[Rhabdomyolysis due to drug-drug interaction of atorvastatin and cobicistat]. / Rhabdomyolyse durch Arzneimittelinteraktion von Atorvastatin und Cobicistat.

A 53-year-old man presented with rhabdomyolysis and acute kidney injury. The symptoms were presumably caused by a drug-drug interaction between an antiretroviral drug combination and atorvastatin. As a booster, cobicistat can also increase the toxicity of statins via inhibition of the enzyme cytochrome p450 3A4 (CYP3A4). After stopping atorvastatin and after intravenous fluid therapy, the symptoms regressed completely.

Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial.

OBJECTIVE: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice. METHOD: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months. RESULTS: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit. CONCLUSIONS: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.

Simulation of a tablet coating process at different scales using DEM.

Spray coating of tablets is an important unit operation in the pharmaceutical industry and is mainly used for modified release, enteric protection, better appearance and brand recognition. It can also be used to apply an additional active pharmaceutical ingredient to the tablet core. Scale-up of such a process is an important step in commercialization. However, scale-up is not trivial and frequently, at manufacturing scales the required coating quality cannot be reached. Thus, we propose a method where laboratory experiments are carried out, yet scale-up is done via computational methods, i.e., by extrapolating results to larger scales. In the recent years, the Discrete Element Method (DEM) has widely been used to simulate tablet behavior in a laboratory scale drum coater. Due the increasing computational power and more sophisticated DEM algorithms, it has become possible to simulate millions of particles on regular PCs and model industrial scale tablet coating devices. In this work, simulations were performed on the laboratory, pilot and industrial scales and DEM was used to study how different scale-up rules influence the bed behavior on larger scales. The material parameters of the tablets were measured in the laboratory and a glued sphere approach was applied to model the tablet shape. The results include a vast amount of qualitative and quantitative data at the different scales. In conclusion, the evolution of the inter-tablet coating variation for the different scales and process parameters is presented. The results suggest that keeping the Froude number constant during the scale up process leads to faster processes as the cycle time is shorter and the spray residence time is more uniform when compared to keeping the circumferential velocity constant.

Analysis of large-scale tablet coating: Modeling, simulation and experiments.

This work concerns a tablet coating process in an industrial-scale drum coater. We set up a full-scale Design of Simulation Experiment (DoSE) using the Discrete Element Method (DEM) to investigate the influence of various process parameters (the spray rate, the number of nozzles, the rotation rate and the drum load) on the coefficient of inter-tablet coating variation (cv,inter). The coater was filled with up to 290kg of material, which is equivalent to 1,028,369 tablets. To mimic the tablet shape, the glued sphere approach was followed, and each modeled tablet consisted of eight spheres. We simulated the process via the eXtended Particle System (XPS), proving that it is possible to accurately simulate the tablet coating process on the industrial scale. The process time required to reach a uniform tablet coating was extrapolated based on the simulated data and was in good agreement with experimental results. The results are provided at various levels of details, from thorough investigation of the influence that the process parameters have on the cv,inter and the amount of tablets that visit the spray zone during the simulated 90s to the velocity in the spray zone and the spray and bed cycle time. It was found that increasing the number of nozzles and decreasing the spray rate had the highest influence on the cv,inter. Although increasing the drum load and the rotation rate increased the tablet velocity, it did not have a relevant influence on the cv,inter and the process time.

Development and in-line validation of a Process Analytical Technology to facilitate the scale up of coating processes.

Incorporation of an active pharmaceutical ingredient (API) into the coating layer of film-coated tablets is a method mainly used to formulate fixed-dose combinations. Uniform and precise spray-coating of an API represents a substantial challenge, which could be overcome by applying Raman spectroscopy as process analytical tool. In pharmaceutical industry, Raman spectroscopy is still mainly used as a bench top laboratory analytical method and usually not implemented in the production process. Concerning the application in the production process, a lot of scientific approaches stop at the level of feasibility studies and do not manage the step to production scale and process applications. The present work puts the scale up of an active coating process into focus, which is a step of highest importance during the pharmaceutical development. Active coating experiments were performed at lab and production scale. Using partial least squares (PLS), a multivariate model was constructed by correlating in-line measured Raman spectral data with the coated amount of API. By transferring this model, being implemented for a lab scale process, to a production scale process, the robustness of this analytical method and thus its applicability as a Process Analytical Technology (PAT) tool for the correct endpoint determination in pharmaceutical manufacturing could be shown. Finally, this method was validated according to the European Medicine Agency (EMA) guideline with respect to the special requirements of the applied in-line model development strategy.

A comparison of quality control methods for active coating processes.

