Towards safer and efficient formulations: Machine learning approaches to predict drug-excipient compatibility

Predicting drug-excipient compatibility is a critical aspect of pharmaceutical formulation design. In this study, we introduced an innovative approach that leverages machine learning techniques to improve the accuracy of drug-excipient compatibility predictions. Mol2vec and 2D molecular descriptors combined with the stacking technique were used to improve the performance of the model. This approach achieved a significant advancement in the predictive capacity as demonstrated by the accuracy, precision, recall, AUC, and MCC of 0.98, 0.87, 0.88, 0.93 and 0.86, respectively. Using the DE-INTERACT model as the benchmark, our stacking model could remarkably detect drug-excipient incompatibility in 10/12 tested cases, while DE-INTERACT managed to recognize only 3 out of 12 incompatibility cases in the validation experiments. To ensure user accessibility, the trained model was deployed to a user-friendly web platform (URL: https://decompatibility.streamlit.app/). This interactive interface accommodated inputs through various types, including names, PubChem CID, or SMILES strings. It promptly generated compatibility predictions alongside corresponding probability scores. However, the continual refinement of model performance is crucial before applying this model in practice.

Physical compatibility of sulbactam/durlobactam with select intravenous drugs during simulated Y-site administration

PURPOSE

Sulbactam/durlobactam is a combination antibiotic designed to target Acinetobacter baumannii, including carbapenem-resistant and multidrug-resistant strains. The objective of this study was to determine the physical compatibility of sulbactam/durlobactam solution during simulated Y-site administration with 95 intravenous (IV) drugs.

METHODS

Vials of sulbactam/durlobactam solution were diluted in 0.9% sodium chloride injection to a volume of 100 mL (the final concentration of both drugs was 15 mg/mL). All other IV drugs were reconstituted according to the manufacturer's recommendations and diluted with 0.9% sodium chloride injection to the upper range of concentrations used clinically or tested undiluted as intended for administration. Y-site conditions were simulated by mixing 5 mL of sulbactam/durlobactam with 5 mL of the tested drug solutions in a 1:1 ratio. Solutions were inspected for physical characteristics (clarity, color, and Tyndall effect), turbidity, and pH changes before admixture, immediately post admixture, and over 4 hours. Incompatibility was defined as any observed precipitation, significant color change, positive Tyndall test, or turbidity change of ≥0.5 nephelometric turbidity unit during the observation period.

RESULTS

Sulbactam/durlobactam was physically compatible with 38 out of 42 antimicrobials tested (90.5%) and compatible overall with 86 of 95 drugs tested (90.5%). Incompatibility was observed with albumin, amiodarone hydrochloride, ceftaroline fosamil, ciprofloxacin, daptomycin, levofloxacin, phenytoin sodium, vecuronium, and propofol.

CONCLUSION

The Y-site compatibility of sulbactam/durlobactam with 95 IV drugs was described. These compatibility data will assist pharmacists and nurses to safely coordinate administration of IV medications with sulbactam/durlobactam.

Compatibility and Stability of Ten Commonly Used Clinical Drugs in Pediatric Electrolyte Supplements Injection

Objective

Pediatric electrolyte supplements injection is mainly used to supplement heat and body fluid, and commonly used in pediatrics. Its compatibility and stability with common clinical drugs such as antibiotics was rarely reported to ensure the children’s safety and the rational use of drugs. The aim of the present study was to investigate physical and chemical stability of pediatric electrolyte supplements injection mixed with ten commonly used clinical drugs.

Methods

According to clinical drug concentration, we mix the pediatric electrolyte supplements injection mixed with ten drugs. The compatible solutions were withdrawn at certain time intervals (0, 0.5, 1, 2, 4, 6 hours) after mixing and tested by description, insoluble particles detection, pH determination and high performance liquid chromatography (HPLC) assay of active ingredient as measures of physicochemical compatibility.

Results

No obvious appearance changes were observed when mixing. Furthermore, over the 6 hours post-preparation period the pH values were within the requirements of each drug quality standard and the number of insoluble particles (≥10 and ≥25μm) met requirements of Chinese Pharmacopeia (Edition 2020) except for mezlocillin sodium for injection. The percentages of the initial concentrations maintained at a minimum of 97% in the mixtures within 6 hours.

Conclusions

Nine commonly used clinical drugs remained stable in the pediatric electrolyte supplements injection for 6 hours at 25°C and avoiding from light. Mezlocillin sodium for injection was not recommended to be combined with electrolyte supplement injection for children because its insoluble particles exceed the standard.

Intestinal bacteria are involved in Radix Glycyrrhizae and Radix Euphorbiae Pekinensis incompatibility

ETHNOPHARMACOLOGICAL RELEVANCE

Eighteen Incompatible Medicaments (EIM) belongs to the category of incompatibility of Traditional Chinese medicine (TCM). This theory forbids concomitant using any one of the eighteen herbal pairs such as Radix Glycyrrhizae (RG)-Radix Euphorbiae Pekinensis (REP), Radix Aconiti-Bulbus Fritiliariae Cirrhosae, and Radix et Rhizoma Veratri Nigri-Radix Ginseng. Concomitant using RG and REP could result in more serious adverse effects on major organs such as kidney, heart, and liver.

AIM OF THE STUDY

To investigate the effects of RG-REP decoctions on gut microbiota and short-chain fatty acids (SCFAs) for the purpose of elucidating the mechanism of RG-REP incompatibility.

MATERIALS AND METHODS

Six groups of male SD rats were intragastrically administrated with distilled water, RG decoction, REP decoction, 1:1 RG-REP decoction, 2:1 RG-REP decoction and 3:1 RG-REP decoction, respectively, twice daily for 30 consecutive days, and the feces of each rat was separately sampled for gut microbiota analysis and SCFAs assay. 16S rDNA sequencing was employed to comparatively investigate the structure and abundance of intestinal bacteria in rat feces. Gas chromatography (GC) was used to quantitatively determine the contents of SCFAs in rat feces and in vitro samples. The correlation between bacteria and the production of SCFAs was analyzed by Spearman correlation analysis. An in vitro model of human intestinal bacteria was also constructed to simulate and validate the in vivo experiment.

RESULTS

The contents of butyric acid in both rat feces and in vitro samples decreased in RG-REP groups. The general structure of gut microbiota in RG-REP groups was not significantly different from that in control group. However, RG alone increased the abundance of Lactobacillus while this effect was counteracted by concomitant using with REP. REP alone decreased the abundance of two interrelated species, Akkermansia and Butyricimonas, and this effect was strengthened by concomitant using REP with RG in the ratio of 1:1. In comparison with REP alone, RG-REP combination also significantly increased the abundance of Streptococcus and Prevotella.

CONCLUSION

The incompatibility of RG-REP combination is associated with its negative effect against probiotic bacteria and positive effect on conditional pathogenic bacteria as well as its inhibition on butyric acid production.

Assessment of the physical compatibility of injectable enrofloxacin with commonly used intravenous fluids and drugs during simulated Y-port administration

OBJECTIVE

To evaluate physical compatibility of small animal (SAE) and large animal (LAE) injectable formulations of enrofloxacin with select IV fluids and drugs.

SAMPLE

162 admixtures containing SAE or LAE with saline (0.9% NaCl) solution, lactated Ringer solution (LRS), Plasma-Lyte A (PLA), 6% hydroxyethylstarch 130/0.4 (HES), metoclopramide, or ampicillin-sulbactam.

PROCEDURES

In the first of 2 simultaneously conducted experiments, admixtures containing enrofloxacin (10 mg/kg) and a volume of IV fluid that would be administered over a 20-minute period when dosed at the maintenance infusion rate (40 mL/kg/d for saline solution, LRS, and PLA and 20 mL/kg/d for HES) were created. In the second experiment, enrofloxacin (10 mg/kg) was admixed with saline solution (40 mL/kg/d) and metoclopramide (2 mg/kg/d) or ampicillin-sulbactam (30 mg/kg). In both experiments, admixture components were infused into a flask over 20 minutes assuming patient weights of 5, 10, and 20 kg. Admixtures were created by use of undiluted SAE and SAE diluted 1:1 with saline solution and undiluted LAE and LAE diluted 1:1 and 1:10 with saline solution. Admixtures were assessed for physical incompatibility at 0, 15, 30, and 60 minutes after completion of mixing. Physical incompatibility was defined as gross precipitation, cloudiness, Tyndall effect, or change in turbidity.

RESULTS

Admixtures containing undiluted SAE or LAE were physically incompatible with saline solution, PLA, LRS, and HES. Because saline solution was used to dilute SAE and LAE, all admixtures containing diluted SAE or LAE were also physically incompatible. Physical compatibility of enrofloxacin with metoclopramide or ampicillin-sulbactam could not be assessed because those admixtures also contained saline solution.

CONCLUSIONS AND CLINICAL RELEVANCE

Enrofloxacin was physically incompatible with all tested solutions.

