Cushion-coated pellets for tableting without external excipients

Multiple-unit dosage forms prepared by compacting pellets offer important manufacturing and compliance advantages over pellet-filled capsules. However, compaction may negatively affect the release control mechanism of pellets, and subunits may not be readily available after intake. Application of a cushioning layer to the starting units is here proposed as a strategy to obtain tablets with satisfactory mechanical strength, rapid disintegration and maintenance of the expected release profile of individual subunits while avoiding the use of mixtures of pellets and excipients to promote compaction and limit the impact of the forces involved. Cushion-coating with PEG1500, a soft and soluble material, was proved feasible provided that the processing temperature was adequately controlled. Cushioned gastro-resistant pellets were shown to consolidate under relatively low compaction pressures, which preserved their inherent release performance after tablet disintegration. Adhesion problems associated with the use of PEG1500 were overcome by applying an outer Kollicoat® IR film. Through design of experiment (DoE), robustness of the proposed approach was demonstrated, and the formulation as well as tableting conditions were optimized. The tableted cushion-coated pellet systems manufactured would allow a relatively high load of modified-release units to be conveyed, thus setting out a versatile and scalable approach to oral administration of multiple-unit dosage forms.

The effects of a structured communication tool in patients with medically unexplained physical symptoms: a cluster randomized trial

Background

Medically Unexplained Physical Symptoms (MUPS) are prevalent among primary care patients and frequently lead to diminished quality of life, increased healthcare costs, and decreased work participation. We aimed to examine the effects of a work-focused structured communication tool based on cognitive-behavioral therapy in patients with MUPS.

Methods

In a Norwegian two-arm cluster randomized trial, the effectiveness of the structured communication tool Individual Challenge Inventory Tool (ICIT) was compared to usual care for patients with MUPS using a two-arm cluster randomized design. Enrollment period was between March 7 and April 1, 2022. Ten groups (clusters) of 103 General Practitioners (GPs) were randomized to provide the ICIT or usual care for 11 weeks. Patients received two or more sessions with their GP, and outcomes were assessed individually. Primary outcome was patient-reported change in function, symptoms, and quality of life measured by the Patient Global Impression of Change (PGIC). Secondary outcomes included sick leave, work-related self-efficacy (RTW-SE), health-related quality of life (RAND-36), and patient experiences with consultants (PEQ). The trial was registered on ClinicalTrials.gov (NCT05128019).

Findings

A total of 541 patients with MUPS were enrolled in the study. In the intervention group 76% (n = 223) showed a significant overall improvement in function, symptoms, and quality of life as measured by the PGIC, compared to 38% (n = 236) in the usual care group (mean difference -0.8 ([95% CI -1.0 to -0.6]; p < 0.0001). At 11 weeks, the intervention group had a 27-percentage point decrease in sick leave (from 52.0 to 25.2), compared to 4-percentage point decrease (from 49.7 to 45.7) in the usual care group. Furthermore, compared to usual care, the intervention group reported significant improvements in work-related self-efficacy, health-related quality of life, and greater satisfaction with the communication during the consultations. No adverse events were reported.

Interpretation

The implementation of the structured communication tool ICIT in primary care significantly improved patient outcomes and reduced sick leave among patients with MUPS.

Funding

The study was funded by The Norwegian Research Fund for General Practice.

Perspectives of patients, caregivers, and healthcare professionals in Indian context: A qualitative study on Medically Unexplained Physical Symptoms (MUPS)

BACKGROUND

Approximately one-fourth of individuals who seek treatment in outpatient medical settings have Medically Unexplained Physical Symptoms (MUPS), a prevalent medical ailment. Patients with MUPS have a considerable functional impairment, and a lower quality of life, and may also have co-occurring psychiatric conditions.

MATERIALS AND METHODS

Eleven Focus Group Discussions (FGDs) (four virtual and seven face-to-face) were conducted with patients, caregivers, and healthcare professionals in 2021 in a tertiary care hospital in New Delhi. Thematic analysis was carried out using QSR Nvivo software.

RESULTS

A total of 36 participants were recruited in the study, including patients with MUPS (n = 12), caregivers (n = 10), and healthcare professionals (n = 14) dealing with the patients of MUPS. Three themes were identified: burden of MUPS, symptom profile of patients with MUPS, and psychological profile of patients with MUPS. These were further categorized into eight sub-themes: prevalence, symptoms, course of illness, improvement with treatment, duration of symptoms, attribution of symptoms, psychological impact, and coping strategies.

