Propylene glycol toxicity in children

Laboratory features in acute paediatric poisoning with liquid laundry detergent capsules: a seven-year retrospective study in Romania

INTRODUCTION

The epidemiological and clinical characteristics of acute poisoning with liquid laundry detergent capsules have been comprehensively reported. However, studies of laboratory test results in these exposures are uncommon. This study analyzed the impact of the ingestion of liquid laundry detergent capsules on admission laboratory tests in paediatric patients.

METHODS

This retrospective study was conducted in the clinical toxicology unit of a paediatric poison centre between 2015 and 2021. Paediatric patients (less than 18 years of age) who ingested liquid laundry detergent capsules were included. The relationship between the European Association of Poisons Centers and Clinical Toxicologists/European Commission/International Programme on Chemical Safety Poisoning Severity Score and admission laboratory test results was assessed using Fisher's exact test or analysis of variance.

RESULTS

A total of 156 patients were included in the study. A considerable proportion of patients presented with leucocytosis, acidosis, hyperlactataemia or base deficit. The median values of white blood cell count (P = 0.042), pH (P = 0.022), and base excess (P = 0.013) were significantly different among the Poisoning Severity Score groups. Hyperlactataemia was strongly associated with the Poisoning Severity Score (P = 0.003).

DISCUSSION

Leucocytosis is a non-specific marker of severity following ingestion of liquid laundry detergent capsules. The incidence of metabolic acidosis and hyperlactataemia was higher in this study than in previous reports, but these metabolic features were not related to the severity of exposure. The exact mechanisms of toxicity are not yet known, but the high concentration of non-ionic and anionic surfactants, as well as propylene glycol and ethanol, in the capsule are likely contributing factors.

CONCLUSIONS

Pediatric patients who ingest liquid laundry detergent capsules may develop leucocytosis, metabolic acidosis, hyperlactataemia, and a base deficit.

Exposure to potentially harmful excipients in medications among neonates at a state hospital in Malaysia

OBJECTIVES

This study aimed to determine the incidence, types and predictors of Potentially Harmful Excipients (PHE) exposure among hospitalized neonates.

METHODS

A prospective observational study was conducted from March to April 2022 in neonatal wards at a state hospital in Malaysia. The PHEs of interest were aspartame, benzalkonium chloride, benzyl alcohol, benzoic acid or benzoates, ethanol, parabens, polysorbate 80, propylene glycol, saccharin sodium, sorbitol and sulfites. Product information leaflets (PILs) and summaries of product characteristics (SPCs) were referred to obtain information on active pharmaceutical ingredient, strength, trade name as well as type and amount of the excipients.

RESULTS

A total of 108 neonates were recruited and 97.2% of them were exposed to at least one PHE. Parabens (47.2%) and sulfites (27.5%) were the two most commonly administered PHEs. Benzyl alcohol is contraindicated in neonates but was administered to 8% of neonates in this study. The median daily dose of ethanol (24.11 mg/kg/day, IQR 19.73, 28.49) exceeded the acceptable daily intake (ADI) by four times. However, the dose was not available for all PHEs as this information is not always available in the PIL or SPC. Administration of cardiovascular drugs was associated with a higher risk of exposure to any PHE (OR 6.38, CI 2.75, 14.79, p-value < 0.001).

CONCLUSION

The exposure of PHE among neonates in this study is high with certain PHEs exceeding the ADI. It highlights the need for certain strategies to be implemented to reduce such exposure in neonates.

Opportunities for Community Pharmacists to Counsel Patients With Epilepsy and Seizure Clusters to Overcome Barriers and Foster Appropriate Treatment

Some patients with epilepsy experience seizure clusters, which may be defined as 2 or more seizures occurring within 24 hours. Left untreated, seizure clusters increase the risk for physical injury and may progress to status epilepticus, irreversible neurologic injury, and death. Rescue therapy is based on benzodiazepine treatment. Prompt, appropriate use should be specified in patients' individualized seizure action plans. Most seizure clusters occur outside the hospital setting. The ideal rescue therapy allows for easy and quick administration by a nonmedical person, which may minimize the need for intervention by emergency medical personnel or transportation to the hospital. In the 2 decades before the approval of 2 intranasal benzodiazepines in 2019 and 2020, rectal diazepam was the only route of administration approved by the US Food and Drug Administration specifically for seizure clusters. Each of the approved intranasal formulations has a unique profile. Both offer a convenient and socially acceptable route of administration. Recognition of seizure clusters and timing of proper administration are key to successful use of rescue therapy. Pharmacists' counseling plays an important role in reinforcing when and how to appropriately administer rescue therapies and the importance of consistently using rescue treatment when indicated to promote effective management. This review includes resources for pharmacists, patients, and caregivers; reviews currently available treatments; and discusses seizure action plans that support effective treatment of seizure clusters.

Toxicity of chemical-based hand sanitizers on children and the development of natural alternatives: a computational approach

The unintended exposure of children to hand sanitizers poses a high risk of potentially fatal complications. Skin irritation, dryness, cracking, peeling, hypoglycemia, apnea, and acidosis are examples of unintended consequences of hand sanitizer. The sanitizer reportedly kills normal microbial flora on hands, which usually promotes innate immunity among children under 12. Children are more susceptible to the toxicity associated with the chemical constituents of marketed chemical-based hand sanitizers; however, the studies to develop sanitizer formulations for children are rudimentary. The adverse events limit the use of hand sanitizers specifically in children because of their sensitive and delicate skin. Additionally, it is reported that many chemical-based hand sanitizer formulations, especially alcohol-based ones may also contain contaminants like methanol, acetaldehyde, benzene, isopropanol, and ethyl-acetate. These contaminants are found to be hazardous to human health exhibiting toxicity on ingestion, inhalation, or dermal exposure, especially in children. Therefore, it is important to design novel, innovative, safer sanitizer formulations for children. The study aims to discuss the toxic contaminants in chemical-based sanitizer formulations and propose a design for novel herbal formulations with minimal toxicity and adverse effects, especially for children. The review focuses on ADMET analysis of the common contaminants in hand sanitizers, molecular docking, Lipinski's rule of five analysis, and molecular simulation studies to analyze the efficacy of interaction with the receptor leading to anti-microbial activity and drug-likeness of the compound. The in silico methods can effectively validate the potential efficacy of novel formulations of hand sanitizers designed for children as an efficient alternative to chemical-based sanitizers with greater efficacy and the absence of toxic contaminants.

