"Inactive" ingredients in pharmaceutical products: update (subject review). American Academy of Pediatrics Committee on Drugs

Exposure to potentially harmful excipients in medications among neonates at a state hospital in Malaysia

OBJECTIVES

This study aimed to determine the incidence, types and predictors of Potentially Harmful Excipients (PHE) exposure among hospitalized neonates.

METHODS

A prospective observational study was conducted from March to April 2022 in neonatal wards at a state hospital in Malaysia. The PHEs of interest were aspartame, benzalkonium chloride, benzyl alcohol, benzoic acid or benzoates, ethanol, parabens, polysorbate 80, propylene glycol, saccharin sodium, sorbitol and sulfites. Product information leaflets (PILs) and summaries of product characteristics (SPCs) were referred to obtain information on active pharmaceutical ingredient, strength, trade name as well as type and amount of the excipients.

RESULTS

A total of 108 neonates were recruited and 97.2% of them were exposed to at least one PHE. Parabens (47.2%) and sulfites (27.5%) were the two most commonly administered PHEs. Benzyl alcohol is contraindicated in neonates but was administered to 8% of neonates in this study. The median daily dose of ethanol (24.11 mg/kg/day, IQR 19.73, 28.49) exceeded the acceptable daily intake (ADI) by four times. However, the dose was not available for all PHEs as this information is not always available in the PIL or SPC. Administration of cardiovascular drugs was associated with a higher risk of exposure to any PHE (OR 6.38, CI 2.75, 14.79, p-value < 0.001).

CONCLUSION

The exposure of PHE among neonates in this study is high with certain PHEs exceeding the ADI. It highlights the need for certain strategies to be implemented to reduce such exposure in neonates.

Effective low-dose sirolimus regimen for kaposiform haemangioendothelioma with Kasabach-Merritt phenomenon in young infants

AIMS

Management of kaposiform haemangioendotheliomas (KHE) with Kasabach-Merritt phenomenon is challenging in young infants who are subjected to developmental pharmacokinetic changes. Sirolimus, sometimes combined with corticosteroids, can be used as an effective treatment of KHE. Simultaneously, toxicities such as interstitial pneumonitis related to the use of sirolimus may be fatal. As infants have a very low CYP3-enzyme expression at birth, which rises during ageing, we hypothesize that a reduced metabolization of sirolimus might lead to high sirolimus serum levels and low dose may be sufficient without the side effects.

METHODS

A case series of 5 infants with kaposiform haemangioendothelioma with Kasabach-Merritt phenomenon was analysed retrospectively. All infants were treated with sirolimus 0.2 mg/m2 every 24 or 48 hours according to their age. Prednisone was added to the therapy for additional effect in 4 patients.

RESULTS

In all patients, low dose of sirolimus led to therapeutic sirolimus levels (4-6 ng/mL). All infants (aged 4 days-7 months) had a complete haematological response, without serious adverse events. In all patients, the Kasabach-Merritt phenomenon resolved, the coagulation profile normalized and tumour size reduction was seen.

CONCLUSION

Low-dose sirolimus treatment is safe for infants with kaposiform haemangioendothelioma and Kasabach-Merritt phenomenon. It is essential to realize that during the first months of life, metabolism is still developing and enzymes necessary to metabolise drugs like sirolimus still have to mature. To avoid toxic levels, the sirolimus dosage should be based on age and the associated pharmacological developments.

Differentiation of Protonated Sulfonate Esters from Isomeric Sulfite Esters and Sulfones by Gas-Phase Ion-Molecule Reactions Followed by Diagnostic Collision-Activated Dissociation in Tandem Mass Spectrometry Experiments

Sulfonate esters, a class of potentially mutagenic drug impurities, are strictly regulated in pharmaceuticals. On the other hand, sulfite esters and sulfones, analogs of sulfonate esters, have limited safety concerns. However, previously developed analytical methods for sulfonate ester identification cannot be used to differentiate sulfonate esters from the isomeric sulfite esters and sulfones. A tandem mass spectrometric method is introduced here for the differentiation of these compounds. Diisopropoxymethylborane (DIMB) reacts with protonated sulfonate esters, sulfite esters, and sulfones (and many other compounds) in the gas phase to form the product ion [M + H + DIMB - CH₃CH(OH)CH₃]⁺. Upon collision-activated dissociation (CAD), these product ions generate diagnostic fragment ions that enable the differentiation of sulfonate esters, sulfite esters, and sulfones from each other. For example, SO₂ elimination enabled the unambiguous identification of sulfite esters. On the other hand, elimination of CH₃B═O followed by elimination of (CH₃)₂C═O was only observed for sulfonate esters. Neither type of diagnostic fragment ions was detected for the products of sulfones. However, the product ions formed for sulfones with an additional hydroxyl substituent underwent the elimination of another CH₃CH(OH)CH₃ molecule, which enabled their identification. Finally, ion-molecule reactions of DIMB with various other functionalities were also examined. Some of them yielded the product ions [M + H + DIMB - CH₃CH(OH)CH₃]⁺ but none of these product ions underwent the diagnostic CAD reactions discussed above. Quantum chemical calculations were employed to explore the mechanisms of the reactions. The limits of detection for the diagnostic ion-molecule reaction product ions in high-performance liquid chromatography (HPLC)/mass spectrometry (MS²) experiments were found to range from 0.075 to 1.25 nmol.

Thirteen-week nose-only inhalation exposures of propylene glycol aerosols in Sprague Dawley rats with a lung systems toxicology analysis

The objectives of this study were to increase PG exposure above concentrations tested by Suber et al. and use systems toxicology analysis of lung tissue to understand molecular events. Sprague Dawley rats were exposed to filtered air (sham), propylene glycol/water (PG/W; 90:10) or a propylene glycol/vegetable glycerin/water (PG/VG/W; 50:40:10) reference. The reference group was added at the high dose to observe any changes that might be associated with a carrier more in line with e-vapor products. Macroscopic examinations and terminal organ weights revealed no observations associated with exposure to PG/W or reference. Food consumption and body weights were unaffected by PG/W or reference when compared to sham. No exposure related alterations were observed in serum chemistry, hematology, coagulation, urinalysis or BALF cytology and clinical chemistry. Although clinical observations of dried red material around the nose in the high dose PG/W group were reported, histopathology showed no nasal hemorrhaging which was previously reported by Suber et al. Non-adverse PG/W and reference related findings of minimal mucous cell hyperplasia were noted in nasal cavity section II. No other exposure-related findings were noted in the primary or recovery necropsies. A systems toxicology analysis on lung tissue showed no statistically significant differentially expressed transcripts or proteins compared to the sham group. The endpoints measured from the PG/W high dose group did not differ significantly from those in the more common carrier PG/VG/W. As anticipated, exposure to PG aerosols was slightly irritating but well tolerated. Accordingly, the highest PG exposure (5 mg/L, 6 hrs/day) was regarded as the NOAEC, corresponding to a PG delivered dose of 1,152 mg/kg/day in rats.

