Diagnosis of Agglomeration and Crystallinity of Active Pharmaceutical Ingredients in Over the Counter Headache Medication by Electrospray Laser Desorption Ionization Mass Spectrometry Imaging

Agglomeration of active pharmaceutical ingredients (API) in tablets can lead to decreased bioavailability in some enabling formulations. In a previous study, we determined that crystalline APIs can be detected as agglomeration in tablets formulated with amorphous acetaminophen tablets. Multiple method advancements are presented to better resolve agglomeration caused by crystallinity in standard tablets. In this study, we also evaluate three “budget” over-the-counter headache medications (subsequently labeled as brands A, B, and C) for agglomeration of the three APIs in the formulation: Acetaminophen, aspirin, and caffeine. Electrospray laser desorption ionization mass spectrometry imaging (ELDI-MSI) was used to diagnose agglomeration in the tablets by creating molecular images and observing the spatial distributions of the APIs. Brand A had virtually no agglomeration or clustering of the active ingredients. Brand B had extensive clustering of aspirin and caffeine, but acetaminophen was observed in near equal abundance across the tablet. Brand C also had extensive clustering of aspirin and caffeine, and minor clustering of acetaminophen. These results show that agglomeration with active ingredients in over-the-counter tablets can be simultaneously detected using ELDI-MS imaging.

Efficacy of Nonprescription Moisturizers for Atopic Dermatitis: An Updated Review of Clinical Evidence

Twice-daily moisturization is recommended by international guidelines as the bedrock of the management of atopic dermatitis (AD). Moisturizers should be selected based on proven clinical effectiveness in improving the skin barrier and improving the symptoms of AD. We searched the PubMed database for clinical trials assessing daily moisturization for the treatment of AD published between 2006 and 2019. Studies had to assess the efficacy of commercially available moisturizers using objective measures of corneometry, transepidermal water loss, or incidence of flare as endpoints, and treatments had to be currently available to patients. Clinical studies showed that moisturization (typically twice daily) significantly improved the skin barrier in adults and children with AD. Longer-term flare studies showed that daily moisturization reduced the incidence of flares and extended the time between flares. Proactive moisturization of infants at high risk of developing AD may reduce its manifestation. Therapeutic moisturizers for AD are specifically formulated with ingredients that target symptoms of AD, such as itch, inflammation, or compromised skin barrier. The US FDA requires that any moisturizer available in the USA and claiming to treat AD must contain colloidal oatmeal. Healthcare providers can maximize compliance and outcomes by educating patients on the benefits of liberally applying a therapeutic moisturizer twice daily to support the skin barrier and help reduce the incidence of flares. Specific recommendations should be for clinically tested moisturizers evaluated using objective, validated skin assessments.

Triclosan in over the counter medicines of South China

Triclosan (TCS) is an endocrine disruptor which may affect endocrine function, antibiotic resistance, and thyroid hormone homeostasis. As a broad-spectrum antimicrobial agent used in medical and personal care products, TCS was frequently detected in human urine, indicating widespread human exposure to this chemical. Over-the-counter medicines (OTCs) may be a potential source of human exposure to TCS. In this study, 84 OTCs were collected from Guangzhou, South China, including medicines intended for both children and adults. We determined the concentration of TCS in OTCs and the estimated daily intakes (EDIs) of TCS by evaluating OTCs for different age groups of the Chinese population. Our results indicated over half of the evaluated medicines contained TCS and the highest concentration reached 7.825 ng/g, with a median value of 0.017 ng/g. TCS was frequently found in adult medicines (detected in 85% of samples), and the concentrations were significantly higher than those in children's medicines. TCS in OTCs may come from packaging materials, cultivated soils, or production process (Chinese patent medicines). The EDIs of TCS (estimated with 95th concentration in OTC medicines) were 0.305, 0.191, 0.287, 0.331, and 0.135 and 0.110 ng/kg-bw/day for infants, toddlers, children, teenagers, and adult females and males, respectively. Compared to other potential sources, human exposure to TCS from OTCs was limited in China-much less than TCS exposure through personal care products or indoor dust.

A 1% Colloidal Oatmeal Cream Alone is Effective in Reducing Symptoms of Mild to Moderate Atopic Dermatitis: Results from Two Clinical Studies

<p>BACKGROUND: The epidermal barrier in patients with atopic dermatitis (AD) is deficient in ceramides and cathelicidins. Such epidermal defects may be a trigger for AD, thereby encouraging research toward development of skin-barrier-targeted preventive strategies.</p> <p>METHODS: Two single-center, single-arm clinical trials were conducted (study 1, age greater than equal to 8 years and study 2, greater than equal to 10 years) in patients with mild to moderate AD to evaluate the effects of an over-the-counter 1% colloidal oatmeal cream administered for 14 days. Study 1 assessed the Eczema Area and Severity Index (EASI) and Investigator's Global Atopic Dermatitis Assessment (IGADA) on day 3, and itch severity using a Visual Analogue Scale (VAS) immediately after application as primary efficacy endpoints. In study 2, the primary efficacy endpoint was change from baseline in patients' assessment of itch. Both studies assessed safety through adverse event (AE) recording.</p> <p>RESULTS: Study 1: 29 patients were enrolled (mean age [range], 27.07 [8 -67]). Comparing to baseline, EASI, IGADA, and itch were improved after the application, and improvements were maintained until day 14. Improvements of greater than/equal to 20% over baseline were noted in 53.6% and 25.0% patients at day 3 for EASI and IGADA scores, respectively, and in 37.9% patients for itch score immediately after the product application. On day 14, these percentages were 82.8%, 62.1%, and 85.7%, respectively.</p> <p>STUDY 2: 30 patients were enrolled (mean age [range], 32.9 [10-80]). Itch severity and EASI score were significantly improved after product application and improvements were maintained until day 14. Transepidermal water loss values were significantly reduced and skin hydration was significantly increased at all assessment time points. No adverse events (AEs) were reported in study 2 and 2 AEs were reported by 1 patient in study 1.</p> <p>CONCLUSIONS: The colloidal oatmeal cream was well tolerated and clinically effective in patients with mild to moderate AD.</p> <p><em>J Drugs Dermatol. 2017;16(7):671-676.</em></p>.

Occurrence of phthalate esters in over-the-counter medicines from China and its implications for human exposure

Food, air, personal care products and indoor dust have been recognized as the main routes of exposure to phthalates in Chinese population, but other sources may have been overlooked, e.g., medicines. To fill the knowledge gap, phthalate esters were measured in 96 over-the-counter medicines made in China, including selected 71 Chinese patented medicines and 25 western medicines. It was found that none of the medicines was free of phthalates. The mean concentrations of individual phthalates ranged from 0.001μg/g (dicyclohexyl phthalate) to 5.85μg/g (diethyl phthalate). Among 9 targeted phthalates, di-n-butyl phthalate was the dominant congener, accounting for >65% of the total phthalates in all medicine samples, followed by di-(2-ethylhexyl) phthalate and diethyl phthalate. Phthalates in medicines appeared to derive from gastroresistant film coatings, plastic packing materials or phthalate contaminated rural herbal plants (especially for Chinese patented medicines). Daily human exposure to phthalates was estimated for local patients for one treatment cycle (e.g., one week) based on suggested consumption dosage and phthalate concentrations. Almost all exposure levels were below the guidelines suggested by the United States Environmental Protection Agency or European Food Safety Authority, indicating low health risk with phthalates from consumption of the medicines. In addition, concentration levels of phthalates in patients would increase upon administration but are expected to decrease to the same values as those in patients before they took medicines in several days. Because the number of medicine samples was limited and the concentrations of phthalates varied in a large range, further investigations are needed to acquire more data for better assessment of human health effects for Chinese population. Capsule: Distribution of phthalate esters in over-the-counter medicines and related exposure for Chinese population are examined.