CONCLUSION

The study helped us to gain insight into the characteristics and experiences of patients, caregivers, and healthcare professionals dealing with MUPS in an Indian setup. Greater awareness of MUPS and training of care providers about the occurrence, management, and referral of MUPS can be beneficial.

Psychological interventions for medically unexplained physical symptoms: A systematic review and meta-analysis

OBJECTIVE

Individuals seeking treatment for physical symptoms having unknown etiology are common in the primary healthcare setup. Factors such as biomedical, environmental, social, and psychological ones are expected to play an important role in the treatment of Medically Unexplained Physical Symptoms (MUPS). Therefore, this systematic review and meta-analysis aimed to investigate the efficacy of psychological interventions for the treatment of MUPS.

METHOD

Studies were selected using different electronic databases (PubMed, Wiley, Cochrane), to identify RCTs published in the last 11 years on psychological interventions to treat MUPS. A total of 12 studies were finalized for systematic review and 7 for meta-analysis based on the inclusion criteria. The risk of bias was assessed by the two reviewers independently using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. OpenMeta[Analyst] was used to perform meta-analysis.

RESULTS

The findings revealed that psychological interventions can possibly be effective in treating patients with MUPS. Somatic symptom severity and depression improved in the intervention groups as compared to controls, while anxiety, and physical and mental component summary of Short-Form General Health Survey 36 did not significantly improve in the intervention group.

CONCLUSION

A tailored module including psychological interventions to deal with these patients in primary care may be useful in improving the overall functioning of the individuals.

Validity and responsiveness of GHC-index in patients with amalgam-attributed health complaints

OBJECTIVE

Many patients have medically unexplained physical symptoms (MUPS); some of them attribute their health complaints to dental amalgam fillings. The aim of this study was to assess the validity and responsiveness of General Health Complaints index (GHC-index) for measuring the symptom load in MUPS patients compared to the widely used symptom outcome measure, Giessen Subjective Complaints List (GBB-24).

METHODS

Three outcome measures - GHC-index, GBB-24, and Munich Amalgam Scale (MAS) - were administered at baseline and 12 months after removal of all dental amalgam restorations. The validity and responsiveness of these symptom measures were tested against external anchors: bodily distress syndrome (BDS), SF-36 vitality, and visual analogue scale (VAS). We tested both convergent and known group validities. We also examined the predictive validity and responsiveness to changes for each instrument.

RESULTS

All the main outcome measures showed evidence of convergent and known group validities. The GHC-index, GBB-24 and MAS were all able to detect the anticipated differences in BDS and Energy. But the GBB-24 was more efficient in discriminating the BDS compared with the GHC-index (relative efficiency: RE = 0.69; 95% CI: 0.41-0.96) and MAS (RE = 0.59; 95% CI: 0.32-0.86). Each main outcome variable revealed good predictive validity for vitality (standardized coefficient: b ≈ 0.71 and R² ≈ 0.50). Moderate to high sensitivity to change over time was demonstrated, with GHC-index performing better.

CONCLUSION

The GHC-index is a valid and responsive instrument for assessing symptom load in MUPS patients attributing their health complaints to amalgam fillings and undergoing amalgam removal.

Highlighting DEM's Potential to Gauge Mechanistic Attributes of MUPS Tablet and Capsule Formulations

Simulation of pharmaceutical unit operations by the discrete element method (DEM) has elevated our understanding of the impact of single-particle interactions on themselves, and on the entire tablets/powder. Studies in the past have shown how this knowledge helps to mitigate/solve multiple challenges during conventional formulation and process development/modernization/troubleshooting, with minimal use of active drug material. This communication adds to this- highlighting the tool's potential for a rapid preliminary assessment of the mechanistic attributes of multiple unit particle system (MUPS) based tablet and capsule drug products.

Modeling the coating layer thickness in a pharmaceutical coating process

Although mechanistic numerical simulations can offer great insights into a process, they are limited with respect to resolved process time. While statistical models provide long-term predictability, determining the underlying probability distributions is often challenging. In this work, detailed CFD-DEM simulations of a pharmaceutical Wurster coating process for microspheres are used to evaluate the input parameters for a novel Monte-Carlo simulation approach. The combined strengths of both modeling approaches make it possible to predict the coating mass and thickness distributions over the entire process time. It was observed that smaller beads receive a thicker coating layer since they pass the spray zone closer to the nozzle. Moreover, it was established that, in contrast to the airflow rate, the spray rate has a great impact on the inter-particle coating variability. A stochastic model was developed to investigate the relative contribution of coating layer variability and fill weight variability to the product non-uniformity in a capsule filling process of Multiple Unit Pellet Systems (MUPS).

