
KU Leuven, Pharmaceutical Analysis, Gasthuisberg O&N2, Herestraat 49 Box 923, 3000 Leuven, Belgium,

NU
kris.wolfs@kuleuven.be; erwin.adams@kuleuven.be

c
KU Leuven, Translational Research Center for Gastrointestinal Disorders (TARGID), Gasthuisberg O&N1,
MA
Herestraat 49 Box 701, 3000 Leuven, Belgium; jan.tack@med.kuleuven.be

*Corresponding author at: KU Leuven, Drug Delivery & Disposition, Campus Gasthuisberg O&N 2, Box 921,
D

Herestraat 49, 3000 Leuven, Belgium.

TE

E-mail address: patrick.augustijns@pharm.kuleuven.be (P. Augustijns).

P
CE
AC
 ACCEPTED MANUSCRIPT
2

ABSTRACT

Introduction: The goal of this study was to monitor gastric and duodenal ethanol concentrations

arising from the consumption of commonly used alcoholic beverages.

T
Materials and methods: In a cross-over study, five fasting volunteers were asked to drink two

IP
standard consumptions of commercially available alcoholic beverages, including beer (Stella Artois,

R
500 mL, 5.2% ethanol), wine (Blanc du Blanc, 200 mL, 11% ethanol) and whisky (Gallantry Whisky,

SC
80 mL, 40% ethanol). The volunteers finished drinking beer within 10 minutes and wine or whisky

NU
within 5 minutes. Ethanol concentrations in gastric and duodenal fluids, aspirated as a function of

time, were analyzed by headspace gas chromatography.

MA
Results: In all three conditions, the average gastric profile shows a maximum ethanol concentration

(Cmax) at 7 minutes, while the mean duodenal profiles have a Tmax at 20, 7 and 12 minutes for beer,
D

wine and whisky, respectively. The median gastric ethanol Cmax (min max) for the beer, wine and
TE

whisky conditions amounts to 4.1 % (3.1 4.1), 4.1 % (2.6 7.3) and 11.4 % (6.3 21.1), respectively.
P

The mean duodenal profiles follow the same pattern as their corresponding gastric profiles, albeit
CE

with lower percentages of ethanol. Median duodenal ethanol Cmax (min max) for beer, wine and

whisky are 1.97% (0.89- 4.3), 2.39 % (2.02 5.63) and 5.94 % (3.55 17.71), respectively.
AC

Intraluminal ethanol concentrations appear to decline relatively rapidly in fasting conditions: both

stomach and duodenum contained less than 0.05% of ethanol after 120 minutes.

Conclusions: This in vivo study is the first to present intraluminal ethanol concentrations in man after

the intake of alcoholic beverages. Relatively low and fast declining gastric ethanol concentrations

were observed, contrasting with the current Food and Drug Administration guidelines for the in vitro

testing of formulations with respect to ethanol resistance. The presented gastric and duodenal

ethanol concentrations and their variation may serve as reference data to design relevant models for

predicting (i) ethanol resistance of drug formulations and (ii) ethanol effects on drug solubility and

permeability.
 ACCEPTED MANUSCRIPT
3

Key words

Alcohol

T
IP
Stomach

R
Intestine

SC
Alcoholic beverages

NU
Intraluminal ethanol concentrations

Clinical study
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
4

1. Introduction

In clinical trials and bio-equivalence studies, drugs are typically administered orally with 240 mL of

water. (FDA, 2002) This does not necessarily reflect what happens in daily practice. Patients take

T
their medication with soft drinks, hot drinks or even alcoholic beverages. The resulting intraluminal

IP
alterations in fluid volume, pH, temperature, osmolality and solubilizing capacity can influence the

R
local behavior of the administered formulation and may cause significant variability in drug

SC
absorption and systemic exposure.