Evaluating the bioequivalence of levetiracetam brand and generic oral tablets available in the Saudi market in vivo

Background

Epilepsy is a common global neurological disorder. About 30% of epileptic patients are managed with anti-epileptic Drugs (AEDs). Since 2000, Levetiracetam (LEV) has been marketed around the world as an AED under the brand name Keppra, and recently more generics are found in the Saudi market as cheaper alternatives. The objective of this study is to evaluate the bioequivalence of LEV brand and generics available in the Saudi market in mice.

Methods

Pharmacokinetics (PK), liver function test, and behavioral studies were conducted for LEV brand and generic in different groups of Blab/c mice.

Results

PK results show a significance difference in PK parameters mostly evidenced with generic 3, then generic 2. The only significant different between Keppra and generic 1 was in T1/2. In addition, Keppra did not significantly increase liver enzymes in comparison to other generics. On the other hand, other generics showed less favorable results in increasing liver enzymes. Keppra reduced the number and intensity of epileptic attacks, had no mortality rate due to epilepsy, and was associated with less sever seizures attacks.

Conclusion

Keppra, the brand form of LEV, has better safety and efficacy profiles in mice compared to 3 generics found in the Saudi market. Therefore, we recommend evaluating the same parameters tested in this study in patients utilizing similar generics and brand to establish the existence of bioequivalence between LEV brand and generics.

Toxicity of Propylene Glycol Extract of Propolis on Central Nervous System and Liver in Pregnant and Neonatal Rats

BACKGROUND

Propolis has become one of the most preferred supplements due to its beneficial biological properties. Organic (water and vegetable oils) and chemical (ethyl alcohol, propylene glycol, and glycerol) solvents are used for propolis extraction. However, the effects of these chemicals on health should be taken into account.

OBJECTIVES

In this study, the effects of propolis extracts on health were evaluated.

METHODS

32 pregnant Wistar albino rats and 64 neonatal/young adults were given three different extractions of propolis (propylene glycol, water, and olive oil). Histopathological analyses were performed on the liver and brain, and blood samples were taken from the hearts of rats.

RESULTS

Histopathological scoring showed that the intensity of pycnotic hepatocyte, sinusoidal dilatation, and bleeding was high in liver samples of pregnant and baby rats given propylene glycol extract of propolis (p<0.05). Propylene glycol extract caused dilatation of blood vessels and apoptosis of neurons in brain tissue. The histopathological score was significantly lower in liver and brain tissues of rats treated with water and olive oil extract compared to propylene propolis groups (p<0.05). Liver enzyme levels in the blood increased in propylene propolis rats (p<0.05).

CONCLUSION

Histopathological changes and biochemical alterations may indicate that propylene glycol extracts of propolis are more toxic than olive oil and water extracts. Therefore, olive oil and water extracts of propolis are more reliable than propylene glycol extract in pregnant and infant rats.

Ambient 1,2-propanediol exposure accelerates the degradation of lipids and amino acids in milk via allosteric effects and affects the utilization of nutrients containing amide bond

The scandal of detecting 1, 2-propanediol (PL) in milk brought a crisis to the trust of consumers in the dairy industry, and the potential toxicity of PL has aroused the public concern about dietary exposure. A total of 200 pasteurized milk samples were collected from 15 regions, and the quantity of PL ranged between 0 and 0.31 g kg^-1. Pseudo-targeted quantitative metabolomics integrated with proteomics demonstrated that PL enhanced the reduction of κ-casein, β-casein, and 107 substances (41 amines and 66 amides) containing amide bonds. Pathway enrichment and topological analysis indicated that PL induced the metabolism of lipids, amino acids, oligosaccharide nucleotides, and alkaloids by accelerating the rate of nucleophilic reaction, and acetylcholinesterase, sarcosine oxidase, and prolyl 4-hydroxylase were determined as the vital enzymes related to the degradation of above nutrients. The results of molecular simulation calculation illustrated that the number of hydrogen bonds between acetylcholinesterase, sarcosine oxidase, and substrate increased to 2 and 3, respectively, while the position of hydrogen bonds between prolyl 4-hydroxylase and proline was shifted, indicating the change of conformation and the enhancement of hydrogen bond force were essential factors for the up-regulation of enzyme activity. This study first revealed the mechanism of deposition and transformation of PL in milk, which contributed to the knowledge of the quality control of milk and provided vital indicators to evaluate the adverse risks of PL in dairy products.

Effects of RU486 in Treatment of Traumatic Stress-Induced Glucocorticoid Dysregulation and Fear-Related Abnormalities: Early versus Late Intervention

Central glucocorticoid receptor (GR) activity is enhanced following traumatic events, playing a key role in the stress-related cognitive abnormalities of posttraumatic stress disorder (PTSD). GR antagonists are expected to have potential as pharmacological agents to treat PTSD-related symptoms such as anxiety and fear memory disruption. However, an incubation period is usually required and stress-induced abnormalities do not develop immediately following the trauma; thus, the optimal intervention timing should be considered. Single prolonged stress (SPS) was employed as a rodent PTSD model to examine the effects of early or late (1–7 versus 8–14 days after the SPS) sub-chronic RU486 (a GR antagonist) administration. Behaviorally, fear conditioning and anxiety behavior were assessed using the fear-conditioning test and elevated T-maze (ETM), respectively. Neurochemically, the expressions of GR, FK506-binding proteins 4 and 5 (FKBP4 and FKBP5), and early growth response-1 (Egr-1) were assessed in the hippocampus, medial prefrontal cortex (mPFC), amygdala, and hypothalamus, together with the level of plasma corticosterone. Early RU486 administration could inhibit SPS-induced behavioral abnormalities and glucocorticoid system dysregulation by reversing the SPS-induced fear extinction deficit, and preventing SPS-reduced plasma corticosterone levels and SPS-induced Egr-1 overexpression in the hippocampus. Early RU486 administration following SPS also increased the FKBP5 level in the hippocampus and hypothalamus. Finally, both early and late RU486 administration inhibited the elevated hippocampal FKBP4 level and hypothalamus GR level in the SPS rats. Early intervention with a GR antagonist aids in the correction of traumatic stress-induced fear and anxiety dysregulation.

