Stability profiles of drug products extended beyond labeled expiration dates

Expiration analysis of the International Space Station formulary for exploration mission planning

Effective medications will be required to maintain human health for long-duration space operations. Previous studies have explored the stability and potency of several of the medications used on the International Space Station (ISS). This study is a comprehensive analysis of the expected terrestrial shelf-lives of the entire 2023 ISS formulary using 4 international registries. Of the 106 medications in the ISS formulary, shelf-life data was found in at least 1 of the registries for 91 (86%) medications. Of these 91 medications, 54 have an estimated terrestrial shelf-life of ≤36 months when stored in their original packaging. 14 will expire in less than 24 months. The results of this study provide operational insight to supplying a pharmacy for an exploration mission, optimize therapeutic outcomes, and prevent diseases associated with extended spaceflight operations. Ultimately, those responsible for the health of spaceflight crews will have to find ways to extend the expiration of medications to the complete mission duration or accept the elevated risk associated with administration of an expired medication.

Pharmaceuticals in the Environment: A hospital pharmacy's perspective

Drugs do not disappear once they have been excreted. In fact, 992 active principles have already been measured in the different environmental matrices. A recent study led by scientists from the University of York has studied the presence of drugs in the rivers of more than 100 different countries, showing that environmental contamination by pharmaceuticals is a global issue and that, concentrations found are frequently harmful to the environment. In this work, we have tried to briefly expose the problem of environmental contamination with medicines, but above all, we have tried to address the possible solutions, with a perspective from the field of hospital pharmacy. This is a very complex matter (a wicked problem), since it involves multiple stakeholders with different visions and interests regarding medicines. In order to find solutions, we will probably need to act at all steps of the drug's life cycle. Until now, health professionals have been part of the problem. It is time for us to be part of the solution.

[Translated article] Pharmaceuticals in the environment: A hospital pharmacy perspective

Drugs do not disappear once they have been excreted. In fact, 992 active principles have already been measured in the different environmental matrices. A recent study led by scientists from the University of York has studied the presence of drugs in the rivers of more than 100 different countries, showing that environmental contamination by pharmaceuticals is a global issue and that, concentrations found are frequently harmful to the environment. In this work, we have tried to briefly expose the problem of environmental contamination with medicines, but above all, we have tried to address the possible solutions, with a perspective from the field of hospital pharmacy. This is a very complex matter (a wicked problem), since it involves multiple stakeholders with different visions and interests regarding medicines. In order to find solutions, we will probably need to act at all steps of the drug's life cycle. Until now, health professionals have been part of the problem. It is time for us to be part of the solution.

Efficacy of Expired Antibiotics: A Real Debate in the Context of Repeated Drug Shortages

This narrative review aims to discuss the main interest in and cautions associated with the use of expired antibiotics in the context of repeated shortages, notably in Europe. Articles concerning the topic of expiry dates related to antibiotic use were reviewed using keywords in the PubMed®/MEDLINE and Google Scholar databases to identify the most extensive evidence-based documentation. The present review evaluates the potential interest and efficacy of using expired drugs and their possible related adverse events. Overall, in the context of drug shortages, expiry dates could be safely extended for at least one year for most solid antibiotics (tablets or powder) used in daily clinical practice, as long as they are stored under the right conditions, in accordance with the summary of product characteristics.

Broadening the Perspective on Reducing Pharmaceutical Residues in the Environment

The present study reviews options for reducing harm from pharmaceuticals that are known to cause adverse impacts by their presence in the environment. It reviews recent global and European Union policy development, which could go further in recognizing and addressing the issue in a global context. It considers green chemistry, which can help clean up production processes but holds only long-term promise for creating "green" alternatives. It explores the potential of health promotion and disease prevention, which can contribute significantly to a reduction of the disease burden and thus the need for medicines, both for infectious and for noncommunicable disease. Eco-directed sustainable prescribing practices are reviewed, which have been adopted successfully to reduce the use of harmful pharmaceuticals. We note recent developments in medicines optimization and precision medicine, which hold promise for improving patient outcomes, saving costs, and reducing pharmaceutical use, through individually tailored prescribing whereby the patient codecides their therapy. Waste prevention through reuse or redistribution is beginning to find public support and "take-back" waste disposal schemes set up via extended producer responsibility systems have achieved high returns. Finally, the paper summarizes preferred advanced wastewater technologies, including innovative low-cost, low-energy options. In summary, although end-of-pipe options have a role to play, particularly for highly concentrated wastewaters, solutions further up the medicinal chain and disease prevention interventions, informed by a broad view of health and health care, are needed to pursue a much greater potential reduction of pharmaceuticals in the environment than can be achieved by end-of-pipe solutions alone. Environ Toxicol Chem 2024;43:653-663. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Assessment of Directional-Hemispherical Reflectance of Tablets with Cefuroxime during Storage under Elevated Temperature and Ultraviolet Radiation

Environmental conditions can lead to changes in the physical and chemical structures of drug products. In this study, the stability of cefuroxime tablets stored under adverse conditions was evaluated based on total directional-hemispherical reflectance (THR). The THR value was measured before and after the tablets' exposure to stress factors (temperature of 45 °C and UV radiation). Each measurement was performed three times within seven spectral bands at the beginning of the experiment (day 0), and then on days 1, 2, 3, 5, and 7. In addition, hyperspectral profiles (400-1030 nm) were analyzed on days 0 and 7. A significant decrease in THR values in all wavelength ranges was observed when day 7 vs. day 0 were compared, especially for spectral bands of 335-380 nm and 1700-2500 nm (Δ = 0.220, p < 0.001 and Δ = 0.171, p < 0.001, respectively). The hyperspectral analysis confirmed a decrease in the reflectance after the end of stress conditions in the visible light range (400-700 nm) compared to tablets before the experiment. This may indicate that more radiation entered the tablets. In conclusion, the THR of cefuroxime tablets decreases during the exposure to heat and UV radiation, which may result from some physicochemical changes that have occurred during storage.

