Prochlorperazine tablets repackaged into dose administration aids: can the patient be assured of quality?

Telmisartan Tablets Repackaged into Dose Administration Aids: Physicochemical Stability under Tropical Conditions

Dose administration aids (DAAs) are commonly used to assist patients with chronic disease to manage multiple medications and thus improve adherence. Several brands of telmisartan, commonly prescribed for hypertension, are available in Australia. Manufacturer’s storage advice is to leave tablets in the blister strip until administered to patients. This study aimed to investigate the stability of telmisartan tablets when repackaged and stored in DAAs, to identify a brand, which is sufficiently stable to be repackaged. All available brands of telmisartan tablets in Australia, which contain different excipients, were repackaged into DAAs and stored at 30 °C, 75% RH for 28 days before screening, using visual inspection and physical testing. A candidate brand was then selected for physicochemical and photostability testing using pharmacopoeial methods. Repackaged Mizart^® tablets were shown to be sufficiently stable, when repackaged and stored under tropical conditions (30 °C, 75% RH) for 28 days. Several of the other brands were deemed inappropriate for repackaging, due to physical instability, highlighting the importance of considering not only the drug, but also excipients to ensure the stability of repackaged medicines. Although the repackaging of telmisartan tablets is not advised, this study provides evidence to support the Mizart^® brand as an option for pharmacists to recommend for repackaging.

Stability implications of repackaged medications in dose administration aids: a systematic review

BACKGROUND

Dose administration aids (DAAs) or multi-compartment compliance aids are commonly used to organise doses of medications in accordance with a patient's dosing schedule. Despite their widespread use, there is a paucity of information on the stability of repackaged medications in DAAs.

OBJECTIVES

The objectives of this work were to evaluate stability studies conducted on repackaged medicine in DAAs and to provide a summary of the latest stability data available.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed on studies associated with repackaged medications in DAAs and drug stability. PubMed, CINAHL, EMBASE and SCOPUS were searched from January 1998 to June 2021.

KEY FINDINGS

A total of 342 articles were retrieved and 29 articles met the inclusion criteria. Data regarding medications from the reviewed papers were reported according to stability testing and physicochemical properties. The extracted data were then compared with stability information on DAA provision available on the database in the UK. This review identified several discrepancies between this dataset and reported stability and reveals a significant shortage in the stability data of medications repackaged in DAAs.

CONCLUSION

This review highlights the need for further studies to be conducted to better understand the impact of DAA repackaging on the stability, safety and efficacy of medications. It is recommended that a database of stability information of repackaged medications via systematic stability testing studies could be established, serving as a valuable resource for pharmacists when preparing DAAs without compromising patient safety.

Current evidence in the stability of medicines in dose administration aids: implications for patient safety

INTRODUCTION

As the elderly population and polypharmacy are increasing, it is predicted that interventions to enhance medication adherence, as dose administration aids (DAA), will grow. One of the limitations of repackaging medicines into DAA is to assure the stability of medicines, and, therefore, their quality, efficacy and safety.

AREAS COVERED

This article collects and summarises data of all the stability studies of repackaged medicines into DAAs. Computerized search in databases: PubMed, Google Scholar, SciELO, and reference texts related to the field (keywords: drug stability, DAAs, compliance aids, and repackaging), open access databases and guidelines. Also, it provides recommendations on the suitability of repackaging and compares them with those established.

EXPERT OPINION

Since medicines are removed from primary package, their stability can be compromised due to psychochemical characteristics of the drug substance and product, the dosage form, the type of DAA selected, the co-storage and splitting, the repackaging conditions, and the conditions of storage. This review reflects the need of more standardized stability studies to guarantee the quality of repackaged medicines. In addition, the importance of them to support the pharmacist to make the best decisions in order to maximize outcomes and minimize risks related to patients' medication when repackaging it.

Investigating the physical stability of repackaged medicines stored into commercially available multicompartment compliance aids (MCAs)

Background

Compliance aids are devices which have been developed and are currently used to assist individuals in their medicines management. The use of compliance aids involves the transfer of medicines from the manufacturers' original packaging and repackaged into an multicompartment compliance aid (MCA). MCAs do not guarantee the same level of protection compared to manufacturer's original packaging.

Objective

The aim of this study was to investigate the stability profile of atenolol, aspirin and lansoprazole dosage forms repackaged together in two different commercially available MCAs.

