Stability of furosemide and chlorothiazide stored in syringes

Randomized controlled trial of urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE): Rationale and design

Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple clinical trials have investigated initial diuretic strategies for a designated period of time, there is a paucity of evidence to guide diuretic titration strategies continued until decongestion is achieved. The use of urine chemistries (urine sodium and creatinine) in a natriuretic response prediction equation accurately estimates natriuresis in response to diuretic dosing, but a randomized clinical trial is needed to compare a urine chemistry-guided diuresis strategy with a strategy of usual care. The urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE) trial is designed to test the hypothesis that protocolized diuretic therapy guided by spot urine chemistry through completion of intravenous diuresis will be superior to usual care and improve outcomes over the 14 days following randomization. ESCALATE will randomize and obtain complete data on 450 patients with acute heart failure to a diuretic strategy guided by urine chemistry or a usual care strategy. Key inclusion criteria include an objective measure of hypervolemia with at least 10 pounds of estimated excess volume, and key exclusion criteria include significant valvular stenosis, hypotension, and a chronic need for dialysis. Our primary outcome is days of benefit over the 14 days after randomization. Days of benefit combines patient symptoms captured by global clinical status with clinical state quantifying the need for hospitalization and intravenous diuresis. CLINICAL TRIAL REGISTRATION: NCT04481919.

Stability of Oral Liquid Dosage Forms in Pediatric Cardiology: A Prerequisite for Patient's Safety-A Narrative Review

The development of safe and effective pediatric formulations is essential, especially in therapeutic areas such as pediatric cardiology, where the treatment requires multiple dosing or outpatient care. Although liquid oral dosage forms are considered the formulation of choice given the dose flexibility and acceptability, the compounding practices are not endorsed by the health authorities, and achieving stability can be problematic. The purpose of this study is to provide a comprehensive overview of the stability of liquid oral dosage forms used in pediatric cardiology. An extensive review of the literature has been performed, with a particular focus on cardiovascular pharmacotherapy, by consulting the current studies indexed in PubMed, ScienceDirect, PLoS One, and Google Scholar databases. Regulations and guidelines have been considered against the studies found in the literature. Overall, the stability study is well-designed, and the critical quality attributes (CQAs) have been selected for testing. Several approaches have been identified as innovative in order to optimize stability, but opportunities to improve have been also identified, such as in-use studies and achieving dose standardization. Consequently, the information gathering and the results of the studies can be translated into clinical practice in order to achieve the desired stability of liquid oral dosage forms.

Fate, modeling, and human health risk of organic contaminants present in tomato plants irrigated with reclaimed water under real-world field conditions

Using reclaimed water to irrigate crops can be an important route for organic contaminants of emerging concern (CECs) to be introduced into agricultural production and thus find their way into the food chain. This work aims to establish accumulation models for the different parts of a crop (fruit/leaves/roots) and the soil of some of the most commonly detected CECs in reclaimed water, through field trials in greenhouses. For this, tomato plants were permanently irrigated under realistic agricultural conditions with a mixture of the selected compounds at approx. 1 μg/L. A total of 30 contaminants were analyzed belonging to different compound categories. A modified QuEChERS extraction method followed by liquid chromatography coupled to tandem mass spectrometry was the procedure used. The study revealed the presence of 21 target contaminants in the tomatoes, and 18 CECs in the leaves, roots, and soil. The average total concentration of pesticides detected in the tomatoes was 3 μg/kg f.w., whereas the average total load of pharmaceuticals was 5.8 μg/kg f.w. after three months, at the time of crop harvesting. The levels of pharmaceutical products and pesticides in the non-edible tissues were up to 3.5 and 2.1 μg/kg f.w., respectively, in the leaves and up to 89.3 and 31.3 μg/kg f.w., respectively, in the roots. In the case of the soil samples, the pesticide concentration found after crop harvesting was below 11.4 μg/kg d.w., and less than 3.0 μg/kg d.w. for pharmaceuticals. Overall, the concentration levels of CECs detected in the tomatoes, which were permanently irrigated with contaminated reclaimed water, do not pose a risk to human health via dietary intake.

