Age-appropriate and acceptable paediatric dosage forms: Insights into end-user perceptions, preferences and practices from the Children's Acceptability of Oral Formulations (CALF) Study

Amiodarone chewable gels as a potential appproach for paediatric congenital cardiopathies treatment: Comparison between animal and vegetal gelling agents

The difficulty in swallowing is a frequent problem when oral solid dosage forms (conventional tablets or capsules) are administered to paediatric population or patients with dysphagia. An interesting alternative to overcome these problems are non-conventional formulations like chewable gels, commonly known as 'gummies'. Therefore, this work addresses the design, development and characterization of gummies using gelatine and pectin, for the vehiculization of the antiarrhythmic amiodarone (AMIO). Applying a Design of Experiments (DoE) approach, four gelatine (GG1-GG4) and eight pectin formulations (PG1-PG8) were developed. Considering the obtained results for responses during DoE evaluation (i.e., volume, syneresis, hardness, and gumminess), GG3 and PG8 were selected for complete characterization. Water activity, pH, drug content, texture parameters (adhesiveness, springiness, cohesiveness, and fracturability), disintegration time, in vitro dissolution, and microbiological features were evaluated. The obtained results were within the expected values for this type of formulation. The dissolution profiles showed a 94 % - 99 % of the AMIO content released for GG3 and PG8, respectively, so they could be considered suitable as immediate release dosage forms. In conclusion, the chewable gels were successfully developed and characterised, suggesting a potential means to accomplish a final prototype for the improvement of congenital cardiopathies treatment.

Designs of clinical swallowability assessments of solid oral dosage forms in regulatory submissions

The swallowability of solid oral dosage forms (SODFs) is crucial for medication safety and adherence. Both regulatory agencies and sponsors are concerned with bringing swallowable SODFs to patients. However, no best practices are available for assessing swallowability. Therefore, we conducted a comparative analysis of clinical swallowability assessments (CSAs) for SODFs in regulatory submissions to identify current study design practices. CSAs were identified from a "swallowability" keyword search of a Food and Drug Administration database. Notable design trends among the 17 CSAs were not assessing swallowability as a primary endpoint (76 %); enrolling pediatric patients (76 %); administering assessments post-screening (76 %); and utilizing questionnaires (100 %). A design trend with near equal frequency (∼50 %) was single- or multiple-doses of product administration. Study subjects were the primary questionnaire respondents (82 %), usually using a Likert scale (92 %, 12/13). CSAs generally dichotomized the responses for analysis (65 %) without pre-specified threshold values (59 %). Overall, while study designs exhibited trends, methodology variations may impact swallowability measurements affecting the interpretation of results. Thus, developing robust and valid assessment tools for swallowability is imperative to produce clinically relevant data and inform regulatory decision-making. Collaboration between regulatory agencies and sponsors is warranted to create best practices and ensure high quality swallowability data.

Acceptability of compounded preparations - A Romanian pediatric hospital perspective

Compounded medicines are widely used, especially for pediatric patients. The aim of this study was to evaluate children's acceptability of compounded preparations and to provide information regarding compounding practices' characteristics in a Romanian hospital setting. An observational, cross-sectional, and retrospective study was conducted in three Clinical Pediatric Departments (Emergency Clinical Hospital for Children, Cluj-Napoca). The study population comprised patients under 18 years old taking at least one compounded medication. Study data was collected mainly through an interviewer-administered questionnaire and medicine acceptability was assessed based on the children's first reaction to the preparations using a 3-point facial hedonic scale. A total of 162 compounded medications were evaluated. A positive/negative reaction was reported for 20.83%/58.33%, 20.63%/49.21%, and 66.67%/7.41% of oral, oromucosal and cutaneous dosage forms. Although patient disapproval was recorded for various reasons, medication administration was successful in over 75% of cases. Factors such as fewer steps required for intake of a dose, capsule dosage form, no additional food/drink immediately after drug intake, medication perceived as "easy/very easy" to swallow, were correlated with a better acceptability of oral preparations. This study highlights the importance of identifying factors that can improve the acceptability of compounded preparations and, subsequently, treatment outcomes in pediatric patients.

Current State of Minitablet Product Design: A Review

Interest in minitablets (MTs) has grown exponentially over the last 20 years and especially the last decade, as evidenced by the number of publications cited in Scopus and PubMed. MTs offer significant opportunities for personalized medicine, dose titration and flexible dosing, taste masking, and customizing drug delivery systems. Advances in specialized MT tooling, manufacturing, and characterization instrumentation have overcome many of the earlier development issues. Breakthrough MT swallowability, acceptability, and palatability research have challenged the long-standing idea that only liquids are acceptable dosage forms for infants and young children. MTs have been shown to be a highly acceptable dosage form for infants, small children, and geriatric patients who have difficulty swallowing. This review discusses the current state of MT applications, acceptability in pediatric and geriatric populations, medication adherence, manufacturing processes such as tableting and coating, running powder and tablet characterization, packaging and MT dispensing, and regulatory considerations.

Off-Label Prescribing in Pediatric Population-Literature Review for 2012-2022

Off-label prescribing is widespread among pediatricians, and it is unlikely that this trend will soon be bound by a uniform legal framework. This is necessitated by the fact that there are four variables: the patient's health condition, the physician's experience and knowledge, the legislative measures (laws, directives, guidelines, and recommendations), and finally, the pharmaceutical industry. There is considerable concern worldwide about the use of off-label medicines in children. We may call it an enormous global problem that is much talked about and written about; however, we should not forget that the goal around which everyone should unite is the patient's life. For healthcare providers, the most important thing will always be the health and preservation of the patient's life, particularly when it comes to children with life-threatening conditions in neonatal and pediatric intensive care units (NICU and PICU). The study aimed to examine the prevalence of off-label drug use in pediatrics. Literature research was conducted, and we included studies from 2012 to 2022 that evaluated off-label drug prevalence in various pediatric patient populations.

Medication adherence and pharmaceutical design strategies for pediatric patients: An overview

Medication adherence in pediatric patients is a key factor in drug development and dosage form design. High medication adherence is not only important to achieve the expected treatment effects but can also effectively reduce medical costs. It is an ongoing task to accurately identify differences in medication adherence between children and adults and analyze the factors related to pediatric medication adherence. This is necessary to guide the development of pediatric drugs. This review focuses on factors that influence pediatric medication adherence as well as pharmaceutical design strategies to improve adherence. Current new dosage forms, new technologies, and new devices are comprehensively summarized in terms of their advantages and limitations.

Survey-based investigation into the current use of paediatric medicines and administration devices in China

The accurate, rapid and convenient administration of medicines to children is not possible without the use of appropriate administration devices. However, due to the unique nature of this patient population, inappropriate paediatric medication administration has been widely observed worldwide. According to previous surveys carried out in other countries including the UK and Japan, there has been a wide variation in the handling of paediatric devices among children. To date, little is known about the current situation in China where the variety of available paediatric administration devices is more limited than in Europe and the UK. The aim of this study was therefore to conduct a China-wide survey to gain a better understanding of the perspectives of children and their caregivers on paediatric medicines and devices. This study was conducted throughout China with 215 children as well as 749 caregivers of paediatric year groups from 1 to less than 18 years old. The majority of participants (83%) took oral dosage forms where granules, syrup and tablets were ranked as the Top 3 commonly used oral dosage forms. The most commonly used devices, i.e., measuring cups (47.3%) and household spoons (41.1%) were both well accepted by the vast majority of children. More instruction and demonstration by the healthcare professionals were provided to inhalation devices users with the nebuliser and facemask being the most commonly used. In particular, the role of pharmacists in China is expected to be better defined, which may in turn help with the education provided to paediatric users in operating medical devices. The data collected varied considerably with the age of children but not statistically significantly with the region in which the survey was conducted.