Methods

In a laboratory in the United Kingdom, the physical stability of the formulations repackaged into two commercially available brands of MCAs was evaluated. After 8 weeks of storage (under controlled ambient conditions), changes in the disintegration (tablets only) and dissolution properties (all formulations) were examined in accordance with British Pharmacopoeia (BP) specifications.

Key findings

Findings from this study confirm that changes in solid‐dosage form quality are observed when repackaged into MCAs compared to manufacturers packaging resulting in differences in in‐vitro dissolution performance. However, even with these changes, overall product performance was acceptable and within BP specifications.

Conclusion

There is a need for greater collaboration in this area between manufacturers, hospital and community pharmacists, academics and policymakers to increase the data available on the physical stability and in turn performance of medicines repackaged into MCAs.

Stability of chronic medicines in dosage administration aids. How much have been done?

BACKGROUND

The prevalence of chronic diseases is increasing in Asia, therefore compliance to the medications is of utmost importance to slow disease progression and improve outcomes. Dosage administration aids (DAAs) serve as important tool to improve the compliance of patients. However, there is a dearth of data on the stability of chronic medications in DAAs. Furthermore, data presented by our Western counterparts may not be applicable to us because of our extreme humidity and temperature. In this study, we aim to summarize the data available in the literature on the stability of chronic medications in DAA.

METHODS

We performed a literature search using electronic databases and related keywords.

RESULTS

In total, 24,336 articles were retrieved and 21 articles were found to be relevant to our topic. This commentary stratified drugs according to their treatment categories and key stability conclusions, DAA and conditions used and recommendations were presented.

CONCLUSION

Due to the lack of specific data, pharmacists have to exercise their professional judgment with the help from professional guidelines when using DAA in repackaging medication. Manufacturers and regulators can play a greater role in filling the gap needed to provide pharmacists with necessary information to fulfill their function.

Repackaged sodium valproate tablets--Meeting quality and adherence to ensure seizure control

PURPOSE

Sodium valproate, which is commonly repacked to assist with adherence to ensure seizure control, is hygroscopic and therefore sensitive to moisture. The aim of this study was thus to determine the stability implications of removing the enteric coated tablets from their original packaging and repackaging into a Dose Administration Aid (DAA) with storage under various environmental conditions.

METHODS

Physicochemical stability of enteric coated sodium valproate tablets repackaged into a DAA and stored at controlled room temperature, accelerated and refrigerated conditions was evaluated for 28 days. A validated high performance liquid chromatography method was used for the quantitation of the drug content.

RESULTS

Although the chemical stability (sodium valproate between 95 and 105% of labelled content) was maintained for 28 days for all storage conditions, for those tablets stored under accelerated conditions the integrity of the enteric coat was compromised after only 8 days.

CONCLUSIONS

Repackaging of enteric coated sodium valproate should be undertaken with caution and be informed by storage climate. This is particularly relevant for those patients living in hot, humid environments where they should be advised to store their DAA in a refrigerator.

Taking the guesswork out of supplying multicompartment compliance aids: do pharmacists require further guidance on medication stability?

OBJECTIVE

The purpose of this article is to identify information that is currently available to pharmacists concerning the stability of medications repackaged into multicompartment compliance aids (MCAs). This article explores the potential risks associated with repackaging medications into MCAs for pharmacists who supply and patients who use them.

KEY FINDINGS

There is a paucity of information currently available to pharmacists concerning the stability of medications repackaged into MCAs as it is not routinely provided by pharmaceutical manufacturers. However, some studies have identified the potential for adverse effects on safety, bioavailability and stability that may have a clinical impact. There are also professional and legal implications of removing medications from their original packaging for storage in MCAs.

CONCLUSION

There is a growing need for further information concerning the stability of medications repackaged into MCAs to guide pharmacists who are supplying these compliance aids to primary and secondary care. Pharmaceutical manufacturers and researchers should be advised to conduct stability testing in MCAs for orally administered medications. This information should be readily available, and pharmacists should be made aware of it via their pharmaceutical bodies. As a result, decisions regarding MCA preparation can be more informed, and pharmacist and patient risks associated with repackaging potentially unstable medications can be minimised.

Clozapine repackaged into dose administration aids: a common practice in Australian hospitals

OBJECTIVES

Clozapine is an atypical antipsychotic used in the treatment of schizophrenia. Due to the patient profile there is a high rate of repackaging of clozapine into dose administration aids (DAAs). Because of reports from hospital pharmacists about discoloration of returned clozapine tablets that have been repackaged into DAAs, the aim of this study was to evaluate the chemical, physical and photostability of these tablets repackaged into a DAA.

