dosage - chapter 15
TRANSCRIPT
Sterile Dosage Forms and Delivery Systems
PARENTERALS
Sterile dosage forms: - various
small-volume & large-volume injectable preparations irrigation fluids - intended to bathe body wounds or surgical
openings, and dialysis solutions.
Sterility - essential: in direct contact with
the internal body fluids/tissues, - infection easily arises.
INJECTIONS Injections - sterile, pyrogen-free preparations intended to be
administered parenterally. parenteral - injectable routes of administration. - derived from the Greek words para (outside) and
enteron (intestine) - additives: buffer, stabilizer, antibacterial preservative, antioxidant - packaged in hermetic containers Pyrogens - fever-producing organic substances arising from
microbial contamination - responsible for many of the febrile reactions in patients following IV injections.
DIFF. PARENTERAL ROUTES ADMINISTRATION
Drugs may be injected into the almost any organ or area of the body:
joints (intra-articular) joint fluid area (intrasynovial) spinal column (intraspinal) spinal fluid (intrathecal) arteries (intra-arterial) heart (intracardiac) vein (intravenous, IV) muscle (intra-muscular, IM) skin (intradermal, ID, intracutaneous) under the skin (subcutaneous, SC, sub-Q, SQ,
hypodermic, hypo)
INTRAVENOUS ROUTE
INTRVENOUS ROUTE
Thrombus and embolus formation - main hazard of IV infusion -induced by intravenous needles/catheters
touching the wall of the vein and the possibility of particulate matter in parenteral solutions.
Thrombus - blood clot within the blood vessel or heart - slowing of the circulation or an alteration of the
blood or vessel wall. Embolus - clot circulates carried by the blood stream → blood vessel (obstruction and results in a block or occlusion - embolism)
Intravenous drugs Advantages: - rapid action compared with other routes of
administration. - Optimum blood levels achieved with accuracy
and immediacy not possible by other routes. - lifesaving in emergencies, prompt action with the
direct placement of the drug to the circulation Disadvantages: - once administered it cannot be retrieved. - drug cannot be easily removed from the
circulation in adverse drug reaction
Intravenous drugs part selected: veins of the antecubital area (in
front of the elbow) - large, superficial, and easy to see and enter.
Sterile/disinfected: *injectable solutions, syringes and needles,
and the point of entrance - reduces the chance of carrying bacteria from
the skin into the blood via the needle.
infusion or flow rate for intravenous fluids - adjusted according to the needs of patient - expressed in mL/hour and range from 42 to 150 mL/hour.
Intravenous drugs - in aqueous solution - must mix with the circulating blood and not
precipitate from solution: lead to pulmonary microcapillary occlusion and blockage of blood flow.
Intravenous fat emulsions - use: source of calories and essential fatty acids
for patients requiring parenteral nutrition for extended periods.
Patient-controlled analgesia (PCA)- controls pain (surgical procedures, labor, sickle cell crisis, and cancer), with less side effects
- minimizes variations bet. suboptimal pain relief & overuse of opioids
ADVANTAGES: - provides constant & uniform analgesia - prevents pharmacokinetic and
pharmacodynamic differences between patients from interfering with the effectiveness of analgesia
- permits patients to medicate themselves for breakthrough pain
INTRAMUSCULAR ROUTE Intramuscular injections of drugs - oleaginous suspension can only be administered
through this route - effects are less rapid but longer lasting than IV
administration. - performed deep into the skeletal muscles
Injuries to patients are related to *point at which the needle entered and where the
medication was deposited. - injuries include: *paralysis resulting from neutral damage *abscess *cyst *embolism *hematoma *sloughing of the skin *scarring
INTRAMUSCULAR ROUTE
frequently used site - adults
*upper outer quadrant of the gluteus maximus - infants and young children * deltoid muscles of the upper arm/midlateral
muscles of the thigh volume of medication administered : - 5 mL in the gluteal region - 2 mL in the deltoid of the arm.
Z-track injection technique for IM- stain upper tissue by sealing medications in the lower muscle- creates a Z pattern that blocks infiltration of medication into the subcutaneous tissue
- injection is 2 to 3 inches deep, and 20-gauge and 22-gauge needle is used.