Physical Compatibility of Cefiderocol with Selected Intravenous Drugs During Simulated Y-site Administration

The physical compatibility of cefiderocol for injection (prepared as a diluted 2% cefiderocol solution) with potential co-administration drug products is presented. The compatibility of cefiderocol with a selection of 91 intravenous drugs was tested at clinically relevant concentrations using the admixed volume ratio 1:1. Compatibility of the mixtures was determined by visual observations, turbidity, and particulate-matter measurements. The mixtures were examined immediately after mixing, and then at 1 hour and 4 hours thereafter at room temperature. When using 0.9% sodium chloride or 5% dextrose injection for diluents, solutions of dobutamine hydrochloride, esomeprazole sodium, methylprednisolone acetate, propofol, rocuronium bromide, amiodarone hydrochloride, famotidine, labetalol hydrochloride, mycophenolate mofetil, acyclovir sodium, amphotericin B, caspofungin acetate, doxycycline, posaconazole, diphenhydramine hydrochloride, and phenytoin sodium were found to cause visible cloudiness upon mixing with 2% cefiderocol in both diluents. Solutions of lorazepam, tobramycin sulfate, and vancomycin hydrochloride were determined incompatible by examining the mixtures with the aid of a Tyndall light. These 19 drugs were clearly incompatible with cefiderocol for injection by visual examination. In addition, solutions of iron sucrose and albumin were incompatible with 2% cefiderocol based on sub-visual tests for turbidity and/or particulate matter. Based on sub-visual data, the 0.9% sodium chloride admixture of aminophylline and 2% cefiderocol was incompatible, while inconclusive results were obtained for the 0.9% sodium chloride admixtures of 2% cefiderocol with amikacin sulfate. Similarly, the 5% dextrose admixtures of either ciprofloxacin or polymyxin B sulfate with 2% cefiderocol were incompatible, whereas data for phenylephrine hydrochloride morphine sulfate, or undiluted sodium bicarbonate were inconclusive. Overall, the 2% cefiderocol solution was physically compatible with 63 of 91 drugs challenged at 1:1 volume ratio in both 0.9% sodium chloride and 5% dextrose diluents for at least 4 hours at the concentrations tested in this study.

Development, optimization, and evaluation of PEGylated brucine-loaded PLGA nanoparticles

The application of nanotechnology to drug delivery systems for cancer therapy has progressively received great attention. The most heavily investigated approach is the development of nanoparticles (NPs) utilizing biodegradable and biocompatible polymers such as poly (lactic-co-glycolic acid) (PLGA). These NPs could be further improved by surface modification utilizing a hydrophilic biodegradable polymer such as polyethylene glycol (PEG) to achieve passive targeting. Modified NPs can deliver drugs such as brucine (BRU), which has shown its potential in cancer therapy. The objective of the current investigation was to develop and evaluate the passive targeting of long-circulating PLGA NPs loaded with BRU. NPs were characterized in terms of drug-excipient compatibility studies, including FTIR and DSC; physicochemical evaluations including particle size, zeta potential, morphological evaluation, entrapment efficiency and percentage yield; total serum protein adsorbed onto NP surfaces; and in vitro release of the loaded drug. Factorial design was employed to attain optimal PLGA-loaded NPs. Finally, the in vivo anti-tumor activity of BRU-loaded PLGA NPs was evaluated in tumor-bearing mice. The NPs obtained had smooth surfaces with particle sizes ranged from 94 ± 3.05 to 253 ± 8.7 nm with slightly positive surface charge ranged from 1.09 ± 0.15 to 3.71 ± 0.44 mV. Entrapment of BRU ranged between 37.5 ± 1.8% and 77 ± 1.3% with yields not less than 70.8%. Total protein adsorbed was less than 25.5 µg total protein/1 mg NP. In vitro drug release was less than 99.1% at 168 h. Finally, significant reductions in tumor growth rate and mortality rate were observed for PEG PLGA NP formulations compared to both BRU solution and naked NPs.

Towards more efficient use of intravenous lumens in multi-infusion settings: development and evaluation of a multiplex infusion scheduling algorithm

BACKGROUND

Multi-drug intravenous (IV) therapy is one of the most common medical procedures used in intensive care units (ICUs), operating rooms, oncology wards and many other hospital departments worldwide. As drugs or their solvents are frequently chemically incompatible, many solutions must be administered through separate lumens. When the number of available lumens is too low to facilitate the safe administration of these solutions, additional (peripheral) IV catheters are often required, causing physical discomfort and increasing the risk for catheter related complications. Our objective was to develop and evaluate an algorithm designed to reduce the number of intravenous lumens required in multi-infusion settings by multiplexing the administration of various parenteral drugs and solutions.

METHODS

A multiplex algorithm was developed that schedules the alternating IV administration of multiple incompatible IV solutions through a single lumen, taking compatibility-related, pharmacokinetic and pharmacodynamic constraints of the relevant drugs into account. The conventional scheduling procedure executed by ICU nurses was used for comparison. The number of lumens required by the conventional procedure (LCONV) and multiplex algorithm (LMX) were compared.

RESULTS

We used data from 175,993 ICU drug combinations, with 2251 unique combinations received by 2715 consecutive ICU patients. The mean ± SD number of simultaneous IV solutions was 2.8 ± 1.6. In 27% of all drug combinations, and 61% of the unique combinations the multiplex algorithm required fewer lumens (p < 0.001). With increasing LCONV, the reduction in number of lumens by the multiplex algorithm further increased (p < 0.001). In only 1% of cases multiplexing required > 3 lm, versus 12% using the conventional procedure.

CONCLUSION

The multiplex algorithm addresses a major issue that occurs in ICUs, operating rooms, oncology wards, and many other hospital departments where several incompatible drugs are infused through a restricted number of lumens. The multiplex algorithm allows for more efficient use of IV lumens compared to the conventional multi-infusion strategy.

Intravenous Compatibility of Ceftazidime-Avibactam and Aztreonam Using Simulated and Actual Y-site Administration

PURPOSE

The objective of this communication was to determine the intravenous compatibility of ceftazidime/avibactam and aztreonam using simulated and actual Y-site administration.

METHODS

Ceftazidime-avibactam was reconstituted and diluted to concentrations of 8, 25, and 50 mg/mL in 0.9% sodium chloride. Aztreonam was reconstituted and diluted to concentrations of 10 and 20 mg/mL. Each combination of concentrations was tested for compatibility using visual, Tyndall beam, microscopy, turbidity, and pH assessments. Microscopy results were compared to those from sodium chloride 0.9% in water, pH was compared to that at time 0, and turbidity of combinations was compared to that of individual agents. Actual Y-site mixing was conducted over 2-h infusions with samples collected at 0, 1, and 2 h. Test results were evaluated at 0, 1, 2, 4, 8, and 12 h after mixing. All experiments were completed in triplicate.

FINDINGS

Across simulated and actual Y-site experiments, no evidence of incompatibility between combinations of ceftazidime-avibactam + aztreonam was observed. Visual and microscopic tests revealed no particulate matter, color changes, or turbidity. Tyndall beam tests were negative with all combinations. No evidence of incompatibility was observed in turbidity testing. The pH values were consistent across each of the 6 combinations, from immediately after mixing until 12 h after mixing. When the addition of agents was reversed in simulated Y-site experiments, no differences in compatibility were observed. No differences in compatibility between actual and simulated Y-site administration were observed, and there was minimal variability across all replicate experiments.

IMPLICATIONS

Ceftazidime-avibactam, at concentrations of 8, 25, and 50 mg/mL, appeared compatible with aztreonam at concentrations of 10 and 20 mg/mL.

Effect of subinhibitory exposure to quaternary ammonium compounds on the ciprofloxacin susceptibility of Escherichia coli strains in animal husbandry

BACKGROUND

Quaternary ammonium compound based disinfectants are commonly used in pig and poultry husbandry to maintain farm hygiene. However, studies have shown that subinhibitory concentrations of these disinfectants may increase antibiotic resistance. Investigation of antibiotic susceptibility is usually assessed via the microbroth dilution method, although this conventional culture-based technique only provides information on the bacteriostatic activity of an antimicrobial agent. Therefore, experiments were performed to investigate the effect of prior benzalkonium chloride (BKC) exposure on the viability of subsequent ciprofloxacin (CIP) treated Escherichia coli.

RESULTS

Following CIP treatment, bacterial cell counts were significantly higher after exposure to a subinhibitory BKC concentration than without BKC exposure. The flow cytometric results suggested a BKC-dependent onset of membrane damage and loss of membrane potential.

CONCLUSION

Our results indicate a lower bactericidal effect of CIP treatment on BKC-exposed E. coli isolates compared to unexposed E. coli isolates.

Intravenous Admixture Preparation Considerations, Part 3: Methods and Techniques to Decrease Incompatibilities

The study of intravenous admixture compatibility is an excellent application of "clinical pharmaceutics." Clinical pharmaceutics involves the study and application of pharmaceutics and pharmaceutic (physical pharmacy/ chemistry) principles to clinical compounding situations to aid in the evaluation of each intravenous admixture. This series includes compatibility and stability considerations in intravenous admixture compounding. Part 2 of this series of articles discussed many factors that should be considered that may give rise to compatibility concerns, as well as drug sorption issues. In this issue (Part 3), there is a discussion on the methods and techniques that can be used to decrease the occurrence and incidence of incompatibilities, along with some alternate techniques to consider when some approaches do not seem feasible.