Excipients in the Paediatric Population: A Review

This theoretical study seeks to critically review the use of excipients in the paediatric population. This study is based on the rules and recommendations of European and American drug regulatory agencies. On the one hand, this review describes the most frequent excipients used in paediatric medicine formulations, identifying the compounds that scientific literature has marked as potentially harmful regarding the side effects generated after exposure. On the other hand, this review also highlights the importance of carrying out safety -checks on the excipients, which, in most cases, are linked to toxicity studies. An excipient in the compilation of paediatric population databases is expected to target safety and toxicity, as in the STEP database. Finally, a promising pharmaceutical form for child population, ODT (Orally Disintegrating Tablets), will be studied.

The paradoxical response to short-acting bronchodilator administration in patients with chronic obstructive pulmonary disease

Background

There are a few studies about paradoxical bronchodilator response (BDR), which means a decrease in forced expiratory volume in 1 second (FEV₁) or forced vital capacity (FVC) after short-acting bronchodilator administration in patients with chronic obstructive pulmonary disease (COPD). We evaluated the effect of paradoxical BDR on the clinical outcomes of COPD patients in South Korea.

Methods

We analyzed the KOrea COpd Subgroup Study team (KOCOSS) cohort data in South Korea between January 2012 and December 2017. BDR was defined as at least a 12% and 200-mL reduction in FEV₁ or FVC after bronchodilator administration.

Results

A total of 1,991 patients were included in this study. A paradoxical BDR was noted in 57 (2.9%) patients and was independently associated with worse dyspnea and poor quality of life. High C-reactive protein (CRP) levels were associated with a paradoxical BDR (OR, 1.05; 95% CI, 1.01-1.09; P=0.003). However, paradoxical BDR was not associated with severe acute exacerbations. Pre-bronchodilator FEV₁ (L) showed a higher area under the curve (AUC) for predicting severe acute exacerbations than the post-bronchodilator FEV₁ (L) in the paradoxical BDR group (0.788 vs. 0.752).

Conclusion

A paradoxical reduction of FEV₁ or FVC after bronchodilator administration may be associated with chronic inflammation in the airway and independently associated with worse respiratory symptoms and poor quality of life.

Developmental toxicity triggered by benzyl alcohol in the early stage of zebrafish embryos: Cardiovascular defects with inhibited liver formation and degenerated neurogenesis

Benzyl alcohol (BnOH) is an aromatic alcohol used worldwide as an excipient in foods, cosmetics, household products, and medications. Although BnOH is a bacteriostatic agent found in many parenteral preparations, this agent is responsible for precipitating the gasping syndrome in premature neonates. Increasing evidence of human exposure to BnOH and environmental contamination of BnOH requires a detailed toxicity assessment of this aromatic chemical. Few studies on the toxicity of BnOH have been reported on different animal models, but its developmental toxicity effects are not fully understood yet. Studies on the effects of BnOH on the specific endpoints of organ toxicity are rare. Thus, the present study aimed to examine the developmental toxicity effects of BnOH by using zebrafish (Danio rerio) embryo as a biological disease model. Four-hour post fertilization zebrafish embryos were exposed to BnOH for 72 h to assess BnOH toxicity on an ecological viewpoint. The median lethal concentrations of varying BnOH concentrations in zebrafish embryos were estimated. The embryonic toxicity induced by BnOH was revealed by the apoptosis in embryos and pathological alterations, such as increased mortality, inhibited hatching rate, and decreased somite number. Moreover, pericardial edema and string heartbeat were observed because of arrhythmia and cardiac malformation. The number of normal vessels in the head and trunk regions was remarkably reduced in transgenic zebrafish line Tg (Fli-1: EGFP). Morphological defects and yolk sac retention were related to the degenerated liver formation in Tg (Lfabp: dsRED). Furthermore, BnOH exposure led to the disruption of motor neuron axonal integrity and the alteration of the axon pattern in Tg (olig2: dsRED). In addition, the results exhibited the pathological effects of BnOH exposure on major organs. We believe that this study is the second to report the developmental organ toxicity of BnOH to zebrafish embryos. This study provides important information for further elucidating the mechanism of BnOH-induced developmental organ toxicity.

A quarter pound of acetaminophen with propylene glycol on the side: A case report

Particularly large acetaminophen overdoses, termed massive, create a therapeutic challenge given the standardized, N-acetylcysteine-based treatment. One consideration in addition to N-acetylcysteine is the initiation of hemodialysis due to the dialyzable nature of acetaminophen, though encumbered by the concurrent removal of the antidote, N-acetylcysteine. Such cases of large acetaminophen overdose, along with possible concomitant ingestions of other drugs or inactive ingredients, can be complicated by challenging-to-interpret clinical signs and laboratory findings. We describe a case of a 46-year-old man for whom we were consulted regarding consideration of dialysis treatment 7 hours after ingestion of 125 g of acetaminophen. The patient developed multiple early signs and laboratory findings consistent with a significant acetaminophen overdose. He also developed a rarely described, likely acetaminophen-interference-induced laboratory abnormality. Finally, he possibly had toxicity from an “inactive” ingredient. He was treated with a single session of prolonged hemodialysis (9.5 hours) and increased dosing of N-acetylcysteine with a positive outcome. Herein, we discuss the decision making and interpretation of clinical data pertaining to dialysis treatment and other therapies after a massive acetaminophen overdose.

Possible effects of excipients used in the parenteral drugs administered in critically ill adults, children, and neonates

BACKGROUND

Critically ill patients receiving parenteral drugs are at an increased risk of exposure to various excipients administered simultaneously and at increased amounts. Hence, we carried out the present study.

RESEARCH DESIGN AND METHODS

Patients admitted in the adult, pediatric, and neonatal intensive care units were recruited following their consent. Details on their demographics, diagnoses, and drugs administered and the excipients were collected.

RESULTS

Almost all the critically ill patients received drugs containing at least one excipient. Significant numbers of critically ill neonates received at least one of either known to be harmful or potentially harmful excipients. Critically ill neonates had significantly greater daily exposure of macrogol than children and adults; and benzyl alcohol (v/v) and propyl paraben compared to adults. Critically ill neonates and children had greater exposure to benzyl alcohol (w/v), methyl paraben, sodium metabisulfite than adults did. Benzyl alcohol exposure was likely to be several-fold high in critically ill patients. Exposures to benzyl alcohol and propylene glycol were possibly linked to increased risk of mortality particularly in neonates.

CONCLUSION

Critically ill neonates and children are likely to receive a significantly greater quantity of harmful excipients than critically ill adults. Benzyl alcohol and propylene glycol exposure are likely to be associated with increased risk of mortality in critically ill.

Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List

OBJECTIVES

The safe use of medications in pediatric patients requires practitioners to consider the unique pharmacokinetics and pharmacodynamics of drugs prescribed in this age group. In an effort to create a standard of care for the safe use of medications in this population, a list of drugs that are potentially inappropriate for use in pediatric patients has been developed and titled the "KIDs List."

METHODS

A panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association were recruited to evaluate primary, secondary, and tertiary literature; FDA Pediatric Safety Communications; the Lexicomp electronic database; and product information for drugs that should be considered potentially inappropriate for use in pediatric patients. Information was rated using predefined criteria. A PubMed search was conducted using the following terms: adverse drug events OR adverse drug reactions. The search was limited to humans; age <18 years; case reports, observational studies, or clinical trials; and English language. No date range was used. Results were used to create an evidence-based list of candidate drugs that was then peer-reviewed and subjected to a 30-day public comment period prior to being finalized.

RESULTS

A PubMed search yielded 4049 unique titles, of which 210 were deemed relevant for full review. Practitioner recommendations highlighted an additional 77 drugs. FDA Pediatric Safety Communications and the Lexicomp database yielded 22 and 619 drugs, respectively. After critical analysis, peer review, and public review the final KIDs List contains 67 drugs and/or drug classes and 10 excipients.

CONCLUSIONS

This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or in a select subgroup of pediatric patients. If avoidance is not clinically possible, the drug should be used with caution and accompanied by appropriate monitoring.

Off-label Use in Ambulatory Paediatric Clinics in a Central South African Hospital

AIM

The aim of this article was to determine off-label (OL) use in paediatric ambulatory clinics in a South African central hospital.

PATIENTS AND METHODS

OL medicine events were documented in three paediatric clinics (general, highly specialized and dedicated HIV paediatric clinics) at Tygerberg Hospital, South Africa, and analysed according to South African medicine registration information.

RESULTS

There were 2167 medicine events for 658 children. Mean age was 5.6 years (interquartile range 1.8-8.8). There were 123 OL medicine events (6%). Extemporaneous OL use was most common (n = 58, 47%), followed by weight (n = 45, 37%) and lack of paediatric data (n = 38, 31%). Of note was OL use for weight for general paediatrics (n = 32, 78%, p < 0.001), lack of appropriate paediatric data for highly specialized paediatrics (n = 26, 61%, p = 0.004) and extemporaneous use for HIV-infected children (n = 34, 87%, p < 0.001), with significant less OL use for HIV-infected children (p = 0.009).

CONCLUSIONS

Of note is significant extemporaneous OL use in HIV-infected children.

Prevalence of ethanol and other potentially harmful excipients in pediatric oral medicines: survey of community pharmacies in a Nigerian City

OBJECTIVE

Excipients are needed in the formulation of oral liquid medicines intended for children; they have however been reported to trigger safety issues. This study evaluated the concentrations and prevalence of ethanol and other potentially harmful excipients in pediatric formulations marketed in South Eastern Nigeria in line with international labeling guidelines and allowable daily limits (ADL). The study sampled oral pediatric formulations offered for sale in registered pharmacies. Those with accessible information leaflets were assessed for the presence and quantity of previously flagged excipients with potential to harm the pediatric population.

RESULT

Of the 380 oral pediatric medicines, 140 provided access to list/quantity of ingredients. 47.9% (67) of the formulations contain at least one of the flagged excipients while the remaining only listed the active ingredients. Ethanol had the highest occurrence (62.7%) and was more in cough/cold medicines. A homeopathic cough and cold remedy had concentration of 90% v/v. Ethanol and sucrose in some formulations exhibited concentrations with a potential of crossing their approved daily intake (ADI) (1-90% v/v and 1.7 g-3.7 g/5 ml respectively). Ethanol use in studied pediatric formulations was quite high, with ethanol-containing formulations being prescribed for children 0-6 years and older. Only 26 (38.8%) completely satisfied the labelling requirements for ethanol containing formulations.

Paper-Based Enzyme Competition Assay for Detecting Falsified β-Lactam Antibiotics

Falsified and substandard antibiotics are a growing worldwide problem that leads to increased patient mortality and decreased trust in healthcare, and contributes to antimicrobial resistance. Monitoring falsified antibiotics is difficult because most falsified pharmaceuticals are most commonly found in developing countries, where detecting the active ingredient is difficult due to lack of access to complex instrumentation. Herein, we describe the development and optimization of a microfluidic paper-based analytical device (μPAD) to detect the active ingredient in the most falsified class of antibiotics, β-lactams. The assay is based on enzyme competition, making it the first demonstrated competitive enzyme assay reported in paper-based devices. The assay uses nitrocefin, a chromogenic substrate, to compete with β-lactam antibiotics in a reaction with β-lactamase. A yellow color indicates legitimate drugs, while a color change from yellow to red indicates falsified drugs. In addition to testing for the active ingredient, another section of the device was added to test the sample pH to further verify results and identify common falsified ingredients like aspirin or baking soda. Calibration curves for four different antibiotics, including cefazolin, have been generated making it the first paper-based device capable of detecting both cephalosporin and penicillin antibiotics. The μPAD has also been tested with common falsified ingredients and four antibiotics in tablet or injectable form, demonstrating its potential for in-field falsified antibiotic testing.

[Medication safety in children : What role do dosing and formulations play?]

Medication errors are more common in children compared to adults due to often missing efficacy evidence and limited or missing regulatory approvals for paediatric drugs.Roots of errors are located at different levels. They result, for example, from missing clinical studies that particularly investigate efficacy and correct dosing in younger age groups, the lack of age-appropriate dosage forms, the use of harmful ingredients, as well as the complicated and high-risk prescribing process.Electronic systems may improve the quality of drug prescriptions and reduce medication errors. The basic assumption is valid, evidence-based data behind such a system. In contrast to other countries, such a database is not yet available in Germany. The Plan of Action for the improvement of medication safety in Germany 2016-2019 (Aktionsplan) contains an action point "Creation of a database for dosing of paediatric medicines". Initial funding for 2 years has been granted for its implementation.Through systematic literature searches and the availability and provision of up-to-date knowledge on paediatric medicines, medication safety for children and adolescents can be improved. A database with relevant information to support more correct prescriptions within the paediatric population appears productive. The Aktionsplan has paved the way for the dissemination of evidence-based drug information for the country's paediatric population.

Excipient exposure in very low birth weight preterm neonates

OBJECTIVE

The excipients benzyl alcohol, propylene glycol and ethanol are present in medications used in the neonatal intensive care unit. Exposure to high levels can have adverse effects in a neonatal population. The objective was to quantify excipient exposure in very low birth weight (VLBW) neonates and identify risk factors associated with greater exposure.