Drug shortages. Part 2: Trends, causes and solutions

Drug shortages make it difficult or impossible to meet the therapeutic needs of individual patients or populations. In the first part of this review we proposed an operational definition that incorporates the processes by which products are manufactured, the causes of shortages and stock-outs (local shortages), and the contributory factors. Here we discuss causes and possible solutions. Drug shortages have complex causes, and a single cause cannot always be identified. Reasons include lack or shortage of raw materials, manufacturing difficulties, regulatory and political actions, voluntary recalls, just-in-time inventory systems, halts in production for financial or other business reasons, low demand (eg, orphan products, reduced usage), mergers, market shifts (eg, diversion to home markets) and unexpected increases in demand (eg, improved diagnosis, new trial information, epidemics and pandemics, inappropriate use, off-label use). Potential solutions are as diverse as the potential causes. Prevention is hard, because shortages are not easily predicted. Everyone in the supply chain is involved in anticipating and managing shortages, with responsibilities for preventing them or at least trying to mitigate their effects. This includes manufacturers and suppliers, particularly of generic formulations, pharmacists, prescribers, patients and governments. Solutions can therefore be linked to the causes and classified according to where the responsibility for implementing them lies.

The effect of long-term spaceflight on drug potency and the risk of medication failure

Pharmaceuticals selected for exploration space missions must remain stable and effective throughout mission timeframes. Although there have been six spaceflight drug stability studies, there has not been a comprehensive analytical analysis of these data. We sought to use these studies to quantify the rate of spaceflight drug degradation and the time-dependent probability of drug failure resulting from the loss of active pharmaceutical ingredient (API). Additionally, existing spaceflight drug stability studies were reviewed to identify research gaps to be addressed prior to exploration missions. Data were extracted from the six spaceflight studies to quantify API loss for 36 drug products with long-duration exposure to spaceflight. Medications stored for up to 2.4 years in low Earth orbit (LEO) exhibit a small increase in the rate of API loss with a corresponding increase in risk of product failure. Overall, the potency for all spaceflight-exposed medications remains within 10% of terrestrial lot-matched control with a ~1.5 increase in degradation rate. All existing studies of spaceflight drug stability have focused primarily on repackaged solid oral medications, which is important because non-protective repackaging is a well-established factor contributing to loss of drug potency. The factor most detrimental to drug stability appears to be nonprotective drug repackaging, based on premature failure of drug products in the terrestrial control group. The result of this study supports a critical need to evaluate the effects of current repackaging processes on drug shelf life, and to develop and validate suitable protective repackaging strategies that help assure the stability of medications throughout the full duration of exploration space missions.

To infinity and beyond: Strategies for fabricating medicines in outer space

Recent advancements in next generation spacecrafts have reignited public excitement over life beyond Earth. However, to safeguard the health and safety of humans in the hostile environment of space, innovation in pharmaceutical manufacturing and drug delivery deserves urgent attention. In this review/commentary, the current state of medicines provision in space is explored, accompanied by a forward look on the future of pharmaceutical manufacturing in outer space. The hazards associated with spaceflight, and their corresponding medical problems, are first briefly discussed. Subsequently, the infeasibility of present-day medicines provision systems for supporting deep space exploration is examined. The existing knowledge gaps on the altered clinical effects of medicines in space are evaluated, and suggestions are provided on how clinical trials in space might be conducted. An envisioned model of on-site production and delivery of medicines in space is proposed, referencing emerging technologies (e.g. Chemputing, synthetic biology, and 3D printing) being developed on Earth that may be adapted for extra-terrestrial use. This review concludes with a critical analysis on the regulatory considerations necessary to facilitate the adoption of these technologies and proposes a framework by which these may be enforced. In doing so, this commentary aims to instigate discussions on the pharmaceutical needs of deep space exploration, and strategies on how these may be met.

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Space is a hostile environment that threatens human health and drug stability.

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Data on the behaviour of medicines in space is critical but lacking.

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Novel drug manufacturing and delivery strategies are needed to safeguard crewmembers’ safety.

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Chemputing, synthetic biology, and 3D printing are examples of such emerging technologies.

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A regulatory framework for space medicines must be implemented to assure quality.

A study to investigate the chemical potency, physical stability, and efficacy of analgesic agents over a period of two years post their expiry date

Background

As per regulations, drugs have to be used within their shelf life and must be discarded after their expiry date. The present study was conducted in commonly used analgesic agents to investigate the change in the physical, chemical, and efficacy parameters of the drugs over a period of two years after their expiry date.