Dissolution rates of over-the-counter painkillers: a comparison among formulations

BACKGROUND

We wanted to compare the dissolution profile of several over-the-counter analgesics to understand whether the different formulation techniques employed to enhance absorption were associated with variations in the dissolution rate, a parameter known to affect drug absorption.

METHODS

We considered 5 formulations currently marketed in Italy: aspirin tablets (Aspirina Dolore e Infiammazione®), ibuprofen tablets and liquid capsules (Moment®), ibuprofen lysine tablets (Nurofenimmedia®) and dexketoprofen trometamol tablets (Enantyum®). Dissolution tests were performed according to the current USP/NF monograph dissolution procedure. Drug dissolution was evaluated at 1, 3, 6, 15, and 30 minutes since the start of the test. Dissolution was evaluated at three different pH: 1.2, 4.5 and 6.8. Every test was repeated 12 times.

RESULTS

The aspirin formulation was by far the most rapid dissolving formulation, among those tested, with more than 80% of the tablet dissolved at 6 minutes for every pH considered. At pH 1.2 and 4.5, only the dexketoprofen formulation was able to reach the dissolution level of aspirin at 30 minutes, but had lower levels of dissolution at the previous time points. Instead, at pH 6.8, most of the formulations approached aspirin dissolution level, but only after 15 minutes. Ibuprofen capsules had the slowest kinetics, with a lag phase the first 6 minutes.

CONCLUSIONS

Different formulation strategies can lead to great differences in the dissolution rates even among drugs of the same class, suggesting that enhancements in the formulation of painkillers can lead to improvements in drug absorption, and thus in the onset of analgesia.

Simplified Bryostatin Analogues Protect Cells from Chikungunya Virus-Induced Cell Death

Chikungunya virus (CHIKV) is a mosquito-borne alphavirus showing a recent resurgence and rapid spread worldwide. While vaccines are under development, there are currently no therapies to treat this disease, except for over-the-counter (OTC) analgesics, which alleviate the devastating arthritic and arthralgic symptoms. To identify novel inhibitors of the virus, analogues of the natural product bryostatin 1, a clinical lead for the treatment of cancer, Alzheimer's disease, and HIV eradication, were investigated for in vitro antiviral activity and were found to be among the most potent inhibitors of CHIKV replication reported to date. Bryostatin-based therapeutic efforts and even recent anti-CHIKV strategies have centered on modulation of protein kinase C (PKC). Intriguingly, while the C ring of bryostatin primarily drives interactions with PKC, A- and B-ring functionality in these analogues has a significant effect on the observed cell-protective activity. Significantly, bryostatin 1 itself, a potent pan-PKC modulator, is inactive in these assays. These new findings indicate that the observed anti-CHIKV activity is not solely mediated by PKC modulation, suggesting possible as yet unidentified targets for CHIKV therapeutic intervention. The high potency and low toxicity of these bryologs make them promising new leads for the development of a CHIKV treatment.

Over the counter (OTC) artificial tear drops for dry eye syndrome

BACKGROUND

Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye-related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta-analytical look at all randomized and quasi-randomized clinical trials that have analyzed head-to-head comparisons of OTC artificial tears.

OBJECTIVES

To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the US Food and Drugs Administration (FDA) website (www.fda.gov). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches.

SELECTION CRITERIA

This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head-to-head comparisons of artificial tears with another type of dry-eye therapy.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full-text copies for eligibility, examined risk of bias, and extracted data. We performed meta-analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text.

MAIN RESULTS

We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta-analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid-based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol-based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between-group results or found no between-group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias.

AUTHORS' CONCLUSIONS

OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations.

Estimation of bioaccessibility and potential human health risk of mercury in Chinese patent medicines

Mercury (Hg), mainly in cinnabar species, has been used in medicine for thousands of years in China, and worldwide concern has been raised on its toxicity. In this work, the amount of bioaccessible mercury in 16 Chinese patent medicines (CPMs) was measured by using an in vitro simulated digestion system, consisting of simulated gastric and intestinal fluid, to investigate the bioavailability of mercury in CPMs and evaluate its potential risk to human health. Total mercury and mercury in the gastrointestinal extracts were measured by inductively coupled plasma mass spectrometry (ICP-MS). The levels of total Hg in 16 CPMs ranged from not detected to 11.89 mg/g, with a mean value of 1.13 mg/g, while the extractable Hg ranged from not detected to 4.37 μg/g, with a mean value of 0.42 μg/g. Mercury bioaccessibility varied significantly in the investigated CPMs, depending on the ingredient. Compared to the CPMs without cinnabar (2.5%-30.9%), the percentage of mercury in the gastrointestinal supernatants for CPMs with cinnabar was quite a bit lower (0.037%). By comparing with the Food and Agricultural Organization/World Health Organization Joint Expert Committee on Food Additives (FAO/WHO) safety guideline, the average daily intake dose (ADD) of Hg in the medicines was then calculated to access the risk of mercury to human health from taking CPMs.

Patients' Knowledge About Analgesic-Antipyretic Medications Purchased in Community Pharmacies: A Descriptive Study

The objective of this study was to describe the level of knowledge about paracetamol (acetaminophen), ibuprofen, and aspirin of subjects who purchased nonprescription medications containing one of these drugs. We conducted this cross-sectional descriptive study in 42 community pharmacies located in southwestern France between July and November 2013. A six-item self-administered questionnaire was used. Participants were asked to identify the active ingredient contained in 14 brand-name analgesic-antipyretics, to state the maximum daily dose of paracetamol, ibuprofen, and aspirin, the recommended first-line analgesic, and precautions of use or contraindications for paracetamol, ibuprofen, and aspirin. Among 576 participants, the identification of paracetamol ranged from 58% (for Dafalgan or Efferalgan) to 90% (for Doliprane), the identification of ibuprofen from 34% (for Nureflex) to 63% (for Nurofen), and the identification of aspirin was 70% (for Aspegic). The maximum recommended daily dose of paracetamol, ibuprofen, and aspirin was known by 58.3%, 17.7%, and 19.3% of participants, respectively, whereas 6.8%, 17.2%, and 13.2% stated supratherapeutic daily doses. Paracetamol was correctly stated as the first-line analgesic-antipyretic by 76.2% of participants. Knowledge on major precautions of use or contraindications was poor (45.8% and 53.6% for ibuprofen and aspirin use during pregnancy, and 14.1% for concurrent use of anticoagulants and ibuprofen). Purchasers of nonprescription analgesic-antipyretics had poor knowledge on the medication they purchased.

