Hot and Cold Drugs: National Park Service Medication Stability at the Extremes of Temperature

Emergency care drugs' chemical stability after eight weeks' deployment in the prehospital setting

Temperature conditions vary in emergency service vehicles, which may pose a risk to the integrity of the drugs on board, possibly rendering them ineffective and increasing morbidity and mortality in patients.

Aim

This study assessed the stability of four emergency care drugs (adrenaline, etomidate, ketamine, and rocuronium) after eight weeks of deployment in the prehospital context.

Methods

The study adopted a longitudinal quantitative design to evaluate the chemical stability of emergency care drugs. The study was conducted at four emergency medical service bases in Ballito, Durban and Pietermaritzburg, South Africa. The primary outcome was the relative reduction in drug concentration from the labelled concentration after four and eight weeks. High-performance liquid chromatography-mass spectrometry (HPLC-MS) analysed samples to determine the concentration of active ingredients in the drug samples.

Results

HPLC analysis was done on 176 samples. The ambient temperature ranged from 18.7 to 44 °C in the first four weeks, averaging 26.8 °C ± 3.0. At 4 and 8 weeks, Adrenaline decreased 24.93 % and 22.73 %, respectively. Etomidate's control had 3.06 mg/ml, not the 2 mg/ml on the bottle. After 4 and 8 weeks, the samples had 3.10 and 3.15 mg/ml active components, respectively. Ketamine degraded over 30 % after four weeks but not beyond that. The Ketamine package states 10 mg/ml. However, we found 17.46 mg/ml. Rocuronium was 6.45 mg/ml in the control, although the manufacturer specified 10 mg/ml. At four weeks, the concentration was 6.70 mg/ml; at eight weeks, 6.56.

Conclusion

This study suggests that adrenaline and ketamine degrade by more than 20 % within four weeks of deployment in the prehospital field, whereas etomidate and rocuronium remain stable after eight weeks.

Can we use normal saline stored under stress conditions? A simulated prehospital emergency medical setting

Background

Data on stability and suitability to use normal saline stored under stress conditions in ambulances is lacking.

Objective

We aimed to study the impact of exposure to extreme temperature variations on normal saline stability and compatibility with its packaging.

Methods

Normal saline in 96 polyolefin bags were exposed to continuous temperature of 22, 50, and 70 °C or to a cyclic temperature of 70 °C per 8 h and 22 °C per 16 h. The bags were sampled at 12, 24, 48 and 72 h and at 1, 2, 3, and 4 weeks in the short- and long-term experiments, respectively. Solution inside the bags was evaluated for any evidence of crystallization, discoloration, turbidity, or pH changes. A sample of normal saline was withdrawn from each bag to analyze sodium and chloride levels.

Results

Precipitation, discoloration, or turbidity were not observed in the solution inside normal saline bags. The average pH was 5.59 at 22 °C, 5.73 at 50 °C, 5.86 at 70 °C and 5.79 at cyclic exposure. In the short- and long-term experiments, sodium and chloride concentrations were within 100.2-111.27% and 99.04-110.95%, respectively. Leaching of the plastic components in the polyolefin bag into the normal saline solution was not detected.

Conclusions

Sodium and chloride levels of normal saline were stable and compatible with polyolefin bags stored in simulated continuous and cyclic extreme temperatures for around one month. The effect of storage in the cabinet of operational ambulance vehicles during different seasons in arid countries is yet to be evaluated in real-world conditions, to further confirm our results.

LC-MS/TOF Characterization and Stability Study of Artesunate in Different Solvent Systems

