Identification and quantification of glucose degradation products in heat-sterilized glucose solutions for parenteral use by thin-layer chromatography

During heat sterilization of glucose solutions, a variety of glucose degradation products (GDPs) may be formed. GDPs can cause cytotoxic effects after parenteral administration of these solutions. The aim of the current study therefore was to develop a simple and quick high-performance thin-layer chromatography (HPTLC) method by which the major GDPs can be identified and (summarily) quantified in glucose solutions for parenteral administration. All GDPs were derivatized with o-phenylenediamine (OPD). The resulting GDP derivatives (quinoxalines) were applied to an HPTLC plate. After 20 minutes of chamber saturation with the solvent, the HPTLC plate was developed in a mixture of 1,4-dioxane-toluene-glacial acetic acid (49:49:2, v/v/v), treated with thymol-sulfuric acid spray reagent, and heated at 130°C for 10 minutes. Finally, the GDPs were quantified by using a TLC scanner. For validation, the identities of the quinoxaline derivatives were confirmed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Glyoxal (GO)/methylglyoxal (MGO) and 3-deoxyglucosone (3-DG)/3-deoxygalactosone (3-DGal) could be identified and quantified in pairs, glucosone (2-KDG), 5-hydroxymethylfurfural (5-HMF), and 3,4-dideoxyglucosone-3-ene (3,4-DGE) each individually. For 2-KDG, the linearity of the method was demonstrated in the range of 1–50 μg/mL, for 5-HMF and 3,4-DGE 1–75 μg/mL, for GO/MGO 2–150 μg/mL, and for 3-DG/3-DGal 10–150 μg/mL. All GDPs achieved a limit of detection (LOD) of 2 μg/mL or less and a limit of quantification (LOQ) of 10 μg/mL or less. R² was 0.982 for 3.4-DGE, 0.997 for 5-HMF, and 0.999 for 2-KDG, 3-DG/3-DGal, and GO/MGO. The intraday precision was between 0.4 and 14.2% and the accuracy, reported as % recovery, between 86.4 and 112.7%. The proposed HPTLC method appears to be an inexpensive, fast, and sufficiently sensitive approach for routine quantitative analysis of GDPs in heat-sterilized glucose solutions.

A standardized glucose-insulin-potassium infusion protocol in surgical patients: Use of real clinical data from a clinical data warehouse

AIMS

We evaluated the clinical usefulness of a new unified glucose-insulin-potassium (GIK) regimen in a general surgical department.

METHODS

Surgical patients treated under the previous diverse GIK regimens (September 2016 to August 2017) and the new unified GIK regimen (September 2017 to August 2018) were identified in records of the Clinical Data Warehouse of Seoul National University Bundang Hospital. Serial and area under the curve (AUC) glucose levels, and percentages of time within the target glucose levels were compared in propensity score matched patients in the diverse GIK regimen and in the unified GIK regimen (n = 227 in each group).

RESULTS

The AUC of glucose at 6 h and 12 h was lower under the unified GIK regimen than the diverse GIK regimen. The percentage of target glucose levels was higher in the unified GIK regimen compared to the diverse GIK regimen (81.5% vs. 75.0%, P = 0.026), but the occurrence of hypoglycaemia did not differ significantly between groups.

CONCLUSIONS

The unified GIK regimen was more effective than the diverse GIK regimen for glycaemic control and did not increase the number of patients developing hypoglycaemia. This validated written GIK regimen can be safely used in a general surgical department.

Quality of outpatient parenteral antimicrobial therapy (OPAT) care from the patient's perspective: a qualitative study

OBJECTIVES

Current outpatient parenteral antimicrobial therapy (OPAT) guidelines recommend delivering patient-centred care. However, little is known about what patients define as good quality of OPAT care and what their needs and preferences are.The aim of this qualitative study is to explore the patients' perspective on high-quality care, and to explore what patient-centred care means to adult OPAT patients.

DESIGN AND SETTING

This is an explorative, descriptive study using qualitative methods. We conducted focus group interviews with 16 adult patients (5 female, 11 male) from 3 different hospitals, who received OPAT and 2 individual semistructured interviews with their informal caregivers in the Netherlands. We used purposive sampling to ensure diversity of participants. We used the eight Picker principles of patient-centredness to guide data collection and analysis.

RESULTS

Participants reported several elements considered as important for patient-centred OPAT care, like patient involvement in the decision-making process, a responsible OPAT lead, intensive collaboration between all disciplines involved, information provision and adherence to hygiene guidelines. Two central dimensions emerged as essential constituents of patient-centred OPAT care: freedom and safety. Both are heavily influenced by the behaviours of healthcare professionals and by organisational aspects beyond the direct influence of these professionals.

CONCLUSION

This study provides insights into the needs and preferences of adult patients who receive OPAT care. Future interventions directed at the improvement of patient-centredness of OPAT care should focus on elements that enhance patients' feelings of freedom and safety.