SUBCUTANEOUS ROUTE Use: for injection of small amounts of
medication. Usual route for insulin injection Injection beneath the skin - in the loose interstitial tissue of the outer, upper
arm, the anterior thigh, or the lower abdomen. maximum amount of medication injected - 1.3 mL, *greater than 2 mL will most likely cause
painful pressure.
SUBCUTANEOUS ROUTESUBCUTANEOUS ROUTE
Syringes used - up to 3 mL capacities and 24-gauge to
26-gauge needles are. Irritating drugs and those in thick
suspension - produce indurations, sloughing, or
abscess and may be painful
INTRADERMAL ROUTE injected into the corium, the more vascular
layer of the skin just beneath the epidermis. substances include - various agents for diagnostic determinations,
desensitization, or immunization. site for intradermal injection -anterior forearm. needle employed - short (three-eights of an inch) and narrow (23-
gauge to 26 gauge)
INTRADERMAL ROUTEINTRADERMAL ROUTE
OFICIAL TYPES OF INJECTIONS Injection
-liquid preparations that are drug substances or solutions
For Injection-dry solids + suitable vehicles → solutions conforming to the requirements for injections
Injectable Emulsion-liquid preparation of drug substance dissolved or dispersed in a suitable emulsion medium
Injectable suspension-liquid preparation of solid suspended in a suitable liquid medium
For Injectable Suspension-dry solid + suitable vehicle → preparation conforming to the requirements for injectable suspensions
Differences parenteral products & Differences parenteral products & other dosage formsother dosage forms
Solvents/vehicles Solvents/vehicles
- meet - meet special purity & other standardsspecial purity & other standards ensuring their ensuring their safety by injectionsafety by injection
restricted in certain parenteral productsrestricted in certain parenteral products: use of added : use of added subs’s (buffers, stabilizers & antimicrobial subs’s (buffers, stabilizers & antimicrobial preservatives) preservatives)
Parenterals:Parenterals:
- always - always sterilizedsterilized
- - meet the compendial standards meet the compendial standards for particulate matterfor particulate matter
- - packaged in special hermetic containerpackaged in special hermetic containers of special & s of special & high qualityhigh quality
Differences parenteral products & Differences parenteral products & other dosage formsother dosage forms
Each injection container Each injection container
- - filled slightly in excess filled slightly in excess of the labeled volume to be of the labeled volume to be withdrawnwithdrawn
volume of injection permitted in multiple-dose volume of injection permitted in multiple-dose containers containers
- restricted, as the types of containers that may be - restricted, as the types of containers that may be used for certain injectionsused for certain injections
Specific labeling regulations Specific labeling regulations apply to injectionsapply to injections Sterile powders intended for solution/suspensions Sterile powders intended for solution/suspensions
immediately prior to injection immediately prior to injection
- - packaged as freeze-dried powders packaged as freeze-dried powders to permit ease of to permit ease of soln/suspension upon the addition of the soln/suspension upon the addition of the solvent/vehiclesolvent/vehicle
SOLVENTS AND VEHICLES FOR INJECTIONS
Water for Injection, USP- most frequently used solvent in the large scale manufacturer of injections- purified by distillation or by reverse osmosis and meets the same standards for presence of total solids - use: manufacture of injectable products to be sterilized after preparation.
Purified Water, USP- not more than 1 mg/100 mL Water for Injection
Sterile Water for Injection, USP- may contain slightly more total solids than Water for Injection because of the leaching of solids from the glass-lined tanks during sterilization- use: solvent or diluent for already sterilized and packaged injectable medication.
Bacteriostatic Water for Injection, USP- sterile water for injection containing one or more suitable antimicrobial agents.