NU
As the consumption of alcoholic beverages is widespread and socially accepted, patients may co-

ingest their medication with ethanol. Many drugs interact with ethanol at a pharmacodynamic
MA
and/or pharmacokinetic level, potentially leading to serious adverse effects. (Lennerns, 2009)

Ethanol is also known to disrupt the extended release mechanism of formulations resulting in dose
D

dumping and possible safety concerns. (Jedinger et al., 2014) In 2005, the US Food and Drug
TE

Administration (FDA) requested Perdue Pharma to suspend their extended release pain treatment

drug Palladone, an extended-release capsule of the opioid analgesic hydromorphone, after the
P

observation of severe ethanol-induced dose-dumping in healthy volunteers. (FDA, 2005) Compared

CE

with water, ingestion of a single dose of Palladone with 240 mL of an ethanol solution at 4, 20 and
AC

40%, resulted in an increased mean Cmax of hydromorphone by 1.06-, 1.89-, and 5.53-fold,

respectively. One volunteer even had a 16-fold increase in Cmax when the formulation was co-

ingested with a 40% ethanol solution. (Walden et al., 2007) This type of ethanol induced dose

dumping poses serious safety concern for drugs with a small therapeutic window or known

pharmacodynamic interaction with ethanol. Ever since, the FDA established guidelines to test the

robustness of certain drug formulations towards ethanol in vitro. These tests are required for all

(generic) extended release formulations containing opioid drugs and are preferred for other

modified-release formulations with risk of alcohol-induced dose dumping. (FDA, 2013) (FDA, 2015)

Drug release from the dosage form should be tested during two hours in a medium of 0.1N HCl with
 ACCEPTED MANUSCRIPT
5

concentrations of 0, 5, 20 and 40% ethanol in order to simulate the consumption of common

alcoholic beverages like beer (5%), mixed drinks (20%) and liquor (40%). (FDA, 2014)(Anand et al.,

2011) The European Medicines Agency (EMA) recommends in vitro ethanol resistance testing for all

T
modified-release products and other formulations with scientific grounds for an ethanol effect on

IP
release characteristics. The EMA does not provide authoritative methodological requirements in

R
terms of minimum testing time or dissolution medium. The dissolution medium should contain

SC
ethanol at levels that are likely to be reached in the proximal gastrointestinal tract: concentrations of

5%, 10% and 20% ethanol are suggested. (EMA, 2009) Based on literature, Lennernas et al.

NU
concluded that the FDA test is physiologically relevant. (Lennerns, 2009) However, it is important to

note that the relevance of the in vitro test imposed by the FDA has never been judged by in vivo
MA
studies.

Besides the impairment of formulation behavior, high concentrations of ethanol in the stomach and
D
TE

duodenum may also act as a co-solvent and increase the solubilizing capacity for lipophilic

compounds, resulting in more effective drug absorption. Fagerberg et al. measured the solubilities of
P

9 lipophilic compounds in fasted state simulated gastric fluids (FaSSGF) with 20% ethanol. (Fagerberg
CE

et al., 2015) A large ethanol-induced increase in solubility was observed for the neutral compounds

and for two out of three weak acids. The solubility of ionized weak bases was unaffected. The same
AC

group also investigated the apparent solubility of 22 poorly soluble compounds in Fasted State

Simulated Intestinal Fluids (FaSSIF) in the presence of 0, 5 and 20% ethanol. The effects of 5%

ethanol were negligible. 13 out of 22 compounds displayed a more than 3-fold increased solubility in

FaSSIF with 20% ethanol, although this effect may be temporarily due to ethanol dilution and

absorption in the intestine. (Fagerberg et al., 2012)(Lennerns, 2009) A large increase in solubility

may also affect the release mechanism of a drug from its dosage form; diffusion-mediated release

will become more important than erosion-mediated release. (Roberts et al., 2007)
 ACCEPTED MANUSCRIPT
6

Ethanol can also enhance drug absorption directly through modulation of the intestinal permeability

by causing mucosal injury, disruption of membrane integrity and even mucosal leakage. (Draper et

al., 1983)(Tarnawski et al., 1985)(Lavo, 1992) Volpe et al. found that ethanol concentrations up to 5%

T
significantly increased the permeability of oxycodone, oxymorphone and atenolol across Caco-2 cell

IP
monolayers. (Volpe et al., 2008)

R
The demand for tools to evaluate ethanol impact on formulation performance and drug absorption

SC
on the one hand and the ignorance of relevant in vivo ethanol concentrations on the other hand,

proves the need for further fundamental research in humans. Existing studies on the gastrointestinal

NU
fate of ethanol typically administer an artificial ethanol solution or instill a solution directly into the
MA
stomach through a gastric tube (Johnoson et al., 1991)(Levitt et al., 1997)(Klockhoff et al.,

2002)(Franke et al., 2004)(Halsted et al., 1973), which may affect the disposition of intraluminal

ethanol in a non-relevant manner. The present study therefore aims to assess intraluminal ethanol
D
TE

concentrations in the stomach and duodenum of healthy volunteers after the consumption of

common alcoholic beverages.

