Effectiveness of pediatric pill swallowing interventions: a systematic review

Drinkable in situ-forming tough hydrogels for gastrointestinal therapeutics

Pills are a cornerstone of medicine but can be challenging to swallow. While liquid formulations are easier to ingest, they lack the capacity to localize therapeutics with excipients nor act as controlled release devices. Here we describe drug formulations based on liquid in situ-forming tough (LIFT) hydrogels that bridge the advantages of solid and liquid dosage forms. LIFT hydrogels form directly in the stomach through sequential ingestion of a crosslinker solution of calcium and dithiol crosslinkers, followed by a drug-containing polymer solution of alginate and four-arm poly(ethylene glycol)-maleimide. We show that LIFT hydrogels robustly form in the stomachs of live rats and pigs, and are mechanically tough, biocompatible and safely cleared after 24 h. LIFT hydrogels deliver a total drug dose comparable to unencapsulated drug in a controlled manner, and protect encapsulated therapeutic enzymes and bacteria from gastric acid-mediated deactivation. Overall, LIFT hydrogels may expand access to advanced therapeutics for patients with difficulty swallowing.

Acceptability of compounded preparations - A Romanian pediatric hospital perspective

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

A comprehensive assessment of machine learning algorithms for enhanced characterization and prediction in orodispersible film development

Orodispersible films (ODFs) have emerged as innovative pharmaceutical dosage forms, offering patient-specific treatment through adjustable dosing and the combination of diverse active ingredients. This expanding field generates vast datasets, requiring advanced analytical techniques for deeper understanding of data itself. Machine learning is becoming an important tool in the rapidly changing field of pharmaceutical research, particularly in drug preformulation studies. This work aims to explore into the application of machine learning methods for the analysis of experimental data obtained by ODF characterization in order to obtain an insight into the factors governing ODF performance and use it as guidance in pharmaceutical development. Using a dataset derived from extensive experimental studies, various machine learning algorithms were employed to cluster and predict critical properties of ODFs. Our results demonstrate that machine learning models, including Support vector machine, Random forest and Deep learning, exhibit high accuracy in predicting the mechanical properties of ODFs, such as flexibility and rigidity. The predictive models offered insights into the complex interaction of formulation variables. This research is a pilot study that highlights the potential of machine learning as a transformative approach in the pharmaceutical field, paving the way for more efficient and informed drug development processes.

Evaluating the Acceptability, Swallowability, and Palatability of Film-Coated Mini-Tablet Formulation in Young Children: Results from an Open-Label, Single-Dose, Cross-Over Study

Mini-tablets are advantageous over liquid formulations in overcoming challenges related to stability, taste, and dosage. This open-label, single-dose, cross-over study investigated the acceptability and safety of drug-free, film-coated mini-tablets in children aged 1 month-6 years (stratified: 4-6 years, 2-<4 years, 1-<2 years, 6-<12 months, and 1-<6 months), and their preference for swallowing either a high quantity of 2.0 mm or a low quantity of 2.5 mm diameter mini-tablets. The primary endpoint was acceptability derived from swallowability. The secondary endpoints were investigator-observed palatability, acceptability as a composite endpoint derived from both swallowability and palatability, and safety. Of 320 children randomized, 319 completed the study. Across all tablet sizes, quantities and age groups, acceptability rates based on swallowability were high (at least 87%). Palatability was rated as "pleasant/neutral" in 96.6% of children. The acceptability rates as per the composite endpoint were at least 77% and 86% for the 2.0 mm and 2.5 mm film-coated mini-tablets, respectively. No adverse events or deaths were reported. Recruitment in the 1-<6-months group was stopped early due to coughing-evaluated as "choked on" in three children. Both 2.0 mm and 2.5 mm film-coated mini-tablets are suitable formulations for young children.

Drugs for neglected tropical diseases: availability of age-appropriate oral formulations for young children

It is recognised that paediatric indications and age-appropriate formulations are required to ensure that paediatric populations receive appropriate pharmacotherapeutic treatment. The lack of information on dosing, efficacy and safety data (labelling) is a well-recognised problem for all diseases affecting children. For neglected tropical diseases, the fact that they affect to a large extent poor and marginalised populations in low- and middle-income countries means that there is a low economic return on investment into paediatric development activities compared to other diseases [e.g. human immunodeficiency virus (HIV)]. This review provides an introduction to issues affecting the availability and development of paediatric population-relevant data and appropriate formulations of drugs for NTDs. We are summarising why age-appropriate formulations are important to ensure treatment efficacy, safety and effectiveness, outline initiatives to increase the number of paediatric indications/labelling and age-appropriate formulations, provide an overview of publicly available information on the formulations of oral drugs for NTDs relative to age appropriateness and give an introduction to options for age-appropriate formulations. The review completes with 'case studies' of recently developed paediatric formulations for NTDs, complemented by case studies for fixed-dose combinations for HIV infection in children since such formulations have not been developed for NTDs.