Putting children first: Understanding caregivers' and children's perspectives on the usability of oral and respiratory administration devices for paediatric medication

A multi-national online survey was developed to obtain feedback on users' experiences of administration devices for oral and inhaled paediatric medicines. The questionnaire was divided into two identical parts: 1) for caregivers looking after children aged 0-18 years, and 2) for children aged 10 years and above, with parental consent. Each part of the questionnaire consisted of a section regarding oral devices and the other about respiratory devices. All data were anonymous and handled and stored in compliance with GDPR. Ethics approval (REC4612-016) was obtained. The study involved eight countries: Albania, Italy, Israel, the Netherlands, Romania, Spain, UK, and USA. A total of 206 adults and 43 children agreed to take part in the survey. Oral dosage forms were more used than inhaled medicines. For oral liquid medicines, oral syringe was the device mostly used by European and Israeli participants. Measuring spoon was the second most common device used, and was also often used in the USA. For respiratory devices, manually actuated and breath actuated metered dose inhalers were the most common everywhere. All devices were deemed easy to use by most of respondents and instructions clear. However, a recurrent suggestion was to simplify device instructions by adding explanatory images and to summarise or highlight key points. Moreover, respondents proposed other improvements related to device appearance and design that would make the device more acceptable for them to use. Understanding paediatric patients and caregivers' experiences about oral and respiratory devices is key to provide industry with information that can help improve the use and acceptability of administration devices. Aspects that device suppliers and healthcare professionals would need to prioritise are the provision of simpler instructions in the form of images and key summaries, and to provide adequate training on device use. These improvements are essential to ensure that children and caregivers are able to use the device appropriately.

Colour of Medicines and Children's Acceptability? A Systematic Literature Review of Children's Perceptions about Colours of Oral Dosage Forms

The colour of a product plays an important role in consumer experiences, and in the context of pharmaceutical products, this could potentially affect a patient's expectations, behaviours, and adherence. Several studies have been conducted on adults, but little is known about children's opinions on colours of medicines and to what extent medicines' colour affects their acceptability. To address this gap, a systematic search in PubMed, Scopus, MEDLINE, and Web of Science was conducted. Two authors independently screened the titles, abstracts, and references of all articles and selected studies conducted on children (0-18 years old), assessing children's preferences or opinions about colour of oral dosage forms as either a primary or secondary objective or as an anecdotal record. A total of 989 publications were identified and, after screening, 18 publications were included in the review. Red and pink were the most liked colours and there appeared to be a relationship between the colour of a medicine and expected taste/flavour. The review also highlighted a scarcity of information, usually collected as an anecdotal record. Several gaps in the current knowledge were underlined, emphasizing the need of patient-centred studies to understand if the use of certain colours can improve or worsen the acceptability of a paediatric medicine. This will help inform pharmaceutical manufacturers and regulators on the role and need of colours in children's medicines beyond quality purposes.

Oral drug delivery strategies for development of poorly water soluble drugs in paediatric patient population

Selecting the appropriate formulation and solubility-enabling technology for poorly water soluble drugs is an essential element in the development of formulations for paediatric patients. Different methodologies and structured strategies are available to select a suitable approach and guide formulation scientists for development of adult formulations. However, there is paucity of available literature for selection of technology and overcoming the challenges in paediatric formulation development. The need for flexible dosing, and the limited knowledge of the safety of many formulation excipients in paediatric subjects, impose significant constraints and in some instances require adaptation of the approaches taken to formulating these drugs for the adult population. Selection of the best drug delivery system for paediatrics requires an efficient, systematic approach that considers a drug's physical and chemical properties and the targeted patient population's requirements. This review is a step towards development of a strategy for the design of solubility enhancing paediatric formulations of highly insoluble drugs. The aim of this review is to provide an overview of different approaches and strategies to consider in order to assist development of paediatric formulation for poorly water-soluble drugs with the provision of examples of some marketed products. In addition, it provides recommendations to overcome the range of challenges posed by these strategies and adaptations of the adult approach/product presentation required to enable paediatric drug development and administration.

Dose Titration of Solid Dosage Forms via FDM 3D-Printed Mini-Tablets

The robustness of 3D-printed mini-tablets as a platform to administer milligram dosages, intended for age-specific therapy, without the need of tablet splitting while maintaining similar release profiles, was investigated. Griseofulvin, as a model poorly water-soluble drug, and hydroxypropyl cellulose along with Kollicoat Protect as polymers were used to prepare filaments at 1–20% drug concentrations via hot-melt extrusion (HME). Higher drug concentrations served for testing the feasibility of a reduced number of mini-tablets to be administered. A reliable dose titration in the range 0.19–3.91 mg at a high accuracy (R2 of 0.999) was achieved through composite unit (multi-unit) mini-tablets. All mini-tablets produced had excellent content uniformity and their label claim values were within the acceptable range, proving that HME processing followed by 3D printing promotes content uniformity even for mini-tablets containing low drug doses (0.19 mg). Remarkably, the proposed approach allowed achieving similar drug release profiles via composite unit mini-tablets as well as single mini-tablets at high drug concentrations. In contrast, split tablets demonstrated different release behaviors, attributed to their size and shape differences. Overall, the distinct advantages of mini-tablets to provide dose flexibility while maintaining similar release profiles was demonstrated.

Overcoming Challenges in Pediatric Formulation with a Patient-Centric Design Approach: A Proof-of-Concept Study on the Design of an Oral Solution of a Bitter Drug

Designing oral formulations for children is very challenging, especially considering their peculiarities and preferences. The choice of excipients, dosing volume and palatability are key issues of pediatric oral liquid medicines. The purpose of the present study is to develop an oral pediatric solution of a model bitter drug (ranitidine) following a patient centric design process which includes the definition of a target product profile (TPP). To conclude on the matching of the developed solution to TPP, its chemical and microbiological stability was analyzed over 30 days (stored at 4 °C and room temperature). Simulation of use was accomplished by removing a sample with a syringe every day. Taste masking was assessed by an electronic tongue. The developed formulation relied on a simple taste masking strategy consisting in a mixture of sweeteners (sodium saccharine and aspartame) and 0.1% sodium chloride, which allowed a higher bitterness masking effectiveness in comparison with simple syrup. The ranitidine solution was stable for 30 days stored at 4 °C. However, differences were noted between the stability protocols (unopened recipient and in-use stability) showing the contribution of the simulation of use to the formation of degradation products. Stock solution was subjected to acid and alkali hydrolysis, chemical oxidation, heat degradation and a photo degradation stability assessment. The developed pediatric solution matched the TPP in all dimensions, namely composition suitable for children, preparation and handling adapted to hospital pharmaceutical compounding and adequate stability and quality. According to the results, in-use stability protocols should be preferred in the stability evaluation of pediatric formulations.

Acceptability of different oral dosage forms in paediatric patients in hospital setting

OBJECTIVE

The understanding of acceptability of existing dosage forms is limited in most of the world and hinders the development of acceptable, age-appropriate medicines. The attributes of paediatric medicine acceptability may differ from country to country based on culture, healthcare infrastructure and health policies. This study was designed to map the acceptability of oral medicines in paediatric patients treated in hospital in India.

METHODS

An observational, cross-sectional study was conducted in patients aged below 18 years and taking any form of oral medication. Acceptability scores were obtained using CAST-ClinSearch Acceptability Score Test tool.

FINDINGS

490 patients were recruited and 193 evaluations of different pharmaceutical products available in 20 dosage forms and 7 routes of administration were studied. Oral liquids (50%) and tablets (35%) were the most commonly prescribed and administered forms. Regardless of the therapeutic class and age, the oral liquids were 'positively accepted' in infants and toddlers. Acceptability of tablets improved with age and appeared to be generally good from the age of 6.

