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Morris S, Salm V, Salm A. Harm to a child caused by the off-label use of prochlorperazine maleate tablets due to the discontinuation of licensed prochlorperazine mesilate liquid in the UK. Eur J Hosp Pharm 2024:ejhpharm-2023-003791. [PMID: 38876766 DOI: 10.1136/ejhpharm-2023-003791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/13/2024] [Indexed: 06/16/2024] Open
Abstract
Prochlorperazine is a commonly used medicine to treat nausea and vomiting. The only liquid formulation in the UK was discontinued in November 2022 due to safety concerns. One alternative option available is to use crushed tablets instead. Crushing and mixing tablets in water to produce a liquid is a widespread practice in paediatrics. However, there is often little evidence to support this practice.In this case report, a patient established on liquid prochlorperazine mesilate who was switched to crushed prochlorperazine maleate tablets experienced significant harm. The child's vomiting became uncontrolled and led to multiple healthcare attendances and a prolonged hospital admission. Control was re-established by increasing the prochlorperazine dose to accommodate for loss of drug during preparation. Care should be taken when converting prochlorperazine mesilate liquid doses to crushed prochlorperazine maleate tablets, and the doses used should not be treated as equivalent.
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Affiliation(s)
- Stephen Morris
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vicki Salm
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew Salm
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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2
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Kelleher ST, Regan IE, Cox D, Shaw K, Franklin O, Kenny DP, Walsh KP, McMahon CJ. Aspirin Responsiveness in a Cohort of Pediatric Patients with Right Ventricle to Pulmonary Artery Conduits and Transcatheter Valve Replacement Systems. Pediatr Cardiol 2024:10.1007/s00246-024-03449-1. [PMID: 38489091 DOI: 10.1007/s00246-024-03449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/10/2024] [Indexed: 03/17/2024]
Abstract
The aim of this study was to determine the rate of aspirin responsiveness in a cohort of pediatric patients with in situ xenograft valved right ventricle to pulmonary artery (RV-PA) conduits and/or transcatheter valve replacements (TVR). Aspirin is routinely prescribed to these patients. Optimizing anti-platelet therapy could promote valve longevity and reduce the risk of infective endocarditis in this at-risk group. This was a prospective, observational study. Patients were recruited from both ward and outpatient settings. Patients were eligible if under 18 years and taking aspirin. Non-response to aspirin was defined as > 20% platelet aggregation using light transmission platelet aggregometry (LTA) and < 50% platelet inhibition by thromboelastography with platelet mapping (TEGPM). Participants were invited to provide a confirmatory sample in cases of aspirin resistance and dose adjustments were made. Thirty patients participated. Median age was 9 years (2 months to 18 years). The majority (93%) had complex right ventricular outflow tract pathology. 13 (43%) had an RV-PA conduit and 24 (80%) had a TVR, with valve situated in conduit in 7 (23%) cases. Rate of aspirin non-response on initial testing was 23% (n = 7/30) with median LTA 74.55% (60-76%) and TEG 13.25% (0-44%) in non-responders. Non-responders were more likely to be under 1 year. Two patients required dose increases and one patient non-adherence to dose was identified. Four patients on repeat testing were responsive to aspirin by laboratory tests. The rate of aspirin non-response on laboratory testing in this cohort of patients was 23% and resulted in therapeutic intervention in 10%.
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Affiliation(s)
- Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Irene E Regan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Dermot Cox
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Kathryn Shaw
- Department of Paediatric Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Damien P Kenny
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Kevin P Walsh
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland.
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands.
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland.