Artemisinin (ART) is a sesquiterpene lactone and a popular malaria drug used in many parts of the world. Artesunate (ARTS) is a semi-synthetic derivative of ART with improved pharmacokinetic properties. However, the half-life of ARTS is less than an hour in vivo. The analysis of this drug in vitro in different solvent systems using LC-MS/TOF showed a solvent-driven breakdown. ARTS breakdown formed several derivatives, including dihydroartemisinin (DHA), artemether (ARTM) and DHA-dimer among others, at different rates in different solvent composition systems. The change in temperature from room temperature to physiological temperature (37 °C) was found to enhance the rate of the ARTS breakdown. In methanol, ARTS mainly formed ARTM with a chromatographic peak decrease of about 3.13%, while methanol and water (90:10) v/v mainly gave rise to DHA and ARTM with about an 80% chromatographic peak decrease. On the other hand, ARTS in methanol and ammonium acetate (85:15) v/v formed DHA, ARTM, DHA-dimer and other reaction peaks with about a 97% peak decrease and the formation of an orange solution pointing to a molecular re-arrangement reaction. These results have an important bearing on research on the analysis of artemisinin drugs conducted on these common solvents.

Stability of Drugs Stored in Helicopters for Use by Emergency Medical Services: A Prospective Observational Study

STUDY OBJECTIVE

Drugs stored in rescue helicopters may be subject to extreme environmental conditions. The aim of this study was to measure whether drugs stored under the real-life conditions of a Swiss helicopter emergency medical service (HEMS) would retain their potency over the course of 1 year.

METHODS

A prospective, longitudinal study measuring the temperature exposure and concentration of drugs stored on 2 rescue helicopters in Switzerland over 1 year. The study drugs included epinephrine, norepinephrine, amiodarone, midazolam, fentanyl, naloxone, rocuronium, etomidate, and ketamine. Temperatures were measured inside the medication storage bags and the crew cabins at 10-minute intervals. Drug stability was measured on a monthly basis over the course of 12 months using high-performance liquid chromatography. The medications were considered stable at a minimum remaining drug concentration of 90% of the label claim.

RESULTS

Temperatures ranged from -1.2 °C to 38.1 °C (29.84 °F to 100.58 °F) inside the drug storage bags. Of all the temperature measurements inside the drug storage bags, 37% lay outside the recommended storage conditions. All drugs maintained a concentration above 90% of the label claim. The observation periods for rocuronium and etomidate were shortened to 7 months because of a supply shortage of reference samples.

CONCLUSION

Drugs stored under the real-life conditions of Swiss HEMS are subjected to temperatures outside the manufacturer's approved storage requirements. Despite this, all drugs stored under these conditions remained stable throughout our study. Real-life stability testing could be a way to extend drug exchange intervals.

Impact of Ambient Temperature on 5 Emergency Drugs Aboard an Emergency Medical Car Over a 1-Year Period

STUDY OBJECTIVE

Drugs in emergency medical service (EMS) cars are often exposed to temperature variations that could affect the stability of these drugs. We aimed to study the influence of real-life temperature exposure on the stability of 5 drugs onboard an EMS vehicle.

METHODS

Concentrations of active principles of 5 emergency drugs (amiodarone, rocuronium, fentanyl, succinylcholine, and epinephrine) aboard an EMS vehicle were analyzed every 3 months up to 1 year. The samples were compared to the same drugs stored for 1 year either at room temperature or in a refrigerator in the pharmacy. Succinylcholine was additionally analyzed once a week for 4 weeks after being taken out of the refrigerator. The dosage of the active principle was measured using high-pressure liquid chromatography coupled with ultraviolet detection.

RESULTS

After the 12-month period, all drugs from the EMS car, except succinylcholine, presented concentrations still above 90% of the concentrations measured at the start of the project. Concentrations ranged from 96.3% to 103%. For succinylcholine at 12 months, the remaining concentration was 89%. Temperatures in the EMS car ranged from 13.9 °C to 33.9 °C (median, 22.8 °C [interquartile range, 20.5 °C to 25.8 °C]).

CONCLUSION

In real-life conditions, amiodarone, rocuronium, fentanyl, succinylcholine, and epinephrine onboard an EMS vehicle did not suffer pharmacologically relevant degradation from temperature variations. All concentrations measured remained in the specification intervals given by the manufacturers.

