Virtual accreditation visits for pharmacy programs in light of the COVID-19 pandemic: Team members' perspective.

PURPOSE: This wisdom of experience commentary, from peer academic reviewers serving on accreditation teams, will discuss benefits and challenges of international and national virtual accreditation visits (VAVs) using a "What? So What? Now What?" reflective model. DESCRIPTION: Onsite accreditation reviews for health professional education programs require investments in time, effort, and money to maintain program alignment with accreditation standards and continuously generate quality practitioners. When COVID-19 entered the accreditation world, reviewers had to pivot modalities to a VAV format. ANALYSIS/INTERPRETATION: Adaptation and expectations of VAVs present several challenges. Barriers and advantages will be discussed as well as implications for the future. While medical and pharmacy education standardization has long been established, the authors propose national and international accrediting bodies will utilize the ingenuity of emergency COVID-19-driven onsite accreditation alternatives to develop protocols for novel accreditation methodology. CONCLUSIONS: Whether the continued mutation of COVID-19 prevents the return to previous accreditation visits or not, the experiences gained from the emergency-driven VAV, can inform and enrich accrediting bodies knowledge, theories, and practices of future VAVs. IMPLICATIONS: Higher-education institutions, accreditation bodies, and government entities will use experiences during COVID-19 to transform and improve academic requirements and future practices. Even if there is a full return to onsite reviews, such guidelines or improved versions of them can be applied to situations where immobility or restricted mobility is an issue, such as in illness, pregnancy, travel, war, etc. It is crucial for educators and accrediting bodies to evolve as we navigate these unprecedented times.

Formulation Challenges and Strategies to Develop Pediatric Dosage Forms.

The development of pediatric-specific dose forms is particularly difficult due to a variety of factors relating to pediatric population differences from adult populations. The buccal dosage form is considered a good alternative to oral dosage form if the latter cannot be used in pediatric patients. Both oral and buccal dosage formulations uphold great application qualities for pediatric patients. This review sheds light on both oral and buccal, as they are the most convenient dosage forms for pediatrics. The use of adult drugs to treat children is a legislation concern, as it may result in incorrect dose, safety, and efficacy. The Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA) are two key pieces of legislation that encourage and regulate pediatric medication research. Both contribute to a well-balanced approach to emphasizing critical safety and efficacy warnings for the of medications within pediatric populations. These contributions are what enable companies to continue making significant investments in pediatric drug developments. Despite the importance of investigating medicines for children, there is still a demand for pediatric-specific formulations and dosage forms. Many formulations and dosage forms can be designed, among which the buccal drug delivery seems a good modality for pediatric-friendly dosage forms. The main issues associated with these pediatric dosage forms development, particularly clinical and physiological factors, are discussed in this review. In addition, formulation developments and regulatory expectations are highlighted. In turn, suggestions are made to potentially improve future pediatric formulation development.

Cultural Sensitivity and Global Pharmacy Engagement in the Arab World.

Objective. To create a resource on cultural sensitivity for schools and colleges of pharmacy that are currently engaged or considering future outreach opportunities in the Arab world. Methods. A literature review (2000-2018) of databases and Internet searches with specific keywords and terms were conducted. Authors who had experience in travelling to and hosting students and professionals from the Arab world and authors with local work experience in the Arab world were solicited. Results. General information about the Arab world, including unique aspects of individual countries, is presented. Stereotypes and misconceptions regarding the region and the people are discussed. Specific information about the government and infrastructure of each country, including their health care system is provided, with emphasis given to pharmacy education and practice in the region. In addition, recommendations for culturally sensitive engagement for pharmacy and other health care practitioners are discussed. Finally, recommendations for culturally sensitive engagement when hosting students and/or faculty members from the Arab world are also addressed. Conclusion. Global engagement between schools and colleges of pharmacy in the United States and those in the Arab world is increasing. For an enriching and fruitful engagement, sensitivity toward the cultural and clinical needs of the people, and in particular, the professionals of that region is critical.

Sterility and Stability Testing of Preservative-free Albuterol.