STUDY DESIGN

A retrospective record review of VLBW infants admitted over 1 year. Excipient exposures were calculated and multivariable regression analyses identified risk factors for increasing exposure.

RESULTS

In total, 98% of subjects were exposed to at least one excipient. A total of 5 to 9% received doses higher than recommended for adults. Necrotizing enterocolitis, seizure, bronchopulmonary dysplasia and longer stay predicted higher excipient exposure.

CONCLUSION

The excipients examined are in medications commonly prescribed for VLBW neonates, and cumulative doses may exceed recommended exposures for adults. Although safety profiles have not been established, judicious use of medication containing these excipients is warranted for this population.

Organic Colouring Agents in the Pharmaceutical Industry

Food dyes are largely used in the process of manufacturing pharmaceutical products. The aim of such a procedure is not only to increase the attractiveness of products, but also to help patients distinguish between pharmaceuticals. Various dyes, especially organic colouring agents, may in some cases have a negative impact on the human body. They are incorporated into pharmaceutical products including tablets, hard gelatine capsules or soft gelatine capsules, lozenges, syrups, etc. This article provides an overview of the most widely used colouring agents in pharmaceuticals, their characteristics and the EU legislation which regulates their use.

Development of Extended-Release Oral Flexible Tablet (ER-OFT) Formulation for Pediatric and Geriatric Compliance: an Age-Appropriate Formulation

Development of age-appropriate formulation suitable for pediatric and geriatric patients involves various challenges. The objective of this research was to develop extended-release oral flexible tablet (ER-OFT) formulation using carbamazepine (CBZ) as model drug for pediatric and geriatric compliance. ER-microparticles of carbamazepine, a BCS class 2, and narrow therapeutic index (NTI) drug, were prepared using ethyl cellulose as matrixing polymer and hypromellose as hydrophilic pore former. Microparticles were prepared using high-shear granulator fitted with an atomizing spray system. Granulation of carbamazepine and ethyl cellulose (EC-FP) with ethanolic binder solution resulted in ER-microparticles with extended-release >16 h. Release kinetics of ER microparticles showed Higuchi model by drug diffusion and erosion. Korsemeyer-peppas release exponent "n" value 0.42 suggested Fickian diffusion. ER-OFT was prepared by blending of ER-microparticles with water-insoluble compressible aid and disintegrating agent. ER-OFT was characterized for performance characteristics and elemental impurities. As the polymer content in formulation was <10%, the size of ER-OFT was smaller compared to marketed ER-formulations. ER-OFT showed in vitro disintegration time of <30 s as per USP and dispersion time of ∼60 to 180 s in 5 to 10 mL of water. Drug release profiles of ER-microparticles and ER-OFT were comparable as f2 values were >50. In vitro dissolution of ER-OFT was comparable to the marketed ER formulation in the pH range of GIT. ER-OFT can be orally swallowed, orally disintegrating, and used as dispersible tablets. Compared to non-disintegrating type ER-formulations, ER-OFT would provide uniform drug release in GIT with low within-subject variability an essential criterion for NTI drug.

Development of Oral Flexible Tablet (OFT) Formulation for Pediatric and Geriatric Patients: a Novel Age-Appropriate Formulation Platform

Development of palatable formulations for pediatric and geriatric patients involves various challenges. However, an innovative development with beneficial characteristics of marketed formulations in a single formulation platform was attempted. The goal of this research was to develop solid oral flexible tablets (OFTs) as a platform for pediatrics and geriatrics as oral delivery is the most convenient and widely used mode of drug administration. For this purpose, a flexible tablet formulation using cetirizine hydrochloride as model stability labile class 1 and 3 drug as per the Biopharmaceutical Classification System was developed. Betadex, Eudragit E100, and polacrilex resin were evaluated as taste masking agents. Development work focused on excipient selection, formulation processing, characterization methods, stability, and palatability testing. Formulation with a cetirizine-to-polacrilex ratio of 1:2 to 1:3 showed robust physical strength with friability of 0.1% (w/w), rapid in vitro dispersion within 30 s in 2-6 ml of water, and 0.2% of total organic and elemental impurities. Polacrilex resin formulation shows immediate drug release within 30 min in gastric media, better taste masking, and acceptable stability. Hence, it is concluded that ion exchange resins can be appropriately used to develop taste-masked, rapidly dispersible, and stable tablet formulations with tailored drug release suitable for pediatrics and geriatrics. Flexible formulations can be consumed as swallowable, orally disintegrating, chewable, and as dispersible tablets. Flexibility in dose administration would improve compliance in pediatrics and geriatrics. This drug development approach using ion exchange resins can be a platform for formulating solid oral flexible drug products with low to medium doses.

Using fiberoptic endoscopic evaluation of swallowing to detect laryngeal penetration and aspiration in infants in the neonatal intensive care unit

OBJECTIVE

To evaluate the safety of fiberoptic endoscopic evaluation of swallowing (FEES) and the reliability of both FEES and a videofluoroscopic swallowing study (VFSS) in identifying laryngeal penetration and tracheal aspiration in infants under 3 months old in the neonatal intensive care unit (NICU).

STUDY DESIGN

Twenty-five infants at least 37 weeks postmenstrual age suspected of aspirating were assessed with FEES and VFSS. Complications, autonomic instability and vital signs before endoscope insertion and following FEES were documented. Blinded video recordings were coded by two reviewers to determine reliability.

RESULTS

We found no major complications or significant differences between FEES prefeeding and postfeeding vital signs, including respiratory rate, heart rate or oxygen saturation. FEES interrater reliability was 80% for both penetration and aspiration, compared with 87 and 90%, respectively, for VFSS.

CONCLUSION

FEES is safe and reliable in assessing laryngeal penetration and tracheal aspiration in NICU infants.

Compatibility of proton pump inhibitors in a preservative-free suspending vehicle

Objectives

To evaluate the microbiological and physicochemical compatibility of commonly used proton pump inhibitors (PPIs) esomeprazole, lansoprazole, omeprazole and pantoprazole compounded at a single concentration using SyrSpend SF Alka and stored at refrigerated temperatures (omeprazole was also stored at room temperature because it has the most widespread use).

Methods

Compatibility was assessed by measuring the per cent recovery at varying time points throughout a 90-day period. Quantification of the APIs was performed by a validated high performance liquid chromatography (HPLC-UV) method. This same assay was also used to determine the dosage content uniformity of the suspensions. Microbiological stability ('test in use') was assessed during 60 days and total aerobic microbial count (TAMC), total combined yeasts and moulds count (TYMC), detection of Escherichia coli and pH determination were performed. Antimicrobial effectiveness testing was determined following European Pharmacopoeia guidelines.

