Using simulation to improve pharmacy operators' handling of cytotoxic spills

INTRODUCTION

International Society of Oncology Pharmacy Practitioners guidelines recommend having standard operating procedures (SOPs) and initial and yearly retraining programs on cytotoxic spill handling for pharmacy operators (POs). This study aimed to create a simulation-based training (SBT) program on this subject and evaluate its impact on POs' real-life performance.

METHODS

Randomly formed pairs of POs underwent a 2.5-hour training program, including two simulation exercises (a broken cytotoxic vial on the floor and a leaking cytotoxic bag) in a simulated pharmacy production unit. Each participant applied the cytotoxic spill handling SOPs. The PO and trainer-pharmacist did a debriefing after each exercise. Satisfaction was recorded on a 0-to-100% scale. A 20-item questionnaire assessed general knowledge about cytotoxic spill handling before and after the training. One month before and one month after the training, the POs underwent a real-life test when the trainer broke a fake cytotoxic vial in the cytotoxic storage area. Their performance in applying the SOPs was assessed on a 20-point checklist, and the time to handle the spill was recorded.

RESULTS

Twelve POs participated. Mean satisfaction score was 98.9%. Mean knowledge score improved from 10.8/20 (SD = 2.0) before training to 14.5/20 (SD = 1.6) after training (p < 0.05). Mean real-life SOP performance improved from 78.6% (SD = 7.4%) to 97.1% (SD = 5.2%) (p < 0.05). Mean time to handle cytotoxic spills decreased from 17.3 minutes (SD = 3.6 minutes) to 11.9 minutes (SD = 1.5 minutes) (p < 0.05).

CONCLUSION

POs improved their knowledge and real-life competencies for handling cytotoxic spills. This training will be included in POs' initial and continuing training programs.

[Overwiew of compounding oncology pharmacy in France in 2021]

The pharmacotechnical expert group of the French Society of Oncological Pharmacy presents the results of its national survey carried out in 2021 in the form of an inventory of pharmaceutical compounding units dedicated to oncology. Premises, equipment, controls, production flows and trends are described in this article, providing an overview of the sector at a time when the new Good Manufacturing Practices (GMP) are applicable. This overview will allow us to better address the needs and expectations of production pharmacists regarding the application of GMP and the development of their units.

Advanced Formulation Approaches for Proteins

Proteins and peptides are highly desirable as therapeutic agents, being highly potent and specific. However, there are myriad challenges with processing them into patient-friendly formulations: they are often unstable and have a tendency to aggregate or degrade upon storage. As a result, the vast majority of protein actives are delivered parenterally as solutions, which has a number of disadvantages in terms of cost, accessibility, and patient experience. Much work has been undertaken to develop new delivery systems for biologics, but to date this has led to relatively few products on the market. In this chapter, we review the challenges faced when developing biologic formulations, discuss the technologies that have been explored to try to overcome these, and consider the different delivery routes that can be applied. We further present an overview of the currently marketed products and assess the likely direction of travel in the next decade.

Game-based learning as training to use a chemotherapy preparation robot

INTRODUCTION

In 2015, our university hospital pharmacy acquired the PharmaHelp robot system to automate part of its chemotherapy production. Complex technical use, downtime periods, and insufficient training caused a drop in motivation and disparities in operators' knowledge. We created a short, playful, standardized, gamed-based training program to address this, and evaluated its impact.

METHODS

Operators were classified as trainers or trainees according to their knowledge about Information and Communication Technologies. Before, after the training, and at 6 months (6M), their robot knowledge was assessed on a 0-24-scale, motivation and self-efficacy in using it on 0-to-100 scales. Pairwise comparison t-test with Bonferroni adjustment was used (p < 0.05 considered significant). Satisfaction was measured using a six-point Likert scale. Trainer/trainee teams participated in 2-hour training sessions with three games and a debriefing. For "Knowing the manufacturing steps," cards with the steps were placed in the correct order. For "Knowing the criteria for using the robot," teams guessed whether certain compounds could be used with the robot. For "Knowing how to handle production errors," the answer to each error (taken from real-life issues) was selected from four options.

RESULTS

Participants (n  =  14) were very satisfied about sessions' interactivity and playfulness. Knowledge improved from 57% pretraining to 77% (p < 0.005) to 76.6% (6M) (p < 0.05 compared to pretraining). Motivation and self-efficacy, respectively, improved from 57.6% to 86.6% (p < 0.05) to 70.4% (6M) and from 48.5% to 75.6% (p < 0.05) to 60.2% (6M) (p > 0.1 compared to pretraining) (t-test).