[Summary and analysis of safety warning on clinical application of anti-cold Chinese patent medicine preparations]

In China, many surveys have shown that most people do not have a correct understanding about cold and administration of anti-cold Chinese patent medicine preparations. The author conducted a systematic summary and analysis on the actual application of anti-cold Chinese patent medicine preparations as well as the warning on safe application of anti-cold Chinese patent medicine preparations in Clinical Medication Information of China Pharmacopoeia, in the expectation of reducing the blind application of anti-cold Chinese patent medicine preparations and providing traditional Chinese medicine pharmacists new ideas in monitoring the safe application of exterior syndrome-relieving Chinese patent medicine preparations.

Discriminatory components retracing strategy for monitoring the preparation procedure of Chinese patent medicines by fingerprint and chemometric analysis

Chinese patent medicines (CPM), generally prepared from several traditional Chinese medicines (TCMs) in accordance with specific process, are the typical delivery form of TCMs in Asia. To date, quality control of CPMs has typically focused on the evaluation of the final products using fingerprint technique and multi-components quantification, but rarely on monitoring the whole preparation process, which was considered to be more important to ensure the quality of CPMs. In this study, a novel and effective strategy labeling "retracing" way based on HPLC fingerprint and chemometric analysis was proposed with Shenkang injection (SKI) serving as an example to achieve the quality control of the whole preparation process. The chemical fingerprints were established initially and then analyzed by similarity, principal component analysis (PCA) and partial least squares-discriminant analysis (PLS-DA) to evaluate the quality and to explore discriminatory components. As a result, the holistic inconsistencies of ninety-three batches of SKIs were identified and five discriminatory components including emodic acid, gallic acid, caffeic acid, chrysophanol-O-glucoside, and p-coumaroyl-O-galloyl-glucose were labeled as the representative targets to explain the retracing strategy. Through analysis of the targets variation in the corresponding semi-products (ninety-three batches), intermediates (thirty-three batches), and the raw materials, successively, the origins of the discriminatory components were determined and some crucial influencing factors were proposed including the raw materials, the coextraction temperature, the sterilizing conditions, and so on. Meanwhile, a reference fingerprint was established and subsequently applied to the guidance of manufacturing. It was suggested that the production process should be standardized by taking the concentration of the discriminatory components as the diagnostic marker to ensure the stable and consistent quality for multi-batches of products. It is believed that the effective and practical strategy would play a critical role in the guidance of manufacturing and help improve the safety of the final products.

Characteristics of caffeine intoxication-related death in Tokyo, Japan, between 2008 and 2013

OBJECTIVES

Caffeine is widely available in beverages and over-the-counter products; however, in large doses, it can lead to lethal arrhythmia. This study aims to clarify the characteristics of caffeine intoxication-related deaths in Tokyo, Japan.

SUBJECTS

Among the 4754 forensic autopsy cases between 2008 and 2013 in which a toxicological investigation was performed, cases in which the blood concentration of caffeine exceeded toxic levels (15 μg/ml) were selected (N = 22). We examined subjects' ages, medical histories, direct/underlying causes of death, and manner of death. We also assessed concurrent drug substance detection and identified the origin of the caffeine.

RESULTS

More than 60% of the subjects were between the ages of 20 and 49 years (n = 14, 63.6%). Sixteen cases (72.7%) showed a history of psychiatric diseases such as depression and sleep disorders. The underlying cause of death for all cases except two was caffeine intoxication, and manner of death was classified as undetermined (n = 11), accidental (n = 7), suicide (n = 2), or others (n = 2). Toxicological analysis revealed the presence of ingredients common to analgesics/cold remedies in 12 cases (54.5%). The origin of the caffeine was identified in 11 cases (50.0%); the proportion of identification was significantly lower among the cases in which analgesic/cold remedy ingredients were not detected (20.0%).

CONCLUSIONS

Caffeine intoxication-related deaths mainly occurred in young and middle-aged persons with common psychiatric diseases. Psychiatrists should take note of caffeine dependence while diagnosing common psychiatric symptoms. In half of the cases, the origin of the caffeine was unidentified; nevertheless, dietary sources or over-the-counter drugs containing caffeine were suspected. As it becomes easier to obtain caffeinated products, continuous monitoring of the number of deaths from caffeine intoxication, in addition to detailed investigations of the caffeine's origin, will be necessary.

Relationships between perceptual attributes and rheology in over-the-counter vaginal products: a potential tool for microbicide development

Vaginal microbicides are believed to have substantial potential to empower women to protect themselves from HIV, although clinical trials to date have had mixed results at best. Issues with patient adherence in these trials suggest additional emphasis should be placed on optimizing acceptability. Acceptability is driven, in part, by the sensory properties of the microbicide, so better understanding of the relationships between sensory properties and the physical and rheological properties of microbicides should facilitate the simultaneous optimization of sensory properties in parallel with the biophysical properties required for drug deployment. Recently, we have applied standard methods to assess the potential acceptability of microbicide prototypes ex vivo and to quantify the sensory properties of microbicide surrogates. Here, we link quantitative perceptual data to the rheological properties of 6 over-the counter (OTC) vaginal products used as ex vivo microbicide surrogates. Shear-thinning behavior (n) and tan δ (10 rad/s) showed no relationship with any perceptual attributes while shear storage modulus, G’ (10 rad/s) was correlated with some attributes, but did not appear to be a strong predictor of sensory properties. Conversely, the storage loss modulus, G” (10 rad/s) and the consistency coefficient, K, were correlated with several sensory attributes: stickiness, rubberiness, and uniform thickness for G’’ and stickiness, rubberiness, and peaking for K. Although these relationships merit confirmation in later studies, this pilot study suggests rheological principles can be used to understand the sensory properties evoked by microbicide surrogates assessed ex vivo. Additional work is needed to determine if these findings would apply for microbicides in vivo.

Miconazole: a historical perspective

Miconazole is an imidazole that has been successfully used for over 30 years for the treatment of superficial and cutaneous disease. This agent is distinguished from other azoles by possessing two mechanisms of action. The first mechanism is shared with other azoles and involves the inhibition of ergosterol synthesis. Another mechanism involves inhibition of peroxidases, which results in the accumulation of peroxide within the cell resulting in cell death. Susceptibility patterns for miconazole demonstrate that yeast fungi remain largely susceptible even in light of repeated exposures. Despite the release of newer azoles and other classes of antifungals, miconazole remains a highly prescribed treatment for vaginal candidiasis.

Association between cardiovascular events and sodium-containing effervescent, dispersible, and soluble drugs: nested case-control study

OBJECTIVE

To determine whether patients taking formulations of drugs that contain sodium have a higher incidence of cardiovascular events compared with patients on non-sodium formulations of the same drugs.

DESIGN

Nested case-control study.