Simulated Leaching (Migration) Study for a Model Container-Closure System Applicable to Parenteral and Ophthalmic Drug Products

A simulating leaching (migration) study was performed on a model container-closure system relevant to parenteral and ophthalmic drug products. This container-closure system consisted of a linear low-density polyethylene bottle (primary container), a polypropylene cap and an elastomeric cap liner (closure), an adhesive label (labeling), and a foil overpouch (secondary container). The bottles were filled with simulating solvents (aqueous salt/acid mixture at pH 2.5, aqueous buffer at pH 9.5, and 1/1 v/v isopropanol/water), a label was affixed to the filled and capped bottles, the filled bottles were placed into the foil overpouch, and the filled and pouched units were stored either upright or inverted for up to 6 months at 40 °C. After storage, the leaching solutions were tested for leached substances using multiple complementary analytical techniques to address volatile, semi-volatile, and non-volatile organic and inorganic extractables as potential leachables.The leaching data generated supported several conclusions, including that (1) the extractables (leachables) profile revealed by a simulating leaching study can qualitatively be correlated with compositional information for materials of construction, (2) the chemical nature of both the extracting medium and the individual extractables (leachables) can markedly affect the resulting profile, and (3) while direct contact between a drug product and a system's material of construction may exacerbate the leaching of substances from that material by the drug product, direct contact is not a prerequisite for migration and leaching to occur.LAY ABSTRACT: The migration of container-related extractables from a model pharmaceutical container-closure system and into simulated drug product solutions was studied, focusing on circumstances relevant to parenteral and ophthalmic drug products. The model system was constructed specifically to address the migration of extractables from labels applied to the outside of the primary container. The study demonstrated that (1) the extractables that do migrate can be correlated to the composition of the materials used to construct the container-closure systems, (2) the extent of migration is affected by the chemical nature of the simulating solutions and the extractables themselves, and (3) even though labels may not be in direct contact with a contained solution, label-related extractables can accumulate as leachables in those solutions.

Drug administration via enteral feeding tube in residential care facilities for individuals with intellectual disability: A focus group study on guideline implementation

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present qualitative study aimed to identify barriers and facilitators experienced by RCF staff members to following guidelines on medication administration via EFT, by conducting focus group interviews. Time constraints, lack of knowledge, lack of clear administration instructions, lack of necessary materials, and limited gastric fluid tolerance in certain residents were identified as barriers to following guidelines. Other influencing factors were the number of staff members, residents, and medications; habits; and the residents' comfort and well-being. To optimize care for this vulnerable patient population with EFT, an intervention can be set up focusing on improving staff members' medication-related knowledge and providing clear administration instructions and the necessary materials.

Filtration of Glass Delamination Particles with West Pharmaceutical Vial Adapters

One major current challenge facing companies producing injectable drugs contained in glass vials is the phenomenon of delamination that results in drug contamination. Particulate contamination of parenteral fluids is a fact of life. Particulate infusion is unlikely to cause immediate or severe signs and symptoms, but adverse effects, tissue damage, and loss of function are likely in the long term. Since 2010, recalls due to glass delamination have increased, and recently the U.S. Food and Drug Administration exercised temporary regulatory flexibility by allowing filtration as means of removing glass particles. The vial adapter is a needle-free product from West Pharmaceuticals Services that provides a simple and cost-effective solution for the safe and rapid transfer reconstitution of drugs between vials and syringes. One variant of the vial adapter is integrated with a filter to address various types of particles. In the present study, the performance of the filter-integrated vial adapter is evaluated with respect to glass delamination particles. Silica particles of 0.5-10 μm are used to emulate glass delamination particles. High-filtration efficiency is demonstrated according to the severest criteria stated by the British Pharmacopoeia that allows up to 100 particles smaller than 5 μm for every 1 mL liquid of a large-volume parenteral. The study was conducted using environmental scanning electron microscopy and statistical analysis.

LAY ABSTRACT

One major current challenge facing companies producing injectable drugs contained in glass vials is the phenomenon of delamination that results in drug contamination. Glass delamination is defined as degradation of surface glass, as from a vial, that produces glass flakes. Contamination of injectable drugs due to glass delamination is a fact of life. Normally, this type of contamination does not involve immediate severe signs, but rather accumulative damage to tissues in the long run. Recently, the U.S. Food and Drug Administration allowed the filtration as means of removing particles. The vial adapter is a needle-free product from West Pharmaceuticals Services that provides a simple and cost-effective solution for the safe and rapid transfer reconstitution of drugs between vials and syringes. One variant of the vial adapter is integrated with a filter to address various types of particles. In the present study, the performance of the filter-integrated vial adapter is evaluated with respect to glass delamination particles. Silica particles of 0.5-10 μm are used to emulate glass delamination particles. High-filtration efficiency is demonstrated according to the severest criteria stated by the British Pharmacopoeia that allows up to 100 particles smaller than 5 μm for every 1 mL liquid of a large-volume parenteral. The study was conducted using environmental scanning electron microscopy and statistical analysis.

A reduction in severe hypoglycaemia in type 1 diabetes in a randomized crossover study of continuous intraperitoneal compared with subcutaneous insulin infusion

AIM

Continuous intraperitoneal insulin infusion (CIPII) with the DiaPort system using regular insulin was compared to continuous subcutaneous insulin infusion (CSII) using insulin Lispro, to investigate the frequency of hypoglycemia, blood glucose control, quality of life, and safety.

METHODS

In this open, randomized, controlled, cross-over, multinational, 12-month study, 60 type 1 diabetic patients with frequent hypoglycemia and/or HbA1c > 7.0% with CSII were randomized to CIPII or CSII. The aim was to obtain the best possible blood glucose while avoiding hypoglycemia.