Feasibility of rapidly assessing reactive impurities mediated excipient incompatibility using a new method: A case study of famotidine-PEG system

The present work demonstrates the utility of temperature controlled set up with pressurized headspace oxygen as an approach to effectively reduce the time required for solid-state drug-excipient compatibility study. To illustrate the utility, the incompatibility of polyethylene glycol (PEG) and polyethylene oxide (PEO) with Famotidine (Fam) was shown. Owing to thermal and oxidative stress, polyethylene ether moieties of PEG generated reactive impurities, resulting in the degradation of Fam. The chemical degradation was evaluated via liquid chromatography. Around 20% of degradation was observed in the pressurized oxygen set up, whereas, no degradation was found in the absence of oxidative stress. On increasing the excipient fraction, the Fam degradation increased proportionally. Formation of aldehydes and free radicals from excipients were proposed as the precursors for Fam degradation. The generation of aldehydes and free radicals was confirmed by infrared and Electron Spin Resonance (ESR) spectroscopic analysis, respectively. Overall, the present study demonstrated the utility of pressurized oxygen set up as a rapid and routine tool for studying drug-excipient incompatibility at temperatures relevant drug-product manufacture.

Intravenous Admixture Preparation Considerations, Part 2: Incompatibilities and Factors Involved

Intravenous admixture compounding requires a knowledge of stability, compatibility, and incompatibility issues related to the complete composition and formulation of the admixture. Referring to tables, charts, etc. is valuable but not always sufficient to determine whether or not a specific intravenous admixture will be stable and compatible. In evaluating an intravenous admixture, one is not just concerned with the active ingredients but with all the excipients. Excipients used in the formulations of commercially available products may vary between manufacturers, and these variations can influence drug compatibility and stability. Clinical pharmaceutics involves the study and application or pharmaceutics to real-life clinical compounding situations to aid in the evaluation of each intravenous admixture. This series continues with compatibility considerations in intravenous admixture compounding and will cover most aspects of the issues involved, to include in-syringe admixtures and small-volume and large-volume admixtures.

Evaluation of Y-site compatibility of home total parenteral nutrition and intravenous loop diuretics

In chronic kidney disease (CKD), the design of the parenteral nutrition (PN) regimen becomes more challenging where only individualized PN is appropriate, coupled with the increased risk of unintended interactions with diuretic therapy. In an effort to ensure safe therapy in the home, we assessed the physical stability of bespoke PN formulations intended for use in CKD in the simultaneous presence of Y-site compatibility of furosemide and torasemide. The patient's daily needs were determined based on both metabolic demands as well as the demand for fluids.Complete admixtures were subjected to physical stability analysis consisting of visual inspection, a validated light microscope method, pH measurement, zeta potential measurement, and characterization of oily globule size distribution. Y-site compatibility of furosemide and torasemide with the formulated admixtures was also performed.The total parenteral admixture was stable over 7 days at +4°C and 24 h at +25°C and compatible via the Y-line together with furosemide and torasemide over 12 h at +25°C.The stability assessment guarantees the safety and efficiency of home PN with loop diuretics therapy in CKD patients. This means that these patients do not need long hospitalization and they can be safely treated at home. Furthermore, this study proved that torasemide is the same safety diuretic as furosemide, which has a great impact on clinical practice.

Prolonged In-use Stability of Reconstituted Herceptin in Commercial Intravenous Bags

Herceptin is a humanized monoclonal antibody that selectively binds to the extracellular domain of human epidermal growth factor receptor 2 (HER2). Herceptin has an important role in the treatment of HER2-positive breast cancer when used in the neoadjuvant, adjuvant, and metastatic settings, and in the treatment of HER2-positive metastatic gastric cancer, and gastroesophageal junction adenocarcinoma. Prior to intravenous infusion, Herceptin must be reconstituted with sterile water for injection and then diluted in intravenous bags with normal saline. The objective of this study was to test the in-use physicochemical stability of the Herceptin drug product after dilution in 0.9% sodium chloride in commercial polyvinylchloride, and polyolefin/ polyethylene/polypropylene infusion bags over the course of a 7-day storage at 2°C to 8°C followed by 24 hours of storage at 30°C with ambient light exposure. Three batches of Herceptin were reconstituted to yield a 21-mg/mL solution that was stored for 48 hours at 2°C to 8°C prior to dilution with 0.9% sodium chloride to create low (0.24-mg/mL) and high (3.84-mg/mL) concentration solutions that were then tested in simulated infusions with a polyvinylchloride or polyolefin/polyethylene/polypropylene infusion bag. Samples for analysis were obtained immediately after dilution of the reconstituted solution (T0), after 7 days of storage at 5°C (T7), after 1 further day of storage at 30°C (T7+1), and after administration through intravenous tubing (Tend). Control samples were obtained from bags containing only 0.9% sodium chloride at each time point. For experiments with both infusion bags, all samples were practically free from particles, were colorless, and had low numbers of subvisible particles with no differences between control and experimental samples. No change in turbidity was detected between T0 and Tend for low and high-concentration samples for each batch. The pH values remained consistent between T0 and T7+1, and osmolality values were consistent across low-concentration and high-concentration samples. Protein content, size, and potency remained consistent throughout storage and simulated infusion. In conclusion, Herceptin remains physicochemically stable for 7 days when stored at 2°C to 8°C, followed by an additional 24 hours at 30°C when diluted in 0.9% sodium chloride and stored in commercially available polyvinylchloride or polyolefin/polyethylene/polypropylene infusion bags.

Calcium Chloride and Calcium Gluconate in Neonatal Parenteral Nutrition Solutions without Cysteine: Compatibility Studies Using Laser Light Obscuration Methodology

There are no compatibility studies for neonatal parenteral nutrition solutions without cysteine containing calcium chloride or calcium gluconate using light obscuration as recommended by the United States Pharmacopeia (USP). The purpose of this study was to do compatibility testing for solutions containing calcium chloride and calcium gluconate without cysteine. Solutions of TrophAmine and Premasol (2.5% amino acids), containing calcium chloride or calcium gluconate were compounded without cysteine. Solutions were analyzed for particle counts using light obscuration. Maximum concentrations tested were 15 mmol/L of calcium and 12.5 mmol/L of phosphate. If the average particle count of three replicates exceeded USP guidelines, the solution was determined to be incompatible. This study found that 12.5 and 10 mmol/L of calcium and phosphate, respectively, are compatible in neonatal parenteral nutrition solutions compounded with 2.5% amino acids of either TrophAmine or Premasol. There did not appear to be significant differences in compatibility for solutions containing TrophAmine or Premasol when solutions were compounded with either CaCl₂ or CaGlu-Pl. This study presents data in order to evaluate options for adding calcium and phosphate to neonatal parenteral nutrition solutions during shortages of calcium and cysteine.

Compatibility and Stability of VARUBI (Rolapitant) Injectable Emulsion Admixed with Intravenous Granisetron Hydrochloride

Prophylaxis or therapy with a combination of a neurokinin 1 (NK-1) receptor antagonist (RA), a 5-hydroxytryptamine- 3 (5-HT3) RA, and dexamethasone is recommended by international antiemesis guidelines for the prevention of chemotherapy-induced nausea and vomiting for patients receiving highly emetogenic chemotherapy and for select patients receiving moderately emetogenic chemotherapy. VARUBI (rolapitant) is a substance P/NK-1 RA that was recently approved by the U.S. Food and Drug Administration as an injectable emulsion in combination with other antiemetic agents in adults for the prevention of delayed nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including, but not limited to, highly emetogenic chemotherapy. Granisetron Hydrochloride Injection USP is one of the 5-HT3 RAs indicated for the prevention of nausea and/or vomiting associated with initial and repeat courses of emetogenic cancer therapy, including high-dose cisplatin. Herein, we describe the physical and chemical compatibility and stability of VARUBI (rolapitant) injectable emulsion (166.5 mg/92.5 mL [1.8 mg/mL], equivalent to 185 mg of rolapitant hydrochloride) admixed with Granisetron Hydrochloride Injection USP (1.0 mg/mL, equivalent to 1.12 mg/mL hydrochloride). Binary admixtures of VARUBI injectable emulsion and Granisetron Hydrochloride Injection USP were prepared and stored in VARUBI ready-to-use glass vials and in four types of commonly used intravenous administration (tubing) sets. Evaluation of the physical and chemical compatibility and stability of the admixtures in the VARUBI ready-to-use vials stored at room temperature (20°C to 25°C) under fluorescent light and under refrigeration (2°C to 8°C protected from light) was conducted at 0, 1, 6, 24, and 48 hours, and that of the admixtures in the intravenous tubing sets was evaluated at 0, 2, and 6 hours of storage at 20°C to 25°C. Physical stability was evaluated by visual examination of the container contents under normal room light, and measurement of turbidity, globule size, and particulate matter. Chemical stability was assessed by measuring the pH of the admixture and determining drug concentrations (potency) and impurity levels by high-performance liquid chromatographic analysis. The pH, turbidity, globule size, and particulate matter of all samples remained within narrow and acceptable ranges at all study time points, indicating that combining the two formulations into a binary admixture is physically and chemically compatible and stable. VARUBI injectable emulsion admixed with Granisetron Hydrochloride Injection USP demonstrated compatibility and stability in a ready-to-use glass vial for at least 24 hours at room temperature and 48 hours under refrigeration, as well as in the four intravenous tubing sets for at least 6 hours at 20°C to 25°C. No decrease of drug concentration (or potency) of any admixed components occurred in the samples stored at the two conditions and time periods studied based on high-performance liquid chromatographic analysis. The levels of impurities stayed below the safety limits set by International Conference on Harmonisation during the study period.