BACKGROUND: Continuous albuterol administration (CAA) is commonly used in hospitalized patients for treatment of asthma exacerbations. Due to higher dose requirements, CAA requires large volumes of albuterol obtained from multidose vials containing benzalkonium chloride (BAC). BAC is a common pharmaceutical preservative and potent bronchoconstrictor, which may antagonize the bronchodilation effects of albuterol. Some institutions are using preservative-free (PF) albuterol for their CAA. However, no published data currently exist to support the extended sterility or stability of this formulation. OBJECTIVE: To evaluate the sterility and stability of PF-albuterol. METHODS: Sterility testing was conducted for PF- and BAC-albuterol when stored at room temperature. Samples were incubated for 10 days in aerobic and anaerobic blood culture media to assess for bacterial growth. Stability of both albuterol formulations at high (0.67 mg/mL) and low (0.17 mg/mL) concentrations was determined at room temperature and under refrigeration. High performance liquid chromatography was used to evaluate samples up to 168 hours after preparation. RESULTS: No bacterial growth was witnessed from either albuterol formulation at day 10 of observation. Both high and low concentrations of PF-albuterol and BAC-albuterol were stable at room temperature for up to 168 hours. There were no differences in stability between storage conditions for any formulation. CONCLUSIONS: Under the current study conditions, there was no difference in sterility or stability for PF-albuterol when compared with BAC-albuterol. Thus, based on the findings of this study, PF-albuterol is sterile and stable up to 168 hours when stored at room temperature or under refrigerated conditions. The findings of this study do not confirm the therapeutic efficacy of PF-albuterol compared with BAC-albuterol for the treatment of asthma exacerbations. Further studies are warranted to determine the efficacy of PF-albuterol verses BAC-albuterol when used for CAA.

A Call to Action to Transform Pharmacy Education and Practice in the Arab World.

Globally, pharmacy education is evolving to reflect a more patient-centered, interprofessional approach to clinical practice. In the 22 countries of the Arab world, advancements in regulatory support for pharmacy practice and changes to the health care system have been slower than in Europe, Asia, and the Americas. Significant cultural, logistical, and legal barriers exist in many countries, and a consensus approach to accreditation, educational outcomes, and curricula design is lacking. This commentary briefly examines the current state of both pharmacy education and practice in the Arab world, and it highlights recent reports of curricular reform and innovation. Additionally, it provides potential strategies for improving the quality of education and for expanding pharmacy practice to ensure graduates and practitioners have adequate experiential opportunities and institutional support.

Sublingual spray drug delivery of ketorolac-loaded chitosan nanoparticles.

INTRODUCTION: The aim of this study was to investigate ketorolac (KT) systemic absolute bioavailability after sublingual (SL) administration in vivo to conscious rabbits. Furthermore, the study investigated the potential use of chitosan nanoparticles as a delivery system to enhance the systemic bioavailability of KT following SL administration. METHODS: Ketorolac-loaded chitosan nanoparticles were prepared through ionotropic gelation of chitosan with tripolyphosphate anions. The KT-nanoparticles were administered SL as a spray to rabbits and KT plasma concentration at predetermined time points was compared to SL spray administration of KT in solution. The concentrations of KT in plasma were analyzed by ultra-performance liquid chromatography mass spectroscopy (UPLC/MS). RESULTS: KT-loaded chitosan nanoparticles significantly (p < .05) enhanced systemic absorption with 97% absolute bioavailability as compared to 70% after SL administration of KT solution. CONCLUSIONS: The results of the present study suggest that SL absorption of KT illustrated flip-flop kinetics with prolonged persistence in the body compared to intravenous administration. Formulation of KT as chitosan nanoparticles has increased its systemic bioavailability after SL spray administration. The new delivery system could be an attractive approach for the delivery of KT.

Development of a Sustained Antiplaque and Antimicrobial Chewing Gum of a Decapeptide.