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3
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Larsen BS, Kissi E, Nogueira LP, Genina N, Tho I. Impact of drug load and polymer molecular weight on the 3D microstructure of printed tablets. Eur J Pharm Sci 2024; 192:106619. [PMID: 37866675 DOI: 10.1016/j.ejps.2023.106619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
This study investigates the influence of drug load and polymer molecular weight on the structure of tablets three-dimensionally (3D) printed from the binary mixture of prednisolone and hydroxypropyl methylcellulose (HPMC). Three different HPMC grades, (AFFINISOLTM HPMC HME 15LV, 90 Da (HPMC 15LV); 100LV, 180 Da (HPMC 100LV); 4M, 500 Da (HPMC 4M)), which are suitable for hot-melt extrusion (HME), were used in this study. HME was used to fabricate feedstock material, i.e., filaments, at the lowest possible extrusion temperature. Filaments of the three HPMC grades were prepared to contain 2.5, 5, 10 and 20 % (w/w) prednisolone. The thermal degradation of the filaments was studied with thermogravimetric analysis, while solid-state properties of the drug-loaded filaments were assessed with the use of X-ray powder diffraction. Prednisolone in the freshly extruded filaments was determined to be amorphous for drug loads up to 10%. It remained physically stable for at least 6 months of storage, except for the filament containing 10% drug with HPMC 15LV, where recrystallization of prednisolone was detected. Fused deposition modeling was utilized to print honeycomb-shaped tablets from the HME filaments of HPMC 15LV and 100LV. The structural characteristics of the tablets were evaluated using X-ray microcomputed tomography, specifically porosity and size of structural elements were investigated. The tablets printed from HPMC 15LV possessed in general lower total porosity and pores of smaller size than tablets printed from the HPMC 100LV. The studied drug loads were shown to have minor effect on the total porosity of the tablets, though the lower the drug load was, the higher the variance of porosity along the height of the tablet was observed. It was found that tablets printed with HPMC 15LV showed higher structural similarity with the virtually designed model than tablets printed from HPMC 100LV. These findings highlight the relevance of the drug load and polymer molecular weight on the microstructure and structural properties of 3D printed tablets.
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Affiliation(s)
- Bjarke Strøm Larsen
- Department of Pharmacy, University of Oslo, Sem Sælands vei 3, 0371 Oslo, Norway.
| | - Eric Kissi
- Department of Pharmacy, University of Oslo, Sem Sælands vei 3, 0371 Oslo, Norway; Nanoform Finland PLC, Viikinkaari 4, 00790 Helsinki, Finland
| | - Liebert Parreiras Nogueira
- Oral Research Laboratory, Department of Biomaterials, Institute of Clinical Dentistry, University of Oslo, Geitmyrsveien 71, 0455 Oslo, Norway
| | - Natalja Genina
- Department of Pharmacy, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Ingunn Tho
- Department of Pharmacy, University of Oslo, Sem Sælands vei 3, 0371 Oslo, Norway
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4
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Andersson ÅC, Nydert P, Paulsson M. Preparing paediatric medicines by dissolving tablets and extracting a portion may compromise dosing accuracy. Acta Paediatr 2023; 112:2560-2562. [PMID: 37615233 DOI: 10.1111/apa.16951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Åsa C Andersson
- Karolinska University Hospital, Division of Paediatrics, Astrid Lindgren Children's Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Per Nydert
- Karolinska University Hospital, Division of Paediatrics, Astrid Lindgren Children's Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Paulsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Al-Rayess H, Lahoti A, Simpson LL, Palzer E, Thornton P, Heksch R, Kamboj M, Stanley T, Regelmann MO, Gupta A, Raman V, Mehta S, Geffner ME, Sarafoglou K. Practice Variation among Pediatric Endocrinologists in the Dosing of Glucocorticoids in Young Children with Congenital Adrenal Hyperplasia. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1871. [PMID: 38136073 PMCID: PMC10742174 DOI: 10.3390/children10121871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
A Pediatric Endocrine Society (PES) Drugs and Therapeutics Committee workgroup sought to determine the prescribing practices of pediatric endocrinologists when treating children <10 years of age with congenital adrenal hyperplasia (CAH). Our workgroup administered a 32-question online survey to PES members. There were 187 respondents (88.9% attending physicians), mostly from university-affiliated clinics (~80%). Ninety-eight percent of respondents prescribed the short-acting glucocorticoid hydrocortisone to treat young children, as per the Endocrine Society CAH Guidelines, although respondents also prescribed long-acting glucocorticoids such as prednisolone suspension (12%), prednisone tablets (9%), and prednisone suspension (6%). Ninety-seven percent of respondents indicated that they were likely/very likely to prescribe hydrocortisone in a thrice-daily regimen, as per CAH Guidelines, although 19% were also likely to follow a twice-daily regimen. To achieve smaller doses, using a pill-cutter was the most frequent method recommended by providers to manipulate tablets (87.2%), followed by dissolving tablets in water (25.7%) to create a daily batch (43.7%) and/or dissolving a tablet for each dose (64.6%). Thirty-one percent of providers use pharmacy-compounded hydrocortisone suspension to achieve doses of <2.5 mg. Our survey shows that practices among providers in the dosing of young children with CAH vary greatly and sometimes fall outside of the CAH Guidelines-specifically when attempting to deliver lower, age-appropriate hydrocortisone doses.
