Physical Compatibility of Cefiderocol with Selected Intravenous Drugs During Simulated Y-site Administration

The physical compatibility of cefiderocol for injection (prepared as a diluted 2% cefiderocol solution) with potential co-administration drug products is presented. The compatibility of cefiderocol with a selection of 91 intravenous drugs was tested at clinically relevant concentrations using the admixed volume ratio 1:1. Compatibility of the mixtures was determined by visual observations, turbidity, and particulate-matter measurements. The mixtures were examined immediately after mixing, and then at 1 hour and 4 hours thereafter at room temperature. When using 0.9% sodium chloride or 5% dextrose injection for diluents, solutions of dobutamine hydrochloride, esomeprazole sodium, methylprednisolone acetate, propofol, rocuronium bromide, amiodarone hydrochloride, famotidine, labetalol hydrochloride, mycophenolate mofetil, acyclovir sodium, amphotericin B, caspofungin acetate, doxycycline, posaconazole, diphenhydramine hydrochloride, and phenytoin sodium were found to cause visible cloudiness upon mixing with 2% cefiderocol in both diluents. Solutions of lorazepam, tobramycin sulfate, and vancomycin hydrochloride were determined incompatible by examining the mixtures with the aid of a Tyndall light. These 19 drugs were clearly incompatible with cefiderocol for injection by visual examination. In addition, solutions of iron sucrose and albumin were incompatible with 2% cefiderocol based on sub-visual tests for turbidity and/or particulate matter. Based on sub-visual data, the 0.9% sodium chloride admixture of aminophylline and 2% cefiderocol was incompatible, while inconclusive results were obtained for the 0.9% sodium chloride admixtures of 2% cefiderocol with amikacin sulfate. Similarly, the 5% dextrose admixtures of either ciprofloxacin or polymyxin B sulfate with 2% cefiderocol were incompatible, whereas data for phenylephrine hydrochloride morphine sulfate, or undiluted sodium bicarbonate were inconclusive. Overall, the 2% cefiderocol solution was physically compatible with 63 of 91 drugs challenged at 1:1 volume ratio in both 0.9% sodium chloride and 5% dextrose diluents for at least 4 hours at the concentrations tested in this study.

Serum Monitoring and Phenotype Identification of Stage I Non-Small Cell Lung Cancer Patients

A stage I non-small cell lung cancer (NSCLC) serum profiling platform is presented which is highly efficient and accurate. Test sensitivity (0.95) for stage I NSCLC is the highest reported so far. Test metrics are reported for discriminating stage I adenocarcinoma vs squamous cell carcinoma subtypes. Blinded analysis identified 23 out of 24 stage I NSCLC and control serum samples. Group-discriminating mass peaks were targeted for tandem mass spectrometry peptide/protein identification, and yielded a lung cancer phenotype. Bioinformatic analysis revealed a novel lymphocyte adhesion pathway involved with early-stage lung cancer.

Topical Metered-dosing Dispenser Performance Evaluation

Topical metered-dosing dispensers are designed for dosing accuracy and ease-of-use by the patients while protecting the packaged products from environmental exposure and contamination. The objective of this study was to evaluate the accuracy, precision, and residual of available topical metered-dosing dispensers with different types of topical cream for practical application. Triplicate samples of five different dispensers were tested. This test was completed using three types of commercial topical cream-bases of dissimilar Total Active Pharmaceutical Ingredient Load Percentages, Transdermal Penetration Percentages, and Specific Gravities. The dispensers were evaluated according to specified dose-uniformity criteria for a total dispensing capacity of 30 mL at 0.5 mL per dose for 60 doses. The study shows Topi-CLICK performed with the best precision and accuracy of dosing in comparison to the airless-pump type dispensers. While the dispensing was highly variable with airless pumps and may require calibration for each packaged product, remarkably the performance of Topi-CLICK was not affected by different types of cream-bases and does not require additional metering calibration.

Quality Control: microbial limit tests for nonsterile pharmaceuticals, part 2

Cases of contaminated nonsterile products have been reported in increasing numbers. Often, these contaminated products are associated with the presence of objectionable microorganisms. The major contaminants of nonsterile pharmaceutical products and ingredients are bacteria, yeasts, and molds. The combination of parts 1 and 2 of this series of articles provides a thorough examination of microbiological quality testing for nonsterile products.

Quality control analytical methods: microbial limit tests for nonsterile pharmaceuticals, Part 1

Contamination of pharmaceuticals with microorganisms may lead to deleterious effects on the therapeutic properties of the drug, and may potentially cause injuries to intended recipients. Cases of contaminated nonsterile products have been reported in increasing numbers, and often associated with the presence of objectionable microorganisms. Methods for detection of these organisms are described in three major Pharmacopeias. Their functions and their limitations in the examination of microbiological quality for nonsterile products will be reviewed in this report.

The essentials of United States Pharmacopeia Chapter <51> antimicrobial effectiveness testing and its application in pharmaceutical compounding

Antimicrobial preservatives are excipients added to multi-dose containers of both sterile and non-sterile drug products. Antimicrobial preservatives are used primarily to inhibit growth of microbial contamination occurring during the period of use. Demonstration of antimicrobial preservative effectiveness is required for these functional excipients. This article reviews key factors for consideration in the selection of preservatives, principles of the preservative-effectiveness test, and the significance of requirements for preservative-effectiveness testing in the compounding practice.

Distinguishing patients with stage I lung cancer versus control individuals using serum mass profiling

Serum mass profiling can discern physiological changes associated with specific disease states and their progression. Sera (86 total) from control individuals and patients with stage I nonsmall cell lung cancer or benign small pulmonary nodules were discriminated retrospectively by serum changes discerned by mass profiling. Control individuals were distinguished from patients with Stage I lung cancer or benign nodules with test sensitivities of 89% and 83%. Lung cancer patients versus those with benign nodules were distinguished with 80% sensitivity. This study exhibits progress toward a minimally-invasive aid in early detection of lung cancer and monitoring small pulmonary nodules for malignancy.