CONCLUSIONS

This highly appreciated training program efficiently improved knowledge retention out to six months.

Topical formulation containing chitosan-chamomile microparticles in cutaneous wound healing in rats

Objective: The aim of this research was to evaluate the efficacy of a topical formulation containing chitosan-chamomile microparticles in cutaneous healing in rats. Method: Male Wistar rats (n=57) were randomly distributed into three groups: treatment; vehicle; and control. Evaluations were performed on days 2, 7 and 14 after the surgical procedure using skin lesion photography, and histological and biochemical analyses. Results: The results showed that there was no difference in the healing index and in the histological analysis of the inflammatory infiltrate among groups. Fibrogenesis was more significant in the group treated with the test formulation at day 7, and angiogenesis was greater in the vehicle and chamomile groups at day 2. The quantification of hydroxyproline showed a higher amount of collagen in the group treated with chamomile, mainly at day 14, although the histological quantification of collagen showed no difference between the groups. Conclusion: From the results of this study, it can be concluded that the formulation, although it had no effect on the healing time, improved the quality of the cicatricial tissue formed with a greater quantity of fibroblasts and collagen.

Topical formulation containing chitosan-chamomile microparticles in cutaneous wound healing in rats

Objective: The aim of this research was to evaluate the efficacy of a topical formulation containing chitosan-chamomile microparticles in cutaneous healing in rats. Method: Male Wistar rats (n=57) were randomly distributed into three groups: treatment; vehicle; and control. Evaluations were performed on days 2, 7 and 14 after the surgical procedure using skin lesion photography, and histological and biochemical analyses. Results: The results showed that there was no difference in the healing index and in the histological analysis of the inflammatory infiltrate among groups. Fibrogenesis was more significant in the group treated with the test formulation at day 7, and angiogenesis was greater in the vehicle and chamomile groups at day 2. The quantification of hydroxyproline showed a higher amount of collagen in the group treated with chamomile, mainly at day 14, although the histological quantification of collagen showed no difference between the groups. Conclusion: From the results of this study, it can be concluded that the formulation, although it had no effect on the healing time, improved the quality of the cicatricial tissue formed with a greater quantity of fibroblasts and collagen.

Evolution of pediatric pharmaceutical forms for treatment of Hansen's disease (leprosy)

INTRODUCTION

Leprosy is a neglected, infectious, granulomatous and chronic disease caused by the pathological agent Mycobacterium leprae. The course of the disease is more aggressive in patients under 15 years of age, but the current treatment offered worldwide consists of solid forms, by the combination of antibiotics such as rifampicin, clofazimine and dapsone. This represents results in lack of adherence in pediatric patients and drug therapy failure, although numerous formulations and technologies have already been developed.

AREA COVERED

This study aims to analyze the technological evolution of the pharmaceutical treatment of leprosy, aimed at children. A review of patents around the world was conducted to look for technical and clinical aspects of formulations and devices.

EXPERT OPINION

Innovative formulations for pediatric patients were classified according to the routes of administration as oral, inhalable, injectable and transdermal. The formulations were organized as alternatives for pediatric therapy, taking into account the physicochemical aspects of drugs and the physiological aspects of pediatric patients. Among the difficulties for the patented formulations to reach the market, of special note is the low stability of the physicochemical characteristics of the drugs. Optimization of formulations would favor the pediatric treatment of leprosy, aiming at therapeutic success.

Perceptions of community pharmacists to implementing technologies in the workplace: an exploratory study

Background The proliferation of different technologies in pharmacies has begun to change the role and work of pharmacists; however, while workplace integration of technologies has been shown to be beneficial, there are still barriers to their implementation. Few studies have investigated pharmacists' perceptions of these technologies. Objective To investigate the views of community pharmacists on the implementation of technologies in pharmacy practice. Setting Community pharmacies in Auckland, New Zealand. Methods Semi-structured interviews were conducted June-September 2018 with a convenience sample of 20 pharmacists. Interviews explored current medication management and technologies used to support this service, experiences with technologies, confidence in learning new technologies, and whether the introduction of technologies could solve any needs in pharmacy practice. Data were analysed using inductive thematic analysis. Main outcome measure Community pharmacists views on pharmacy technologies. Results Four key themes were identified: attitudes to existing medication management technologies, adapting to new technologies, acceptance of technology, and barriers to implementing technology in pharmacies. Pharmacists were accepting of technology to help with medication management and allowing them to provide more patient-centered care. Most pharmacists expressed confidence in using new technologies and viewed technology as a tool to address current limitations in their practice. Barriers to technology were cost, consequences of medication error, fear that technology may replace people, and an over-reliance on technology. Conclusion Community pharmacists made use of several types of technologies to promote medication management, including robotics. While mostly accepting of new technologies to streamline tasks and reduce error, pharmacists highlighted the importance of addressing barriers to technology implementation prior to workplace implementation.