RESULTS

The frequency of any hypoglycemia was similar (CIPII 118.2 (SD 82.6) events / patient year, CSII 115.8 (SD 75.7) p = 0.910). The incidence of severe hypoglycemia with CSII was more than twice the one with CIPII (CIPII 34.8 events / 100 patient years, CSII 86.1, p = 0.013). HbA1c, mean blood glucose, and glucose fluctuations were not statistically different. Treatment-related severe complications occurred mainly during CIPII: port infections (0.47 events / patient year), abdominal pain (0.21 events / patient year), insulin underdelivery (0.14 events / patient year). Weight gain was greater with CSII (+ 1.5 kg vs. - 0.1 kg, p = 0.013), quality of life better with CIPII.

CONCLUSIONS

In type 1 diabetes CIPII with DiaPort reduces the number of severe episodes of hypoglycemia and improves quality of life with no weight gain. Because of complications, indications for CIPII must be strictly controlled. CIPII with DiaPort is an alternative therapy when CSII is not fully successful and provides an easy method of intraperitoneal therapy.

Treatment of ovarian cancer with intraperitoneal chemotherapy

In early 2006, the National Cancer Institute (NCI) issued a Clinical Announcement suggesting that intraperitoneal (IP) chemotherapy should become the standard of care for patients with newly diagnosed stage III optimally debulked epithelial ovarian cancer. IP chemotherapy, the administration of chemotherapy or biologic therapy via catheter into the peritoneal space, is new to many healthcare providers (physicians, nurses, and pharmacists). The goals of this article are to address the rationale for IP chemotherapy, present the data supporting its use, and describe the nursing management of patients undergoing this treatment. Education of patients and staff regarding IP therapy is essential for successful patient outcomes.

International Conference on Harmonisation; Guidance on Q4B Evaluation and Recommendation of Pharmacopoeial Texts for Use in the International Conference on Harmonisation Regions; Annex on Test for Extractable Volume of Parenteral Preparations General Chapter; availability. Notice

The Food and Drug Administration (FDA) is announcing the availability of a guidance entitled "Q4B Evaluation and Recommendation of Pharmacopoeial Texts for Use in the ICH Regions; Annex 2: Test for Extractable Volume of Parenteral Preparations General Chapter." The guidance was prepared under the auspices of the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). The guidance provides the results of the ICH Q4B evaluation of the Test for Extractable Volume of Parenteral Preparations General Chapter harmonized text from each of the three pharmacopoeias (United States, European, and Japanese) represented by the Pharmacopoeial Discussion Group (PDG). The guidance conveys recognition of the three pharmacopoeial methods by the three ICH regulatory regions and provides specific information regarding the recognition. The guidance is intended to recognize the interchangeability between the local regional pharmacopoeias, thus avoiding redundant testing in favor of a common testing strategy in each regulatory region. In the Federal Register of February 21, 2008 (73 FR 9575), FDA made available a guidance on the Q4B process entitled "Q4B Evaluation and Recommendation of Pharmacopoeial Texts for Use in the ICH Regions."

Leak testing in parenteral packaging: establishment of direct correlation between helium leak rate measurements and microbial ingress for two different leak types

A direct test method using helium leak detection was developed to determine microbial ingress in parenteral vial/rubber closure systems. The purpose of this study was to establish a direct correlation between the helium leak rate and the presence of ingress when vials were submersed under pressure in a broth of bacteria. Results were obtained for two different types of leaks: microholes that have been laser-drilled into thin metal plates, and thin copper wire that was placed between the rubber closure and the glass vial's sealing surface. The results from the microholes showed that the helium leak rate was a function of the square of the hole diameter and fit well with theoretical calculations. The relationship with the wire gave a far more complex dependence and was not modeled theoretically. Comparison with the microbial challenge showed that for microholes a lower size limit was found to be 2 microm with a corresponding leak rate of 1.4 x 10(-3) mbarl/s. For the fine wire experiment the lower limit was 15-microm wire and a corresponding leak rate of 1.3 x 10(-5) mbarl/s. From these tests a safe, lower limit, leak rate was established.

[Safety of parenteral iron therapy]

Intravenous iron supplementation is generally required to optimize the action of agents stimulating erythropoiesis. All parenterally administrated iron preparations raise risk of acute or chronic side effects related to allergic reactions, cell toxicity, or endothelial dysfunction. Each product proposed has specific structural and biochemical characteristics explaining its specific pharmacological and biochemical properties. None of the available products contains free iron but all contain a small fraction of biologically active labile iron. The anaphylactoid reactions initially described after administration of high-molecular-weight iron dextran are rare with iron sucrose. In clinical practice, the problem is generally iron deficiency, iron overload generally not being a serious problem. The contribution of biologically active iron to increased oxidative stress in the dialysis patient is an important issue for debate. The cardiovascular risk of iron was pointed out by evidence from experimental studies but the epidemiological data have been contradictory, both in dialysis patients and in the general population, and are insufficient to confirm an increased cardiovascular risk in dialysis patients when the serum ferritin level is maintained within the recommended range. The risk of infection is related to the effect of iron on bacterial virulence and on the organism's defense mechanism against bacterial infection. An analysis of the clinical evidence obtained in dialysis patients suggests that the role iron i.v. might play in increased bacterial risk would require, if it truly exists, doses so high the real effect would be marginal compared with identified major risk factors.

