Premix versus On-Demand Workflow Models in a Veterans Affairs Hematology/Oncology Pharmacy: Impact on Estimated Waste Costs and Patient Wait Time

Background: The balance between reducing patient wait time and mitigating waste of parenteral products has not been well described in literature. Objective: Evaluate the patient wait times and cost-effectiveness of employing a premix versus an on-demand workflow model for compounding parenteral admixtures in a hematology/oncology infusion setting. Methods: This single center, retrospective cost analysis compiled manually documented monthly waste reports and estimated drug pricing for the institution to calculate the cost of waste during both premix and on-demand compounding workflows. Time to administration was audited for one week with both models. Results: Over a period of 28.5 months following the premix model, 564 products were documented as wasted ($1,196,014.01 in estimated drug purchasing cost). Over a period of 3 months following the on-demand model, 12 products were wasted ($34,823.98 in estimated drug purchasing cost). Switching models reduced the monthly average number of wasted products from 20 to 4 per month; the average cost of waste was reduced from $41,965.40 to $11,607.99 per month (P < .0001). Overall patient wait time from clearance until administration, excluding any recommended wait times after premedication administration (if applicable), was similar in both models: an average of 38.26 minutes in the premix model and 40.97 minutes in the on-demand model. Conclusion: Premixing parenteral admixtures was not cost effective at our institution. After resuming an on-demand compounding model, the monthly cost of waste (based on drug pricing alone) was reduced by over 70%. The wait time from clearance to treatment administration was similar in both models.

Pharmacokinetic Similarity between Biosimilar Insulin Aspart Premix SAR341402 Mix 70/30 and Originator Insulin Aspart Mix 70/30 (NovoMix 30) in Indian Adults with Type 2 Diabetes: GEMELLI M Substudy

BACKGROUND

We compared the pharmacokinetic exposure, efficacy, safety and immunogenicity of biosimilar insulin aspart premix SAR341402 Mix 70/30 (SAR_Asp-Mix) with its originator NovoMix^® 30 insulin aspart mix (NN-Mix) in adults with type 2 diabetes.

METHODS

This was a randomized, open-label, parallel-group, substudy of the phase 3 GEMELLI M trial performed in three Indian centres. Totally 13 Indian participants previously treated with premix insulin received a single subcutaneous 0.3 U/kg dose of each treatment and underwent pharmacokinetic sampling for 16 h after dosing. Participants were then treated for 26 weeks as per the main GEMELLI M trial with efficacy, safety and immunogenicity compared between groups.

RESULTS

The extent of exposure (area under the plasma concentration-time curve and maximum insulin aspart concentration) to SAR341402 insulin aspart in SAR_Asp-Mix and to insulin aspart in NN-Mix was similar following single doses of the allocated treatment. After 26 weeks, the mean ± SD [median] change in HbA1c from baseline was similar in both treatment groups (SAR_Asp-Mix -0.38% ± 1.54 [-1.00%]; NN-Mix -0.18% ± 1.97 [-0.80%]). Other efficacy endpoints, insulin dosages, anti-insulin aspart antibody response, hypoglycemia and adverse events were similar between groups.

CONCLUSIONS

Our results support the findings from previous studies, that SAR_Asp-Mix has a similar pharmacokinetic profile to NN-Mix and provides effective glycemic control with similar safety and immunogenicity profile in Indian adults with type 2 diabetes.

Spray drift potential of dicamba plus S-metolachlor formulations

BACKGROUND

Early-postemergence herbicide applications in the USA often include residual herbicides such as S-metolachlor to suppress late late-emerging Amaranthus spp. Although this practice benefits weed control, herbicide tankmixes can influence spray droplet size and drift potential during applications. The addition of S-metolachlor products to dicamba spray solutions generally decreases spray droplet size and increases spray drift potential. Advances in formulation technology fostered the development of products with reduced spray drift potential, especially for herbicide premixes containing multiple active ingredients. The objective of this study was to compare the drift potential of a novel dicamba plus S-metolachlor premix formulation (capsule suspension) against a tankmix containing dicamba (soluble liquid) and S-metolachlor (emulsifiable concentrate) using different venturi nozzles.