Results

Beyond-use dates of maximum 60 days for omeprazole (5 mg/mL), pantoprazole (3 mg/mL) and esomeprazole (3 mg/mL) were established. All suspensions that met the physicochemical criteria for stability also met the content uniformity criteria. The suspensions showed no antimicrobial efficiency against bacteria, yeasts and moulds as SyrSpend SF Alka is an unpreserved vehicle, but the 'test in use' showed that the suspensions can remain microbiologically stable for up to 60 days.

Conclusions

SyrSpend SF Alka can be used to compound palatable (taste-masking properties) preservative-free oral suspensions with almost all commonly used PPIs.

Compatibility of caffeine, carvedilol, clomipramine hydrochloride, folic acid, hydrochlorothiazide, loperamide hydrochloride, methotrexate, nadolol, naltrexone hydrochloride and pentoxifylline in SyrSpend SF PH4 oral suspensions

Objectives

The objective of this study was to evaluate the compatibility of 10 commonly used active pharmaceutical ingredients (APIs) compounded in oral suspensions using a globally available suspending vehicle (SyrSpend SF PH4 liquid): caffeine 10.0 mg/mL, carvedilol 1.0 mg/mL, clomipramine hydrochloride 5.0 mg/mL, folic acid 1.0 mg/mL, hydrochlorothiazide 5.0 mg/mL, loperamide hydrochloride 1.0 mg/mL, methotrexate 2.5 mg/mL, nadolol 10.0 mg/mL, naltrexone hydrochloride 1.0 mg/mL and pentoxifylline 20.0 mg/mL, stored at both controlled refrigerated (2-8°C) and room (20-25°C) temperature.

Methods

Compatibility was assessed by measuring the per cent recovery at different time points throughout a 90-day period. Quantification of the APIs was performed by high performance liquid chromatography (HPLC-UV) using a stability-indicating method.

Results

Methods were adequately validated. Forced degradation studies showed that at least one parameter influenced the stability of the APIs. All suspensions were assayed and showed API contents of between 90% and 110% over 90 days.

Discussion

Given the percentage of recovery of the APIs within the suspensions, the expiration date of the final products (API+vehicle) was found to be at least 90 days for all suspensions, for both controlled refrigerated and room temperature.

Conclusions

The results suggest that SyrSpend SF PH4 liquid is a stable suspending vehicle for compounding APIs from different pharmacological classes.

Are Pediatric Antibiotic Formulations Potentials Risk Factors for Dental Caries and Dental Erosion?

Introduction:

One of the most frequent parents’ concerns is that oral antibiotic formulations induce dental damage in their children’s. This study aimed to assess the cariogenic and erosive potentials of 29 pediatric antibiotics.

Materials and Methods:

Replicates of each antibiotic were analyzed for the concentration of sugars (sucrose, glucose and fructose) and sorbitol by high performance liquid chromatography (HPLC). The pH was determined by digital pHmeter. Titratable acidity was determined in triplicate using the same pHmeter by gradual addition of 0.1N sodium hydroxide (NaOH) until pH 7.0. Viscosity measurements were carried out using a viscosimeter. In order to rank the relative performance of each medicine, the DEA (Data Envelopment Analysis) methodology was used.

Results:

Sucrose was present in most samples (n=24) with concentrations ranging from 26 to ≈ 100g% (w/w). Only one antibiotic contained sorbitol (66.9g%). Twenty seven antibiotics presented pH values ranging from 4.1 to 6.9 and most of them (n=15) showed the pH below the critical value for dissolution of hydroxyapatite. The values of titratable acidity and viscosity ranged from 0.26 to 40.48 ml and from 20 to 1780cP, respectively. DEA methodology showed that two medicines were distant from the performance frontier (Klaricid^® 50mg and Zinnat^® 250mg), which means that these medicines showed the worst performance and, therefore, greater potential for dissolution of dental enamel.

Conclusion:

Many antibiotics presented high concentration of sugars, high titratable acidity, pH below the critical value and high viscosity which can be considered risk factors for dental caries and erosion, when consumed frequently.

Moisturizers: The Slippery Road

Moisturizers are an important part of a dermatologist's armamentarium although little is written and well, a less is truly known about them. There is a cornucopia of projected skin products in the market whose real scientific role is not proven. These products although at times are regarded as mere cosmetics but have a well-known role in many skin disorders. Adequate knowledge about their mechanism of action, dosage, usage, and adverse effects is must for a dermatologist in this era. This article aims to bring forth the ever hidden facts of the much-hyped moisturizers. It is probably the first of its kind covering all aspects of moisturizers ranging from basic science to clinical usage, a subject that receives a short shrift in the current dermatological text.

An accurate and precise representation of drug ingredients

BACKGROUND

In previous work, we built the Drug Ontology (DrOn) to support comparative effectiveness research use cases. Here, we have updated our representation of ingredients to include both active ingredients (and their strengths) and excipients. Our update had three primary lines of work: 1) analysing and extracting excipients, 2) analysing and extracting strength information for active ingredients, and 3) representing the binding of active ingredients to cytochrome P450 isoenzymes as substrates and inhibitors of those enzymes.

METHODS

To properly differentiate between excipients and active ingredients, we conducted an ontological analysis of the roles that various ingredients, including excipients, have in drug products. We used the value specification model of the Ontology for Biomedical Investigations to represent strengths of active ingredients and then analyzed RxNorm to extract excipient and strength information and modeled them according to the results of our analysis. We also analyzed and defined dispositions of molecules used in aggregate as active ingredients to bind cytochrome P450 isoenzymes.

RESULTS

Our analysis of excipients led to 17 new classes representing the various roles that excipients can bear. We then extracted excipients from RxNorm and added them to DrOn for branded drugs. We found excipients for 5,743 branded drugs, covering ~27% of the 21,191 branded drugs in DrOn. Our analysis of active ingredients resulted in another new class, active ingredient role. We also extracted strengths for all types of tablets, capsules, and caplets, resulting in strengths for 5,782 drug forms, covering ~41% of the 14,035 total drug forms and accounting for ~97 % of the 5,970 tablets, capsules, and caplets in DrOn. We represented binding-as-substrate and binding-as-inhibitor dispositions to two cytochrome P450 (CYP) isoenzymes (CYP2C19 and CYP2D6) and linked these dispositions to 65 compounds. It is now possible to query DrOn automatically for all drug products that contain active ingredients whose molecular grains inhibit or are metabolized by a particular CYP isoenzyme. DrOn is open source and is available at http://purl.obolibrary.org/obo/dron.owl.

Fiberoptic Endoscopic Evaluation of Swallowing: A Multidisciplinary Alternative for Assessment of Infants With Dysphagia in the Neonatal Intensive Care Unit

BACKGROUND

The standard procedure to assess an infant in the neonatal intensive care unit (NICU) who is suspected of aspirating on oral feedings is a videofluoroscopic swallowing study (VFSS). The VFSS has been used for more than 30 years to assess dysphagia and is considered the gold standard. However, there are challenges to the VFSS, including radiation exposure, transport to radiology, usage of barium, limited positioning options, and cost. An alternative approach is fiberoptic endoscopic evaluation of swallowing (FEES), which uses a flexible endoscope passed transnasally into the pharynx to assess anatomy, movement/sensation of structures, swallow function, and response to therapeutic interventions. Fiberoptic endoscopic evaluation of swallowing has been established as a valid tool for evaluating dysphagia and utilized as an alternative or supplement to the VFSS in both adults and children.