Compatibility and Stability of VARUBI (Rolapitant) Injectable Emulsion Admixed with Intravenous Palonosetron Hydrochloride Injection and Dexamethasone Sodium Phosphate Injection

Prophylaxis or therapy with a combination of a neurokinin 1 (NK-1) receptor antagonist (RA), a 5-hydroxytryptamine-3 (5-HT3) RA, and dexamethasone is recommended by international antiemesis guidelines for the prevention of chemotherapy-induced nausea and vomiting for patients receiving highly emetogenic chemotherapy and for selected patients receiving moderately emetogenic chemotherapy. VARUBI (rolapitant) is a substance P/NK-1 RA that was recently approved by the U.S. Food and Drug Administration as an injectable emulsion in combination with other antiemetic agents in adults for the prevention of delayed nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including, but not limited to, highly emetogenic chemotherapy. Palonosetron is one of the 5-HT3 RAs indicated for the prevention of nausea and/or vomiting associated with initial and repeat courses of emetogenic cancer therapy, including high-dose cisplatin. Herein, we describe the physical and chemical compatibility and stability of VARUBI injectable emulsion (166.5 mg/92.5 mL [1.8 mg/mL, free base], equivalent to 185 mg of rolapitant hydrochloride) admixed with palonosetron injection 0.25 mg free base in 5 mL (equivalent to 0.28 mg hydrochloride salt) and with either 5 mL (20 mg) or 2.5 mL (10 mg) of dexamethasone sodium phosphate. Admixtures were prepared and stored in VARUBI injectable emulsion ready-to-use glass vials as supplied by the rolapitant manufacturer and in four types of commonly used intravenous administration (tubing) sets. Assessment of the physical and chemical compatibility and stability of the admixtures in the VARUBI ready-to-use vials stored at room temperature (20°C to 25°C) under fluorescent light and under refrigeration (2°C to 8°C protected from light) was conducted at 0, 1, 6, 24, and 48 hours, and that of the admixtures in the intravenous tubing sets was evaluated at 0, 2, and 6 hours of storage at 20°C to 25°C. Physical stability was evaluated by visual examination of the container contents under normal room light, and measurement of turbidity, globule size, and particulate matter. Chemical stability was assessed by measuring the pH of the admixture and determining drug concentrations (potency) and impurity levels by high-performance liquid chromatographic analysis. All samples were physically and chemically compatible throughout the study duration. The pH, turbidity, globule size, and particulate matter of the admixture stayed within narrow and acceptable ranges. VARUBI injectable emulsion admixed with intravenous palonosetron and dexamethasone was chemically and physically stable in the ready-to-use glass vials for at least 24 hours at room temperature and 48 hours under refrigeration, as well as in the four selected intravenous tubing sets for at least 6 hours at room temperature. No decrease of drug concentration (or potency) of any admixed components occurred in the samples stored at the two temperature ranges and time periods studied as measured by high-performance liquid chromatographic analysis.

Compatibility and Stability of Nab-Paclitaxel in Combination with Other Drugs

Albumin-bound paclitaxel (Abraxane®, nab-paclitaxel) is not recommended to be administered concurrently or sequentially with other drugs due to concern for instability. The need to administer drugs separately increases infusion time. We evaluated the compatibility and stability of solutions containing nab-paclitaxel and other drugs, including gemcitabine hydrochloride, carboplatin, dexamethasone sodium phosphate, granisetron hydrochloride, and palonosetron hydrochloride. We visually examined changes in appearance, pH, and concentration of the mixed solutions of nab-paclitaxel and other drugs for up to 24 h. Concentration was measured using high-performance liquid chromatography (HPLC). The appearance and pH of the mixed solutions did not change for up to 24 h. The change in concentration up to 24 h was within 2%. The chromatogram did not change until 8 h. The results showed that the physical compatibility and chemical stability of nab-paclitaxel were not influenced when it was combined with other drugs until 8 h. This study suggests that nab-paclitaxel could be administered in a mixture or sequentially with other drugs to reduce administration time.

Compatibility and Stability of Rolapitant Injectable Emulsion Admixed with Dexamethasone Sodium Phosphate

Neurokinin-1 receptor antagonist, 5-hydroxytryptamine-3 receptor antagonist, and dexamethasone combination therapy is the standard of care for the prevention of chemotherapy-induced nausea and vomiting. Herein, we describe the physical and chemical stability of an injectable emulsion of the Neurokinin-1 receptor antagonist rolapitant 185 mg in 92.5 mL (free base, 166.5 mg in 92.5 mL) admixed with either 2.5 mL of dexamethasone sodium phosphate (10 mg) or 5 mL of dexamethasone sodium phosphate (20 mg). Admixtures were prepared and stored in two types of container closures (glass and Crystal Zenith plastic bottles) and four types of intravenous administration tubing sets (or intravenous tubing sets). The assessment of the physical and chemical stability was conducted on admixtures packaged in bottled samples stored at room temperature (20°C to 25°C under fluorescent light) and evaluated at 0, 1, and 6 hours. For admixtures in intravenous tubing sets, the assessment of physicochemical stability was performed after 0 and 7 hours of storage at 20°C to 25°C, and then after 20 hours (total 27 hours) under refrigeration (2°C to 8°C) and protected from light. Physical stability was assessed by visually examining the bottle contents under normal room light and measuring turbidity and particulate matter. Chemical stability was assessed by measuring the pH of the admixture and determining drug concentrations through high-performance liquid chromatographic analysis. Results showed that all samples were physically compatible throughout the duration of the study. The admixtures stayed within narrow and acceptable ranges in pH, turbidity, and particulate matter. Admixtures of rolapitant and dexamethasone were chemically stable when stored in glass and Crystal Zenith bottles for at least 6 hours at room temperature, as well as in the four selected intravenous tubing sets for 7 hours at 20°C to 25°C and then for 20 (total 27 hours) hours at 2°C to 8°C. No loss of potency of any admixed component occurred in the samples stored at the temperature ranges studied.

Compatibility and Stability of Rolapitant Injectable Emulsion Admixed with Intravenous Palonosetron Hydrochloride

Neurokinin-1 receptor antagonist, 5-hydroxytryptamine-3 RA, and dexamethasone combination therapy is standard of care for the prevention of chemotherapy-induced nausea and vomiting. Herein we describe the physical and chemical stability of rolapitant injectable emulsion 166.5 mg in 92.5 mL (185 mg hydrochloride salt) admixed with palonosetron injection 0.25 mg in 5 mL (0.28 mg hydrochloride salt). Admixtures were prepared and stored in two types of container closures (110-mL Crystal Zenith plastic and glass bottles) and four types of intravenous administration sets (or intravenous tubing sets). Assessment of the physical and chemical stability was conducted on the admixtures in the ready-to-use container closure systems as supplied by the manufacturer, stored at room temperature (20°C to 25°C under fluorescent light), and evaluated at 0, 1, and 6 hours; 1 and 2 days; and under refrigeration (2°C to 8°C protected from light) after 1, 3, and 7 days. For admixtures in intravenous tubing sets, the assessment of physicochemical stability was performed after 0 and 7 hours of storage at 20°C to 25°C initially, and then after 20 hours (total 27 hours) at 2°C to 8°C protected from light. Physical stability was assessed by visual examination of the container contents under normal room light, and measuring turbidity and particulate matter. Chemical stability was assessed by measuring the pH of the admixture and determining drug concentrations and impurity levels with high-performance liquid chromatographic analysis. The results indicated that all samples were physically compatible throughout the duration of the study. The pH, turbidity, and particulate matter of the admixture stayed within narrow and acceptable ranges. Rolapitant admixed with palonosetron was chemically stable when admixed in glass and Crystal Zenith bottles for at least 48 hours at room temperature and for 7 days under refrigeration, as well as in the four selected intravenous tubing sets for 7 hours at 20°C to 25°C and then for 20 hours at 2°C to 8°C. No loss of potency of any admixed components occurred in the samples stored at the two temperature ranges and time period studied.

Incompatibility of Oxalate Desensitizers with Acidic, Fluoride-containing Total-etch Adhesives

The use of oxalate desensitizers on acid-etched dentin prior to adhesive application can result in subsurface tubular occlusion by calcium oxalate crystals. However, the solubility of calcium oxalate increases in acidic solution. We hypothesized that total-etch adhesives can, depending upon their pH, interact with oxalate-desensitizer-treated dentin in an adverse manner. Acid-etched human dentin treated with 2 oxalate desensitizers (BisBlock and Super Seal) was bonded with 4 simplified total-etch adhesives: One-Step (OS), Single Bond (SB), OptiBond Solo Plus (OB), and Prime&Bond NT (PB). Composite-dentin beams were examined by SEM and TEM, both of which revealed numerous spherical globules on OB- and PB-bonded, desensitizer-treated dentin, but not in OS or SB samples. Bond strengths produced by OB and PB were significantly lower in oxalate-treated specimens than those produced by OS or SB. These surface globules may have interfered with hybridization of demineralized dentin with OB and PB resins and caused compromised bond strengths.