METHOD

Clozapine tablets were repackaged into DAAs and evaluated for physicochemical stability over a 6-week period at a controlled room temperature (25±1°C; 60±1.5% relative humidity (RH)) and accelerated conditions (40±1°C; 75±1.5% RH). In addition, photostability studies were performed according to the International Committee on Harmonisation (ICH) guidelines.

KEY FINDINGS

Chemical stability was confirmed for all storage conditions, including for those photostability (ICH conditions), with the clozapine content occurring within the British Pharmacopoeial (BP) range of 90-110%. Although the physical stability was confirmed for all tests at room temperature (weight uniformity, hardness, friability, disintegration and dissolution), under accelerated conditions the disintegration test did not meet BP requirements. However, the subsequent dissolution test was successful with 85% of clozapine dissolving in 45min.

CONCLUSIONS

This study illustrates that clozapine, when correctly repackaged, maintains its physical and chemical stability for 6 weeks. As no discoloration of the tablets was observed, it is assumed that the reports received were as a result of improper handling by patients. Based on these findings, it is recommended that patients be advised on the correct handling and storage of their DAAs.

Dose administration aids: Pharmacists' role in improving patient care

Dose administration aid (DAA) usage has become increasingly prevalent among populations worldwide and as such has become an important part of pharmacy practice. The evidence for the use of these aids has been favourable in Australia resulting in 2006 in a community based DAA program being considered by the Australian Government Department of Health and Ageing PPSAC (Professional Programs and Services Advisory Committee) and the first phase of this program implemented in October 2007. The program was established under the Better Community Health Initiative of the 4(th) Community Pharmacy Agreement between the Pharmacy Guild of Australia and the Commonwealth Government. The aim of this program is to reduce medication-related hospitalisations and adverse events through improved medication management and adherence by people in the community. The most common patient groups that access this service include the elderly, who are often on several different medications, and patients with cognitive disabilities who may have trouble understanding or remembering their dosage regimes.Repackaging of a medication, involving removal from its primary packaging invalidates the stability guarantee of the manufacturer. It is in fact the role of the healthcare team to ensure optimal patient care by making an informed judgment as to the effect on the quality and safety of this repackaging process. Drug manufacturers, on the whole, tend to discourage repackaging of medications and there is little quality data available to support this process. Indeed, only a small number of medications have been investigated for their stability following repackaging into DAAs, namely atenolol, paracetamol, frusemide, prochlorperazine, sodium valproate, aspirin (dosette boxes) and clozapine. This paper will review the repackaging of medications into DAAs and the role that the pharmacist plays in this process to improve patient care, in addition to presenting the Australian research that has contributed substantially to the body of information available internationally on the quality implications, relating to the stability of medicines repackaged into DAAs.

Dose administration aids: Pharmacists' role in improving patient care

Dose administration aid (DAA) usage has become increasingly prevalent among populations worldwide and as such has become an important part of pharmacy practice. The evidence for the use of these aids has been favourable in Australia resulting in 2006 in a community based DAA program being considered by the Australian Government Department of Health and Ageing PPSAC (Professional Programs and Services Advisory Committee) and the first phase of this program implemented in October 2007. The program was established under the Better Community Health Initiative of the 4(th) Community Pharmacy Agreement between the Pharmacy Guild of Australia and the Commonwealth Government. The aim of this program is to reduce medication-related hospitalisations and adverse events through improved medication management and adherence by people in the community. The most common patient groups that access this service include the elderly, who are often on several different medications, and patients with cognitive disabilities who may have trouble understanding or remembering their dosage regimes.Repackaging of a medication, involving removal from its primary packaging invalidates the stability guarantee of the manufacturer. It is in fact the role of the healthcare team to ensure optimal patient care by making an informed judgment as to the effect on the quality and safety of this repackaging process. Drug manufacturers, on the whole, tend to discourage repackaging of medications and there is little quality data available to support this process. Indeed, only a small number of medications have been investigated for their stability following repackaging into DAAs, namely atenolol, paracetamol, frusemide, prochlorperazine, sodium valproate, aspirin (dosette boxes) and clozapine. This paper will review the repackaging of medications into DAAs and the role that the pharmacist plays in this process to improve patient care, in addition to presenting the Australian research that has contributed substantially to the body of information available internationally on the quality implications, relating to the stability of medicines repackaged into DAAs.