Development of a Biphasic-Release Multiple-Unit Pellet System with Diclofenac Sodium Using Novel Calcium Phosphate-Based Starter Pellets

Novel calcium phosphate-based starter pellets were used to develop a biphasic-release multiple-unit pellet system (MUPS) with diclofenac sodium as a model drug in the form of hard gelatin capsules. For comparative purposes, corresponding formulations based on the inert cores made of microcrystalline cellulose, sucrose and isomalt were prepared. The developed system consisted of two types of drug-layered pellets attaining different release patterns: delayed-release (enteric-coated) and extended-release. Dissolution characteristics were examined using both compendial and biorelevant methods, which reflected fed and fasting conditions. The results were collated with an equivalent commercial product but prepared with the direct pelletization technique.

Prevalence and Associated Factors of Nocturnal Eating Behavior and Sleep-Related Eating Disorder-Like Behavior in Japanese Young Adults: Results of an Internet Survey Using Munich Parasomnia Screening

Nocturnal (night) eating syndrome and sleep-related eating disorder have common characteristics, but are considered to differ in their level of consciousness during eating behavior and recallability. To date, there have been no large population-based studies determining their similarities and differences. We conducted a cross-sectional web-based survey for Japanese young adults aged 19-25 years to identify factors associated with nocturnal eating behavior and sleep-related eating disorder-like behavior using Munich Parasomnia Screening and logistic regression. Of the 3347 participants, 160 (4.8%) reported experiencing nocturnal eating behavior and 73 (2.2%) reported experiencing sleep-related eating disorder-like behavior. Smoking (p < 0.05), use of hypnotic medications (p < 0.01), and previous and/or current sleepwalking (p < 0.001) were associated with both nocturnal eating behavior and sleep-related eating disorder-like behavior. A delayed sleep-wake schedule (p < 0.05) and sleep disturbance (p < 0.01) were associated with nocturnal eating behavior but not with sleep-related eating disorder-like behavior. Both nocturnal eating behavior and sleep-related eating disorder-like behavior had features consistent with eating disorders or parasomnias. Nocturnal eating behavior but not sleep-related eating disorder-like behavior was characterized by a sleep-awake phase delay, perhaps representing an underlying pathophysiology of nocturnal eating syndrome.

Three-Dimensional Imaging with Infrared Matrix-Assisted Laser Desorption Electrospray Ionization Mass Spectrometry

Mass spectrometry imaging as a field has pushed its frontiers to three dimensions. Most three-dimensional mass spectrometry imaging (3D MSI) approaches require serial sectioning that results in a loss of biological information between analyzed slices and difficulty in reconstruction of 3D images. In this contribution, infrared matrix-assisted laser desorption electrospray ionization (IR-MALDESI) was demonstrated to be applicable for 3D MSI that does not require sectioning because IR laser ablates material on a micrometer scale. A commercially available over-the-counter pharmaceutical was used as a model to demonstrate the feasibility of IR-MALDESI for 3D MSI. Depth resolution (i.e., z-resolution) as a function of laser energy levels and density of ablated material was investigated. The best achievable depth resolution from a pill was 2.3 μm at 0.3 mJ/pulse. 2D and 3D MSI were performed on the tablet to show the distribution of pill-specific molecules. A 3D MSI analysis on a region of interest of 15 × 15 voxels across 50 layers was performed. Our results demonstrate that IR-MALDESI is feasible with 3D MSI on a pill, and future work will be focused on analyses of biological tissues.

Estimated prevalence of medically unexplained physical symptoms in the medicine outpatient department of a tertiary care hospital in India

PURPOSE

There is a paucity of scientific evidence from the Indian subcontinent regarding the magnitude and burden of Medically Unexplained Physical Symptoms (MUPS). This study aims to fill the evidence gap by assessing the prevalence and pattern of MUPS amongst patients attending the Medicine Out-Patient Department (OPD).