Acute and subacute oral toxicity of propylene glycol enantiomers in mice and the underlying nephrotoxic mechanism

Propylene glycol (PG; 1,2-propanediol) has been commonly used as a food additive and vehicle in pharmaceutical preparations. PG can form rectus (R-) enantiomers and sinister (S-) enantiomers. Herein, Kunming mice were used as the animal model to evaluate the acute and subacute oral toxicity of R-PG, S-PG and RS-PG (1:1 racemic mixture of R-PG and S-PG). The median lethal doses of R-PG, S-PG and RS-PG administered by oral gavage to mice were 22.81 g/kg, 26.62 g/kg and 24.92 g/kg, respectively. In the 28-day oral subacute toxicity study, the body weight, organ weights, serum biochemical, and renal histology were examined. There was no difference in subacute toxicity among R-PG, S-PG and RS-PG. The administration of 1 and 5 g/kg/day PG for 28 days caused nephrotoxicity. The kidney somatic index and levels of blood urea nitrogen exhibited a significant increase. Moreover, the activities of superoxide dismutase, catalase, and glutathione peroxidase significantly decreased after the treatment with PG. The levels of malondialdehyde, tumor necrosis factor α, interleukin 1β, and interleukin 6 significantly increased in the kidney. The results show that the nephrotoxic effects of PG are induced by oxidative stress, and the activation of the inflammatory response is mediated by the NF-κB signaling pathway. Together, these findings provide information on R-PG, S-PG and RS-PG treatments for the risk assessment of toxicity and effects on human health.

Cumulative Risks of Excipients in Pediatric Phytomucolytic Syrups: The Implications for Pharmacy Practice

Expectorant phytomucolytic syrups are widely used pediatric OTC-medicines. Physicians, pediatricians, and pharmacists are traditionally concerned with the efficacy of the active ingredients in cough syrups, and rarely consider the safety aspects of excipients that however are not absolutely “inactive” and are proved to initiate some negative reactions and interactions with other drugs. This paper presents a review, categorization, and comparative analysis of the safety profile of excipients contained in the 22 best-selling OTC pediatric phytomucolytic syrups available in pharmaceutical markets in Ukraine and Germany and proposes an approach to the consideration of the excipients’ safety risks for a pharmacist in the process of pharmaceutical care. The study has revealed that only one of the twenty-two analyzed syrups does not contain any potentially harmful excipients. The results of this analysis were used for developing a specific decision tool for pharmacists that can be used for minimizing excipient-initiated reactions when delivering OTC phytomucolytic syrups for children.

The plasma metabolome of Atlantic salmon as studied by 1H NMR spectroscopy using standard operating procedures: effect of aquaculture location and growth stage

INTRODUCTION

Metabolomics applications to the aquaculture research are increasing steadily. The use of standardized proton nuclear magnetic resonance (¹H NMR) spectroscopy can provide the aquaculture industry with an unbiased, reproducible, and high-throughput screening tool, which can help to diagnose nutritional and disease-related metabolic disorders in farmed fish.

OBJECTIVE

Standard operating procedures developed for analysing (human) plasma by ¹H NMR were applied to fingerprint the metabolome in plasma samples collected from Atlantic salmon. The aim was to explore the metabolome of salmon plasma in relation to growth stage and sampling site.

METHODS

A total of 72 salmon were collected from three aquaculture sites in Norway (Lat. 65, 67, and 70 °N) and over two sampling events (December 2017 and November 2018). Plasma drawn from each salmon was measured by ¹H NMR and metabolites were quantified using the SigMa software. The NMR data was analysed by principal component analysis (PCA) and ANOVA-simultaneous component analysis (ASCA).

RESULTS

Important metabolic differences were evidenced, with adult salmon having a much higher content of very low-density lipoproteins and cholesterol in their plasma, while smolts displayed significantly higher levels of propylene glycol. Overall, 24% of the metabolite variation was due to the growth stage, whereas 12% of the metabolite variation was related to the aquaculture site and practice (p < 0.001).

CONCLUSION

This study provides a baseline investigation of the plasma metabolome of the Atlantic salmon and demonstrates how ¹H NMR metabolomics can be used in future investigations for comparing aquaculture practices and their influence on the fish metabolome.

MR Spectroscopy Shows Long Propylene Glycol Half-Life in Neonatal Brain

INTRODUCTION

Neonatal propylene glycol (PG) clearance is low with long plasma half-life. We hypothesized that neonatal brain PG clearance is diminished and may be related to perinatal asphyxia, infection, or stroke, via different blood-brain barrier permeability. This study aimed to estimate cerebral PG half-life with a clearance model including PG measured with MR spectroscopy (MRS) in neonates that received phenobarbital as the only PG source and to evaluate whether PG clearance was related to intracerebral pathology, for example, perinatal asphyxia, infection, or stroke.

METHODS

In this retrospective cohort study, 45 neonates receiving any dose of phenobarbital underwent MRS (short echo time single-voxel MRS at 1.5 T). Cumulative phenobarbital/PG doses were calculated. MRS indications were perinatal asphyxia (n = 22), infection (n = 4), stroke (n = 10), metabolic disease (n = 4), and others (n = 5).

RESULTS

Medians (interquartile range) included gestational age 39.4 (3.1) weeks, birth weight 3,146 (1,340) g, and cumulative PG dose 700 (1,120) mg/kg. First-order kinetics with mono-exponential decay showed cerebral PG half-life of 40.7 h and volume of distribution of 1.6 L/kg. Zero-order kinetics showed a rate constant of 0.048 mM/h and a volume of distribution of 2.3 L/kg, but the fit had larger residuals than the first-order model. There were no differences in ΔPG (i.e., PG estimated with clearance model minus PG observed with MRS) in infants with perinatal asphyxia, infection, or stroke.

DISCUSSION/CONCLUSION

This study showed a long cerebral PG half-life of 40.7 h in neonates, unrelated to perinatal asphyxia, infection, or stroke. These findings should increase awareness of possible toxic PG concentrations in neonatal brain due to intravenous PG-containing drugs.