SETTING

UK Primary Care Patients registered on the Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

All patients aged 18 or over who were prescribed at least two prescriptions of sodium-containing formulations or matched standard formulations of the same drug between January 1987 and December 2010.

MAIN OUTCOME MEASURES

Composite primary outcome of incident non-fatal myocardial infarction, incident non-fatal stroke, or vascular death. We performed 1:1 incidence density sampling matched controls using the UK Clinical Practice Research Datalink (CPRD). For the secondary analyses, cases were patients with the individual components of the primary study composite endpoint of hypertension, incident heart failure, and all cause mortality.

RESULTS

1,292,337 patients were included in the study cohort. Mean follow-up time was 7.23 years. A total of 61,072 patients with an incident cardiovascular event were matched with controls. For the primary endpoint of incident non-fatal myocardial infarction, incident non-fatal stroke, or vascular death the adjusted odds ratio for exposure to sodium-containing drugs was 1.16 (95% confidence interval 1.12 to 1.21). The adjusted odds ratios for the secondary endpoints were 1.22 (1.16 to 1.29) for incident non-fatal stroke, 1.28 (1.23 to 1.33) for all cause mortality, 7.18 (6.74 to 7.65) for hypertension, 0.98 (0.93 to 1.04) for heart failure, 0.94 (0.88 to 1.00) for incident non-fatal myocardial infarction, and 0.70 (0.31 to 1.59) for vascular death. The median time from date of first prescription (that is, date of entry into cohort) to first event was 3.92 years.

CONCLUSIONS

Exposure to sodium-containing formulations of effervescent, dispersible, and soluble medicines was associated with significantly increased odds of adverse cardiovascular events compared with standard formulations of those same drugs. Sodium-containing formulations should be prescribed with caution only if the perceived benefits outweigh these risks.

Over the counter drugs (and dietary supplement) exercise: a team-based introduction to biochemistry for health professional students

For successful delivery of basic science topics for health-professional students, it is critical to reduce apprehension and illustrate relevance to clinical settings and everyday life. At the beginning of the Biochemistry course for Physician Assistants, a team-based assignment was designed to develop an understanding of the mechanism of action, effectiveness, and toxicity of five common over the counter (OTC) drugs and dietary supplements, and place these familiar medicines in a political and historical context. The objectives of this exercise were to stimulate interest in biochemistry; to provide basic information on enzymes and enzyme inhibitors related to these drugs to be expanded upon later in the course; and to encourage active and interactive learning. Teams of five students were formed, and each student was given an information sheet on aspirin, alpha-galactosidase, orlistat, dextromethorphan, or simvastatin, a low dose statin, which was previously available without prescription at pharmacies in the UK. After each member of the team acquired information on one OTC drug/dietary supplement by reading an assigned information sheet, the team was asked to go through a series of questions, and then submit answers to a quiz as a group. A high rate of success on the quiz, an overwhelmingly positive response on formal course evaluations, and enthusiastic exchanges during class suggested this team-based session accomplished its goals.

Natural ingredients for darker skin types: growing options for hyperpigmentation

Dyschromia is one of the most common dermatological concerns in patients with darker skin.1 Disorders of hyperpigmentation, including postinflammatory hyperpigmentation, melasma, solar lentigines, and miscellaneous causes of facial hyperpigmentation, are the most frequently treated dyschromias and can have a considerable psychosocial impact. Given the high prevalence of hyperpigmentation and the considerable demand for an even complexion, newer treatment options for hyperpigmentation are of growing interest among consumers, manufacturers, and dermatologists. Blinded, controlled studies demonstrating skin lightening effects in soy, niacinamide, n-acetylglucosamine, licorice extract, arbutin, vitamin c, kojic acid, emblica extract, lignin peroxidase, and glutathione have led to the development of a growing list of non-prescription skin care products that can be incorporated (mostly as adjuncts) in the management of hyperpigmentation.

Over-the-Counter Progesterone Cream Produces Significant Drug Exposure Compared to a Food and Drug Administration-Approved Oral Progesterone Product

Progesterone products are available in prescription form as well as over-the-counter (OTC) topical preparations sold for "cosmetic" uses. In a randomized study design, the authors compared the drug exposure from an OTC progesterone cream to a Food and Drug Administration-approved oral preparation at the labeled daily doses recommended for each product. Twelve healthy postmenopausal women received 200-mg oral progesterone capsules once daily for 12 days or progesterone cream 40 mg twice daily for 12 days. At steady state (day 12 of each phase), whole-blood samples were collected over 24 hours (oral progesterone) or 12 hours (topical progesterone) and assayed for total progesterone concentration. No significant differences were found in dose-normalized 24-hour progesterone exposure comparing the cream to oral capsules (median AUC(0-24) 12.5 ng x h/mL vs 10.5 ng x h/mL, respectively; P = .81). In light of the potential risks associated with long-term progesterone use, the authors question whether topical progesterone products should be available OTC.

Heavy metal contaminants in yerberia shop products

Complementary and alternative medications, including the use of herbal medications, have become quite popular in the USA. Yerberias are found throughout the southwest and specialize in selling Hispanic herbal products. The products sold in these stores are not regulated by any governmental agency. Previous reports have found Ayurvedic medications contain high levels of lead, mercury, and arsenic. The primary purpose of this study is to examine the prevalence of heavy metal contaminants sold at Yerberia stores in the southwest. Yerberias in the Phoenix, Arizona area were identified via search of an on-line search engine using the words "Yerberia Phoenix." Every second store was selected, and products were purchased using a standard script. The products were subsequently analyzed for mercury, lead, and arsenic. The main outcome is the prevalence of heavy metal content in over-the-counter "cold" medications purchased at a Yerberia. Twenty-two samples were purchased. One product contained pure camphor (2-camphone) and was subsequently not further analyzed. Of the 21 samples analyzed, lead was found in 4/21 (19.4 %). Arsenic and mercury were in 1/21 (4.8 %) each. Because two samples contained two heavy metals, the total prevalence of heavy metals was 4/21 (19.4). Heavy metal contaminants are commonly encountered in over-the-counter herbal "cold" medications purchased at Yerberias in the southwest.

Prodrugs of nonsteroidal anti-inflammatory drugs (NSAIDs), more than meets the eye: a critical review

The design and the synthesis of prodrugs for nonsteroidal anti-inflammatory drugs (NSAIDs) have been given much attention by medicinal chemists, especially in the last decade. As a therapeutic group, NSAIDs are among the most widely used prescribed and over the counter (OTC) medications. The rich literature about potential NSAID prodrugs clearly shows a shift from alkyl, aryalkyl or aryl esters with the sole role of masking the carboxylic acid group, to more elaborate conjugates that contain carefully chosen groups to serve specific purposes, such as enhancement of water solubility and dissolution, nitric oxide release, hydrogen sulfide release, antioxidant activity, anticholinergic and acetylcholinesterase inhibitory (AChEI) activity and site-specific targeting and delivery. This review will focus on NSAID prodrugs that have been designed or were, later, found to possess intrinsic pharmacological activity as an intact chemical entity. Such intrinsic activity might augment the anti-inflammatory activity of the NSAID, reduce its side effects or transform the potential therapeutic use from classical anti-inflammatory action to something else. Reports discussed in this review will be those of NO-NSAIDs, anticholinergic and AChEI-NSAIDs, Phospho-NSAIDs and some miscellaneous agents. In most cases, this review will cover literature dealing with these NSAID prodrugs from the year 2006 and later. Older literature will be used when necessary, e.g., to explain the chemical and biological mechanisms of action.