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Affiliation(s)
- Heba Al-Rayess
- Department of Pediatrics, Division of Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA;
| | - Amit Lahoti
- Department of Pediatrics, Division of Endocrinology, Nationwide Children’s Hospital at The Ohio State University, Columbus, OH 43205, USA; (A.L.); (M.K.)
| | - Leslie Long Simpson
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN 55455, USA; (L.L.S.); (E.P.)
| | - Elise Palzer
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN 55455, USA; (L.L.S.); (E.P.)
| | - Paul Thornton
- Division of Endocrinology and Diabetes, Cook Children’s Medical Center, Fort Worth, TX 76104, USA;
| | - Ryan Heksch
- Center for Diabetes and Endocrinology, Department of Pediatrics, Akron Children’s Hospital, Akron, OH 44308, USA;
| | - Manmohan Kamboj
- Department of Pediatrics, Division of Endocrinology, Nationwide Children’s Hospital at The Ohio State University, Columbus, OH 43205, USA; (A.L.); (M.K.)
| | - Takara Stanley
- Pediatric Endocrine Unit and Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA;
| | - Molly O. Regelmann
- Division of Pediatric Endocrinology and Diabetes, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY 10467, USA;
| | - Anshu Gupta
- Division of Pediatric Endocrinology, Children’s Hospital of Richmond, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Vandana Raman
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Utah, Salt Lake City, UT 84112, USA;
| | - Shilpa Mehta
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, New York Medical College, Valhalla, NY 10595, USA
| | - Mitchell E. Geffner
- The Saban Research Institute, Children’s Hospital Los Angeles, The Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA;
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Division of Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA;
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
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Wang B, Liu H, Zhang S, Cheng A, Yan C, Xu B, Gao Y. Aspirin microcrystals deposited on high-density microneedle tips for the preparation of soluble polymer microneedles. Drug Deliv Transl Res 2023; 13:2639-2652. [PMID: 37040032 DOI: 10.1007/s13346-023-01343-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2023] [Indexed: 04/12/2023]
Abstract
To reduce mucosal damage in the gastrointestinal tract caused by aspirin, aspirin microcrystals were loaded in soluble polymeric microneedle (MN) tips. Aspirin was prepared into aspirin microcrystals by jet milling. Aspirin microcrystals with particle sizes of 0.5-5 μm were loaded on MN tips with a height of 250 µm or 300 µm. The aspirin microcrystals suspended in a polymer solution were concentrated in the MN tips under negative pressure. The aspirin microcrystals had high stability in the MNs since they were not dissolved in solution during the fabrication process. The MN patch packaged in an aluminum-plastic bag containing silica gel desiccant can be stored at 4 °C. The MN tips implanted in the skin of Institute of Cancer Research (ICR) mice dissolved within 30 min. Isolated porcine ear skin was punctured by MNs with heights of 300 μm and 250 μm to depths of 130 μm and 90 μm, respectively. The fluorescent red (FR) release from MNs reached 98.59% within 24 h. The MNs delivered aspirin microcrystals to the epidermis and dermis, providing a smooth plasma concentration in rats. The MNs loaded with aspirin microcrystals did not evoke primary irritation on the dorsal skin of Japanese white rabbits. In summary, MNs loaded with aspirin microcrystals provide a new approach to improve the stability of aspirin in MN patches.
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Affiliation(s)
- Baorui Wang
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry of Chinese Academy of Sciences, Beijing, 100190, China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Han Liu
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry of Chinese Academy of Sciences, Beijing, 100190, China
| | - Suohui Zhang
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry of Chinese Academy of Sciences, Beijing, 100190, China
- Beijing CAS Microneedle Technology Ltd, Beijing, 102609, China
| | - Aguo Cheng
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry of Chinese Academy of Sciences, Beijing, 100190, China
| | - Chenxin Yan
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry of Chinese Academy of Sciences, Beijing, 100190, China
| | - Bo Xu
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry of Chinese Academy of Sciences, Beijing, 100190, China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yunhua Gao
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry of Chinese Academy of Sciences, Beijing, 100190, China.
