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Process Analytical Technology for the Production of Parenteral Lipid Emulsions According to Good Manufacturing Practices. Processes (Basel) 2022. [DOI: 10.3390/pr10061174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The good manufacturing practices (GMP) and process analytical technology (PAT) initiatives of the US Food and Drug Administration, in conjunction with International Council for Harmonisation (ICH) quality guidelines Q8, Q9, and Q10, ensure that manufacturing processes for parenteral formulations meet the requirements of increasingly strict regulations. This involves the selection of suitable process analytics for process integration and aseptic processing. In this article, we discuss the PAT requirements for the GMP-compliant manufacturing of parenteral lipid emulsions, which can be used for clinical nutrition or for the delivery of lipophilic active ingredients. There are risks associated with the manufacturing processes, including the potential for unstable emulsions and the formation of large droplets that can induce embolisms in the patient. Parenteral emulsions are currently monitored offline using a statistical approach. Inline analytics, supplemented by measurements of zeta potential, could minimize the above risks. Laser scanning technology, ultrasound attenuation spectroscopy, and photo-optical sensors combined with image analysis may prove to be useful PAT methods. In the future, these technologies could lead to better process understanding and control, thus improving production efficiency.
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Zettler PJ, Shah SK. Broader Implications of Eliminating FDA Jurisdiction Over Execution Drugs. Am J Public Health 2021; 111:1764-1767. [PMID: 34473535 PMCID: PMC8561201 DOI: 10.2105/ajph.2021.306425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Patricia J Zettler
- Patricia J. Zettler is with the Moritz College of Law, Comprehensive Cancer Center, and Drug Enforcement and Policy Center, The Ohio State University, Columbus. Seema K. Shah is with the Feinberg Medical School and Pritzker School of Law (by courtesy), Northwestern University, Chicago, IL, and Lurie Children's Hospital, Chicago
| | - Seema K Shah
- Patricia J. Zettler is with the Moritz College of Law, Comprehensive Cancer Center, and Drug Enforcement and Policy Center, The Ohio State University, Columbus. Seema K. Shah is with the Feinberg Medical School and Pritzker School of Law (by courtesy), Northwestern University, Chicago, IL, and Lurie Children's Hospital, Chicago
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Watson CJ, Whitledge JD, Siani AM, Burns MM. Pharmaceutical Compounding: a History, Regulatory Overview, and Systematic Review of Compounding Errors. J Med Toxicol 2021; 17:197-217. [PMID: 33140232 PMCID: PMC7605468 DOI: 10.1007/s13181-020-00814-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Medications are compounded when a formulation of a medication is needed but not commercially available. Regulatory oversight of compounding is piecemeal and compounding errors have resulted in patient harm. We review compounding in the United States (US), including a history of compounding, a critique of current regulatory oversight, and a systematic review of compounding errors recorded in the literature. METHODS We gathered reports of compounding errors occurring in the US from 1990 to 2020 from PubMed, Embase, several relevant conference abstracts, and the US Food and Drug Administration "Drug Alerts and Statements" repository. We categorized reports into errors of "contamination," suprapotency," and "subpotency." Errors were also subdivided by whether they resulted in morbidity and mortality. We reported demographic, medication, and outcome data where available. RESULTS We screened 2155 reports and identified 63 errors. Twenty-one of 63 were errors of concentration, harming 36 patients. Twenty-seven of 63 were contamination errors, harming 1119 patients. Fifteen errors did not result in any identified harm. DISCUSSION Compounding errors are attributed to contamination or concentration. Concentration errors predominantly result from compounding a prescription for a single patient, and disproportionately affect children. Contamination errors largely occur during bulk distribution of compounded medications for parenteral use, and affect more patients. The burden falls on the government, pharmacy industry, and medical providers to reduce the risk of patient harm caused by compounding errors. CONCLUSION In the US, drug compounding is important in ensuring access to vital medications, but has the potential to cause patient harm without adequate safeguards.
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Affiliation(s)
- C James Watson
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA.