Analysis of liquid medication dose errors made by patients and caregivers using alternative measuring devices

BACKGROUND

Patients use several types of devices to measure liquid medication. Using a criterion ranging from a 10% to 40% variation from a target 5 mL for a teaspoon dose, previous studies have found that a considerable proportion of patients or caregivers make errors when dosing liquid medication with measuring devices.

OBJECTIVE

To determine the rate and magnitude of liquid medication dose errors that occur with patient/caregiver use of various measuring devices in a community pharmacy.

METHODS

Liquid medication measurements by patients or caregivers were observed in a convenience sample of community pharmacy patrons in Korea during a 2-week period in March 2011. Participants included all patients or caregivers (N = 300) who came to the pharmacy to buy over-the-counter liquid medication or to have a liquid medication prescription filled during the study period. The participants were instructed by an investigator who was also a pharmacist to select their preferred measuring devices from 6 alternatives (etched-calibration dosing cup, printed-calibration dosing cup, dosing spoon, syringe, dispensing bottle, or spoon with a bottle adapter) and measure a 5 mL dose of Coben (chlorpheniramine maleate/phenylephrine HCl, Daewoo Pharm. Co., Ltd) syrup using the device of their choice. The investigator used an ISOLAB graduated cylinder (Germany, blue grad, 10 mL) to measure the amount of syrup dispensed by the study participants. Participant characteristics were recorded including gender, age, education level, and relationship to the person for whom the medication was intended.

RESULTS

Of the 300 participants, 257 (85.7%) were female; 286 (95.3%) had at least a high school education; and 282 (94.0%) were caregivers (parent or grandparent) for the patient. The mean (SD) measured dose was 4.949 (0.378) mL for the 300 participants. In analysis of variance of the 6 measuring devices, the greatest difference from the 5 mL target was a mean 5.552 mL for 17 subjects who used the regular (etched) dosing cup and 4.660 mL for the dosing spoon (n = 10; P < 0.001). Doses were within 10% of the 5 mL target volume for 88.7% (n = 266) of the participant samples. Only 34 cases (11.3%) had dose errors greater than 10%, and only 6 cases (2.0%) had a variance of more than 20% from the 5 mL target volume. Dose errors greater than 10% of the target volume were more common for the etched dosing cup (47.1%, n = 8), the dosing spoon (50.0%, n = 5), and the printed dosing cup (30.8%, n = 4), but these 3 devices were used by only 13.3% of the study participants.

CONCLUSIONS

Approximately 1 in 10 participants measured doses of liquid medication with a volume error greater than 10%, and these dose errors were more common with the etched dosing cup, the dosing spoon, and the printed dosing cup. Pharmacists have an opportunity to counsel patients or caregivers regarding the appropriate use of measuring devices for liquid medication.

Simultaneous determination of synephrine, arecoline, and norisoboldine in Chinese patent medicine Si-Mo-Tang oral liquid preparation by strong cation exchange high performance liquid chromatography

CONTEXT

Chinese patent medicine Si-Mo-Tang oral liquid preparation (SMT) is composed of Aucklandia luppa Decne (Compositae), Citrus aurantium Linn (Rutaceae), Lindera aggregata (Sims) Kosterm (Lauraceae), and Areca catechu Linn (Arecaceae). Studies of SMT have been impeded due to the lack of quality control methods.

OBJECTIVE

This study aimed to simultaneously determine three alkaloids including synephrine, arecoline, and norisoboldine in SMT for the first time.

MATERIALS AND METHODS

A strong cation exchange (SCX) high performance liquid chromatography (HPLC) method was developed to simultaneously determine synephrine, arecoline, and norisoboldine in SMT, and was compared with ion-pairing chromatography using regular reversed-phase chromatography columns. System suitability parameters of synephrine, arecoline, and norisoboldine using the SCX chromatography column were investigated.

RESULTS

Results demonstrated that good separations were achieved on an Agilent SCX (250 × 4.6 mm, 5 µm) column at 35 °C. The mobile phase consisting of methanol-0.2% phosphoric acid was delivered at a constant flow of 1.0 mL min(-1) and the eluent was monitored at 215 nm. The HPLC method showed good linearity for the examined concentration ranges of 2.55-255.0, 1.30-208.0, and 2.06-201.6 µg mL(-1) for synephrine, arecoline, and norisoboldine, respectively. The limits of quantification (S/N = 10) were 2.55, 1.30, and 2.06 µg mL(-1), the limits of detection (S/N = 3) were 1.53, 0.78, and 1.21 µg mL(-1), and average recoveries were 98.99, 95.63 and 99.04%, respectively, for synephrine, arecoline, and norisoboldine.

DISCUSSION AND CONCLUSION

This method has been successfully applied to determine synephrine, arecoline, and norisoboldine in Chinese patent medicine SMT.

Over-the-counter topical skincare products: a review of the literature

Topical "anti-aging" products, with their seemingly limitless list of ingredients, make extensive claims to reduce wrinkles, fine lines, and sun damage, among others. Sales in the United States alone for cosmeceutical products are expected to increase by 7.4% per year to $8.2 billion by 2012. However, in this enormous industry, there has been a significant lack of rigorous controlled trials of efficacy. It is difficult for both dermatologists and consumers to make informed decisions in a market that is yet to be clearly defined and regulated. We elucidate the scientific basis for, as well as the literature behind, common active ingredients found in products intended to reverse photoaging, discuss some interesting new activities, and provide a review of several comprehensive studies on over-the-counter (OTC) products.

Atmospheric identification of active ingredients in over-the-counter pharmaceuticals and drugs of abuse by atmospheric pressure glow discharge mass spectrometry (APGD-MS)

Atmospheric pressure glow discharge mass spectrometry was used to characterize the active ingredients in pharmaceutical over-the-counter (OTC) drug formulations (Tylenol Allergy, Alka-Seltzer Plus Nighttime, Sudafed, Aleve and Mucinex DM) and drugs of abuse (crack cocaine, methamphetamine, MDMA (ecstasy) and hydrocodone). Material was desorbed and directly ionized under atmospheric conditions by allowing the substance to come in direct contact with the plasma followed by mass spectrometric detection. With this technique, controlled substances and OTC medications were readily distinguished from one another. Characteristic mass spectra were identified for the active ingredients in the OTC and drugs of abuse. Importantly, all drug compounds studied here, both OTC and illicit, demonstrated signals for either molecular ions or protonated molecules as well as fragmentation patterns that are readily identified in the National Institute of Standards and Technology (NIST) electron ionization (EI) mass spectral library. It is believed that this technique holds promise for forensic and law enforcement communities for real-time atmospheric analysis of drugs with database-searchable spectra of controlled substances.