- “not intended for neonates”- use: only in parenterals administered in small volumes because of the presence of antimicrobial agents
Sodium Chloride Injection, USP- sterile isotonic solution of NaCl in water for injection
- use: *sterile vehicle in solutions or suspensions of drugs for parenteral administration
*catheter or intravenous line to infuse fluids & medications to maintain potency Bacteriostatic Sodium Chloride Injection
- sterile isotonic solution of NaCl in water for injection
- Use: *for bacteriostatic water for injection
*catheter or intravenous line flush to maintain potency
Ringer’s Injection, USP- sterile solutions of NaCl, KCl, and CaClCaCl22
in water for injection- use: vehicle for other drugs/ alone as an electrolyte replenisher and plasma volume expander
Lactated Ringer’s Injection- contains NaCl, KCl, CaClCaCl22 & Na lactate
- fluid and electrolyte replenisher and a systemic alkalyzer
NONAQUEOUS VEHICLES- use: when physical or chemical factors limit the use of a wholly aqueous vehicle
Qualities:- nonirritating, nontoxic, and not sensitizing- must not exert a pharmacologic activity of its own, nor affect the activity of the medicinal agent
- physical and chemical properties evaluated and determined:
stability at various pH levels, viscosity, fluidity, boiling point, miscibility with body fluids, low vapor pressure and constant purity.
ADDED SUBSTANCES in injections
USP permits addition of suitable substances: antibacterial preservatives, buffers, solubilizers, antioxidants, and other adjuncts.
- to increase stability or usefulness (but not interdicted in the individual monographs)
- harmless in the amounts administered - do not interfere with the therapeutic efficacy of
the preparation or with specified assays and tests.
METHODS OF STERILIZATIONSterilization
- destruction of all living organisms and their spores or their complete removal from the preparation.
Steam Sterilization- conducted in an autoclave and employs steam under pressure
- microbial destruction is caused by denaturation & coagulation of bacterial proteins by moist heat
- Bacillus stearothermophilus: biological indicator - applicable to pharmaceutical preparations and materials:
*withstand the required temperatures *penetrated but not adversely affected by moisture
Dry Heat Sterilization- carried out in ovens, heated by gas or electricity and are generally thermostatically controlled
- Bacillus subtilis: biological indicator- use: for substances not effectively sterilized by moist heat
Sterilization by Filtration- depends on the physical removal of microorganisms by adsorption on the filter medium or by a sieving mechanism- use: for heat-sensitive solutions
Millipore filter - thin plastic membrane of cellulosic esters with
millions of pores per square inch
Bacterial FiltrationBacterial Filtration- Best suited for extemporaneous preparation of sterile
solutionadvantages - speed in the filtration of small quantities of solution- ability to sterilize thermolabile materials- relatively inexpensive equipment required- development and proliferation of membrane filter
technology- complete removal of living and dead microorganisms and
other particulate matter from the solutiondisadvantage
- membrane tends to be fragile- essential to determine that the assembly was properly
made (membrane not ruptured/flawed during assembly, sterilization, or use).
Gas Sterilization- requires specialized equipment resembling an autoclave, and many combination steam autoclaves and ethylene oxide sterilizers
- for sterilizing heat resistant & moisture resistant products
Sterilization by Ionization Radiation - sterilization by gamma rays and by cathode
rays, but application of such techniques is limited because of the highly specialized equipment required and the effects of irradiation on products and their containers
- biological indicator: Bacillus pumilus
VALIDATION OF STERILITY- effectiveness of thermal sterilization quantified:
*determination & calculation of F value to express thermal death.
Biologic Indicator - best used to validate sterility for steam
sterilization- a characterized preparation of specific microorganisms resistant to a particular
sterilization process- use: to monitor a sterilization cycle and/or periodically to revalidate the process
Thermal Death Time- time required to kill a particular organism under specified conditions
PYROGENS
causative material of pyrogens - a lipopolysaccharide from the outer cell wall of
the bacteria and endotoxins. - material is thermostable and water soluble
(remain in water even after sterilization by autoclaving or by bacterial filtration).
common means of removing pyrogens - by oxidizing: easily eliminate gases or
nonvolatile salts of any acidic compounds present.