A fatality due to an accidental methadone substitution in a dental cocktail

A 6-year-old male child was scheduled for a dental procedure requiring conscious sedation. Prior to the procedure, the child was administered a dental cocktail containing chloral hydrate, hydroxyzine, and methadone. After returning from the dentist, the child appeared groggy and was allowed to sleep. A few hours later, he was found unresponsive, and following resuscitation attempts at a local medical center, he was pronounced dead. Toxicological analyses of femoral blood indicated the presence of hydroxyzine at less than 0.54 μg/mL, trichloroethanol (TCE) at 8.3 μg/mL, and methadone at 0.51 μg/mL. No meperidine was detected. The cause of death was reported to be due to the toxic effects of methadone. The toxicological analysis was corroborated by the analysis of the contents of the dental cocktail, which revealed the presence of hydroxyzine, chloral hydrate, and methadone. Residue from a control sample obtained from the same pharmacy, but administered to a different subject, was found to contain hydroxyzine, chloral hydrate, and meperidine. This report represents the first known fatality due to accidental substitution of methadone in a dental cocktail.

Compatibility of ceftaroline fosamil for injection with selected drugs during simulated Y-site administration

PURPOSE

The physical compatibility of ceftaroline fosamil with commonly used medications and diluents (a total of 73 drugs in 219 admixtures) during simulated Y-site administration was evaluated.

METHODS

Duplicate 5-mL samples of ceftaroline fosamil (2.22 mg/mL) in 5% dextrose injection, 0.9% sodium chloride injection, and lactated Ringer's injection were combined at a 1:1 ratio with samples of 73 drugs (diluted or undiluted). Visual examinations were performed with the unaided eye in fluorescent light and with the aid of a Tyndall beam; the turbidity and particulate content of each sample were also measured. The compatibility of ceftaroline fosamil with propofol was evaluated by visually inspecting for emulsion separation and particle formation after centrifugation. All evaluations were performed within 15 minutes of sample preparation and at one and four hours after preparation.

RESULTS

Ceftaroline fosamil was physically compatible with 64 drugs in a combination of 196 admixtures for at least four hours, exhibiting color, clarity, turbidity, and microparticle content similar to those of control solutions. Signs of physical incompatibility, including visible precipitation, increased turbidity, and microparticle formation, were observed with 9 drugs in 23 admixtures during the four-hour observation period.

CONCLUSION

Of the 73 drugs evaluated, 64 were compatible and 7 were incompatible with ceftaroline fosamil 2.22 mg/mL in 3 standard infusion solutions. Nine drugs in 23 admixtures were observed to exhibit signs of incompatibility with ceftaroline fosamil within four hours of mixing; those drugs should not be simultaneously administered via a Y-site with ceftaroline preparations.

Serum discrimination of early-stage lung cancer patients using electrospray-ionization mass spectrometry

The goal of this study was to evaluate the usefulness of electrospray ionization-mass spectrometry (ESI-MS) technology to distinguish sera of early-stage lung cancer patients from control individuals. ESI-MS m/z (mass divided by charge) data were generated from sera of 43 non-small cell lung cancer patients (pathological stages I and II) and 21 control individuals. Identifications of m/z peak area significances between cancer and control ESI-MS sera spectra were performed using t-tests. A "leave one out" cross validation procedure, which mimics blinded sera analysis and corrects for "over-fitting" of data, yielded discriminatory cancer versus control distribution p value and ROC curve area value of <0.001 and 0.87, respectively. Analysis without the "leave one out" cross validation procedure yielded a ROC curve area of 0.99 for discrimination of sera from lung cancer patients versus control individuals. Predictive value measurements revealed overall test efficiency and sensitivity for distinguishing sera from lung cancer patients from controls (using "leave one out" cross validation) of 80% and 84%, respectively. ESI-MS serum analysis between control individuals and lung cancer patients who smoked or did not smoke had p values in ranges indicating that smoking effects are not pronounced in our analysis. These studies indicate that ESI-MS analyses of sera from early stage non-small cell lung cancer patients were helpful in distinguishing these patients from control individuals.

Applications and sterility of autologous serum eye drops

Severe dry eye syndrome can adversely affect a patient's quality of life. When preservative-free artificial tear solutions are not adequate to reduce symptons, the patient's own serum can be compounded into eye drops that improve the ocular surface. The aim of our study was to test the sterility of autologous serum eye drops in refrigerator conditions for up to 30 days and in freezer conditions for up to 180 days. It was determined that sterility was maintained throughout this period.

Drug Compatibility with a New Generation of VISIV Polyolefin Infusion Solution Containers

A new generation of VISIV polyolefin intravenous solution containers, made of a new and different proprietary polymer, were evaluated for sorption and leaching potential with a cadre of drugs known to exhibit those phenomena with polyvinylchloride containers. Sorption potential was evaluated for amiodarone hydrochloride, carmustine, regular human insulin, lorazepam, nitroglycerin, sufentanil citrate, and thiopental sodium. Leaching potential was evaluated for tacrolimus and teniposide as well as the vehicles of docetaxel and paclitaxel. Representative concentrations of the drugs in infusion solutions or undiluted were placed into the new generation of VISIV containers and left in contact for up to 24 hours at room temperature. High performance liquid chromatography was used to determine drug concentrations and the presence of plasticizer or other plastic components, if any. Only regular human insulin exhibited any substantial loss of concentration in the polyolefin containers that could be attirbuted to sorption. Other drugs' concentrations were consistent with their stabilities over the test periods. No evidence of leaching of plasiticizer or other plastic components was observed.

Quality-control analytical methods: compounding slow-release pharmaceuticals

Slow-release dosage forms are designed to release active drugs at slower rates for prolonging drug effects. These unconventional dosage forms are complex drug delivery systems, which require specialized technical knowledge and skills in their formulation. Verification of the compounding process for slow-release oral dosage forms can be accomplished through quality-control testing of pilot batches to ensure acceptable preparation and patient safety.