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - James D Whitledge
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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Abstract
One of the defining moments of the 80-year evolution of menopausal hormone therapy (MHT) was the 2002 reveal of the initial results of the combined hormone therapy arm of the Women's Health Initiative (WHI) clinical trial. The exodus from regulatory approved MHT was prompt and profound and accompanied by a rapid acceleration of the compounding pharmacy 'bioidentical' hormone therapy industry. Compounders had recruited prescribers and promoted compounded bioidentical hormone therapy (cBHT) well before the WHI, yet the startling results provided a catalyst that enabled a leap in production of compounded hormones that were variably regulated, basically unstudied, and inconsistently labeled. In this review, the story of the rise of cBHT and the regulatory double standard is eclipsed only by the 2020 findings and recommendations of the US National Academies of Science, Engineering, and Medicine. Their investigation, commissioned by the US Food and Drug Administration, was tasked to: provide an evidence-based summary of the clinical utility of cBHT; evaluate whether the evidence of safety and efficacy supports the use of cBHT; and identify patient populations that might need cBHT in lieu of an approved drug product. Their conclusions are consistent with sound science and their recommendations are in harmony with global menopause societies.
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Affiliation(s)
- C A Stuenkel
- University of California, San Diego, School of Medicine, La Jolla, CA, USA
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He ZH, Li Y, Trivedi N, Gill S, Hennessey JV. Thyrotoxicosis after massive triiodothyronine (LT3) overdose: a coast-to-coast case series and review. Drugs Context 2020; 9:dic-2019-8-4. [PMID: 32158485 PMCID: PMC7048132 DOI: 10.7573/dic.2019-8-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/06/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Excessive exogenous thyroid hormone ingestion may lead to severe thyrotoxicosis and cause potential harm. We have reviewed the literature and suggested that thyroid hormone supplementation should not be used to alleviate nonspecific complaints in patients with normal endogenous thyroid function. Failure to do so may cause serious harm, as demonstrated in one of the cases described here. In addition, treatment based on symptom relief only without biochemical measure may lead to overmedication - as reported from academic hospitals both in Canada and the United States. Given the risk of severe thyrotoxicosis from potential compounding errors, pharmacies providing a compounding service should be subject to more rigorous monitoring by the food and drug administration. Clinicians should also use local biochemical markers when titrating thyroid hormone supplements even though the normal thyroid function reference range has its limitation, failure to do so may result in iatrogenic thyrotoxicosis.
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Affiliation(s)
- Zhiheng H He
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yan Li
- Department of Medicine, St. Vincent Hospital, Worcester, MA, USA
| | - Nitin Trivedi
- Department of Medicine, St. Vincent Hospital, Worcester, MA, USA
| | - Sabrina Gill
- Division of Endocrinology & Metabolism, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - James V Hennessey
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Ossorio PN, Zhou Y. FMT and Microbial Medical Products: Generating High-Quality Evidence through Good Governance. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:505-523. [PMID: 31957588 DOI: 10.1177/1073110519897727] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This article argues that current data for the safety and efficacy of fecal microbiota transplants as a treatment for any indication, including recurrent Clostridioides difficile infection, is low-quality. It develops a governance proposal that encourages production of high-quality evidence by incentivizing well-designed RCTs of stool and stoolderived microbial products. The proposal would require that FDA change its current enforcement approach, but it would not require any change in statutes or regulations.
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Affiliation(s)
- Pilar N Ossorio
- Pilar N. Ossorio, Ph.D., J.D., is Professor of Law and Bio-ethics at the University of Wisconsin-Madison and the Bio-ethics Scholar-in-Residence at the Morgridge Institute for Research. Yao Zhou, S.J.D., is a Research Assistant at the Morgridge Institute for Research in the Bioethics group
| | - Yao Zhou
- Pilar N. Ossorio, Ph.D., J.D., is Professor of Law and Bio-ethics at the University of Wisconsin-Madison and the Bio-ethics Scholar-in-Residence at the Morgridge Institute for Research. Yao Zhou, S.J.D., is a Research Assistant at the Morgridge Institute for Research in the Bioethics group