The objective of this paper was to design a chewing gum formulation delivery system in situations where typical dental hygiene practice is not practical. Thus, an analog of decapeptide KSL (KSL-W), known to possess antimicrobial and antiplaque activity, was incorporated into a chewing gum formulation containing cetylpyridinium chloride (CPC). The effect of the excipients, xylitol, and peppermint oil on active ingredients in vitro release was also assessed. Gum formulations were prepared with different excipient parameters, including heating xylitol and gum base at 65 or 85°C, using ground and unground xylitol, and the addition of 1.5, 3, and 7% peppermint oil, to determine the effect of these changes on the in vitro release of KSL-W and CPC using a chewing machine. The antimicrobial and antiplaque activities of solutions released from chewed gum formulation as well as prepared standard solutions with different concentrations were tested against placebo. The optimal temperature to avoid crystallization of xylitol during preparation was 65°C. Grinding xylitol to 104.5 µm improved release of active ingredients as compared to commercially unground xylitol. Peppermint oil had opposite effects on release of KSL-W and CPC. Peppermint oil at 1.5% was determined to be suitable (91 and 88% of KSL-W and CPC released, respectively, after 40 min). The gum formulation illustrated good sustained release of KSL-W and CPC with antibacterial and antiplaque activities after chewing. An effective antimicrobial and antiplaque chewing gum formulation was developed. This formulation has the potential to overcome oral hygiene issues in those unable to follow normal dental protocols.

Intranasal drug delivery of olanzapine-loaded chitosan nanoparticles.

The aim of this study was to investigate olanzapine (OZ) systemic absolute bioavailability after intranasal (i.n.) administration in vivo to conscious rabbits. Furthermore, the study investigated the potential use of chitosan nanoparticles as a delivery system to enhance the systemic bioavailability of olanzapine following intranasal administration. Olanzapine-loaded chitosan nanoparticles were prepared through ionotropic gelation of chitosan with tripolyphosphate anions and studied in terms of their size, drug loading, and in vitro release. The OZ nanoparticles were administered i.n. to rabbits, and OZ plasma concentration at predetermined time points was compared to i.n. administration of OZ in solution. The concentrations of OZ in plasma were analyzed by ultra performance liquid chromatography mass spectroscopy (UPLC/MS). OZ-loaded chitosan nanoparticles significantly (p < 0.05) enhanced systemic absorption with 51 ± 11.2% absolute bioavailability as compared to 28 ± 6.7% after i.n. administration of OZ solution. The results of the present study suggest that intranasal administration of OZ-loaded chitosan nanoparticles formulation could be an attractive modality for delivery of OZ systemically.

Advances in brain targeting and drug delivery of anti-HIV therapeutic agents.

INTRODUCTION: Human immunodeficiency virus (HIV) is a neurotropic virus that enters the central nervous system (CNS) early in the course of infection. Although antiretroviral drugs are able to eliminate the majority of the HIV virus in the bloodstream, however, no specific treatment currently exist for CNS infections related to HIV. This is mainly attributed to the poor penetrability of antiretroviral therapy across the blood-brain barrier (BBB), and the protective nature of the BBB. Therefore, in order to increase the efficacy of anti-HIV drugs, novel drug delivery methodologies that can exhibit activity in the CNS are most needed and warranted. AREAS COVERED: In this review article, the authors discussed the challenges with delivering drugs to the brain especially under HIV infection pathophysiology status. Also, they discussed the approaches currently being investigated to enhance brain targeting of anti-HIV drugs. A literature search was performed to cover advances in major approaches used to enhance drug delivery to the brain. EXPERT OPINION: If drugs could reach the CNS in sufficient quantity by the methodologies discussed, mainly through intranasal administration and the utilization of nanotechnology, this could generate interest in previously abandoned therapeutic agents and enable an entirely novel approach to CNS drug delivery.

Bioavailability of Δ9-tetrahydrocannabinol following intranasal administration of a mucoadhesive gel spray delivery system in conscious rabbits.