Breast cancer patients unknowingly dosing themselves with estrogen by using topical moisturizers

Abstract #4087

Background: Topically applied estrogens are more efficiently absorbed into the body than estrogens administered orally, due to the first pass effect by the liver. Estrogen receptor positive breast cancer patients need to avoid exogenously administered estrogen to minimize chance of recurrence. This is especially significant for women on aromatase inhibitor treatment,where topical estrogen may overcome the therapeutic effect. Also, non breast cancer patients using estrogen containing topical moisturizers may be unknowingly dosing themselves daily with estrogen, often for years, increasing their chances of developing breast cancer.&#x2028; Materials and Methods: Sixteen different topical moisturizers were purchased or donated from department stores or chain drugstores. None of the creams noted any estrogen content in their list of ingredients. Each of the sixteen commercial products was analyzed for estradiol, estriol and estrone utilizing High Performance Liquid Chromatography (HPLC). HPLC is commonly used in the pharmaceutical industry to provide component analysis. Detection was carried out through use of a Variable Wavelength Detector (VWD) and a Diode Array Detector.&#x2028; Results: Four samples contained greater than 0.40% estriol, one contained 0.17% estriol, and one contained 0.05% estrone, despite having no listing on the ingredient list.&#x2028; Discussion: Topical estrogens are considered effective in enhancing the “youthful look” of aging skin. Manufacturers are marketing incompletely labeled moisturizers containing estrogens. Consumers are unaware their moisturizer may be providing them with unwanted systemic estrogen exposure. The FDA cosmetics division is not presently testing for this potential risk for breast cancer patients. Other breast cancer advocacy groups and the FDA need to promptly repeat these procedures and also check for exotic "designer" estrogens.&#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4087.

Compatibility and stability of palonosetron hydrochloride and propofol during simulated y-site administration

Palonosetron hydrochloride is a longer-acting, selective 5-HT3 receptor antagonist that has been approved for prevention of chemotherapy-induced nausea and vomiting and is being evaluated for prevention of postoperative nause and vomiting. The objective of this study was to evaluate the physical and chemical stablity of palonosetron hydrochloride 50 mcg/mL when mixed with undiluted propofol 1% during simulated Y-site administation. Duplicate samples of this mixture were tested. Samples were stored and evaluated for up to 4 hours at room temperature. Physical stability was assessed by visual inspection. Chemical stability was assessed by high-performance liquid chromatographic analysis. All of the admixtures were opaque white when viewed in normal fluorescent room light and when viewed with a Tyndall beam. After centrifugation, no evidence of precipitation was found. The drug concentrations were essentially unchanged in all of the samples throughout the study. Palonosetron hydrochloride is physically and chemically stable when mixed with propofol as undiluted injections during simulated Y-site administration over 4 hours at ambient room temperature.

Stability of Metronidazole Benzoate in SyrSpend SF One-Step Suspension System

The objective of this study was to determine the stability of metronidazole benzoate suspension in SyrSpend SF One-Step Suspension system. The studied samples were packaged in 60-mL amber plastic prescription bottles, which were stored protected from light under controlled environmental conditions for a period of 360 days. Stability of metronidazole benzoate suspension in SyrSpend SF was assessed based on retention of initial color or appearance, pH of suspension, and recovery of metronidazole benzoate from the packaged product. Duplicate samples were evaluated at each predefined time interval. An assay method by high performance liquid chromatography was validated for its specificity and stability-indicating characteristscs through a forced-degradation study, and was used in metronidazole benzoate assay. Metronidazole benzoate in SyrSpend SF retained its normal appearance of an opaque suspension, with acceptable pH values ranging from 4.43 to 4.53 (range 4.45 +/- 0.5). Recovery of metronidazole benzoate at subsequent time points was within 90% to 110% of inital concentration for samples stored at refrigerated temperature (2 deg C to 8 deg C), and ambient condition (25 deg C/60% relative humidity), with no detectable changes in chromatographic profile for most tested samples. The rates of change in potency for metronidazole benzoate were determined under the assumptions of first-order kinetics, and the time to reach 90% to 110% initial concentration was determined to be 366 days for samples in ambient storage, or 716 days for samples stored at refrigerated temperature. Metronidazole benzoate in SyrSpend SF, which was packaged in amber plastic prescription bottles, is stable for at least 1 year when stored protected from light at ambient condition (25 deg C/60% relative humidity). The shelf life for this product may be extended to 2 years when stored at refrigerated temperature.

Compatibility and Stability of Palonosetron Hydrochloride with Lactated Ringer's Hetastarch in Lactated Electrolyte, and Mannitol Injections During Simulated Y-Site Administration

Palonosetron hydrochloride is a longer-acting, selective 5-HT3 receptor antagonist that has been approved for the prevention of chemotherapy-induced nausea and vomiting ad is being evaluated for the prevention of postoperative nausea and vomiting. The objective of this study was to evaluate the physical and chemical stability of palonosetron hydrochloride 50mcg/mL when mixed with Lactated Ringer's injection, 6% hetastarch in lactated electrolyte injection, or 15% mannitol injection during simulated Y-site administration. Duplicate samples of each admixture were tested. The samples were stored and evaluated for 4 hours at room temperature. Physical stability was assessed by turbidimetric and particulate measurements, and by visual inspection. Chemical stability was assessed by using high-performance liquid chromatography. All of the admixtures were clear and colorless when viewed in normal fluorescent room light and when viewed with a Tyndall beam. Measured turbidity and particulate content were low initially and remained low throughout the observation period. Palonosetron hydrochloride concentration was unchanged in any of the samples throughout the study period. Palonosetron hydrochlorie is physically and chemically stable with Lactated Ringer's injection, 6% hetastarch in lactated elecrolyte injection, or 15% mannitol injection during simulated Y-site administration over 4 hours at ambient room temperature.