Design of Non-Haemolytic Nanoemulsions for Intravenous Administration of Hydrophobic APIs

Among advanced formulation strategies, nanoemulsions are considered useful drug-delivery systems allowing to improve the solubility and the bioavailability of lipophilic drugs. To select safe excipients for nanoemulsion formulation and to discard any haemolytic potential, an in vitro miniaturized test was performed on human whole blood. From haemolysis results obtained on eighteen of the most commonly used excipients, a medium chain triglyceride, a surfactant, and a solubilizer were selected for formulation assays. Based on a design of experiments and a ternary diagram, the feasibility of nanoemulsions was determined. The composition was defined to produce monodisperse nanodroplets with a diameter of either 50 or 120 nm, and their physicochemical properties were optimized to be suitable for intravenous administration. These nanoemulsions, stable over 21 days in storage conditions, were shown to be able to encapsulate with high encapsulation efficiency and high drug loading, up to 16% (w/w), two water practically insoluble drug models: ibuprofen and fenofibrate. Both drugs may be released according to a modulable profile in sink conditions. Such nanoemulsions appear as a very promising and attractive strategy for the efficient early preclinical development of hydrophobic drugs.

Ultrasonic-assisted virgin coconut oil based extraction for maximizing polyphenol recovery and bioactivities of mangosteen peels

Virgin coconut oil (VCO) and propylene glycol (PG) have received more attention as bio-based solvents for natural bioactive recovery in green extraction process. Here, maceration extraction and ultrasound-assisted extraction (UAE) of bioactive phenolics from mangosteen peel (MP) by VCO, PG and VCO-PG mixture were compared. The goal was to maximize the phenolic extraction and improve bioactivities. Based on a single-factor experiment for UAE with VCO, the optimal condition was sample to solvent ratio of 1:6.6 g/mL, amplitude of 55 µm, and extraction time of 7 min, which yielded total phenolic content of 365 mg GAE/100 g. Regarding the extraction methods and bio-based solvents, UAE with mixed VCO-PG was not only provided greater polyphenol yield in a shorter time, but it also enhanced the bioactivities (radical scavenging, antibacterial, and antidiabetic activities) of the extract. Therefore, UAE can be potentially used in combination with bio-based solvents, especially mixed VCO-PG, for maximizing bioactive phenolic isolation from MP. This study provided an alternative method for production of bio-based oil solution from MP which can be directly used as a functional ingredient in emulsion based food, neutraceutical and cosmetic products.

Should we worry about children's exposure to third-hand by-products generated from electronic nicotine delivery systems?

Children and other individuals sharing spaces with END users frequently become exposed to first-, second- and third-hand chemicals. This editorial discusses the findings from a recent study exploring the impact of third-hand exposure. https://bit.ly/3cogiw0.

Neurotoxicity of e-cigarettes

It appears that electronic cigarettes (EC) are a less harmful alternative to conventional cigarette (CC) smoking, as they generate substantially lower levels of harmful carcinogens and other toxic compounds. Thus, switching from CC to EC may be beneficial for smokers. However, recent accounts of EC- or vaping-associated lung injury (EVALI) has raised concerns regarding their adverse health effects. Additionally, the increasing popularity of EC among vulnerable populations, such as adolescents and pregnant women, calls for further EC safety evaluation. In this state-of-the-art review, we provide an update on recent findings regarding the neurological effects induced by EC exposure. Moreover, we discuss possible neurotoxic effects of nicotine and numerous other chemicals which are inherent both to e-liquids and EC aerosols. We conclude that in recognizing pertinent issues associated with EC usage, both government and scientific researchers must address this public health issue with utmost urgency.

Safety, Effectiveness, and Pharmacokinetics of Crisaborole in Infants Aged 3 to < 24 Months with Mild-to-Moderate Atopic Dermatitis: A Phase IV Open-Label Study (CrisADe CARE 1)

Background

Crisaborole ointment, 2%, is a nonsteroidal phosphodiesterase 4 inhibitor for the treatment of mild-to-moderate atopic dermatitis (AD).

Objectives

The aim of this study was to evaluate the safety, effectiveness, and pharmacokinetics (PK) of crisaborole in infants aged 3 to < 24 months with mild-to-moderate AD in an open-label study.

Methods

Infants (3 to < 24 months) with Investigator’s Static Global Assessment (ISGA) of mild (2) or moderate (3) and percentage of treatable body surface area (%BSA) ≥ 5 received crisaborole twice daily for 28 days; a cohort with moderate AD per ISGA and %BSA ≥ 35 were included in a PK analysis. Endpoints included safety (primary), efficacy, and PK (exploratory).

Results

Included were 137 infants total (mean age [SD], 13.6 months [6.42]), with 21 in the PK cohort (12.7 months [6.58]). Treatment-emergent adverse events (TEAEs) were reported for 88 (64.2%) patients (98.9% rated as mild/moderate). TEAEs were considered treatment-related for 22 patients (16.1%); most frequently reported were application site pain (3.6%), application site discomfort (2.9%), and erythema (2.9%). ISGA clear/almost clear with ≥ 2-grade improvement at day 29 was achieved by 30.2% of patients. From baseline to day 29, mean percentage change in Eczema Area and Severity Index score was − 57.5%, and mean change in Patient-Oriented Eczema Measure total score was − 8.5. Crisaborole systemic exposures in infants were characterized and, based on nonlinear regression analysis, were comparable with that in patients aged ≥ 2 years.

Conclusions

In this open-label study, crisaborole was well tolerated and effective in infants (3 to < 24 months) with mild-to-moderate AD with systemic exposures similar to patients aged ≥ 2 years.

Clinical Trial Registration

NCT03356977.

Electronic supplementary material

The online version of this article (10.1007/s40257-020-00510-6) contains supplementary material, which is available to authorized users.

Plain Language Summary

Atopic dermatitis (AD) is a skin disease that causes inflamed and itchy skin. Crisaborole is an ointment that is approved to treat patients aged 2 years and older with mild-to-moderate AD. This clinical trial studied crisaborole in infants with mild-to-moderate AD who were 3 to under 24 months old. These infants were treated with crisaborole twice a day for 28 days. The trial studied crisaborole’s safety, effectiveness, and absorption into the bloodstream. In total, 137 infants were treated. Although side effects of some sort occurred in about two-thirds of patients, only 1 in 6 patients experienced side effects that were attributed to crisaborole. When these side effects did occur, these were mainly pain, discomfort, or redness where crisaborole was applied. Fewer than 1 in 25 patients experienced each side effect where crisaborole was applied. The doctors saw improvement in the AD symptoms of some patients at day 29 of the study compared to the beginning of the study. Crisaborole blood-level measurements in this age group were consistent with those seen in patients aged 2 years and older. Overall, crisaborole was considered well tolerated and effective in infants (3 to under 24 months old) with mild-to-moderate AD.