BACKGROUND: The purpose of this study was to investigate the potential of the intranasal route for systemic delivery of solubilized Δ9-tetrahydrocannabinol (THC). A further aim was to investigate the effect of nasally administered chitosan-based nasal bioadhesive gel on THC bioavailability as a formulation strategy to decrease normal mucociliary drug clearance. METHOD: The THC formulations were administered intranasally and compared to intravenous administration utilizing conscious rabbits. RESULTS: After nasal administration, the THC nasal solution afforded a C(max) value of 20 ± 3 ng/mL at 20 minutes. Interestingly, the THC loaded in chitosan gel formulation followed almost the same profile at early time points and subsequently afforded a higher C(max) value of 31 ± 4 ng/mL (T(max) = 45 minutes). The absolute bioavailability of THC after nasal delivery was studied to compare plasma THC concentrations after nasal administration with those after intravenous injection. Absolute bioavailability values were 13.3 ± 7.8% and 15.4 ± 6.5% for the THC nasal solution and gel formulations, respectively. CONCLUSION: The results of the present study suggest that intranasal administration of THC in solution or in a chitosan-based nasal gel formulation could be an attractive modality for delivery of THC systemically.

Formulation-based approach to support early drug discovery and development efforts: a case study with enteric microencapsulation dosage form development for a triarylmethane derivative TRAM-34; a novel potential immunosuppressant.

BACKGROUND: Enteric microencapsulation of the potential immunosuppressant TRAM-34 was investigated as a means of enhancing oral drug delivery and minimizing or eliminating hydrolysis of pyrazole-substituted triarylmethane to the respective alcohol. METHOD: TRAM-34 was successfully enteric microencapsulated by a coacervation method using the pH-sensitive Eudragit L 100 polymer. In this study, we utilized water-miscible organic solvents such as acetone and ethanol, which are considered safe class 3 solvents according to the ICH guideline. We deemed such an approach suitable for safe scale up and for enteric coating application to other compounds of a similar lipophilicity. RESULTS: The resulting microparticles were spherical and uniform with an average particle size of 460 microm at 15% theoretical loading. The encapsulation efficiency was 90 +/- 1.9% and the percentage yield was found to be 91.5 +/- 0.3%. The oral administration in rhesus macaques of TRAM-34-loaded enteric-coated microparticles illustrated six times enhancement in its oral bioavailability. However, the TRAM-34 plasma concentration was less than the therapeutic effective level. CONCLUSION: The low oral bioavailability, even after enteric coating, could be attributed to the compound's inherent absorption characteristics and high lipophilicity.

Intranasal drug delivery of didanosine-loaded chitosan nanoparticles for brain targeting; an attractive route against infections caused by AIDS viruses.

The primary aim of this study was to investigate intranasal (i.n.) administration as a potential route to enhance systemic and brain delivery of didanosine (ddI). A further aim was to investigate the potential use of chitosan nanoparticles as a delivery system to enhance the systemic and brain targeting efficiency of ddI following i.n. administration. Didanosine-loaded chitosan nanoparticles, were prepared through ionotropic gelation of chitosan with tripolyphosphonate anions, and characterized in terms of their size, drug loading, and in vitro release. The nanoparticles were administered i.n. to rats, compared to i.n. and intravenous (i.v.) administration of ddI in solution. The concentrations of ddI in blood, CSF, and brain tissues were analyzed by ultra performance liquid chromatography mass spectroscopy (UPLC/MS). The brain/plasma, olfactory bulb/plasma and CSF/plasma concentration ratios were significantly higher (P < 0.05) after i.n. administration of ddI nanoparticles or solution than those after i.v. administration of didanosine aqueous solution. The ratio of ddI concentration values of the nanoparticles to the solution at 180 min post-i.n. dosing was 2.1 and 1.9 in CSF and brain, respectively. Thus, both the i.n. route of administration and formulation of ddI in chitosan nanoparticles increased delivery of ddI to CSF and brain.

Urine and plasma pharmacokinetics of lofexidine after oral delivery in opiate-dependent patients.