Physical compatibility of tedizolid phosphate with selected i.v. drugs during simulated Y-site administration

PURPOSE

The physical compatibility of commonly used agents that could be coadministered in the clinical setting with tedizolid phosphate during Y-site administration was evaluated.

METHODS

Tedizolid phosphate vials were reconstituted to a final concentration of 0.8 mg/mL. All other drugs were prepared according to manufacturers' recommendations and diluted with 0.9% sodium chloride injection (where applicable) to the highest standard concentrations used clinically. Y-site conditions were simulated in culture tubes by mixing 5 mL of tedizolid phosphate solution with 5 mL of the test drug solutions. The physical characteristics, turbidity, and pH of all admixtures were examined immediately after mixing and at 15, 60, and 120 minutes. Incompatibility was defined as gross precipitation, a positive Tyndall beam test, color changes, or increases in turbidity.

RESULTS

With simulated Y-site administration, tedizolid phosphate was compatible with 69 of 86 drugs in 0.9% sodium chloride injection, including 24 of 31 antimicrobial agents. Of note, incompatibility was observed immediately after mixing except with ceftaroline and diphenhydramine, whose incompatibility with tedizolid phosphate was apparent after 15 and 60 minutes, respectively. Among the drug classes tested, tedizolid phosphate was compatible only with 1 aminoglycoside (amikacin) and incompatible with 1 echinocandin (caspofungin) and 1 cephalosporin (ceftaroline). In addition, tedizolid phosphate was incompatible with divalent cations (calcium chloride, calcium gluconate, and magnesium sulfate), probably due to precipitation with the phosphate component. A pH change of >1 unit occurred only with epinephrine (at 120 minutes).

CONCLUSION

Tedizolid phosphate 0.8 mg/mL in 0.9% sodium chloride injection was physically compatible with 69 of 86 study drugs during simulated Y-site administration.

Compatibility and stability of the novel anti-cancer agent C1311 in infusion devices and its in vitro biocompatibility

C1311 is the lead compound from the imidazoacridinones, a novel group of rationally designed anti-cancer agents. The compound is pharmaceutically formulated as a lyophilized product containing 100 mg C1311 (anhydrous free base) per dosage unit and requires reconstitution before intravenous administration. The aim of this study was to determine the stability of C1311 in the reconstituted solution and infusion solution and its compatibility with infusion devices. Moreover, the buffer capacity and haemolytic potential of C1311 infusion solutions, which exhibit a relatively low pH of 2-3, were evaluated in vitro. C1311 was shown to be stable in the reconstituted solution for at least 48 h and for at least 96 h after subsequent dilution in 0.9% sodium chloride and 5% dextrose. In vitro infusion simulation studies showed C1311 infusion solutions to be compatible with a low-density polyethylene administration set. Furthermore, the buffer capacity and haemolysis studies showed no indications for haemolysis or potential for vascular irritation upon continuous infusion of C1311. In conclusion, C1311 lyophilized product is adequately stable and compatible after reconstitution and in infusion fluids to be used in the clinic and is not expected to cause formulation-associated side effects in the intended administration schedule in the forthcoming Phase I clinical study.

Y-site Physical Compatibility of Beta-blocker Infusions with Intensive Care Unit Admixtures

Parenteral beta-blocker therapy via continuous infusion has shown promising results for improved outcomes for patients with septic shock. As patients with septic shock may require multiple intravenous medications, compatibility is necessary to co-infuse these medications through a y-site connector. The purpose of this study was to examine the physical compatibility of select intravenous drugs used for patients with septic shock combined with various intravenous beta-blockers including esmolol, labetalol, and metoprolol through a simulated y-site infusion. The tested drugs included albumin, levothyroxine, acetaminophen, esomeprazole, doripenem, epinephrine, ibuprofen, norepinephrine, levofloxacin, cefepime, ciprofloxacin, meropenem, cisatracurium, and hydrocortisone. Equal volumes of normal saline, esmolol, labetalol, and metoprolol were combined with each test drug at maximum or commercially available concentrations as appropriate used clinically in intensive care units.The samples were examined visually against a white and black background andalso using turbidimetric measurements to determine physical compatibility.Beginning immediately after mixing, observations and analyses were taken over a one-hour period at 15-minute intervals. Each test was performed in triplicate. Many of the test drugs demonstrated visual and/or turbidimetric physical compatibility when combined with esmolol, labetalol, or metoprolol during a simulated y-site infusion. Albumin, cefepime, and hydrocortisone demonstrated physical incompatibility when combined with labetalol and should not be co-infused with labetalol. Esomeprazole and ibuprofen demonstrated physical incompatibility when combined with esmolol and labetalol and should not be co-infused with either beta-blocker. Esmolol and ciprofloxacin mixtures exhibited a statistically significant difference from control solutions and should not be co-infused.

HPLC Investigated Physicochemical Compatibility between Artrosilene® Injectable Solution and other Pharmaceutical Products Frequently Used for Combined Therapy into Elastomeric Baxter LV5 Infusion Devices

Ketoprofen lysine salt (Artrosilene®, injectable solution) is a non-steroidal anti-inflammatory agent frequently administered by slow intravenous infusion with portable elastomeric infusion systems in association regimen with other analgesic drugs. The aim of this study was to investigate the physicochemical compatibility between ketoprofen lysine salt (Artrosilene®, injectable solution) and other injectable drugs frequently used in association, such as tramadol hydrochloride, keterolac tromethamine and morphine hydrochloride, into the Infusor LV5, Baxter elastomeric infusion system. Physicochemical properties of drug mixture, including colour, clarity, pH and drug content were observed or measured by a reversed-phase HPLC method with UV detection, before and after (up to 7 days) mixing at room temperature and under light protection. The results obtained demonstrated the physicochemical compatibility of ketoprofen lysine salt (Artrosilene®, injectable solution) with all drug formulations at every tested mixing ratios into Baxer Infusor LV5 infusion devices.

Incompatibilities of lornoxicam with 4 antiemetic medications in polyolefin bags during simulated intravenous administration

The administration of drugs by patient-controlled analgesia (PCA) is routinely practiced for the management of postoperative pain. It is common for 2 or more drugs to be combined in PCA solutions. The combination of analgesics and antiemetic agents is frequently required. Unfortunately, the compatibility and stability of lornoxicam and antiemetic agents, such as droperidol, ondansetrone, granisetron, and tropisetron, has not been determined. The aim of this study was to evaluate the compatibility and stability of solutions containing lornoxicam with the 4 antiemetic agents in combination for PCA administration.In our study, test samples were prepared in triplicate by adding 40 mg lornoxicam and 5 mg droperidol, 8 mg ondansetron, 6 mg granisetron, or 5 mg tropisetron to 100-mL polyolefin bags of sodium chloride 0.9% and stored at 25 °C. The analgesic mixture samples were visually inspected for precipitation, cloudiness, and discoloration at each sampling interval. Drug concentrations were determined using high-performance liquid chromatographic (HPLC) analysis.No loss of lornoxicam occurred with any of the 4 antiemetic agents tested for up to 48 hours. However, the contents of droperidol, ondansetron, granisetron, and tropisetron were significant loss >48 hours. After storage of 4.0 to 48.0 hours, the presence of a slight precipitate was observed in all the injection combinations.The results indicate that combinations of lornoxicam with droperidol, ondansetrone, granisetron, or tropisetron in infusion solution during simulated intravenous PCA administration were incompatibility when stored protected from light at 25 °C.

Compatibility of Norepinephrine Bitartrate with Levofloxacin and Moxifloxacin During Simulated Y-site Administration

The purpose of this study was to determine the physical compatibility and chemical stability of norepinephrine bitartrate with selected fluoroquinolones during simulated intravenous Y-site administration. Simulation of Y-compatibility of intravenous fluids can be experimentally demonstrated by mixing equal volumes of two drugs of interest. Hence, we prepared 1:1 mixture of norepinephrine bitartrate and levofloxacin or moxifloxacin by mixing 64 .g/mL of norepinephrine bitartrate individually with clinically relevant concentrations of levofloxacin (5 mg/mL) and moxifloxacin (1.6 mg/mL). The physical stability of these mixtures was assessed via measurement of change in turbidity, and visual inspection for color change, haziness, and precipitate formation. The chemical stability of these mixtures was assessed via high-performance liquid chromatography by evaluating the change in concentration for norepinephrine bitartrate and individual fluoroquinolones, from 0 to 4 hours after mixing. The visual evaluation and turbidity measurements revealed that norepinephrine bitartrate is compatible with individual fluoroquinolones. No color change, haziness, or precipitate formation was observed at 0 and 4 hours when the drugs were mixed at equal volume. The change in turbidity for the mixture as compared to the individual drugs was very minimal (0.001 to 0.004 nephelometric turbidity unit). No significant change in drug concentrations was observed during the 4-hour period for norepinephrine bitartrate and the individual fluoroquinolones following high-performance liquid chromatography analysis of the norepinephrine bitartrate/levofloxacin and norepinephrine bitartrate/moxifloxacin mixtures, which further confirms the stability of this mixture. Our data indicates that norepinephrine bitartrate is compatible with levofloxacin and moxifloxacin, and can be used for intravenous Y-site administration with either of these fluoroquinolone antibiotics.