Ketamine Stability over Six Months of Exposure to Moderate and High Temperature Environments

Background: All medications should be stored within temperature ranges defined by manufacturers, but logistical and operational challenges of prehospital and military settings complicate adherence to these recommendations. Lorazepam and succinylcholine experience clinically relevant heat-related degradation, whereas midazolam does not. Because ketamine's stability when stored outside manufacturer recommendations is unknown, we evaluated the heat-related degradation of ketamine exposed to several temperature ranges. Methods: One hundred twenty vials of ketamine (50 mg/mL labeled concentration) from the same manufacturer lot were equally distributed and stored for six months in five environments: an active EMS unit in southwest Ohio (May-October 2019); heat chamber at constant 120 °F (C1); heat chamber fluctuating over 24 hours from 86 °F-120 °F (C2); heat chamber fluctuating over 24 hours from 40 °F-120 °F (C3); heat chamber kept at constant 70 °F (manufacturer recommended room temperature, C4). Four ketamine vials were removed every 30 days from each environment and sent to an FDA-accredited commercial lab for high performance liquid chromatography testing. Data loggers and thermistors allowed temperature recording every minute for all environments. Cumulative heat exposure was quantified by mean kinetic temperature (MKT), which accounts for additional heat-stress over time caused by temperature fluctuations and is a superior measure than simple ambient temperature. MKT was calculated for each environment at the time of ketamine removal. Descriptive statistics were used to describe the concentration changes at each time point. Results: The MKT ranged from 73.6 °F-80.7 °F in the active EMS unit and stayed constant for each chamber (C1 MKT: 120 °F, C2 MKT: 107.3 °F, C3 MKT: 96.5 °F, C4 MKT: 70 °F). No significant absolute ketamine degradation, or trends in degradation, occurred in any environment at any time point. The lowest median concentration occurred in the EMS-stored samples removed after 6 months [48.2 mg/mL (47.75, 48.35)], or 96.4% relative strength to labeled concentration. Conclusion: Ketamine samples exhibited limited degradation after 6 months of exposure to real world and simulated extreme high temperature environments exceeding manufacturer recommendations. Future studies are necessary to evaluate ketamine stability beyond 6 months.

Medication Handling and Storage among Pilgrims during the Hajj Mass Gathering

We aimed to investigate the knowledge and practices of Hajj pilgrims regarding medication storage and handling during the Hajj mass gathering. In this cross-sectional study, adult pilgrims from 30 countries were interviewed using a structured questionnaire during the 2019 Hajj. The study enrolled 1221 participants with a mean age of 50.8 years (SD = 12.5, range = 18-98) and male:female ratio of 1.7:1. Most pilgrims were literate, 50.4% had a university or higher education, and 38% reported at least one underlying health condition. Most pilgrims reported receiving education regarding the proper way to store their medication during Hajj, mainly from physicians (73.7%) and pharmacists (39.4%). Although 68.2% of pilgrims had good knowledge regarding medication storage and the potential effect of inappropriate storage conditions on medications and health, inadequate knowledge and poor practice were identified among some. Level of education, having an underlying health condition and receiving health education on mediation storage were independently associated with good knowledge. Most pilgrims took their medications with them during Hajj, although storage and handling of their medication also varied depending on the stages of their Hajj pilgrimage journey. Improving Hajj pilgrims' awareness and knowledge about appropriate storage and handling of their medications are beneficial in reducing the risk of associated adverse health outcomes, both during Hajj and beyond the mass gathering.

Atropine in topical formulations for the management of anterior and posterior segment ocular diseases

INTRODUCTION

Atropine is an old-known drug which is gaining increasing attention due to the myriad of therapeutic effects it may trigger on eye structures. Nevertheless, novel applications may require more adequate topical formulations.

AREAS COVERED

This review aims to gather the existing knowledge about atropine and its clinical applications in the ophthalmological field when administered topically. Atropine ocular pharmacokinetics is paid a special attention, including recent evidences of the capability of the drug to access to the posterior segment. Ocular bioavailability and systemic bioavailability are counterbalanced. Finally, limitations of traditional dosage forms and potential advantages of under investigation delivery systems are analyzed.