Pyrogen Test, USP
Uses: healthy rabbits properly maintained in terms of environment and diet before the test
Normal, or control, temperatures are taken for each animal
- used as the base for the determination of any temperature increase resulting from injection of a test solution
- rabbits used: temperatures do not differ by more than 1ºC from each other
Examples of sterile drugs prepared and packaged without
pharmaceutical additives (buffers, preservatives, stabilizers, and
tonicity agents): Ampicillin sodium Ceftizoxime sodium Ceftazidime sodium Cefuroxime sodium Kanamycin sulfate Nafcillin sodium Penicillin G benzathine Streptomycin sulfate Tobramycin sulfate
Sterile drugs formulated with pharmaceutical additives and
intended to be reconstituted prior to injection:
Cyclophosphamide Dactinomycin Eryhtromycin lactobionate Hydrocortisone sodium succinate Mitomycin Nafcillin sodium Oxytetracycline hydrochloride Penicillin G potassium Vinblastine sulfate
Innovations done for powders for Innovations done for powders for reconstitutionreconstitution
Sometimes a liquid is packaged along with the Sometimes a liquid is packaged along with the dry powderdry powder
Dry powders are packaged in containers large Dry powders are packaged in containers large enough to permit proper shaking with the liquid enough to permit proper shaking with the liquid componentcomponent
Mix-O-vialMix-O-vial
- incorporates the IV systems that allow - incorporates the IV systems that allow preparing small volumes infusions preparing small volumes infusions extemporaneouslyextemporaneously
Abbott ADD-Vantage System IVPBAbbott ADD-Vantage System IVPB
Monovial Safety GuardMonovial Safety Guard Manufacturer: Becton Dickinson Manufacturer: Becton Dickinson
Pharmaceutical SystemsPharmaceutical Systems New IV system for use in preparing New IV system for use in preparing
extemporaneous small-volume infusions extemporaneous small-volume infusions using using plastic minibagsplastic minibags
Saves time, uses fewer materials & costs lessSaves time, uses fewer materials & costs less Integrated drug transfer with a protective shield Integrated drug transfer with a protective shield
surrounding the attached transfer needlesurrounding the attached transfer needle
PACKAGING, LABELING, AND STORAGE OF INJECTIONS
Single-dose container- hermetic container for parenteral
administration as a single dose - when opened, cannot be resealed with
assurance that sterility has been maintained
Multiple-dose container- hermetic container that permits withdrawal of successive portions of the contents without changing the strength, quality, or purity of the remaining portion
ASHP RISK LEVEL CLASSIFICATION OF PHARMACY-PREPARED STERILE
PRODUCTSRisk Level 1
1. Products Stored at: - room temperature and administered within
28 hours of preparation - under refrigerator for 7 days or less before
complete administration over a period not to exceed to 24 hours
Frozen for 30 days or less before complete administration
ASHP RISK LEVEL CLASSIFICATION OF PHARMACY-PREPARED STERILE PRODUCTS
Risk Level 1
2. Unpreserved sterile products for administration to one patient or batch-prepared products
- containing suitable preservatives for administration to more than one patient
3. Products prepared by closed-system aseptic transfer of sterile nonpyrogenic finished pharmaceutics obtained from licensed manufacturer into sterile final containers obtained from licensed manufacturer
ASHP RISK LEVEL CLASSIFICATION OF PHARMACY-PREPARED STERILE PRODUCTS
Risk Level 2
Products : stored beyond 7 days under refrigeration/stored
beyond 30 days frozen or administered beyond 28 hours after preparation and storage at room temperature
Batch-prepared without preservatives for use by more than one patient.
compounded by complex or numerous manipulations of sterile ingredients obtained from:
- licensed manufacturers in a sterile container or reservoir obtained from a licensed manufacturer by using closed-system aseptic transfer
ASHP RISK LEVEL CLASSIFICATION OF PHARMACY-PREPARED STERILE PRODUCTS
Risk Level 3 Products: compounded from nonsterile ingredients or
compounded with nonsterile compounds with nonsterile components, containers, or equipment before terminal sterilization
prepared by combining multiple ingredients by using an open-system transfer or open reservoir before terminal sterilization.