Stability of 4 Intravenous Drug Formulations in Prefilled Syringes Stored Frozen for Up to 60 Days

Purpose: Prefilled drug syringe use may reduce the cost of routine antibiotic drug delivery. Storage of prefilled syringes frozen (-20°C) or refrigerated (4°C-5°C), can optimize the use of robotic syringe filling systems if acceptable stability data is gathered per USP 797 standards. Methods: Four intravenous (IV) drug formulations were prepared from bulk standard solutions and filled into 10 mL syringes using an Intellifill© IV Robot. Formulations were Piperacillin (2.0 g) and Tazobactam (0.25 g) as 2.25 g in 10 mL; Piperacillin (3.0 g) and Tazobactam (0.375 g) as 3.375 g in 10 mL; Cefuroxime as 1.5 g in 11 mL; and Vancomycin as 1.0 g in 10 mL. Concentrations were assayed at "zero time," and after 21, 45, and 60 days frozen. Syringes were warmed to room temperature (RT) by gently rolling in hands. Three syringes of each formulation were assayed by stability-indicating HPLC per USP procedures. Assay results are the average of 5 injections of samples from each syringe upon return to RT and repeated for 3 separate syringes maintained at RT for 24 hours. Results: All formulations were stable out to 60 days frozen. Both of the piperacillin/tazobactam formulations were also stable when kept at refrigerated temperature for 9 days. Conclusion: Piperacillin/Tazobactam formulations can be stored frozen (-20°C) for up to 60 days with no appreciable loss. Cefuroxime and Vancomycin formulations can be stored frozen for up to 60 days. Both Piperacillin/Tazobactam formulations can be refrigerated for up to 9 days. Implementation of larger batch compounding coupled with frozen syringe storage and delivery could result in enhanced uniformity of composition and significant manpower savings.

Use of Furosemide and Chlorothiazide Combination Continuous Infusion in Furosemide-Refractory Patients in the Pediatric Intensive Care Unit: A Retrospective Cohort Study

OBJECTIVE

Our objective was to describe the efficacy and safety of furosemide and chlorothiazide combination continuous infusion (FCCCI) in children in a pediatric intensive care unit (ICU), including postoperative cardiac patients.

METHODS

This was a retrospective cohort study in a pediatric ICU within a tertiary care teaching hospital. Children aged < 18 years admitted from 1 January 2010 to 31 December 2019 were included if they received a furosemide infusion for at least 6 h and then transitioned to FCCCI. Each patient acted as their own control.

RESULTS

A total of 203 patients (107 [53%] postoperative cardiac) met the study inclusion criteria. The study population was 55% male and 74% Caucasian, with a median age of 4.9 months. Of the total patients, 143 (70.4%) required mechanical ventilation and 39 (19.2%) required dialysis. The median duration of furosemide and FCCCI was 24.6 h (interquartile range [IQR] 12.4-54) and 41 h (IQR 15-162), respectively. Urine output increased by 52% with FCCCI (mean increase of 2.2 mL/kg/h [95% confidence interval {CI} 1.8-2.5]; p < 0.01). The change to FCCCI led to a net negative daily fluid balance (mean difference - 301.9 mL/day [95% CI - 390.9 to - 212.9]; p < 0.01). FCCCI resulted in a greater requirement for potassium bolus supplementation (mean increase of 12.8 boluses [95% CI 8.5-17.2]; p < 0.01) and a small but statistically significant increase in serum creatinine (mean difference 0.1 mg/dL [95% CI 0.06-0.14]; p < 0.01) with a resultant decrease in estimated glomerular filtration rate (mean difference - 13.5 [95% CI 9.7-17.4]; p < 0.01). Of the furosemide-refractory patients, 78.9% were responsive to FCCCI. Younger patients and patients who underwent cardiothoracic surgery were more likely to be responsive. Nonresponders to FCCCI had slightly higher mortality (21 vs. 6.6%, p = 0.05).

CONCLUSIONS

FCCCI resulted in a significant improvement in diuresis with achievement of negative fluid balance in pediatric ICU patients. FCCCI is a reasonable approach to aggressive diuresis in the pediatric patient, particularly in patients with limited access. Serum potassium should be routinely monitored during such therapy.

Determination study of contaminants of emerging concern at trace levels in agricultural soil. A pilot study

In this study, we aimed to develop and validate a quick, easy, and robust extraction method for the simultaneous determination of 30 organic contaminants of emerging concern (CECs) including some transformation products in soil samples. Three different extraction methods based on an ultrasonic cylindrical probe (UAE), a pressurized liquid extraction (PLE), and a QuEChERS method were compared. Ultra-performance liquid chromatography coupled with electrospray tandem mass spectrometry (LC-MS/MS) was used for identification and quantification of the target analytes. A modified QuEChERS method showed the best results in terms of extractability and accuracy. The extraction procedure developed provided adequate extraction performances (70% of the target analytes were recovered within a 70-99% range), with good repeatability and reproducibility (variations below 20%) and great sensitivity (LOQ < 0.1 ng/g in most cases). No matrix effects were observed for 70% of the compounds. Finally, the analytical methodology was applied in a pilot study where agricultural soil was irrigated with reclaimed water spiked with the contaminants under study. Of the 25 CECs added in irrigation water, a total of 13 pesticides and 5 pharmaceutical products were detected at concentration ranges from 0.1 to 1.2 ng/g (d.w) and from 0.1 to 2.0 ng/g (d.w), respectively.