Outpatient parenteral antibiotic therapy (OPAT) in different countries: a comparison

In order to assess how outpatient parenteral antibiotic therapy (OPAT) is managed in different countries, we analyzed the data collected in the USA, UK and Italy by the International OPAT Registry using an ad hoc Access/Excel Microsoft program. The analysis of data concerned 9826 patients in the USA, 981 in the UK and 620 in Italy. Differences were observed in several aspects of OPAT management such as the infections treated and the antibiotics utilized. The duration of therapy also differed: it was much longer in Italy (56.0 average days), than in the USA (22.5 days) and UK (19.9 days). Delivery model, delivery route and infusion devices show substantial differences. The present analysis shows that OPAT is carried out with substantial differences in different countries probably according to different programmes and guidelines adopted.

Changing practice in the subcutaneous infusion of fluids to improve safety

Many nurses administer subcutaneous infusion therapy; it is seen as an alternative to intravenous therapy. But how sharp-safe is the equipment they use? An evaluation of a clinical trial on a catheter to replace metal butterfly needles is outlined, together with details of how this was introduced into clinical areas.

Critical evaluation of the standard hydrolytic resistance test for glasses used for containers for blood and parenteral formulations

As prescribed by pharmacopoeias, containers should meet certain condition of stability to be used for pharmaceutical products. Glass containers are classified according to their resistance to chemical attack, a test executed by heating the glass in contact with water for 30 min at 121 degrees C. The USP powdered glass test for glass containers was applied to different kinds of glasses used as containers for parenteral formulations. In this experiment not only the released alkalinity was measured but also the release of glass constituents: silicate, borate, sodium, and aluminum, and also the release of some impurities as copper and lead. The USP powdered glass test was also carried out with glass ampoules, clear and amber, in the presence of solution of some inorganic salts, NaCl, KCl, CaCl2, MgCl2, NaHCO3, NaH2PO4, KH2PO4, and sodium gluconate, citric acid and glucose. The results showed that even when releasing very low alkalinity, glasses also released their constituents, in concentration ranges from 8.8 to 33 mg/l for silicate, 0.9 to 6.9 mg/l for borate, 3 to 37 for mg/l for sodium and 0.5 to 2.4 mg/l for aluminum. More expressive results were found, however, for the tests done with solutions instead of pure water. The tests showed that, for most of the solutions, while the measured alkalinity was very low, high levels of the other constituents were found. Basic solutions of bicarbonate and gluconate presented the higher levels of all investigated constituents, confirming the ability of basic solutions to attack and dissolve the glass network. Glucose and citric acid interacted with the glass surface, selectively extracting aluminum, copper, and lead. Whereas silicate, borate and sodium found in these solutions were at levels similar to those found with pure water, the aluminum level was almost 20 times higher. This specific action of citrate and glucose could be related to their metal-complexing ability. The results indicate that even so-called "chemical-resistant glasses," as measured by the hydrolytic resistance test, react with many substances when packaged in contact with them. The hydrolytic resistance test, when used as the sole measure of potential drug-container compatibility, is not reliable.

A commentary on 'Administration of as required subcutaneous medications by lay carers'

In this article commentary Philip Saltmarsh discusses some issues arising from an initiative to provide guidance for community nurses involved in the administration of as required medication by lay carers.

Assuring quality and performance of sustained and controlled release parenterals: AAPS workshop report, co-sponsored by FDA and USP

This is a summary report of the American Association of Pharmaceutical Scientists, the Food and Drug Administration, and the United States Pharmacopoeia cosponsored workshop on "Assuring Quality and Performance of Sustained and Controlled Release Parenterals." Experts from the pharmaceutical industry, the regulatory authorities, and academia participated in this workshop to review, discuss, and debate formulation, processing, and manufacture of sustained and controlled release parenterals and identify critical process parameters and their control. Areas were identified where research is needed to understand the performance of these drug delivery systems and to assist in the development of appropriate testing procedures. Recommendations were made for future workshops, meetings, and working groups in this area.

Continuous infusion of porcine factor VIII: stability, microbiological safety and clinical experience

Porcine factor VIII (pFVIII) is an effective haemostatic treatment for bleeding in selected patients with FVIII inhibitors. Its use is sometimes associated with a transient fall in platelet count and transfusion reactions, the risk of which may be related to the rate of administration. Theoretical considerations suggest that the administration of pFVIII by continuous infusion should be effective, and could have pharmacokinetic advantages that lead to an improvement in the side-effect profile. The results of a retrospective survey of continuous infusion of pFVIII with respect to clinical safety and efficacy are reported. Porcine FVIII stability and microbiological studies are included. It is concluded that pFVIII given by continuous infusion is safe and effective. The risk of transfusion reactions and fall in platelet count appears to be reduced, compared with bolus administration. Stability studies showed that pFVIII activity declined at room temperature, most rapidly in the dilute solution (5-10 U mL(-1)). More concentrated mixtures showed acceptable stability for up to 24 h using a variety of infusion devices. Various concentrations of pFVIII did not support the growth of Escherichia coli or Staphylococcus aureus. These observations suggest that the porcine factor is suitable for continuous infusion (CI).