DISSOLUTION AND COMPATIBILITY STUDY OF BINARY AND TERNARY INTERACTIVE MIXTURES OF INDOMETHACIN: COMPARISON WITH COMMERCIALLY AVAILABLE CAPSULES

The main objective of this work was to use Weibull distribution function and Baker-Lonsdale models to study the dissolution kinetics of prepared binary and ternary interactive mixtures containing indomethacin in comparison with three commercially available capsules of indomethacin, namely, Rothacin®, Indomin® and Indylon®. Differential scanning calorimetry (DSC) in conjunction with cloud point method was used to study the compatibility of indomethacin with polyvinylpyrrolidone (PVP) and lactose and to provide an explanation(s) for the insignificant increase in dissolution rate observed in the ternary interactive mixture as well as for the reduction in the dissolution rate observed from the binary system in our previous study. Results showed that the Weibull distribution function equation was the best fit to the dissolution data for all formulations used in this study. DSC curves showed that the decrease in dissolution rate from the binary and ternary interactive mixtures was due to incompatibility of indomethacin with PVP. Also DSC curves showed that lactose was compatible with indomethacin and that lactose was used as excipient in two commercial products (Rothacin® and Indylon®). Results from the cloud point method showed that the addition of indomethacin to 1% PVP solution containing ammonium sulfate (with cloud point at 76°C) reduces the cloud point of PVP indicating that there is an interaction between indomethacin and PVP, while the cloud point of 1% PVP containing ammonium sulfate was not affected by the addition of lactose.

Compatibility of cholecalciferol, haloperidol, imipramine hydrochloride, levodopa/carbidopa, lorazepam, minocycline hydrochloride, tacrolimus monohydrate, terbinafine, tramadol hydrochloride and valsartan in SyrSpend SF PH4 oral suspensions

A challenge with compounding oral liquid formulations is the limited availability of data to support the physical, chemical and microbiological stability of the formulation. This poses a patient safety concern and a risk for medication errors. The objective of this study was to evaluate the compatibility of the following active pharmaceutical ingredients (APIs) in 10 oral suspensions, using SyrSpend SF PH4 (liquid) as the suspending vehicle: cholecalciferol 50,000 IU/mL, haloperidol 0.5 mg/mL, imipramine hydrochloride 5.0 mg/mL, levodopa/carbidopa 5.0/1.25 mg/mL, lorazepam 1.0 mg/mL, minocycline hydrochloride 10.0 mg/mL, tacrolimus monohydrate 1.0 mg/mL, terbinafine 25.0 mg/mL, tramadol hydrochloride 10.0 mg/mL and valsartan 4.0 mg/mL. The suspensions were stored both refrigerated (2 - 8 degrees C) and at controlled room temperature (20 - 25 degrees C). This is the first stability study for these APIs in SyrSpend SF PH4 (liquid). Further, the stability of haloperidol,ilmipramine hydrochloride, minocycline, and valsartan in oral suspension has not been previously reported in the literature. Compatibility was assessed by measuring percent recovery at varying time points throughout a 90 days period. Quantification of the APIs was performed by high performance liquid chromatography (HPLC-UV). Given the percentage of recovery of the APIs within the suspensions, the beyond-use date of the final preparations was found to be at least 90 days for most suspensions both refrigerated and at room temperature. Exceptions were: Minocycline hydrochloride at both storage temperatures (60 days), levodopa/carbidopa at room temperature (30 days), and lorazepam at room temperature (60 days). This suggests that compounded suspensions of APIs from different pharmacological classes in SyrSpend SF PH4 (liquid) are stable.

[Compatibility of intravenous medications needs attention. Catheter occlusion, treatment failure and embolisms can be prevented]

When dealing with more drugs than available lumens, intravenous medications need to be co-administered in the same catheter. This type of scenario may induce therapeutic risks, such as catheter occlusion, changes in drug effect or embolization of precipitated particles. Various sources are available to provide information on compatibilities of intravenous medications. When using these sources, the applicability of the information must be assessed, comparing concentrations, diluents used and other pharmaceutical aspects. For the last three years, a group of pharmacists at Sahlgrenska University Hospital has worked on a project collecting and validating compatibility data for intravenous medications. In the future, this data will be available to more hospitals in Sweden.

Classification of drugs with different risk profiles

INTRODUCTION

A risk stratification approach is needed to identify patients at high risk of medication errors and a resulting high need of medication review. The aim of this study was to perform risk stratification (distinguishing between low-risk, medium-risk and high-risk drugs) for drugs found to cause serious adverse reactions due to medication errors. The study employed a modified Delphi technique.

METHODS

Drugs from a systematic literature search were included into two rounds of a Delphi process. A panel of experts was asked to evaluate each identified drug's potential for harm and for clinically relevant drug-drug interactions on a scale from 1 (low risk) to 9 (high risk).

RESULTS

A total of 36 experts were appointed to serve on the panel. Consensus was reached for 29/57 (51%) drugs or drug classes that cause harm, and for 32/57 (56%) of the drugs or drug classes that cause interactions. For the remaining drugs, a decision was made based on the median score. Two lists, one stating the drugs' potential for causing harm and the other stating clinically relevant drug-drug interactions, were stratified into low-risk, medium-risk and high-risk drugs.

CONCLUSION

Based on a modified Delphi technique, we created two lists of drugs stratified into a low-risk, a medium-risk and a high-risk group of clinically relevant interactions or risk of harm to patients. The lists could be incorporated into a risk-scoring tool that stratifies the performance of medication reviews according to patients' risk of experiencing adverse reactions.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

[Study on incompatibility of traditional Chinese medicines]

The incompatibility of traditional Chinese medicines is related to the clinical medication safety, so has attracted wide attentions from the public. With the deepening of studies on the incompatibility of traditional Chinese medicines represented by 18 incompatible herbs, the incompatibility of theory traditional Chinese medicines has raised to new heights. From the origin of incompatibility theory of traditional Chinese medicines, relationship of herbs, harms of incompatible herbs and principle of prevention to toxic effects of specific incompatible medicines, the innovation and development of the traditional Chinese medicine incompatibility theory was explored. Structurally, the incompatibility of traditional Chinese medicines refers to the opposition of two herbs based on seven emotions and clinical experience. The combination of incompatible herbs may lead to human harms, especially latent harm and inefficacy of intervention medicines. The avoidance of the combination of incompatible herbs and the consideration of both symptoms and drug efficacy are the basic method to prevent adverse reactions. The recent studies have revealed five characteristics of incompatible herbs. Toxicity potentiation, toxication, efficacy reduction and inefficacy are the four manifestations of the incompatible relations. The material changes can reflect the effects of toxicity potentiation and toxication of opposite herbs. The accumulation of toxicity and metabolic changes are the basis for latent harms. The antagonistic effect of main efficacies and the coexistence of positive and negative effects are the distinctive part of the incompatibility. The connotation of incompatible herbs plays an important role in the innovation of the traditional Chinese medicine incompatibility theory.

Utilization of the tyndall effect for enhanced visual detection of particles in compatibility testing of intravenous fluids: validity and reliability

PURPOSE

This study investigates the validity, reliability, and detection limit of a visual examination method utilizing the Tyndall effect to enhance visible detection of particles. The suitability of the method for compatibility testing of intravenous fluids in a hospital pharmacy context is discussed.

METHODS

A panel of 20 inspectors examined 20 samples, with and without particles, using two light sources (halogen lightbulb in a focused desk lamp and a red pocket laser pointer). The samples contained particles of different origin (precipitate, polystyrene standards), varying size, and concentrations. Light obscuration and turbidimetric measurements were used to obtain numeric references. The samples were divided into rejection probability zones, and the validity (sensitivity, specificity, and likelihood ratios) and reliability (inter-rater agreement coefficients Fleiss' kappa and Gwet's AC1) were estimated.

RESULTS

The sensitivity of the laser pointer for detecting microprecipitates was quite high; however, it also showed a high false rejection rate. The specificity was slightly higher for the focused desk lamp than the laser pointer. The likelihood ratios were not within the recommended limits of a useful test, indicating that the method could not securely confirm the presence/absence of particles in the samples. The inter-rater agreement coefficients indicated fair to moderate agreement between the inspectors.

CONCLUSIONS

The validity and reliability were not satisfactory for either of the light sources. The visual detection limit seemed to be around 5 μm, although we propose that an exact detection limit is not that relevant for compatibility testing. Based on the current findings, the visual examination method cannot be recommended as the sole method for judging compatibility of parenteral nutrition and drugs, but rather in a program of several methods. In the hospital pharmacy, the method may be a resource, together with theoretical considerations, in situations where other methods are unavailable; however, use of in-line-filters is essential to protect the patient.