Video abstract

A young child with HIV and unsteady gait: A case report

Background

We would like to raise awareness about the toxicities related to the added excipients present in the oral solution of Liponavir/ritonavir in particular alcohol and propylene glycol.

Case presentation

In this case report, we describe an 18 month-old child with a newly diagnosed HIV infection on antiretroviral therapy (ART). She developed shortly after starting the ART unsteady gait and imbalance.

Conclusions

The excipient-excipient interaction in Lopinavir/ritonavir may contribute to major toxicities not only in premature neonates and infants; but also in older children specifically from Asian ethnicity.

Techno-biofunctionality of mangostin extract-loaded virgin coconut oil nanoemulsion and nanoemulgel

Techno-biofunctional characteristics of nanoemulsion and (nano)emulgel loaded with mangostin extracts were elucidated. Crude mangostins from mangosteen peels recovered by virgin coconut oil (VCO), mixed VCO and propylene glycol (PG), and pure PG were used. The extracts were loaded in the dispersed phase in the presence of mixed surfactants (Tween20/Span20) with a varying hydrophilic-lipophilic balance (HLB) from 10.2 to 15.1. Results showed that globular and uniformly distributed droplets of the nanoemulsion were observed. The small particle sizes (typically 18-62 nm) with the zeta potential of -39 to -54.5 mV were obtained when mixed emulsifiers with HLB values of 12.6 and 15.1 were employed. With HLB values of 12.6 and 15.1, nanoemulsions loaded with mangostin extracts prepared with mixed VCO-PG and pure PG-based extracts showed approximately a 2 to 3-fold lower droplet size diameter when compared with the VCO-based extract. For the stability test, all nanoemulsions were stable over three freeze-thaw cycles with some changes in pH, zeta potential, and droplet size. The DPPH● scavenging activity, H2O2 scavenging activity, reducing power and antibacterial activities (E. coli and S. aureus) of the nanoemulsions were greater than their corresponding bulk extracts. Nanoemulgels produced by embedding the nanoemulsions in a hydrogel matrix was homogeneous and creamy yellow-white in appearance. The nanoemulgels had a higher mangostin release (87-92%) than their normal emulgels (74-78%). Therefore, this study presented the feasibility of nanoemulsions and nanoemulgels loaded with mangostin extracts as a promising delivery system for bioactive polyphenol in food supplements, pharmaceuticals and cosmetics.

Correlation of osmolal gap with measured concentrations of acetone, ethylene glycol, isopropanol, methanol, and propylene glycol in patients at an academic medical center

The ingestion of toxic alcohols including methanol, ethylene glycol, and isopropanol remains a significant public health problem. These compounds can cause central nervous system depression and, for methanol and ethylene glycol, organ damage from toxic metabolites. The presence of these compounds in serum/plasma can often be determined and monitored by measuring the osmolal gap (OG). However, other compounds originating from endogenous or exogenous sources, such as propylene glycol and acetone, can also increase the OG. Conversion factors can be used to estimate specific concentrations of acetone and toxic alcohols from OG. In this retrospective study, data were analyzed for 260 samples originating from 158 unique patients that had determination of both OG and concentrations for toxic alcohols at an academic medical center central laboratory. Specific analysis included gas chromatography (acetone, isopropanol, methanol, ethylene glycol, propylene glycol) and/or enzymatic assay (ethylene glycol). Many samples also contained ethanol. The data was grouped by type of ingestion. The present study analyzed the relationship between the OG calculated from measured plasma/serum osmolality and the OG estimated by applying conversion factors to measured concentrations of the different compounds. The correlations tend to be linear and vary by compound, with methanol and ethylene glycol having the highest R2 values of 0.93 and 0.95, respectively, consistent with other published studies. Higher variability was seen for the data for isopropanol and acetone. For each of the data subsets, the estimated toxic alcohol concentration calculated using conversion factors from OG tends to overestimate the actual concentration of the compound. Overall, the present study demonstrates the generally linear relationship between OG determined by osmolality and the OG estimated using measured concentrations of acetone and toxic alcohols.

Iatrogenic Propylene Glycol Intoxication Due to High-Dose Pentobarbital for Refractory Intracranial Hypertension: A Case Report

Propylene glycol is a rarely reported toxicity from high-dose administration of certain intravenous drugs, including lorazepam and pentobarbital. We present a case of iatrogenic propylene glycol toxicity secondary to a high-dose pentobarbital infusion for the treatment of refractory intracranial hypertension due to cerebral venous sinus thrombosis. The patient developed metabolic acidosis and acute kidney failure secondary to propylene glycol toxicity. After initiation of continuous renal replacement therapy, the patient's acute renal failure and lactic acidosis resolved. Using the Naranjo scale, this case received a score of 5, defining it as a "probable" adverse drug event. In patients who develop lactic acidosis and acute renal failure after initiation of high-dose pentobarbital, propylene glycol toxicity should be higher up in the differential diagnosis. Monitoring the serum osmolality while on pentobarbital could help provide valuable information to prevent iatrogenic propylene glycol toxicity.

Sickly Sweet: Insecticidal Polyols Induce Lethal Regurgitation in Dipteran Pests

Polyols are commonly used in food and medicines as sweeteners and preservatives but may also have insecticidal properties against some species of Diptera. Here we compared the insecticidal activity and feeding response of glycerol and propylene glycol (PG) on two tephritids: Anastrepha ludens and Anastrepha obliqua, and the drosophilid Drosophila suzukii. First, flies were exposed to solutions of 50% sucrose and the two polyols at concentrations of 1.67 M, 2.78 M and 4.18 M for 24 h and then observed at 24 h intervals for a period of three days. Both polyols elicited strong regurgitation behavior in the three flies and killed them. Regurgitation apparently also reduced flies' body weight, and this was particularly apparent in insects that fed on 4.18 M PG solutions. A high percentage of individuals exposed to PG solutions perished after 72 hours. The number of proboscis extensions, which is associated with feeding preference, was lower in the 4.18 M polyols + sucrose mixtures than in the 50% sucrose solution. Glycerol had a lower insecticidal effect in Anastrepha spp. and very little insecticidal effect in D. suzukii. Finally, elevated regurgitation and mortality was confirmed in A. ludens treated with 1.0⁻2.78 M of erythritol plus sucrose. Our results demonstrate that PG, and to a lower extent glycerol, have the potential for being used as a safer method of insect pest control. The hyper-regurgitation response may contribute to the insecticidal properties of these polyols in Diptera.