RESULTS

The MUG nozzle had greater D_V0.5 (1128.6 μm) compared to the ULDM (930.3 μm), TDXL-D (872.9 μm), and TTI nozzles (854.8 μm). The premix formulation had greater D_V0.5 (971.0 μm) compared to the tankmix (922.3 μm). Nozzle influenced spray drift deposition (P < 0.0001) and soybean biomass reduction (P = 0.0465). Herbicide formulation influenced spray drift deposition (P < 0.0001), and biomass reduction of soybean (P < 0.0001) and cotton (P = 0.0479). The novel capsule suspension formulation (premix) of dicamba plus S-metolachlor had reduced area under the drift curve (AUDC) (577.6) compared to the tankmix (913.7). Applications using the MUG nozzle reduced AUDC (459.9) compared to the other venturi nozzles (ranging from 677.4 to 1141.7).

CONCLUSION

Study results evidence that advances in pesticide formulation can improve pesticide drift mitigation. © 2021 Society of Chemical Industry.

Shrink, weighing accuracy, and weighing precision of mineral supplement in five commercial dairies in the Western United States

Shrink, accuracy, and precision of ingredient weighing are critical factors of efficiency in TMR-fed dairy systems. Those factors have been evaluated for major feeds; however, we are not aware of any reports for mineral supplement. Farms commonly mix mineral supplement with other low-inclusion ingredients into a premix which is used later as a single ingredient for TMR formulation. Our objectives were to evaluate shrink, weighing accuracy, and weighing precision of mineral supplement during premix formulation, and variation in concentration of minerals in mineral supplement and TMR, in five large dairies in the Western United States. We used the automated weight-tracking system at each farm to account for all the mineral supplement loaded into the mixing-wagon and collected samples of mineral supplement and TMR from time of mineral supplement delivery at the farm until 100% of it was consumed. Mean, standard deviation and coefficient of variation (CV) for each variable were calculated with SAS 9.4. Average shrink was estimated at 2.0% for mineral supplement during storage and loading, ranging from 0.37% to 3.25%. Mineral supplement weighing deviation from the targeted amount was 1.54% on average for the five dairies with a 95% CV. Mineral composition of mineral supplements averaged 11.3%, 0.27%, and 3.16% for Ca, P, and Mg, and 215, 881, and 1533 ppm for Cu, Mn, and Zn, respectively. Mineral compositions in TMR averaged 0.84%, 0.41%, and 0.37% for Ca, P, and Mg, respectively; and 15.1, 71, and 94.5 ppm for Cu, Mn, and Zn, respectively. The CV of all minerals except Ca, were larger for mineral supplement than TMR, and with the exception of P in mineral supplement, CV of trace minerals were larger than CV values for macro minerals. Our shrink estimates for mineral supplement represent an initial approximation to this issue. Results of our weighing deviation analysis suggest some room for improvement on the precision of weighing mineral supplement at the time when premix is prepared at the farm, which could improve consistency in chemical composition of the premix and consequently reduce the variation (CV values) of mineral concentrations in TMR.

Effects of Sources and Forms of Vitamin K3 on Its Storage Stability in Vitamin Premixes or Vitamin Trace Mineral Premixes

Six types of vitamin K₃ (VK₃); two sources (menadione sodium bisulfite, MSB; menadione nicotinamide bisulfite, MNB), and three different forms (crystal, micro-capsule, and micro-sphere) were used to determine the retention of VK₃ in vitamin premixes (Experiment 1) or vitamin trace mineral (VTM) premixes (Experiment 2) after 1, 2, 3, and 6 months of storage. The retention of VK₃ in vitamin premixes was evaluated at 25 °C/60% relative humidity or 40 °C/75% relative humidity in an incubator in Experiment 1 and in VTM premixes (choline chloride: 0 vs. 16,000 mg/kg) stored at room temperature in Experiment 2. The VK₃ retention in vitamin premix or VTM premix decreased significantly with the extension of storage time (p < 0.05). In Experiment 1, the VK₃ retention was higher in the 25 °C/60% incubator (56%) than in the 40 °C/75% incubator (28%). The MNB retention (52%) was higher than MSB retention (32%). The retention of VK₃ in micro-capsules (43%) or micro-spheres (48%) was higher than the crystal form (35%) after six months of storage. In Experiment 2, there was no difference between the retention of MSB (49%) or MNB (47%). The retention of VK₃ of micro-capsule (51%) or micro-sphere (54%) was higher than that of crystal form (40%). The VK₃ retention was higher in the choline-free group (51%) than in the choline group (47%) after six months of storage. Finally, the predicted equations of VK₃ retention with storage time in vitamin premixes or VTM premixes were established. The R² of the prediction equations was ≥0.9005, indicating that time is an important factor in predicting VK₃ retention. In conclusion, the higher temperature-relative humidity, choline had negative effects on VK₃ retention during premix storage. MNB retention was higher than MSB during storage of vitamin premix. The encapsulated forms of VK₃, micro-capsules and micro-spheres, could improve VK₃ storage stability in vitamin premix and VTM premix.