New perspectives on the topical management of recurrent candidiasis

Candidiasis is a common opportunistic infection caused by fungi of the Candida genus that affects mainly mucocutaneous tissues (e.g., vaginal, oral, and mammary). This condition has been known for a long time; thus, innumerous topical and systemic treatments are already available on the market worldwide. Yet, recurrent superficial candidiasis (RSC) is an expected outcome, still lacking effective and convenient treatments. Although several individual conditions may contribute to disease recurrence, biofilms' presence seems to be the main etiological factor contributing to antifungal resistance. More than proposing novel antifungal agents, current research seems to be focusing on improving the pharmaceutical technology aspects of formulations to address such a challenge. These include extending and improving intimate contact of drug delivery systems with the mucocutaneous tissues, increasing drug loading dose, and enhancing topical drug permeation. This review discusses the current understanding of the RSC and the use of pharmaceutical technology tools in obtaining better results. Even though several drawbacks of conventional formulations have been circumvented with the help of nano- or microencapsulation techniques and with the use of mucoadhesive formulation excipients, many challenges remain. In particular, the need to mask the unpalatable taste of formulations for the treatment of oral candidiasis, and the necessity of formulations with a "dryer" sensorial feeling and improved performances in providing higher bioavailability for the treatment of mammary and vaginal candidiasis.

New missions of a hospital pharmaceutical technology unit during the COVID-19 pandemic

The pharmaceutical technology unit of the Geneva University Hospitals played a significant role in the fight against COVID-19 through four different missions: (1) providing enough hydroalcoholic solution at the peak of the pandemic; (2) facing supply chain management issues; (3) adapting the workload to the crisis and, above all, (4) managing the human resources necessary to handle these activities.

Perceptions, preferences and acceptability of patient designed 3D printed medicine by polypharmacy patients: a pilot study

Background 3D-printing, compared to conventional medicine manufacturing technologies, is a versatile and highly modifiable technique that has the flexibility to produce medicine that meet patients' specific requirements such as individualized dosing, but also to customize the appearance of the dosage form, e.g., shape and colour. Objective To explore polypharmacy patients' perceptions and preferences regarding 3D-printed medicine, including their acceptability of patient-designed medicine. Setting The study was conducted in Zealand, Denmark. Method Polypharmacy patients were recruited using convenience sampling (mostly on Facebook) and interviewed twice using semi-structured interviews. Interviews were analysed thematically into five predetermined themes (shapes, colours, embossing designs, polypills, and patient-designed dosage forms). At the first interview patients were asked about their perceptions and preferences towards 3D-printed solid dosage forms, and were presented to different shapes, colours, embossing designs and examples of polypills. They were also invited to design their own medicine from the ones presented. Their self-designed medicines were presented at the second interview, where acceptability of both their self-designed medicine and the concept of designing one's own medicine, was investigated. Main outcome measure Patients' perceptions, preferences towards and acceptability of 3D-printed medicines. Results Eight patients were included. They tended to prefer shapes similar to conventional medicine. Different colours were preferred by different people. The presented embossing designs seemed to be irrelevant. Polypills were generally believed to be a good idea due to the reduction of number of medicines. Acceptability of patient-designed medicine was mainly determined by whether patients thought 3Dprinting technology was reliable or not. Conclusions The patients had various perceptions and preferences of 3D-printed medicine. Factors affecting the patient views were aesthetic (appealing), physiological (swallowing), practical (handling), pedagogical (understanding) and psychological (relate to). Trust in the technology seemed to be important for acceptability.

[Pharmaceutical system of fecal microbiota transplantation: Heterogeneous practices]

OBJECTIVE

To describe current pharmaceutical practice in French hospitals regarding fecal microbiota transplantation in terms of prescription, preparation and compounding, as well as local legislation.

MATERIAL AND METHODS

A national survey was conducted at 28 French university hospital centers followed by the sending of a GoogleForm^® questionnaire from June to August 2018 in the 16 respondent centers either performing or subcontracting fecal microbiota transplant.