Development of Medication Administration Protocols for In-Home Pediatric Feeding Cases

Medication administration can be a significant issue in pediatric populations, and especially with patients with developmental disabilities and comorbid feeding disorders. Research has focused largely on consumption of solids rather than medication and liquids in pediatric feeding programs, with most studies being conducted within specialized hospital settings in the United States. No studies to our knowledge have detailed treatment evaluations for medication administration in pediatric feeding except for a few studies on pill swallowing. We report results of treatment protocols for medication administration using empirically-supported treatments in a short-term intensive home-based behavior-analytic program in Australia. Two males with autism spectrum and pediatric feeding disorders participated. We used a multiple baseline single-case experimental design for medication administration conducted concurrently with a treatment evaluation for solid foods. Consumption increased in number (9; supplements, laxatives, pain relievers), flavors (8; chocolate, blackcurrent and apple, strawberry, lemon-lime, orange, chocolate-vanilla, cherry, apple), forms (4; thin and thick liquids, chewables, gummies), and delivery methods (5; finger-fed, spoon, cup, medicine spoon, medicine cup) within the first treatment session. For one participant, we taught open cup drinking for a variety of liquids (milk, juices, medications). For both participants, we taught self-feeding with utensils for thick liquid medications. Treatment results were similar for solids and participants increased food variety to over 160 across food groups. All goals were met including training parents to maintain gains at home.

Accuracy of Antibiotic Prescription Dosing for Urinary Tract Infections in a Regional Pediatric Ambulatory Care Setting

OBJECTIVE

Antibiotics are the most common class of medication prescribed in pediatrics, with the majority of prescriptions occurring in the outpatient setting. Our objective was to evaluate the accuracy of antibiotic dose, frequency, and formulation prescribed for urinary tract infections (UTIs) in the pediatric ambulatory care setting.

METHODS

This was a retrospective review of electronic medical records conducted at 2 suburban pediatric practices in a mid-sized metropolitan region. Encounter-related prescriptions were identified using UTI-associated International Classification of Diseases, 10th Revision codes. Patients aged 2 months through 18 years were included if they had been prescribed an oral antibiotic for the treatment of UTI. Antibiotic dose, frequency, and formulation were considered accurate if consistent with clinical guidelines and tertiary dosing references.

RESULTS

Nearly 1 in 4 prescriptions had dosing inaccuracies. The proportion of errors was highest with amoxicillin-clavulanate (75%; 9/12) and amoxicillin (52%; 33/64). The most common reasons for dosing incorrectly were "low dose" or "unnecessarily high dose." Additionally, 55% of the included prescriptions were for oral suspensions, and 1 in 4 of these were dosed incorrectly.

CONCLUSIONS

Inaccuracies in antibiotic prescribing for pediatric UTI are common, including for frequently prescribed agents and oral formulations. To address these missed opportunities for stewardship in the outpatient setting, key educational sessions with providers should include reviewing optimal antibiotic dosing for uropathogens and highlighting common errors when oral suspensions are prescribed.

Treatment of Plexiform Neurofibromas with MEK Inhibitors: First Results with a New Therapeutic Option

Neurofibromatosis type-1 (NF1)-associated plexiform neurofibromas (PN) are peripheral nerve sheath tumors that can significantly affect the quality of life. Until recently, surgery was the only treatment for these tumors. However, in most cases, surgery cannot achieve complete tumor removal and carries a high risk of postoperative deficits. Therefore, the recent approval of the MEK inhibitor selumetinib for the treatment of NF1-associated PN provides a long-awaited novel therapeutic option. Here, we report our experience with MEK inhibitor treatment in 12 pediatric NF1 patients with inoperable symptomatic PN. Eight patients received trametinib (median therapy duration 12.13 months and range 4-29 months), and four patients received selumetinib (median therapy duration 6.25 months and range 4-11 months). Volumetric magnetic resonance imaging (MRI) after 6 months of treatment was available for seven trametinib patients (median tumor volume reduction of 26.5% and range 11.3-55.7%) and two selumetinib patients (21.3% tumor volume reduction in one patient and +3% tumor volume change in the other one). All patients reported clinical benefits such as improved range of motion or reduced disfigurement. Therapy-related adverse events occurred in 58.3% of patients and mainly consisted of skin toxicity, paronychia, and gastrointestinal symptoms. Two patients discontinued trametinib treatment after 14 and 29 months when severe skin toxicity occurred and no further reduction of tumor size was observed. In one patient, discontinuation of therapy resulted in a 27.2% tumor volume increase as demonstrated on volumetric MRI 6 months later. Our data show that MEK inhibition is a novel therapeutic approach for inoperable PN with promising results and a manageable safety profile.

Data-Enriched Edible Pharmaceuticals (DEEP) with Bespoke Design, Dose and Drug Release

Data-enriched edible pharmaceuticals (DEEP) is an approach to obtain personalized medicine, in terms of flexible and precise drug doses, while at the same time containing data, embedded in quick response (QR) codes at a single dosage unit level. The aim of this study was to fabricate DEEP with a patient-tailored dose, modify drug release and design to meet patients' preferences. It also aimed to investigate physical stability in terms of the readability of QR code patterns of DEEP during storage. Cannabinoids, namely, cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC), were used as the model active pharmaceutical ingredients (APIs). Three different substrates and two colorants for the ink were tested for their suitability to fabricate DEEP by desktop inkjet printing. Flexible doses and customizable designs of DEEP were obtained by manipulating the digital design of the QR code, particularly, by exploring different pattern types, embedded images and the physical size of the QR code pattern. Modification of the release of both APIs from DEEP was achieved by applying a hydroxypropyl cellulose (HPC) polymer coating. The appearance and readability of uncoated and polymer-coated DEEP did not change on storage in cold and dry conditions; however, the HPC polymer layer was insufficient in preserving the readability of the QR code pattern in the extreme storage condition (40 °C and 75% relative humidity). To sum up, the DEEP concept provides opportunities for the personalization of medicines, considering also patients' preferences.

