Stability of repackaged dabigatran etexilate capsules in dose administration aids

Improving adherence by investigating the stability of dabigatran outside of the manufacturer's original packaging: a New Zealand perspective

BACKGROUND

Dose administration aids (DAA) are widely used to improve adherence. In New Zealand (NZ) more pharmacies are utilizing automated filling robots to meet DAA demand. Pradaxa™ capsules containing dabigatran etexilate (DE) is problematic. It is moisture-sensitive, and Medsafe (NZ regulator), recommends keeping the capsule in its original packaging until administration. This prevents DE from repacking into DAA, reducing the effectiveness of the DAA. Overseas studies demonstrated stability of DE in DAA. However, the findings cannot be extrapolated to NZ environments.

RESEARCH DESIGN AND METHODS

Pradaxa™ 110 mg capsules repackaged in DAA were stored in conditions mimicking real-life settings (room temperature, bedroom and fridge) for 16 weeks. At predetermined timepoints, the capsules were evaluated for drug content and dissolution profile.

RESULTS

DE samples stored in NZ conditions for 16 weeks met the drug content requirement of 85-115% except for unit-dose sachet samples stored in fridge condition (79.7% ± 6.82). Samples demonstrated similarity in dissolution profile until 8 weeks with release rate decreased at 16 weeks under all storage conditions.

CONCLUSION

DE capsules repackaged in DAA demonstrated stability for up to 8 weeks in all NZ storage conditions, confirming the safety of repackaging DE into a DAA.

Intake Patterns and Experiences of Patients Using Direct Oral Anticoagulants Measured by Electronic Monitoring in Community Pharmacies

Purpose

Several international organizations advocate for monitoring of adherence to direct oral anticoagulants (DOACs), given the prevalent issue of suboptimal adherence to DOACs. The aim was to investigate intake patterns in patients on DOAC therapy by electronic monitoring of medication adherence in community pharmacies (using a Medication Event Monitoring System® (MEMS®)-device), and to assess patients' experiences with this device.

Patients and Methods

Patients using apixaban, rivaroxaban or edoxaban and visiting a community pharmacy, were included. Adherence was electronically monitored over a twelve-week period. Pharmacists conducted data readings from the electronic device at six and twelve weeks, and discussed these data with the patients. At the beginning and end of the study, patients completed a questionnaire about their expectations and experiences respectively.

Results

Eighty-nine patients were included and high taking adherence rates were observed (median adherence of 100% for once-daily dosed patients and 96.7% for twice-daily dosed patients), but more than half of the patients took at least one dose too late or skipped at least one dose, possibly resulting in temporarily reduced protection against thromboembolic events. Most patients who felt that their adherence had improved, believed this was due to the combination of the electronic device and the personal follow-up by the pharmacist. Although most patients stated that medication adherence is their own responsibility, they were grateful for the support they received from their community pharmacist.

Conclusion

High adherence rates were observed, but there was still room for improvement regarding intake moments. Positive experiences with an electronic device for medication adherence monitoring were reported.

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.

Opportunities for changes in the drug product design to enhance medication safety in older people: Evaluation of a national public portal for medication incidents

AIMS

Medication safety requires urgent attention in hospital pharmacy. This study evaluated the medication-related problems/errors as reported to the Dutch medication incident registry and disseminated for information to pharmacists. Through analysis by an expert panel we aimed to better understand which problems could have been mitigated by the drug product design. Additionally, the (wider) implications of the problems for current hospital/clinical practice were discussed.

METHODS

Items were extracted from the public Portal for Patient Safety. Items were included if relevant for older people and connected with the drug product design and excluded if they should reasonably have been intercepted by compliance to routine controls or well-known professional standards in pharmaceutical care. To explore any underreporting of well-known incidents, it was investigated if different medication-related problems could be observed in a regional hospital practise over a 1-month period. For 6 included items (cases), the implications for hospital/clinical practise were discussed in an expert panel.

RESULTS

In total, 307 items were identified in the Portal for Patient Safety; all but 14 were excluded. Six cases were added from daily hospital practice. These 20 cases commonly related to confusing product characteristics, packaging issues such as the lack of a single unit package for an oncolytic product, or incorrect or incomplete user instructions.

CONCLUSION

Medication registries provide important opportunities to evaluate real-world medication-related problems. However, underreporting of well-known problems should be considered. The product design can be used as an (additional) risk mitigation measure to support medication safety in hospital practice.