Methods

The drugs studied were Tab Ibuprofen, Tab Diclofenac, Tab Piroxicam, Inj Diclofenac, and Inj Piroxicam. The parameters investigated were chemical potency, physical stability, and analgesic efficacy. Testing for these parameters was carried out once before expiry to establish the baseline followed by at expiry, and then every six months for two years post expiry date.

Results

The active ingredient in all the drugs were within the accepted range as per IP during the study period indicating that they retained their potency up to a period of two years post expiry. The analgesic efficacy as determined by the "Radiant Heat Tail flick" and "Acetic acid-induced writhing" model also showed no significant difference in the Maximum Possible Efficacy and Percent protection, indicating that the drugs retained their efficacy. There was a slight difference in the dissolution times at expiry as compared to different time periods in the case of Ibuprofen and Diclofenac, while there are was no statistical difference in the disintegration times during the study period.

Conclusion

The analgesic drugs in our study retained their chemical potency, physical stability and analgesic efficacy up to a period of two years after expiry. The expiry date of a drug, as estimated currently, is not an accurate reflection of its actual shelf life.

Stability of Drugs Stored in Helicopters for Use by Emergency Medical Services: A Prospective Observational Study

STUDY OBJECTIVE

Drugs stored in rescue helicopters may be subject to extreme environmental conditions. The aim of this study was to measure whether drugs stored under the real-life conditions of a Swiss helicopter emergency medical service (HEMS) would retain their potency over the course of 1 year.

METHODS

A prospective, longitudinal study measuring the temperature exposure and concentration of drugs stored on 2 rescue helicopters in Switzerland over 1 year. The study drugs included epinephrine, norepinephrine, amiodarone, midazolam, fentanyl, naloxone, rocuronium, etomidate, and ketamine. Temperatures were measured inside the medication storage bags and the crew cabins at 10-minute intervals. Drug stability was measured on a monthly basis over the course of 12 months using high-performance liquid chromatography. The medications were considered stable at a minimum remaining drug concentration of 90% of the label claim.

RESULTS

Temperatures ranged from -1.2 °C to 38.1 °C (29.84 °F to 100.58 °F) inside the drug storage bags. Of all the temperature measurements inside the drug storage bags, 37% lay outside the recommended storage conditions. All drugs maintained a concentration above 90% of the label claim. The observation periods for rocuronium and etomidate were shortened to 7 months because of a supply shortage of reference samples.

CONCLUSION

Drugs stored under the real-life conditions of Swiss HEMS are subjected to temperatures outside the manufacturer's approved storage requirements. Despite this, all drugs stored under these conditions remained stable throughout our study. Real-life stability testing could be a way to extend drug exchange intervals.

Filling the Gaps in the Pharmacy Workforce in Post-Conflict Areas: Experience from Four Countries in Sub-Saharan Africa

Background: While the pharmacy workforce is the third largest professional healthcare group worldwide, the pharmacy workforce landscape remains unclear in post-conflict areas in sub-Saharan Africa. Method: Key informants were selected for semi-structured interviews due to their role in providing pharmacy services in the selected country: the Central African Republic (CAR), the Democratic Republic of Congo (DRC), Ethiopia, and South Sudan. Transcripts from the interviews were anonymized, coded, and analyzed. Results: Nine participants were recruited (CAR: 2; DRC: 2; Ethiopia: 2; South Sudan: 3), and all except two were pharmacists. Conflict-specific challenges in pharmacy service delivery were identified as the following: unpredictable health needs and/or mismatched pharmaceutical supply, transport difficulties due to insecure roads, and shortage of pharmacy workforce due to brain drain or interrupted schooling. Barriers to health workforce retention and growth were identified to be brain drain as a result of suboptimal living and working conditions or remuneration, the perception of an unsafe work environment, and a career pathway or commitment duration that does not fit the diaspora or expatriate staff. Conclusion: To tackle the barriers of pharmacy health workforce retention and growth, policy solutions will be required and efforts that can bring about long-term improvement should be prioritized. This is essential to achieve universal health coverage and the targets of the sustainable development goals for conflict affected areas, as well as to “leave no one behind”.

Should We Use Expired Drugs When Necessary?

BACKGROUND

Medication shortages commonly occur in resource-poor settings. The relatively short expiry dates on many medications exacerbate these shortages, often requiring clinicians to choose between providing needed medications to the patient and violating rules governing drug dispensing.

CASE REPORT

A patient presented to an emergency department in a resource-poor setting with an acute anterior myocardial infarction. Standard of care required using thrombolytics due to the unavailability of percutaneous coronary intervention. The only available thrombolytic, streptokinase, was 2 weeks past its labeled expiration date. The physicians faced the ethical dilemma of violating regulations and using the medication vs. failing to provide the patient with the best available therapy.

DISCUSSION

The physicians in this case needed to weigh their obligation to improve the patient's health against the professional danger to themselves, their colleagues, and their institution for violating a health care regulation. The information they needed to make this decision and to provide the patient with factual informed consent requires an understanding of the myths, regulations, and science surrounding drug expiry dates. Two myths about medications pervade both the professional and lay communities-that they are uniformly effective and that medications taken past their expiry dates may be ineffective or even harmful. Scientific studies have demonstrated that both are false.

