‘What a pity!’ – Exploring the use of ‘pitilho’ as harm reduction among crack users in Salvador,Brazil

Aims: The aim of this study was to explore the use of ‘pitilho’ (the co-smoking of crack and marijuana in a cigarette-like form) among crack users in Salvador, Brazil as a potential harm reduction measure.

Methods: In-depth interviews were conducted with two outreach workers who frequently encountered the use of ‘pitilho’ as part of their community outreach programme work, as well as four ‘pitilho’ users who were clients of the programme. Daily field notes were also collected. Transcribed data were analysed for common reasons for ‘pitilho’ use.

Findings: Several key reasons crack users have adopted the ‘pitilho’ as a harm reduction tool were uncovered: it was reported to reduce the negative pharmaco-behavioural and physical effects of crack use, is more economical, provides users with better control over their behaviours, and decreases their vulnerability for violence and betters their sub-cultural position.

Conclusions: ‘Pitilho’ may offer several relevant short-term benefits to users and therefore may constitute a potentially important ‘harm reduction’ tool in an area where little other targeted prevention measures exist. Our exploratory data need to be investigated in depth by appropriate and rigorous methods.     

Increasing the Robustness of Biopharmaceutical Precipitation Assays – Part II: Recommendations on the use of FaSSIF

Biopharmaceutical precipitation assays are an important in vitro tool to characterize the precipitation behavior of weakly basic drugs during their transit from the stomach into the small intestine. To mimic the intestinal fluids more closely, biorelevant media like Fasted State Simulated Intestinal Fluid (FaSSIF) and versions thereof are often applied. When applying UV analytics to measure the drug concentration during the transfer experiments, changes in the UV spectrum of the medium have been observed when FaSSIF was stored over a longer period of time or under accelerated conditions. Therefore, this study aimed at evaluating the stability of FaSSIF under various storage conditions. Furthermore, the impact of stressed FaSSIF on the supersaturation and precipitation behavior of ketoconazole was investigated. As a result of this study, it was demonstrated that the FaSSIF powder composition changes during storage, which, in turn, impacts the supersaturation and precipitation behavior of ketoconazole in in vitro transfer studies. Based on the results of this study, we provide recommendations on the application of FaSSIF in biopharmaceutical precipitation assays with the aim to increase reproducibility and enhance data reliability for those compounds where changing FaSSIF composition may impact the supersaturation and precipitation behavior.     

Preparation and evaluation of PLGA microparticles as carrier for the pulmonary delivery of rhIL-2 : I. Effects of some formulation parameters on microparticle characteristics

In this study, recombinant human interleukin-2 (rhIL-2) containing poly(lactic-co-glycolic acid) (PLGA) microparticles were prepared for pulmonary administration by modified w/o/w double emulsion solvent extraction method and the effects of various formulation parameters on the physicochemical properties of the microparticles were investigated. Microparticles in suitable size for pulmonary administration (4.02?µm) were obtained by increasing dichloromethane volume used in the organic phase. Also, a very high encapsulation efficiency (99.22%) value could be reached in these microparticles. In the sodium dodecyl sulphate-polyacrylamide gel electrophoresis analysis, rhIL-2 extracted from microparticles having a similar band with native rhIL-2 showed that the protein was not affected by the encapsulation process. The release curves of microparticles exhibited a biphasic fashion, characterized by a fast release phase at initial 1 day, followed by a slower one on the remaining days. Bioactivity investigations using T cells show that rhIL-2 encapsulated in PLGA microparticles retain their biological activity.     