RESULTS

All hospitals performing or subcontracting fecal transplant (n=16,%57) report prescription indication of recurrent Clostridium difficile infection treatment, and 6 of them also as part of a clinical trial protocol. In hospitals performing fecal transplant themselves (n=11), the number of pre-donation consultations with donors varies from one (n=6) to two (n=5). Fecal sample is collected at the donor's home in 45% of cases. Route of administration for transplant is either naso-gastric administration (n=4), rectal (n=4) or both (n=5). Fecal samples for transplant are compounded either in the hospital pharmacy (n=73%) or in the laboratory (27%). Thawing methods include refrigeration between 2-8°C (50%), room temperature (25%) and water bath (25%). Billing system and reporting to health authorities are highly heterogeneous from one hospital to another.

CONCLUSION

This survey shows significant pharmaceutical practice heterogeneity within French hospitals regarding fecal microbiota transplantation despite the existence of national and European recommendations.

Technological innovation strategies for the specific treatment of Chagas disease based on Benznidazole

Caused by Trypanosoma cruzi, Chagas disease is responsible for public health problems greater in magnitude than those attributed to malaria, schistosomiasis, or leishmaniasis. A factor in the socioeconomic development of poor countries, Chagas disease can cause death due to a high parasitic burden during its acute phase due and irreversible damage in organs such as the heart, esophagus, and colon during its chronic phase, even when the number of parasites is minimal. For treating Chagas disease, benznidazole (BNZ) remains the drug of choice and, in Latin America, the only drug on the market for treating the disease. However, BNZ has exhibited insufficient activity in the chronic phase of Chagas disease, required administration in large doses, prolonged treatment, and shown a high incidence of adverse reactions (vomiting, rash, peripheral neuropathy, and spinal cord depression), toxicity, and low solubility in water. As an antidote, pharmaceutical technologies have been introduced that can improve BNZ's solubility and dissolution, as well as reduce side effects in light of its bioavailability, all of which can enhance therapy for Chagas disease. In response to that trend, by conducting a literature review, we sought to identify current pharmaceutical technologies used in tandem with BNZ to improve therapy for Chagas disease. Documented techniques include emulsion and microemulsion formation, solutions, parenteral formulas, micronization, and drug delivery systems supported by the development of nanoparticles and cyclodextrins, solid dispersions, and the use of metal-organic frameworks as innovative excipients. Such technologies increase the water solubility of BNZ by 4-25-fold on dissolution and an 85% release with efficacy in only a few minutes, as recorded during a viability experiment with nanoparticle suspensions. That experiment demonstrated the need for a lower concentration of BNZ to kill 50% of trypomastigote forms of T. cruzi, described in terms of the formation of BNZ-cyclodextrin complexes, and modulating and vectoring of the antichagasic by using metal-organic frameworks. Altogether, the promising results of research identified can enable strategies to improve solubility and efficacy of BNZ, as well as therapy for Chagas disease.

Stability of an ophthalmic formulation of polyhexamethylene biguanide in gamma-sterilized and ethylene oxide sterilized low density polyethylene multidose eyedroppers

Background

Polyhexamethylene biguanide (PHMB) eye drops are a frequently used medication to treat Acanthamoeba keratitis. In the absence of marketed PHMB eye drops, pharmacy-compounding units are needed to prepare this much needed treatment, but the lack of validated PHMB stability data severely limits their conservation by imposing short expiration dates after preparation. In this study we aim to assess the physicochemical and microbiological stability of a 0.2 mg/mL PHMB eye drop formulation stored in two kinds of polyethylene bottles at two different temperatures.

Methods

A liquid chromatography coupled with diode array detector stability-indicating method was validated to quantify PHMB, using a cyanopropyl bonded phase (Agilent Zorbax Eclipse XDB-CN column 4.6 × 75 mm with particle size of 3.5 μm) and isocratic elution consisting of acetonitrile/deionized water (3/97 v/v) at a flow rate of 1.3 mL/min. PHMB eye drops stability was assessed for 90 days of storage at 5 and 25 °C in ethylene oxide sterilized low density polyethylene (EOS-LDPE) and gamma sterilized low density polyethylene (GS-LDPE) bottles. The following analyses were performed: visual inspection, PHMB quantification and breakdown products (BPs) screening, osmolality and pH measurements, and sterility assessment. PHMB quantification and BP screening was also performed on the drops emitted from the multidose eyedroppers to simulate in-use condition.

Results

The analytical method developed meets all the qualitative and quantitative criteria for validation with an acceptable accuracy and good linearity, and is stability indicating. During 90 days of storage, no significant decrease of PHMB concentration was found compared to initial concentration in all stored PHMB eye drops. However, BP were found at day 30 and at day 90 of monitoring in both kind of bottles, stored at 5 and 25 °C, respectively. Although no significant variation of osmolality was found and sterility was maintained during 90 days of monitoring, a significant decrease of pH in GS-LDPE PHMB eye drops was noticed reaching 4 and 4.6 at 25 °C and 5 °C respectively, compared to initial pH of 6.16.