Compatibility of doripenem with other drugs during simulated Y-site administration

PURPOSE

The compatibility of doripenem diluted for infusion with 82 other drugs during simulated Y-site administration was studied.

METHODS

Five-milliliter samples of doripenem 5 mg/mL in 5% dextrose injection and separately in 0.9% sodium chloride injection were combined with 5 mL of 82 other drugs, undiluted or diluted in 5% dextrose injection or 0.9% sodium chloride injection. Visual examinations were performed with the unaided eye in fluorescent light and using a Tyndall beam to enhance visualization of small particles and low-level turbidity. The turbidity of each sample was measured, and particulate content was evaluated. Samples were inspected initially and one and four hours after preparation.

RESULTS

Of the drugs tested, doripenem 5 mg/mL in 5% dextrose injection and in 0.9% sodium chloride injection was incompatible with diazepam, potassium phosphates, and undiluted propofol. Doripenem 5 mg/mL in 0.9% sodium chloride injection but not in 5% dextrose injection was incompatible with amphotericin B-containing drugs due to the diluent. Doripenem was found to be compatible when combined with the other 75 drugs for at least four hours.

CONCLUSION

Doripenem 5 mg/mL in 5% dextrose injection or in 0.9% sodium chloride injection was physically compatible for four hours at room temperature with 75 drugs during simulated Y-site administration. Three drugs combined with doripenem in 5% dextrose injection or 0.9% sodium chloride injection and 7 drugs combined with doripenem in 0.9% sodium chloride injection resulted in unacceptable precipitation or an increase in measured haze and should not be simultaneously administered with doripenem admixtures.

Physical and chemical stability of esomeprazole sodium solutions

BACKGROUND

Esomeprazole sodium (Nexium IV, AstraZeneca) is the S-isomer of omeprazole and acts as a proton pump inhibitor gastric antisecretory agent indicated for the short-term treatment of gastroesophageal reflux disease in patients with a history of erosive esophagitis. Currently, there is no information on the long-term stability of esomeprazole sodium in infusion solutions beyond 12 hours.

OBJECTIVE

To evaluate the stability of esomeprazole sodium in 5% dextrose, 0.9% sodium chloride, and lactated Ringer's injection, at 2 concentrations, at room temperature and when refrigerated.

METHODS

Triplicate samples of esomeprazole 0.4 and 0.8 mg/mL as the sodium salt were prepared in the solutions required. Stability evaluations were performed initially, over 2 days stored at 23 degrees C, and over 5 days stored at 4 degrees C. Physical stability was assessed using turbidimetric and particulate measurement, as well as visual observation. Chemical stability was evaluated by stability-indicating high-performance liquid chromatography.

RESULTS

The samples in all 3 infusion solutions were physically stable throughout the study. None of the samples had evidence of visible haze or particulates. Most samples developed a slight yellow discoloration within 24 hours, but this discoloration was not accompanied by an excessive loss of drug content. The esomeprazole sodium samples in all 3 infusion solutions exhibited less than 7% loss over 2 days at 23 degrees C and over 5 days at 4 degrees C.

CONCLUSIONS

Esomeprazole 0.4 and 0.8 mg/mL as the sodium salt in the infusion solutions tested is chemically and physically stable for at least 2 days at room temperature and 5 days under refrigeration.

Quality-control analytical methods: homogeneity of dosage forms

Content uniformity is the degree of consistency in the amount of the drug substance among dosage units. There are two ways to determine content uniformity according to United States Pharmacopeial Chapter 905: by means of Content Uniformity or Weight Variation methods. It is essenetial that compounding pharmacists know the different methods, how they work, and when to use each method to determine the content uniformity of their individual dosages.

Physical and chemical stability of palonosetron hydrochloride with glycopyrrolate and neostigmine during simulated y-site administration

The objective of this study was to evaluate the physical and chemical stability of undiluted palonosetron hydrochloride 50 mcg/mL when mixed with undiluted glycopyrrolate 0.2 mg/mL and neostigmine methylsulfate 0.5 mg/mL during simulated Y-site administration. Duplicate test samples were prepared by admixing 7.5 mL of palonosetron hydrochloride with 7.5 mL of glycopyrrolate and neostigmine methylsulfate injections. Physical stability was assessed by using a multi-step evaluation procedure that included both turbidimetric and particulate measurements and visual inspection. Chemical stability was assessed by using a multi-step evalutation procedure that included both turbidimetric and particulate measurements and visual inspection. Chemical stability was assessed by using stability-indicating high-performance liquid chromatography analytical techniques based on the determination of drug concentrations. Evaluations were perfromed initially upon mixing and 1 and 4 hours after mixing. The samples were clear and colorless when viewed with a Tyndall beam. Measured turbidity remained unchanged and particulate content was low and exhibited little change. High-performance liquid chromatography analysis found palonosetron hydrochloride and both glycopyrrolate and neostigmine methylsulfate remained stable throughout the 4-hour test with no drug loss. Palonosetron hydrochloride is physically compatible and chemically stable with glycopyrrolate and neostigmine methylsulfate during simulated Y-site administration.

Compatibility of caspofungin acetate injection with other drugs simulated y-site coadministration

The physical compatibility of caspofungin acetate injection with selected other drugs during simulated Y-site coadministration was evaluated by visual observation and turbidity measurement. Five-milliliter samples of caspofungin acetate 0.7 mg/mL in 0.9% sodium chloride injection were combined with 5 mL of 67 other drugs including antineoplastics,analgesics, anti-infectives, and supportive care drugs, undiluted or diluted in 0.9% sodium chloride injection or 5% dextrose injection, and with a parenteral nutrition admixture. Visual examinations were performed with the unaided eye in normal laboratory fluorescent light and with a Tyndall beam (high-intensity monodirectional light beam) to enhance visualization of small particles and low-level turbidity. The turbidity of each sample was measured as well. The sample mixtures were evaluated immediately and at 1 and 4 hours after preparation. Nineteen of the drugs tested and the parenteral nutrition admixture were incompatible with caspofungin acetate 0.7 mg/mL during the 4-hour observation period. The remaining drugs were compatible for at least 4 hours. Gross precipitation or turbidity changes visible in normal diffuse room light with the unaided eye occurred with 18 drugs and with the parenteral nutrition admixture. Microprecipitation of particulates not visible with the unaided eye occurred with cytarabine. The measured turbidity of the caspofungin acetate control solutions and the compatible test samples remained essentially unchanged throughout the observation period. In combination with caspofungin acetate, 48 drugs and a parenteral nutrition admixture were considered to be physically compatible. In contrast, 19 drugs with the parenteral nutrition admixture exhibited frank precipitation or microparticulate formation within 4 hours and should not be simultaneously administered via Y-site with caspofungin acetate.