Preparation and evaluation of PLGA microparticles as carrier for the pulmonary delivery of rhIL-2 : I. Effects of some formulation parameters on microparticle characteristics

In this study, recombinant human interleukin-2 (rhIL-2) containing poly(lactic-co-glycolic acid) (PLGA) microparticles were prepared for pulmonary administration by modified w/o/w double emulsion solvent extraction method and the effects of various formulation parameters on the physicochemical properties of the microparticles were investigated. Microparticles in suitable size for pulmonary administration (4.02?μm) were obtained by increasing dichloromethane volume used in the organic phase. Also, a very high encapsulation efficiency (99.22%) value could be reached in these microparticles. In the sodium dodecyl sulphate-polyacrylamide gel electrophoresis analysis, rhIL-2 extracted from microparticles having a similar band with native rhIL-2 showed that the protein was not affected by the encapsulation process. The release curves of microparticles exhibited a biphasic fashion, characterized by a fast release phase at initial 1 day, followed by a slower one on the remaining days. Bioactivity investigations using T cells show that rhIL-2 encapsulated in PLGA microparticles retain their biological activity.     

Surface-active derivative of inulin (Inutec® SP1) is a superior carrier for solid dispersions with a high drug load

The aim of this study was to compare the applicability of inulin, its surface-active derivative (Inutec? SP1), and polyvinylpyrrolidone (PVP) as carriers in high drug load solid dispersions (SDs) for improving the dissolution rate of a range of lipophilic drugs (diazepam, fenofibrate, ritonavir, and efavirenz). The SDs were prepared by spray freeze-drying. Scanning electron microscopy showed that the obtained samples were highly porous spherical particles. Modulated differential scanning calorimetry showed that the drugs incorporated in these carriers were fully or partially amorphous. The solubility of the drugs in solutions of the different carriers was increased in an order: inulin 2.3 kDa < PVP K30 ? Inutec? SP1. The dissolution behavior of SD tablets was evaluated. Inutec? SP1-based SD tablets showed the best performance followed by PVP- and inulin-based SD tablets. The superior dissolution behavior of the drugs from Inutec? SP1-based SDs could be ascribed to its surface-active nature. In addition, Inutec? SP1-based SD tablets gave good physical stability at 20 °C/45% relative humidity (RH) and 40 °C/75% RH for 3 months.     

Physicochemical properties of tadalafil solid dispersions – Impact of polymer on the apparent solubility and dissolution rate of tadalafil

To improve solubility of tadalafil (Td), a poorly soluble drug substance (3 μg/ml) belonging to the II class of the Biopharmaceutical Classification System, its six different solid dispersions (1:1, w/w) in the following polymers: HPMC, MC, PVP, PVP-VA, Kollicoat IR and Soluplus were successfully produced by freeze-drying. Scanning electron microscopy showed a morphological structure of solid dispersions typical of lyophilisates. Apparent solubility and intrinsic dissolution rate studies revealed the greatest, a 16-fold, increase in drug solubility (50 μg/ml) and a significant, 20-fold, dissolution rate enhancement for the Td/PVP-VA solid dispersion in comparison with crystalline Td. However, the longest duration of the supersaturation state in water (27 μg/ml) over 24 h was observed for the Td solid dispersion in HPMC. The improved dissolution of Td from Td/PVP-VA was confirmed in the standard dissolution test of capsules filled with solid dispersions. Powder X-ray diffraction and thermal analysis showed the amorphous nature of these binary systems and indicated the existence of dispersion at the molecular level and its supersaturated character, respectively. Nevertheless, as evidenced by film casting, the greatest ability to dissolve Td in polymer was determined for PVP-VA. The crystallization tendency of Td dispersed in Kollicoat IR could be explained by the low T_g (113 °C) of the solid dispersion and the highest difference in Hansen solubility parameters (6.8 MPa^0.5) between Td and the polymer, although this relationship was not satisfied for the partially crystalline dispersion in PVP. Similarly, no correlation was found between the strength of hydrogen bonds investigated using infrared spectroscopy and the physical stability of solid dispersions or the level of supersaturation in aqueous solution.     

Cardiovascular safety of oncologic agents: a double-edged sword even in the era of targeted therapies – Part 2

Introduction: Patients with cancer are subject to the cardiotoxic effects of cancer therapy. Improved cancer treatments lead to more cancer-survivors, who though are exposed to various forms of cardiovascular (CV) disease (CVD) as they age. Aging patients are at increased risk of developing both malignancy and CVD or they may have survived some form of CVD as a result of effective CV treatments. Furthermore, patients with CVD may develop cancer and require treatment (and vice versa), all contributing to increased morbidity and mortality. The prevalence of both malignancy and CVD will increase due to the trend toward a longer lifespan.