Discussion

Although no significant decrease in PHMB concentration was found during 90 days of monitoring in all conditions, the appearance of BPs and their unknown toxicities let us believe that 0.2 mg/mL PHMB solution should be conserved for no longer than 60 days in EOS-LDPE bottles at 25 °C.

Stability of an ophthalmic micellar formulation of cyclosporine A in unopened multidose eyedroppers and in simulated use conditions

Cyclosporine A eye drops are used at concentrations ranging from 0.5 to 20mg/mL to treat a variety of ophthalmic diseases. Cyclosporine A formulations at high concentrations are difficult to manufacture because of cyclosporine's lipophilicity, and generally require an oil based vector. In this study, we investigated the physicochemical and microbiological stability of two high concentrations (10mg/mL and 20mg/mL) of an ophthalmic cyclosporine A micellar solution in a low density polyethylene multidose eyedropper, at two conservation conditions (5°C and 25°C), before and with simulated use. Analyses used were the following: visual inspection, cyclosporine quantification by a stability-indicating liquid chromatography method, osmolality and pH measurements and turbidity. A complementary analysis by dynamic light scattering was implemented to evaluate potential particle formation or micelle size change. In the in-use study, cyclosporine quantification was also performed on the drops emitted from the multidose eyedroppers. Our results show that the cyclosporine micellar formulation retains good physicochemical and microbiological stability, as all parameters stayed within acceptable range limits, however a higher variability in cyclosporine concentrations was observed for 20mg/mL units stored at 25°C. The in-use study showed that cyclosporine concentrations in the emitted drops were also within acceptable range limits. The micellar formulation presented in this study can therefore be stored at 5°C or at ≤25°C for up to 6months.

The strategic relevance of manufacturing technology: An overall quality concept to promote innovation preventing drug shortage

Manufacturing is the bridge between research and patient: without product, there is no clinical outcome. Shortage has a variety of causes, in this paper we analyse only causes related to manufacturing technology and we use shortage as a paradigm highliting the relevance of Pharmaceutical Technology. Product and process complexity and capacity issues are the main challenge for the Pharmaceutical Industry Supply chain. Manufacturing Technology should be acknowledged as a R&D step and as a very important matter during University degree in Pharmacy and related disciplines, promoting collaboration between Academia and Industry, measured during HTA step and rewarded in terms of price and reimbursement. The above elements are not yet properly recognised, and manufacturing technology is taken in to consideration only when a shortage is in place. In a previous work, Panzitta et al. proposed to perform a full technology assessment at the Health Technological Assessment stage, evaluating three main technical aspects of a medicine: manufacturing process, physicochemical properties, and formulation characteristics. In this paper, we develop the concept of manufacturing appraisal, providing a technical overview of upcoming challenges, a risk based approach and an economic picture of shortage costs. We develop also an overall quality concept, not limited to GMP factors but broaden to all elements leading to a robust supply and promoting technical innovation.

Inclusion of terpenes in cyclodextrins: Preparation, characterization and pharmacological approaches

Terpenes constitute the largest class of natural products and are important resources for the pharmaceutical, food and cosmetics industries. However, due to their low water solubility and poor bioavailability there has been a search for compounds that could improve their physicochemical properties. Cyclodextrins (natural and derived) have been proposed for this role and have been complexed with different types of terpenes. This complexation has been demonstrated by using analytical techniques for characterizing complexes such as DSC, NMR, XRD, FTIR, and TGA. The formation of inclusion complexes has been able to improve drug characteristics such as bioavailability, solubility and stability; and to enhance biological activity and efficacy. This review shows strong experimental evidence that cyclodextrins improve the pharmacological properties of terpenes, and therefore need to be recognized as being possible targets for clinical use.

Pharmaceutical innovation: impact on expenditure and outcomes and subsequent challenges for pharmaceutical policy, with a special reference to Greece

Over the recent decades, advances in healthcare technology have led to significant improvements in the quality of healthcare and in population health. At the same time, technological change in healthcare, rising national income and expansion of insurance coverage have been acknowledged as the main determinants of the historical growth in health spending in industrialized countries. The pharmaceutical sector is of particular interest as it constitutes a market characterized by rapid technological change and high expenditure growth rates. The purpose of this article is to provide an overview of research findings on the impact of pharmaceutical innovation on pharmaceutical expenditure growth, total health expenditure and population health outcomes and to bring forward the challenges that arise for pharmaceutical policy in Greece.