P
CE
AC
 ACCEPTED MANUSCRIPT
7

2. Materials and methods

2.1. Chemicals

Ethanol absolute AnalaR NORMAPUR was purchased from VWR Chemicals (Heverlee, Belgium).

T
Na2CO3 was purchased from Merck (Darmstadt, Germany). Water was purified by using a Maxima

IP
system (Elga Ltd., High Wycombe Bucks, UK).

R
2.2. Alcoholic beverages

SC
Gallantry Whisky and Blanc du Blanc Wine were purchased from Aldi market (Leuven, Belgium);

NU
Stella Artois Beer was purchased from Carrefour market (Leuven, Belgium). The characteristics of the

administered beverages are reported in Table 1. pH and osmolality were measured using a Hamilton
MA
SlimTrode pH electrode (Bonaduz, Switzerland) and an Advanced Instruments osmometer model

3250 (Norwood, MA, USA), respectively.

D

2.3. In vivo study

TE

Five healthy volunteers (3 females, 2 males) were enrolled in a cross-over study. Studies were
P

performed at the University Hospitals Leuven and were approved by the Committee of Medical
CE

Ethics (ML10920). Candidate volunteers with gastrointestinal diseases, hepatitis B or C or HIV were
AC

excluded. All volunteers gave written informed consent prior to participation. After 12 h of fasting,

two double-lumen catheters (Salem Sump Tube 14 Ch, external diameter 4.7mm; Covidien, Dublin,

Ireland) were introduced trough nose or mouth, and positioned into the stomach and the

duodenum, respectively. Positioning was checked by fluoroscopy. In a cross-over design, volunteers

were asked to drink two standard consumptions of beer, wine or whisky. One standard consumption

was defined as 250 mL beer, 100 mL wine and 40 mL whisky. Volunteers finished drinking beer within

10 minutes and wine or whisky within 5 minutes. Subsequently, gastric and duodenal fluids were

collected for 3 hours. Sample preparation was performed on site immediately after aspiration.
 ACCEPTED MANUSCRIPT
8

2.4. Assessment of intraluminal ethanol concentration and osmolality.

Immediately after aspiration, gastric and duodenal aspirates were centrifuged (20,817g, 5 min, room

temperature). Preliminary tests demonstrated that centrifugation did not affect the measured

T
ethanol level. The supernatant of gastric aspirates was diluted in 0.4 mM Na2CO3 (1:50 for the wine

IP
and whisky conditions, 1:25 for the beer condition). The supernatant of duodenal aspirates was

R
diluted in purified water (same dilution strength as gastric aspirates). Samples were sealed with

SC
PTFE/Sil-caps in 20 mL crimp top vials (Perkin Elmer, Zaventem, Belgium) and analyzed by a HP6890

gas chromatography system (Wilmington, DE, USA) equipped with a Perkin Elmer (Waltham, MA,

NU
USA) Turbomatrix 40 HS autosampler (balanced pressure system). Headspace parameters were as

follows: oven at 80C, needle at 120C, transfer line at 140C and injector at 160C. Carrier pressure
MA
was set at 129.9 kPa. The withdrawal time was set at 0.4 s, injection time at 0.04 s and pressurization

time at 1 min. Split ratio of injection was 1/5. Separations were carried out on a ZB-624 column (30 m
D

x 0.53 mm, 3 m film thickness) from Phenomenex (Utrecht, The Netherlands) with a flow of 4
TE

mL/min helium 5.6. Detection was performed with a flame ionisation detector at 220 C, air: 450
P

ml/min, H2: 40 ml/min, and make-up flow N2: 45 ml/min. Separations were carried out using the
CE

following temperature program: holding for 7 min at 40 C, heating 40 C/min towards 240 C and

holding at 240 C for 10 min. The osmolality of gastric and duodenal aspirates of healthy volunteer
AC

(HV) 3 was measured with the equipment described in section 2.2.