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Warsi MH, Yusuf M, Al Robaian M, Khan M, Muheem A, Khan S. 3D Printing Methods for Pharmaceutical Manufacturing: Opportunity and Challenges. Curr Pharm Des 2019; 24:4949-4956. [PMID: 30520367 DOI: 10.2174/1381612825666181206121701] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/28/2018] [Accepted: 12/04/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND A recently FDA approved 3D printed drug is paving a path for new pharmaceutical manufacturing era. The 3D printing is a novel approach of producing 3D pharmaceuticals from digital designs, in a layer-by-layer fashion. However, traditional manufacturing of drug products is being carried out from decades with well-established manufacturing processes and with well approved regulatory guidelines but these processes are too obsolete in concern of process aptitude and manufacturing flexibility. On the other hand, 3D printing provides a competitive flexibility in terms of personalized drug dosage forms with complex geometries that will be made on-demand with desired drug release kinetics, hence providing the formulator a substantial provision of improvising the safety and efficacy of the drugs. Furthermore, this novel 3D technology allows tailoring of composite tissue scaffolds and sample models for characterization that closely mimic in-vivo simulations. Nevertheless, certain limitations are there in terms of regulatory aspects hindering the launch of 3DP products in the market. METHODS Exhaustive search were made on Google Scholar and PubMed databases concerning 3-D printing methods, drug delivery applications, and past to present evolution of personalized medicine. RESULTS Although a high magnitude of progress have been made on 3-D printing techniques in a short span of time, still inkjet, nozzle-based deposition, stereolithography and selective laser sintering techniques are the most popular ones. Their application is adapted in the fabrication of tablets, implants, polypills and nanoparticles. CONCLUSION 3D printing is revolutionizing the pharma expectations towards customized medicines but still there is a need to explore the aspects of cost, flexibility and bioequivalence. The present review provides a comprehensive account of various 3D printing technologies and highlights the opportunities and key challenges of 3D printing relevant to pharmaceuticals.
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Affiliation(s)
- Musarrat H Warsi
- College of Pharmacy, Taif University, Taif-Al-Haweiah 21974, Saudi Arabia
| | - Mohammad Yusuf
- College of Pharmacy, Taif University, Taif-Al-Haweiah 21974, Saudi Arabia
| | - Majed Al Robaian
- College of Pharmacy, Taif University, Taif-Al-Haweiah 21974, Saudi Arabia
| | - Maria Khan
- College of Pharmacy, Taif University, Taif-Al-Haweiah 21974, Saudi Arabia
| | - Abdul Muheem
- Department of Pharmaceutics, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi-110062, India
| | - Saba Khan
- Department of Pharmaceutics, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi-110062, India
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Drumond N. Future Perspectives for Patient-Centric Pharmaceutical Drug Product Design with Regard to Solid Oral Dosage Forms. J Pharm Innov 2019. [DOI: 10.1007/s12247-019-09407-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Purpose
Additional costs for healthcare provision are expected for cases where the level of care provided is not according to the patient’s needs and demands. To address these issues and reduce costs, fundamental changes need to be made on how healthcare provision is administered to patients, which raises the opportunity for the implementation of patient-centric systems.
Methods
This review addresses the importance of implementing a patient-centric approach in current healthcare provision and emphasizes the need to adjust current development and business models for a successful application of patient-centric care.
Results
To increase awareness and avoid confusion, the purpose of patient-centric pharmaceutical drug product design is reviewed in detail and future market opportunities for patient-centric drug products are discussed.
Conclusions
With regard to solid oral dosage forms, the subject of patient-centric pharmaceutical drug product design will focus more on the customization of existing technologies (e.g., dosage form size reduction) to address the needs of specific patient populations such as pediatrics, geriatrics, dysphagia patients, or the cognitively impaired.
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Gomez‐Marquez J, Hamad‐Schifferli K. Distributed Biological Foundries for Global Health. Adv Healthc Mater 2019; 8:e1900184. [PMID: 31420954 DOI: 10.1002/adhm.201900184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/24/2019] [Indexed: 01/25/2023]
Abstract
Historically, many industries such as manufacturing have undergone a trend away from centralized, large-scale production toward a more distributed form. Currently, this same trend is witnessed in biological manufacturing and bioprocessing, with the rise of biological foundries where one can synthesize, grow, isolate, and purify a broad range of biologics. The adoption of distributed practices for biological processing has significant implications for healthcare, diagnostics, and therapies. This essay discusses the many diverse factors that have facilitated this growth, ranging from the establishment of available biological components, or "parts," low-cost programmable hardware, and others. Currently existing examples of distributed biological foundries are also identified, separating the discussion into those that are accessible only by elite users and the more recent emerging foundries that are more accessible to the general population. Taking lessons from other fields, it is argued that this trend toward distributed biological manufacturing is inevitable, so adapting to this trend is important for the progress of creating new therapeutics, sensors, diagnostics, and reagents for biomedical applications.
