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.

Medication use in pregnancy: a cross-sectional, multinational web-based study

OBJECTIVES

Intercountry comparability between studies on medication use in pregnancy is difficult due to dissimilarities in study design and methodology. This study aimed to examine patterns and factors associated with medications use in pregnancy from a multinational perspective, with emphasis on type of medication utilised and indication for use.

DESIGN

Cross-sectional, web-based study performed within the period from 1 October 2011 to 29 February 2012. Uniform collection of drug utilisation data was performed via an anonymous online questionnaire.

SETTING

Multinational study in Europe (Western, Northern and Eastern), North and South America and Australia.

PARTICIPANTS

Pregnant women and new mothers with children less than 1 year of age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of and factors associated with medication use for acute/short-term illnesses, chronic/long-term disorders and over-the-counter (OTC) medication use.

RESULTS

The study population included 9459 women, of which 81.2% reported use of at least one medication (prescribed or OTC) during pregnancy. Overall, OTC medication use occurred in 66.9% of the pregnancies, whereas 68.4% and 17% of women reported use of at least one medication for treatment of acute/short-term illnesses and chronic/long-term disorders, respectively. The extent of self-reported medicated illnesses and types of medication used by indication varied across regions, especially in relation to urinary tract infections, depression or OTC nasal sprays. Women with higher age or lower educational level, housewives or women with an unplanned pregnancy were those most often reporting use of medication for chronic/long-term disorders. Immigrant women in Western (adjusted OR (aOR): 0.55, 95% CI 0.34 to 0.87) and Northern Europe (aOR: 0.50, 95% CI 0.31 to 0.83) were less likely to report use of medication for chronic/long-term disorders during pregnancy than non-immigrants.

CONCLUSIONS

In this study, the majority of women in Europe, North America, South America and Australia used at least one medication during pregnancy. There was a substantial inter-region variability in the types of medication used.

Evidence for lipids-calcium ions interactions using fluorescent probing in paediatric nutrition admixtures

The aim of this work was to envisage a new analytical fluorescent method to study the molecular interactions between cations and negatively charged lipid droplets contained in total parenteral nutrition (TPN) admixtures. For this purpose, two fluorescent probes were tested: 9-diethylamino-5H-benzo[alpha]phenoxazine-5-one, commonly named nile red (NR), and 2-(p-toluidinyl)-naphthalene-6-sulfonate (TNS). NR, a neutral molecule, and TNS, an anionic one, are both polarity probes. Their fluorescence emission was enhanced in an apolar environment. They were used at 1 and 2.5 muM, respectively. Results showed that scattered light was very intense in weak aqueous dilution (1/10 vv(-1)) of fat emulsion and appeared as an experimental constraint. The sensitivity of fluorescence measurement in fat emulsion samples was constantly higher for NR than for TNS. When calcium addition occurs, as in pharmaceutical practice, a dramatic increase of fluorescence emission signal was showed for TNS, but no effect was observed for NR. As a conclusion, it was pointed out that the interactions between lipid droplets and calcium ions were likely to take place at the interface of the droplet and that TNS was a more appropriate probe than NR to prove it. Thus, fluorescent probing appeared to be a convenient new analytical tool for the investigation of lipid-cations interactions in TPN mixtures.

[Therapeutic patient education in heart failure: a program's assessment]

Heart failure is a chronic, common and severe disease. It leads to frequent hospitalizations and decrease of patient's quality of life. A therapeutic patient education program, named "school of heart failure" was implemented at Antoine-Béclère hospital.

AIM OF THE STUDY

To assess the effectiveness of this program.

PATIENTS AND METHODS

This therapeutic patient education program included patients with heart failure, hospitalized in a cardiology unit. Four types of evaluation were carried out: evaluation of patients' skills before they leave the hospital, patient's knowledge (associated with the degree of certainty), satisfaction regarding the program and self-assessment of changes in their lifestyle 3 months after discharge.

RESULTS

Twenty-four patients were included in 9 months. The program's evaluation showed promising results with respect to the acquisition of skills (94%), the improvement of patients' knowledge associated with self-confidence increase, their satisfaction towards the program (80%) and their ability to change their habits (75%). Self-assessment has demonstrated changes in their lifestyle.

CONCLUSION

These preliminary results are promising according to the program's effectiveness and its ability to meet patients' educational needs. The program was certified by French authorities in 2011. Knowledge and skills acquisition will have to be confirmed on long term.

Sédation au pentobarbital par voie rectale pour enregistrement des PEA chez l'enfant

OBJECTIVES

The aim of our study was to determine if rectal sedation with pentobarbital sodium provides safe and effective sedation for children undergoing auditory brainstem response (ABR) testing.