CRITERIA IN DETERMINING THE PRODUCT’S TITLE FOR ESTABLISHED NAMES OF INJECTABLE PRODUTCS
a. Liquids [Drug]Injection
- title for liquid preparations that are drug substances or solutions thereof
[Drug]Injectable suspension- title for liquid preparations of solids suspended in a suitable liquid medium
[Drug]Injectable emulsions- title for liquid preparations of drug substances dissolved or dispersed in suitable emulsion medium
b. Solids [Drug]For injection
- dry solids + suitable vehicles → solutions conforming in all respects to the requirements for injections
[Drug]For injectable suspension- dry solids that + suitable vehicles
→preparations conforming to the requirements for Injectable Suspensions
SMALL-VOLUME PARENTERALS Insulin Injection (regular)
-sterile aqueous solution of insulin: the only one administered intravenously- prepared from beef or pork pancreas or both or through biosynthetic means- problems encountered:
*lipohypertrophy (buildup of fibrous tissue) *lipodystrophy Human Insulin
- produced by using a special non-diseases-forming laboratory strain of E. coli and recombinant DNA technology
Lispro Insulin Solution- consists of zinc insulin lispro crystals dissolved in a
clear aqueous fluid- created when the amino acids at positions
28 and 29 on the insulin B-chain are reversed
Insulin Aspart- recombinant ultra-short acting insulin using Saccharomyces cerevisiae (baker’s yeast) as the production organism
Isophane Insulin Suspension (NPH/neutral protamine hagedorn Insulin)
- protamine is added- sterile suspension in aqueous vehicle buffered with dibasic sodium phosphate to pH 7.1 to 7.4
Isophane Insulin Suspension and Insulin Injection- premixed formation of isophane insulin suspension and insulin suspension and insulin injection
Humalog Mix- manufactured premixed insulin lispro and neutral protamine lispro (NPL) in fixed ratio
Insulin Zinc Suspension - the smaller amorphous form has most
prompt hypoglycemic action & absorbed more rapidly than the larger crystalline form
- contains zinc chloride
Insulin Glargine- long-acting basal insulin preparation intended for once daily subcutaneous administration at bedtime in the treatment of type I diabetes melitus in adults and children- can also be used by adults with type II diabetes who require long-acting insulin
Extended Insulin Zinc-Suspension- sterile suspension of zinc insulin crystals in an aqueous solution medium buffered with sodium acetate to pH 7.2 to 2.5
Insulin Infusion Pumps- patients achieve and maintain blood glucose to nearly normal levels on a constant basis
INSULIN PREPARATIONS:- Expiration date is set after 24 months after
filling- Amorphous form of zinc chloride added to
insulin prep. Has prompt action than the crystals- Freezing is avoided during storage- Preparations with neutral pH are more stable
than with acidic pH
SOME INJECTIONS USUALLY PACKAGED AND ADMINISTERED IN SMALL VOLUME
Chlorpromazine HCl- Antipsychotic drug with antiemetic
Cimetidine HCl- Histamine H2 antagonist
Dexamethasone sodium phosphate- Glucocorticoid
Digoxin- Carditonic
Diphenhydramine HCl- Ethaqnolamine, nonselective antihistamine
Furosemide- Loop diuretic
Phenytoin sodium- Anticonvulsant
Procaine penicillin G- Anti-infective
Propranolol HCl- Beta-adrenergic receptor blocker for hypertension
Verapamil HCl- Calcium channel blocker
Heparin sodium- Anticoagulant
Hydromorphone HCl- Opioid analgesic
Lidocaine HCl- Cardiac depressant
Meperidine HCl- Opioid analgesic
Methoclopramide monohydrochloride- Gastrointestinal stimulant
Morphine sulfate- Opioid analgesic
Oxytocin- Oxytocic
Single- dose containerSingle- dose container Hermetic container holding a quantity of sterile drug for Hermetic container holding a quantity of sterile drug for
single dosesingle dose When opened cannot be resealed for assurance When opened cannot be resealed for assurance
sterility is maintainedsterility is maintained
Multiple- dose containerMultiple- dose container Hermetic container permits withdrawal of successive Hermetic container permits withdrawal of successive
portions of the contents without changing the strength, portions of the contents without changing the strength, quality or purity of remaining portionquality or purity of remaining portion