LAY ABSTRACT

Many patients under intensive care are in need of several intravenous drugs simultaneously. These drugs cannot be given in the same infusion line unless compatibility has been documented. Incompatibilities can result in, for example, precipitation of particles. Injected particles can harm the patient and should be avoided. Visual screening of blends of drugs for possible incompatibility, using a focused light source to enhance visual detection based on the Tyndall effect, could be a quick and easy methodology to identify incompatibility. In the following study the objective was to investigate how reliable visual inspection, with the utilization of the Tyndall effect, is at detecting particles and precipitations in blends of intravenous drugs and parenteral nutrition mixtures. Twenty inspectors each examined 20 different samples with two different light sources. Some of the samples were without particles (clean), and some contained different types and degrees of particle contamination. The inspectors' judgment of the samples was recorded and validity and reliability parameters were calculated to evaluate the method's suitability. The conclusion was that because of false positive and negative findings the visual inspection method alone is not enough to securely document compatibility/incompatibility, but it is more suitable as support together with additional methods.

[Clinical study on aconite prescriptions with incompatible herbs in different areas based on association rules and analysis on compatibility features]

OBJECTIVE

To explore the current application and features of Aconite prescriptions with incompatible herbs in grade A class three hospitals in east China and central China through a clinical study and comparative analysis.

METHOD

Clinical prescriptions containing Aconite with incompatible herbs were collected. Association rules were utilized to analyze the compatible features of these herbs.

RESULT

This analysis found that the frequently used incompatible herba; pairs are Aconiti Lateralis Radix Praeparata-Pinelliae Rhizoma, with the support rate of 44.45%, occupying nearly half of the surveyed prescriptions; Pinelliae Rhizoma is the most frequently used herb in the two areas, with support rate up to 76.24%. Among the top 10 herbal pairs in the support rate, except for Aconiti Lateralis Radix Praeparata and Pinelliae Rhizoma, the top 10 herbs in Central China were mostly for warming the middle jiao and tonifying qi, such as Zingiberis Rhizoma, Atractylodis Macrocephalae Rhizoma and Codonopsis Radix; Whereas those in east China were mostly for activating and nourishing blood, such as Angelicae Sinensis Radix, Chuanxiong Rhizoma, and Salviae Miltiorrhizae Radix et Rhizoma. Among the top 10 herbal pairs in the support rate, except for Aconiti Lateralis Radix Praeparata-Pinelliae Rhizoma, the core herbal pairs applied in central China were mainly for resolving phlegm and warming the middle jiao, such as Pinelliae Rhizoma-Glycyrrhizae Radix et Rhizoma, Pinelliae Rhizoma-Zingiberis Rhizoma; Whereas those in east China were principally for activating blood and tonifying qi, like Atractylodis Macrocephalae Rhizoma and Pinelliae Rhizoma, Angelicae Sinensis Radix and Pinelliae Rhizoma. Among the core herbal groups in the two areas, the most frequently used herbal groups in the two areas are Aconiti Lateralis Radix Praeparata, Glycyrrhizae Radix et Rhizoma and Pinelliae Rhizoma with the support rate of 59.73%, accounting for the highest proportion among all of herbal groups.

CONCLUSION

There are the combined clinical application of Aconite with incompatible herbs, mostly with Aconiti Lateralis Radix Praeparata-Pinelliae Rhizoma, but with differences in the combined application in east China and central China.

A pharmacokinetic drug-drug interaction model of simvastatin and verapamil in humans

BACKGROUND

Verapamil is a calcium channel blocker commonly used in treatments of hypertension. Verapamil and its active metabolite, norverapamil, are known to be CYP3A4 inhibitors. Co-administration of verapamil with CYP3A4 substrates can alter the pharmacokinetics of the substrates. Simvastatin, a commonly used HMG-CoA reductase inhibitor for the treatment of hypercholesterolemia is extensively metabolized by CYP3A4. Therefore, concomitant use of simvastatin and verapamil can increase simvastatin plasma concentration levels, resulting in a higher risk of rhabdomyolysis, a serious adverse drug reaction. Even though, pharmacokinetic data regarding the interaction between both drugs have been published, their use is limited to semiquantitative applications. Therefore, we aimed to develop a mathematical model describing drug-drug interaction between simvastatin and verapamil in humans.

METHODS

Eligible pharmacokinetic interaction study between simvastatin and verapamil in humans was selected from PubMed database. The concentration-time courses from this study were digitally extracted and used for model development.

RESULTS

The drug-drug interaction between simvastatin and verapamil was modeled simultaneously with a two compartment model for verapamil with its active metabolite, norverapamil and a one compartment model for simvastatin with its active form, simvastatin hydroxy acid. The effects of verapamil and norverapamil on pharmacokinetics of simvastatin and its active form, simvastatin hydroxy acid were described by Michaelis-Menten equation. Simulated simvastatin and simvastatin hydroxy acid concentrations obtained from the final model produced a good fit to the dataset from a literature. The final model adequately describes pharmacokinetic interaction between simvastatin and verapamil which can be helpful in prediction of rhabdomyolysis in patients with concurrent use of these drugs.

Pharmacokinetic modeling of simvastatin, nelfinavir and their interaction in humans

BACKGROUND

Simvastatin, a commonly used HMG-CoA reductase inhibitor, is extensively metabolized by CYP3A4. Therefore, co-administration of simvastatin and CYP3A4 inhibitor can affect simvastatin pharmacokinetics. Nelfinavir, a protease inhibitor, and its major metabolite (M8) are known to be potent CYP3A4 inhibitors. When simvastatin and nelfinavir are co-administered, simvastatin pharmacokinetics is significantly altered and may result in an increased risk of rhabdomyolysis.

OBJECTIVE

To develop a mathematical model describing a drug-drug interaction between simvastatin and nelfinavir in humans.

METHODS

Eligible pharmacokinetic studies were selected from Pubmed database and concentration time course data were digitally extracted and used for model development. Compartmental pharmacokinetic models for simvastatin and nelfinavir were developed separately. A drug-drug interaction model of simvastatin and nelfinavir was subsequently developed using the prior information. Finally, the final drug-drug interaction modeled was validated against observed simvastatin concentrations.

RESULTS

Three compartmental pharmacokinetic models were successfully developed. Simvastatin pharmacokinetics was best described by a one compartment model for simvastatin linked to its active form, simvastatin hydroxy acid. Nelfinavir pharmacokinetics could be adequately described by a one compartment parent-metabolite model. Our final drug-drug interaction model predicted an increase in simvastatin exposure which is in line with clinical observations linking the simvastatin-nelfinavir combination to an increased risk of rhabdomyolysis.

CONCLUSION

Simvastatin-nelfinavir pharmacokinetic interaction can be explained by our final model. This model framework will be useful in further advanced developing other mechanism based drug-drug interaction model used to predict the risk of rhabdomyolysis occurrence in patients prescribed simvastatin and nelfinavir concurrently.

[Regularity of drugs compatibility of anti-hepatoma traditional Chinese medicine ancient prescriptions and risk evaluation of anti-hepatoma new drug research and development]

Traditional Chinese ancient prescriptions have been used for treatment of liver cancer for a long history and the scientific and rational compatibility is a great wealth for modern research and development (R&D) of new drugs. The research and development of new drugs are often accompanied with a large investment, a long cycle and a high risk, especially for the anti-tumor drugs R&D which are facing more risks and lower successful rate. In this research, the regularity of compatibility of drugs was analyzed from 124 anti-hepatoma ancient prescriptions by computer program. The results can offer help to the R&D of anti-hepatoma new drugs and reduce the risk of drug screening. In addition, we surveyed 22 companies in this field from six provinces such as Beijing, Shanghai, Tianjin and so on and obtained 240 risk assessment questionaires. Then we used qualitative analysis method to interpret the greatest impacts for the risks in the process of R&D, production and sales of anti-hepatoma new drugs. The study provides a basis for anti-liver cancer drugs R&D researchers, who can take effective measures to reduce the R&D risks and improve successful rate.

Physico-chemical stability of butorphanol-tramadol and butorphanol-fentanyl patient-controlled analgesia infusion solutions over 168 hours

This study was to investigate the physical and chemical compatibility of butorphanol with tramadol or fentanyl in 0.9% sodium chloride injections for patient controlled analgesia administration. The solutions were prepared in polyvinyl chloride (PVC) infusion bags and stored without protected from light exposure at room temperature (25 degrees C) or refrigerated (4 degrees C). Over a period of 168 hours, stabilities were determined by visual inspection, pH measurement, and high-pressure liquid chromatography (HPLC) assay of drug concentrations. At both temperatures, admixtures of butorphanol-tramadol and butorphanol-fentanyl were clear in appearance, and no color change or precipitation was observed during the study period. The maximum losses obtained were lower than 5% for the three drugs after 168 hours of storage. The results indicate that, at ambient or refrigerated storage conditions, the drug mixtures of butorphanol-tramadol and butorphanol-fentanyl in 0.9% sodium chloride injections were physically and chemically stable for at least 168 hours when stored in PVC syringes.