Echinacea and trypanasomatid parasite interactions: growth-inhibitory and anti-inflammatory effects of Echinacea

CONTEXT/OBJECTIVE

Herbal preparations derived from various species and parts of Echinacea (Asteraceae) have been advocated for various medical applications, as a result of the many antimicrobial and immunomodulatory activities attributed to them.

MATERIALS AND METHODS

In order to investigate their effects on parasites, four preparations of Echinacea, with distinct chemical compositions, were evaluated for growth inhibition of three species of trypanosomatids: Leishmania donovani, Leishmania major, and Trypanosoma brucei. In addition one Echinacea preparation was tested for anti-inflammatory activity in cell culture models designed to measure pro-inflammatory cytokines induced by L. donovani.

RESULTS AND DISCUSSION

All Echinacea preparations inhibited growth of the organisms, though with different relative potencies, and in some cases morphological changes were observed. However, there was no obvious correlation with the composition of the marker compounds, alkylamides, caffeic acid derivatives, and polysaccharides. L. donovani stimulated the production of the pro-inflammatory cytokines IL-6 and IL-8 in human bronchial epithelial cells and in human skin fibroblasts, but in both cases the standardized ethanol extract of E. purpurea (L.) Moench (Echinaforce) abolished the stimulation, indicating anti-inflammatory activity of this extract.

CONCLUSIONS

Thus various Echinacea extracts can inhibit the proliferation of these parasites and at least one can reverse the pro-inflammatory activity of Leishmania donovani.

Cross-sectional study of availability and pharmaceutical quality of antibiotics requested with or without prescription (Over The Counter) in Surabaya, Indonesia

BACKGROUND

Antimicrobial resistance is an increasing problem in developing countries and antibiotic use is widespread. Our previous surveys in Java, Indonesia, revealed that most antibiotic use was probably unnecessary or ineffective. The aim of this study was to explore a potential connection between resistance and substandard antibiotics sold in the area.

METHODS

A cross-sectional field study using the simulated client method was conducted in Surabaya. Five first-line antibiotics were requested with or without prescription (OTC). A certified laboratory analysed the drug content using validated methods. Possible determinants of substandard quality were explored.

RESULTS

In total, 104 samples from 75 pharmacies, ten drug stores and 39 roadside stalls (kiosks) were obtained. Pharmacy employees filled all OTC requests. Three quarters of kiosks sold antibiotics. Antibiotics were dispensed as single blister strips or repackaged (16%) without label. Ninety five percent of samples carried the label of 14 Indonesian manufacturers. The pharmaceutical quality did not meet BP standards for 18% of samples. Deviations (less active ingredient) were small. There was no association between low content and type of outlet, sold with or without prescription, registration type, price or packaging. Median retail prices of products carrying the same label varied up to 20 fold.

CONCLUSIONS

Antibiotics were available OTC in all visited pharmacies and sold in the streets of an Indonesian city. Most samples contained an active ingredient. We urge to increase enforcement of existing regulations, including legislation that categorizes antibiotics as prescription-only drugs for all types of medicine outlets, to limit further selection of antimicrobial resistance.

The main components of St John's Wort inhibit low-density lipoprotein atherogenic modification: A beneficial “side effect” of an OTC antidepressant drug?

Hypericin and pseudohypericin are polycyclic-phenolic structurally related compounds found in Hypericum perforatum L. (St John's wort). As hypericin has been found to bind to LDL one may assume that it can act as antioxidant of LDL lipid oxidation, a property which is of prophylactic/therapeutic interest regarding atherogenesis as LDL oxidation may play a pivotal role in the onset of atherosclerosis. Therefore, in the present paper hypericin, pseudohypericin and hyperforin, an other structurally unrelated constituent in St John's wort were tested in their ability to inhibit LDL oxidation. LDL was isolated by ultracentrifugation and oxidation was initiated either by transition metal ions (copper), tyrosyl radical (myeloperoxidase/hydrogen peroxide/tyrosine) or by endothelial cells (HUVEC). LDL modification was monitored by conjugated diene and malondialdehyde formation. The data show that all compounds (hypericin, pseudohypericin and hyperforin) at doses as low as 2.5 micromol/l are potent antioxidants in the LDL oxidation systems used. The results indicate that the derivatives found in Hypericum perforatum have possible antiatherogenic potential.

[Simultaneous determination of four highly polar anti-diabetic drugs in Chinese traditional patent medicines using high performance liquid chromatography]

A high performance liquid chromatographic (HPLC) method was established for the simultaneous determination of four highly polar anti-diabetic drugs, metformin hydrochloride, phenformin hydrochloride, acarbose, and voglibose, in Chinese traditional patent medicines. The separation was performed on a Thermo NH2 analytical column (4.6 mm x 250 mm, 5 microm), the mobile phase consisted of 30% A and 70% B, where A included 0.06% potassium dihydrogen phosphate and 0.028% disodium hydrogen phosphate, B was acetonitrile. The flow rate was 1 mL/min, the detection wavelength was set at 195 nm, and the column temperature was 30 degrees C. The limits bf detection were 0.1-3 mg/L. The linear regression equation for each component was obtained, and the correlation coefficients (r2) were better than 0.9981. The intra-day and inter-day relative standard deviations (RDSs) were 0.10%-5.07% and 0.19%-6.41%, respectively. The average recoveries of four anti-diabetic drugs spiked in blank Chinese traditional patent medicine matrixes were more than 80% except that for the low concentration of voglibose was 64.05%. The RSDs of the recoveries were 1.14%-4.82%. The method can be used in the analysis of the four highly polar anti-diabetic drugs in Chinese traditional patent medicines, and it is rapid, convenient, economic and specific.

Considerations for the development of over-the-counter dentifrices for the treatment and relief of dentin sensitivity

There have been many recent articles and reviews covering the effectiveness of dentifrices for the treatment and relief of dentin sensitivity. To date, there are no articles which fully examine all the compromises that a dentifrice formulator and manufacturer have to make when developing an effective dentifrice technology in the context of theoretical approaches and proposed modes of action. This article provides a first review and discussion of the currently available technologies, nerve depolarization and occluding agents. The generalized formulation strategies and approaches of dentifrices containing these agents are discussed, demonstrating that simplified conclusions with regard to efficacy should be drawn with caution.

Stability evaluation of selected polyphenols and triterpene glycosides in black cohosh

Black cohosh ( Actaea racemosa L., syn. Cimicifuga racemosa L.) is rich in both triterpene glycosides and polyphenols, which have various biological activities that may be important to its medical use. To evaluate the stability of the polyphenolic constituents and triterpene glycosides of black cohosh, experiments were conducted using three sample types: plant material, extracts of black cohosh, and encapsulated commercial extract. The samples were stored at various temperatures and humidity conditions. Three triterpene glycosides and six major polyphenols in black cohosh were quantitatively measured with an HPLC-PDA method at 0, 3, 6, and 9 weeks. The triterpene glycosides were stable at the tested conditions, whereas the polyphenols were stable only at room temperature and low humidity and not stable at higher temperature and/or humidity due to hydrolysis and/or oxidation. The rate of compound decomposition depended upon the chemical structure of the individual polyphenols. Polyphenols in the extracts decomposed more readily than those in plant material.