OBJECTIVES: The objective of this study was to investigate lofexidine urine and plasma pharmacokinetics using three different dosing regimens in opioid dependent subjects. To date, there have been no published studies on lofexidine appearance and excretion in urine of opioid dependent subjects. METHODS: Subjects were stabilized with 100 mg morphine sulphate on days 3-8 of the study. The dosing regimens of lofexidine hydrochloride were .8 mg twice a day (BID), 1.2 mg BID, or .8 mg three times a day (TID) on days 9 through 16 of the study. Plasma and urine samples were collected at appropriate time points. Area under the concentration-time curve (AUC), maximum concentration in plasma (C(max)), time when maximum concentration was reached (T(max)) and fraction excreted unchanged in urine (Fe) were calculated. RESULTS: The average half-life obtained from all profiles was 12.1 +/- 6.3 hr. Steady-state (SS) was reached by study day 15. The plasma pharmacokinetic parameters for 1.2 mg BID and .8 mg TID dosing regimens did not seem to be different at steady state (day 15). T(max) was not statistically significantly different across dosing regimens. Fe values ranged between .01% and 34% with high variability within the same dosing regimen. For the total dose of 2.4 mg/day the two dosing regimens that were evaluated, namely 1.2 mg BID and .8 mg TID, did not show a significant statistical difference in plasma and urine pharmacokinetic parameters. CONCLUSION: Although preliminary due to the limited number of subjects, these findings are the first to document lofexidine urine pharmacokinetics in opiate addicts using a highly sensitive liquid chromatography tandem mass spectrometric analysis.

Intratumoral delivery of Paclitaxel in solid tumor from biodegradable hyaluronan nanoparticle formulations.

In the current study, novel paclitaxel-loaded cross-linked hyaluronan nanoparticles were engineered for the local delivery of paclitaxel as a prototype drug for cancer therapy. The nanoparticles were prepared using a desolvation method with polymer cross-linking. In vitro cytotoxicity studies demonstrated that less than 75% of the MDA-MB-231 and ZR-75-1 breast cancer cells were viable after 2-day exposure to paclitaxel-loaded hyaluronan nanoparticles or free paclitaxel, regardless of the dose. These results suggest that hyaluronan nanoparticles maintain the pharmacological activity of paclitaxel and efficiently deliver it to the cells. Furthermore, in vivo administration of the drug-loaded nanoparticles via direct intratumoral injection to 7,12-dimethylbenz[a]anthracene (DMBA)-induced mammary tumor in female rats was studied. The paclitaxel-loaded nanoparticles treated group showed effective inhibition of tumor growth in all treated rats. Interestingly, there was one case of complete remission of tumor nodule and two cases of persistent reduction of tumor size that was observed on subsequent days. In the case of free paclitaxel-treated group, the mean tumor volume increased almost linearly (R(2) = 0.93) with time to a size that was 4.9-fold larger than the baseline volume at 57 days post-drug administration. Intratumoral administration of paclitaxel-loaded hyaluronan nanoparticles could be a promising treatment modality for solid mammary tumors.

Nicotine exposure can be detected in cerebrospinal fluid of active and passive smokers.

A simple, rapid and sensitive liquid chromatography/mass spectrometry (LC/MS) method has been utilized for the quantitative determination of nicotine and its major metabolite cotinine (COT) in human cerebrospinal fluid (CSF) of active and passive smokers. CSF samples from 18 smokers, 15 non-smokers, 15 children, 15 infants, and 9 neonatal were analyzed for nicotine (NIC) and cotinine content. Cotinine levels in the CSF of smokers ranged from 27.3 to 457.1 ng/ml, whereas nicotine levels were considerably lower (6.0-215.1 ng/ml). Cotinine could be detected in 4 of the 15 CSF samples from non-smokers (3.5-30.4 ng/ml), and a few other passive smokers, including neonates from smoking mothers (15.6-81.1 ng/ml). The concentrations of cotinine in CSF samples suggests that nicotine easily passes into the CSF, which makes it an excellent CSF marker for tobacco-smoke exposure.

Pharmacokinetics of lofexidine hydrochloride in healthy volunteers.