PURPOSE

This article provides an overview of the current challenges in the NICU with assessing aspiration and introduces a multidisciplinary FEES program for bottle and breastfeeding.

METHODS/SEARCH STRATEGY

A review of the literature of dysphagia, VFSS, and FEES in the adult, pediatric, infant, and neonatal populations was performed. Clinical competency standards were researched and then implemented through an internal process of validation. Finally, a best practice protocol was designed as it relates to FEES in the NICU.

FINDINGS/RESULTS

Fiberoptic endoscopic evaluation of swallowing is a safe alternative to the VFSS. It can be utilized at the infant's bedside in a NICU for the diagnosis and treatment of swallowing disorders by allowing the clinician the ability to replicate a more accurate feeding experience, therefore, determining a safe feeding plan.

IMPLICATIONS FOR PRACTICE

Competency and training are essential to establishing a multidisciplinary FEES program in the NICU.

IMPLICATIONS FOR RESEARCH

Further research is needed to compare the efficacy and validity of FEES versus VFSS for infants in the NICU. Furthermore, evaluating the efficacy of FEES during breastfeeding is warranted.

Development and Evaluation of a Guideline for Monitoring Propylene Glycol Toxicity in Pediatric Intensive Care Unit Patients Receiving Continuous Infusion Lorazepam

OBJECTIVES

To develop and determine the safety of a guideline, by using osmol gap as an indicator of propylene glycol toxicity for pediatric patients receiving continuous infusion lorazepam.

METHODS

From existing adult data, a guideline was developed for the use of continuous infusion lorazepam in pediatric critical care patients with recommendations for using osmol gap as an indicator of propylene glycol toxicity. A retrospective medical chart review was performed of patients receiving continuous infusion lorazepam from February 2012 to September 2012 for whom the guideline was used.

RESULTS

Twenty-one patients received continuous infusion lorazepam for sedation in the pediatric intensive care unit during the 9-month study period for a total of 23 infusions. Eight patients (34.8%) had an osmol gap of ≥ 12 mOsm/kg during lorazepam infusion, and 7 patients (30.4%) did not have an elevated osmol gap at any point during the infusion. Two patients (8.6%) had clinical toxicity as indicated by elevated anion gap or lactate in addition to an osmol gap ≥ 12 mOsm/kg, while no patients experienced clinical toxicity with an osmol gap < 12 mOsm/kg.

CONCLUSIONS

A guideline for the use of lorazepam infusion in pediatric critical care patients was developed and evaluated for safety. Lorazepam continuous infusions appeared to be associated with minimal toxicity in pediatric intensive care unit patients when the osmol gap monitoring guideline was used.

Pediatric drug formulations: a review of challenges and progress

Children differ from adults in many aspects of pharmacotherapy, including capabilities for drug administration, medicine-related toxicity, and taste preferences. It is essential that pediatric medicines are formulated to best suit a child's age, size, physiologic condition, and treatment requirements. To ensure adequate treatment of all children, different routes of administration, dosage forms, and strengths may be required. Many existing formulations are not suitable for children, which often leads to off-label and unlicensed use of adult medicines. New regulations, additional funding opportunities, and innovative collaborative research initiatives have resulted in some recent progress in the development of pediatric formulations. These advances include a paradigm shift toward oral solid formulations and a focus on novel preparations, including flexible, dispersible, and multiparticulate oral solid dosage forms. Such developments have enabled greater dose flexibility, easier administration, and better acceptance of drug formulations in children. However, new pediatric formulations address only a small part of all therapeutic needs in children; moreover, they are not always available. Five key issues need to be addressed to stimulate the further development of better medicines for children: (1) the continued prioritization of unmet formulation needs, particularly drug delivery in neonates and treatment gaps in pediatric cancers and childhood diseases in developing countries; (2) a better use of existing data to facilitate pediatric formulation development; (3) innovative technologies in adults that can be used to develop new pediatric formulations; (4) clinical feedback and practice-based evidence on the impact of novel formulations; and (5) improved access to new pediatric formulations.

Risk assessment of neonatal excipient exposure: lessons from food safety and other areas

Newborn babies can require significant amounts of medication containing excipients intended to improve the drug formulation. Most medicines given to neonates have been developed for adults or older children and contain excipients thought to be safe in these age groups. Many excipients have been used widely in neonates without obvious adverse effects. Some excipients may be toxic in high amounts in which case they need careful risk assessment. Alternatively, it is conceivable that ill-founded fears about excipients mean that potentially useful medicines are not made available to newborn babies. Choices about excipient exposure can occur at several stages throughout the lifecycle of a medicine, from product development through to clinical use. Making these choices requires a scalable approach to analysing the overall risk. In this contribution we examine these issues.

Paediatric oral biopharmaceutics: key considerations and current challenges

The complex process of oral drug absorption is influenced by a host of drug and formulation properties as well as their interaction with the gastrointestinal environment in terms of drug solubility, dissolution, permeability and pre-systemic metabolism. For adult dosage forms the use of biopharmaceutical tools to aid in the design and development of medicinal products is well documented. This review considers current literature evidence to guide development of bespoke paediatric biopharmaceutics tools and reviews current understanding surrounding extrapolation of adult methodology into a paediatric population. Clinical testing and the use of in silico models were also reviewed. The results demonstrate that further work is required to adequately characterise the paediatric gastrointestinal tract to ensure that biopharmaceutics tools are appropriate to predict performance within this population. The most vulnerable group was found to be neonates and infants up to 6 months where differences from adults were greatest.

Effective use of transdermal drug delivery in children

Transdermal administration offers a non-invasive and convenient method for paediatric drug delivery. The competent skin barrier function in term infants and older children limits both water loss and the percutaneous entry of chemicals including drugs; but the smaller doses required by children eases the attainment of therapeutic concentrations. Transdermal patches used in paediatrics include fentanyl, buprenorphine, clonidine, scopolamine, methylphenidate, oestrogens, nicotine and tulobuterol. Some patches have paediatric labelling supported by clinical trials whereas others are used unlicensed. Innovative drug delivery methods, such as microneedles and sonophoresis are being tested for their safety and efficacy; needleless injectors are primarily used to administer growth hormone; and two iontophoretic devices were approved for paediatrics. In contrast, the immature and rapidly evolving skin barrier function in premature neonates represents a significant formulation challenge. Unfortunately, this population group suffers from an absence of approved transdermal formulations, a shortcoming exacerbated by the significant risk of excessive drug exposure via the incompletely formed skin barrier.