Evaluation of patients' knowledge about oral anticoagulant medicines and use of alert cards by community pharmacists

Background Anticoagulants continue to pose high risk of harm to patients despite the discovery of novel direct-acting oral anticoagulant agents that require less monitoring than warfarin. Objective To evaluate patients’ knowledge about their oral anticoagulants and the potential role for community pharmacists in optimising safety. Setting Community pharmacies in England. Methods An online survey-based evaluation conducted over a 5-month period to ascertain patients’ knowledge, use of anticoagulant alert cards, compliance with national monitoring requirements for warfarin, and frequency and nature of community pharmacist involvement in optimisation. Differences between patients on direct-acting oral anticoagulant agents and warfarin were assessed using Chi squared tests. Main outcome measure Patients’ knowledge and use of anticoagulant alert cards. Results A total of 1515 pharmacies participated. Of 22,624 patients, 97% knew that they were taking anticoagulants; 20% had alert cards with them at time of dispensing; 17% had no card and 10% refuted their usefulness. Patients on warfarin were more aware of interactions with over-the-counter or herbal medicines than those on direct-acting oral anticoagulant agents. Of the patients on warfarin, 82% confirmed monitoring in the previous 12 weeks in accordance with national standards, with the international normalised ratio value known for 76%. Pharmacists intervened in a fifth of the patients to issue an alert card, contact the general practitioner for a change in the prescription or due to interacting medicines. Conclusion Patients had reasonable knowledge of their anticoagulation therapy, but areas for improvement were identified. Community pharmacists are well placed to optimise the safe use of anticoagulants.

Developing patient-centric medicines for older people: Reflections from the draft EMA paper on the pharmaceutical development of medicines for use in the older population

Increased global longevity requires a re-evaluation of current structures in society to adapt to the consequential demographic shift. As (very) old people are prone to impaired human organ and body functions resulting in, for example, multimorbidity, polypharmacy, hospitalisation and problems in medication management, it is increasingly acknowledged that re-evaluations should include the suitability of pharmaceutical patient care as one of the cornerstones of public health. Following the 2011 European Medicines Agency (EMA) Geriatric Strategy, in 2017 the EMA published the draft "Reflection paper on the pharmaceutical development of medicines for use in the older population". The draft paper was opened for public consultation and specific attention and feedback (either supportive or with a proposal for revision) was asked on three design aspects: tablet breaking, drug administration through enteral feeding tubes and medication management. Following publication, the draft paper was presented at two public conferences attended by participants from different disciplines. This manuscript is intended to draw the attention of different stakeholder parties to the urgent need to collaborate on the emerging issues arising from increasing longevity and multimorbidity, and especially those associated with pharmaceutical patient care and drug product design, including the need for collaborative research into existing or emerging knowledge gaps. The manuscript focuses on the three aforementioned aspects of pharmaceutical development (tablet breaking, drug administration through enteral feeding tubes and medication management) as these highly relate to medication safety and efficacy and constitute persistent and typical challenges for older people, caregivers and healthcare professionals in daily clinical practice.

Comparing the clinical efficacy and safety of abiraterone and enzalutamide in metastatic castration-resistant prostate cancer: A systematic review and meta-analysis

BACKGROUND

Two new drugs, abiraterone and enzalutamide, had recently shown beneficial effects on survival in patients with metastatic castration-resistant prostate cancer. We systematically reviewed the efficacy and safety of abiraterone and enzalutamide in metastatic castration-resistant prostate cancer in real-world practice.

METHODS

A search from PubMed, Web of Science, Cochrane, Embase was conducted up to 6 March 2019. Available articles from conferences were searched. The endpoint was prostate-specific antigen response, overall survival, progression-free survival, number of patients with any adverse event.

RESULTS

Fourteen cohort studies involving 3469 participants were included. Pooled result showed that prostate-specific antigen response was higher for patients receiving enzalutamide than abiraterone (790 patients, odds ratio (OR) 0.47, 95% confidence interval (CI) 0.29-0.77, P = 0.003, I²=59%). Enzalutamide was significantly associated with increased adverse events rate in comparison with abiraterone (730 patients, OR 0.35, 95%CI 0.13-0.92, P = 0.03, I²=65%). There was no statistical difference between abiraterone and enzalutamide with respect to perceived cognitive impairments (1856 patients, OR 0.90, 95%CI 0.29-2.76, P = 0.85, I²=5%). Enzalutamide was significantly associated with increased fatigue risk in comparison with abiraterone (2477 patients, OR 0.46, 95%CI 0.34-0.63, P＜0.00001, I²=0%).

CONCLUSIONS

Our results demonstrated that enzalutamide was more efficacious than abiraterone for patients with metastatic castration-resistant prostate cancer, but was associated with a significantly elevated risk of side effects, particularly fatigue.