2.5. Validation

Calibration curves were made in purified water and linearity was observed between 0.8% and 0.003%

ethanol. Accuracy and precision were measured by spiking concentrations of 40, 10, 1.5 and 0.2%

ethanol in blank gastric and duodenal fluids. Following the dilution as described above, all spiked

samples could be analyzed accurately (between 95% and 110%) and precisely [RSD less than 5%

(n=5)]. Interday repeatability was less than 6.2%. Fresh calibration curves were made on each

analysis day. Quality controls of 0.08% and 0.005% ethanol were made in water and stored in the

freezer. They were thawed and analyzed together with the gastrointestinal samples. Ethanol
 ACCEPTED MANUSCRIPT
9

concentrations in QC samples could be determined accurately (between 98% and 102%) and

precisely (RSD less than 5%).

3. Results

T
Average ethanol concentrations in the stomach and duodenum as a function of time after intake of

IP
two glasses of beer, wine or whisky are depicted in Figure 1. In all conditions, the average gastric

R
profile shows a Tmax at 7 minutes, followed by a non-linear decline of ethanol levels over time. The

SC
average gastric Cmax is similar for the beer and wine condition (3.6 and 3.9 % ethanol, respectively)

NU
and higher for the whisky condition (11.1 % ethanol) which was accompanied with more variation.

The duodenal Tmax values of the average profiles for the beer, wine and whisky condition are at 20, 7
MA
and 12 minutes, respectively. The mean duodenal profiles follow the same pattern as the

corresponding gastric profiles but depict lower percentages of ethanol. Intraluminal ethanol
D

concentrations appear to decline relatively rapidly in fasting conditions as stomach and duodenal
TE

fluids contain less than 0.05% of ethanol after two hours in all conditions.
P

The interindividual variation in maximum ethanol concentrations and the degree of gastric dilution
CE

are reported in Table 2. The variation is expressed by the median and the range in the observed

ethanol concentrations. The degree of dilution is calculated as the ratio of alcohol content in the
AC

administered beverage to the gastric Cmax. In all conditions, the median duodenal Cmax is about half

than the median gastric Cmax. The observed interindividual variation on both gastric and duodenal

ethanol Cmax is most pronounced after intake of whisky, but very limited following the consumption

of beer. Maximum gastric ethanol concentrations were always lower than the ethanol content of the

beverage, resulting in a median degree of gastric dilution of 1.4 (beer) and 3.9 (wine and whisky).

The intake of alcoholic beverages resulted in a significant increase in intraluminal osmolality, as was

demonstrated for the samples collected from HV 3. The average osmolality of samples absent of

ethanol was 123 mOsm/kg (SD 51, n=18) and 187 mOsm/kg (SD 42, n=17) for stomach and duodenal

fluids, respectively. In the presence of ethanol, the osmolality increased proportionally to the ethanol
 ACCEPTED MANUSCRIPT
10

concentration as illustrated in Figure 2 (Pearsons correlation coefficient r = 0.98 and 0.97 for gastric

and duodenal samples, respectively).

T
R IP
SC
NU
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
11

4. Discussion

In vivo, intraluminal ethanol levels arising from the consumption of an alcoholic beverage are the

result of many interacting processes. In all conditions, the maximum gastric ethanol concentrations

T
were lower than the ethanol content of the corresponding beverages, indicating that at least part of

IP
the ethanol is immediately diluted, absorbed and/or transferred upon arrival in the stomach. (Levitt

R
et al., 1997) Considering the relatively small residual volume in the stomach (on average 45 ml

SC
according to Schiller et al, 2005), the observed degree of dilution was related to the volume ingested

and most distinct after intake of 80 mL of whisky and 200 mL of wine, but limited after intake of 500

NU
mL of beer (Table 2). The relatively large degree of dilution after ingesting wine (3.85) and whisky
MA
(3.89) contrasts the statement by Lennerns et al. who claim gastric dilution to only minimally affect

intragastric ethanol concentrations when the ingested volume is large enough (>120 mL). (Lennerns,

2009) Interestingly, the observed inter-individual variability in gastric dilution and maximum gastric
D
TE

ethanol concentrations (Table 2) decreases when a larger volume is ingested (variability for whiskey >

wine > beer).