Areas covered: In part 2 of this review, the discussion of the CV effects of specific oncology drugs is completed with inclusion of additional immunological agents, current hormonal and other agents. Early detection and monitoring of cardiotoxicity, use of biomarkers and other imaging and diagnostic methods and prevention and treatment options are also discussed.

Expert opinion: As outlined in part 1 of this review, oncologists need to be aware of the CV adverse-effects of their treatments and make careful and expectant clinical decisions, especially in patients with preexisting CVD or CV risk factors. Similarly, cardiologists should consider a detailed previous history of treatment for malignant disease, including prior chemotherapy exposure, dose(s) received, and/or combined modality therapy with chest radiotherapy. Both specialists should collaborate in order to minimize the impact of these two ubiquitous diseases (cancer and CVD) and mitigate the adverse effects of treatment modalities.     

Antioxidants as precision weapons in war against cancer chemotherapy induced toxicity – Exploring the armoury of obscurity

Cancer is the leading cause of mortality worldwide, accounting for almost 13% of deaths in the world. Among the conventional cancer treatments, chemotherapy is most frequently carried out to treat malignant cancer rather than localised lesions which is amenable to surgery and radiotherapy. However, anticancer drugs are associated with a plethora of side effects. Each drug, within every class, has its own set of adverse reactions which may cause patient incompliance and deterioration of the quality of life. One of the major causes of adverse reactions, especially for drugs targeting DNA, is the excessive production of reactive oxygen species (ROS) and subsequent build up of oxidative stress. To curb these undesired side effects, several dietary supplements have been tested, amongst which antioxidants have gained increasing popularity as adjuvant in chemotherapy. However, many oncologists discourage the use of antioxidant rich food supplements because these may interfere with the modalities which kill cancer by generating free radicals. In the present review, all studies reporting concomitant use of several antioxidants with chemotherapy are indiscriminately included and discussed impartially.The effect of supplementation of thirteen different antioxidants and their analogues as a single agent or in combination with chemotherapy has been compiled in this article. The present review encompasses a total of 174 peer-reviewed original articles from 1967 till date comprising 93 clinical trials with a cumulative number of 18,208 patients, 56 animal studies and 35 in vitro studies. Our comprehensive data suggests that antioxidant has superior potential of ameliorating chemotherapeutic induced toxicity. Antioxidant supplementation during chemotherapy also promises higher therapeutic efficiency and increased survival times in patients.     

Potential use of glucuronylglucosyl-β-cyclodextrin/dendrimer conjugate (G2) as a DNA carrier in vitro and in vivo

In this study, we evaluated the polyamidoamine starburst dendrimer (dendrimer, generation 2: G2) conjugate with 6-O-α-(4-O-α-D-glucuronyl)-D-glucosyl-β-cyclodextrin (GUG-β-CDE (G2)) as a gene transfer carrier. The in vitro gene transfer activity of GUG-β-CDE (G2, degree of substitution (DS) of cyclodextrin (CyD) 1.8) was remarkably higher than that of dendrimer (G2) conjugate with α-CyD (α-CDE (G2, DS 1.2)) and that with β-CyD(β-CDE (G2, DS 1.3)) in A549 and RAW264.7 cells. The particle size, ζ-potential, DNase I-catalyzed degradation, and cellular association of plasmid DNA (pDNA) complex with GUG-β-CDE (G2, DS 1.8) were almost the same as those of the other CDEs. Fluorescent-labeled GUG-β-CDE (G2, DS 1.8) localized in the nucleus 6?h after transfection of its pDNA complex in A549 cells, suggesting that nuclear localization of pDNA complex with GUG-β-CDE (G2, DS 1.8), at least in part, contributes to its high gene transfer activity. GUG-β-CDE (G2, DS 1.8) provided higher gene transfer activity than α-CDE (G2, DS 1.2) and β-CDE (G2, DS 1.3) in kidney with negligible changes in blood chemistry values 12?h after intravenous injection of pDNA complexes with GUG-β-CDE (G2, DS 1.8) in mice. In conclusion, the present findings suggest that GUG-β-CDE (G2, DS 1.8) has the potential for a novel polymeric pDNA carrier in vitro and in vivo.     