The objective of this study was to characterize the clinical pharmacokinetic profile of lofexidine after oral delivery. A single dose, cross-over study and a multidose study using healthy volunteers were conducted for that purpose. In the single dose study the average time to maximum concentration was observed at approximately 3 h for the single doses tested (1.2 mg dose and 2.0 mg). Area under the curve from time zero to infinity (AUC(0-infinity)) demonstrated a degree of dose proportionality with a 1.72-fold increase as the dose increased by a factor of 1.67. Elimination rates and terminal half-lives were comparable between dose levels. The average elimination rates for the 1.2 mg and the 2.0 mg doses were 0.063 and 0.065 h(-1), respectively. In the multidose study, the average maximum concentration observed after the first dose of 0.4 mg was 433 ng/L and ranged from 338 to 586 ng/L. This was slightly lower in proportion to the maximum concentration observed in the single dose study where C(max) was 1755 ng/L at the 1.2 mg dose (normalized to 585 ng/L for 0.4 mg dose) and for the 2.0 mg dose (normalized to 559 ng/L for 0.4 mg dose). The average time to maximum concentration (T(max)) was 3.33 h which is comparable to values observed in the single dose study. The pharmacokinetic data indicate that lofexidine has a consistent profile. Steady state seems to be reached after 2 days on lofexidine, which is consistent with the lofexidine elimination half-life of approximately 11 h. Evaluation of the T(max), elimination rate, and terminal half-life are consistent across all dose levels studied, suggesting that changing the dose does not affect the absorption or elimination rates of lofexidine HCl. Thus, although preliminary due to the limited number of subjects, these findings are the first to document lofexidine clinical pharmacokinetic parameters in healthy volunteers using a highly sensitive liquid chromatography tandem mass spectrometric analysis.

Clinical pharmacokinetics of lofexidine, the alpha 2-adrenergic receptor agonist, in opiate addicts plasma using a highly sensitive liquid chromatography tandem mass spectrometric analysis.

OBJECTIVES: The objective of this investigation was to characterize the pharmacokinetic profile of lofexidine. Lofexidine is an orally bioavailable alpha 2-adrenergic receptor agonist analogue of clonidine that acts centrally to suppress opiate withdrawal symptoms. METHODS: During the detoxification period of a phase 3 placebo-controlled, randomized, double-blind trial, six subjects were entered in this preliminary pharmacokinetic study. RESULTS: Pharmacokinetic analysis of plasma samples collected during study day 7 indicated that C(max) was 3242 +/- 917 ng/L. The mean trough levels between the study days were not significantly different (p > .05), suggesting that the subjects were at steady-state. CONCLUSIONS: Although preliminary due to the limited number of subjects, these findings are the first to document lofexidine clinical pharmacokinetics in opiate addicts using a highly sensitive liquid chromatography tandem mass spectrometric analysis.

Gamma scintigraphy for testing bioequivalence: a case study on two cromolyn sodium nasal spray preparations.

The present work was carried out to study the deposition patterns and clearance of technetium-99m (99mTc) DTPA labeled cromolyn sodium (CS) solutions when administered from two different CS nasal products using gamma scintigraphy. Five healthy volunteers received a single dose with complete crossover design involving treatment A (test formulation) and treatment B (reference formulation). The deposition patterns as well as the changes in distribution of the radiolabeled CS solutions due to the mucociliary transport were monitored by gamma scintigraphy. Primary deposition of the aforementioned nasal solutions occurred in the anterior portion of the nose. After migration into the posterior nasal cavity, the solutions were rapidly cleared by ciliary action into the nasopharynx where it was swallowed. The test product of cromolyn sodium was shown to be equivalent to the reference product with regard to nasal deposition and clearance. The results from this study indicate that external gamma scintigraphy can be used to demonstrate the equivalence of nasal sprays that are intended for local therapeutic action where the drug is not systemically absorbed into the blood circulation. Furthermore, a non-invasive imaging method such as rhinoscintigraphy may prove to be a useful technique to be utilized during the regulatory approval process for local-acting nasal products, and may facilitate the early introduction of these products to the market.