Continuous infusion of porcine factor VIII in patients with haemophilia A and high-responding inhibitors: stability and clinical experience

A multicentre retrospective survey was conducted to assess the efficacy and side-effect profile of porcine factor VIII (pFVIII:C) given by continuous infusion (CI) to patients with congenital haemophilia A and inhibitors. Twenty-nine episodes in 18 patients were treated by CI of pFVIII:C. Efficacy was graded as good in 79% of infusions and fair in 17%. There was a failed response in only one episode. Fourteen percent of patients experienced transfusion reactions with bolus doses, but no reactions were observed in patients given CI. There were no severe reactions. All the reactions resolved following interruption of the infusion and administration of steroids. Premedication did not prevent reactions. In this series the median decrease in platelet count after bolus injection of pFVIII:C was -67 X 10(9) L(-1) compared with a median decrease of -2 x 109 L(-1) during the course of CI, thus, continuous infusion of pFVIII:C appears to have less effect on platelet count than bolus injection. An anamnestic response was associated with 77% of infusions. This high rate of anamnesis reflects patient selection, in that they were all known to have high-level high-responding FVIII inhibitors with cross-reactivity to pFVIII. After reconstitution, the pFVIII:C showed little loss in factor VIII activity in solution over a 24-h period. We conclude that pFVIII:C may be effectively administered by CI to patients with haemophilia A and high-responding FVIII inhibitors. CI is the probably the mode of administration of choice for intensive replacement therapy with pFVIII.

Out-patient and home-parenteral antibiotic therapy (OHPAT): evaluation of the impact of one year's experience in Tayside

OBJECTIVE

An out-patient and home parenteral antibiotic therapy programme for the treatment of suitable infections was developed over a four year period. This paper describes the impact of one year's experience of its implementation on various measures of outcome.

DESIGN

Each patient treatment has a full integrated care pathway (ICP) and patient satisfaction questionnaire completed. The ICP documents the clinical progress of the patient and incorporates various measures of quality of care on the 101 number of patients treated from April 1998 to March 1999 are presented here.

SETTING

Dundee Teaching Hospitals NHS Trust (now Tayside University Hospitals NHS Trust).

SUBJECTS

Patients with a range of infections requiring intravenous antibiotics.

MAIN MEASURES

Number of patients treated with various infections, clinical and microbiological outcome, drug and vascular access complication rates, impact on drug costs and in-patient bed days, and measurement of patient satisfaction/quality of life.

RESULTS

Patients were treated over a 12 month period. 51.5 per cent had skin & soft tissue infections and 22.8 per cent bone & joint sepsis. 57 per cent of patients received out-patient and 34 per cent self or carer administered home therapy. Ninety-four per cent of patients were cured or improved following treatment. Only 7.5 per cent of patients required an unscheduled admission to hospital. Twelve per cent of patients had some type of vascular device related adverse event (partly due to a faulty batch of lines) and six per cent of patients had a drug related reaction. The additional daily cost of drugs was minimal (< 12 Pounds/day) and more than 1,461 bed days have been saved across the Directorates. The patient satisfaction level was high.

[Standard parenteral solutions for children up to 3 years of age]

Standard parenteral solutions for children up to 3 years of age and body weight 3-15 kg are presented and mixing procedure under laminar flow is described.

An open randomized clinical study of intrarectal versus infused Quinimax for the treatment of childhood cerebral malaria in Niger

The intrarectal route has been shown to be an alternative to parenteral therapy for the treatment of acute uncomplicated malaria. We conducted an open randomized clinical study of intrarectal Quinimax (a Cinchona alkaloids association) (20 mg/kg, then 15 mg/kg every 8 h) vs. intravenous Quinimax (8 mg/ kg infused over 4 h every 8 h) for 2 d in 76 children (39 in the intrarectal and 37 in the infusion groups) with cerebral falciparum malaria in Niger. This treatment was followed by oral chloroquine (10 mg/kg/d for 3 d). The primary end points of the study were fatal outcome and coma recovery time. In the intrarectal group, 35 children were cured (90%) and 4 died. In the infused group, 28 were cured (76%) and 9 died; mean coma recovery times were 34.6 h (SD = 12.8) and 33.0 h (SD = 14.1) for the intrarectal and infused groups, respectively. None of the differences was significant. Both treatments were well tolerated and no anal irritation was observed with intrarectal Quinimax. These findings suggest that intrarectal Quinimax can be an alternative to intravenous administration for rapid onset childhood cerebral malaria in the rural tropics, where the safety of parenteral administration cannot be guaranteed.

Long-term intraduodenal infusion of a water based levodopa-carbidopa dispersion in very advanced Parkinson's disease

OBJECTIVE

To evaluate the effects of continuous duodenal infusion of levodopa over time on the disabling fluctuations in motor performance in advanced parkinsonian patients. It has earlier been demonstrated that these fluctuations can be reduced by keeping the plasma concentration of levodopa constant.

MATERIAL AND METHODS

In view of the low water solubility of levodopa a stable dispersion of the drug was developed and used for continuous intraduodenal infusion in patients with advanced Parkinson's disease. Nine patients were evaluated with respect to an optimal oral treatment, during nasoduodenal infusion by a portable pump and then followed for 6 months to 2 1/2 years when treated via transabdominal infusion. Upon each test occasion, over 2 non-consecutive days, objective movement analysis by means of an opto-electronic system was applied every 15-20 min and video recordings performed twice every h. On several test occasions plasma levodopa concentrations were analysed every 15 min.

RESULTS

The patients showed improvement and decreased variance of their motor function. In the 2 patients followed over a period of 2 1/2 years levodopa plasma concentration showed reduced fluctuations on infusion and the levodopa consumption as well as mean levodopa plasma concentration decreased.

