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Kir F, Al-Sulaiti FK, Sahin S. Evaluation of in vitro dissolution profiles of modified-release metoprolol succinate tablets crushed using mortar and pestle technique. Eur J Pharm Sci 2024; 194:106694. [PMID: 38191064 DOI: 10.1016/j.ejps.2024.106694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
PURPOSE Clinical practice guidelines advise against crushing modified-release dosage forms. Metoprolol succinate modified-release (MS-MR) tablets are commonly crushed in clinical practice to facilitate administration to patients with swallowing difficulties or using feeding tubes. To date, the effect of this practice remains unexplored. The in vitro effects of crushing commercially available MS-MR tablets were explored using a holistic approach. METHODS Dissolution profiles of crushed versus whole MS-MR tablets were compared. Tablets were crushed to powder state using pragmatic method mimicking hospital practices. For standardization purposes, the same operator, duration (60 seconds), hand, and mortar-pestle apparatus were used. Dissolution studies were conducted per U.S. Pharmacopeia at pH 1.2, pH 4.5, and pH 6.8 with USP apparatus 2 (paddle) at rotation speed of 50 rpm at 37±0.5 °C in 500 mL dissolution media. Samples were withdrawn at predetermined time points. Percent drug dissolved was measured by validated UV-vis Spectrophotometry. Comprehensive analysis of the dissolution data was conducted using model-independent, model-dependent, and ANOVA-based approaches (SPSS v.23 at α=0.05). Similarity (f2) and difference (f1) factors were calculated to compare the dissolution profiles between crushed (CT) and whole tablets (WT). Goodness of fit (GOF) analysis examined the compliance between in vitro dissolution behaviors and several drug release models. Model selection was based on GOF plots, Akaike criteria and adjusted coefficient of determination (R2adj). Imaging and particle size distribution analysis were conducted to examine associated surface and morphologic changes. RESULTS The dissolution profiles were not similar at pH 4.5 (f2=45.43, f1=18.97) and pH 6.8 (f2=31.47, f1=32.94). CT best fitted with Higuchi (pH 1.2: R2adj=0.9990), Weibull (pH 4.5: R2adj=0.9884), and Korsmeyer-Peppas (pH 6.8: R2adj=0.9719). Contrastingly, WT best fitted with Hopfenberg (pH 1.2: R2adj=0.9986), logistic (pH 4.5: R2adj=0.9839) and first-order (pH 6.8: R2adj=0.9979) models. A significant difference in the dissolution profiles was found between CT and WT using multivariate analysis of variance per time points and between the tablet forms (p=0.004). This was confirmed by unparalleled dissolution profiles. Crushing resulted in variations in particle size and surface morphological changes to the micropellets. CONCLUSION Crushing practices change the dissolution profile of MS-MR tablets by deforming the surface morphology of embedded micropellets. Amounts of drug dissolved between CT and WT were not the same at the compared time points across gastrointestinal pH ranges. This suggests potential clinical impact on plasma-concentration profiles of critically ill patients using feeding tube.
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Affiliation(s)
- Fatma Kir
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - Fatima K Al-Sulaiti
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - Selma Sahin
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey.
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Omerovic E, Petrie M, Redfors B, Fremes S, Murphy G, Marquis-Gravel G, Lansky A, Velazquez E, Perera D, Reid C, Smith J, van der Meer P, Lipsic E, Juni P, McMurray J, Bauersachs J, Køber L, Rouleau JL, Doenst T. Pragmatic randomized controlled trials: strengthening the concept through a robust international collaborative network: PRIME-9-Pragmatic Research and Innovation through Multinational Experimentation. Trials 2024; 25:80. [PMID: 38263138 PMCID: PMC10807265 DOI: 10.1186/s13063-024-07935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
In an era focused on value-based healthcare, the quality of healthcare and resource allocation should be underpinned by empirical evidence. Pragmatic clinical trials (pRCTs) are essential in this endeavor, providing randomized controlled trial (RCT) insights that encapsulate real-world effects of interventions. The rising popularity of pRCTs can be attributed to their ability to mirror real-world practices, accommodate larger sample sizes, and provide cost advantages over traditional RCTs. By harmonizing efficacy with effectiveness, pRCTs assist decision-makers in prioritizing interventions that have a substantial public health impact and align with the tenets of value-based health care. An international network for pRCT provides several advantages, including larger and diverse patient populations, access to a broader range of healthcare settings, sharing knowledge and expertise, and overcoming ethical and regulatory barriers. The hypothesis and study design of pRCT answers the decision-maker's questions. pRCT compares clinically relevant alternative interventions, recruits participants from diverse practice settings, and collects data on various health outcomes. They are scarce because the medical products industry typically does not fund pRCT. Prioritizing these studies by expanding the infrastructure to conduct clinical research within the healthcare delivery system and increasing public and private funding for these studies will be necessary to facilitate pRCTs. These changes require more clinical and health policy decision-makers in clinical research priority setting, infrastructure development, and funding. This paper presents a comprehensive overview of pRCTs, emphasizing their importance in evidence-based medicine and the advantages of an international collaborative network for their execution. It details the development of PRIME-9, an international initiative across nine countries to advance pRCTs, and explores various statistical approaches for these trials. The paper underscores the need to overcome current challenges, such as funding limitations and infrastructural constraints, to leverage the full potential of pRCTs in optimizing healthcare quality and resource utilization.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden.
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden
| | - Stephen Fremes
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Gavin Murphy
- Cardiovascular Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | | | - Alexandra Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eric Velazquez
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence and National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Christopher Reid
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA, 6102, Australia
| | - Julian Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, VIC, Australia
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia
| | - Peter van der Meer
- Department of Cardiology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Eric Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Peter Juni
- Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK
| | - John McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, University Hospital, Jena, Germany
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Staman KL, Check DK, Zatzick D, Mor V, Fritz JM, Sluka K, DeBar LL, Jarvik JG, Volandes A, Coronado GD, Chambers DA, Weinfurt KP, George SZ. Intervention delivery for embedded pragmatic clinical trials: Development of a tool to measure complexity. Contemp Clin Trials 2023; 126:107105. [PMID: 36708968 PMCID: PMC10126825 DOI: 10.1016/j.cct.2023.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. METHODS We conducted a literature review, developed a tool, and conducted two rounds of phone calls with NIH Pragmatic Trials Collaboratory Demonstration Project principal investigators to develop the Intervention Delivery Complexity Tool. After refining the tool, we piloted it with Collaboratory demonstration projects and developed an online version of the tool using the R Shiny application (https://duke-som.shinyapps.io/ICT-ePCT/). RESULTS The 6-item tool consists of internal and external factors. Internal factors pertain to the intervention itself and include workflow, training, and the number of intervention components. External factors are related to intervention delivery at the system level including differences in healthcare systems, the dependency on setting for implementation, and the number of steps between the intervention and the outcome. CONCLUSION The Intervention Delivery Complexity Tool was developed as a standard way to overcome communication challenges of intervention delivery within an embedded pragmatic trial. This version of the tool is most likely to be useful to the trial team and its health system partners during trial planning and conduct. We expect further evolution of the tool as more pragmatic trials are conducted and feedback is received on its performance outside of the NIH Pragmatic Trials Collaboratory.
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Affiliation(s)
- Karen L Staman
- Duke Clinical Research Institute, CHB Wordsmith, Inc, Raleigh, NC, USA
| | - Devon K Check
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | | | - Kevin P Weinfurt
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, USA.
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