EXPERT OPINION

Mydriasis and cyclopegia have been widely exploited for eye examination, management of anterior segment diseases, and more recently as antidotes of chemical weapons. Improved knowledge on drug receptors and related pathways explains atropine repositioning as an outstanding tool to prevent myopia. The ease with which atropine penetrates ocular tissues is a double edged sword, that is, while it ensures therapeutic levels in the posterior segment, the unspecific distribution causes a wide variety of untoward effects. The design of formulations that can selectively deliver atropine to the target tissue for each specific application is an urgent unmet need.

Pharmakologische Eigenschaften von Notfallmedikamenten unter Extrembedingungen

Notfallmedikamente kommen an nahezu allen Orten dieser Erde zum Einsatz. Damit werden sie unterschiedlichsten Umweltbedingungen (Kälte, Hitze, direkte Sonneneinstrahlung) ausgesetzt. Sämtliche Daten zur Pharmakokinetik, Pharmakodynamik, Medikamentensicherheit und -haltbarkeit werden jedoch unter standardisierten Bedingungen erhoben, die sich von den Anwendungsbedingungen in der Notfallmedizin erheblich unterscheiden können. Durch die Kälte bei Wintereinsätzen im Gebirge können ebenso wie bei Einsätzen in großer Hitze und bei direkter Sonnenexposition chemische Reaktionen entstehen, welche die Eigenschaften der Medikamente bis hin zur kompletten Wirkungslosigkeit verändern können. Zusätzlich können Unterkühlung oder Überhitzung des Patienten zu einer Zentralisation bzw. Vasodilatation führen und damit das pharmakologische Verteilungsvolumen erheblich verändern, woraus Unter- bzw. Überdosierungen resultieren können. Gleichzeitig kann durch einen temperaturbedingt veränderten Metabolismus die Konjugation und Elimination von Medikamenten beeinflusst sein und zu einer unvorhersehbaren Verlängerung der Medikamentenwirkung führen. Trotz der erheblichen klinischen Relevanz dieser Thematik existieren bisher kaum Daten zu den konkreten Effekten extremer Umweltbedingungen auf die pharmakologischen Eigenschaften von Notfallmedikamenten. Diese Übersicht soll dazu dienen, den aktuellen Kenntnisstand der notfallmedizinischen Pharmakotherapie unter Extrembedingungen darzustellen.

Effect of Fluctuating Extreme Temperatures on Tranexamic Acid

INTRODUCTION

Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce morbidity and mortality in hemorrhagic shock. It has potential use in prehospital and wilderness medicine; however, in these environments, TXA is likely to be exposed to fluctuating and extreme temperatures. If TXA degrades under these conditions, this may reduce antifibrinolytic effects.

PROBLEM

This study sought to determine if repetitive temperature derangement causes degradation of TXA.

METHODS

Experimental samples underwent either seven days of freeze/thaw or heating cycles and then were analyzed via mass spectrometry for degradation of TXA. An internal standard was used for comparison between experimental samples and controls. These samples were compared to room temperature controls to determine if fluctuating extreme temperatures cause degradation of TXA.

RESULTS

The coefficient of variability of ratios of TXA to internal standard within each group (room temperature, freeze, and heated) was less than five percent. An independent t-test was performed on freeze/thaw versus control samples (t = 2.77; P = .17) and heated versus control samples (t = 2.77; P = .722) demonstrating no difference between the groups.

CONCLUSION

These results suggest that TXA remains stable despite repeated exposure to extreme temperatures and does not significantly degrade. These findings support the stability of TXA and its use in extreme environments.

The effects of heat and freeze-thaw cycling on naloxone stability

Purpose

The availability of take home naloxone (THN) was increased for Canadians in 2016, including access to kits via pharmacies. Unlike typical over-the-counter (OTC) and prescription drugs, THN kits may be stored in non-standard conditions, including in vehicles, backpacks, and out of doors. To evaluate whether these non-standard storage conditions affect stability, we investigated the impact of heat and freeze-thaw cycling on naloxone hydrochloride stability.

Methods

To assess the effect of heat, naloxone hydrochloride ampoules were exposed to 80 °C in a temperature-controlled oven for 8 h followed by 16 h at room temperature. To assess the effect of freeze-thaw cycles, naloxone hydrochloride ampoules were exposed to − 20 °C for 16 h followed by 8 h at 4 °C. The impact of these conditions on naloxone hydrochloride stability was evaluated each day for 1 week and after 2 and 4 weeks. The concentration of remaining naloxone hydrochloride was quantified using high-performance liquid chromatography (HPLC). Naloxone hydrochloride ampoules stored at room temperature served as the experimental control.