P

The highest average gastric Cmax is found in the whisky condition and amounts to 11% ethanol. The
CE

average intragastric Cmax in the beer and wine condition are similar with 3.6% and 3.9%, respectively.
AC

Previously reported intragastric ethanol concentrations after intake of an alcohol-containing drink

amounted up to 10%, even though the administered ethanol dose was about 2.5-fold higher

compared to the whisky condition in the present study. (Halsted et al., 1973) The gastric ethanol

peak is followed by a relatively fast decline as the average gastric profile shows less than 0.5%

alcohol after 90 minutes. Ethanol is diluted by a basal gastric fluid secretion of 1mL/min (Koziolek et

al., 2013) which is further stimulated by small alcohol concentrations (5 and 10% ethanol) and by

non-alcoholic ingredients in alcoholic beverages (particularly for beer and wine). (Lenz et al., 1983)

(Chari et al., 1993)(Peterson et al., 1986) In addition, ethanol, as a small neutral molecule, may
 ACCEPTED MANUSCRIPT
12

passively diffuse trough gastric mucosa. Levitt et al. estimated that 10% of the administered ethanol

is absorbed by the gastric mucosa. (Levitt and Levitt, 1994)

Differences in the duodenal Tmax may indicate differences in gastric emptying rate of ethanol to the

T
duodenum. The duodenal Tmax in this study varies from 2 to 30 minutes (Table 2). The median Tmax in

IP
the wine and whisky condition is 12 minutes while the median Tmax in the beer condition is 7 minutes,

R
suggesting beer to be emptied slightly faster. Some individual profiles (5 out of 15) have a duodenal

SC
Tmax at 2 or 7 minutes which was even shorter than the gastric Tmax; this was accompanied with a

higher ethanol concentration in the duodenum than in the stomach (data not shown) and indicates a

NU
swift, almost instantaneous, transfer of beverage to the duodenum. The gastric emptying rate is
MA
affected by multiple beverage characteristics. Beverages consumed in larger volumes are usually

emptied at a faster rate from the stomach. (Hunt and Spurrell, 1951)(Costill and Saltin,

1974)(Mitchell and Voss, 1991). The gastric emptying time is increased by intake of beverages with a
D
TE

lower pH (Lin et al., 1990)(Chaw et al., 2001), higher caloric value (Hunt and Stubbs, 1975)(Meeroff et

al., 1975), and higher osmotic value. (Meeroff et al., 1975) Irrespective of its intrinsic caloric and
P

osmotic value, ethanol itself will delay gastric emptying depending on its concentration. (Franke et
CE

al., 2004)(Kaufman and Kaye, 1979) Moreover, Franke et al. suggested that beer and wine, but not

whisky, contain non-alcoholic ingredients that may slow down gastric emptying. (Franke et al., 2004)
AC

The beverages selected for the present study substantially vary in all of these characteristics (Table

1). No straightforward relation was found between beverage characteristics and gastric emptying. It

should be noted that such a mechanistic investigation requires a specific study design, which was

outside the scope of this study.

Following transfer from the stomach, ethanol concentrations are affected by dilution with intestinal

fluids, transit, and absorption of ethanol. The resulting average intraduodenal ethanol concentrations

are depicted in Figure 1. The highest average duodenal Cmax is found in the whisky condition and

amounts to 6.5% ethanol. An average intraduodenal Cmax of 2.7 % and 1.5% ethanol is reached in the

wine and beer condition, respectively. These observations are in line with the maximal duodenal
 ACCEPTED MANUSCRIPT
13

concentrations reported by Halsted et al. (between 1.25 and 6.25%). (Halsted et al., 1973) After this

ethanol peak and similar to the gastric profiles, a fast decline in duodenal ethanol levels is observed.

The average duodenal profile shows less than 0.2% alcohol after 90 minutes. The interindividual

T
variation of these concentrations is depicted in Table 2. Whisky, with a median Cmax of 5.9% duodenal

IP
ethanol (3.6 -17.7) has the highest variability; two volunteers even reached a duodenal Cmax of 17.7%

R
and 9.6% ethanol, respectively.

SC
Interestingly, all studied beverages are highly hyperosmotic and significantly affect intraluminal

osmolality. (Meeroff et al., 1975). The strong linear correlation between ethanol and osmolality for

NU
both gastric and duodenal samples (Figure 2.), clearly proves that ethanol is the major factor
MA
determing intraluminal osmolality.
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
14

5. Implications and conclusion

Intraluminal ethanol concentrations originating from the consumption of common popular alcoholic

drinks were assessed for the first time. The gastric ethanol concentrations observed in this study and

T
their fast decline over time contrast current FDA guidelines for evaluating ethanol resistance of

IP
modified release formulations. Despite the fact that the administration of two standard

R
consumptions within only 5 (wine, whisky) or 10 minutes (beer) reflects worst-case conditions in

SC
real-life practice, median Cmax-values were only 4.1% for beer and wine, and 11.4% for whiskey. The

FDA guideline to test formulations in the presence of 40% ethanol seems excessive as this study only

NU
observes a maximum concentration of 21.1% ethanol after intake of whisky. In addition, the
MA
proposed time window of two hours seems exaggerated as the stomach contains less than 0.05%

ethanol after two hours in all tested conditions. The ethanol concentrations suggested by the EMA

for in vitro testing fit better with the gastric ethanol levels observed in this study, although the gastric
D
TE

ethanol level of 21.1% was only observed at one sampling point in one out of five volunteers.