CONCLUSION

This study indicates the limited progress towards adoption of age-appropriate dosage forms in India and thus impact on the acceptability of existing oral dosage forms. The key challenges posed by the adoption of age-appropriate formulations in India are (1) awareness of importance of appropriate administration and acceptability of medicines to children in India, (2) availability of age-appropriate dosage forms and (3) lack of child-appropriate medicine policies.

Usability of administration devices for oral and respiratory medicines: views from a UK primary school

The correct use of medicine administration devices is pivotal for optimal drug therapy in children. Little is known about end users' perspectives on administration device use. Thus, the aim of this study was to conduct a survey to gain information and opinions from caregivers and children regarding the usability of paediatric medicine administration devices. A survey was conducted at a primary school in the United Kingdom in children aged 10-12 years and their caregivers. It focused on oral and respiratory devices and comprised two identical parts: 1) for the caregivers, 2) for the children with parental consent. Ethics approval (REC4612-016) was obtained. A total of 57 caregiver-child pairs accessed the survey and it was completed by parents only (n=4), children only (n=31) or jointly (n=22). Most participants (65%) had taken liquid dosage forms (e.g., syrups/suspensions) compared to solid dosage forms (34%). Oral devices most frequently used were oral syringes (42%), measuring spoons (22%), and household spoons (18%), with parents most frequently demonstrating device use to their children. Respiratory devices were used less frequently, and pressurised metered-dose inhalers with/without spacer (pMDIs) were the most commonly used devices (11/13). Instructions on use were provided by healthcare professionals to both caregivers and children. Generally, oral and respiratory devices were considered easy to use and instructions were clear. However, for both oral and respiratory devices, some suggestions for device improvement were provided by participants. Education/training by healthcare professionals and clear supplier instructions (e.g., pictograms) may be especially effective in ensuring that caregivers and children are able to use administration devices appropriately and receive sufficient information on their correct use.

Orally Dispersible Dosage Forms for Paediatric Use: Current Knowledge and Development of Nanostructure-Based Formulations

The paediatric population has always suffered from a lack of medicines tailored to their needs, especially in terms of accurate dosage, stability and acceptability. Orodispersible dosage forms have gone through a resurrection as an alternative to liquid formulations or fractioned solid formulations, although they are still subject to several inconveniences, among which the unpleasant taste and the low oral bioavailability of the API are the most significant hurdles in the way of achieving an optimal drug product. Nanostructures can address these inconveniences through their size and variety, owing to the plethora of materials that can be used in their manufacturing. Through the formation and functionalisation of nanostructures, followed by their inclusion in orodispersible dosage forms, safe, stable and acceptable medicines intended for paediatric use can be developed.

A Design Approach to Optimise Secure Remote Three-Dimensional (3D) Printing: A Proof-of-Concept Study towards Advancement in Telemedicine

Telemedicine is defined as the delivery of healthcare services at a distance using electronic means. The incorporation of 3D printing in the telemedicine cycle could result in pharmacists designing and manufacturing personalised medicines based on the electronic prescription received. Even with the advantages of telemedicine, numerous barriers to the uptake hinder the wider uptake. Of particular concern is the cyber risk associated with the remote digital transfer of the computer-aided design (CAD) file (acting as the electronic prescription) to the 3D printer and the reproducibility of the resultant printed medicinal products. This proof-of-concept study aimed to explore the application of secure remote 3D printing of model solid dosage forms using the patented technology, DEFEND3D, which is designed to enhance cybersecurity and intellectual property (IP) protection. The size, shape, and colour of the remote 3D-printed model medicinal products were also evaluated to ensure the end-product quality was user-focused. Thermoplastic polyurethane (TPU) and poly(lactic) acid (PLA) were chosen as model polymers due to their flexibility in preventing breakage printing and ease of printing with fused deposition modelling (FDM). Our work confirmed the potential of secure remote 3D (FDM) printing of prototype solid dosage forms resulting in products with good reproducibility, resolution, and quality towards advancements in telemedicine and digital pharmacies. The limitation of the work presented here was the use of model polymers and not pharmaceutically relevant polymers. Further work could be conducted using the same designs chosen in this study with pharmaceutically relevant polymers used in hot-melt extrusion (HME) with shown suitability for FDM 3D printing. However, it should be noted that any challenges that may occur with pharmaceutically relevant polymers are likely to be related to the polymer’s printability and printer choice as opposed to the ability of the CAD file to be transferred to the printer remotely.

Comparison of Inconvenience Costs Between Influenza Antivirals for Japanese Pediatric Patients: A Conjoint Analysis of Parental Responses

Introduction

Certain drug characteristics, including dosage and form, are associated with either convenience or inconvenience for the patients taking them, and any inconvenience can be considered as a “cost” in disease treatment. Multiple antivirals are available for influenza in Japan, with various dosages and forms. This study evaluated the inconvenience costs associated with influenza antivirals for pediatric patients by using conjoint analysis on responses from their parents.

Methods

An online survey (May 2021) was conducted for parents whose child took antivirals for influenza at 6–11 years during the 3 years until March 2021. Attributes of the conjoint analysis were administration routes and formulation (tablet, capsule, dry syrup, or inhalant), duration of administration, frequency of administration per day, and out-of-pocket expenses. We assumed the efficacy and safety to be equivalent among the antivirals. A logistic regression model was applied to the analysis. We also asked parents about their recent experiences with antiviral treatment for their child.

Results

We collected responses from 3161 eligible individuals. The mean age (standard deviation) of the children when taking the antivirals and percentage of female children were 8.27 (1.63) years old and 53.2%, respectively. The tablet was the most preferred formulation; the inconvenience costs for each administration route and formulation, relative to the tablet as zero, were Japanese yen (JPY) 515 (US dollar 4.61, as of October 2021) for the inhalant, JPY 775 for the capsule, and JPY 804 for the dry syrup. The inconvenience costs for 5 days relative to 1 day and for twice a day relative to once a day were JPY 2150 and JPY 399, respectively.

Conclusion

Based on the conjoint analysis, a single-dose tablet antiviral was suggested to have the lowest inconvenience cost for pediatric patients.

Trial Registration

UMIN000044243.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02062-z.

Solid Dispersion Formulations by FDM 3D Printing-A Review

Additive manufacturing (AM) is revolutionizing the way medicines are designed, manufactured, and utilized. Perhaps, AM appears to be ideal for the fit-for-purpose manufacturing of medicines in contrast to the several disadvantages associated with the conventional fit-for-all mass production that accounts for less than 50% of pharmacotherapeutic treatment/management of diseases especially among children and elderly patients, as well as patients with special needs. In this review, we discuss the current trends in the application of additive manufacturing to prepare personalized dosage forms on-demand focusing the attention on the relevance of coupling solid dispersion with FDM 3D printing. Combining the two technologies could offer many advantages such as to improve the solubility, dissolution, and oral bioavailability of poorly soluble drugs in tandem with the concept of precision medicine and personalized dosing and to address the dilemma of commercial availability of FDM filaments loaded with Class II and/or Class IV drugs. However, thermal treatment especially for heat-sensitive drugs, regulatory, and ethical obligations in terms of quality control and quality assurance remain points of concern. Hence, a concerted effort is needed between the scientific community, the pharmaceutical industries, the regulatory agencies, the clinicians and clinical pharmacists, and the end-users to address these concerns.