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Affiliation(s)
- Jose Gomez‐Marquez
- Little Devices LabMassachusetts Institute of Technology 77 Massachusetts Ave Cambridge MA 02139 USA
| | - Kimberly Hamad‐Schifferli
- Department of EngineeringSchool for the EnvironmentUniversity of Massachusetts Boston 100 Morrissey Blvd. Boston MA 02125 USA
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Shehab N, Brown MN, Kallen AJ, Perz JF. U.S. Compounding Pharmacy-Related Outbreaks, 2001-2013: Public Health and Patient Safety Lessons Learned. J Patient Saf 2018; 14:164-173. [PMID: 26001553 PMCID: PMC4668233 DOI: 10.1097/pts.0000000000000188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pharmacy-compounded sterile preparations (P-CSPs) are frequently relied upon in U.S. health care but are increasingly being linked to outbreaks of infections. We provide an updated overview of outbreak burden and characteristics, identify drivers of P-CSP demand, and discuss public health and patient safety lessons learned to help inform prevention. METHODS Outbreaks of infections linked to contaminated P-CSPs that occurred between January 1, 2001, and December 31, 2013, were identified from internal Centers for Disease Control and Prevention reports, Food and Drug Administration drug safety communications, and published literature. RESULTS We identified 19 outbreaks linked to P-CSPs, resulting in at least 1000 cases, including deaths. Outbreaks were reported across two-thirds of states, with almost one-half (8/19) involving cases in more than 1 state. Almost one-half of outbreaks were linked to injectable steroids (5/19) and intraocular bevacizumab (3/19). Non-patient-specific compounding originating from nonsterile ingredients and repackaging of already sterile products were the most common practices associated with P-CSP contamination. Breaches in aseptic processing and deficiencies in sterilization procedures or in sterility/endotoxin testing were consistent findings. Hospital outsourcing, preference for variations of commercially available products, commercial drug shortages, and lower prices were drivers of P-CSP demand. CONCLUSIONS Recognized outbreaks linked to P-CSPs have been most commonly associated with non-patient-specific repackaging and nonsterile to sterile compounding and linked to lack of adherence to sterile compounding standards. Recently enhanced regulatory oversight of compounding may improve adherence to such standards. Additional measures to limit and control these outbreaks include vigilance when outsourcing P-CSPs, scrutiny of drivers for P-CSP demand, as well as early recognition and notification of possible outbreaks.
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Abstract
In mid-September 2012, the largest healthcare-associated outbreak in U.S. history began. Before it was over, 751 patients were reported with fungal meningitis, stroke, spinal or paraspinal infection, or peripheral osteoarticular infection, and 64 (8.5%) died. Most patients had undergone epidural injection, and a few osteoarticular injection, of methylprednisolone acetate that had been manufactured at the New England Compounding Center (NECC). The offending pathogen in most cases was Exserohilum rostratum, a brown-black soil organism that previously was a rare cause of human infection. Three lots of methylprednisolone were contaminated with mold at NECC; the mold from unopened bottles of methylprednisolone was identical by whole-genome sequencing to the mold that was isolated from ill patients. Early cases manifested as meningitis, some patients suffered posterior circulation strokes, and later cases were more likely to present with localized infection at the injection site, including epidural abscess or phlegmon, vertebral diskitis or osteomyelitis, and arachnoiditis with intradural involvement of nerve roots. Many patients with spinal or paraspinal infection required surgical intervention. Recommendations for treatment evolved over the first few weeks of the outbreak. Initially, combination therapy with liposomal amphotericin B and voriconazole was recommended for all patients; later, combination therapy was recommended only for those who were most ill, and voriconazole monotherapy was recommended for most patients. Among those patients who continued antifungal therapy for at least 6 months, outcomes for most appeared to be successful, although a few patients remain on therapy.