CONCLUSIONS

Ethically, physicians have a duty to place their patient's welfare above their own self-interest. In a time of increasing medication shortages around the globe, clinicians need to push rule makers to synchronize drug expiry dates with scientific findings.

Stability of Diazepam Solution for Injection Following Long-Term Storage in an Ambient Temperature of the Mediterranean Climate

PURPOSE

Diazepam is utilized as a convulsion antidote following nerve gas attacks. As an emergency medicine, it requires storage at ambient temperatures which often doesn't meet manufacturers' requirements, leading to an early invalidation of the product. Current work investigated this issue.

METHODS

Long-term stability of diazepam ampoules for injection stored in an ambient temperature of the Mediterranean climate for ~10 years vs storage at room temperature was studied.

RESULTS

Diazepam assay and pH remained within pharmacopeial specifications irrespective of storage conditions. A major degradation product 2-methylamino-5-chlorobenzophenone (MACB) showed a clear trend of accumulation as a function of storage time, exceeding the permitted limit at ~2 years, irrespective of storage conditions. A strong correlation between the discoloration of the solutions and the concentration of MACB was obtained. Intravenous administration of MACB to rats at doses ~2200-fold higher than permissible specification levels caused neither mortality nor any toxicological nor post-mortem findings.

CONCLUSIONS

Regarding the parameters tested: diazepam assay, MACB assay, and pH, storing ampoules of diazepam solution for injection in field conditions of high temperatures of the Mediterranean climate did not cause accelerated degradation as compared to room temperature. These findings open an option for the usage of expired ampoules in special scenarios.

Recovery of Active Pharmaceutical Ingredients from Unused Solid Dosage-Form Drugs

The concept of drug recycle by recovering active pharmaceutical ingredients (APIs) from unused tablets and capsules was demonstrated using acetaminophen, tetracycline HCl, and (R,S)-(±)-ibuprofen as case examples. The recovery process comprised three core unit operations: solid-liquid extraction, filtration, and crystallization. Recovery yields of 58.7 wt %, 73.1 wt %, and 67.6 wt % for acetaminophen, tetracycline HCl, and (R,S)-(±)-ibuprofen were achieved, respectively. More importantly, all of the APIs were of high purity based on high-performance liquid chromatography assay. The crystal forms of the recovered APIs were in conformity with the standards.

An Overview of Pharmaceutical Production in Thai Hospitals

Purpose: The purpose of this research was to provide an overview of pharmaceutical production in Thai hospitals. Methods: A cross-sectional survey was developed to study pharmaceutical production in the 1347 Thai hospitals. A representative sample was chosen using multistep selection arriving at a final total of 750 hospitals. Five experts in hospital pharmacy production were recruited to evaluate the content validity. The questionnaire consisted of 2 parts: (1) general details of the hospitals and (2) the type of pharmaceutical products. The latter classification were further divided into 6 types: (1) nonsterile products, (2) extemporaneous preparations, (3) total parenteral nutrition, (4) intravenous admixtures, (5) cytotoxic preparations, and (6) herbal medicine products. All data were analyzed via descriptive statistics. Results: From the 750 questionnaires sent out, 395 hospitals (52.67%) responded to the questionnaires. Regarding the 395 respondent sample group, approximately 60% of the hospitals were involved in pharmaceutical production. The top 3 pharmaceutical products were as follows: (1) cytotoxic preparations (315 items); (2) liquid nonsterile preparations (60 items), and (3) liquid extemporaneous preparations (52 items). The most frequently mentioned reasons for the production of each dosage form were as follows: (1) no commercially available product in appropriate dosage form or strength needed and (2) product was prepared following the hospital's policy. The support needs in hospital pharmacy production were revealed as follows: (1) master formula, (2) quality assurance and quality control processes, (3) equipment, (4) standard references, (5) buildings, (6) personnel, (7) budget, (8) raw material suppliers, and (9) the coordination between the faculties of pharmaceutical sciences and hospitals. Conclusions: Approximately 60% of the respondents had pharmaceutical production in their hospitals. The greatest need for support was for a master formula to inform hospital-based pharmaceutical production. These findings provide essential information, especially for stakeholders, to understand the professional challenges and likely pharmaceutically related health service changes in the future.

The neutralization efficacy of expired polyvalent antivenoms: An alternative option

The expense of production and distribution of snakebite antivenom, as well as its relatively infrequent use, has caused antivenom to be increasingly difficult to obtain and ultimately producing an alarming global shortage. Unused, expired antivenom may represent a significant, untapped resource to ameliorate this crisis. This study examines the efficacy of expired antivenom over time using in vitro, whole blood clotting, and platelet function statistics. Representatives from three years for four different global brands of polyvalent antivenom were chosen and tested against their corresponding venoms as well as other venoms that could display cross-reactivity. These antivenoms include Wyeth Polyvalent (U.S.; exp. 1997, 2001, 2003), Antivipmyn^® (Mexico; exp. 2005, 2013, 2017), Biotecfars Polyvalent (Venezuela; exp. 2010, 2014, 2016), and SAIMR (South Africa; exp. 1997, 2005, 2017). Venoms of species tested were Crotalus atrox against Wyeth; C. atrox and Crotalus vegrandis against Antivipmyn^®; C. atrox, C. vegrandis and Bothrops colombiensis against Biotecfar; and Bitis gabonica and Echis carinatus against South African Institute for Medical Research (SAIMR). Parameters recorded were activated clotting time (ACT), clotting rate (CR), and platelet function (PF). Preliminary results are encouraging as the antivenoms maintained significant efficacy even 20 y after their expiration date. We anticipate these results will motivate further studies and provide hope in the cases of snakebite emergencies when preferable treatments are unavailable.