Fagerberg et al. described that the presence of 20% ethanol in the stomach may significantly
P

increase the solubility and bioavailability of certain compounds. (Fagerberg et al., 2015) Considering
CE

the observed rapid decrease of intragastric ethanol levels however, this is unlikely to occur in
AC

practice. In addition, intraduodenal ethanol concentrations do not reach levels as high as needed in

order to affect local drug solubility according to Fagerberg et al. (Fagerberg et al., 2012) In our study

only two volunteers reached a duodenal Cmax of 17.7% and 9.6% ethanol after intake of whisky; in all

other cases, the duodenal Cmax never exceeded 5.6% ethanol.

In conclusion, this in vivo study is the first to present physiologically relevant ethanol concentrations

and their variation, which may serve as reference data to further investigate the impact of

intraluminal ethanol on drug formulations, solubility and permeability in fasting conditions. Further

research is needed on ethanol concentrations in the fed state.

Acknowledgment
 ACCEPTED MANUSCRIPT
15

This work was supported by the Research Foundation Flanders (FWO), grant assigned to Aspirant

applicant 11Z2615N.

T
R IP
SC
NU
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
16

Figure legends

Figure 1. Mean gastric and duodenal concentration-time profiles for ethanol after the administration

of (a) 500 mL of beer, (b) 200 mL of wine, and (c) 80 mL of whisky. Black () and white () dots depict

T
gastric and duodenal ethanol concentrations, respectively (SEM, n=5).

IP
Figure 2. Correlation between intraluminal osmolality and intraluminal ethanol concentration in

R
SC
samples from HV 3. Correlations for both gastric and duodenal samples were indicated using

Pearsons correlation coefficient (r). Dots represent the beer condition, squares represent the wine

NU
condition and triangles represent the whisky condition. Black and white dots represent gastric and

duodenal aspirates, respectively.

MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
17

Table legends

Table 1. Characteristics of administrated beverages.

Table 2. Key parameters (Cmax, Tmax, degree of gastric dilution) of the ethanol concentration-time

T
IP
profiles in stomach and duodenum (data presented as median and range).

R
SC
NU
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
18

Tables
Table 1.
Beverage Volume administrated (mL) Alcohol content pH Caloric Value Osmolality
a
(% ethanol) (Kcal) (mOsm/kg)
Beer 500 5.2 4.09 960 2170

Wine 200 11 3.21 682 1085

T
Whisky 80 40 4.19 812 7208

IP
a
According to the Dutch nutrition databank. (RIVM, 2013)

R
SC
NU
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
19

Table 2.
Beverage Stomach Duodenum
Beer (5,2% Ethanol)
a
Median Cmax (min - max) 4.1 (3.1 - 4.1) 2.0 (0.9 - 4.3)
b
Median Tmax (min - max) 7 (2 - 12) 7 (2 - 20)
c
Median degree of dilution (min - max) 1.37 (1.27 1.67)

T
Wine (11% Ethanol)
a
Median Cmax (min - max) 4.1 (2.6 - 7.3) 2.4 (2.0 - 5.6)

IP
b
Median Tmax (min - max) 12 (7 - 20) 12 (7 - 30)
c
Median degree of dilution (min - max) 3.85 (1.50 4.24)

R
Whisky (40% Ethanol)
a

SC
Median Cmax (min - max) 11.4 (6.3 - 21.1) 5.9 (3.6 - 17.7)
b
Median Tmax (min - max) 20 (7 -20) 12 (7 - 30)
c
Median degree of dilution (min - max) 3.89 (1.89 6.34)
a
Expressed as % ethanol

NU
b
Expressed as minutes
b
Calculated as the ratio of the alcohol content in the administered beverage to the Cmax in the stomach
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
20

Bibliography

Anand, O., Yu, L.X., Conner, D.P., Davit, B.M., 2011. Dissolution Testing for Generic Drugs: An FDA
Perspective. AAPS J. 13, 328335. doi:10.1208/s12248-011-9272-y

Chari, S., Teyssen, S., Singer, M. V, 1993. Alcohol and gastric acid secretion in humans. Gut 34, 8437.