CONCLUSION

Continuous duodenal infusion of levodopa is an alternative treatment strategy for patients with advanced Parkinson's disease when conventional therapy has failed.

[LAL (Limulus Amoebocyte Lysate) test as applied to the safety evaluation of biological preparations]

In the paper some problems concerning of pyrogen testing were described. The risk of reactions after administration parenteral preparations contaminated pyrogenic substances give the cause for searching sensitive, repeated methods of their designation. The paper is review of the adaptation Limulus Amoebocyte Lysate (LAL) test for the estimation of endotoxin in biological preparations. The paper overview, chemical structure of endotoxin the characteristic of Limulus polyphemus, principle basis of the LAL test and general remarks of application. The LAL test according to the opinion of many authors is more sensitive in comparing with the pyrogen rabbit test.

Storing parenteral medication at home

The storage requirements for parenteral products vary with the characteristics of the medication in the product. Temperature, light, moisture, pH, composition of the container, type of infusion fluid, and exposure to other chemical substances are the major determinants of the stability of parenteral medication stored in the patient's home.

Automated polarographic determination of sulfide as contaminant in parenteral amino acid solutions

A method for the automated polarographic determination of sulfide in a gas-diffusion flow system was developed. The volatile sulfide, existing as a contaminant in parenteral amino acid solutions, was measured after gas diffusion using 0.1 mol l-1 NaOH solution as acceptor. The linear range of calibration, for measurements at a dropping-mercury electrode (DME), was from 5 to 100 micrograms of sulfide with r = 0.999 and RSD = 7.5% (n = 5) for 10 micrograms of sulfide. For measurements at the hanging mercury-drop electrode (HMDE), with a preconcentration time of 30 s, the linear range of calibration was from 0.9 to 20 micrograms of sulfide with r = 0.998 and RSD = 5.8% (n = 5) for 2 micrograms of sulfide. Detection limits of 59 and 11 micrograms l-1 at the DME and HMDE, respectively, were calculated and the recoveries of sulfide from spiked samples were 91.5-104.5%. Parameters that affect the sulfide determination using this method, such as the organic content of the matrix, pH, flow rate and sample size, were investigated.

Particulate matter determination in LVPs produced in Dutch hospital pharmacies, Part 1: Particle-counting accuracy

Reproducible particle counting using the light-obscuration technique is often troublesome because no absolute standard is available. Therefore, at the Laboratory of Dutch Pharmacists the "calibration-in-time" method was developed. This method enables checking of the amount of particles counted from a diluted latex suspension as a function of time. A particularity of the method is the one-step dilution procedure. The calibration-in-time method is compared with the particle-counting accuracy test according to the USP < 788 >. Advantages and disadvantages of both methods are discussed.

Secondary pharmaceuticals manufacturing

Drs. Burling and Shah examine the second part of the pharmaceuticals manufacturing process, in which formulations for drug delivery are determined. Several types of formulations and their potentials for occupational exposure are reviewed.

[Report of nationwide questionnaire: intraperitoneal chemotherapy for advanced ovarian cancer based on clinical results--reports of 5th "Gynecologic Intraperitoneal Chemotherapy Study Group" meeting]

We established the "Gynecologic Intraperitoneal Chemotherapy Study Group" in October, 1990. To date 5 annual meetings have been held during the Japanese Cancer Therapy Meeting. The members decided to establish a standard protocol of intraperitoneal chemotherapy (IP-CTX) for advanced ovarian cancer based on the clinical results obtained at each institution. Thus we first collected the clinical data from the affiliated institutes. Questionnaires concerning the indication of IP-CTX and the resulting data were sent to physicians working at 267 facilities in January, 1994. As a result, the reply rate was 28.8% (77/267). According to the results from 40 institutions, the consensus was that patients with residuum less than 0.5 cm in diameter after primary debulking surgery were suitable for IP-CTX. However, the remaining 37 institutions reported that patients with a macroscopic residuum less than 2 cm in diameter or those with bulky residuum greater than 2 cm in diameter demonstrated good responses to IP-CTX. Thus, further analyses are required to elucidate the appropriate indication and establish the standard protocol of IP-CTX for ovarian cancer in a clinical setting.

[Study on the particles in infusion solutions and the means to control it]

This study was conducted to observe the shapes of the particles in infusion solution which had commonly used drugs in by using a scanning electric microscope. The rusult indicated that there were particles in the solution and the shapes of the particles were varies. It is recommended that attention should be paid to the hazards of the particles and the in-line terminal filter should be used to prevent the particles going to the body.