Feasibility of developing children's Pill School within a UK hospital

OBJECTIVE

We assessed the feasibility of introducing an intervention (children's Pill School-PS) within a UK hospital to provide swallowing training for children, identified the proportion of children who can be switched from oral liquid medicines to pills and assessed children/parents' opinions about the PS training.

METHODS

30 inpatient children (aged 3-18 years; taking oral liquid medicines; their liquid medications assessed suitable for switching to pills; can (and their parents) speak/understand English were included. Training sessions were delivered using hard sweets of different sizes.

RESULTS

87% (26) of children successfully learnt how to swallow pills after one training session (mean duration 14.5 min), and 92% (24) were discharged on pills. 75 prescribed oral liquid medications were deemed suitable for switching to pills. Of these, 89% (67) were switched successfully.

CONCLUSION

Children as young as 3 years were successful in swallowing pills after training. Providing children PS training session within hospital is feasible and acceptable to children and their parents.

Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient's age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient's needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

Contribution and Acceptability of Bacteriological Collection Tools in the Diagnosis of Tuberculosis in Children Infected with HIV

OBJECTIVE

The objective of this study is to evaluate the feasibility and tolerability of new bacteriological samples to diagnose tuberculosis (TB) in HIV-infected children.

METHOD AND PATIENTS

HIV1-infected children with suspicion of TB in Universitary Hospital Sourô Sanon (Burkina Faso) were included in a prospective cohort study. Children underwent three gastric aspirates (GA) if aged <4 years; two GA, one string test (ST) if aged 4-9 years and three sputum, one ST if aged 10-13 years. All children underwent one nasopharyngeal aspirate (NPA) and one stool sample. To assess feasibility and tolerability of procedures, adverse events were identified and pain was rated on different scales. Samples were tested by microscopy, culture, GeneXpert® (Xpert®).

RESULTS

Sixty-three patients were included. Mean age was 8.92 years, 52.38% were females. Ninety-five GA, 67 sputum, 62 NPA, 60 stool and 55 ST had been performed. During sampling, the main adverse events were cough at 68/95 GA and 48/62 NPA; sneeze at 50/95 GA and 38/62 NPA and vomiting at 4/55 ST. On the behavioral scale, the average pain score during collection was 6.38/10 for GA; 7.70/10 for NPA and 1.03/10 for ST. Of the 31 cases of TB, bacteriological confirmation was made in 12 patients.

CONCLUSION

ST, stool is well-tolerated alternatives specimens for diagnosing TB in children. NPA has a poor feasibility and tolerability in children.

Adherence Barriers for Adolescent and Young Adult Transplant Recipients: Relations to Personality

OBJECTIVE

Much of the extant literature on adherence barriers has focused on modifiable factors (e.g., knowledge, social support); however, less is known about how barriers may be associated with relatively stable constructs, such as personality traits. The current study examines associations between personality (i.e., agreeableness, conscientiousness, neuroticism) and adherence barriers in a group of adolescent and young adult (AYA) solid organ transplant recipients. Demonstrating associations between barriers and personality may help in understanding why barriers are stable over time. Additionally, different personality traits may relate to different types of barriers.

METHODS

The sample included 90 AYAs (Mage = 17.31; SD = 2.05; 58% male) who received a kidney (n = 36), liver (n = 29), or heart (n = 25) transplant at least 1 year prior to study enrollment. AYAs completed the Agreeableness, Conscientiousness, and Neuroticism scales from the NEO Five-Factor Inventory and the Adolescent Medication Barriers Scale (AMBS).

RESULTS

Lower levels of agreeableness and conscientiousness and higher levels of neuroticism were related to higher self-reported barrier scores (AMBS; r's = .31- .53, p's < .001). The relations differed by personality factor and barrier type.

CONCLUSION

Adherence barriers showed medium to large associations with personality traits that are known to be relatively stable. Our findings indicate that the temporal stability of barriers to adherence may be due in part to their association with relatively enduring personality characteristics.

The KidzMed project: teaching children to swallow tablet medication

Tablets are safer, more convenient and cheaper than liquid medications. Children and young people (CYP) often remain on liquids due to habit, reluctance to change or staff and parents' lack of knowledge about switching to tablets. We describe a quality improvement project to train staff and embed a system of converting eligible children to tablet medication. A series of tests of change were made including training, making kit available, publicity and developing team protocols. In 3 months, 21 out of 25 eligible CYP were successfully converted with added benefit of saving £46 588 per year. Switching children to tablets is simple but requires whole team engagement, culture change of expectations and available resources.

