Storage temperatures of out-of-hospital medications

Mean kinetic temperature evaluations through simulated temperature excursions and risk assessment with oral dosage usage for health programs

Background

Temperature excursions occur during the transport and storage of pharmaceuticals, and often result in considerable losses for public health programs operating in countries with limited resources. After a temperature excursion has been identified, often products are discarded without any additional risk assessments. Consulting the manufacturer is the preferred approach but can be challenging depending on the responsiveness of the manufacturer. However, decisions are often required quickly depending on program needs and available stock in country.

Methods

To provide further guidance, simulations have been conducted based on mean kinetic temperature evaluations using accepted default kinetic parameters to assess loss of shelf-life for scenarios involving various levels of temperature excursions on a model pharmaceutical at different recommended storage conditions, shelf-life, and long-term storage conditions.

Results

Although an immediate loss to shelf-life occurred with excursions when the product was stored at the maximum allowed temperature, more extended excursion could be withstood before loss of shelf-life was detected when long-term storage was maintained at temperatures below the maximum storage condition for the product. With the assumption that a shelf-life loss of 2 weeks was negligible when managing program stock, a risk assessment was conducted to outline the various times that excursions at different temperatures could be considered low risk to the program.

Conclusions

Depending on the level of the temperature excursion and the guidance provided by the manufacturer, public health programs will have further information with this assessment to guide decisions that impact safety to the end user and resource management due to temperature excursions that can occur.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12660-9.

The Effect of High Storage Temperature on the Stability and Efficacy of Lyophilized Tenecteplase

INTRODUCTION

Tenecteplase is a thrombolytic protein drug used by paramedics, emergency responders, and critical care medical personnel for the prehospital treatment of blood clotting diseases. Minimizing the time between symptom onset and the initiation of thrombolytic treatment is important for reducing mortality and improving patient outcomes. However, the structure of protein drug molecules makes them susceptible to physical and chemical degradation that could potentially result in considerable adverse effects. In locations that experience extreme temperatures, lyophilized tenecteplase transported in emergency service vehicles (ESVs) may be subjected to conditions that exceed the manufacturer's recommendations, particularly when access to the ambulance station is limited.

STUDY OBJECTIVE

This study evaluated the impact of heat exposure (based on temperatures experienced in an emergency vehicle during summer in a regional Australian city) on the stability and efficacy of lyophilized tenecteplase.

METHODS

Vials containing 50mg lyophilized tenecteplase were stored at 4.0°C (39.2°F), 35.5°C (95.9°F), or 44.9°C (112.8°F) for a continuous period of eight hours prior to reconstitution. Stability and efficacy were determined through assessment of: optical clarity and pH; analyte concentration using UV spectrometry; percent protein monomer and single chain protein using size-exclusion chromatography; and in vitro bioactivity using whole blood clot weight and fibrin degradation product (D-dimer) development.

RESULTS

Heat treatment, particularly at 44.9°C, was found to have the greatest impact on tenecteplase solubility; the amount of protein monomer and single chain protein lost (suggesting structural vulnerability); and the capacity for clot lysis in the form of decreased D-dimer production. Meanwhile, storage at 4.0°C preserved tenecteplase stability and in vitro bioactivity.

CONCLUSION

The findings indicate that, in its lyophilized form, even relatively short exposure to high temperature can negatively affect tenecteplase stability and pharmacological efficacy. It is therefore important that measures are implemented to ensure the storage temperature is kept below 30.0°C (86.0°F), as recommended by manufacturers, and that repeated refrigeration-heat cycling is avoided. This will ensure drug administration provides more replicable thrombolysis upon reaching critical care facilities.

Effect of Extreme Temperature on Naloxone Nasal Spray Dispensing Device Performance

INTRODUCTION

The opioid epidemic has led to the wide-spread distribution of naloxone to emergency personnel and to the general public. Recommended storage conditions based on prescribing information are between 15°C and 25°C (59°F and 77°F), with excursions permitted between 4°C and 40°C (39°F and 104°F). Actual storage likely varies widely with potential exposures to extreme temperatures outside of these ranges. These potentially prolonged extreme temperatures may alter the volume of naloxone dispensed from the nasal spray device, which could result in suboptimal efficacy.