Bromocriptine – unique formulation of a dopamine agonist for the treatment of type 2 diabetes

Importance to the field: There is a large unmet need for new therapies to treat type 2 diabetes (T2DM) which reduce fasting and postprandial glucose without increasing insulin levels and which are not associated with weight gain or hypoglycemia. The quick-release formulation of bromocriptine (bromocriptine-QR; Cycloset?) represents such a therapy.

Areas covered in the review: Bromocriptine-QR's proposed mechanism of action, unique formulation and clinical efficacy and safety will be discussed. A Medline search was conducted using the terms: bromocriptine quick-release, circadian rhythms, treatment type 2 diabetes, insulin resistance, beta-cell dysfunction (years 1985 – 2009).

What the reader will gain: The reader will gain an understanding of the importance of the brain as a target for the treatment of type 2 diabetes. In addition the safety, efficacy and indication for use of a first-in-class dopamine agonist as a treatment option for type 2 diabetes are discussed.

Take home message: Bromocriptine-QR is indicated to be used alone or in conjunction with all available treatments for type 2 diabetes. Although the mechanism of action is not fully understood, bromocriptine-QR's action points to a central target in the brain (hypothalamus) which may explain the observed peripheral improvements in metabolic parameters.     

Development of transplant immunosuppressive agents – considerations in the use of animal models

ABSTRACT

Introduction: The development of all immunosuppressant agents to date has involved the experimental use of large and small animal models. Over the last half-century, immunosuppressive drugs have extended the lives of transplant patients worldwide. However, the use of animal models in the development of these drugs is not perfect, and this has brought to light a number of issues including idiosyncratic reactions that are found in animal models but not in humans. The 2006 highly publicized case of the ‘elephant man’ TGN 1412 drug trial highlights the importance of being cogent of the limitations of animal models.

Areas covered: This review covers the utility and limitations of the use of animal models for the development of immunosuppressant agents. This includes both large and small animal models, particularly rodent models in the transplant setting.

Expert opinion: The use of animal models represents a critical stage in the development of immunosuppressive drugs. Limitations include physiological differences to humans; this is especially true of immunologically naïve lab rodents with small memory cell populations. Toxic drug levels may differ widely between species. Animal models are also costly and raise ethical concerns. However, there is currently no way to recreate the complex environment of the human immune system purely in vitro.     

Recent trends in stabilising peptides and proteins in pharmaceutical formulation – considerations in the choice of excipients

In the area of peptide and protein pharmaceuticals, both the physical and chemical stability of biopharmaceuticals are critical and need to be optimised when formulating a drug product, in order to optimise the outcome after processing and storage. This review focuses on the effects on the stability from various types of excipient and the choices that have to be made during formulation of drug products containing peptides or proteins. It is illustrated, through examples, how the choice of one excipient over another can affect the stability of a protein drug formulation, along with other problems linked to this choice. The excipients used in pharmaceutical preparations are limited and from an academic point of view there is a clear requirement for new excipients.     

Combining benefits of an adrenergic and a muscarinic blocker in a single formulation – A pharmacokinetic evaluation

A pharmacokinetic bioequivalence study was conducted in Asian subjects, to compare a fixed dose combination capsule single oral dose of alpha adrenoceptor blocker—Alfuzosin hydrochloride 10 mg extended release and muscarinic antagonists—Solifenacin succinate 5 mg against individually administered Xatral XL 10 mg tablets (Alfuzosin) of Sanofi Synthelabo Limited, United Kingdom (UK) and Vesicare 5 mg tablets (Solifenacin) of Astellas Pharma Limited, UK under fed conditions. Blood samples were collected pre-dose up to 72 h post dose for determination of plasma Alfuzosin and Solifenacin concentrations and calculation of the pharmacokinetic parameters. ANOVA was performed on the log (natural)-transformed pharmacokinetic parameters. A 90% confidence interval for the ratios of the test and reference product averages (least square means) were calculated for alfuzosin and solifenacin. The 90% confidence intervals obtained for alfuzosin for C_max, AUC_0−t and AUC_0−∞ were 102.74–122.75%, 95.84–116.96% and 95.82–116.76%, respectively. The 90% confidence intervals obtained for Solifenacin for C_max, and AUC₀₋₇₂ were 89.55–97.91% and 90.47–99.38%, respectively. Based on the results, the fixed dose combination was concluded to be bioequivalent to individually administered products.     