Propylene Glycol–Related Delirium After Esmolol Infusion

Objective: Excipients used in oral or intravenous preparations may cause serious adverse events. Case Summary: We present the case of a 15-year-old boy with hypertrophic cardiomyopathy. In the pediatric intensive care unit, he received high doses of continuous intravenous esmolol (range = 20-400 µg/kg/min) for cardiac rhythm control. After a few days he developed a delirium not responding to high doses of antipsychotics or discontinuation of benzodiazepines. We eventually realized that the IV esmolol formulation contained high doses of propylene glycol and ethanol, which may accumulate after prolonged infusion and cause intoxication. Intoxication with propylene glycolcan cause neuropsychiatric symptoms. The boy’s propylene glycol plasma concentration was approximately 4 g/L, whereas clinical symptoms arise at concentrations above 1 to 1.44 g/L. Application of the Naranjo adverse drug reaction probability scale suggested a probable relationship (score 6) between the propylene glycol infusion and the delirium. After discontinuation of esmolol, the delirium disappeared spontaneously. Discussion: This is the first case describing excipient toxicity of esmolol, with an objective causality assessment revealing a probable relationship for the adverse event—namely, delirium—and esmolol. Conclusion: Although excipient toxicity is a well-known adverse drug reaction, this case stresses the importance for easily available information for and education of physicians.

Developmental pharmacokinetics of propylene glycol in preterm and term neonates

AIM

Propylene glycol (PG) is often applied as an excipient in drug formulations. As these formulations may also be used in neonates, the aim of this study was to characterize the pharmacokinetics of propylene glycol, co-administered intravenously with paracetamol (800 mg PG/1000 mg paracetamol) or phenobarbital (700 mg PG/200 mg phenobarbital) in preterm and term neonates.

METHODS

A population pharmacokinetic analysis was performed based on 372 PG plasma concentrations from 62 (pre)term neonates (birth weight (bBW) 630-3980 g, postnatal age (PNA) 1-30 days) using NONMEM 6.2. The model was subsequently used to simulate PG exposure upon administration of paracetamol or phenobarbital in neonates (gestational age 24-40 weeks).

RESULTS

In a one compartment model, birth weight and PNA were both identified as covariates for PG clearance using an allometric function (CL(i) = 0.0849 × {(bBW/2720)(1.69) × (PNA/3)(0.201)}). Volume of distribution scaled allometrically with current bodyweight (V(i) = 0.967 × {(BW/2720)(1.45)}) and was estimated 1.77 times higher when co-administered with phenobarbital compared with paracetamol. By introducing these covariates a large part of the interindividual variability on clearance (65%) as well as on volume of distribution (53%) was explained. The final model shows that for commonly used dosing regimens, the population mean PG peak and trough concentrations range between 33-144 and 28-218 mg l(-1) (peak) and 19-109 and 6-112 mg l(-1) (trough) for paracetamol and phenobarbital formulations, respectively, depending on birth weight and age of the neonates.

CONCLUSION

A pharmacokinetic model was developed for PG co-administered with paracetamol or phenobarbital in neonates. As such, large variability in PG exposure may be expected in neonates which is dependent on birth weight and PNA.

Development and stability assessment of liquid paediatric formulations containing sildenafil citrate

The purpose of this study is to develop and improve oral liquids formulations of sildenafil citrate for paediatric use. Four different formulations were developed, which are as follows: two aqueous solutions of sildenafil citrate (2.5 mg/mL), with or without preservatives, and two other solutions of sildenafil in simple syrup (1.25 mg/mL), with or without preservatives. All of the formulations were physically, chemically and microbiologically stable for three months. The results of the stability studies allowed for the optimisation of formulations without preservatives due to their simplicity and their similar stable conditions when compared to the formulations containing antimicrobials. The shelf life of both formulations was three months; however, upon opening, aqueous solutions should be used within 10 days and kept refrigerated, and syrup solutions should be used within 14 days in a hospital setting.

Hospitalised neonates in Estonia commonly receive potentially harmful excipients

BACKGROUND

Information on the neonatal exposure to excipients is limited. Our aim was to describe the extent of excipient intake by Estonian neonates; to classify the excipients according to potential neonatal toxicity and thereby to measure the extent of exposure of neonates to potentially harmful excipients.

METHODS

A prospective cohort study that recorded all medicines prescribed to patients aged below 28 days admitted to Tartu University Hospital from 01.02-01.08 2008 and to Tallinn Children's Hospital from 01.02- 01.08 2009 was conducted. Excipients were identified from Summaries of Product Characteristics and classified according to toxicity following a literature review.

RESULTS

1961 prescriptions comprising 107 medicines were written for 348/490 neonates admitted. A total of 123 excipients were found in 1620 (83%) prescriptions and 93 (87%) medicines. 47 (38%) of these excipients were classified as potentially or known to be harmful to neonates. Most neonates (97%) received at least one medicine (median number 2) with potentially or known to be harmful excipient. Parabens were the most commonly used known to be harmful excipients and sodium metabisulphite the most commonly used potentially harmful excipient, received by 343 (99%) and 297 (85%) of treated neonates, respectively.

CONCLUSIONS

Hospitalised neonates in Estonia are commonly receiving a wide range of excipients with their medication. Quantitative information about excipients should be made available to pharmacists and neonatologists helping them to take into account excipient issues when selecting medicines and to monitor for adverse effects if administration of medicines containing excipients is unavoidable.

Anaphylaxis triggered by benzyl benzoate in a preparation of depot testosterone undecanoate

We report the first case of an anaphylactic reaction to Reandron 1000 (depot testosterone undecanoate with a castor oil and benzyl benzoate vehicle). While considered to have a favourable safety profile, serious complications such as oil embolism and anaphylaxis can occur. In our patient, skin testing identified benzyl benzoate to be the trigger, with no reaction to castor oil or testosterone undecanoate components. As benzyl benzoate exists in multiple pharmaceuticals, foods, and cosmetics, individual components of pharmaceuticals should be tested when investigating drug allergies. Doctors should be alert to the potential for serious reactions to any of the components of Reandron 1000.

Neonatal intensive care practices harmful to the developing brain

There has been a marked increase in the survival of extremely low birth weight (ELBW) infants, but these babies have a long stay in the NICU. Strategies to decrease their neurodevelopmental impairment become very important. The maximum development of the brain occurs between 29-41 weeks. From the warm, dark, acquatic econiche, where the baby hears pleasant sounds like the mother's heart beat, the baby suddenly finds itself in the dry, cold, excessively bright, noisy, environment of the NICU. Noise, bright light, painful procedures, and ill-timed caregiving activities, adversely affect the infant's development. Excessive radiation from X-rays of babies on the ventilator and CT scans also affect the brain. Medications like steroids for chronic lung disease also cause damage to the brain. Aminoglycides and frusemide are known to cause hearing impairment. Hence a developmentally supportive, humanized care will go a long way in enhancing the developmental outcome of these babies.