Effectiveness of Antimicrobial Preservation of Extemporaneous Diluted Simple Syrup Vehicles for Pediatrics

OBJECTIVES

Extemporaneous or magistral formulation of active pharmaceutical ingredients using traditional compounding techniques is a common practice when no commercial form is available for pediatrics. For this vulnerable group of patients, the formulation must be prepared with the minimum quantity and lowest proportion of excipients approved for pediatrics, avoiding the use of preservatives. Often the vehicles used for these preparations are dilutions of simple syrup with water. The objective of this study is to assess the effectiveness of antimicrobial preservation in simple syrup diluted with aqua conservans (conserved water), without propylene glycol or with a reduced proportion of parabens.

METHODS

The European Pharmacopoeia test of efficacy of antimicrobial preservation was applied to 5 trial vehicles prepared with simple syrup diluted with water.

RESULTS

Simple syrup is stable during 14 days. Vehicles prepared with simple syrup diluted with purified water did not meet the microbiological quality criteria, but when they are diluted with water that incorporates propylene glycol and parabens (aqua conservans), then they meet the criteria. In addition, if the water is prepared with parabens and without propylene glycol, the criteria for the dilution are met. Nevertheless, if the dilution is done with water prepared with an insufficient proportion of parabens to act as preservatives, the dilution does not meet the pharmacopoeia microbiological criteria.

CONCLUSIONS

Dilution of simple syrup (50:50 v/v) to prepare a vehicle for extemporaneous or magistral preparation is microbiologically safe when water with methylparaben and propylparaben is used in a proportion of 0.08% and 0.02% (w/w), respectively, avoiding the use of propylene glycol as a solvent and thus its toxic effects in pediatrics.

Spectroscopic detection of brain propylene glycol in neonates: Effects of different pharmaceutical formulations of phenobarbital

Background

The first choice for treatment of neonatal convulsions is intravenous phenobarbital, which contains propylene glycol (PG) as a solvent. Although PG is generally considered safe, the dosage can exceed safety thresholds in neonates. High PG levels can cause lactic acidosis.

Purpose/Hypothesis

To investigate a relationship between brain PG concentration and medication administered to neonates, and to study if a correlation between spectroscopically detected PG and lactate was present.

Study Type

Retrospective.

Population

Forty‐one neonates who underwent MRI/MRS.

Field Strength/Sequence

Short echo time single voxel MRS at 1.5T.

Assessment

Spectra were quantified. Concentrations of PG were correlated with medication administered, because intravenously administered phenobarbital solutions contained 10, 25, or 50 mg phenobarbital per ml, all containing 350 mg PG per ml. The interval between medication and MRI/MRS was determined.

Statistical Tests

Chi‐square test, Student's t‐test, Mann–Whitney U‐test and Spearman correlation.

Results

Eighteen neonates had brain PG >1 mM (median 3.4 mM, maximum 9.5 mM). All 18 neonates with high brain PG and 14 neonates with low brain PG (<1 mM) received phenobarbital as the only source of PG. Nine neonates did not receive any phenobarbital/PG‐containing medication. Neonates with high brain PG more often received 10 mg/ml phenobarbital, resulting in higher PG dose (high vs. low brain PG (median [interquartile range]: 1400 [595] vs. 350 [595] mg/kg, respectively, P < 0.01). In addition, the interval between the last phenobarbital dose and MRI was shorter in the high brain PG group (high vs. low brain PG: 16 [21] vs. 95 [83] hours, respectively, P < 0.001). Within neonates that received phenobarbital, there was no conclusive correlation between spectroscopically detected PG and lactate (Spearman's rho = 0.23, P = 0.10).

Data Conclusion

These MRS findings may increase awareness of potentially toxic PG concentrations in the neonatal brain due to intravenous phenobarbital administration and its dependence on the phenobarbital formulation used.

Level of Evidence: 4

Technical Efficacy: Stage 5

J. Magn. Reson. Imaging 2019;49:1062–1068.

Excipients in Neonatal Medicinal Products: Never Prescribed, Commonly Administered

To attain effective and safe pharmacotherapy, formulations in (pre)term neonates should enable extensive dose flexibility. During product development and subsequent authorization and clinical use of such formulations, there is also a need for informed decisions on excipient exposure: in addition to the need to improve the knowledge on active compounds, there is a similar need to improve the knowledge on excipients in neonates. Excipients are added to formulations as co-solvent, surfactant, preservative, colorant and/or sweetener as vehicle(s) to result in a suitable (e.g. taste, shelf life, stability) product. Progress has been made in the awareness, knowledge and access to this knowledge on the clinical pharmacology of excipients in neonates. This is thanks to different initiatives focussing on epidemiological data, excipient pharmacokinetics, or building datasets to create this knowledge. We highlight the Safe Excipient Exposure in Neonates and Small Children (SEEN) and propylene glycol project to illustrate the feasibility to build knowledge, and discuss the methods applied and problems observed during these studies. The information generated in these and other studies (European Study on Neonatal Exposure to Excipients, ESNEE) should be integrated in repositories like the Safety and Toxicity of Excipients for Paediatrics (STEP) to facilitate access to all stakeholders. This merged knowledge should have impact and assist in improving the quality of risk assessment and decision making during drug development, applying a risk-benefit framework (explicit justification of excipients, plan product development early and engage all stakeholders, data sharing and modeling, challenges related to new excipients, context sensitive risk-benefit analysis).

Oxygenated Volatile Organic Compounds (Anti-freezing Agents) in Decorative Water-based Paints Marketed in Nigeria

BACKGROUND

Consumer products such as paints are a potentially significant source of volatile organic compounds (VOCs) and oxygenated VOCs. Paints for construction and household use have been rapidly changing from oil-based to water-based paints and are one of the commonly identified sources of oxygenated VOCs in indoor environments.