STUDY OBJECTIVE

The aim of this study was to assess the naloxone volume deployed following nasal spray device storage at extreme temperatures over an extended period of time.

METHODS

Naloxone nasal spray devices were exposed to storage temperatures of -29°C (-20°F), 20°C (68°F), and 71°C (160°F) to simulate extreme temperatures and a control for 10 hours. First, the density was measured under each temperature condition. Following the density calculation part of the experiment, the mass of naloxone dispensed from each nasal spray device at each temperature was captured and used to calculate volume: calculated volume (microliter, µl) = spray mass (mg converted to g)/mean density (g/mL). Measurements and calculations are reported as means with standard deviation and standard error, and a one-way ANOVA was used to evaluate mean dispensed volume differences at different temperatures.

RESULTS

There was no difference in the mean volume deployed at -29°C (-20°F), 20°C (68°F), and 71°C (160°F), and measurements were 101.44µl (SD = 9.56; SE = 5.52), 99.01µl (SD = 6.31; SE = 3.64), and 108.28µl (SD = 2.04; SE = 1.18), respectively; P value = .289, F-statistic value = 1.535.

CONCLUSION

The results of this study suggest that naloxone nasal spray devices will dispense the appropriate volume, even when stored at extreme temperatures outside of the manufacturer's recommended range.

Survey on transportation and storage of biological therapies by patients

Objective

To assess key aspects of transportation and storage of biological therapies (BTs) on the part of the patients, from the time they collect them from the pharmacy up until the moment of administration.

Methods

This was a cross-sectional study in the form of a survey completed by outpatients older than 18 years who were administered BTs. The survey was carried out by the authors between August 2016 and January 2017.

Results

A total of 83 outpatients were interviewed (mean age, 53; standard deviation, 15; 76% female). Sixty percent had rheumatoid arthritis, 24% had psoriatic arthritis, and 16% sustained other rheumatic and inflammatory diseases. Twenty percent had not been informed of the importance of proper refrigeration when they were first prescribed BTs; 77% had acquired the medication at least 7 days before administration; 28% had misplaced the drug in the fridge (65% of them in the freezer); 90% was unaware of the temperature range at which the BT should be kept in the fridge, and only one (1%) of them had once used a thermometer to find out the fridge temperature. Fifty-three percent had suffered frequent power outages the previous summer, 22% had experienced blackouts longer than 48 hours; 37% had taken the BT to another house to avoid wasting it, and four (5%) patients had disposed of the drug due to a prolonged power outage.

Conclusion

Upon prescribing BTs, it is imperative that physicians brief patients on the relevance of suitable transportation and storage methods, and a treatment failure should prompt a thorough assessment of transportation and storage conditions.

Effect of Fluctuating Extreme Temperatures on Tranexamic Acid

INTRODUCTION

Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce morbidity and mortality in hemorrhagic shock. It has potential use in prehospital and wilderness medicine; however, in these environments, TXA is likely to be exposed to fluctuating and extreme temperatures. If TXA degrades under these conditions, this may reduce antifibrinolytic effects.

PROBLEM

This study sought to determine if repetitive temperature derangement causes degradation of TXA.

METHODS

Experimental samples underwent either seven days of freeze/thaw or heating cycles and then were analyzed via mass spectrometry for degradation of TXA. An internal standard was used for comparison between experimental samples and controls. These samples were compared to room temperature controls to determine if fluctuating extreme temperatures cause degradation of TXA.

RESULTS

The coefficient of variability of ratios of TXA to internal standard within each group (room temperature, freeze, and heated) was less than five percent. An independent t-test was performed on freeze/thaw versus control samples (t = 2.77; P = .17) and heated versus control samples (t = 2.77; P = .722) demonstrating no difference between the groups.