From Paediatric Formulations Development to Access: Advances Made and Remaining Challenges

Developing suitable paediatric formulations and ensuring access to them by the greatest number of the 2.2 billion children worldwide are equally important to provide optimal pharmacotherapy. This review focuses on the progress made over the last two decades with paediatric oral formulations with respect to evidence for acceptability and dosing flexibility of liquid and solid oral dosage forms (SODFs). It also discusses the clinical needs for, and the access to, paediatric formulations for existing authorised medicines. A significant body of new knowledge now supports the acceptability of solid oral dosage forms (SODFs) in children, resulting in an increasing number of medicines commercialised as multiparticulates, including minitablets that are starting to be brought to market. However, there are gaps with these formulations that deserve more research. Even though efforts have been made to identify medicines in need of age-appropriate formulations, there is no common priority list shared internationally. Such prioritization would help to develop paediatric formulations with the greatest potential for providing a health benefit to children worldwide. In addition, available data highlight that paediatric formulation access is fragmented and unequal, with commercialisation of suitable paediatric formulations too often limited to some countries/regions. We propose actions to better align decisions during the development of paediatric formulations and promote a more globalized approach to facilitate registration pathways between different jurisdictions. Furthermore, discussions about alignment between approval, pricing, and reimbursement processes should also happen, leaving working in siloes behind us. It is time adults start thinking outside the box for children.

Creating Acceptable Tablets 3D (CAT 3D): A Feasibility Study to Evaluate the Acceptability of 3D Printed Tablets in Children and Young People

3D printing (3DP) has been proposed as a novel approach for personalising dosage forms for children and young people (CYP). Owing to its low cost and the lack of need for finishing steps, fused deposing modelling (FDM) 3DP has been heavily researched in solid dosage forms (SDFs) manufacturing. However, the swallowability and overall acceptability of 3D printed dosage forms are yet to be established. This work is the first to evaluate the acceptability of different sized 3D printed placebo SDFs in CYP (aged 4–12 years). All participants had previously participated in a feasibility study (CAT study) that assessed the swallowability and acceptability of different sized GMP manufactured placebo conventional film-coated tablets, and therefore only attempted to swallow one 3D printed tablet. The participants assessed the swallowability, acceptability, mouthfeel, volume of water consumed, and taste of the sample using a 5-point hedonic facial scale on a participant questionnaire. A total of 30 participants were recruited, 87% of whom successfully swallowed the 3D printed tablet that they attempted to take. Attributes of the 3D printed tablets were scored as acceptable by the following percentage of participants—swallowability (80%), mouthfeel/texture (87%), the volume of water consumed (80%), taste (93%), and overall acceptability (83%). Overall, 77% of children reported they would be happy to take the tablet every day if it was a medicine. Participants were also asked which tablets felt better in the mouth—the film-coated tablets or the 3D printed tablets, and the most popular response (43%) was that both were acceptable. This study shows that FDM-based 3D printed SDFs may be a suitable dosage form for children aged 4–12 years. The results from this feasibility study will be used to inform a larger, definitive study looking at the acceptability of 3D printed tablets in children.

3D Printing of Pediatric Medication: The End of Bad Tasting Oral Liquids?—A Scoping Review

3D printing of pediatric-centered drug formulations can provide suitable alternatives to current treatment options, though further research is still warranted for successful clinical implementation of these innovative drug products. Extensive research has been conducted on the compliance of 3D-printed drug products to a pediatric quality target product profile. The 3D-printed tablets were of particular interest in providing superior dosing and release profile similarity compared to conventional drug manipulation and compounding methods, such as oral liquids. In the future, acceptance of 3D-printed tablets in the pediatric patient population might be better than current treatments due to improved palatability. Further research should focus on expanding clinical knowledge, providing regulatory guidance and expansion of the product range, including dosage form possibilities. Moreover, it should enable the use of diverse good manufacturing practice (GMP)-ready 3D printing techniques for the production of various drug products for the pediatric patient population.

A randomised controlled trial of a novel tramadol chewable tablet: pharmacokinetics and tolerability in children

Tramadol is a bitter atypical opioid analgesic drug and is prescribed to treat postoperative pain in children. However, in many countries there is no licensed paediatric tramadol formulation available. We have formulated a novel chewable chocolate-based drug delivery system for the administration of tramadol to children. This pilot, single-centre, open-label, randomised clinical study assessed the taste tolerability and comparative population pharmacokinetics of the novel tramadol chewable tablet against a compounded tramadol hydrochloride oral liquid, at a dose of 1 mg.kg^-1 . A 5-point facial hedonic scale was used by the children, parents and nurses to assess tolerability. One hundred and forty-one children aged 3-16 years were given tramadol 30 min before general anaesthesia. Blood samples were taken following the induction of anaesthesia and for up to 5 h following tramadol administration. Tramadol and its active metabolite O-desmethyltramadol were analysed using reversed-phase high-performance liquid chromatography. A population pharmacokinetic model was built using non-linear mixed effects modelling. The relative bioavailability for the tablet was 1.25 times higher (95%CI 1.16-1.35) than for tramadol hydrochloride oral liquid, while the absorption rate constant for the tablet was significantly lower (1.97 h^-1 vs. 3.34 h^-1 , p < 0.001). Larger inter-individual variability in absorption rates were observed with the liquid tramadol. The tramadol chewable tablet was more acceptable in taste to children when assessed by the children, parents and nurses (all p < 0.001). We conclude that the novel tramadol chewable tablet has favourable acceptability and more reliable relative bioavailability in children compared with tramadol hydrochloride oral liquid.

Allergen Release Profiles of Fast-Dissolving Freeze-Dried Orodispersible Sublingual Allergy Immunotherapy Tablets

Background

Sublingual allergy immunotherapy tablets (SLIT-tablets) provide a well-tolerated and clinically efficacious treatment for allergic disease such as allergic rhinitis and allergic asthma. In SLIT, uptake of allergen by immune-competent cells in the oral mucosa activates the immune system and leads to tolerance toward the sensitizing allergen. The ability to deliver the full allergen content into solution within the recommended sublingual holding time is therefore an essential quality of SLIT-tablets that must be supported by the tablet formulation for all relevant allergen sources. SLIT-tablets based on a fast-dissolving orodispersible freeze-dried formulation (Zydis) are currently available for 5 of the most prevalent allergens: tree (birch and related species from the birch-homologous group), grass, ragweed, Japanese cedar, and house dust mite.

Objectives

The purpose of this study was to examine the allergen release properties of three freeze-dried SLIT-tablets containing tree, ragweed, and Japanese cedar extracts, respectively. The correlation between SLIT-tablet allergen release and the level of allergen-specific T-cell activation was examined for the tree SLIT-tablet.

Methods

Allergen release kinetics and tablet disintegration times for the 3 freeze-dried SLIT-tablets were examined. For all 3 tablets, the magnitude of solubilized major allergen relative to time in solution was compared to external controls to achieve a measure of the total allergen release. Additional assessments of allergen release occurring after the initial timepoint (15 or 30 seconds in solution) were done independently of external controls by linear regression analyses. For the tree SLIT-tablet, the immunological potency of the released major allergen was assessed at each experimental timepoint by a Bet v-specific T-cell activation assay.

Results

All 3 SLIT-tablets disintegrated within 1 second after contact with assay buffer without any detectible residue. Complete release of major allergens (Bet v 1, Amb a 1, and Cry j 1, respectively) was seen at the earliest experimental time points (15 or 30 seconds). For the tree SLIT-tablet, full T-cell activation was achieved at 30 seconds (earliest experimental time point).

Conclusions

The freeze-dried SLIT-tablet formulation consistently provides rapid and complete release of allergen from a wide range of species in a standardized in vitro assay. Full release of the SLIT-tablet allergen content within the sublingual holding time is a prerequisite for maximal exposure of allergens to the sublingual mucosa immune system. The freeze-dried SLIT-tablet formulation examined here supports short sublingual holding times and furthermore offers a convenient administration form of allergy immunotherapy.

Orodispersible tablets for pediatric drug delivery: current challenges and recent advances

INTRODUCTION

Child appropriate dosage forms are indispensable in modern medicine and are a prerequisite for successful pediatric drug therapy. For years, experts have called for a paradigm shift, from liquid dosage forms to novel oral solid dosage forms. This review aims to shed light on recent developments in Orodispersible tablets (ODTs) and mini-tablets (ODMTs).