Attention-Deficit Hyperactivity Disorder, Disruptive Behaviors, and Drug Shortage

Kyle is a 10-year-old boy with Down syndrome and intellectual disability who is being followed up by a developmental behavioral pediatrician for attention-deficit hyperactivity disorder (ADHD) and anxiety. Kyle was initially taking a long-acting liquid formulation of methylphenidate for ADHD and fluoxetine for anxiety. Several months ago, the liquid formulation was on back order, and the methylphenidate formulation was changed to an equal dose of a long-acting capsule. Kyle is not able to swallow pills; therefore, the contents of the capsule were sprinkled onto 1 bite of yogurt each morning. Over the course of the next month, Kyle's behaviors became increasingly difficult. He was not able to tolerate loud or crowded places, and despite a visual schedule and warnings, he would become aggressive toward adults when directed to transition away from preferred activities. Fluoxetine was increased from 0.4 to 0.6 mg/kg/day at that time.One month later, his parents reported that although there may have been slight improvement in Kyle's irritability since the increase in fluoxetine, they felt he was nonetheless more aggressive and less cooperative than his previous baseline. Kyle was returned to the long-acting liquid formulation of methylphenidate at that time, and a follow-up was scheduled 2 weeks later.On return to clinic, his parents reported that Kyle's behaviors had continued to become increasingly difficult. He was described as uncooperative and aggressive at home and school. Kyle was easily upset any time he was not given his way, his behavior was corrected, or he felt that he was not the center of attention. When upset, he would yell, bite, kick, spit, or throw his body to the ground and refuse to move. At 110 pounds, Kyle's parents were no longer able to physically move his body when he dropped to the ground. This was a safety concern for his parents because he had displayed this behavior in the parking lot of a busy shopping area. Because of Kyle's aggressive and unpredictable behavior, parents no longer felt comfortable taking him to public places. Family members who had previously been comfortable staying with Kyle while his parents were out for short periods would no longer stay with him. Overall, the behaviors resulted in parents being unable to go to dinner as a couple or provide individual attention to their other children. The parents described the family as "on edge." How would you approach Kyle's management?

An Open-Label Study Evaluating the Pharmacokinetics and Safety of Diclofenac Potassium for Oral Solution for the Acute Treatment of MWA or MWoA in Pediatric Participants

OBJECTIVE

To evaluate the pharmacokinetics, safety, and tolerability of a single 50-mg oral dose of diclofenac potassium for oral solution (OS) in a pediatric cohort with a diagnosis of episodic migraine; the 3-month safety trial following an outpatient dosing period was also evaluated.

BACKGROUND

Children and adolescents often experience migraine pain that is poorly controlled, which may affect their emotional and psychological well-being. Diclofenac potassium for OS is approved for the treatment of migraine with aura (MWA) or migraine without aura (MWoA) in adults 18 years of age or older. It is formulated in a soluble buffered powder that provides more rapid absorption than the tablet formulations of diclofenac potassium. In a randomized, double-blind, crossover trial, more adult patients were pain-free at 2 hours post-dose following treatment with diclofenac potassium for OS than those who received the diclofenac tablet formulation or placebo.

METHODS

This was a Phase 4 open-label study that took place at 2 US sites. Participants 12-17 years of age with a diagnosis of episodic MWA or MWoA for ≥3 months and ≤14 headaches per month were enrolled in the study. Participants received one 50-mg dose of diclofenac potassium for OS under fasted conditions on day 1. Blood samples were collected for PK analysis within 15 minutes pre-dose and at 5, 10, 15, 20, 30, 40, and 60 minutes post-dose, and at 2, 4, and 6 hours post-dose. Safety evaluations were performed after the initial dose and at the end of study on day 90; adverse events were monitored throughout the study. After completing the PK assessments, participants were given a 3-month supply (27 packets) of diclofenac potassium for OS (50-mg doses) for their migraine attacks. Participants were advised to take diclofenac potassium for OS at the onset of a migraine. They were told to take no more than 2 doses daily and not to use it more than 3 days/week.

RESULTS

Twenty-five participants completed the study; 84% were females and 96% were white or Caucasian, with a mean age of 15.5 years and a mean weight of 63.1 kg. Diclofenac was rapidly absorbed with a median time to maximum concentration of 15 minutes and a mean peak plasma concentration of 1412 (±846.2) ng/mL. Diclofenac had a half-life of 66.8 (±9.2) minutes. The mean area under the concentration-time curve from zero to the last measurable time point was 82,920.0 (±25,327.6) minutes × ng/mL, and the mean area under the concentration-time curve from time zero to infinity was 84,388.8 (±25,993.6) minutes × ng/mL. Participants took the study drug an average of 10 times over 79 days, with an overall total drug exposure of 506 mg. No deaths or discontinuations due to an AE were reported during the study. The most frequently reported treatment emergent adverse events were arthralgia and motion sickness, each of which occurred in 2 (8%) of the participants.

CONCLUSIONS

Diclofenac potassium for OS exhibited a favorable pharmacokinetic and safety profile in 12- to 17-year-old patients with a diagnosis of episodic MWA or MWoA.