Compatibility and stability of palonosetron hydrochloride with gentamicin, metronidazole, or vancomycin during simulated y-site administration

Palonosetron hydrochloride is a relatively long-acting selective 5-HT3 receptor antagonist that has been approved for the prevention of chemotherapy-induced nausea and vomiting and is being evaluated for the prevention of postoperative nausea and vomiting. The objective of this study was to evaluate the physical and chemical stability of palonosetron hydrochloride 50 mcg/mL when mixed with gentamicin sulfate 5 mg/mL, metronidazole 5 mg/mL, or vancomycin hydrochloride 5 mg/mL during simulated Y-site administration. Duplicate samples of palonosetron hydrochloride with each of the anti-infectives were tested. Samples were stored and evaluated for up to 4 hours at room temperature. Physical stability was assessed by turbidimetric and particulate measurements and visual inspection. Chemical stability was assessed by high-performance liquid chromatography. All of the admixtures were clear and colorless when viewed in normal fluorescent room light and when viewed with a Tyndall beam. Measured turbidity and particulate content were low initially and remained low throughout the study. The drug concentration was unchanged in all of the samples tesed. Palonosetron hydrochloride is physically and chemically stable with gentamicin sulfate, metronidazole, or vancomycin hydrochloride at the concentrations tested during simulated Y-site administration over 4 hours at ambient room temperature.

Compatibility and stability of palonosetron hydrochloride with four neruomuscular blocking agents during simulated y-site administration

Palonosetron hydrochloride is a longer-acting selective 5-HT3 receptor antagonist that has been approved for the prevention of chemotherapy-induced nausea and vomiting and is being evaluated for the prevention of postoperative nausea and vomiting. The objective of this study was to evaluate the physical and chemical stability of palonosetron hydrochloride 50 mcg/mL when mixed with any of the neuromuscular blocking drugs cisatracurium besylate 0.5 mg/mL, rocuronium bromide 1 mg/mL, succinylcholine chloride 2 mg/mL, and vecuronium bromide 1 mg/mL during simulated Y-site administration. Triplicate samples of palonosetron hydrochloride with each of the neuromuscular blocking drugs were tested. Samples were stored and evaluated for up to 4 hours at room temperature. Physical stability was assessed by turbidimetric and particulate measurements and visual inspection. Chemical stability was assessed by high-performnace liquid chromatography. All of the admixtures were clear and colorless when viewed in normal fluorescent room light and when viewed with a Tyndall beam. Measured turbidity and particulate content were low initially and remained low throughout the study. The drug concentration was unchanged in all of the samples tested. Palonosetron hydrochloride is physically and chemically stable with cisatracurium besylate, rocuronium bromide, succinylcholine chloride, or vecuronium bromide at the concentrations tested during simulated Y-site administration over 4 hours at ambient room temperature.

Stability Versus Potency Testing: The Madness is in the Method

Potency tests, known as quantitative tests, are designed to determine how much of the active drug is in the sample. Stability tests are used to determine a beyond-use date for a preparation. Employing the proper method to determine potency or stability is key to understanding the difference between potency testing and stability testing. Methods of determining potency may or may not be stability-indicating, but stability can be determined only by a stability-indicating method. A stability-indicating method can determine both potency and stability. Quality assurance programs are essential to establishing standards for compounded preparations. It is important that compounding pharmacists understand the differences between potency and stability tests and that these tests are made an integral part of the quality asurance program.

Palonosetron hydrochloride compatiblity and stability with three B-lactam anitbiotic during simulated y-site adminstration

Palonosetron hydrochloride is a relatively long-acting selective 5-HT3 receptor antagonist that has been approved for the prevention of chemotherapy-induced nausea and vomiting and is being ealuated for the prevention of postoperative nausea and vomiting. The objective of this study was to evaluate the physical and chemical stability of palonosetron hydrochloride 50 mcg/mL with the B-lactam antibiotics cefazolin sodium 20 mg/mL, cefotetan disodium 20 mg/mL, and the combination ampicillin sodium-sulbactam sodium 20 mg/mL and 10 mg/mL, respectively, during simulated Y-site administration. The effects of each of the antibiotics on palonosetron hydrochloride in these admixtures were tested in triplicate. Samples were stored and evaluated for up to 4 hours at room temperature. Physical stability was assessed by turbidimetric and particulate measurements and visual inspection. Chemical stability was assessed by high-performnace liquid chromatography. All of the admixtures were clear and colorless when viewed in normal fluorescent room light and when viewed with a Tyndall beam. Measured turbidity and particulate content were low initially and remained low throughout the study . The drug concentration was unchanged in all of the samples tested. Palonosetron hydrochloride is physically and chemically stable in admixtures with cefazolin sodium, cefotetan disodium and the combination ampicillin sodium-sulbactam sodium at the concentrations tested during simulated Y-site administration over 4 hours at ambient room temperature.

Quality-control analytical methods: a discussion of United States pharmacopeia chapter 71 sterility tests

It is apparent that the quality assurance program of a compounding pharmacy cannot adhere to the strict requirements of some of the general chapters in the United States Pharmacopeia. Those chapters containing such strict requirements that may impact pharmacy compounding should be studied thoroughly by the appropriate United States Pharmacoepia expert committee. Afterward, a determination should be made of which standards are reasonable and which can be modified and implemented to ensure timely preparation of quality compounded medications.