CONCLUSION

These results suggest that TXA remains stable despite repeated exposure to extreme temperatures and does not significantly degrade. These findings support the stability of TXA and its use in extreme environments.

How to transport veterinary drugs in insulated boxes to avoid thermal damage by heating or freezing

BACKGROUND

The transport of veterinary drugs must comply with the general standards for drug storage. Although many vehicles are equipped with active heating and/or cooling devices assuring recommended storage conditions, simple insulated transport boxes are also often used. In this study, measurements for typical transport boxes were performed under laboratory conditions by the use of a climate chamber for a temperature of -20 °C and 45 °C to investigate the impact of box size, insulation material, liquid vs. dry filling products, filling degree and other parameters on the thermal performance of insulated boxes. Model calculations and instructions are presented to predict the retention time of recommended drug storage temperatures.

RESULTS

The measurements and the model calculations showed that the loading of the transport boxes with additional water bottles to increase the heat capacity is appropriate to prolong the retention time of the recommended temperature range of the drugs. Insulated transport boxes are not suitable to store drugs over a period of more than approximately 12 h. For practical use a recipe is presented to measure the thermal properties of a transport box and the related retention time for which the recommended storage temperatures can be assured.

CONCLUSIONS

The following principles for drug transportation in vehicles are recommended: (1) Before transfer into boxes, drugs should always be thermally preconditioned (2) Increase the filling degree of the boxes with thermally preconditioned water bottles or re-usable thermal packs will increase the heat capacity. Do not deep-freeze the bottles or packs below 0 °C to avoid drug freezing due to contact. (3) Open the lid of the boxes only to uncase drugs that are immediately needed. (4) The bigger the box and the higher the filling degree, the longer the retention time of the transport box. (5) Wherever possible, place the drug box at a cool site inside the vehicle. (6) The monitoring of the inside temperature of the transport boxes is recommended. By the proper use of such transport boxes the recommended temperatures can be maintained over one working day.

A systematic review of epinephrine degradation with exposure to excessive heat or cold

BACKGROUND

Epinephrine is a lifesaving drug in the treatment of anaphylaxis and cardiac resuscitation. Current US storage recommendations are for controlled room temperature (20°C-25°C), with excursions permitted from 15°C to 30°C. Maintaining epinephrine within this required range is challenging, particularly for patients carrying autoinjectors and during storage in emergency vehicles.

OBJECTIVE

To study epinephrine degradation with extreme temperature exposure for epinephrine concentrations used in anaphylaxis and cardiac resuscitation.

METHODS

We searched the literature for all studies of epinephrine in sealed syringes, vials, or ampules in concentrations between 1:1,000 and 1:10,000, that measured epinephrine in samples exposed to temperatures above and/or below the recommended storage temperature compared with control samples.

RESULTS

Nine studies were included. Heat exposure resulted in epinephrine degradation but only with prolonged exposure. Constant heat resulted in more degradation. None of the studies that evaluated epinephrine exposure to extreme cold found significant degradation. None of the studies evaluating the effects of real-world temperature fluctuations detected significant degradation. Only 2 small studies (1 evaluating heat and 1 freezing) involved autoinjectors, and all 40 devices tested fired correctly.

CONCLUSION

Temperature excursions in real-world conditions may be less detrimental than previously suggested. Freezing and limited heat excursions did not result in epinephrine degradation. Refrigeration of epinephrine appears to reduce degradation. However, the effect of extreme temperatures, particularly freezing, on autoinjectors is not sufficiently well established. More research in needed at clinically relevant high temperatures, with limited exposure to heat, and involving autoinjector devices.