Supplying a pharmacy for NASA exploration spaceflight: challenges and current understanding

In order to maintain crew health and performance during long-duration spaceflight outside of low-Earth orbit, NASA and its international partners must be capable of providing a safe and effective pharmacy. Given few directed studies of pharmaceuticals in the space environment, it is difficult to characterize pharmaceutical effectiveness or stability during spaceflight; this in turn makes it challenging to select an appropriate formulary for exploration. Here, we present the current state of literature regarding pharmaceutical stability, metabolism, and effectiveness during spaceflight. In particular, we have attempted to highlight the gaps in current knowledge and the difficulties in translating terrestrial-based drug studies to a meaningful interpretation of drug stability, safety, and effectiveness in space. We hope to identify high-yield opportunities for future research that might better define and mitigate pharmaceutical risk for exploration missions.

Delayed Cardiotoxicity From a Massive Nortriptyline Overdose Requiring Prolonged Treatment

PURPOSE

A case of a nortriptyline overdose complicated by delayed ventricular arrhythmias necessitating prolonged sodium bicarbonate infusion is presented, along with a review of tricyclic antidepressant (TCA) toxicology and key concepts for massive overdose management.

SUMMARY

A 61-year-old man presented after an intentional nortriptyline overdose with a possible consumption of up to 2500 mg of nortriptyline. Electrocardiogram on presentation demonstrated QRS widening to 240 milliseconds. Despite treatment with a sodium bicarbonate infusion and further narrowing of his QRS interval, his course was complicated by repeated episodes of wide complex tachycardia. Given these episodes, an elevated quantitative serum nortriptyline level of 468 μg/L on hospital day 6 and persistently positive TCA urine screens, the patient was continued on a sodium bicarbonate infusion until hospital day 14. Based on our patient's quantitative serum nortriptyline levels, we calculated an elimination half-life of 184 hours, 6 days post ingestion as compared to the reported half-life of nortriptyline of 14 to 51 hours.

CONCLUSION

This case demonstrates that at toxic levels of ingestion, routine TCA pharmacokinetics may be unreliable due to delayed absorption, enterohepatic recirculation, large volume of distribution, and saturable kinetics. Therefore, in these cases, pharmacokinetic values derived from routine dosing should not be used to make clinical decisions (such as timing of discontinuation of sodium bicarbonate infusion). We found that urine TCA screens provided similar information to quantitative nortriptyline levels and can be used to guide therapy along the QRS duration.

A long-time stability study of 50 drug substances representing common drug classes of pharmaceutical use

For assurance of the quality of active pharmaceutical ingredients (APIs) used for manufacturing medicines, the analytical requirements of the European Pharmacopoeia serve as a guideline and have a binding character. Within a particular timeframe, an API is considered to comply with predefined specifications. If applicable, it can be used for the manufacturing of a finished pharmaceutical product. The objective of the study presented here was to assess the long-term stability of 50 drug substances with an age of 20-30 years or even older in some cases. The substances are part of a collection of old pharmaceuticals at the Institute for Pharmacy in Würzburg, Germany, and represent commonly used drug classes containing β-blockers, β-sympathomimetic drugs, anticholinergics, anti-infectives, non-steroidal anti-inflammatory drugs, antipsychotics, antihistaminic drugs, and one antiarrhythmic drug. The content and the degradation profile of the items were determined by means of potentiometric titration and liquid chromatography techniques based on pharmacopoeial approaches for impurity profiling covering all process and degradation related substances. The results of the study show that 44 out of 49 tested substances still complied with specifications of the current pharmacopoeias. For metipranolol, which is not monographed in any pharmacopoeia, a small degradation by hydrolysis was observed. In one lot of ampicillin sodium, atenolol, atropine, penbutolol, and salbutamol, at least one impurity did not meet the acceptance criteria, respectively. Some impurities were not related to degradation. However, a surprisingly high chemical stability of the old drug substances was revealed after more than two decades of storage.

Expired Drugs in the Remote Environment

INTRODUCTION

The British Antarctic Survey Medical Unit works in a very remote area of the world, with several Antarctic bases receiving only a single annual resupply of consumable goods. Pharmaceuticals supplied in this manner will often be approaching or past the end of their nominal shelf life before the following year's resupply. Drugs are transported from the UK via ship; the hold is not temperature controlled, and the ship crosses through the tropics (air temperature 25-30°C for approximately 3 wk). The drugs then must be transported from the ship to the base, often in temperatures substantially below freezing. This study assessed the stability of 5 expired drugs (atropine, nifedipine, flucloxacillin, naproxen, and bendroflumethiazide) returned from Antarctic bases.

METHODS

Drugs were opportunistically obtained and tested using stability-indicating assays.

RESULTS

All tested drugs were stable.

CONCLUSIONS

The results suggest that the studied drugs may be stable beyond expiry, even when not maintained in strictly temperature-controlled conditions.