[Effect of different compatibility of zhizi dahuang decoction on pharmacokinetics of naringenin and hesperetin]

An HPLC-UV method was developed for the determination of total naringenin and total hesperetin in rat plasma after oral administration of Citrus aurantium Immaturus extracts and Zhizi Dahuang decoction. Plasma samples were pretreated with liquid-liquid extraction procedure and acid hydrolysis method was used for converting conjugated naringenin and hesperetin to their respective free forms. Plasma samples were separated on a C18 column (4.6 mm x 150 mm, 5 microm), using 0.1% phosphoric acid and methanol as mobile phase at a flow rate of 1.0 mL x min(-1) with gradient elution. DAS 2.0 software was applied to calculate the pharmacokinetic parameters while the SPSS 16.0 software was used for statistical analysis. Significant differences were observed, the C(max) AUC(0-t) of total naringenin in ZS group was 73.5% and 65.9% higher than those in ZZDHD group, respectively; the C(max), AUC(0-t) of total hesperetin in ZS group was 63.5% and 119.1% higher than those in ZZDHD group, respectively. There is a obvious decrease in C(max) and AUC(0-t) of total naringenin and total hesperetin after compatibility and their pharmacokinetic characteristics changed greatly due to the combination of other herbs. The established method was rapid, sensitive, selective and accurate, and it could be applied in the determination of total naringenin and total hesperetin in rat plasma.

[Applications of mathematical statistics methods on compatibility researches of traditional Chinese medicines formulae]

The compatibility of traditional Chinese medicines (TCMs) formulae containing enormous information, is a complex component system. Applications of mathematical statistics methods on the compatibility researches of traditional Chinese medicines formulae have great significance for promoting the modernization of traditional Chinese medicines and improving clinical efficacies and optimizations of formulae. As a tool for quantitative analysis, data inference and exploring inherent rules of substances, the mathematical statistics method can be used to reveal the working mechanisms of the compatibility of traditional Chinese medicines formulae in qualitatively and quantitatively. By reviewing studies based on the applications of mathematical statistics methods, this paper were summarized from perspective of dosages optimization, efficacies and changes of chemical components as well as the rules of incompatibility and contraindication of formulae, will provide the references for further studying and revealing the working mechanisms and the connotations of traditional Chinese medicines.

Proposal of a new degradation mechanism of enalapril maleate and improvement of enalapril maleate stability in tablet formulation with different stabilizers

Enalapril maleate (EM) is unstable in poorly designed tablet formulations. To improve the stability of EM, the degradation mechanism should be elucidated. In this study, we found that several commonly used excipients promoted the degradants of EM, particularly a diketopiperazine derivative (DKP). We propose two degradation pathways in which both acid and alkali can promote the formation of DKP, although previous reports suggested that DKP is produced mainly in acidic media. Based on the degradation pathways, we believe that subtle control of the microenvironmental pH can inhibit the formation of DKP. This was confirmed by the observation that the degradation rate became slower when certain organic acids were added to the binary mixtures of EM and excipient. The data showed that the stability of EM in the ternary mixtures was much higher than that in binary mixtures. It was further proved that tablets containing these organic acids produced less DKP after the accelerated test. We also found that the formation of DKP in tablets varied with different ratios of tartaric acid, which was used as a model organic acid. This illustrated that an optimum ratio of tartaric acid is required. These results indicated that the stability of EM in tablet formulation is closely associated with microenvironmental pH and the addition of a suitable organic acid based on the reaction mechanism is an effective strategy for improving the stability of EM.

Drug-excipient compatibility studies in binary mixtures of avobenzone

During preformulation studies of cosmetic/pharmaceutical products, thermal analysis techniques are very useful to detect physical or chemical incompatibilities between the active and the excipients of interest that might interfere with safety and/or efficacy of the final product. Differential scanning calorimetry (DSC) was used as a screening technique for assessing the compatibility of avobenzone with some currently used cosmetic excipients. In the first phase of the study, DSC was used as a tool to detect any interaction. Based on the DSC results alone, cetearyl alcohol, isopropyl myristate, propylparaben, diethylhexyl syringylidene malonate, caprylic capric triglyceride, butylated hydroxytoluene (BHT), glycerin, cetearyl alcohol/ceteareth 20, cetearyl alcohol/sodium lauryl sulfate/sodium cetearyl sulfate, and paraffinum liquidum exhibit interaction with avobenzone. Stressed binary mixtures (stored at 50°C for 15 days) of avobenzone and excipients were evaluated by high-performance liquid chromatography. Binary mixtures were further investigated by infrared (IR) spectroscopy. Based on DSC, isothermal stress testing, and fourier transform infrared results; avobenzone is incompatible with caprylic capric triglyceride, propylparaben, and BHT.

Compatibility of amiodarone hydrochloride with vasopressin during simulated Y-site administration

The objective of this study was to determine the compatibility of amiodarone hydrochloride with vasopressin during simulated Y-site administration. Amiodarone hydrochloride is compatible with vasopressin under simulated-use conditions when administered according to the Advanced Cardiac Life Support Guidelines. A simulated-use approach is a more appropriate way to evaluate compatibility of drug solutions and to assure safe and adequate drug delivery to the patient, particularly when the drug being evaluated is well-documented to have physical or chemical incompatibility concerns with various drugs. When amiodarone hydrochloride (50 mg/mL) was diluted to 6 mg/mL with 5% dextrose injection, then mixed with an equal volume of vasopressin (0.2 units/mL in normal saline) in a glass test tube, no visual incompatibility was observed for up to 24 hours. The purpose of our study was to assess compatibility of the two drugs under simulated-use conditions and to measure the recovery of amiodarone by high-performance liquid chromatography after sequential administration of vasopressin and amiodarone hydrochloride according to the Advanced Cardiac Life Support Guidelines.

Physicochemical compatibility of nebulizable drug admixtures containing colistimethate and tobramycin

Inhalation therapy with nebulizable antibiotic drugs is a mainstay in treating Pseudomonas aeruginosa infections in cystic fibrosis patients. The combination of tobramycin and colistin was found to be superior to monotherapy in killing P. aeruginosa in biofilms. The simultaneous inhalation of tobramycin and colistin might be an option to increase the compliance of patients. The objective of this in-vitro study was to determine whether admixtures of inhalation solutions containing colistin methanesulfonate (CMS) and tobramycin are physicochemically compatible. Physical compatibility was determined by measuring pH and osmolality. Chemical compatibility was determined by testing the antibiotic activity of the mixtures by the pharmacopoeial microbiological assay and comparing the results to those of standard solutions. Samples were analyzed immediately after mixing and after 24 h. Values of pH and osmolality remained unchanged and in physiologically acceptable ranges. Neither for colistin methanesulfonate (CMS) nor for tobramycin losses of antibiotic potency were registered at any time. Admixtures of nebulizer solutions containing CMS and tobramycin were shown to be physicochemically compatible. Further investigations are needed to determine whether drug delivery is affected by mixing the nebulizer solutions to ensure that simultaneous inhalation is recommendable.

[Research on the incompatibility of Radix adenophora, Radix glehniae combined with Veratrum nigrum L. by uniform designed toxicity assay]

OBJECTIVE

To study the toxicity changes of different proportions of Radix Adenophora, Radix Glehniae combined with Veratrum nigrum L., thus providing acute toxicity data and investigating whether decoction factors were correlated with toxicity.

METHODS

The uniform design method was used by two factors and seven levels to investigate the toxicity changes in different proportions of Radix Adenophora, Radix Glehniae combined with Veratrum nigrum L. The decoction factors were also investigated.

RESULTS

The compatibility toxicity was affected mainly by Veratrum nigrum L. and the toxicity increased along with increased doses of Veratrum nigrum L. The toxicity of co-decoction was higher than mixed decoction in the same dosage of Radix Glehniae and Veratrum nigrum L. The promotion of the dissolution of the toxic component of Veratrum nigrum L. in co-decoction may be the cause of the higher toxicity.

CONCLUSION

Radix Adenophora and Radix Glehniae combined with Veratrum nigrum L. resulted in higher toxicity, which indicated that the incompatibility between Radix Adenophora, Radix Glehniae, and Veratrum nigrum L. In clinic practice, a prescription contained these drugs should be avoided.

Physicochemical compatibility of nebulizable drug admixtures containing budesonide and colistimethate or hypertonic saline

Knowledge of the physicochemical compatibility of admixtures of nebulizable drugs is an important issue. In this article, the results of our recent study dealing with the compatibility of drug admixtures containing budesonide and colistin methanesulfonate (brand name Colistin CF) or budesonide and 5.85% sodium chloride solution are presented, as well as the up-to-date version of our compatibility table. Admixtures were prepared by mixing 2.0 mL Pulmicort either with 3.0 mL Colistin CF or 4.0 mL 5.85% sodium chloride solution. Test solutions were stored for 24 hours at room temperature under ambient light conditions. Physical compatibility was determined by measuring pH and osmolality. Concentrations of budesonide were measured by a high-performance liquid chromatography assay. The antibiotic activity of colistin methanesulfonate was determined in comparison to standard solutions using a microbiological assay. No loss in drug concentration of budesonide and no change in antibiotic activity of colistin methanesulfonate were detected over a test period of 24 hours. Osmolality remained unchanged in both types of admixtures. In admixtures of budesonide with colistin methanesulfonate, pH increased during the first 4 hours of storage, while in admixtures of budesonide and hypertonic saline pH remained unchanged. No visible changes could be detected. Due to these results admixtures of budesonide and colistin methanesulfonate or 5.85% sodium chloride solution are designated to be compatible, but it is recommended that mixing should take place immediately before administration. Further investigations are needed to determine whether or not drug delivery is affected by mixing the drugs and to ensure simultaneous nebulization is recommendable.