A new coincidence model for single particle counters, Part II: Advances and applications

Accuracy, acceptance limits and methods for U.S.P. (788) contaminating particle assays published in the XXII Revision are refined in U.S.P. XXIII. In both Revisions, although different numerical values and methods are employed, particle contamination limits remain constants for all S.V.I. container volumes. The effect of this quality standard is high particle concentration acceptance limits in the smallest S.V.I. container sizes. The effect of these high concentrations is to introduce both undercount errors and false counts into U.S.P. (788) SVI contaminating particle assays. There is general agreement that the count of high concentrations of particles by a single particle light extinction counter result in an increase of the average size of the distribution of particles reported and a decrease in their total number. The error mechanism is termed "signal coincidence." Understanding and control of both these problems is unified with the introduction of the count efficiency parameter. Part I of this paper makes available two core concepts with which evaluation and control of coincidence error in single particle counters can be accurately quantified. These two core concepts are the "Particle Triggered Poisson Model," a new more accurate statistical model of the particle counting process and a concentration measure that includes the effect of particle size on the counting capability of a detector. Use of these concepts make it possible to evaluate particle detector count efficiency capability from experimental data of the coincidence effect. This is an application paper. It combines the theory in the Part I paper with the replicability of particle counters into a simple test protocol. The test results can be used to calculate a contour of particle size and count within which both undercount errors and the introduction of false counts into U.S.P. (788) particle assays are controlled. From the data analyzed it can be seen that any single particle size test cannot effectively evaluate detector performance. The use of the theory and methodology described can help realize the intent of the U.S.P. (788) SVI particle contamination assay.

Parameters governing steam sterilization of deadlegs

Use of saturated steam for sterilization-in-place (SIP) is limited by factors effecting displacement of air from deadlegs. Effects of tube diameter, length, orientation and position within a deadleg were quantitatively studied by examining temperature profiles and rates of kill of Bacillus stearothermophilus spores. Tube diameter had the greatest effect on sterilization. For small diameter tubes, 0.4 cm inside diameter (ID), air displacement was minimal and due mainly to diffusion. 8.8 cm long tubes with 0.4 cm IDs could not be sterilized at 121 degrees C. As tube diameter was increased and buoyant driven convective flow became dominant over viscous forces, sterilization was achieved and tube orientation became critical. Sterilization time, as defined by a twelve log reduction in spore population, was 75 minutes in a 19.0 cm long vertical tube with 1.7 cm ID, whereas 167 minutes were required for an 8.8 cm long tube with 1.0 cm ID. For 8.8 cm long tubes, only the 1.7 cm ID tube could be sterilized when orientated 5 degrees above horizontal. Data show that length to diameter ratios, L/Ds, do not provide a general guideline which can be used to predict sterilization. In the absence of steam bleeders, equipment should be designed to assure strong buoyancy driven convective flow to assure adequate air removal. This requires elimination of small diameter deadlegs (0.4 cm ID and less) and vertical positioning of deadlegs.

Approaches to reducing subvisible particle counts in lyophilized parenteral formulations

Reduction in subvisible particle counts in parenteral formulations is an important requirement. Despite selection of best container/closure and use of processing conditions where the drug is most soluble and stable, lyophilized formulations often demonstrate problems of subvisible particle counts greater than the permitted compendial limits. We have studied some formulation and processing approaches with different compounds with the intention of developing lyophilized products, which after reconstitution, pass compendial subvisible particle limits for large volume parenterals (LVP). The approaches studied were targeted to reduce "intrinsic" subvisible particle counts and included the addition of a solubilizing agent, pH adjustment, charcoal treatment of the process solution, and use of a filter with finer pore size for filtering the solution prior to lyophilization. Although the relative efficiency of each of these parameters in reducing subvisible particle counts was found to be slightly different for each compound, the inclusion of a solubilizing agent and charcoal treatment of the processing solution were found to have the most pronounced effect. The combination of two or more parameters was often found to be even more effective. It is suggested that these approaches may be useful in developing other lyophilized products that yield low subvisible particle counts on reconstitution.

Asbestos fibers in parenteral medication

The adequacy of current regulations for the control of particulate matter in injectable medicines has been brought into question by a recent television program which reported that asbestos fibers had been found in a number of such preparations. The fibers were identified as chrysotile, which occurs very widely as a secondary mineral in rocks, and is almost ubiquitous among minerals derived from natural erosion. Fibers are found in almost all drinking water and air samples unrelated to any contamination of fiber resulting from industrial exploitation. Because of this, even extreme laboratory precautions may fail to eliminate every fine fiber. A normal person living in an urban environment inhales about 10(5) asbestos fibers daily and ingests 10(10). There is evidence that a small proportion of these fibers regularly enters the circulation, and some fibers may be excreted in the urine. Elimination also occurs because retained chrysotile fibers fragment and disappear relatively quickly from human tissues, probably through macrophage action. Fiber length and dose are also important in disease causation. Established evidence on fiber length, durability, and quantitative exposure required for disease production does not indicate that the fibers reported to have been found in parenteral preparations constitute any hazard.

Optimization of moist heat sterilization

The use of different combinations of sterilization time and temperature in a pilot scale autoclave, GEV 612 AR-2 (Getinge Ab, Sweden), in optimizing the sterilization process was studied. All three programs used had the same sterilization efficacy (F0 = 15 minutes) but different sterilization temperatures (116, 121, and 126 degrees C) and total process times (98, 57, and 44 minutes). The heat distribution during the sterilization phase was, in all cases, very uniform, the greatest difference being 0.5 degrees C. Also the F0 values differed only by +/- 0.5 minutes from each other. The F0 value increases linearly with all programs until the beginning of the cooling phase. The main effect of different sterilization temperatures on the cumulative F0 curves is an increase in the slope of the curves with increasing sterilization temperature. First order temperature change constants were determined both for the heating phase and the cooling phase. The numeric values of the rate constants for the heating and the cooling phases were 0.20 +/- 0.03 and 0.046 +/- 0.005 min-1, respectively. It is concluded that the pilot autoclave used in this study controls the sterilization process very accurately. The observed variations between F0 values at different positions in the autoclave chamber are acceptable. On the basis of this study an accurately engineered and controlled autoclave is required in process optimization. It also is possible to use higher sterilization temperatures than usually suggested in pharmacopeias and thus to shorten the process time.