T
doi:10.1136/gut.34.6.843

IP
Chaw, C.S., Yazaki, E., Evans, D.F., 2001. The effect of pH change on the gastric emptying of liquids
measured by electrical impedance tomography and pH-sensitive radiotelemetry capsule. Int. J.

R
Pharm. 227, 167175. doi:16/S0378-5173(01)00795-5

SC
Costill, D.L., Saltin, B., 1974. Factors limiting gastric emptying during rest and exercise. J Appl Physiol
37, 679683.

NU
Draper, L.R., Gyure, L. a, Hall, J.G., Robertson, D., 1983. Effect of alcohol on the integrity of the
intestinal epithelium. Gut 24, 399404.

EMA, 2009. Quality of medicines questions and answers: Part 2 [WWW Document]. Qual. Med.
MA
Quest. answers Part 2. URL
http://www.ema.europa.eu/ema/index.jsp?curl=pages/regulation/q_and_a/q_and_a_detail_0
00072.jsp (accessed 1.1.15).
D

Fagerberg, J.H., Al-Tikriti, Y., Ragnarsson, G., Bergstrm, C. a S., 2012. Ethanol effects on apparent
solubility of poorly soluble drugs in simulated intestinal fluid. Mol. Pharm. 9, 194252.
TE

doi:10.1021/mp2006467

Fagerberg, J.H., Sjgren, E., Bergstrm, C. a. S., 2015. Concomitant intake of alcohol may increase the
P

absorption of poorly soluble drugs. Eur. J. Pharm. Sci. 67, 1220. doi:10.1016/j.ejps.2014.10.017
CE

FDA, 2015. Guidances (Drugs) - Product-Specific Recommendations for Generic Drug Development.

FDA, 2014. Draft Guidance on Hydromorphone Hydrochloride [WWW Document]. URL

AC

http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/
UCM406272.pdf (accessed 1.7.16).

FDA, 2013. Guidance for Industry Bioequivalence Studies with Pharmacokinetic Endpoints for Drugs
Submitted Under an ANDA Guidance for Industry Bioequivalence Studies with [WWW
Document]. URL
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/
UCM377465.pdf (accessed 1.4.16).

FDA, 2005. FDA alert for healthcare professionals: hydromorphone hydrochloride extended-release
capsules (marketed as Palladone).

FDA, 2002. Food-Effect Bioavailability and Fed Bioequivalence Studies. Guid. Ind.

Franke, a., Teyssen, S., Harder, H., Singer, M. V., 2004. Effect of ethanol and some alcoholic
beverages on gastric emptying in humans. Scand. J. Gastroenterol. 39, 638644.
doi:10.1080/00365520410005009
 ACCEPTED MANUSCRIPT
21

Halsted, C.H., Robles, E. a, Mezey, E., 1973. Distribution of ethanol in the human gastrointestinal
tract. Am. J. Clin. Nutr. 26, 8314.

Hunt, J.N., Spurrell, W.R., 1951. The pattern of emptying of the human stomach*. J. Physiol. 113,
157168. doi:10.1113/jphysiol.1951.sp004562

T
Hunt, J.N., Stubbs, D.F., 1975. The volume and energy content of meals as determinants of gastric
emptying. J. Physiol. 245, 209225. doi:10.1113/jphysiol.1975.sp010841

IP
Jedinger, N., Khinast, J., Roblegg, E., 2014. The design of controlled-release formulations resistant to

R
alcohol-induced dose dumping A review. Eur. J. Pharm. Biopharm. 87, 217226.
doi:10.1016/j.ejpb.2014.02.008

SC
Johnoson, R.D., Horowitz, M., Maddox, A.F., Wishart, J.M., Shearmen, D.J.C., 1991. Cigarette smoking
and rate of gastric emptying : effect absorption alcohol. Br. Med. J. 302, 2023.