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Kesselheim AS, Connolly J, Rogers J, Avorn J. Mandatory disclaimers on dietary supplements do not reliably communicate the intended issues. Health Aff (Millwood) 2016; 34:438-46. [PMID: 25732494 DOI: 10.1377/hlthaff.2014.0515] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Some efforts by the government to regulate the promotional statements of pharmaceutical manufacturers have recently been found unconstitutional under the First Amendment, which has been interpreted to protect commercial as well as personal speech. As an alternative means of protecting patients from unreliable marketing claims, courts have proposed that the Food and Drug Administration could add disclaimers to promotional messages that discuss off-label, or unapproved, uses. We conducted a systematic review of studies of the disclaimers currently required for dietary supplements, to assess how well disclaimers inform consumers' health choices. A few small studies reported a modest impact of disclaimers on consumers' attitudes about dietary supplements, but larger and more rigorous studies generally revealed that many consumers were unaware of a disclaimer or reported that it did not affect their perceptions of a product. The available evidence indicates that replacing government restrictions on pharmaceutical marketing with potentially ineffective disclaimers will be an inadequate way of informing patients about the efficacy and safety of drugs, and it risks returning the United States to a previous era when inappropriate marketing claims about prescription drugs proliferated and contributed to the inappropriate use of those products.
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Affiliation(s)
- Aaron S Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School, in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital, in Boston, Massachusetts
| | - John Connolly
- John Connolly is a research assistant in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital
| | - James Rogers
- James Rogers is a research assistant in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital
| | - Jerry Avorn
- Jerry Avorn is a professor of medicine at Harvard Medical School and chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital
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Emergence of 3D Printed Dosage Forms: Opportunities and Challenges. Pharm Res 2016; 33:1817-32. [DOI: 10.1007/s11095-016-1933-1] [Citation(s) in RCA: 263] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/27/2016] [Indexed: 01/19/2023]
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Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag 2015; 5:129-46. [DOI: 10.2217/pmt.14.53] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
SUMMARY Epidural steroid injections (ESIs), which can provide significant but temporary pain relief in well-selected patients, are the most commonly performed procedure in pain management. The anatomy of the epidural space provides a framework for understanding risks associated with ESIs, a topic relevant to both patients and physicians in interventional pain, surgery and primary care. Safety considerations of epidural steroids include drug preparation and myriad physiological effects stemming from steroid exposure. Although major complications associated with ESI occur rarely, potentially catastrophic events resulting from infectious, hematologic and neurologic morbidity may lead to permanent injury. The safety profile of ESIs may improve with development and dissemination of sound injection technique, safer compounds manufactured in a sterile manner and deficient of thromboembolic potential and the application of existing technology.
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Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology, Critical Care & Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - David Chang
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - Steven P Cohen
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, 707 North Broadway, Baltimore, MD 21205, USA
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Abstract
The National Center for Health Statistics estimates that more than 100,000 Americans receive chelation each year, although far fewer than 1 % of these cases are managed by medical toxicologists. Unfortunately, fatalities have been reported after inappropriate chelation use. There are currently 11 FDA-approved chelators available by prescription although chelation products may also be obtained through compounding pharmacies and directly over the internet. Promotion of chelation training is prominent on some alternative and complementary medicine websites.
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Affiliation(s)
- Paul M Wax
- Southwestern School of Medicine, University of Texas, Dallas, TX, USA,
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Pignato A, Birnie CR. Analysis of compounded pharmaceutical products to teach the importance of quality in an applied pharmaceutics laboratory course. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2014; 78:61. [PMID: 24761022 PMCID: PMC3996393 DOI: 10.5688/ajpe78361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 10/09/2013] [Indexed: 05/14/2023]
Abstract
OBJECTIVE To assess the effectiveness of a product-analysis laboratory exercise in teaching students the importance of quality in pharmaceutical compounding. DESIGN Second-year pharmacy students (N=77) participated in a pharmaceutical compounding laboratory exercise and subsequently analyzed their final product using ultraviolet (UV) spectrometry. ASSESSMENT Reflection, survey instruments, and quiz questions were used to measure how well students understood the importance of quality in their compounded products. Product analysis showed that preparations compounded by students had an error range of 0.6% to 140%, with an average error of 23.7%. Students' reflections cited common sources of error, including inaccurate weighing, contamination, and product loss during both the compounding procedure and preparation of the sample for analysis. Ninety percent of students agreed that the exercise improved their understanding of the importance of quality in compounded pharmaceutical products. Most students (85.7%) reported that this exercise inspired them to be more diligent in their preparation of compounded products in their future careers. CONCLUSION Integrating an analytical assessment during a pharmaceutical compounding laboratory can enhance students' understanding of quality of compounded pharmaceutical products. It can also provide students a chance to reflect on sources of error to improve their compounding technique in the future.