OBJECTIVES

Four different anti-freezing agents were identified and analyzed in 174 waterbased paint samples, purchased from popular paint markets in two metropolitan cities in Nigeria, Lagos and Ibadan.

METHODS

Paint samples were solvent extracted using acetonitrile and milli-Q water. Antifreezing agents in the extracts were identified and quantified using gas chromatography (GC)-mass spectrometry and a GC-flame ionization detector, respectively.

DISCUSSION

Four different anti-freezing agents were identified in the samples, ethylene glycol, diethylene glycol, triethylene glycol and propylene glycol. Their levels ranged from 1,000-1,980 ppm, diethylene glycol; 1,000-3,900 ppm, triethylene glycol; 1,090-2,510 ppm, propylene glycol and 1,350-2,710 ppm, ethylene glycol. Levels of anti-freezing agents in all of the paint samples were above the permissible limits of the European Union for VOCs in paints of 500 ppm. Results of multivariate statistical analyses clearly showed that triethylene glycol was the most commonly used anti-freezing agent in paints despite its numerous harmful health effects.

CONCLUSIONS

We concluded that water-based paints marketed in Nigeria contain high concentrations of anti-freezing agents, which have harmful environmental and human health effects, especially to sensitive individuals such as children.

COMPETING INTERESTS

The authors declare no competing financial interests.

Pentobarbital-induced lactic acidosis following status epilepticus barbiturate coma

We present a rare case of pentobarbital infusion causing propylene glycol-induced lactic acidosis, during refractory status epilepticus treatment in a 66-year-old man without seizure history.

Assessing Propylene Glycol Toxicity in Alcohol Withdrawal Patients Receiving Intravenous Benzodiazepines: A One-Compartment Pharmacokinetic Model

BACKGROUND AND OBJECTIVES

While some case reports indicate that high doses of propylene glycol (PG) may result in metabolic acidosis, there has been no large-scale study that evaluated the risk of metabolic acidosis in patients receiving PG-containing benzodiazepines for acute alcohol withdrawal. This study was undertaken to evaluate the potential toxicity of PG in patients with acute alcohol withdrawal treated with intermittent intravenous bolus doses of diazepam and/or lorazepam.

METHODS

This is a retrospective case study using data collected from 18 randomly selected patients receiving one or both of these medications per a modified Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Class 3 protocol. Plasma levels of PG were estimated using a one-compartment pharmacokinetic model.

RESULTS

Only two patients had an elevated anion gap compared to their baseline value with one also experiencing a significant increase in serum creatinine. No increases in serum osmolarity were noted. Analysis showed that the benzodiazepine dose received was a good predictor of the estimated PG concentration (r = 0.6), but was poorly correlated with the anion gap. No significant correlation was found with the creatinine clearance or serum creatinine. Patients receiving several daily doses were at higher risk of developing an anion gap (r = 0.33), but the estimated maximum PG concentration did not correlate with the anion gap or serum concentration.

CONCLUSION

It does not appear that intermittent bolus administration of intravenous benzodiazepines for alcohol withdrawal influenced renal function or anion gap regardless of number of administered doses, amount of PG received, or the estimated PG concentration.

Use of a Rapid Ethylene Glycol Assay: a 4-Year Retrospective Study at an Academic Medical Center

Ethylene glycol (EG) is a common cause of toxic ingestions. Gas chromatography (GC)-based laboratory assays are the gold standard for diagnosing EG intoxication. However, GC requires specialized instrumentation and technical expertise that limits feasibility for many clinical laboratories. The objective of this retrospective study was to determine the utility of incorporating a rapid EG assay for management of cases with suspected EG poisoning. The University of Iowa Hospitals and Clinics core clinical laboratory adapted a veterinary EG assay (Catachem, Inc.) for the Roche Diagnostics cobas 8000 c502 analyzer and incorporated this assay in an osmolal gap-based algorithm for potential toxic alcohol/glycol ingestions. The main limitation is that high concentrations of propylene glycol (PG), while readily identifiable by reaction rate kinetics, can interfere with EG measurement. The clinical laboratory had the ability to perform GC for EG and PG, if needed. A total of 222 rapid EG and 24 EG/PG GC analyses were documented in 106 patient encounters. Of ten confirmed EG ingestions, eight cases were managed entirely with the rapid EG assay. PG interference was evident in 25 samples, leading to 8 GC analyses to rule out the presence of EG. Chart review of cases with negative rapid EG assay results showed no evidence of false negatives. The results of this study highlight the use of incorporating a rapid EG assay for the diagnosis and management of suspected EG toxicity by decreasing the reliance on GC. Future improvements would involve rapid EG assays that completely avoid interference by PG.

Cyclodextrins and Iatrogenic Hearing Loss: New Drugs with Significant Risk

Cyclodextrins are a family of cyclic oligosaccharides with widespread usage in medicine, industry and basic sciences owing to their ability to solubilize and stabilize guest compounds. In medicine, cyclodextrins primarily act as a complexing vehicle and consequently serve as powerful drug delivery agents. Recently, uncomplexed cyclodextrins have emerged as potent therapeutic compounds in their own right, based on their ability to sequester and mobilize cellular lipids. In particular, 2-hydroxypropyl-β-cyclodextrin (HPβCD) has garnered attention because of its cholesterol chelating properties, which appear to treat a rare neurodegenerative disorder and to promote atherosclerosis regression related to stroke and heart disease. Despite the potential health benefits, use of HPβCD has been linked to significant hearing loss in several species, including humans. Evidence in mice supports a rapid onset of hearing loss that is dose-dependent. Ototoxicity can occur following central or peripheral drug delivery, with either route resulting in the preferential loss of cochlear outer hair cells (OHCs) within hours of dosing. Inner hair cells and spiral ganglion cells are spared at doses that cause ~85% OHC loss; additionally, no other major organ systems appear adversely affected. Evidence from a first-to-human phase 1 clinical trial mirrors animal studies to a large extent, indicating rapid onset and involvement of OHCs. All patients in the trial experienced some permanent hearing loss, although a temporary loss of function can be observed acutely following drug delivery. The long-term impact of HPβCD use as a maintenance drug, and the mechanism(s) of ototoxicity, are unknown. β-cyclodextrins preferentially target membrane cholesterol, but other lipid species and proteins may be directly or indirectly involved. Moreover, as cholesterol is ubiquitous in cell membranes, it remains unclear why OHCs are preferentially susceptible to HPβCD. It is possible that HPβCD acts upon several targets—for example, ion channels, tight junctions (TJ), membrane integrity, and bioenergetics—that collectively increase the sensitivity of OHCs over other cell types.