AREAS COVERED

This review focuses on the presentation and critical discussion of current challenges as well as recent advances in ODTs for pediatric drug delivery. Highlighted aspects are the evidence for acceptability by children, e.g. in comparison to other dosage forms, and limitations given by tablet size at different ages, as well as advances in special ODT formulations (taste masking, modified release, enabling formulations).

EXPERT OPINION

It is the authors' belief that OD(M)Ts have significant potential as dosage forms in pediatric therapy that has not yet been fully exploited. The reasons for this are, first, that the number of direct acceptance studies is extremely low and the resulting knowledge is therefore rather anecdotal. Despite the high relevance, there seems to be reluctance both in the therapeutic use and conduction of respective studies in children. However, if one combines the knowledge from the few existing studies, surveys, and from approved products, it becomes apparent that so far there is no evidence on limitations of the use of ODTs in pediatric patients.

Development of an Age-Appropriate Mini Orally Disintegrating Carvedilol Tablet with Paediatric Biopharmaceutical Considerations

Owing to considerable differences observed in anatomy and physiology between paediatric subsets, it has been well established that children respond to drugs differently compared to adults. Furthermore, from a formulation perspective, there is a distinct challenge to develop a dosage form that is capable of safely, accurately, and reliably delivering the dose across the whole paediatric population. Orally disintegrating mini-tablets (ODMT) have widely been considered as an age-appropriate formulation option that possess the ability for adequate dose flexibility, avoids swallowing difficulties, and exhibits superior stability due to its solid state. Within this study, two strengths (0.5 mg and 2 mg) of carvedilol ODMT formulations were developed using an excipient composition and load that is appropriate for paediatric use. The formulations demonstrated adequate mechanical strength (>20 N) and fast disintegration times (<30 s). Dissolution profiles observed were robust and comparable to the marketed conventional tablet formulation across various parts of the gastrointestinal (GI) tract in both the fed and fasted state, signifying appropriate efficacy, quality, and performance. As such, the formulations developed in this study show potential to address the need of an 'age-appropriate' formulation of carvedilol, as highlighted by the European Medicines Agency (EMA) Inventory of the Needs for Paediatric Medicine.

Children's Preferences for Oral Dosage Forms and Their Involvement in Formulation Research via EPTRI (European Paediatric Translational Research Infrastructure)

The paucity of evidence-based data on formulation characteristics preferred by the children is known to limit the design of tailored paediatric dosage forms. The European Paediatric Translational Research Infrastructure (EPTRI) commissioned a study to evaluate children's dosage forms perceived preferences in some European countries and explore the feasibility of using the young persons advisory groups (YPAGs) to involve children in formulation research. An online, age-adapted survey was developed and translated into six languages. The survey link was disseminated across seven European countries: Albania, Italy, the Netherlands, and Dutch-speaking part of Belgium, Romania, Spain, and the United Kingdom. Respondents' (n = 1172) perceived preferences for oral dosage forms primarily differed based on age, health status, and experience. Conventional dosage forms, i.e., liquid (35%), tablets (19%), and capsules (14%), were the most selected. Liquid was widely selected by children less than 12 years and by those healthy and taking medicines rarely. Monolithic solid forms were mostly chosen by adolescents and by children with a chronic disease taking medicines frequently. There was a clear lack of familiarity with more novel dosage forms (e.g., orodispersible films and granules). Noteworthy, granules were not appreciated, particularly by adolescents (52.8%). To rationalise the creation of paediatric formulations, it is important to involve children as active stakeholders and to apply tools assessing children's perspectives on medicines to inform acceptable dosage form development from the start.

Enabling modular dosage form concepts for individualized multidrug therapy: Expanding the design window for poorly water-soluble drugs

Multidrug dosage forms (aka combination dosage forms, polypills, etc.) create value for patients through reduced pill burdens and simplified administration to improve adherence to therapy. Enhanced flexibility of multidrug dosage forms would provide further opportunities to better match emerging needs for individualized therapy. Through modular dosage form concepts, one approach to satisfy these needs is to adapt multidrug dosage forms to a wider variety of drugs, each with a variety of doses and release profiles. This study investigates and technically explores design requirements for extending the capability of modular multidrug dosage form concepts towards individualization. This builds on our recent demonstration of independent tailoring of dose and drug release, which is here extended towards poorly water-soluble drugs. The challenging design requirement of carrying higher drug loads in smaller volumes to accommodate multiple drugs at their clinical dose is here met regarding dose and release performance. With a modular concept, we demonstrate high precision (<5% RSD) in dose and release performance of individual modules containing felodipine or naproxen in Kollidon VA64 at both a wide drug loading range (5% w/w and 50% w/w drug) and a small module size (3.6 mg). In a forward-looking design-based discussion, further requirements are addressed, emphasizing that reproducible individual module performance is predictive of dosage form performance, provided the modules are designed to act independently. Therefore, efforts to incorporate progressively higher drug loads within progressively smaller module volumes will be crucial to extend the design window further towards full flexibility of future dosage forms for individualized multidrug therapy.

Toward patient-centered tuberculosis preventive treatment: preferences for regimens and formulations in Lima, Peru

BACKGROUND

To ensure patient-centered tuberculosis preventive treatment, it is important to consider factors that make it easier for patients to complete treatment. However, there is little published literature about patient preferences for different preventive treatment regimen options, particularly from countries with high tuberculosis burdens.

METHODS

We conducted a qualitative research study using a framework analysis approach to understand tuberculosis preventive treatment preferences among household contacts. We conducted three focus group discussions with 16 members of families affected by tuberculosis in Lima, Peru. Participants were asked to vote for preferred preventive treatment regimens and discuss the reasons behind their choices. Coding followed a deductive approach based on prior research, with data-driven codes added.

RESULTS

In total, 7 (44%) participants voted for 3 months isoniazid and rifapentine, 4 (25%) chose 3 months isoniazid and rifampicin, 3 (19%) chose 4 months rifampicin, and 2 (13%) chose 6 months isoniazid. Preferences for shorter regimens over 6 months of isoniazid were driven by concerns over "getting tired" or "getting bored" of taking medications, the difficulty of remembering to take medications, side effects, and interference with daily life. For some, weekly dosing was perceived as being easier to remember and less disruptive, leading to a preference for 3 months isoniazid and rifapentine, which is dosed weekly. However, among caregivers, having a child-friendly formulation was more important than regimen duration. Caregivers reported difficulty in administering pills to children, and preferred treatments available as syrup or dispersible formulations.

CONCLUSIONS

There is demand for shorter regimens and child-friendly formulations for tuberculosis preventive treatment in high-burden settings. Individual preferences differ, suggesting that patient-centered care would best be supported by having multiple shorter regimens available.

Experimental Study on Patient Preferences Regarding the Shape and Size of Medical Tablets and Capsules Using Three-Dimensionally Printed Plastic Model Formulations

BACKGROUND

Tablets and capsules are the most common dosage forms. However, ease of use and/or swallowing influences patients' compliance.

OBJECTIVE

To identify patients' preferences regarding the three-dimensional size of medical tablets/capsules.

METHODS

Eighteen cylindrical-, oblong-, and oval-shaped model formulations having different sizes were prepared by three-dimensional printing using polylactic acid. Participants (40 patients visiting a pharmacy in Japan) evaluated the difficulty of picking up and swallowing these model formulations by touching/observing them, and completed a questionnaire. The visual analogue scale (VAS) was used to evaluate each sample, and the relationship of VAS scores to the major axis, thickness, I₂ (the sum of major/minor axes) and I₃ (the sum of major/minor axes and thickness) of the model formulations was evaluated by ANOVA followed by Tukey's test.