Science or fiction: use of nesiritide as a first-line agent?

Nesiritide is an effective agent for the treatment of decompensated CHF. However, the VMAC trial shows that the agent's efficacy and safety are actually more similar than dissimilar to those of nitroglycerin. Indeed, objective reviews have placed nesiritide as a second-line agent behind current standard drug therapy. Finally, nesiritide is approximately 40 times the purchase price of standard agents such as nitroglycerin. For these reasons, we feel that nesiritide should not be considered as first-line therapy. Reflecting this notion, one institution has implemented a protocol that recommends administration of nitroglycerin and intravenous diuretics (using > or = 2 times the usual daily diuretic dose) before using nesiritide. In light of the existing data, we feel that this approach appears to be an appropriate and prudent one for nesiritide's place in therapy.     

Methodological considerations in nicotine research: the use of “denicotinised” cigarettes as the control condition in smoking studies

In this study, we report on the comparability of the subjective experience and smoking style elicited by two commercially available cigarettes which differ in nicotine levels, one containing a regular delivery of 0.7 mg and the other containing minimal (0.1 mg) nicotine. Our findings suggest subtle differences in the smoking of these two cigarettes, with the denicotinised cigarette being smoked for longer and with more puffs taken. While these subtle differences have little significance for studies concerned with the effects of nicotine on cognitive performance measures, they are certainly important for studies concerned with the role of nicotine in maintaining smoking behaviour.     

Keeping the “continuous” in continuous quality improvement: Exploring perceived outcomes of CQI program use in community pharmacy

BackgroundGiven the significant potential of continuous quality improvement (CQI) programs in enhancing overall levels of patient safety, community pharmacies in North America are under increasing pressure to have a formal and documented CQI program in place. However, while such initiatives may seem great on paper, in practice the outcomes of such programs to community pharmacy practice remain unclear.ObjectiveTo explore the perceived outcomes identified by community pharmacies that adopted and actively used a standardized (i.e., common across pharmacies) CQI program for at least 1 year and to develop a framework for how such outcomes were achieved.MethodsA multi-site study of SafetyNET-Rx, a standardized and technologically sophisticated (e.g., online reporting of medication errors to a national database) CQI program, involving community pharmacies in Nova Scotia, Canada, was performed. During the summer and fall of 2011, 22 interviews were conducted with the CQI facilitators in 12 Nova Scotia community pharmacies; equally split between independent/banners and corporate chains. Of the CQI facilitators, 14 were pharmacists, while the remaining eight were pharmacy technicians. Thematic analysis following the procedures presented by Braun and Clarke was adopted to identify and explore the major outcomes.ResultsResults of the thematic analysis highlighted a number of perceived outcomes from the use of a standardized CQI program in community pharmacies, specifically: (1) perceived reduction in the number of medication errors that were occurring in the pharmacy, (2) increased awareness/confidence of individual actions related to dispensing, (3) increased understanding of the dispensing and related processes/workflow, (4) increased openness to talking about medication errors among pharmacy staff, and (5) quality and safety becoming more entrenched in the workflow (e.g., staff is more aware of their roles and responsibilities in patient safety and confident that the dispensing processes are safe and reliable). In achieving such outcomes, pharmacies had to balance customizing the CQI program to address a number of operational challenges, with ensuring that the core standardized components remained in place.ConclusionsThis research identified the perceived outcomes of CQI program use by CQI facilitators. Additionally, the findings are incorporated into a framework for CQI implementation that can be used by pharmacy managers, corporate head offices, and regulatory authorities to leverage greater CQI adoption and success.     