SOME INTRAVENOUS INFUSIONS ADMINISTERED IN VOLUMES OF 1 L OR MORE (ALONE OR WITH OTHER
DRUGS) Amino acid
- Fluid and nutrient replenisher Dextrose Injection, USP
- Fluid and nutrient replenisher Dextrose and Sodium Chloride
Injection, USP- Fluid, nutrient, electrolyte replenisher
Mannitol Injection, USP- Diagnostic aid in renal functions, diuretic, fluid and nutrient replenisher
Ringer’s Injection, USP- Fluid and electrolyte replenisher
Lactated Ringer’s Injection, USP- Systemic alkalinizer; fluid and electrolyte replenisher
Sodium Chloride Injection, USP- Fluid and electrolyte replenisher; isotonic vehicle
LARGE-VOLUME PARENTERALS Maintenance Therapy Replacement Therapy Water Requirement Electolyte Requirement Caloric Requirement Parenteral Nutrition
Electrolytes- Sodium- Potassium- Magnesium- Calcium- Chloride- Acetate- Phosphate
Enteral Nutrition Intravenous Infusion Devices
SPECIAL CONSIDERATIONS ASSOCIATED WITH PARENTERAL THERAPY
Look-alike Products Adsorption of Drugs
- Chlorpromazine HCl- Diazepam- Insulin - Nitroglycerin- Promazine HCl- Promethazine HCl- Thiopental sodium- Thioridazine HCl- Thrifluoperazine HCl- Warfarin sodium
Handling and Disposal of Chemotherapeutic Agents for Cancer
OTHER INJECTABLE PRODUCTS:PALLETS OR IMPLANTS
Levonorgestrel Implants - Norplant system
- set of 6 flexible closed capsules of a dimethylsiloxane-methyl vinyl Siloxane copolymer, each containing 36 mg of the progestin
- excellent contraceptiveZoladex implant - Goserelin acetate implant, Zeneca Pharmaceuticals– treatment of prostatic cancerCrinone Gel – assists in reproductionLacrisert – for treatment of dry eyes-
IRRIGATION AND DIALYSIS SOLUTIONS
- Does not enter into the circulatory system- Packaged as LVP
Irrigation Solutions- intended to bathe or wash wounds, surgical incisions, or body tissues
Dialysis Solutions- separations of substances from one another in solution by taking advantage of their differing diffusibility through membranes
EXAMPLES OF IRRIGATION SOLUTIONS Acetic Acid Irrigation, USP Neomycin and Polymixin B Sulfates Solution for
Irrigation, USP Ringer’s Irrigatio, USP Sodium Chloride Irrigation, USP Sterile Water for Irrigation USP
Some precautions observed during Some precautions observed during manufacture, storage & use of products manufacture, storage & use of products to prevent entry of contaminantsto prevent entry of contaminants
Once opened, ampul cannot be resealed, unused portion Once opened, ampul cannot be resealed, unused portion not retained & used (content loss sterility)not retained & used (content loss sterility)
Prime requisite of parenteral soln: clarityPrime requisite of parenteral soln: clarity
- sparkling clear & free of particulate matter- sparkling clear & free of particulate matter During mfture, parenteral soln is filtered before it goes into During mfture, parenteral soln is filtered before it goes into
the containerthe container Containers are selected:Containers are selected:
- Chemically resistant to the solnChemically resistant to the soln
- Highest quality to minimize chances of container Highest quality to minimize chances of container components leaching into the solnscomponents leaching into the solns
During container filling – use laminar flow hoodsDuring container filling – use laminar flow hoods
Some precautions observed during Some precautions observed during manufacture, storage & use of products manufacture, storage & use of products to prevent entry of contaminantsto prevent entry of contaminants
Personnel mfg parenteralsPersonnel mfg parenterals
- provided with monofilament fabrics (does not lint), face - provided with monofilament fabrics (does not lint), face hoods, caps, gloves & disposable shoe covers to hoods, caps, gloves & disposable shoe covers to prevent contaminationprevent contamination
After filling & sealing: visual/automatic inspection for After filling & sealing: visual/automatic inspection for particulate matterparticulate matter
- clarity : test requirement done to avoid distribution & - clarity : test requirement done to avoid distribution & use of parenterals that contain particulate matteruse of parenterals that contain particulate matter
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