RESULTS

Female participants showed lower VAS scores (less difficult) for picking difficulty compared with male participants, and those taking many drugs showed higher VAS scores (more difficult) for swallowing difficulty compared with those taking fewer drugs. Otherwise, age, gender, disease status, number of drugs usually taken, and ingestion problems did not greatly influence the evaluation. Overall, larger model formulations showed less picking difficulty, but greater swallowing difficulty. Model formulations 2 mm thick or less were harder to pick up, whereas those 6 mm thick or more were harder to swallow. I₃ values greater than 20-22 mm were associated with a negative evaluation by participants.

CONCLUSION

Participants in this study preferred model formulations with an I₃ value below 22 mm and a thickness of 2-6 mm.

Multiparticulate oral formulations as a viable strategy for precise drug dosing in pediatrics: Propranolol case study

The development of solid dosage forms that are both convenient for administration and allow precise drug dosing for pediatric patients is one of the great challenges in contemporary pharmaceutical technology. The presented study has utilized propranolol hydrochloride, as one of the most frequently prescribed drugs that require manipulation of the conventional dosage forms to be administered to children. Multiparticulate oral formulations, powderand granulefilled capsules, as well as mini tablets, were prepared and characterized in terms of their mass and content uniformity and compared to conventional marketed tablets split into halves and quarters. The obtained results have demonstrated the superiority of the multiparticulate formulations, in terms of their average mass and drug content uniformity. It has also been demonstrated that, due to improved flowability, granule-filled capsules are more conveniently compounded and provide higher content uniformity compared to powder-filled capsules. The presented compounding method could be easily employed in community pharmacy settings. Mini tablets with high and uniform content of propranolol hydrochloride have been successfully prepared, thereby presenting a viable strategy for efficient drug dose adjustment.

I Spy with My Little Eye: A Paediatric Visual Preferences Survey of 3D Printed Tablets

3D printing (3DP) in the pharmaceutical field is a disruptive technology that allows the preparation of personalised medicines at the point of dispensing. The paediatric population presents a variety of pharmaceutical formulation challenges such as dose flexibility, patient compliance, taste masking and the fear or difficulty to swallow tablets, all factors that could be overcome using the adaptable nature of 3DP. User acceptability studies of 3D printed formulations have been previously carried out in adults; however, feedback from children themselves is essential in establishing the quality target product profile towards the development of age-appropriate medicines. The aim of this study was to investigate the preference of children for different 3D printed tablets (Printlets™) as an important precursor to patient acceptability studies. Four different 3DP technologies; digital light processing (DLP), selective laser sintering (SLS), semi-solid extrusion (SSE) and fused deposition modeling (FDM) were used to prepare placebo printlets with similar physical attributes including size and shape. A single-site, two-part survey was completed with participants aged 4-11 years to determine their preference and opinions based on visual inspection of the printlets. A total of 368 participants completed an individual open questionnaire to visually select the best and worst printlet, and 310 participants completed further non-compulsory open questions to elaborate on their choices. Overall, the DLP printlets were the most visually appealing to the children (61.7%) followed by the SLS printlets (21.2%), and with both the FDM (5.4%) and SSE (11.7%) printlets receiving the lowest scores. However, after being informed that the SSE printlets were chewable, the majority of participants changed their selection and favoured this printlet, despite their original choice, in line with children's preference towards chewable dosage forms. Participant age and sex displayed no significant differences in printlet selection. Printlet descriptions were grouped into four distinct categories; appearance, perceived taste, texture and familiarity, and were found to be equally important when creating a quality target product profile for paediatric 3D printed formulations. This study is the first to investigate children's perceptions of printlets, and the findings aim to provide guidance for further development of paediatric-appropriate medicines using different 3DP technologies.

Bioavailability of the Common Cold Medicines in Jellies for Oral Administration

Jellies for oral administration have been suggested as alternative dosage forms to conventional tablets for improved palatability and compliances for pediatric and geriatric patients. To evaluate the effect of jelly formulation on the bioavailability of cold medicines, two types of jellies were prepared for a fixed-dose combination of acetaminophen (AAP), chlorpheniramine maleate (CPM), dextromethorphan hydrobromide (DMH), and dl-methylephedrine hydrochloride (MEH). Jelly-S and Jelly-H were fabricated using carrageenan and locust bean gum in the absence and presence of xanthan gum, respectively. In vitro dissolution and in vivo absorption of the four drugs in the jellies were compared with other conventional formulations, a syrup and two types of immediate-release (IR) tablets with different hardness, Tablet-S (15 kPa) and Tablet-H (20 kPa). All the formulations exhibited more than 80% dissolution rate within 2 h even though the syrup, Jelly-S, and Tablet-S showed higher 30-min dissolution compared to Jelly-H and Tablet-H. The dissolution rates from the jellies decreased with increasing pH, which resulted in the slowest dissolution in pH 6.8 compared to the syrup and IR tablets. When administered orally to beagle dogs, all five formulations were determined not to be bioequivalent. However, Jelly-S and Jelly-H showed 0.82-1.05 of the geometric mean ratios (GMRs) of AUC_0-t for all four drugs compared to the syrup suggesting comparable absorption. In two IR tablets, GMRs of AUC_0-t were in a range of 0.55-0.95 indicating a tendency of lower absorption than the syrup and jellies. In conclusion, jelly can be a patient-centered formulation with comparable bioavailability to syrup.

The Development of Minitablets for a Pediatric Dosage Form for a Combination Therapy

Minitablets are an appealing option for an age-appropriate pediatric dosage form. In particular, for combination therapies where multiple active ingredients are dosed simultaneously, the use of minitablets will enable independent adjustments of each dose. The work presented describes the development of Compound A and Compound B minitablets for a combination therapy. Since both actives are formulated as spray dried amorphous solid dispersions (ASDs) due to low solubility of their crystalline forms, the choice of minitablets for the pediatric dosage form allows the application of the same formulation strategy across different age groups. To address the potential need for taste-masking, an ethylcellulose-hydroxypropyl cellulose coating system was developed. In-vitro performance testing was conducted to guide coating development and to ensure proper taste-masking without slowing down API dissolution in the GI tract that can negatively impact exposures. As a result, the exposure of orally dosed coated tablets was comparable to those of uncoated minitablets in the canine model. The work presented can serve as a case study on how minitablets can be designed and developed as an appropriate pediatric dosage form for a combination therapy comprised of ASD of active ingredients.

Orphan Formulations for Pediatric Use: Development and Stability Control of Two Sildenafil Citrate Solutions for the Treatment of Pulmonary Hypertension

Sildenafil citrate causes vasodilatation, relaxation of the smooth muscle, and reduction of pulmonary arterial pressure. The latter property makes sildenafil citrate efficient for the treatment of cardiovascular diseases, including pulmonary arterial hypertension. Pediatric patients with pulmonary arterial hypertension are more susceptible to errors in drug administration than adults because of a lack of suitable drug dosages. Thus, the purpose of this study was to develop stable (chemically and microbiologically) sildenafil citrate drop liquid formulation, suitable for pediatric patients (including diabetics), ensuring safety during preparation and storing and improving palatability by using milk as a carrier for administration. The significant factors that affect the sildenafil solubility were evaluated by applying a Plackett-Burman design using two levels with six variables. The experiment showed that the type of buffer and glycerin content influenced the sildenafil solubility. The developed formulations proved to be stable for 6 months at all three assayed conditions (40± 2°C, 75 ± 5% RH; 25± 2°C, 60 ± 5% RH; and 4 ± 2°C). The microbiological tests fit with the requirement of the pharmacopeia at day 0 and 90 and even more at day 180. Finally, the palatability assay showed that 0.82 mL of the formulation containing buffer phosphate, 20% glycerin, and 4 mg mL^-1 of sildenafil citrate diluted in 4.8 mL milk (which fits the medium pediatric dose) presented similar palatability to milk alone, and no precipitate or turbidity was observed. Graphical abstract.