Results

Naloxone hydrochloride ampoules exhibit no changes in drug concentration following exposure to heat or freeze-thaw cycles for up to 28 days compared to ampoules maintained at room temperature (as indicated in the product monograph).

Conclusions

Naloxone hydrochloride remains chemically stable following exposure to heat or freeze-thaw cycles after 28 days. If THN kits are stored in non-standard conditions (for up to 28 days) the active naloxone is likely to remain stable. Despite this, pharmacists should continue to emphasize the importance of appropriate storage of THN kits to ensure optimal efficacy should naloxone administration be required in an emergency situation.

Electronic supplementary material

The online version of this article (10.1186/s12954-019-0288-4) contains supplementary material, which is available to authorized users.

Expired Drugs in the Remote Environment

INTRODUCTION

The British Antarctic Survey Medical Unit works in a very remote area of the world, with several Antarctic bases receiving only a single annual resupply of consumable goods. Pharmaceuticals supplied in this manner will often be approaching or past the end of their nominal shelf life before the following year's resupply. Drugs are transported from the UK via ship; the hold is not temperature controlled, and the ship crosses through the tropics (air temperature 25-30°C for approximately 3 wk). The drugs then must be transported from the ship to the base, often in temperatures substantially below freezing. This study assessed the stability of 5 expired drugs (atropine, nifedipine, flucloxacillin, naproxen, and bendroflumethiazide) returned from Antarctic bases.

METHODS

Drugs were opportunistically obtained and tested using stability-indicating assays.

RESULTS

All tested drugs were stable.

CONCLUSIONS

The results suggest that the studied drugs may be stable beyond expiry, even when not maintained in strictly temperature-controlled conditions.

Expired Epinephrine Maintains Chemical Concentration and Sterility

OBJECTIVES

Epinephrine shortages affect nearly all American emergency medical services (EMS) systems. Utilization of expired epinephrine could mitigate this situation in daily EMS operations. Concerns about using expired medications include sterility, potency, and potential harmful chemical decay byproducts. There are no cross-platform analyses of sterility and chemical purity of multiple samples of expired parenteral epinephrine. We hypothesized that epinephrine injections will remain sterile and will retain their active ingredient's content for more than 30 months past expiration.

METHODS

Six parenteral epinephrine prefilled syringes, 1 mg/10 mL, with an expiration date of January 1, 2012 had been stored in the climate controlled setting of a hospital inpatient pharmacy where they remained until they were taken for chemical or microbial analysis 30 months after expiration. An unexpired parenteral epinephrine prefilled syringe content was used as a control. Contents of three separate syringes with expired content from the same lot and one control underwent ultra-high pressure liquid chromatography-mass spectrometry (UHPLC-MS) and nuclear magnetic resonance (NMR) to determine epinephrine content and stability. In parallel, contents of another three expired epinephrine syringes were analyzed for sterility by plating on aerobic, anaerobic, and fungal media in a hospital microbiology laboratory. The aerobic plates were checked for growth in 3 days, the anaerobic in 5 days, and the fungal in 28 days.

RESULTS

UHPLC-MS and NMR showed that content of epinephrine present in the original sample remained unchanged compared to the control. There was no statistical difference in the UHPLC-MS and NMR signal amplitudes between the control and the expired samples. No chemical degradation byproducts were detected using NMR. There was no growth of any bacteria or fungus.

CONCLUSION

Recurrent epinephrine shortages impact EMS and hospital operations in the United States. Individual administrators may be hesitant to authorize use of expired pharmaceuticals due to perceived potential complications or fear of litigation. This study shows that the original parenteral epinephrine remains sterile and detectably pure more than 2.5 years after expiration. Further study of the sterility and chemical integrity of expired medications that had been subjected to the conditions of EMS vehicles may be a future research endeavor based on the aforementioned paradigm.