Physical and chemical stability of palonosetron hydrochloride with five opiate agonists during simulated Y-site administration

PURPOSE

The physical and chemical compatibility of palonosetron hydrochloride with fentanyl citrate, hydromorphone hydrochloride, meperidine hydrochloride, morphine sulfate, and sufentanil citrate during simulated Y-site administration was studied.

METHODS

Test samples were prepared in triplicate by mixing 7.5-mL samples of undiluted palonosetron 50 microg/mL (of palonosetron) with 7.5-mL samples of fentanyl citrate 50 microg/mL, morphine sulfate 15 mg/mL, hydromorphone hydrochloride 0.5 mg/mL, meperidine hydrochloride 10 mg/mL, and sufentanil citrate 12.5 microg/mL (of sufentanil) per milliliter individually in colorless 15-mL borosilicate glass screw-cap culture tubes with polypropylene caps. Physical stability of the admixtures was assessed by visual examination and by measuring turbidity and particle size and content. Chemical stability was assessed by stability-indicating high-performance liquid chromatography. Evaluations were performed immediately and one and four hours after mixing.

RESULTS

All of the admixtures were initially clear and colorless in normal fluorescent room light and when viewed with a high-intensity monodirectional light (Tyndall beam) and were essentially without haze. Changes in turbidity were minor throughout the study. Particulates measuring 10 microm or larger were few in all samples throughout the observation period. The admixtures remained colorless throughout the study. No loss of palonosetron hydrochloride occurred with any of the opiate agonists tested over the four-hour period. Similarly, little or no loss of the opiate agonists occurred over the four-hour period.

CONCLUSION

Palonosetron hydrochloride was physically and chemically stable with fentanyl citrate, hydromorphone hydrochloride, meperidine hydrochloride, morphine sulfate, and sufentanil citrate during simulated Y-site administration.

Quality-control analytical methods: the quality of sterility testing

Microbiology, like compounding, is a science that must be demonstrated to show that it is reliable, reproducible, and scientifically sound. Aseptic technique must become second nature to the microbiologist and the compounding pharmacist. With each new drug tested by a quality-control laboratory, there is a responsibility that everything possible is done to ensure that the test result reported is accurate and reliable. While it is recognized that the conventional sterility-testing method has inherent deficiencies, an alternative method cannot be used unless it provides equivalent asurance of detecting microbial contamination. A quality-control laboratory and compounding pharmacists should adhere to the standards of the United States Pharmacopeia when compounding and testing preparations.

Physical and chemical stability of palonosetron with metoclopramide and promethazine during simulated y-site administration

The objective of this study was to evaluate the physical and chemical stability of mixtures of undiluted palonosetron hydrochloride 50 micrograms/mL with undiluted metoclopramide hydrochloride 5 mg/mL and with promethazine hydrochloride 2 mg/mL diluted in 5% dextrose injection during simulated Y-site administration. Triplicate test samples were prepared by admixing 7.5 mL of palonosetron hydrochloride with 7.5 mL of the undiluted metoclopramide hydrochloride and, separately, with the promethazine hydrochloride dilution. Physical stability was assessed using a multistep evaluation procedure that included both turbidimetric and particulate measurement as well as visual inspection. Chemical stability was assessed by using stability-indicating high-performance liquid chromatographic analytical techniques based on the determination of drug concentrations. Evaluations were performed initially upon mixing and 1 and 4 hours after mixing. The samples were clear and colorless when viewed in normal fluorescent room light and when viewed with a Tyndall beam. Measured turbidities remained unchanged; particulate contents were low and exhibited little change. High-performance liquid chromatographic analysis revealed that palonosetron hydrochloride and both metoclopramide hydrochloride and promethazine hydrochloride remained stable throughout the 4-hour test with no drug loss. Palonosetron hydrochloride is physically compatible and chemically stable with undiluted metoclopramide hydrochloride and also with promethazine hydrochloride diluted in 5% dextrose injection during simulated Y-site adminstration.

Compatibility of micafungin injection with other drugs during simulated y-site co-administration

The objective of this study was to evaluate the physical compatibility of micafungin injection with selected other drugs during simulated Y-site co-administration. Physical stability was assessed by both visual observation and turbidity measurement. Micafungin in 0.9% sodium chloride injection was combined with each of 48 other drugs, including antineoplastics, analgesics, anti-infectives, and supportive care drugs undiluted or diluted in 0.9% sodium chloride injection, and with a parenteral nutrition admixture. Visual examinations were performed with the unaided eye in fluorescent light and by using a Tyndall beam, and the turbidity of each sample was measured. The samples were evaluated immediately after mixing and again 1 and 4 hours after preparation. Twenty-nine of the drugs tested were found to be compatible for at least 4 hours. The measured turbidity of the micafungin control solutions and the compatible test samples remained essentially unchanged throughout the study. The other 19 drugs exhibited frank precipitation, microparticulate formation or unacceptable increases in turbidity within 4 hours of mixture with micafungin and thus should not be administered simultaneously via Y-site with micafungin.

Pharmacogenomics for the Forensic Toxicologist

Pharmacogenomics is the study of the linkage between an individual's genotype and the disposition of drugs in the body. The first association between adverse drug reactions and inherited variations was recognized in the 1950s, and since then, pharmacogenomics has come a long way. The importance of pharmacogenomics is accentuated by the incidence of adverse drug reactions, which may account for hospital expenditures of up to 5.6 billion dollars annually. Interindividual variations in drug metabolism are often the result of genetic variants or genetic polymorphisms, and polymorphisms have been known to alter the relationship between dose and plasma drug concentration. Drug disposition can be affected by polymorphisms in drug metabolizing enzymes, drug transport proteins, and drug targets. The cytochrome P450 (CYP) enzymes are responsible for the metabolism of a large number of drugs. Polymorphisms of the CYP enzymes have been well documented, and CYP2D6 is the most polymorphic CYP enzyme. However, there is a relative dearth of research on the role of transport proteins and drug targets. This review attempts to provide a brief synopsis of the pharmacogenomics of some common drug-metabolizing enzymes, transport proteins, and targets. The examples of tramadol, methadone, and oxycodone are used to illustrate the potential role of pharmacogenomics in forensic toxicology. Pharmacogenomics may present a practicable hypothesis in cases of incongruence between dose and plasma drug concentration, and the possibility of genotype-mediated drug plasma levels needs to be considered.