Pharmacokinetics of AR19, an Immediate-Release Amphetamine Sulfate Formulation Designed to Deter Manipulation for Administration Via Nonoral Routes: Bioequivalence to Reference Racemic Amphetamine Sulfate, Dose Proportionality, and Food Effect

Objectives: We evaluated the pharmacokinetics (PK) of an investigational immediate-release amphetamine (AMP) sulfate formulation (AR19) designed to deter nonoral administration versus reference racemic amphetamine sulfate (RA-AMPH). We investigated AMP bioavailability from AR19, the effect of taking AR19 with food or sprinkling the capsules on food, and dose proportionality. Methods: Participants received AR19 (20 mg) or reference RA-AMPH (20 mg) (bioequivalence study) or AR19 5 or 30 mg (dose comparison study). Food effect study participants received AR19 (20 mg) as intact capsule while fasted or after high-fat/-calorie meal, or as pellets sprinkled on applesauce or yogurt (≥6-day washout). Blood samples were analyzed for dextroamphetamine (d-AMP) and levoamphetamine (l-AMP) PK: C_max, AUC_last, AUC_inf, λ_z, T_½, and T_max. Safety was assessed. Results: Bioequivalence, dose comparison, and food effect studies included 36, 24, and 36 participants. The 90% confidence intervals (CIs) of C_max, AUC_last, and AUC_inf for AR19 20 mg versus reference RA-AMPH or AR19 with intact capsule and meal or sprinkled AR19 pellets on food versus fasted were between 80% and 125%. Dose-normalized C_max/D, AUC_last/D, and AUC_inf/D for AR19 5 versus 30 mg had CIs within 80%-125%. Mean ± standard deviation (SD) T_max was comparable for AMP (d-AMP; l-AMP) following AR19 20 mg (2.84 ± 1.05; 3.05 ± 1.22) versus reference RA-AMPH (2.52 ± 0.75; 2.75 ± 1.00), and AR19 5 mg (2.48 ± 0.57; 2.65 ± 0.65) versus AR19 30 mg (2.55 ± 0.56; 2.72 ± 0.65). Mean ± SD T_max for AMP (d-AMP; l-AMP) was higher with intact capsule and meal (5.59 ± 1.57; 5.59 ± 1.59) versus fasted (2.85 ± 0.76; 2.97 ± 0.79). No serious adverse events were reported. Conclusion: AR19 was bioequivalent to reference RA-AMPH. Bioavailability was similar at doses between 5 and 30 mg and was not impacted by meal consumption or sprinkling on food. AR19 at tested doses was well tolerated.

The Stability and Influence of Barriers to Medication Adherence on Seizure Outcomes and Adherence in Children With Epilepsy Over 2 Years

Objective

To determine the stability and influence of adherence barriers on medication adherence and seizure control in pediatric epilepsy.

Methods

Caregivers of 118 children aged 2-12 years old with epilepsy completed the Pediatric Epilepsy Medication Self-Management Questionnaire at nine time points over 2 years post diagnosis. Electronically monitored antiepileptic drug adherence and seizure outcome data were collected.

Results

Hierarchical linear modeling results for overall barriers remained stable over 2 years. Specific item-level barriers were also generally stable over time, with the exception of running out of medication becoming more of a barrier over time. No specific barriers were related to seizure control; however, difficulties swallowing medication, forgetting, and medication refusal were related to electronically monitored adherence over time.

Conclusions

Assessing for specific adherence barriers over time may lead to identification of interventions that result in improved adherence and care.

Optimizing opioid prescribing and pain treatment for surgery: Review and conceptual framework

Purpose

Millions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period.

Methods

We reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts.

Results

Opioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment’s ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes.

Conclusions

The severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.

Bioavailability and swallowability of an age-appropriate, delayed-release mesalamine formulation in healthy volunteers

Objective: Delayed-release mesalamine 400 mg capsules containing four 100 mg tablets have been developed for children with ulcerative colitis who have difficulty swallowing. Bioavailability of the mesalamine capsules was compared with existing mesalamine tablets in healthy adults, and the effect of food on bioavailability from mesalamine capsules was determined. Tablet swallowability in healthy children was evaluated.

Methods: In the open-label, replicate-treatment, single-dose, crossover, comparative bioavailability study, healthy adult volunteers were randomized to one of four treatment sequences to receive mesalamine 400 mg tablets (fasted) twice, mesalamine 400 mg capsules (fasted) twice, and a mesalamine 400 mg capsule (with food) once, with ≥7 days between treatments. Pharmacokinetic (PK) parameters were calculated and analyzed using the reference-scaled average bioequivalence procedure. In the open-label, single-dose swallowability study, healthy children aged 5–11 years were asked to swallow eight placebo tablets identical to those contained in two mesalamine capsules.

Results: In the bioavailability study (n=160), mesalamine capsules and tablets in fasted volunteers exhibited similarly delayed absorption and were shown to be bioequivalent; statistical parameters calculated from PK values met the criteria for bioequivalence. A slight increase in mesalamine bioavailability was observed with food administration, but the delayed-release performance of the capsules was not affected. Overall safety profiles between capsules and tablets were similar. In the swallowability study (n=60), the majority of children swallowed eight placebo tablets, with slight variability between age groups.

Conclusion: Evaluation of PK parameters confirmed mesalamine capsules are bioequivalent to mesalamine tablets. Mesalamine capsules were well tolerated, can be administered with or without food, and are an age-appropriate product for children.

Greater number of perceived barriers to hydroxyurea associated with poorer health-related quality of life in youth with sickle cell disease

BACKGROUND

Despite medical benefits, hydroxyurea adherence in adolescents is often poor. As part of a baseline assessment of 28 youth (10-18 years) parent dyads who participated in a 6-month feasibility trial to improve hydroxyurea adherence, we measured the relationship between greater barriers to adherence and health-related quality of life (HRQL) from youth and parent perspectives.