Investigational trends: clean room environmental monitoring

GMP problems associated with microbiological environmental monitoring are among those most commonly cited as objectionable during FDA inspections of parenteral drug manufacturing facilities. This presentation describes FDA inspection approaches and techniques and audit applications used in evaluating the effectiveness of firms environmental monitoring programs. Environmental monitoring programs involve considerable data, and many variables are interrelated to make difficult detection of patterns and trends during FDA audits. Consequently, systematic computer-aided audit techniques have been developed by the author to permit detection of patterns, trends and GMP documentation problems by the FDA. The strategies and techniques described in this paper may provide management with ideas about ways to review and audit their own environmental data. Presented are some practical details about the use of a portable computer to systematically assess trends and patterns. Several program applications (algorithms) were developed to determine if cleanroom environmental data are under a state of control.

Multi-purpose evaluation of H2-antagonist usage

At Cabrini Medical Center, drug usage evaluation (DUE) and monthly purchasing data analysis were used to determine the indications for which H2 antagonists were being used, the appropriateness of parenteral therapy, the use of extended dosing intervals, and the cost effectiveness of cimetidine (Tagamet). The study was also used to review a decision of the P & T Committee to maintain cimetidine and remove ranitidine from the hospital formulary.

Industrial perspective on validation of tangential flow filtration in biopharmaceutical applications. Technical Report No. 15. Parenteral Drug Association. Biotechnology Task Force on Purification and Scale-up

Validation of tangential flow filtration is required to ensure the process delivers a product of consistent quality, safety, and efficacy. A thorough and sound validation program not only satisfies regulatory requirements, but also provides a valuable source of information which facilitates development of future processes, training of production personnel, and trouble shooting for the validated process. Validation of TFF shares many common elements with validation of other traditional operations and equipment. Existing personnel and procedures should be readily adapted to execute the TFF validation protocols. IQ's and OQ's will most likely follow familiar formats. In performance qualification, key areas needing attention include: assessment of compatibles, testing of parameters affecting membrane retention and selectivity, cleaning, sanitization, and membrane lifetime. Finally, the hallmark of a sound validation program is the quality of its scientific approach and its congruence with the definition of validation contained in the 1987 guidelines (6).

Intraosseous administration of digoxin: same-dose comparison with intravenous administration in the dog model

Intraosseous access has become the method of choice for venous access in critically ill and injured children when more traditional methods are not immediately available. However, there is a paucity of information concerning drug levels achieved via the intraosseous route. We report initial data on the comparison of serum digoxin levels after administration of the drug to dogs through both the intraosseous and intravenous routes. These data indicate that intraosseous infusion of digoxin results in similar serum levels to those attained after IV administration, and may therefore afford a reliable means of initial digitalization.

[The value of a Tenckhoff catheter in ovarian cancer]

It is generally difficult to treat patients with ovarian cancer. A Tenckhoff catheter was implanted in eighteen patients for intraperitoneal chemotherapy and drainage of ascites. Sixteen cases including 5 recurrent cases were treated with anticancer drug. It could not be used in two cases by bowel adhesion, so immediately catheters were removed. CDDP (100-150 mg/body) with or without Etoposide (180-300 mg/body) in 2 liters of saline was administered via Tenckhoff catheter over 30 minutes with a dwell time of 4 hours. We have studied the kinetics of CDDP and Etoposide in ascites and blood after intraperitoneal chemotherapy. High concentrations of free-CDDP and Etoposide were reached for 4 hours in the ascites but concentrations in the blood varied. These results showed obviously high values and direct effects on the tumor cells in the abdominal cavity and the peritoneal clearance depended on the severity of carcinomatous peritonitis in each case. Twelve cases showed decrease, but 4 cases increase of ascites. Five recurrent cases and one patient of stage IV died. Seven cases are outpatients and the disease free duration of their ranges are from 1 to 24 months. Three patients are now under treatment. Intraperitoneal chemotherapy elicited only mild nausea, myelosuppression and no significant changes of renal function. No patients had signs of catheter infection and peritonitis. These findings suggested that a Tenckhoff catheter was valuable to treat and manage ovarian cancer patients with little side effect.

Effect of intraosseous saline infusion on hematologic parameters

STUDY OBJECTIVE

To examine the effects of intraosseous saline infusion on hematologic parameters.

DESIGN AND SETTING

Eight New Zealand White rabbits were anesthetized with intramuscular ketamine. An initial blood sample was withdrawn from a earlobe vein on induction of anesthesia. An 18-gauge intraosseous needle was then inserted into the rabbit's proximal tibia, and 10 mL/kg of normal saline was infused over one minute. Two additional blood samples were obtained 15 and 30 minutes after the intraosseous infusion.

MEASUREMENTS

Complete blood counts were performed on the blood samples.

RESULTS

Significant differences were found in monocytes, basophils, and nucleated RBCs from samples drawn before and after intraosseous infusion. The microscopic examination of the peripheral blood smear revealed an increase in the number of burr cells, schistocytes, and polychromasia in the postinfusion samples.

CONCLUSION

We advocate caution in the interpretation of hematologic studies performed on blood samples obtained shortly after an intraosseous infusion.