[Effect of heat transfer in the packages on the stability of thiamine nitrate under uncontrolled temperature conditions]

To accurately predict the stability of thiamine nitrate as a model drug in pharmaceutical products under uncontrolled temperature conditions, the average reaction rate constant was determined, taking into account the heat transfer from the atmosphere to the product. The stability tests of thiamine nitrate in the three packages with different heat transfers were performed under non-isothermal conditions. The stability data observed were compared with the predictions based on a newly developed method, showing that the stability was well predicted by the method involving the heat transfer. By contrast, there were some deviations observed from the predicted data, without considering heat transfer in the packages with low heat transfer. The above-mentioned result clearly shows that heat transfer should be considered to ensure accurate prediction of the stability of commercial pharmaceutical products under non-isothermal atmospheres.

Effects of packaging and heat transfer kinetics on drug-product stability during storage under uncontrolled temperature conditions

To predict the stability of pharmaceutical preparations under uncontrolled temperature conditions accurately, a method to compute the average reaction rate constant taking into account the heat transfer from the atmosphere to the product was developed. The average reaction rate constants computed with taken into consideration heat transfer (κ(re) ) were then compared with those computed without taking heat transfer into consideration (κ(in) ). The apparent thermal diffusivity (κ(a) ) exerted some influence on the average reaction rate constant ratio (R, R = κ(re) /κ(in) ). In the regions where the κ(a) was large (above 1 h(-1) ) or very small, the value of R was close to 1. On the contrary, in the middle region (0.001-1 h(-1) ), the value of R was less than 1.The κ(a) of the central part of a large-size container and that of the central part of a paper case of 10 bottles of liquid medicine (100 mL) fell within this middle region. On the basis of the above-mentioned considerations, heat transfer may need to be taken into consideration to enable a more accurate prediction of the stability of actual pharmaceutical preparations under nonisothermal atmospheres.

[Quality of storage of thermolabile drugs in patients' homes]

OBJECTIVE

To evaluate storage conditions of two thermolabile drugs, etanercept and adalimumab, in patients' homes, and the possible influence over the average storage temperature of variables such as the number of people living at home, age of the patient or age of the refrigerator.

MATERIALS AND METHODS

Prospective observational study. The sample consisted of 60 patients treated with Enbrel or Humira. Data loggers cards were used, with an integrated thermal sensor VarioSens, which were placed on the outer packaging of the product, programmed to record temperatures every 90 min for approximately 30 days. The average storage temperature recorded in refrigerators was used as the main variable.

RESULTS

It was shown that there is a greater risk of not maintaining adequate storage when the mean temperature of the refrigerator is outside a range of 2-8 degrees C, RR = 3.9 (95% CI = 1.95-7.93), P = 0.0001. A total of 35 patients (58.3%) stored medicines outside the correct temperature range. There were significant differences in average storage temperatures depending on the whether the age of the refrigerator was greater or less than 5 years, P = 0.029. Older than 5 years represents a risk factor for inadequate storage, RR = 1.68 (95% CI = 1.04-2.71), P = 0.023 with the Pearson chi-squared test.

CONCLUSIONS

Procedures need to be established to ensure traceability of the storage of heat-labile drugs in patients' homes. New technologies allow this to be done, by providing advice to patients and for making decisions regarding dispensing and reuse in the event of return, thus improving our quality of care.

Alteration in prehospital drug concentration after thermal exposure

OBJECTIVE

The aim of the study was to determine the remaining concentration of 23 commonly carried emergency medical services medications used in the United States after they have experienced thermal extremes that have been documented in the prehospital environment for a period of 1 month.

METHODS

Pharmaceuticals were thermally cycled (-6 degrees C and 54 degrees C) every 12 hours and then assayed by high-performance liquid chromatography.

RESULTS

Eight (35%) of 23 prehospital pharmaceuticals revealed ending concentrations of less than 90% with strong correlation to thermal exposure time. These included lidocaine, diltiazem, dopamine, nitroglycerin, ipratropium, succinylcholine, haloperidol, and naloxone.