Impact of premix antimicrobial preparation and time to administration in septic patients

OBJECTIVE

Strategies that reduce the time to antimicrobial administration, such as the availability of premix antimicrobials (PMAs) in the emergency department (ED), may better align with the goals of the Surviving Sepsis Campaign and improve outcomes in septic patients. The objective of this study was to evaluate the impact of antimicrobial preparation on time to administration in septic patients located in the emergency department (ED).

METHODS

This was a retrospective, single-center, cohort study and adult patients with a diagnosis of sepsis who received at least one initial intravenous (IV) antimicrobial in the ED were included. Time to complete an empiric antimicrobial therapy was defined as the time between prescriber order entry and the infusion initiation time of the final antimicrobial agent of a patient's antimicrobial regimen. Appropriate, empiric antimicrobial therapy was based on treatment recommendations by nationally accepted guidelines for the specific indication.

RESULTS

The first antimicrobial was initiated earlier when available as a PMA preparation (median (IQR): premix 25 minutes (16.5-42.3) vs. non-premix 46 minutes (20-102), p=0.027). When comparing complete, empiric antimicrobial regimen administration, there was no difference in time to administration between regimens containing one or more non-premix antimicrobials and regimens containing all PMAs (median (IQR): premix 69 minutes (21-115) vs. non-premix 65 minutes (38.5-133.8); p=0.455).

CONCLUSIONS

PMA preparations significantly reduced time to administration of the first antimicrobial agent for septic patients treated in the ED, but time to administration of subsequent antimicrobials were not improved.

Biphasic insulin aspart 30/70 (BIAsp 30) in the treatment of type 1 and type 2 diabetes

The pharmacological advantages of the rapid-acting analog, insulin aspart, over human insulin have contributed to the widespread prescription of the premix, biphasic insulin aspart 30/70 (BIAsp 30), in type 1 (T1DM) and type 2 diabetes (T2DM). This article reviews the available literature on the pharmacology, efficacy and safety of BIAsp 30 in T1DM and T2DM from an online search of the PubMed database. Following injection, BIAsp 30 reaches higher plasma insulin levels more quickly than human premix or basal insulin, giving effective reduction of postprandial hyperglycemia. In T1DM patients, randomized controlled trials (RCTs) have shown that HbA(1c) reduction is similar, but postprandial glycemic control is better, with BIAsp 30 than with human insulin regimens. In T2DM patients, lowering of HbA(1c) and postprandial hyperglycemia with BIAsp 30 compare favorably with optimized oral antidiabetes drug treatment, insulin glargine, and, in obese patients, human premix. An increase in minor hypoglycemia with BIAsp 30 relative to basal insulin has been reported in T2DM patients, but major and nocturnal hypoglycemia rates are generally low. Findings from RCTs in T2DM patients are supported by large observational studies. In summary, BIAsp 30 once to three times daily represents a simple and effective tool for the modern management of diabetes.

Interest of 50% nitrous oxide and oxygen premix sedation in gerodontology

Elderly patients presenting cardiovascular, respiratory, or neurological disorders require a specific dental care approach, especially patients presenting Alzheimer's disease. Sedative procedures can prevent dental care-induced stress, even when there is effective pain control, but they have to be adapted to accommodate age-induced physiological modifications, age-related pathologies, and the concomitant treatments. In many situations, routine sedative prescriptions for dental care, such as benzodiazepine or antihistaminics, are not recommended for these patients. Nitrous oxide inhalation together with a specific behavioral threshold is currently the only sedative procedure adapted to cognitively-impaired elderly patients. Nitrous oxide is able to curb stress and its cardiovascular consequences, improve oxygenation, and optimize cooperation during dental care, making not only rehabilitation treatments but also routine dental care a viable option.