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, 100049, China.
- Beijing CAS Microneedle Technology Ltd, Beijing, 102609, China.
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7
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Chachlioutaki K, Gioumouxouzis C, Karavasili C, Fatouros DG. Small patients, big challenges: navigating pediatric drug manipulations to prevent medication errors - a comprehensive review. Expert Opin Drug Deliv 2023; 20:1489-1509. [PMID: 37857515 DOI: 10.1080/17425247.2023.2273838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/18/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Medication errors during drug manipulations in pediatric care pose significant challenges to patient safety and optimal medication management. Epidemiological studies have revealed a high prevalenceof medication errors throughout the medication process. Due to the lack of age-appropriate dosage forms, medication manipulation is common in pediatric drug administration. The consequences of these manipulations on drug efficacy and safety could be devastating, highlighting the need for evidence-based guidelines and standardized compounding practices. AREAS COVERED This review focuses on examining medication errors in pediatric care and delving into the manipulation of medicinal products. EXPERT OPINION The observed prevalence of medication errors and manipulations underscores the importance of addressing these issues to enhance patient safety and improve medication outcomes in pediatric care. Overall, the development of age-appropriate formulations and the dissemination of comprehensive clinical guidelines are essential steps toward improving medication safety and minimizing manipulations in pediatric healthcare settings.
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Affiliation(s)
- Konstantina Chachlioutaki
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Thessaloniki, Greece
| | - Christos Gioumouxouzis
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina Karavasili
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Fatouros
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Thessaloniki, Greece
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Andersson ÅC, Eksborg S, Förberg U, Nydert P, Lindemalm S. Manipulated Oral and Rectal Drugs in a Paediatric Swedish University Hospital, a Registry-Based Study Comparing Two Study-Years, Ten Years Apart. Pharmaceuticals (Basel) 2022; 16:ph16010008. [PMID: 36678505 PMCID: PMC9866613 DOI: 10.3390/ph16010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
This is a registry-based study with the aim of describing and comparing the frequency of manipulations of solid oral and rectal medicines in 2009 and 2019 at inpatient units and an emergency department in a paediatric hospital within a Swedish university hospital. All patients aged 1 month−18 years with oral or rectal administrations were included. In total, 140,791 oral and rectal administrations were included in 2009, and 167,945 oral and rectal administrations were included in 2019. The frequency of patients receiving at least one manipulated oral medicine decreased between the study years, both in inpatient units and in the emergency department (from 19% to 17%, p = 0.0029 and from 11% to 5%, p < 0.0001, respectively). The frequency of patients receiving a manipulated rectal medicine also decreased between the study years, both in inpatient units and in the emergency department (from 22% to 10%, p < 0.0001 and from 35% to 7% 2019, p < 0.0001, respectively). The results show a decrease in the manipulation of both oral and rectal medicines to paediatric patients in 2019 compared to 2009. Even though this implies a safer practice, there is still a pronounced lack of child-friendly dosage forms and suitable strengths enabling the safe administration of medicines to sick children.