Formulation and Characterisation of a Combination Captopril and Hydrochlorothiazide Microparticulate Dosage Form

Cardiovascular diseases such as hypertension and cardiac failure in South African children and adolescents are effectively managed long term, using a combination treatment of captopril and hydrochlorothiazide. The majority of commercially available pharmaceutical products are designed for adult patients and require extemporaneous manipulation, prior to administration to paediatric patients. There is a need to develop an age appropriate microparticulate dosing technology that is easy to swallow, dose and alter doses whilst overcoming the pharmacokinetic challenges of short half-life and biphasic pharmacokinetic disposition exhibited by hydrochlorothiazide and captopril. An emulsion solvent evaporation approach using different combinations of polymers was used to manufacture captopril and hydrochlorothiazide microparticles. Design of experiments was used to develop and analyse experimental data, and identifyoptimum formulation and process conditions for the preparation of the microparticles. Characterisation studies to establish encapsulation efficiency, in vitro release, shape, size and morphology of the microparticles were undertaken. The microparticles produced were in the micrometre size range, with an encapsulation efficiency >75% for both hydrochlorothiazide and captopril. The microparticulate technology is able to offer potential resolution to the half-life mediated dosing frequency of captopril as sustained release of the molecule was observed over a 12-h period. The release of hydrochlorothiazide of >80% suggests an improvement in solubility limited dissolution.

A chewable pediatric preparation of ibuprofen is palatable and acceptable to children

The development of palatable and acceptable analgesics for children is a major challenge. Given the majority of medications are administered orally, and children are more sensitive to and less tolerant of bitterness, novel “child‐friendly” preparations need to be developed and tested specifically in this patient population. This study investigated the palatability and acceptability of a therapeutic dose of ibuprofen in the form of soft chewable capsules in 100 healthy children aged 7‐12 years of age and the acceptability of this novel preparation to their caregivers. About 97% of children adhered to a full therapeutic age‐related dose, with 72% of these participants rating the preparation as acceptable on a hedonic facial scale. Despite 22% of children noting a “hot, spicy, or burning” sensation, consistent with known chemesthetic effects of ibuprofen, 83% of children confirmed they would take the medication in future, which rose to 87% in the context of future illness. In addition, after observing their children ingesting the medication, 92% of parents/guardians confirmed that they would be happy to administer this preparation of ibuprofen to their child if they were unwell. In conclusion, ibuprofen administered in the form of soft chewable capsules was palatable and acceptable to the majority of children and their parents/guardians and may provide a convenient and easy to dose preparation to reduce fever and relieve pain in children.

A Focus Group Study about Oral Drug Administration Practices at Hospital Wards-Aspects to Consider in Drug Development of Age-Appropriate Formulations for Children

Oral drug administration to pediatric patients is characterized by a lack of age-appropriate drug products and the off-label use of medicines. However, drug administration practices at hospital wards is a scarcely studied subject. The aim of this study was to explore the oral drug administration practices at pediatric hospital wards, with a focus on experiences and challenges faced, methods used to mitigate existing problems, drug manipulation habits, perceptions about oral dosage forms and future needs of oral dosage forms for children. This was a qualitative study consisting of focus group discussions with physicians, nurses and clinical pharmacists in a tertiary university hospital with the objective of bringing forward a holistic view on this research topic. These healthcare professionals recognized different administration challenges that were classified as either dosage form-related or patient-related ones. A lack of depot formulations developed especially for children as well as oral pediatric dosage forms of drug substances currently available as intravenous dosage forms was recognized. The preferred oral dosage forms were oral liquids and orodispersible tablets. Patient-centered drug administration practices including factors facilitating drug administration both at hospital wards and at home after patient discharge were identified. Among all healthcare professionals, the efficient cooperation in drug prescribing and administration as well as in educating the child’s caregivers in correct administration techniques before discharge and improving the overall discharge process of patients was emphasized. This study complements the prevalent understanding that new dosage forms for children of varying ages and stages of development are still needed. It also brings a holistic view on different aspects of oral drug administration to pediatric patients and overall patient-centered drug administration practices.

Patient Centric Pharmaceutical Drug Product Design-The Impact on Medication Adherence

Medication adherence is a growing concern for public health and poor adherence to therapy has been associated with poor health outcomes and higher costs for patients. Interventions for improving adherence need to consider the characteristics of the individual therapeutic regimens according to the needs of the patients. In particular, geriatric and paediatric populations as well as dermatological patients have special needs/preferences that should be considered when designing drug products. Patient Centric Drug Product Pharmaceutical Design (PCDPD) offers the opportunity to meet the needs and preferences of patients. Packaging, orodispersible formulations, fixed dose combinations products, multiparticulate formulations, topical formulations and 3D printing are of particular relevance in a PCDPD process. These will be addressed in this review as well as their impact on medication adherence.

Threshold Size of Medical Tablets and Capsules: Based on Information Collected by Japanese Medical Wholesaler

BACKGROUND

Medical tablets and capsules are superior with regard to portability and are the most common dosage form in Japan. However, their large size often results in difficulties during ingestion, sometimes leading to reduced medication adherence.

OBJECTIVE

The authors used postmarketing surveillance data to determine the threshold size of medical tablets and capsules that patients feel are too large to ingest.

PATIENTS AND METHODS

The marketing specialists of Toho Pharmaceutical Co., Ltd. collected opinions of patients and medical workers (November 2014-April 2016). Regarding 709 reports from patients stating that the tablet or capsule for too large for ingestion, a dataset was prepared from package inserts of the reported drugs. Two analyses were conducted: histogram analysis of size distribution and geometric analysis using linear approximation. Six indices of tablet/capsule size were considered: length; length + width; length + width + depth; length × width; length × width × depth; and weight.

RESULTS

Histogram analysis revealed that length + width + depth is an excellent index of tablet/capsule size, and negative reports on tablet/capsule size drastically increase when this index is ≥21 mm. Geometric analysis using linear approximation also revealed similar results.

CONCLUSION

The threshold size of tablets/capsules that patients feel are too large to ingest is length + width + depth = 21 mm. Therefore, when designing or altering tablets/capsules, if length + width + depth is ≥21 mm, the drug should be scored, split into smaller doses, or redesigned as an orally disintegrating formulation.

Embedded 3D Printing of Novel Bespoke Soft Dosage Form Concept for Pediatrics

Embedded three-dimensional printing (e-3DP) is an emerging method for additive manufacturing where semi-solid materials are extruded within a solidifying liquid matrix. Here, we present the first example of employing e-3DP in the pharmaceutical field and demonstrate the fabrication of bespoke chewable dosage forms with dual drug loading for potential use in pediatrics. Lego^TM-like chewable bricks made of edible soft material (gelatin-based matrix) were produced by directly extruding novel printing patterns of model drug ink (embedded phase) into a liquid gelatin-based matrix (embedding phase) at an elevated temperature (70 °C) to then solidify at room temperature. Dose titration of the two model drugs (paracetamol and ibuprofen) was possible by using specially designed printing patterns of the embedded phase to produce varying doses. A linearity [R² = 0.9804 (paracetamol) and 0.9976 (ibuprofen)] was achieved between percentage of completion of printing patterns and achieved doses using a multi-step method. The impact of embedded phase rheological behavior, the printing speed and the needle size of the embedded phase were examined. Owning to their appearance, modular nature, ease of personalizing dose and geometry, and tailoring and potential inclusion of various materials, this new dosage form concept holds a substantial promise for novel dosage forms in pediatrics.