Status Epilepticus due to Intraperitoneal Injection of Vehicle Containing Propylene Glycol in Sprague Dawley Rats

Published reports of status epilepticus due to intraperitoneal injection containing propylene glycol in rats are sparse. In fact, there are no reports specifying a maximum safe dose of propylene glycol through intraperitoneal administration. We report here a case of unexpected seizures in Sprague Dawley rats after receiving an intraperitoneal injection containing propylene glycol. Nine-week-old, 225–250 gram male rats were reported to experience tremor progressing to seizures within minutes after given injections of resveratrol (30 mg/kg) dissolved in a 40 : 60 propylene glycol/corn oil vehicle solution by direct intraperitoneal (IP) slow bolus injection or via a preplaced intraperitoneal catheter. The World Health Organization suggests a maximum dose of 25 mg/kg/day of propylene glycol taken orally and no more than 25 mg/dL in blood serum, whereas the animals used in our study got a calculated maximum 0.52 g/kg (25 times lower dose). Blood tests from the seizing rat support a diagnosis of hemolysis and lactic acidosis which may have led to the seizures, all of which appeared to be a consequence of the propylene glycol administration. These findings are consistent with oral and intravenous administration of propylene glycol toxicity as previously reported in other species, including humans. To our knowledge, this report represents the first published case of status epilepticus due to an IP injection containing propylene glycol.

Continuous-Infusion Etomidate in a Patient Receiving Extracorporeal Membrane Oxygenation

We describe a 16-year-old, 65-kg male deployed on extracorporeal membrane oxygenation (ECMO) for refractory respiratory failure secondary to ingestion of multiple substances. During his ECMO course, standard sedative and analgesic strategies failed and alternative medications were used. The patient received various dosages of fentanyl, morphine, hydromorphone, clonidine patches, dexmedetomidine, lorazepam, methadone, pentobarbital, olanzapine, and propofol. Despite administration of multiple agents, on day 29 of ECMO the patient experienced elevated blood pressures due to agitation, and continuous infusion etomidate was started. At the time of etomidate initiation, the osmolar gap was 8 mOsm/kg. During etomidate therapy, the blood pressure remained normal, sedative agents were slowly weaned, and the patient required few PRN medications. On day 6 of etomidate, the osmolar gap increased to 127 mOsm/kg and etomidate was discontinued. Continuous-infusion ketamine was started, but the blood pressure was not controlled. Metabolic acidosis is a known side effect of etomidate due to inclusion of propylene glycol as a pharmaceutical solvent in the formulation. Despite high-dose etomidate (20 mcg/kg/min) for approximately 6 days, our patient did not experience metabolic acidosis. Absence of this adverse effect caused us to question the role of the ECMO circuit. To our knowledge, this is the first report of the use of continuous-infusion etomidate during ECMO. Etomidate infusion could be considered in difficult-to-manage patients after other alternatives have failed.

Propylene Glycol Toxicity in Adolescent with Refractory Myoclonic Status Epilepticus

Propylene glycol (PG) is a solvent commonly used in medications that, while benign at low doses, may cause toxicity in adults and children at high doses. We describe a case and the physiologic sequelae of propylene glycol toxicity manifested in a critically ill adolescent male with refractory myoclonic status epilepticus aggressively treated with multiple PG-containing medications (lorazepam, phenobarbital, and pentobarbital)—all within accepted dosing guidelines and a total daily PG exposure previously recognized to be safe. Hemodynamic measurements by bedside echocardiography during clinical toxicity are also reported. Clinicians should have a high index of suspicion for propylene glycol toxicity in patients treated with PG-containing medications even when the total PG exposure is lower than currently accepted limits.

Smoke on the water: A case report of chronic renal failure resulting from the ingestion of smoke machine fluid

We report the case of an 18-year-old male admitted to the Intensive Care Unit in Basingstoke and North Hampshire Hospital, who developed chronic kidney disease following the ingestion of smoke machine fluid. Smoke machine fluid may contain ethylene glycol, and a diagnosis of ethylene glycol toxicity with calcium oxalate nephropathy was made. This case resulted in a National Poisons Information Service internal review of the subject and a new TOXBASE entry for smoke machine fluid ingestion.

Trimethoprim/Sulfamethoxazole-Induced Severe Lactic Acidosis: A Case Report and Review of the Literature

Propylene glycol (PG) is used as a solvent in numerous medications, including trimethoprim/sulfamethoxazole (TMP/SMX) and lorazepam, and is metabolized in the liver to lactic acid. Cases of lactic acidosis related to PG toxicity have been described and always involved large doses of benzodiazepines and PG. We present the first case of severe lactic acidosis after a 3-day course of TMP/SMX alone, involving allegedly safe amounts of PG.A 31-year-old female with neurofibromatosis and pilocytic astrocytoma, receiving temozolomide and steroids, was admitted to the intensive care unit for pneumonia and acute respiratory failure requiring intubation. Her initial hemodynamic and acid-base statuses were normal. She was treated with intravenous TMP/SMX for possible Pneumocystis jirovecii pneumonia and was successfully extubated on day 2. On day 3, she developed tachypnea and arterial blood gas analysis revealed a severe metabolic acidosis (pH 7.2, PCO2 19 mm Hg, bicarbonates 8 mEq/L) with anion gap of 25 mEq/L and lactate of 12.1 mmol/L. TMP/SMX was discontinued and the lactate decreased to 2.9 mmol/L within 24 hours while her plasma bicarbonates normalized, without additional intervention. The patient never developed hypotension or severe hypoxia, and her renal and liver functions were normal. No other cause for lactic acidosis was identified and it resolved after TMP/SMX cessation alone, suggesting PG toxicity.Although PG-related lactic acidosis is well recognized after large doses of lorazepam, clinicians should bear in mind that TMP/SMX contains PG as well and should suspect PG toxicity in patients developing unexplained metabolic acidosis while receiving TMP/SMX.