Look What I Found! Poison Hunting on eBay®

BACKGROUND

Many substances deemed too dangerous for commercial use are still available to the general public. The purchase of these substances may potentially place members of the general public at risk for serious poisonings. This study was designed to document the large variety of dangerous poisons readily available on a popular online auction Web site. Methods. Over a 10-month period, the online auction Web site eBays was searched daily using the terms "poison" and "contents." Product name, active ingredients, what form the product is in, amount in container, and relative toxicity rating (Clinical Toxicology of Commercial Products, Gosselin, et al.) were recorded. If available, pictures of the products were saved.

RESULTS

One hundred twenty-one individual products were identified. Fifty-five were in solid/tablet form, 37 were powders, and 29 were liquids. Product containers were full for 56 items and partially full for 65. Twenty-four products contained ingredients rated as "supertoxic" and included strychnine (10), arsenic trioxide (8), cyanide (2) and nicotine, pilocarpine, phosphorus, powdered conium maculatum (1 each). Sixty-three products contained "extremely toxic" ingredients including thallium, picrotoxin, soluble barium, antimony, mercury, arsenates, podophyllin, fluoride, zinc phosphide, atropine, scopolamine, and plant extracts of gelsemium, aconite, larkspur, and croton. Twenty-one products contained "very toxic" ingredients including lead, copper, camphor, caffeine, theobromine, creosote, pyrogallic acid, sparteine, quinine, lindane, warfarin, phenol, and digitalis. The remaining 13 were "moderately-slightly toxic."

CONCLUSION

While the viability of the labeled ingredients could not be verified, the transportation, handling, and potential utilization of these dangerous poisons by the general public could result in serious poisonings.

The spectroscopic detection of exogenous material in fingerprints after development with powders and recovery with adhesive lifters

The application of powders to fingerprints has long been established as an effective and reliable method for developing latent fingerprints. The powders adhere to the ridge pattern of the fingerprint only, thus allowing the image to be visualised. Fingerprints developed in situ at a crime scene routinely undergo lifting with specialist tapes to facilitate subsequent laboratory analysis. As with all recovered evidence these samples would be stored in evidence bags to allow secure transit from the scene to the laboratory and also to preserve the chain of evidence. In this paper, the application of Raman spectroscopy for the analysis of exogenous material in latent fingerprints is reported for contaminated fingerprints that had been treated with powders and also subsequently lifted with adhesive tapes. A selection of over the counter (OTC) analgesics were used as samples for the analysis and contaminated fingerprints were deposited on clean glass slides. The application of aluminium or iron based powders to contaminated fingerprints did not interfere with the Raman spectra obtained for the contaminants. In most cases background fluorescence attributed to the sebaceous content of the latent fingerprint was reduced by the application of the powder thus reducing spectral interference. Contaminated fingerprints developed with powders and then lifted with lifting tapes were also examined. The combination of these two techniques did not interfere with the successful analysis of exogenous contaminants by Raman spectroscopy. The lifting process was repeated using hinge lifters. As the hinge lifters exhibited strong Raman bands the spectroscopic analysis was more complex and an increase in the number of exposures to the detector allowed for improved clarification. Raman spectra of developed and lifted fingerprints recorded through evidence bags were obtained and it was found that the detection process was not compromised in any way. Although the application of powders did not interfere with the detection process the time taken to locate the contaminant was increased due to the physical presence of more material within the fingerprint. The presence of interfering Raman bands from lifting tapes is another potential complication. This, however, could be removed by spectral subtraction or by the choice of lifting tapes that have only weak Raman bands.

[The assessment and characteristic of dietary supplements with lutein and zeaxanthin on the Polish pharmaceutical market]

Lutein and zeaxanthin, two xanthophylls supposed to delay formation eye's disease (AMD, cataract), and found in numerous new dietary supplements appearing on market also in Poland. In the observed period on polish pharmaceutical market was evaluated presence about 50 supplements with lutein and 12 contained zeaxanthin as well. The lutein concentration ranges from 0.25 to 20.0 mg/serving size and zeaxanthin from 0.02 to 0.50 mg. Most of them were multicomponent (multi-vitamin products) in form of capsules or tabs for adults, advised for the eyes' protections or supply of nutritional components with various contents of lutein and zeaxanthin and various costs of daily treatment.

Persistence of NSAIDs at effect sites and rapid disappearance from side-effect compartments contributes to tolerability

BACKGROUND

Non-steroidal, anti-inflammatory drugs (NSAIDs) are still the most widely used drugs worldwide. The introduction of selective cyclooxygenase (COX)-2 inhibitors has led to compounds which appear less damaging to the gastrointestinal tract, but possibly more risky to the cardiovascular system than older drugs. None has as yet reached OTC-status.

OBJECTIVE

This situation necessitates an analysis of the characteristics of those older ones which - due to their relative safety - have achieved over-the-counter (OTC) status.

DESIGN

The pharmacodynamic and pharmacokinetic characteristics of non-selective COX inhibitors in OTC use were obtained from the literature by systematic search, examined and used to construct a coherent hypothesis why they achieved OTC status, i.e. effectiveness and relative safety at low doses.

RESULTS

Pharmacodynamic (COX-2 preferential, but not selective inhibition) and, more importantly, pharmacokinetic characteristics of some of the older compounds may make them particularly safe drugs if used at low (OTC) doses with treatment limited to a few days of intake. The reason why some NSAIDs are particularly active while being relatively free from side-effects may be due to their specific biodistribution and metabolism, leading to drug accumulation and persistence in inflamed tissue (effect compartment) together with fast clearance from the central compartment, including blood, vascular wall, heart and kidney, i.e., possible sideeffect compartments.

CONCLUSION

This specific pharmacokinetic behavior of some non-selective COX inhibitors, such as diclofenac and ibuprofen, may explain why these widely used, non-steroidal, anti-inflammatory compounds are relatively well suited for OTC use and why some are more appropriate for the therapy of certain pain conditions than others.

Analogues of erectile dysfunction drugs: an under-recognised threat

OBJECTIVES

To investigate the problem of drug analogue adulteration in male erectile dysfunction health products.

DESIGN

Survey of over-the-counter male erectile dysfunction health products available in convenience stores and pharmacies in Hong Kong.

SETTING

Tertiary referral centre for clinical toxicology analysis in Hong Kong.

MAIN OUTCOME MEASURES

The pattern and extent of adulteration of male erectile dysfunction health products with sildenafil, tadalafil, and vardenafil as well as their structurally modified analogues.

RESULTS

Of 26 products studied, one (4%) was found to contain undeclared sildenafil, while 14 (54%) contained drug analogues of different kinds. The latter included acetildenafil, hydroxyacetildenafil, hydroxyhomosildenafil, and piperidenafil. The first three were analogues of sildenafil and the last was an analogue of vardenafil. One young patient presented with ataxia after taking an acetildenafil-containing product.