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Affiliation(s)
- Åsa C. Andersson
- Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-123-75579
| | - Staffan Eksborg
- Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Ulrika Förberg
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden
- School of Health and Welfare, Dalarna University, 79131 Falun, Sweden
| | - Per Nydert
- Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 14152 Stockholm, Sweden
| | - Synnöve Lindemalm
- Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 14152 Stockholm, Sweden
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Kader R, Liminga G, Ljungman G, Paulsson M. Manipulations of Oral Medications in Paediatric Neurology and Oncology Care at a Swedish University Hospital: Health Professionals' Attitudes and Sources of Information. Pharmaceutics 2021; 13:pharmaceutics13101676. [PMID: 34683968 PMCID: PMC8538608 DOI: 10.3390/pharmaceutics13101676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/11/2021] [Indexed: 02/01/2023] Open
Abstract
Oral administration of medications to children requires age-appropriate dosage forms and strengths. In this study, we: (i) assessed the extent of oral dosage form manipulations, (ii) documented how it is carried out, and (iii) examined the attitudes and sources of information regarding the handling from healthcare professionals. Prospective reviews of electronic records, ward observations, and clinician surveys were performed at a paediatric neurology ward and a paediatric oncology ward in Sweden during April to May of 2018. Approximately 15% of oral medications were manipulated for the studied patient group (median age 12.9 years in oncology, 5.8 years in neurology) with approximately 30% of the patients having an enteral feeding tube. Manipulations were performed both to obtain an appropriate dose from, for example, a fraction of the original tablet or to obtain a powder that could be used to prepare a slurry for administration through enteral feeding tubes. Risks identified were related to patient safety such as cross contamination, suboptimal absorption/pharmacokinetics and inaccurate dose. When examining the working environment of nurses, we observed safe handling of hazardous substances but the nurses occasionally experienced stress and a fear of making mistakes due to absence of information. Paediatricians experienced a lack of time to search for proper information on manipulations. As a step towards improving safety in paediatric medication, we suggest the introduction of clinical pharmacists into the team and further evaluating the possibilities of using more ready-to-administer medications with necessary product information and pharmacovigilance support.
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Affiliation(s)
- Rania Kader
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
- Division of Pharmacokinetics and Drug Therapy, Department of Pharmaceutical Biosciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Gunnar Liminga
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
| | - Gustaf Ljungman
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
| | - Mattias Paulsson
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
- Correspondence: ; Tel.: +46-18-611-3733
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Direct Powder Extrusion of Paracetamol Loaded Mixtures for 3D Printed Pharmaceutics for Personalized Medicine via Low Temperature Thermal Processing. Pharmaceutics 2021; 13:pharmaceutics13060907. [PMID: 34205280 PMCID: PMC8234073 DOI: 10.3390/pharmaceutics13060907] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 01/20/2023] Open
Abstract
Three-dimensional printed drug development is nowadays an active area in the pharmaceutical industry, where the search for an appropriate edible carrier that permits the thermal processing of the mixture at temperature levels that are safe for the drug is an important field of study. Here, potato starch and hydroxypropyl cellulose based mixtures loaded with paracetamol up to 50% in weight were processed by hot melt extrusion at 85 °C to test their suitability to be thermally processed. The extruded mixtures were tested by liquid chromatography to analyze their release curves and were thermally characterized. The drug recovery was observed to be highly dependent on the initial moisture level of the mixture, the samples being prepared with an addition of water at a ratio of 3% in weight proportional to the starch amount, highly soluble and easy to extrude. The release curves showed a slow and steady drug liberation compared to a commercially available paracetamol tablet, reaching the 100% of recovery at 60 min. The samples aged for 6 weeks showed slower drug release curves compared to fresh samples, this effect being attributable to the loss of moisture. The paracetamol loaded mixture in powder form was used to print pills with different sizes and geometries in a fused deposition modelling three-dimensional printer modified with a commercially available powder extrusion head, showing the potential of this formulation for use in personalized medicine.
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11
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Brustugun J, Notaker N, Paetz LH, Tho I, Bjerknes K. Adjusting the dose in paediatric care by dispersing fragments of four different aspirin tablets. Acta Paediatr 2020; 109:2394-2401. [PMID: 32034802 PMCID: PMC7687227 DOI: 10.1111/apa.15216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 11/28/2022]
Abstract
AIM Tablets can be manipulated in several ways to obtain a fraction as the dose-a practice frequently seen in paediatric care due to lack of suitable formulations. Splitting tablets prior to fragment dispersion in a small volume of liquid is one such method. The objective of this study was to investigate the accuracy and precision of this method. METHODS Four different types of aspirin tablets (two dispersible, one conventional and one chewing) were split with a tablet splitter into half and quarter fragments. The fragments were dispersed in a medicine measure or an oral syringe. The amount recovered was determined by UHPLC analysis. RESULTS The largest quarter fragments ranged from 26.7% to 31.5% of the full tablet weight. Dispersing the fragment in an oral syringe, the amount recovered was greater than 90.8% of the fragment manipulated for all four tablet types, when rinsing was performed. Dispersing the fragment in a medicine measure, the amounts recovered spanned from 32.9% for the conventional tablets to 98.7% for one of the dispersible tablets. CONCLUSION Dispersion of half or quarter tablets directly in an oral syringe, but not a medicine measure, could give satisfactory recovery from fragments of all the investigated aspirin tablets.