NU
Kaufman, S.E., Kaye, M.D., 1979. Effect of ethanol upon gastric emptying. Gut 20, 688692.
doi:10.1136/gut.20.8.688
MA
Klockhoff, H., Nslund, I., Jones, a W., 2002. Faster absorption of ethanol and higher peak
concentration in women after gastric bypass surgery. Br. J. Clin. Pharmacol. 54, 587591.
doi:10.1046/j.1365-2125.2002.01698.x
D

Koziolek, M., Garbacz, G., Neumann, M., Weitschies, W., 2013. Simulating the postprandial stomach:
Physiological considerations for dissolution and release testing. Mol Pharm 10, 16101622.
TE

doi:10.1021/mp300604u

Lavo, B.E. Al, 1992. *Acute exposure of small intestine to ethanol induces mucosal leakage and
P

prostaglandin E2 synthesis. Gastroenterology 102, 468473.

CE

Lennerns, H., 2009. Ethanol-drug absorption interaction: potential for a significant effect on the
plasma pharmacokinetics of ethanol vulnerable formulations. Mol. Pharm. 6, 142940.
doi:10.1021/mp9000876
AC

Lenz, H.J., Ferrari-Taylor, J., Isenburg, J.I., 1983. Wine and five percent ethanol are potent stimulants
of gastric acid secretion in humans. Gastroenterol. Int. 85, 10821087.

Levitt, M.D., Levitt, D.G., 1994. The critical role of the rate of ethanol absorption in the interpretation
of studies purporting to demonstrate gastric metabolism of ethanol. J. Pharmacol. Exp. Ther.
269, 297304.

Levitt, M.D., Li, R., DeMaster, E.G., Elson, M., Furne, J., Levitt, D.G., 1997. Use of measurements of
ethanol absorption from stomach and intestine to assess human ethanol metabolism. Am. J.
Physiol. 273, G951G957.

Lin, H.C., Doty, J.E., Reedy, T.J., Meyer, J.H., 1990. Inhibition of gastric emptying by acids depends on
pH, titratable acidity, and length of intestine exposed to acid. Am. J. Physiol. 259, G1025
G1030.

Meeroff, J.C., Go, V.L.W., Phillips, S.F., 1975. Control of Gastric Emptying by Osmolality of Duodenal
Contents in Man. Gastroenterology 68, 11441151. doi:10.1016/S0016-5085(75)80228-9
 ACCEPTED MANUSCRIPT
22

Mitchell, J.B., Voss, K.W., 1991. The influence of volume on gastric emptying and fluid balance during
prolonged exercise. Med. Sci. Sports Exerc.

Peterson, W.L., Barnett, C., Walsh, J.H., 1986. Effect of intragastric infusions of ethanol and wine on
serum gastrin concentration and gastric acid secretion. Gastroenterology 91, 13901395.

T
RIVM, 2013. Nederlands Voedingstoffenbestand (NEVO) [WWW Document]. URL www.nevo-
online.rivm.nl (accessed 1.1.16).

IP
Roberts, M., Cespi, M., Ford, J.L., Dyas, a. M., Downing, J., Martini, L.G., Crowley, P.J., 2007. Influence

R
of ethanol on aspirin release from hypromellose matrices. Int. J. Pharm. 332, 3137.
doi:10.1016/j.ijpharm.2006.09.055

SC
Tarnawski, a, Hollander, D., Gergely, H., 1985. Ethanol-induced gastric mucosal injury: sequential
analysis of morphologic and functional changes. Gastroenterol. Clin. Biol. 9, 8892.

NU
Volpe, D. a., Asafu-Adjaye, E.B., Ellison, C.D., Doddapaneni, S., Uppoor, R.S., Khan, M. a., 2008. Effect
of Ethanol on Opioid Drug Permeability Through Caco-2 Cell Monolayers. AAPS J. 10, 360362.
doi:10.1208/s12248-008-9046-3
MA
Walden, M., Nicholls, F. a, Smith, K.J., Tucker, G.T., 2007. The effect of ethanol on the release of
opioids from oral prolonged-release preparations. Drug Dev. Ind. Pharm. 33, 11011111.
doi:10.1080/03639040701377292
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
23

T
IP
R
SC
NU
MA
D
PTE
CE
AC

Figure 1
 ACCEPTED MANUSCRIPT
24

T
IP
R
SC
Figure 2
NU
MA
D
PTE
CE
AC
 ACCEPTED MANUSCRIPT
25

Graphical Abstract

T
RIP
SC
NU
MA
D
TE
P
CE
AC