PROCEDURE

Barriers were measured using the Adolescent and Parent Medication Barriers Scales with nine hydroxyurea items added. Barriers reported by ≥25% of the sample were considered common. Generic and disease-specific HRQL were measured by PedsQL and PedsQL Sickle Cell Disease modules. Data were analyzed using descriptive statistics, Cronbach alpha, Spearman correlation coefficients, and paired t tests.

RESULTS

Fifty-six subjects (28 dyads) participated. Youth reported greater barriers compared with parents (5.0 ± 3.9 and 3.5 ± 3.2; P = 0.03), with >80% of respondents reporting ≥1 barriers. Twelve barriers were reported by ≥25% of adolescents, whereas six were reported by ≥25% of parents. Of these, only two were common to both dyad members. Approximately one-third of youth had generic and disease-specific HRQL scores that fell at or below cutoff scores, suggesting being at risk for impaired HRQL. Greater barriers were inversely associated with poorer generic (parent r = -0.43, P = 0.03; youth r = -0.44, P < 0.001) and disease-specific HRQL (parent r = -0.53, P = 0.005; youth r = -0.53, P < 0.001).

CONCLUSIONS

Hydroxyurea barriers were frequently reported but differed by dyad members' perspective. Greater barriers were associated with poorer generic and disease-specific HRQL. To reduce barriers to hydroxyurea in youth with sickle cell disease, perspectives of both dyad members should be addressed.

Multifaceted Approach to Enhance Pill-Swallowing Ability in Children and Adults With Barth Syndrome

Importance: People with Barth syndrome (BTHS) present with sensory and motor deficits that affect their ability to swallow medications in solid form. Inability to swallow pills can reduce opportunities for people with BTHS to participate in clinical trial research.

Objective: To evaluate the effectiveness of a brief, multifaceted pill-swallowing program that used evidence-based training methods.

Design: Pretest–posttest with 6-mo follow-up.

Setting: Community setting.

Participants: A convenience sample of children, adolescents, and adults with a genetically confirmed diagnosis of BTHS.

Intervention: Possible intervention strategies included behavioral approaches (e.g., shaping), adaptive approaches, and positioning approaches. Interventions were tailored to each participant’s needs and were carried out by occupational therapy practitioners with advanced training in feeding and eating.

Outcomes and Measures: Pill-swallowing milestones were ranked on a scale ranging from 0 to 12; participants were scored pretraining, immediately posttraining, and at 6-mo posttraining.

Results: Sixteen participants with BTHS, ages 6–34 yr, participated in the training. Fourteen of the 16 participants demonstrated improvement in their pill-swallowing ability. Overall, there was a statistically significant change in pill-swallowing ability from pretraining to posttraining, and these changes were maintained after 6 mo.

Conclusions and Relevance: This study suggests that a brief multifaceted training approach, led by trained professionals, may be effective for helping people with sensory and motor deficits learn to swallow pills independently.

What This Article Adds: Very little has been published in the occupational therapy literature describing how to teach the skill of pill swallowing to clients or how to measure progress toward this goal. This study tested the outcomes of a multifaceted approach to pill swallowing that can be conducted by occupational therapy practitioners; a novel measurement approach is also introduced that can be used with clients in clinical practice.

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

Objective

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

Methods

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

Results and Conclusions

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

Electronic supplementary material

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

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis and treatment of ADHD in children vs adults: What nurses should know

Attention-deficit/hyperactivity disorder (ADHD) commonly occurs in childhood and may persist into adulthood. Important differences exist between pediatric and adult ADHD with regard to symptoms, comorbidities, diagnosis, and management. Both patient populations benefit from a treatment plan tailored to individual patient needs, and the availability of new stimulant formulations contributes to treatment personalization. To guide nurses' clinical practice in improving ADHD treatment outcomes, this review examines the differences between pediatric and adult ADHD and new treatment options.

Feasibility of the string test for tuberculosis diagnosis in children between 4 and 14 years old

BACKGROUND

The enteric string test can be used to obtain a specimen for microbiological confirmation of tuberculosis in children, but it is not widely used for this. The aim of this analysis to evaluate this approach in children with tuberculosis symptoms.

METHODS

We conducted a cross-sectional study to assess children's ability to complete the test (feasibility), and self-reported pain (tolerability). We examined caregivers' and children's willingness to repeat the procedure (acceptability) and described the diagnostic yield of cultures for diagnostic tools. We stratified estimates by age and compared metrics to those derived for gastric aspirate (GA).

RESULTS

Among 148 children who attempted the string test, 34% successfully swallowed the capsule. Feasibility was higher among children aged 11-14 than in children 4-10 years (83% vs 22% respectively, p < 0.0001). The string test was better tolerated than GA in both age groups; however, guardians and older children reported higher rates of willingness to repeat GA than the string test (86% vs. 58% in children; 100% vs. 83% in guardians). In 9 children with a positive sputum culture, 6 had a positive string culture. The one children with a positive gastric aspirate culture also had a positive string culture.

CONCLUSION

Although the string test was generally tolerable and accepted by children and caregivers; feasibility in young children was low. Reducing the capsule size may improve test success rates in younger children.