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Affiliation(s)
- Alyssa Pignato
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York
| | - Christine R Birnie
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York
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Exserohilum and the compounding pharmacy: pushing the envelope of virulence. Int J Infect Dis 2014. [DOI: 10.1016/j.ijid.2014.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Conway JM, Brown MC. A flowchart for selecting an ointment base. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2014; 78:16. [PMID: 24558284 PMCID: PMC3930240 DOI: 10.5688/ajpe78116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 07/07/2013] [Indexed: 06/03/2023]
Abstract
UNLABELLED OBJECTIVES. To improve students' skills in selecting appropriate ointment bases through the development and implementation of a flowchart. DESIGN A flowchart was designed to help students select the appropriate base for an ointment. Students used the flowchart throughout the semester in both dry and wet laboratory activities. At the end of the semester, students completed a dry laboratory practical that required them to select an appropriate ointment base and levigating agent. ASSESSMENT Student performance data from the year prior to implementation was compared to data for 2 years after implementation. Calculation, procedure, and labeling errors also were compared. Prior to implementation of the flowchart, 51 of 101 students selected the correct base. After implementation, 169 of 212 students selected the correct base (p<0.001). Calculation, procedure, and labeling errors were not significantly different. CONCLUSION. Use of a flowchart to select an ointment base improved student performance when used in the context of a dry laboratory assignment.
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Affiliation(s)
- Jeannine M Conway
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Michael C Brown
- Dr. Brown's current affiliation is with the School of Pharmacy, Concordia University Wisconsin, Mequon, Wisconsin
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Parmet WE, Jacobson PD. The courts and public health: caught in a pincer movement. Am J Public Health 2014; 104:392-7. [PMID: 24432949 DOI: 10.2105/ajph.2013.301738] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Public health practitioners are familiar with the general outlines of legal authority and with judicial standards for reviewing public health regulations. What may not be as familiar are 3 emerging judicial doctrines that pose considerable risks to public health initiatives. We explain the contentious series of judicial rulings that now place health departments' broad grant of authority in jeopardy. One doctrine invokes the First Amendment to limit regulatory authority. The second involves the Supreme Court's reinterpretation of federalism to limit both federal and state public health interventions. The third redefines the standard of evidence required to support regulations. Together, these judicial trends create a pincer movement that places substantial new burdens on the ability of health departments to protect health.
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Affiliation(s)
- Wendy E Parmet
- Wendy E. Parmet is with the Northeastern University School of Law, Boston, MA. Peter D. Jacobson is with the Center for Law, Ethics, and Health, University of Michigan School of Public Health, Ann Arbor
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The Exserohilum rostratum Incident. Emerg Infect Dis 2014. [DOI: 10.1016/b978-0-12-416975-3.00022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Larone DH, Walsh TJ. Exserohilum rostratum: Anatomy of a national outbreak of fungal meningitis. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.clinmicnews.2013.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, Marshall N, Neal A, Sacks G, Seres DS, Worthington P, Malone A, Teitelbaum D, Andris DA, Ayers P, Baroccas A, Compher C, Ireton-Jones C, Jaksic T, Robinson LA, Van Way CW, Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft M, Neal T, Sacks G, Seres DS, Taylor B, Worthington PA. A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations. JPEN J Parenter Enteral Nutr 2013; 38:296-333. [DOI: 10.1177/0148607113511992] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Phil Ayers
- Baptist Health Systems, Department of Pharmacy, Jackson, Mississippi
| | - Stephen Adams
- Vitaline Infusion Pharmacy Services, Geisinger Medical Center, Danville, Pennsylvania
| | | | - Jane Gervasio
- Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Beverly Holcombe
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland
| | - Michael D. Kraft
- University of Michigan Health System, Department of Pharmacy Services, Ann Arbor
| | | | - Antoinette Neal
- Infusion Pharmacy, Cleveland Clinic at Home, Independence, Ohio
| | - Gordon Sacks
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - David S. Seres
- Division of Preventive Medicine and Nutrition, New York Presbyterian Hospital–Columbia University Medical Center, New York
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Compounding Pharmacies: A Viable Option, or Merely a Liability? PM R 2013; 5:974-81. [DOI: 10.1016/j.pmrj.2013.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/08/2013] [Indexed: 11/23/2022]