Terahertz pulsed imaging (TPI) is a recent and nondestructive technique to quantify coating thickness of pharmaceutical tablet film coatings. In this study, TPI is used for the first time to quantify the progress of an active coating process. The dosage form consisted of a push-pull osmotic system comprising a two-layer tablet core with a functional film coating and a laser drilled hole. On top of this system an active coating was applied. The coating thickness data acquired by TPI and optical microscopy was compared to the quantification of the active pharmaceutical ingredient (API) via HPLC. Good correlation of TPI and HPLC data was shown for coating thicknesses up to 500 µm. Due to the special structure of the dosage form, the TPI detection limit of 38 µm layer thickness was circumvented by analysing the coating thickness of active coating and functional subcoat in one. Therefore it was possible to monitor the active coating process from the very beginning of the process. Optical microscopy was no suitable reference technique for TPI thickness measurements. The active coating showed deformation artefacts during sample preparation, which biased the subsequent thickness measurements.

Sport and oxidative stress in oncological patients.

Oxidative stress is thought to be an important factor in the onset, progression and recurrence of cancer. In order to investigate how it is influenced by physical activity, we measured oxidative stress and antioxidative capacity (aoC) in 12 women with breast cancer and 6 men with prostate cancer, before and after long hiking trips. Before the hike, the men had a ROS-concentration of 1.8±0.6 mM H2O2 and an aoC of 0.7±0.6 mM Trolox-equivalent (Tro), while the women had a ROS-concentration of 3.1±0.7 mM H2O2 and an aoC of 1.2±0.2 mM Tro. After the hike, women showed no significant change in ROS and a significant increase in aoC (1.3±0.2 mM Tro), while the ROS concentration in men increased significantly (2.1±0.3 mM H2O2) and their aoC decreased (0.25±0.1 mM Tro). After a regenerative phase, the ROS concentration of the men decreased to 1.7±0.4 mM H2O2 and their aoC recovered significantly (1.2±0.4 mM Tro), while the women presented no significant change in the concentration of H2O2 but showed an ulterior increase in antioxidant capacity (2.05±0.43 mM Tro). From this data we conclude that physical training programs as for example long distance hiking trips can improve the aoC in the blood of oncological patients.

Human basophils: a unique biological instrument to detect the allergenicity of food.

BACKGROUND: Labeling of major food allergens is mandatory for the safety of allergic consumers. Although enzyme-linked immunosorbent assay, polymerase chain reaction, and mass spectrometry are sensitive and specific instruments to detect trace amounts of food proteins, they cannot measure the ability of food constituents to trigger activation of mast cells or basophils. AIM: We evaluated the basophil activation test as an instrument to determine the allergenic potential of trace amounts of food allergens in complex matrices. Peanut (Arachis hypogaea) allergy was selected as a proof-of-concept model. METHODS: The study population comprised 5 severely peanut-allergic patients (3 males/2 females; median age, 12 years) all sensitized to 3 major peanut allergens (Ara h 1, Ara h 2, and Ara h 3) and 5 peanut-tolerant individuals (2 males/3 females; median age, 8 years). Basophils from patients and controls were stimulated with pure peanut extract and blank and peanut-spiked (0.1, 0.01, and 0.001 ppm) biscuits (baking time 11, 16, 21, 26 minutes) and chocolate extracts. RESULTS: Blank biscuits and chocolate did not induce cell activation in patients or controls. A comparison between patients and controls showed significantly higher activation of basophils after stimulation with 0.1 and 0.01 ppm of peanut-spiked biscuit at all baking times and peanut-spiked chocolate (P < .05). CONCLUSIONS: The basophil activation test is a highly sensitive and specific tool to detect traces of functionally active food allergens. For biscuits, its accuracy seems independent of baking time. Furthermore, it allows even the most sensitive patients to be included in study protocols.

Multicentric reticulohistiocytosis associated arthritis responding to anti-TNF and methotrexate.

We present a patient with therapy resistant multicentric reticulohistiocytosis (MRH). MRH is a rare granulomatous, multisystem disease characterised most frequently by disfiguring papulonodular skin lesions and sometimes a destructive polyarthritis, though any organ can be involved. Abnormal histiocytic reactions to an undetermined stimulus (possibly an associated mycobacterial infection, auto immune process or neoplastic process) have been proposed as an underlying mechanism. The diagnosis is confirmed by histopathology of the cutaneous nodules and/or synovial membrane by the presence of CD68-positive histiocytes and multinucleated giant cells with an eosinophilic 'ground-glass' cytoplasm. Recent studies have identified TNFalpha and other inflammatory cytokines to be highly expressed in the synovium and synovial fluid of affected joints in patients with MRH. Based on these findings, we treated our patient with infliximab in combination with methotrexate with marked improvement of morning stiffness, tender and swollen joint count, visual analogue scale and health assessment questionnaire after his third infusion. However, the nodules did not markedly resolve. When treating patients with MRH with TNFa neutralizing drugs, one has to keep the possible association with malignancy in 15-30% of cases in mind and these products should be used with caution.

Suspension pellet layering using PVA-PEG graft copolymer as a new binder.