Hyaluronic acid (Supartz®): a review of its use in osteoarthritis of the knee

Hyaluronic acid (Supartz?; molecular weight 620-1170?kDa) is a sterile, viscoelastic, non-pyogenic solution that is indicated as a medical device for the treatment of pain in patients with osteoarthritis of the knee who have failed to respond adequately to conservative nonpharmacological therapy and simple analgesics. Intra-articular injections of Supartz? were significantly more effective than control injections, according to an integrated longitudinal analysis of pooled data from five randomized, double-blind, vehicle-controlled, multicentre trials in patients with osteoarthritis of the knee. Supartz?, compared with the phosphate-buffered saline control, significantly reduced the total Lesquésne Index score in the post-injection period. Data from the individual trials demonstrated that the reduction in the total Lesquésne Index score was significantly greater than the control in two of the five studies. According to another efficacy endpoint (the mean reduction in the Western Ontario and McMaster Universities Osteoarthritis Index), which was assessed in only one of these trials, Supartz? was significantly more effective than the control in reducing the pain and stiffness subscale scores. Clinical scores of pain/inflammation and visual analogue scale (VAS) scores of pain during walking improved from baseline values for up to 6 months after treatment with Supartz? or a corticosteroid, with no significant between-group differences, in a small, randomized, open-label, multicentre trial in patients with osteoarthritis of the knee. Intra-articular injections of both Supartz? and Synvisc?, as well as a phosphate-buffered saline control, significantly reduced VAS scores of weight-bearing pain versus baseline after 26 weeks of therapy in a well designed trial; however, there were no significant differences between the three treatment groups. Neither hyaluronic acid formulation had a longer duration of clinical benefit than the saline control. Supartz? was well tolerated in patients with osteoarthritis of the knee. An integrated analysis of the five, well designed clinical trials demonstrated no significant difference between the Supartz? or control groups in the incidence of adverse events. The most common adverse events reported in Supartz? recipients were arthralgia, arthropathy/arthrosis/arthritis, back pain, nonspecific pain, injection-site reaction, headache and injection-site pain.     

Impulsivity as a moderator of the intention–behavior relationship for illicit drug use in patients undergoing treatment

Introduction

Evident across clinical practice and clinical trials is a divergence between stated intentions and subsequent drug-related behaviors in substance abuse treatment settings. Impulsivity, itself related to drug abuse, may be one variable which may moderate the degree of disconnect in the intention–behavior relationship. The present study examines the relationship between self-stated desire to quit, impulsivity, and drug use in a group of outpatients receiving methadone maintenance treatment. In particular, we examined the direct and moderating influence of different facets of impulsivity (urgency, lack of premeditation, sensation seeking, and lack of perseverance) on drug use in the context of a stated desire to abstain from drugs.

Method

84 opioid-dependent individuals undergoing counseling and methadone maintenance treatment completed a battery of self-report questionnaires including measures of impulsivity (UPPS Impulsivity Scale), stated desire to quit, and past 30-day drug use. We hypothesized that two facets of impulsivity, urgency and (lack of) premeditation, would moderate the relationship between desire to quit and past 30-day drug use, such that the relationship between intention and behavior would be weaker in those with high levels of these facets of impulsivity.

Results

Consistent with the disconnect between intentions and drug-use behaviors typical of treatment settings, desire to quit was not directly associated with self-reported past month drug use. However, in separate regression analyses, 2 facets of impulsivity, premeditation and sensation seeking, moderated the relationship between desire to quit and past month use. Whereas there was not a significant relationship between desire to quit and drug use in individuals high in sensation-seeking or lack of premeditation, the relationship between intention and drug use behaviors was preserved in those low in these facets of impulsivity.

Conclusion

These findings indicate that the relationship between desire to quit and self-reported past-month drug use is weak for those high in sensation seeking or low in premeditation. These results are discussed in the context of current interventions for substance dependence.