Quality-Control Analytical Methods: Microbial-Testing Aspects of USP Chapter 797 for Compounded Sterile Preparations

The standards set forth by the United States Pharmacopeia (USP) Chapter 797 have now been in effect since January 1 or 2004. As the first practice standards of sterile pharmacy compounding in US history, they have "attracted both respect and criticism" because they have also been cited as a practice expectation by the Joint Commission on Accreditation of Healthcare Organizations. USP 797 expands the scope of facilities governed by the regulatinos and defines the practices covered, emphasizing the importance of environmental quality and control, verification of accuracy and sterility, training and evaluation, quality control after preparations leave the pharmacy, patient monitoring and adverse events reporting. The purpose of this article is to help the reader understand the criteria set forth by USP Chapter 797 regarding finished-product testing, including criteria for the microbial-testing aspects of sterility testing (USP Chapter 71) and endotoxin (pyrogen) testing (USP Chapter 85).

Stability of admixture containing morphine sulfate, bupivacaine hydrochloride, and clonidine hydrochloride in an implantable infusion system

Intrathecal infusion is often performed using drug combinations. This study was conducted to evaluate the stability of the admixture of morphine sulfate, bupivacaine hydrochloride, and clonidine hydrochloride when used in an implantable pump under simulated clinical use conditions. SynchroMed implantable pumps were filled with an admixture and incubated at 37 degrees C for a period of 90 days. Drug admixture stored in glass vials at 4 degrees C and at 37 degrees C served as controls. Samples which included pump reservoir and catheter delivered aliquots were collected every 30 days and analyzed for drug concentrations using a stability-indicating HPLC method. All drugs contained in the admixture were stable and the original concentrations remained greater than 96%. Over 90 days, and with the pump at the simulated body temperature of 37 degrees C, there were no evident heat catalyzed or device catalyzed reactions.

A Non-Fatal Case of Sodium Toxicity

A non-fatal case of sodium toxicity in a six-year-old boy is presented. Hypernatremia is the clinical term for an excessive concentration of sodium relative to water in the body. The diagnosis of hypernatremia was made at serum sodium (Na(+)) concentrations exceeding 150 mEq/L, and few people have been reported to survive concentrations greater than 160 mEq/L. This case involves a six-year-old boy who was taken to the hospital following a seizure attack, and lab analyses revealed serum sodium (Na(+)) levels of 234 mEq/L and serum chloride (Cl(-)) levels of 205 mEq/L. Clinical tests ruled out diabetes insipidus, dehydration, renal pathology, and other primary causes of hypernatremia. The child's purported history of pica, and the lab results indicating corresponding increases in levels of serum sodium (Na(+)) and serum (Cl(-)), led to a diagnosis of acute sodium toxicity by ingestion of sodium chloride. A search of the boy's house led to the discovery of rock salt in the cabinet and a container of table salt. Extrapolating from the serum sodium (Na(+)) level, it was estimated that the child had ingested approximately four tablespoons of rock salt, leading to the acute toxicity. A literature search revealed that the serum sodium (Na(+)) concentration in the present report was the highest documented level of sodium in a living person.

Impact of hypericum (St.-John's-wort) given prenatally on cognition of mice offspring

This study investigated the cognitive impact of prenatal exposure to the herbal antidepressant hypericum in CD-1 mice. Hypericum (182 mg/kg/day) or a placebo was consumed in food bars for 2 weeks before mating and throughout gestation. The hypericin content in our hypericum formulation was in the middle range of standardized hypericum products. One offspring per gender from each litter (hypericum 13, placebo 12) was tested on each of the following tasks: juvenile runway with adult memory, adult Morris maze, adult passive avoidance, or adult straight water runway followed by a dry Cincinnati maze. Learning occurred in both genders in all tasks (P<.003) with no significant differences between treatments at the final trial. Female offspring exposed to hypericum, rather than to a placebo, required more time to learn the Morris maze task (P<.05). Postlearning sessions did not show any significant differences. In conclusion, prenatal exposure to a therapeutic dose of hypericum did not have a major impact on certain cognitive tasks in mice offspring.

Stability of Adderall in extemporaneously compounded oral liquids

The short-term stability of Adderall in three extemporaneously compounded oral liquids was studied. Three suspensions of Adderall 1 mg/mL were prepared from commercially available 10-mg Adderall tablets with Ora-Sweet, Ora-Plus, and a 1:1 mixture of Ora-Sweet and Ora-Plus. Each suspension was stored in the dark in a stability chamber at 25 degrees C and 60% relative humidity for 30 days. The stability of the active drug (a mixture of levoamphetamine and dextroamphetamine salts) in each of the three vehicles was determined immediately after preparation and at 10, 20, and 30 days by using gas chromatography-mass spectrometry (GCMS). No significant changes in concentrations of either amphetamine isomer occurred during the 30-day study period. Visual inspection of samples revealed no changes in color or odor. Extemporaneously compounded liquid oral formulations of Adderall 1 mg/mL in Ora-Sweet, Ora-Plus, or a 1:1 mixture of Ora-Sweet and Ora-Plus were stable for at least 30 days at 25 degrees C and 60% relative humidity.