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Guharoy R, Noviasky J, Haydar Z, Fakih MG, Hartman C. Compounding pharmacy conundrum: "we cannot live without them but we cannot live with them" according to the present paradigm. Chest 2013; 143:896-900. [PMID: 23412546 DOI: 10.1378/chest.13-0212] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Compounding pharmacies serve a critical role in modern health care to meet special patient care needs. Although the US Food and Drug Administration (FDA) has clearly delineated jurisdiction over drug companies and products manufactured under Good Manufacturing Practice (GMP) regulations to ensure quality, potency, and purity, compounding pharmacies are regulated by the State Boards and are not registered by the FDA. In recent years, some compounding pharmacies acted like a manufacturer, preparing large amounts of injectable drugs with interstate activities. Multiple outbreaks have been linked to compounding pharmacies, including a recent outbreak of fungal meningitis related to contaminated methylprednisolone, exposing > 14,000 patients in multiple states. This tragedy underscores the urgency of addressing safety related to compounding pharmacies. There is a call for action at the federal and state levels to set minimum production standards, impose new labeling conditions on compounded drugs, and require large-scale compounders be regulated by the FDA. "Industrial" compounding must come under FDA oversight, require those pharmacies to meet GMP standards, and ensure quality and safe products for patient use. Moreover, compliance with the Institute for Safe Medication Practices 2011 recommendations that any type of sterile compounding must be in compliance with the United States Pharmacopoeia chapter 797 guidelines will reduce the risk of patient harm from microbial contamination. Finally, other critical factors that require close attention include addressing injectable products compounded in hospitals and other outpatient health-care centers. The FDA and State Boards of Pharmacy must be adequately funded to exercise the oversight effectively.
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Affiliation(s)
- Roy Guharoy
- Ascension Health, St. Louis, MO; University of Massachusetts Medical School, Worcester, MA.
| | - John Noviasky
- SUNY-Upstate Medical University Hospital at Community General, Syracuse, NY
| | | | - Mohamad G Fakih
- Department of Infection Prevention and Control, St. John Hospital and Medical Center, Detroit, MI; Wayne State University School of Medicine, Detroit, MI
| | - Christian Hartman
- University of Massachusetts Medical School, Worcester, MA; Wolters Kluwer Health, Minneapolis, MN
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Straight from the headlines: what is going on in compounding pharmacies, and how can clinical microbiologists help? J Clin Microbiol 2013; 51:3168-71. [PMID: 23784132 DOI: 10.1128/jcm.00160-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wu AY, Morrow DM. Autologous fat transfer with in-situ mediation (AIM): a novel and compliant method of adult mesenchymal stem cell therapy. J Transl Med 2013; 11:136. [PMID: 23725573 PMCID: PMC3679930 DOI: 10.1186/1479-5876-11-136] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 05/20/2013] [Indexed: 02/06/2023] Open
Abstract
Background In an attempt to engineer a regulatory compliant form of cell assisted lipotransfer in the U.S., the authors developed Autologous Fat Transfer with In-situ Mediation (AIM) for reconstruction of a refractory surgical scar. Methods This method incorporates use of accepted standard procedures like autologous fat grafting and intradermal injection of NB6 collagenase to release adipose stem cells from a naturally occurring high concentration stromal vascular fraction (SVF) fat graft. To prevent off-target effects of collagenase, a hyaluronic acid and serum deactivation barrier is placed circumferentially around the operative site. Findings This novel protocol was well tolerated by the patient and improved scar appearance, mobility and texture. Deepest scar contour defect correction was 80% and 77% at 4 and 12 weeks respectively. Conclusion AIM appears to be a practical and viable option for scar reconstruction requiring small to moderate volume correction.
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What gastroenterologists should know about the gray market, herbal remedies, and compounded pharmaceuticals and their regulation by the Food and Drug Administration. Am J Gastroenterol 2013; 108:642-6. [PMID: 23644956 DOI: 10.1038/ajg.2012.348] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Drug shortages in the United States: a critical evaluation of root causes and the need for action. Clin Pharmacol Ther 2013; 93:133-5. [PMID: 23337520 DOI: 10.1038/clpt.2012.229] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Every day it is easy to find news articles detailing the impact of drug shortages on patients. Where this was once only a concern of patients with rare, orphan diseases, it is now the concern of patients receiving even the most common chemotherapeutic regimens, the most efficacious antimicrobial therapy, or even the most rapid-acting analgesics, largely as a result of manufacturing quality problems. Unfortunately for many of these patients, there are no efficacious alternatives.
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