CONCLUSIONS

The positive rate of concealed drug analogues in male erectile dysfunction health products is alarmingly high. Such analogues are difficult to detect by ordinary laboratory methods, and might be used in an attempt to evade regulatory inspection. Without going through the stringent drug testing process, the adverse effects of these chemicals remain largely unknown and unpredictable. Effective surveillance system and control measures are needed urgently. The medical profession and the public should be alerted to this under-recognised threat.

Orlistat for the management of overweight individuals and obesity: a review of potential for the 60-mg, over-the-counter dosage

Orlistat, in the 60-mg over-the-counter dose, was recently approved by the FDA. This lipase inhibitor blocks absorption of ~25% of ingested fat and has ~85% of the efficacy of the 120-mg dose for weight loss. Over 16 weeks weight loss with diet and orlistat 60 mg averages ~5% of initial body weight. The 60-mg dose is better tolerated than the 120-mg dose and the gastrointestinal side effects are minimal when individuals consume < 30% of their energy from fat. In addition to facilitating modest weight loss, orlistat use decreases serum LDL-cholesterol values by ~10%. When taken three times daily before meals, orlistat 60 mg modifies lifestyle behavior, encourages lower fat-consumption and sets the stage for other healthy lifestyle changes.

A woman with Cushing's syndrome after use of an Indonesian herb: a case report

A 69-year-old woman developed Cushing's syndrome after long-term use of Sinatren, an Indonesian over the-counter drug, which was pharmacologically analysed three times before the correct content was discovered. After discontinuation she developed adrenal insufficiency, for which she needed substitution of steroids. Physicians should be aware of the presence of corticosteroids in over-the-counter products, that are not mentioned on the instruction leaflet.

[Side effects after the usage of Chinese dieting product Meizitanc]

Side effects of self-treatment of eight obese women aged between 28 and 45 (average 36.5) with the body mass index (BMI) between 28 and 32 (average 30) kg/m2 have been described. All these women, without any medical consultation and upon their own will had been using Meizitanc as the only remedy for slimming. They started with a dosage of 1 capsule per day, gradually increasing the Meizitanc dose to 3 capsules a day. The patients had used the drug from 2.5 to 6 (average 3.2) months. There were many side effects observed in all women like palpitation, headache and vertigo, warm feeling, nervousness, and tremor of the hands which was observed in four patients. All these effects appeared during the last few weeks and thus forced them to get the consultation in the Poison Information Centre in the Medical University of Gdańsk. All capsules were examined with the use of gas chromatography and mass spectrophotometer GC/MS. It was found that each capsule contained 10 mg of sibutramine. There was no information about the presence of sibutramine in the composition of Meizitanc on the package and leaflet. After discontinuation of Meizitanc all side effects disappeared.

CONCLUSIONS

Special caution is advised during the Meizitanc treatment. In case of any side effects like palpitation, headache and vertigo, nervousness or tremor which take place during the Meizitanc treatment the medical consultation is needed.

Quantitative LC–MS determination of strychnine in urine after ingestion of a Strychnos nux-vomica preparation and its consequences in doping control

A simple, fast and sensitive method for the quantitative determination of strychnine residues in urine has been developed and validated. The method consists of a liquid-liquid extraction step with ethyl acetate at pH 9.2, followed by LC-MS/MS in positive atmospheric pressure chemical ionization (APCI)-mode. The method is linear in the range of 1-100 ng/mL and allows for the determination of strychnine at sub-toxicological concentrations. The accuracy of the method ranged from 1.3% to 4.4%. The method was used to determine the excretion profile of strychnine after the ingestion of an over-the-counter herbal preparation of Strychnos nux-vomica. Each volunteer ingested a dose equivalent to 380 micro g of strychnine. This dose is lower than the prescription dose but results in the detection of strychnine for over 24-h post administration. Maximum detected urinary concentrations ranged from 22.6 to 176 ng/mL. The results of this study show that the use of this type of preparation by athletes can lead to a positive doping case.

Managing ichthyosis: a case study

Ichthyoses-- rare, genetic, incurable dermatologic diseases characterized by dry, thickened, scaling skin-- affect more than 1 million Americans and can cause devastating disfigurement with numerous physical, social, and emotional consequences. Topical treatments typically focus on symptom management. A 44-year-old man presented with severe X-linked type ichthyosis. When his condition did not improve with the use of a variety of topical and systemic treatments, a once-a-day, over-the-counter skin care regimen consisting of a surfactant-free cleanser followed by the application of moisturizer containing amino acids, vitamins, antioxidants, and methylsulfonylmethane was prescribed. After 4 weeks of using this management regimen on a test area on his left arm, the skin was clear and discomfort and itching had subsided. Subsequent application of the skin care products on other affected areas also did not cause any adverse reactions and his skin continued to improve. Symptom resolution and patient satisfaction indicate the product line may be a viable consideration for use in patients with similarly compromised skin.

Research of stimulants and anabolic steroids in dietary supplements

The purpose of this study was to analyze the composition of 103 dietary supplements bought on the internet. The supplements were dispatched in four different categories according to their announced contents [creatine, prohormones, "mental enhancers" and branched chain amino acids (BCAA)]. All the supplements were screened for the presence of stimulants and main anabolic steroids parent compounds. At the same time, the research was focused on the precursors and metabolites of testosterone and nandrolone. The study pointed out three products containing an anabolic steroid, metandienone, in a very high amount. The ingestion of such products induced a high quantity of metandienone metabolites in urines that would be considered as a positive antidoping test. The results have also shown that one creatine product and three "mental enhancers" contained traces of hormones or prohormones not claimed on the labels and 14 prohormone products contained substances other than those indicated by the manufacturer. The oral intake of the creatine product revealed the presence of the two main nandrolone metabolites (19-norandrosterone and 19-noretiocholanolone) in urine.

Investigation of vitamin and mineral tablets and capsules on the Canadian market

PURPOSE

The goal of this study was to investigate the disintegrating properties of tablets and capsules containing minerals and vitamins commercially available on the Canadian market and to review their label information.

METHODS

The labels were examined for product-related information. The first disintegration test stage was performed using Simulated Intestinal Fluid (SIF) pH 6.8 for 20 minutes. Products which did not disintegrate were further investigated using USP disintegration conditions for dietary supplements.

RESULTS

The provided label information is difficult to understand and in some cases pseudo-scientific. Thirty out of thirty-nine tablets and six out of ten capsules had a Drug Identification Number (DIN). Twenty-one of thirty-nine tablets and four out of the ten capsules did not disintegrate within 20 minutes. Using the USP disintegration conditions for dietary supplements nine tablet products did not fully disintegrate but all capsules passed the test. None of the three "time-released" products disintegrated under the applied conditions.

CONCLUSIONS

Industry should follow already existing label recommendations more closely to allow the consumers to make an informed decision on their products by providing only essential information rather than using pseudo-scientific terms. The results of the disintegration study indicated that disintegration, one of the most basic quality control parameters, is still a concern for dietary supplements.