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Affiliation(s)
| | - Nikolai Notaker
- Department of Pharmacy Faculty of Mathematics and Natural Sciences University of Oslo Oslo Norway
| | - Lasse Holtan Paetz
- Department of Pharmacy Faculty of Mathematics and Natural Sciences University of Oslo Oslo Norway
| | - Ingunn Tho
- Department of Pharmacy Faculty of Mathematics and Natural Sciences University of Oslo Oslo Norway
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12
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Zahn J, Hoerning A, Trollmann R, Rascher W, Neubert A. Manipulation of Medicinal Products for Oral Administration to Paediatric Patients at a German University Hospital: An Observational Study. Pharmaceutics 2020; 12:E583. [PMID: 32586000 PMCID: PMC7355957 DOI: 10.3390/pharmaceutics12060583] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/17/2020] [Accepted: 06/20/2020] [Indexed: 01/06/2023] Open
Abstract
Pharmacotherapy in children requires medicinal products in age-appropriate dosage forms and flexible dose strengths. Healthcare professionals often encounter a lack of licensed and commercially available formulations, which results in the need for manipulation. This study aimed to investigate the nature, frequency and preventability of the manipulation of medicinal products before oral drug administration to paediatric inpatients in Germany. A prospective, direct observational approach was used. Two thousand and three medication preparation processes (MPP) in 193 patients were included in the analysis. Medicines were manipulated in 37% of oral administrations, affecting 57% of the patients. The percentage of manipulations was highest in infants/toddlers (42%) and lowest in adolescents (31%). Antiepileptics were most frequently manipulated (27%), followed by vitamins (20%) and drugs for acid-related disorders (13%). Fifty-six per cent of all manipulations were off-label. In 71% of these, no alternative appropriate medicinal product was commercially available. These results demonstrate that the manipulation of medicinal products before oral administration is common in paediatric wards in Germany. About half of the manipulations were off-label, indicating that no suitable formulation was available. Evidence-based guidelines for manipulations are required, with the overall aim of improving the safety of paediatric drug therapy.
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Affiliation(s)
- Julia Zahn
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (A.H.); (R.T.); (W.R.)
| | | | | | | | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (A.H.); (R.T.); (W.R.)
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Brustugun J, Birkedal Aas E, Tho I, Bjerknes K. Comparing Two Methods of Tablet Manipulation to Adjust the Warfarin Dose in Paediatric Care. Pharmaceutics 2020; 12:E375. [PMID: 32325777 PMCID: PMC7238213 DOI: 10.3390/pharmaceutics12040375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 11/24/2022] Open
Abstract
Tablets containing prescribed doses are not always available, and this is of particular importance in paediatric care where suitable age-appropriate formulations are generally lacking. To obtain a child-adjusted dose, tablets are manipulated in several ways; e.g., they may be dispersed in water before a fraction is extracted, or they may be split before the resulting fragment is dispersed. In this study, the accuracy attained through these manipulation methods was investigated for two generic tablets containing the anticoagulant warfarin. Tablets were dispersed in water (10 mL) before a fraction (10%) was withdrawn, alternatively tablets were split in half or quarter fragments before the fragments were dispersed in water. To investigate the contribution of variability from the different steps in the manipulation processes, the amount of warfarin recovered from the various dispersions was determined, as was the accuracy of the splitting. A validated UHPLC-method was used for quantitative determination of warfarin. Splitting of the tablets could result in deviation >30% from the ideal, theoretical weight. The amount of drug substance extracted as a fraction from the dispersed tablets deviated no more than 10% from the intended amount. To obtain the most accurate child-adjusted fraction dose of warfarin, the tablets investigated in this study should be dispersed and the desired proportion extracted. Practices that involve splitting tablets are likely to increase the variation, and should be avoided.
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Affiliation(s)
- Jørgen Brustugun
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
| | - Elisabeth Birkedal Aas
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
- Department of Pharmacy, University of Oslo, 0316 Oslo, Norway
| | - Ingunn Tho
- Department of Pharmacy, University of Oslo, 0316 Oslo, Norway
| | - Kathrin Bjerknes
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
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