Dosage form modification and oral drug delivery in older people

Many people cannot swallow whole tablets and capsules. The cause ranges from difficulties overriding the natural instinct to chew solids/foodstuff before swallowing, to a complex disorder of swallowing function affecting the ability to manage all food and fluid intake. Older people can experience swallowing difficulties because of co-morbidities, age-related physiological changes, and polypharmacy. To make medicines easier to swallow, many people will modify the medication dosage form e.g. split or crush tablets, and open capsules. Some of the challenges associated with administering medicines to older people, and issues with dosage form modification will be reviewed. Novel dosage forms in development are promising and may help overcome some of the issues. However, until these are more readily available, effective interdisciplinary teams, and improving patient health literacy will help reduce the risk of medication misadventures in older people.

Current opinions and recommendations of paediatric healthcare professionals - The importance of tablets: Emerging orally disintegrating versus traditional tablets

The appropriate prescribing of paediatric dosage forms is paramount in providing the desired therapeutic effect alongside successful medication adherence with the paediatric population. Often it is the opinion of the healthcare practitioner that dictates which type of dosage form would be most appropriate for the paediatric patient, with liquids being both the most commonly available and most commonly used. Orally disintegrating tablets (ODTs) are an emerging dosage form which provide many benefits over traditional dosage forms for paediatric patients, such as rapid disintegration within the oral cavity, and the reduction in the risk of choking. However the opinion and professional use of healthcare practitioners regarding ODT's is not known. This study was designed to assess the opinions of several types of healthcare professionals (n = 41) regarding ODTs, using a survey across two hospital sites. Results reaffirmed the popularity of liquids for prescribing in paediatrics, with 58.0% of participants preferring this dosage form. ODTs emerged as the second most popular dosage form (30.0%), with healthcare practitioners indicating an increasing popularity amongst patients in the hospital setting, belief with 63.0% of practitioners agreeing that many liquid formulations could be substituted with a suitable ODT. The desired properties of an ideal ODT were also identified by healthcare practitioners preferring a small, fast disintegrating tablet (90.2% and 95.1% respectively), with the taste, disintegration time and flavour being the three most important attributes identified (29.5%, 28.7% and 21.7% respectively). This study provided a pragmatic approach in assessing healthcare professional's opinions on ODTs, highlighting the ideas and thoughts of practitioners who are on the frontline of paediatric prescribing and treatment and gave an indication to their preference for ODT properties.

Beyond the pill: new medication delivery options for ADHD

Successful treatment of pediatric disorders has necessitated the development of alternative medication formulations, as children may prefer alternative dosage forms to tablets or capsules. This is especially true for attention-deficit/hyperactivity disorder (ADHD), which is one of the most common chronic pediatric conditions and often involves children with a variety of overlapping physical, psychological, or neurodevelopmental disorders. A special challenge for developing alternative dosage forms for ADHD treatment is the incorporation of a once-daily long-acting formulation. Traditional ADHD medication formulations have been limited, and issues surrounding prescribed dosing regimens-including poor medication adherence, difficulty swallowing, and the lack of dosing titration options-persist in ADHD treatment. In other disease areas, the development of alternative formulations has provided options for patients who have issues with consuming solid dosage forms, particularly children and individuals with developmental disorders. In the light of these new developments, several alternative formulations for ADHD medications are under development or have recently become available. This article reviews the various strategies for developing alternative dosage forms in other disease areas and discusses the application of these strategies in ADHD treatment. Alternative dosage forms may increase medication adherence, compliance, and patient preference and, therefore, improve the overall treatment for ADHD.

Comparing swallowing of capsule to endoscopic placement of capsule endoscopy in children

Background and Aim

Capsule endoscopy (CE) offers a method of directly visualizing areas of the small bowel not accessible by conventional endoscopy. Some children are unable to swallow the capsule requiring endoscopic placement under general anesthesia. The aim of the present study was to identify any differences between children requiring endoscopic placement and those able to swallow the capsule.

Methods

Retrospective chart review of consecutive CE in a tertiary pediatric center was conducted. Patient demographics, outcomes, and complications between the two groups were noted. Paired t-test comparing continuous variables and Fisher exact test for categorical data were used.

Results

A total of 104 CEs were performed in 88 patients, median age 12.8 (range: 1.6-18.5) years. Almost half, 49% (51/104), swallowed the capsule. Children requiring endoscopic placement were significantly younger (9.8 vs 14.2 years; P < 0.001), lighter (34.5 vs 54.9 kg; P < 0.0001), and had longer small intestinal transit time (308 vs 229 min; P < 0.0001). Positive findings were more likely in those who swallowed the capsule (50% vs 30%, P = 0.017), likely a reflection of the indications for procedure. Poor views were found in 30% (16/53) of patients in the endoscopic placement group due to iatrogenic bleeding from biopsies taken from concurrent procedures but did not affect outcome or subsequent patient management.

Conclusions

CE is safe and well tolerated in children. Children requiring endoscopic placement were significantly younger, lighter, had longer small intestine transit time, and less likely to have positive findings. Concurrent biopsies during capsule placement increase the likelihood of inadequate views but did not affect outcome or management.

The Impact of Cancer and its Treatment on the Growth and Development of the Pediatric Patient

BACKGROUND

Cancer treatment can have profound effects on the growth and development of pediatric patients. Different models of psychosocial development and behavioral treatment approaches aid children receiving medical treatment. Providing education, anticipatory guidance, and individualized support to child and their families is a psychosocial standard.

OBJECTIVE

Clarify the different models of psychosocial development and applicable psychosocial interventions to better prepare and tailor cancer treatment to pediatric patients.