Introduction to the Canadian Scientific Advisory Committee on Respiratory and Allergy Therapies: in vivo evaluation for clinical testing in COPD and asthma therapy using generics

BACKGROUND

Health Canada posted a guidance for in vivo testing of subsequent market entry (SME) inhaled corticosteroids (ICS) for treatment of asthma and published proceedings regarding SME products for chronic obstructive pulmonary disease (COPD). This manuscript reviews these recommendations and outlines their rationale.

METHODS

The Scientific Advisory Committee on Respiratory and Allergy Therapies (SAC-RAT) met between 2007 and 2009. The committee reviewed approval processes for SME ICS for asthma treatment and a draft guidance was posted by Health Canada. SAC-RAT also reviewed SME long-acting beta agonists (LABA) and fixed drug dose combinations (FDDC) for COPD treatment.

RESULTS

SAC-RAT concluded that measuring airway eosinophils in mild, stable, steroid-naive, subjects was reproducible and measurable. Study duration could be reduced to only 3 weeks using this inflammatory outcome to establish therapeutic equivalence between SME ICS and Canadian reference product. A placebo limb of the trial was added to establish biological activity of the products. The committee recommended that LABA SME products be tested in a clinically stable, representative population with GOLD stage 2 and/or 3 COPD. There was not agreement regarding the extent of allowed FEV(1) reversibility in this population. The FEV(1) area under the curve (AUC) was recommended as a primary endpoint. For equivalence, both AUC and the shape of the curve (assessed by the peak and trough) over a 12-h period should be different from placebo but similar for the SME and reference products. Secondary endpoints were not recommended.

CONCLUSIONS

Clinical presentations of asthma and COPD may overlap but prespecified disease phenotypes can separate the populations. ICS therapeutic equivalence can be assessed by reduction in eosinophil counts tested in steroid naive subjects. Increases in FEV(1) define LABA effects in moderate to severe COPD. When designing trials to assess therapeutic equivalence, the anticipated mechanism of action of the drug should be used to determine outcome measures.

Non-clinical safety and pharmacokinetic evaluations of propylene glycol aerosol in Sprague-Dawley rats and Beagle dogs

Aerosolized propylene glycol (PG) was generated as log-normally distributed particulate clouds in different concentrations using a novel capillary aerosol generator (CAG) and evaluated in a battery of non-clinical studies intended to assess its potential inhalation and systemic toxicity in 2 species before ICH-compliant "first-time-in-man" studies. Exposures were nose-only in rats, and via face mask with oropharyngeal tube in dogs. The CAG-generated PG aerosol had a mass median aerodynamic diameter (MMAD) of 2.29μm, with a 1.56 geometric standard deviation (GSD) in the rat studies, and a MMAD of 1.34μm (1.45 GSD) in the dog studies, consistent with expected particle size exposures in man. International Congress on Harmonization (ICH) Guidelines were followed, which recommend preliminary non-clinical safety studies using the vehicle and device (CAG-PG) prior to the first human exposure including safety pharmacology, pharmacokinetic (PK) studies, single dose toxicity studies, and repeated dose toxicity studies in two species. In the rat, the only biologically relevant findings included clinical signs of ocular and nasal irritation indicated by minor bleeding around the eyes and nose, and minimal laryngeal squamous metaplasia. This finding is commonly observed in inhalation studies in the rat, and likely related to the unique sensitivity of the tissue, as well as the circuitous airflow pathway through the larynx which increases particle deposition. In the female Beagle dog, treatment-related decreases in hemoglobin, red blood cells and hematocrit were observed in the two highest exposure groups, equivalent to approximately 18 and 60mg/kg/day. In male dogs from the high dose group, similar small decreases, albeit, non-statistically significant decreases were observed in these hematological markers as well. PK studies in rats and dogs showed that the absorption of PG following pulmonary inhalation exposure occurs rapidly, and equilibrium between lung tissue and plasma is achieved quickly. With daily inhalations of PG aerosols, there is evidence of minor tissue accumulation of PG in each species. Inhalation exposure to CAG-generated PG aerosols achieved PG concentrations in the systemic circulation that were similar to those attained via the oral route. Systemic elimination of PG appears to be saturable, presumably via hepatic metabolism. PG elimination in the high dose groups for both species showed terminal plasma and lung concentration-time profiles suggesting a zero-order elimination process. There was no apparent tissue toxicity of the lung, liver and kidney in these studies. Under the conditions of these studies, the NOEL for the rat was determined to be 20mg/kg/day for the 28-day study. In the Beagle dog, the NOEL was approximately 6.05mg/kg/day for the 28-day study. Overall, these studies allowed us to conclude that PG aerosol generated with the capillary aerosol generator could be administered safely in man, with an adequate margin of safety needed to conduct "first-time-in-man" human exposure studies.

Excipients in medicinal products used in gastroenterology as a possible cause of side effects

Although most adverse drug reactions are caused by the active substances, excipients may sometimes affect the safety profile of a medicinal product. The aim of this review is twofold: (1) To identify the excipients most frequently contained in oral medicinal products marketed in Italy for gastrointestinal indications, and to evaluate the main safety concerns, considering both intrinsic toxicity and patient-related risk factors. (2) To analyze possible differences with medicinal products marketed in the United Kingdom and USA in terms of excipients and relevant warnings reported in the label. We identified excipients with potential impact on safety profile and calculated frequency of use of each identified excipient in 98 selected medicinal products. We discussed possible safety concerns in clinical practice. We also analyzed US and UK Summary of Products Characteristics (SmPC) of oral gastrointestinal products by searching in appropriate collections of regulatory agencies. Eleven excipients with a safety impact were identified (sucrose, saccharin, aspartame, sorbitol, mannitol, lactose, ethanol, propylene glycol, parabens, menthol and silica) and no substantial differences were found between drugs marketed in the three countries concerning excipient content. Warnings were more detailed in the SmPC of UK or USA products rather than Italian products. Information about pharmaceutical excipients with known effects is important in clinical practice, but the frequent lack of details in the related section of the SmPCs makes it difficult for health professionals to provide relevant advice. The availability of alternative products of the same therapeutic class, but lacking specific excipient(s) should be considered in selected patients.

Safety issues with ethanol as an excipient in drugs intended for pediatric use

Ethanol is commonly used as an excipient in the manufacture of medicines, including the ones intended for administration in children. However, ethanol cannot be considered an inert substance; on the contrary, its use in pharmaceutical preparations is associated with safety issues. Newborns, infants and children are not able to metabolize ethanol as efficiently as adults; as a consequence, they may be at higher risk of both acute and chronic alcohol-related toxicities.