A systematic review of the stability of finished pharmaceutical products and drug substances beyond their labeled expiry dates

In recent years, there has been a very active debate about the stability of drug products especially after exceeding the expiry dates. The regulatory authorities require comprehensive stability data for market approval. The shelf-life obtained determines the expiry date, which is typically between 1 and 5 years and commonly set in a conservative manner. Conducting stability studies is a resource- and time-consuming matter for the pharmaceutical manufacturer. Short shelf-lives of drug products are also a challenge for managers of hospitals, nursing homes, and strategic national stockpile agencies which have to dispose of large quantities of outdated medicines every year. This conflict raises the question whether shelf-lives are often longer than the labeled one. In the past years, the FDA has launched several programs for shelf-life extension in order to defer replacement costs and to prevent drug shortages due to supply disruption. The aim of this review was to bring together the available literature of expired drug products as well as historical pharmaceutical relicts with an age of more than 80 years and to discuss the actual shelf-life with regard to the respective dosage form and the affiliation of the drug class. It seems to be reasonable for a large portion of drugs to extend the expiry dates far beyond five years.

Quantitative Raman assays for on-site analysis of stockpiled drugs

We present a rapid Raman assay for on-site analysis of stockpiled drugs in aqueous solution. This approach was tested on Tamiflu (oseltamivir phosphate). Tamiflu is a drug approved by the FDA for treatment of influenza and is the most common antiviral included in stockpiles for use in the event of a national emergency. Rapid assays were performed on three concentrations (30, 45, and 75 mg) of oseltamivir using three different portable & handheld Raman instruments. PLS regression models were developed to establish a calibration curve and applied to the Tamiflu samples. Raman assay values were compared against the standard HPLC assay to demonstrate the viability of this approach, yielding an average assay value within 0.3% of that obtained from the HPLC analysis for the 35 different capsules analyzed. The Raman method demonstrates the potential for rapid screening of stockpiled pharmaceuticals on-site using portable Raman instrumentation and readily available consumables for sample preparation. In addition to routine screening to ensure product quality past the expiration date, this approach could also be used to assist in rapid deployment of such medications in the case of a national emergency.

Expired Epinephrine Maintains Chemical Concentration and Sterility

OBJECTIVES

Epinephrine shortages affect nearly all American emergency medical services (EMS) systems. Utilization of expired epinephrine could mitigate this situation in daily EMS operations. Concerns about using expired medications include sterility, potency, and potential harmful chemical decay byproducts. There are no cross-platform analyses of sterility and chemical purity of multiple samples of expired parenteral epinephrine. We hypothesized that epinephrine injections will remain sterile and will retain their active ingredient's content for more than 30 months past expiration.

METHODS

Six parenteral epinephrine prefilled syringes, 1 mg/10 mL, with an expiration date of January 1, 2012 had been stored in the climate controlled setting of a hospital inpatient pharmacy where they remained until they were taken for chemical or microbial analysis 30 months after expiration. An unexpired parenteral epinephrine prefilled syringe content was used as a control. Contents of three separate syringes with expired content from the same lot and one control underwent ultra-high pressure liquid chromatography-mass spectrometry (UHPLC-MS) and nuclear magnetic resonance (NMR) to determine epinephrine content and stability. In parallel, contents of another three expired epinephrine syringes were analyzed for sterility by plating on aerobic, anaerobic, and fungal media in a hospital microbiology laboratory. The aerobic plates were checked for growth in 3 days, the anaerobic in 5 days, and the fungal in 28 days.

RESULTS

UHPLC-MS and NMR showed that content of epinephrine present in the original sample remained unchanged compared to the control. There was no statistical difference in the UHPLC-MS and NMR signal amplitudes between the control and the expired samples. No chemical degradation byproducts were detected using NMR. There was no growth of any bacteria or fungus.

CONCLUSION

Recurrent epinephrine shortages impact EMS and hospital operations in the United States. Individual administrators may be hesitant to authorize use of expired pharmaceuticals due to perceived potential complications or fear of litigation. This study shows that the original parenteral epinephrine remains sterile and detectably pure more than 2.5 years after expiration. Further study of the sterility and chemical integrity of expired medications that had been subjected to the conditions of EMS vehicles may be a future research endeavor based on the aforementioned paradigm.

Impact of space environment on stability of medicines: Challenges and prospects

To upkeep health of astronauts in a unique, isolated, and extreme environment of space is the primary goal for a successful space mission, hence, safe and efficacious medications are essential for the wellness of astronauts. Space medication has been challenged with problems related to efficacy. Along with altered physiology, one of the possible reasons could be instability of space medications in the presence of harsh spaceflight environmental conditions. Altered physical and chemical stability can result in reduced potency which can result in reduced efficacy. Right now, medicines from the International Space Station are replaced before their expiration. But, for longer duration missions to Mars or any other asteroid, there will not be any chance of replacement of medicines. Hence, it is desired that medicines maintain the shelf-life throughout the space mission. Stability of medicines used for short term or long term space missions cannot be judged by drug stability guidelines based on terrestrial environmental factors. Unique environmental conditions related to spaceflight include microgravity, excessive vibration, hard vacuum, humidity variation, temperature differences and excessive radiation, which may cause instability of medicines. This write-up provides a review of the problem and countermeasure approaches for pharmaceuticals exposed to the space environment. The first part of the article discusses thought processes behind outlining of International Conference on Harmonization drug stability guidelines, Q1A (R2) and Q1B, and its acceptance limits for accelerated stability study. The second part of the article describes the difference in the radiation environment of deep space compared to radiation environment inside the space shuttle based on penetration power of different types of radiation. In the third part of the article, various promising approaches are listed which can be used for assurance of space medicine stability. One of the approaches is the use of ground-based space simulation analogues and statistical treatment to data to calculate failure rate of drugs and probabilistic risk assessment. Another approach is to innovate storage and packaging technology using radiation harden polymer or using cryogenic temperatures.