Self-microemulsifying oral fast dissolving films of vitamin D3 for infants: Preparation and characterization

Combining the advantages of self-microemulsifying technology and oral fast dissolving technology, a self-microemulsifying oral fast dissolving films (SMEOFDF) of vitamin D3 was developed in this study. The pseudoternary phase diagram of microemulsion was constructed using water titration method, and the formulation of films was optimized by orthogonal experimental design. The prepared SMEOFDF of vitamin D3 was a thin film, in which the liquid drops of self-microemulsion were embedded. It had good mechanical properties (thickness 166.7 ± 3.30 µm, tensile strength 38.45 ± 3.72 MPa, elongation 23.38 ± 4.23%, and folding endurance >200 times), and its disintegration time was about 18 ± 1.23 s. After being redissolved in water, microemulsion could form spontaneously, with particle size of 181.2 nm and zeta potential of 16.1 mV. The release profile of vitamin D from SMEOFDF could be well described by first-order equation.

Manipulation of oral medication for children by parents and nurses occurs frequently and is often not supported by instructions

AIM

Due to a lack of age-appropriate formulations, administration of drugs to children remains a challenge. This study aimed to identify the problems experienced in both the outpatient setting and the clinical setting.

METHODS

Between June 2017 and January 2018, we performed a cross-sectional, prospective study at the Sophia Children's Hospital, The Netherlands. The study comprised of a structured interview on drug manipulations with parents visiting the outpatient clinic, and an observational study of drug manipulations by nurses at the wards.

RESULTS

A total of 201 questionnaires were collected, accounting for 571 drugs and 169 manipulations (30%). Drug substances that were most often mentioned as manipulated were macrogol (n = 23), esomeprazole (n = 15), paracetamol (n = 8), methylphenidate (n = 7) and melatonin (n = 7). Of all manipulated medicines, 93/169 (55%) were manipulated according to the instructions or recommendations of the Summary of Product Characteristics (SmPC) or patient information leaflet. During the observational study, manipulation was performed by 21/35 of observed nurses (60%), of whom 11 deviated from the hospital protocol for manipulation or SmPC (52%).

CONCLUSION

Manipulation was a widely used method to administer drugs to children. Validated information regarding manipulation of drugs for both parents and nursing staff is needed.

Assessment of Taste and Grittiness of Riomet® ER Strawberry, Riomet® ER Grape, Riomet® Cherry, and Metformin Immediate-Release Tablets in Healthy Subjects

Objective

This study was conducted to evaluate the taste and grittiness of two formulations of Riomet^® ER (metformin hydrochloride for extended release [ER] oral suspension 100 mg/mL) differing only in their flavoring agents (strawberry and grape) in comparison with two commercially available immediate-release (IR) formulations of metformin, Riomet^® Cherry (metformin hydrochloride oral solution 500 mg/5 mL) and metformin IR tablets (metformin hydrochloride IR tablets 500 mg), in healthy human subjects aged 10–70 years.

Methods

Five comparison sets (i.e., Riomet^® Cherry vs. Riomet^® ER Strawberry; Riomet^® Cherry vs. Riomet^® ER Grape; metformin IR vs. Riomet^® ER Strawberry; metformin IR vs. Riomet^® ER Grape; and Riomet^® Cherry vs. metformin IR) were evaluated. Riomet^® ER was reconstituted as instructed on the label. Metformin IR tablets were crushed one at a time into a fine powder using a pharmaceutical pill crusher and mixed with 5 mL of water. A 2.5-mL dose of each product was administered to each subject. Subjects were instructed not to swallow any of the products. Each product in the comparison set was rated by the subjects for taste and grittiness according to a 7-point hedonic facial scale and a 5-point level of agreement scale. A comparison questionnaire was also completed by the subjects after evaluating each set. In all, 56 subjects were enrolled and 55 subjects completed the study. The taste preference was statistically evaluated.

Results and Conclusions

All Riomet^® formulations were significantly preferred overall to metformin IR crushed tablets. Both the strawberry and the grape flavors of Riomet^® ER tended to be preferred to Riomet^® Cherry.

Electronic supplementary material

The online version of this article (10.1007/s40268-018-0260-x) contains supplementary material, which is available to authorized users.

Considering formulation characteristics when prescribing and dispensing medicinal products for children: a qualitative study among GPs and pharmacists

BACKGROUND

Finding appropriate medicinal product formulations and dosage forms for children can be challenging. Knowledge about considerations behind which medicinal product to prescribe or dispense for children is lacking.

OBJECTIVE

To explore considerations of formulation characteristics of medicinal products made by GPs when prescribing and by pharmacists when dispensing medicines for children 0-6 years of age.

METHOD

A qualitative study was performed by conducting three semi-structured focus groups with GPs and three with pharmacists, using nearly identical thematic interview guides. Analysis was performed using systematic text condensation.

RESULTS

Both GPs and pharmacists considered whether children and parents were willing and able to use medicinal products such as tablets and poor-tasting liquids before prescribing and dispensing them. These considerations were commonly based on health care workers' prior experiences, although parents and sometimes children were asked about their experiences with solid formulations. For antibiotics, GPs primarily wanted to prescribe first-choice antibiotics according to guidelines. Parents' concerns about getting the child to take the medicinal product due to poor taste could lead to the prescription of second-choice antibiotics. The pharmacists sometimes changed the prescribed formulation at parents' request but never changed the type of antibiotic without contacting the prescriber.

CONCLUSION

Formulation characteristics strongly influenced which medicinal product children were prescribed and dispensed. Individualizing formulation choices for children through an increased collaboration between physicians, pharmacists and parents is suggested.

Register-based study showed that the age when children were prescribed antibiotic tablets and capsules instead of liquids increased from 2004 to 2016

AIM

We investigated the age when the prescriptions of oral antibiotic formulations for children from birth to 12 years of age changed from being mostly liquid to mostly solid and the associations between solid formulations and child, prescriber and medication characteristics.

METHODS

This register-based study comprised data from the Norwegian Prescription Database on oral antibiotics dispensed between 2004 and 2016 when both solid and liquid dosage forms were available in appropriate doses.

RESULTS

Just over 1.2 million prescriptions were studied, and the age when children were prescribed oral solid antibiotics gradually increased. The mean age of conversion from liquids to solid formulations was 6.9 years and ranged from 5.7 years in 2004/2005 to 7.9 years in 2015/2016. Patient factors associated with solid dosage forms were the children's increasing age and male gender. Practitioner factors were the prescribers' increasing age, male gender, being a general practitioner and issuing fewer than 23 paediatric antibiotic prescriptions per year. Medication factors were bad-tasting liquids and the size and shape of solid dosage forms.

CONCLUSION

The age when children were prescribed antibiotic tablets and capsules increased from 2004 to 2016. The medicine characteristics were quite consistent, so this was probably caused by a shift in formulation preferences.

Stability and compatibility of Basmisanil granules co-administered with soft food

Co-administration of solid oral dosage forms with soft food or beverages is commonly used to facilitate administration and to improve compliance in the paediatric and geriatric population and in patient groups with swallowing difficulties. The present case study was conducted to investigate the compatibility, stability and dissolution of Basmisanil administered as granules mixed with different soft food matrices. The data were generated to justify dosing instructions, according which Basmisanil should be sprinkled on or mixed with one tablespoon of soft food to aid swallowing. Different soft food types were selected to cover a broad range of various food components (e.g. fat, protein, carbohydrates, fiber and water) and pH. Active content and degradation products of the active substance were determined after mixing the granules with the semisolid food matrix and after two hours of storage under ambient conditions, respectively. In-vitro dissolution tests of granule/food mixtures were also conducted. Furthermore, the stability of the API polymorph was evaluated. Basmisanil shows good chemical stability when the granules are mixed with soft food and consumed within two hours. No polymorphic conversion (anhydrate to monohydrate) could be detected in the granule/food mixtures after preparation and after storage up to 24 h. The in-vitro dissolution of the API from the granules was not adversely affected by the presence of the food matrix. All results were comparable regardless of the tested food matrix. The results do not prohibit the administration of the granules with soft food to the patient.