MATERIAL AND METHODS

A prospective study was conducted in the ENT pediatric department of Robert Debre's hospital (APHP, Paris). 68 children under 8 years of age were given rectal pentobarbital for ABR testing at a dosage of about 5 mg/kg.

RESULTS

61 children of 68 (89.7%) were adequately sedated with rectal pentobarbital. The mean elapsed time from drug administration to full sedation was 36,1 minutes. No adverse event was reported in 84.1% of children.

CONCLUSION

Pentobarbital provides safe and effective sedation. Rectal administration is easy, painless and with brief duration of action. It's a good alternative to general anesthesia for young children undergoing ABR testing.

A limited sampling strategy to estimate individual pharmacokinetic parameters of methotrexate in children with acute lymphoblastic leukemia

PURPOSE

The objectives of this study were to characterize the population pharmacokinetics of MTX in patients with acute lymphoblastic leukemia (ALL) with ages ranging from 2 to 16 years and to propose a limited sampling strategy to estimate individual pharmacokinetic parameters.

METHODS

Seventy-nine children were enrolled in this study; they received 1-4 courses of chemotherapy. MTX was administered at a dose of 5 g/m2. MTX population parameters were estimated from 61 patients (231 courses; age range: 2-16 years). The data were analyzed by nonlinear mixed-effect modeling with use of a two-compartment structural model. The interoccasion variability was taken into account in the model. Eighteen additional patients (70 courses) were used to evaluate the predictive performances of the Bayesian approach and to devise a limited sampling strategy.

RESULTS

The following population parameters were obtained: total clearance (CL) = 8.8 l/h (inter-individual variability: 43%), initial volume of distribution (V1) = 17.3 l (48%), k12 = 0.0225 h(-1) (41%), and k21 = 0.0629 h(-1) (24%). The inter-individual variability in the initial volume of distribution was partially explained by the fact that this parameter was weight-dependent. Intercourse variability was limited, with a mean variation of 13.2%. The protocol involving two sampling times, 24 and 48 h after the beginning of infusion, allows precise and accurate determination of individual pharmacokinetic parameters and consequently, it was possible to predict the time at which the MTX concentration reached the predicted threshold (0.2 microM) below which the administration of folinic acid could be stopped.

CONCLUSION

The results of this study combine the relationships between the pharmacokinetic parameters of MTX and patient covariates that may be useful for dose adjustment, with a convenient sampling procedure that may aid in optimizing pediatric patient care.

Near infrared spectroscopy and process analytical technology to master the process of busulfan paediatric capsules in a university hospital

The prescription of unlicensed oral medicines in paediatrics leads the hospital pharmacists to compound hard capsules, such as busulfan, an alkylating agent prescribed in preparative regimens for bone marrow transplantation. In this study, we have investigated how the general principle of process analytical technology (PAT) can be implemented at the small size of our hospital pharmacy manufacturing unit. Near infrared spectroscopy (NIRS) was calibrated for raw material identification, blend uniformity analysis and final content uniformity of busulfan hard capsules of 11 different strengths. Measurements were performed on capsules from 2 to 40 mg (n=440). After optimisation, accuracy and linearity of the NIRS quantitative method was demonstrated after comparison with a previously validated quantitative high performance thin layer chromatography (HPTLC) method. Such a comparison led to attractive NIRS precision: +/-0.7 to +/-1.0 mg for capsules from 2 to 40 mg, respectively. As NIRS is a rapid and non-destructive technique, the individual control of a whole batch of busulfan paediatric capsules intended to be administrated is possible. Actually, mastering the process of busulfan paediatric capsules with the NIRS integrated into the notion of PAT is a powerful analytical tool to assess the process quality and to perform content uniformity of at least 5mg busulfan-containing capsules.

[Treatment of severe perianal cutaneous lesions in hospitalized neonates: Orabase ointment interest]

Cholestyramine ointment is an hospital preparation used as a second-intention treatment for severe perianal skin lesions. These preparations have to be declared to AFSSAPS. The aim of this study was to assess the equivalence of Orabase, a marketed paste, with intention of substitution. A clinical trial was performed to evaluate the effectiveness of cholestyramine ointment versus Orabase paste. This study was conducted in the neonatalogy unit. The principal evaluation criterion was the time to clinical recovery. Nurses also gave their subjective evaluation of each product. Although 34 children were included in the study, the time to clinical recovery delay was evaluated in 28. Time to clinical recovery was 90.5 hours for the cholestyramine ointment and 81 hours for Orabase paste. Concerning the subjective assessment, Orabase paste achieved a higher score than cholestyramine ointment (p<0.01). Orabase paste was considered to be equivalent to cholestyramine ointment.