Impact of antenatal exposure of mice to fenfluramine on cardiac development and long-term growth of the offspring

The objective of this investigation was to determine, in a placebo-controlled manner, whether antenatal exposure to formulations of fenfluramine and dexfenfluramine impacted cardiac development and long-term growth of exposed mice offspring. One hundred forty-four CD-1 mice were randomized to six treatment groups (n=23 or 25) to obtain, per group, 5 gravids for killing on gestational day (GD) 15 and < or =10 deliveries for assessing growth of the offspring. Either fenfluramine preparation was administered in feed bars in two doses: 1 and 3.2 times the equivalent human daily dosage according to body surface area. The drugs were given from 2 weeks before mating until GD 15. The mice ingested each drug at target values, averaging 10.5+/-0.3 and 31.8+/-1.9 mg/kg/d for fenfluramine and 5.0+/-0.2 and 16.2+/-0.4 mg/kg/d for dexfenfluramine. The drug concentration was about 36% in the fetal brain compared with the adult brain. The maternal and the offspring hearts, including mitral and aortic valves, of fenfluramine-exposed mice were indistinguishable from the placebo-exposed mice. The duration of gestation and the litter size were the same between the treatment groups. The mean body weights, body lengths, and head circumferences and early functional testing did not differ significantly between the fenfluramine or dexfenfluramine-exposed offspring and the placebo-exposed offspring. There were no significant treatment differences in growth measured as body weights to PND 120. Neither fenfluramine formulation, given before conception and during gestation, impacted cardiac development and long-term growth of the mice offspring.

Dry-heat sterilization of parenteral oil vehicles

The purpose of this study was to evalutate the effect of temperature and time on the dry-heat sterilization conditions of cottonseed, peanut and sesame-seed oils used as vehicles for parenteral drugs. The three oils were inidividually spiked wiht Bacillus subtilis spores and exposed to dry heat at four temperatures (150, 160, 170, and 180 deg C) for three different time intervals (one, 1.5 and two hours). Following inoculation and dry-heat sterilization, samples were placed in a laminar airflow hood and processed according to 71, "Sterility Tests" of the USP XXIV/NF 19 using thioglycolate broth and fluid D. The specimens were then placed into an incubator at 30 deg C and observed for three, five and seven days for bacterial growth. All tests were performed in triplicate. Positive and negative controls were conducted with each group. All three oils were found to be free of viable Bacillus subtilis following dry-heat sterilization at 150, 160, 170 and 180 deg C for one, 1.5 and two hours after incubation for seven days. The positive controls had no observed bacterial growth. Dry-heat sterilization of the three oils at 150 deg C for one hour appeared to be sufficient for time and temperature conditions. However, the authors recommend dry-heat sterilization procedures be validated for each product.

Effect of antenatal exposure to paroxetine (paxil) on growth and physical maturation of mice offspring

OBJECTIVE

Our purpose was to determine, in a placebo-controlled manner, whether antenatal exposure to paroxetine affected long-term growth and physical maturation of mice offspring.

METHODS

Forty-one CD-1 mice consumed paroxetine (n = 21) or a placebo (n = 20) for 2 weeks before conception and throughout gestation. The daily dose of paroxetine (Paxil; 30 mg/kg/d) was known to achieve concentrations in the serum equivalent to the upper therapeutic level in humans and in the fetal brain equivalent to that of the adult mouse. Growth and physical maturation of the offspring were compared by paired t-test, Welch's corrected test, and Fisher's exact test.

RESULTS

The maternal weight gain, litter sizes, number of fetal resorptions, and gestational age at delivery were not different between the paroxetine and the placebo-exposed offspring. Newborn pups exposed to paroxetine were more likely to have low birthweights (1.65 gm vs. 1.70 gm; P < 0.05) and narrower heads (7.7 mm vs. 8.1 mm; P < 0.05). Body weight, body length, and head circumference measurements increased in a manner that was indistinguishable between the two groups of offspring, regardless of gender. No differences in achievement of physical milestones (lower incisor eruption, eye opening, and development of external genitalia) were noted between the two groups. The reproductive capability and the perinatal outcomes of the second-generation offspring were unaffected by paroxetine exposure.

CONCLUSION

A clinically relevant dose of paroxetine, when given throughout gestation, did not affect long-term growth and physical maturation of mice offspring.

Stereochemical determination of selegiline metabolites in postmortem biological specimens

In this study, findings related to an aircraft accident are reported. Biological specimens collected at autopsy from the pilot of the fatal accident and two types of tablets found at the accident scene were submitted for toxicological evaluation. It was determined that the pilot was dead at the crash site and the cause of death was multiple traumatic injuries. The tablets were identified as selegiline and levodopa, commonly prescribed for the treatment of Parkinson's disease. Selegiline, a stereospecific compound, is biotransformed into (-)-N-desmethylselegiline, (-)-methamphetamine, and (-)-amphetamine. The latter two levorotatory metabolites cannot be easily distinguished by routine analysis from their dextrorotatory isomers, which are controlled substances. It was, therefore, prudent to differentiate these isomers to determine if they resulted from the ingestion of a controlled substance, (+)-methamphetamine. Initial immunoassay drug screenings revealed the presence of amphetamine class drugs (867 ng/mL) in urine, amphetamine/methamphetamine (261 ng/mL) in urine, and methamphetamine (46 ng/mL) in blood. The gas chromatography-mass spectrometry (GC/MS) results revealed the presence of methamphetamine in the concentrations of 76 ng/mL of blood and 685 ng/mL of urine. The concentration of amphetamine was 52 ng/mL in blood and 320 ng/mL in urine. To determine the stereospecificity of these amines, the isolated amines from the biosamples were derivatized by a stereospecific agent, (S)-(-)-N-(trifluoroacetyl)-prolyl chloride, and characterized by a GC/MS method to be levorotatory. The 2.14 ratio of (-)-methamphetamine to (-)-amphetamine concentrations in the urine was consistent with a selegiline study in the recent literature. The stereospecific analysis, in conjunction with the history of the pilot being on Parkinson's medications, suggests that the source of these amines was selegiline. This conclusion substantiates the importance of the identification of enantiomers in evaluating and interpreting related analytical results for accident investigations.