Reutilization of Tacrolimus Extracted from Expired Prograf® Capsules: Physical, Chemical, and Pharmacological Assessment

In this study, we investigated whether tacrolimus extracted and purified from the commercial capsules (Prograf® 5 mg) have retained its original quality and activity beyond the capsules expiration date in order to be reused for research purposes after extraction. High-performance liquid chromatography (HPLC) assay method was developed and validated for the quantification of tacrolimus, using cyclosporine A as an internal standard (IS). Moreover, a combination of analytical methods, including nuclear magnetic resonance (NMR), gas chromatography-mass spectrometry (GC-MS), Fourier transform-infrared (FT-IR) spectroscopy, X-ray diffraction (XRD), and differential scanning calorimetry (DSC) were used to assess the quality of extracted/purified tacrolimus. Suppression of murine peripheral-blood mononuclear cells (PBMC) proliferation and the levels of interleukin-2 (IL-2) and interferon gamma (IFN-γ) were also assessed. The data obtained showed no detectable differences in the quality profile between the authentic sample and extracted drug. Also, the results showed that the extracted/purified tacrolimus was able to suppress T cell proliferation, induced by concanavalin A, indicating the retained pharmacological activity. We proved that tacrolimus extracted/purified from expired Prograf® capsuled retains its purity and immunosuppressive activity and can be reused for research and possibly in pharmaceutical manufacturing.

Chemical Potency and Degradation Products of Medications Stored Over 550 Earth Days at the International Space Station

Medications degrade over time, and degradation is hastened by extreme storage conditions. Current procedures ensure that medications aboard the International Space Station (ISS) are restocked before their expiration dates, but resupply may not be possible on future long-duration exploration missions. For this reason, medications stored on the ISS were returned to Earth for analysis. This was an opportunistic, observational pilot-scale investigation to test the hypothesis that ISS-aging does not cause unusual degradation. Nine medications were analyzed for active pharmaceutical ingredient (API) content and degradant amounts; results were compared to 2012 United States Pharmacopeia (USP) requirements. The medications were two sleep aids, two antihistamines/decongestants, three pain relievers, an antidiarrheal, and an alertness medication. Because the samples were obtained opportunistically from unused medical supplies, each medication was available at only 1 time point and no control samples (samples aged for a similar period on Earth) were available. One medication met USP requirements 5 months after its expiration date. Four of the nine (44% of those tested) medications tested met USP requirements 8 months post expiration. Another three medications (33%) met USP guidelines 2-3 months before expiration. One compound, a dietary supplement used as a sleep aid, failed to meet USP requirements at 11 months post expiration. No unusual degradation products were identified. Limited, evidence-based extension of medication shelf-lives may be possible and would be useful in preparation for lengthy exploration missions. Only analysis of flight-aged samples compared to appropriately matched ground controls will permit determination of the spaceflight environment on medication stability.

Adhesive performance of precoated brackets after expiration

OBJECTIVE

To evaluate adhesive performance in terms of debonding forces of precoated metal and ceramic brackets 4 years after expiration.

MATERIALS AND METHODS

Buccal and lingual surfaces of embedded extracted maxillary premolars were etched with 34% Tooth Conditioner Gel (Dentsply Caulk, Milford, Del), rinsed, and dried. Transbond MIP (3M Unitek, Monrovia, Calif) was applied prior to placing adhesive precoated brackets (APC II Victory stainless steel and APC Plus Clarity ceramic brackets, 3M Unitek). The preexpiration brackets had 29-35 months before, and the postexpiration brackets were 45-52 months past, their expiration dates. Sample size was 17-21 per group. Debonding forces were determined by subjecting the bonded brackets to a shear force in a universal testing machine. Debonding forces were compared using two-way ANOVA. Debonded surfaces were examined under a stereomicroscope to determine failure modes, which were compared using the chi-square test.

RESULTS

No statistically significant difference was found in debonding forces (P  =  .8581) or failure modes (P  =  .4538) between expired and unexpired brackets. Metal brackets required statistically significantly higher debonding forces than did ceramic brackets (P  =  .0001). For both expired and unexpired brackets, failure modes were mostly cohesive in the adhesive layer for ceramic brackets, and mixed between adhesive and cohesive failure in the adhesive layer for metal brackets.

CONCLUSIONS

Adhesive precoated brackets did not have any reduction in enamel-adhesion properties up to 4 years after their expiration date. Extended shelf life testing for precoated dental brackets may be worth considering.