METHODS

Authors reviewed existing evidenced-based literature in oncology, psychology, developmental, and psychiatric while drawing on case examples and expert knowledge to illustrate the impact of cancer treatment on pediatric patients, analyze developmentally individualized needs, and describe facilitative interventions.

RESULT

Pediatric patients of all ages cope and adjust better to all phases of treatment when their care is delivered in a developmentally-informed and psychosocially thoughtful way.

CONCLUSION

Providers can comprehensively prepare their patients and families for treatment better by utilizing a psychosocially- and developmentally-informed framework while meeting individualized unique needs of patients. An integrated multidisciplinary psychosocial support team is facilitative in anticipating and meeting the needs of pediatric cancer patients and has recently become a psychosocial standard of care.

Can a Flavored Spray (Pill Glide) Help Children Swallow Their Medicines? A Pilot Study

Pediatric pharmacists are constantly faced with the challenges of supporting children and caregivers for whom the difficulties of swallowing medicines can be a daily struggle. Most medicines are only available as tablets and capsules, and where liquid alternatives exist, these products often have issues with palatability and high costs. The objective of this study was to evaluate whether the swallowing spray, Pill Glide, could help children in taking their solid and liquid medicines. This open label pilot study compared the spray with a behavioral approach alone, the current standard of care at the pediatric hospital. Patients were children on long-term drug therapies, either transitioning from liquid preparations to tablets and capsules, or known to be experiencing swallowing difficulties. Using age-adapted diaries, patients self-reported the difficulty of taking medicines on a 6-point hedonic scale for 2 weeks before the intervention, and then for 1 week while using Pill Glide. Data were analyzed from 10 children aged 6 to 16 years, with an average burden of 3.5 tablets per day. Pill Glide (strawberry was the most popular flavor) was shown to significantly decrease the overall medicine taking difficulty score by 0.93 (range, 0.33-1.53), almost 1 hedonic face point on the scale used (P = .002). There was insufficient data for liquid medicines. Pill Glide could help children with pill swallowing, thus improving patient acceptability of medicines and potentially adherence. It could also be implemented as a useful cost-saving intervention because solid dosage forms are cheaper.

Tablet/Capsule Size Variation Among the Most Commonly Prescribed Medications for Children in the USA: Retrospective Review and Firsthand Pharmacy Audit

INTRODUCTION

Children are frequently asked to take tablets and capsules of different sizes and shapes to manage acute and chronic medical conditions. Medication size is an important factor that contributes to compliance, yet few studies detail size variation or pediatric pharmacy inventory.

OBJECTIVE

This study assesses the available sizes and size variations of common inpatient and outpatient pediatric medications and provides an inventory of the tablet and capsule sizes available in a children's inpatient hospital pharmacy.

METHODS

We derived the most frequently prescribed oral medications from US national databases, including the IMS, Vector One(®): National (VONA) and Pediatric Health Information System (PHIS). We analyzed a composite list using the National Library of Medicine Pillbox website, which provides size measurements. Medications from a children's inpatient pharmacy were audited and hand measured for comparison.

RESULTS

We created a list of the top 15 most prescribed inpatient and outpatient pediatric tablet/capsule medications and observed a wide variation in size: acetaminophen 500 mg ranged from 5 to 22 mm in length, median 15 mm. Common pediatric antibiotics were larger and ranged from 8 to 25 mm in length, median 17 mm. Hand-measured samples from the inpatient pharmacy were often the larger pill sizes, despite smaller alternatives being available.

CONCLUSIONS

We observed a marked variation in the sizes of common pediatric tablet/capsule medications, and pharmacies that serve children may not stock the most child-friendly medications. Tablet/capsule size does not appear to be considered when decisions about tablet and capsule medication selections are made. These results should increase awareness of these sizes and affect how physicians prescribe, how pharmacies order inventory, and how insurers and pharmaceutical companies pay for and produce pediatric medications.

A Pilot Study of the Pediatric Oral Medications Screener (POMS)

OBJECTIVE

Oral medications are commonly used to treat acute and chronic conditions, but formal evaluation of a child's pill-swallowing ability rarely occurs. In this pilot study, the Pediatric Oral Medication Screener (POMS) was used to physically assess a child's pill swallowing ability and identify children who would benefit from a targeted intervention.

METHODS

We identified children 3 to 17 years old admitted to a general pediatric service over a 3-month period in 2014. Patients were asked to swallow several different-sized placebo formulations. If subjects did not meet age-based goals, they were referred for pill swallowing interventions (POMS+). Follow-up parental surveys were performed for patients completing the intervention.

RESULTS

The prospective pilot study recruited 34 patients. Twenty-eight patients (82%) passed the screening, and a majority of this group started or continued taking pill medications. Six did not pass the screen. Three of the 6 completed the intervention, improved their pill swallowing ability, and were taking oral pill medications at discharge. Parent prediction of pill swallowing was accurate only 56% of the time. Follow-up survey of the 3 families who completed POMS+ reported satisfaction with the program, and 2 of the patients had continued success with swallowing pills 5 months later.

CONCLUSIONS

The POMS was effective at identifying children who could benefit from an intervention to improve pill-swallowing ability. Our analysis demonstrated that POMS has the potential to improve patient satisfaction and discharge planning.