CONCLUSION

A decrease in concentration was found to be statistically significant in 8 (35%) of 23 commonly carried emergency medical services pharmaceuticals. These results provide new information and perspective regarding stability of emergency drugs in the prehospital environment by evaluating a broad range of pharmaceuticals as well as by using thermal exposure points that have been documented in the United States.

Can stock rotation effectively mitigate EMS medication exposure to excessive heat and cold?

The United States Pharmacopeia recently published a general chapter specifically addressing on-ambulance storage of medications, including a suggestion for stock rotation. This study describes the effectiveness of a simple stock rotation strategy in mitigating EMS medication exposure to excessive heat and cold. Previously collected on-ambulance temperature data from 5 US cities were randomly resampled to generate model exposures of 2 days to 6 months duration. The temperature measurements for every other 24-hour period were then set at 20 degrees C to model the rotation of medications into a controlled environment. For each model, we then determined consistency with the official United States Pharmacopeia definition of controlled room temperature. Without stock rotation, excessive heat occurred in 39.9% of the model exposures. With stock rotation, exposures to excessive heat occurred in less than 1% of northern city models and in 2.9% of the central US models. Stock rotation did not reduce heat exposures in the models for southern cities.

Evaluation of time-temperature integrators for tracking poultry product quality throughout the chill chain

The goal of this study was to evaluate the application of one type of time-temperature integrator (TTI) to monitor the microbiological quality of ice-packed raw chicken drumsticks as a function of temperature exposure. A kinetics-based model was used to correlate the TTI chroma response to the number of bacteria on the drumstick surface under constant- and variable-temperature conditions. Two constant-temperature studies (4 and 15 degrees C) and one variable-temperature study (4 degrees C for 24 h, 15 degrees C for 24 h, 4 degrees C constant) were conducted to evaluate the applicability of the TTI under ideal and worst-case situations. During the constant-temperature studies, quality predictions made at the midpoint of the product shelf life were accurate within 15% for the observed bacterial populations. The accuracy of the TTI was marginal in the initial and final stages of the response period. During the variable-temperature study, the TTI response demonstrated positive history effects, whereby the observed rate constant is affected by previous temperature exposure. After the TTIs had been held at 15 degrees C for 24 h, the TTI response rate constant observed during subsequent storage at 4 degrees C was higher than what would be predicted for 4 degrees C. Further work will be needed to develop a continuous TTI-based quality monitoring system. However, because the microbiological quality of fresh poultry could be reliably predicted with kinetic models, fresh poultry products would be excellent candidates for a TTI-based quality monitoring system.

Improvements in prehospital medication storage practices in response to research

Previously the authors showed that prehospital medications were stored outside their recommended temperature range. In response, the state office of emergency medical services (EMS) issued regulations regarding temperature control and monitoring of prehospital medications.

OBJECTIVE

To determine the impact of previous research (on medication storage conditions) on current practices among the mobile intensive care units (MICUs) within the state.

METHODS

A statewide, structured telephone survey of MICU directors was conducted between April and December 2000. Questions focused on changes in storage and monitoring practices (including modifications to vehicles, medication boxes, and the use of temperature monitoring devices) since the authors' previous research.

RESULTS

Thirty-three of 35 (94%) programs (100 vehicles) participated in the survey. Eighty-five percent changed their practices since the research five years ago. Of the five that did not change, three already had temperature control measures in place, while two have not made any changes. Twenty-one (63%) of the programs reported changing specifically because of state regulations. Eighty-one percent of the programs have taken some measure to control temperature. Currently, 63% of the 100 vehicles in use have both heating and cooling devices specifically for the medications, whereas 14% have only a heater and 23% have neither. Thirty-one (94%) MICUs monitor the temperature in some manner: 42% in the vehicle, 58% in the medication box. Of these, 68% are using 30-day electronic temperature data recorders, whereas 32% are using non-recording digital thermometers.

CONCLUSIONS

This survey demonstrates a positive impact from previous research. Most of the MICUs in the state have changed their practices in controlling and monitoring prehospital medication storage temperature.