Long-term stability study of Prussian blue - a quality assessment of water content and thallium binding

The purpose of this study is to assess the long-term stability of Prussian blue (PB) drug product (DP) and active pharmaceutical ingredient (API) under laboratory storage conditions by monitoring the loss in water content and the corresponding change of the in vitro thallium binding capacity that represents product performance. The bound water content and the in vitro thallium binding capacity of PB DPs and APIs were measured in 2003 and 2013, respectively. Water content, a critical quality attribute that directly correlates to the thallium (Tl) binding capacity was measured by thermal gravimetric analysis (TGA). The thallium binding study was conducted by testing PB in buffered solutions over the human gastrointestinal pH range with thallium concentrations ranging from 600 to 1,500 ppm. Samples were incubated at physiological temperature of 37°C in a shaking water bath to mimic gastric flux and intestinal transport. The binding equilibrium was reached at 24h. Following incubation, each sample was filtered and the free thallium was analyzed using a validated inductively coupled plasma spectroscopic method (ICP). The Langmuir isotherm was plotted to calculate maximum binding capacity (MBC). Compared with 2003, the water content of DP-1 decreased by about 14.1% (from 15.6 to 13.4 mol), and the MBC of DP-1 decreased by about 12.5% (from 714 to 625 mg/g) at pH 7.5. When low concentration of thallium (600 ppm) was used at pH 7.5, the Tl binding remained comparable for both API-1 (286 vs 276 mg/g) and DP-1 (286 vs 268 mg/g). Similarly, the Tl binding remained unchanged for both API-1 (237 vs 255 mg/g) and DP-1 (234 vs 236 mg/g) at pH 5.0. However, at pH 1.0 the binding was reduced 32.3% and 25.9% for API-1 and DP-1, respectively. Since the majority of binding takes place in the upper GI tract where pH around 5 can be expected, and therefore, the Tl binding capacity of PB should be comparable for new and aged samples. The findings that Tl binding changes with the water loss of PB and pH conditions are consistent with our previously published data. The study also represents the first quantitative assessment of the long-term stability of PB. Over last 10 years, PB DPs and APIs have lost about 20% water under ambient laboratory storage conditions which are consistent with a controlled warehouse environment. While the maximum binding capacity of PB to thallium was decreased after about 10 years of long-term storage, it is still very effective, suggesting that the shelf life of PB should be much longer than the manufacturer ascribed expiration date of 2008 under proper storage conditions.

Managing terrorism or accidental nuclear errors, preparing for iodine-131 emergencies: a comprehensive review

Chernobyl demonstrated that iodine-131 (131I) released in a nuclear accident can cause malignant thyroid nodules to develop in children within a 300 mile radius of the incident. Timely potassium iodide (KI) administration can prevent the development of thyroid cancer and the American Thyroid Association (ATA) and a number of United States governmental agencies recommend KI prophylaxis. Current pre-distribution of KI by the United States government and other governments with nuclear reactors is probably ineffective. Thus we undertook a thorough scientific review, regarding emergency response to 131I exposures. We propose: (1) pre-distribution of KI to at risk populations; (2) prompt administration, within 2 hours of the incident; (3) utilization of a lowest effective KI dose; (4) distribution extension to at least 300 miles from the epicenter of a potential nuclear incident; (5) education of the public about dietary iodide sources; (6) continued post-hoc analysis of the long-term impact of nuclear accidents; and (7) support for global iodine sufficiency programs. Approximately two billion people are at risk for iodine deficiency disorder (IDD), the world's leading cause of preventable brain damage. Iodide deficient individuals are at greater risk of developing thyroid cancer after 131I exposure. There are virtually no studies of KI prophylaxis in infants, children and adolescents, our target population. Because of their sensitivity to these side effects, we have suggested that we should extrapolate from the lowest effective adult dose, 15-30 mg or 1-2 mg per 10 pounds for children. We encourage global health agencies (private and governmental) to consider these critical recommendations.

Resin composite characterizations following a simplified protocol of accelerated aging as a function of the expiration date

This study evaluated the mechanical, thermal, and morphological characteristics of different classifications of dental composites as a function of the material condition (new, aged and expired). Specimens were obtained according to these factors: Composites: Filtek P60, Filtek Z250, Filtek Z350XT, and Filtek Silorane; and Material conditions: new, aged, and expired. The syringe composites underwent an accelerated aging protocol (Arrhenius model). The flexural strength (FS) and flexural modulus (E) were obtained. The thermogravimetric analysis (TGA) and differential thermal analysis (DTA) were also performed and the glass transition temperature (Tg) and the weight loss calculated. Topographic analysis of the composites was performed under SEM. The material conditions influenced the mechanical properties of the composites. The silorane composite exhibited a characteristic thermal behavior different from that of the methacrylates. In general, the Tg increased after the accelerated aging protocol and decreased for expired ones, compared to the new composites. A significant increase in FS of Filtek Z350XT after aging was accompanied by an increase in the Tg. The filler packings were in accordance with the manufacture׳s information. The topographic aspects of the composites were modified as a function of the material condition. The mechanical properties of the composites following a simplified protocol of accelerated aging varied as a function of the expiration date. The silorane composite presented a characteristic thermal behavior. Although the dental manufacturers may not be able to control variables as storage temperature and transportation conditions, these effects on the composite clinical performance can be minimized if properly considered.