METHODOLOGY

The study assessed all consecutive new patients, presenting to the Medicine OPD of a tertiary care center in India over a period of nine months. All consenting patients, between 18 and 60 years of age, irrespective of their reason for consultation were included for the study. The diagnosis in subjects was established by a combination of clinical history, physical examination, and relevant investigations. A diagnosis of MUPS was made in cases with no demonstrable organic cause, and after agreement in the opinion of two independent physicians. All recruited patients with MUPS were subsequently evaluated on a pre-validated symptom checklist of 23 symptoms.

RESULTS

Out of 976 subjects included, a diagnosis of MUPS was established in 24.6% [95% CI = 21.9-27.3] of the sample. An additional 20.6% met the criteria of persistent MUPS (symptoms >2 months), and 19.7% of subjects had symptom duration of more than three months, meeting the stricter definition for 'persistent MUPS'. Prevalence was significantly higher in females (p = 0.02), and patients of MUPS were significantly younger (p = 0.004) than patients with other diagnoses. MUPS patients on average complained of 13 ± 5 symptoms and sought multiple medical consultations [Median (IQR) = 3 (2 - 6)] in the last one year. Non-specific, general symptoms (94.6%) and various types of pain (93.7%) were the most frequent complaints. Pain symptoms, genitourinary symptoms, palpitation, and nausea were more frequent in females as compared to males.

DISCUSSION

Medically unexplained symptoms are as common in India as in the west and therefore pose a significant burden on the healthcare delivery systems. There is a need to sensitize the medical fraternity and policymakers for this condition to develop effective services.

Identifying subgroups based on self-management skills in primary care patients with moderate medically unexplained physical symptoms

OBJECTIVE

Medically Unexplained Physical Symptoms (MUPS) are a major burden on both patients and society and frequently develop into chronic MUPS. Self-management interventions may prevent moderate MUPS from becoming chronic. Tailoring interventions to the patient population is strongly recommended. This can be facilitated by identifying subgroups based on self-management skills. This study aimed to identify these subgroups and their clinical profiles in primary care patients with moderate MUPS.

METHODS

A cross-sectional study was performed on baseline measurements from a randomized clinical trial (PARASOL-study). To identify subgroups based on self-management skills, a hierarchical cluster analysis was conducted for adults with moderate MUPS from primary health care centers. Self-management skills were measured with the Health education impact Questionnaire. Cluster variables were seven constructs of this questionnaire. Additionally, specific patient profiles were determined by comparing the identified clusters on the clinical variables pain, fatigue and physical functioning.

RESULTS

Four subgroups were identified: High-Self-Management Skills (SMS) (n = 29), Medium-SMS (n = 55), Low-SMS (n = 49) and Active & Low Distress-SMS (n = 20). The latter showed a distinctly different pattern on cluster variables, while the other subgroups differed significantly on means of the cluster variables (p < .001). On clinical variables, significant differences between subgroups were mainly found on fatigue and physical functioning.

CONCLUSION

This study found four specific subgroups based on self-management skills in moderate MUPS-patients. One subgroup demonstrated a distinctly different pattern on self-management skills. In other subgroups, more similar patterns on self-management skills were found that negatively correlated with pain and fatigue and positively correlated with physical functioning.

Evaluating Commonalities Across Medically Unexplained Symptoms

This commentary presents commonalities in medically unexplained symptoms (MUS) across multiple organ systems, including symptoms, aetiological mechanisms, comorbidity with mental health disorders, symptom burden and impact on quality of life. Further, treatment outcomes and barriers in the clinician–patient relationship, and cross-cultural experiences are highlighted. This discussion is necessary in aiding an improved understanding and management of MUS due to the interconnectedness underlying MUS presentations across the spectrum of medical specialties.

Bulk Freeze-Drying Milling: a Versatile Method of Developing Highly Porous Cushioning Excipients for Compacted Multiple-Unit Pellet Systems (MUPS)

The compaction of multiple-unit pellet system (MUPS) is a challenging process due to the ease of coat damage under high compression pressure, thereby altering drug release rates. To overcome this, cushioning excipients are added to the tablet formulation. Excipients can be processed into pellets/granules and freeze-dried to increase their porosity and cushioning performance. However, successful formation of pellets/granules has specific requirements that limit formulation flexibility. In this study, a novel top-down approach that harnessed bulk freeze-drying milling was explored to avoid the challenges of pelletization/granulation. Aqueous dispersions containing 20%, w/w hydroxypropyl methylcellulose (HPMC), partially pregelatinised starch or polyvinylpyrrolidone alone, and with lactose (Lac) in 1:1 ratio, were freeze-dried and then milled to obtain particulate excipients for characterization and evaluation of their cushioning performance. This study demonstrated that bulk freeze-drying milling is a versatile method for developing excipients that are porous and directly compressible. The freeze-drying process modified the materials in a unique manner which could impart cushioning properties. Compared to unprocessed excipients, the freeze-dried products generally exhibited better cushioning effects. The drug release profile of drug-loaded pellets compacted with freeze-dried Lac-HPMC excipients was similar to that of the uncompacted drug-loaded pellets (f ₂ value = 51.7), indicating excellent cushioning effects. It was proposed that the specific balance of brittle and plastic nature of the freeze-dried Lac-HPMC composite conferred greater protective effect to the drug-loaded pellets, making it advantageous as a cushioning excipient.

The cross-sectional relation between medically unexplained physical symptoms (MUPS) and the Cortisol Awakening Response

OBJECTIVES

We aimed to assess the cross-sectional relation between levels of cortisol and specific symptom clusters, symptom severity and duration of symptoms in patients with medically unexplained physical symptoms (MUPS).

METHODS

Baseline data of a cohort of MUPS patients were used. We chose the Cortisol Awakening Response (CAR) as a cortisol parameter, using saliva samples. We used confirmatory factor analysis for the identification of 4 specific symptom clusters: (1) gastro-intestinal symptoms; (2) pain; (3) cardio-pulmonary symptoms; and (4) fatigue. For this factor analysis we used the Physical Symptom Questionnaire (PSQ), which assesses the occurrence and frequency of 51 physical symptoms. Symptom severity was measured with the Patient Health Questionnaire-15 (PHQ-15). Duration of symptoms was based on self-reported duration of top 3 symptoms. We performed multiple linear regression to assess relations between CAR and individual factor scores on symptom clusters, symptom severity and duration of symptoms.

RESULTS

Data from 296 patients (76% female) were included in the analyses. The majority of patients suffered from symptoms in multiple organ systems. Factor analysis confirmed that the model with 4 symptom clusters fitted our data. For the total study population, we found no significant relation between CAR and participants' factor scores on any of the symptom clusters. We also found no significant relations between CAR and severity or duration of symptoms.

CONCLUSION

Our results suggest that within a heterogeneous MUPS population there is no relation between CAR and symptom severity and duration. However, more studies are needed to confirm our findings.

Clinical practitioners' views on the management of patients with medically unexplained physical symptoms (MUPS): a qualitative study

OBJECTIVES

By identifying strategies that practicing physicians use in managing patients with medically unexplained physical symptoms (MUPS), we present an interim practical management guide (IPMG) that clinical practitioners may find useful in their clinical practices and that may help guide future research.

DESIGN

A qualitative research study based on interview data from practicing physicians with experience in dealing with MUPS and known to the physician members of the research team. A parallel exploration of patient experiences was carried out simultaneously and is reported elsewhere.

SETTING

2 urban centres in 2 different Canadian provinces in a healthcare system where family physicians provide the majority of primary care and self-referral to specialists rarely occurs.

PARTICIPANTS

The physician members of the research team invited practicing family and specialty physicians to participate in the study.

RESULTS

We characterise the care of patients with MUPS in terms of a 4-part framework: (1) the challenge of diagnosis; (2) the challenge of management/treatment; (3) the importance of communication and (4) the importance of the therapeutic relationship.

CONCLUSIONS

On the basis of the details in the different parts of the framework, we propose an IPMG that practitioners may find useful to facilitate the clinical care of patients with MUPS. The guide can be readily implemented into the practice of any physician who cares for patients with MUPS.

A mechanistic investigation on the utilization of lactose as a protective agent for multi-unit pellet systems

The effect of lactose particle size on the extent of pellet coat damage was investigated. The extent of pellet coat damage increased linearly with lactose median particle size. It was observed that coated pellets compressed with coarser lactose grades had larger and deeper surface indentations. The surfaces of the pellets compressed with coarser lactose grades were also found to be significantly rougher. Micronized lactose was capable of protecting pellet coats from damage brought about by the presence of coarser lactose particles. The findings suggested a protective effect that micronized lactose conferred to pellet coats was not only through dimensional delimitations but also by higher interparticulate friction and longer particle rearrangement phase. As a result, the pellet volume fraction in the system was reduced. The extent of pellet coat damage was found to escalate when the pellet volume fraction in such system increased beyond a critical value of 0.39.