Flow characteristics and binding properties of Kollicoat IR solutions are promising for an application in suspension layering processes to obtain drug loaded pellets. This study is based on the results of three experimental designs. Within the first one, a suitable binder concentration in suspensions with 35-45% solids was determined. The required binder level was high with 20% in the layer, but led to good and robust process performance with a yield between 92.6% and 97.6%. Since the polymer succeeded to immobilize particles on the starter surface, the second set of experiments observed whether Kollicoat IR was able to layer coarser drug particles with only 8% or 30% of the drug mass below ten microns. Large particle size is a generally known limitation for effective suspension layering. It was shown, that Kollicoat IR was suited to bind 98.5% of the coarsest drug quality on the surface. Additionally these coarse particles acted like a separating agent and kept the pellets from sticking to each other. The third experimental design observed the influence of particle size and viscosity changes. All suspensions had a suitable viscosity with maximum of 120 mPa s. A viscosity change, due to solids in the suspension, did not influence the process performance. The product properties were investigated. The pellets were spherical and size distribution of the pellets was excellent. However the structure was porous, due to the sterical arrangement of the drug particles, although the polymer concentration in the layer was high with a polymer to drug ratio of 1:4.

Age-related sensitization profiles for hazelnut (Corylus avellana) in a birch-endemic region.

BACKGROUND: Symptoms of hazelnut allergy seem related to geographic and possibly age variations in allergen recognition. OBJECTIVE: To investigate sensitization profiles of hazelnut allergy in different age groups in a birch-endemic region using component resolved diagnosis (CRD) by microarray. METHODS: Sixty-five patients with hazelnut allergy, 27 healthy control individuals tolerant to hazelnut, and 34 birch pollen allergic but hazelnut tolerant individuals were included. All blood samples were analyzed using ISAC microarray. RESULTS: Twenty-nine patients with hazelnut allergy suffered from a systemic reaction (17 preschool children with a median age of 2 years, six school children, and six adults), whereas 36 patients reported an oral allergy syndrome (OAS; three preschool and nine school children and 24 adults). In the hazelnut allergic preschool children with systemic reactions, 65% were sensitized to Cor a 9, 12% to Cor a 8, 18% to Cor a 1.04, 6% to Cor a 1.0101, and 29% to Bet v 1. Of the school-aged systemic reactors, 50% were sensitized to Cor a 9, 17% to Cor a 8, 50% to Cor a 1.04 and Cor a 1.0101, and 67% to Bet v 1. In adults with hazelnut allergy, 3.3% were sensitized to Cor a 9, 6.7% to Cor a 8, 90% to Cor a 1.04 and Bet v 1, and 87% to Cor a 1.0101. In regard to systemic reactors in this group, 17% were sensitized to Cor a 9, 33% to Cor a 8 and Cor a 1.0101, and 50% to Cor a 1.04 and Bet v 1. In the patients with OAS, irrespective the age group, all were sensitized to Bet v 1 and over 97% to Cor a 1.04 and Cor a 1.0101. No sensitization to Cor a 9 or Cor a 8 was found in patients with only an OAS. Of the patients with birch pollen allergy, tolerant to hazelnut, none were sensitized to Cor a 9 or Cor a 8, 56% to Cor a 1.0101, 82% to Cor a 1.04, and 92% to Bet v 1. In healthy controls, no sensitization to components of hazelnut, hazel pollen or birch pollen was demonstrable. CONCLUSION: Hazelnut allergy in a birch-endemic region exhibits age-related sensitization profiles with distinct clinical outcomes that can be identified using CRD. The majority of hazelnut allergic preschool and school children in a birch-endemic region show systemic reactions on consumption of processed hazelnut, mostly being sensitized to the hazelnut legumin-like allergen Cor a 9 but unrelated to birch pollen allergy. In contrast, adults generally suffer from an OAS apparently as a result of cross-reactivity between Cor a 1.04 from hazelnut and Bet v 1 from birch pollen.

Basophil activation reveals divergent patient-specific responses to thermally processed peanuts.

INTRODUCTION: The impact of processing on the allergenicity of peanut (Arachis hypogaea) proteins has traditionally been studied using immunoglobulin (Ig) E binding assay. However, as this technique does not assess the potential of an allergen to trigger basophils and mast cells, studies based on it can hardly be considered complete. We evaluated the effect of processing on peanut allergenicity using flow-cytometric quantification of in vitro basophil activation (basophil activation test [BAT]). PATIENTS AND METHODS: Basophils from 10 patients with severe peanut allergy and 3 peanut-tolerant individuals were stimulated with extracts from 5 raw and thermally processed peanut varieties. Data were compared using protein staining (sodium dodecyl sulfate-polyacrylamide gel electrophoresis [SDS-PAGE]) and IgE immunoblotting. RESULTS: Stimulation with different extracts resulted in patient-dependent and variety-dependent effects on basophil activation. SDS-PAGE revealed a considerable loss of identifiable bands, especially for the South Africa Common Natal, Argentina Runner, and US Virginia varieties. The results of IgE immunoblotting in patients were similar, irrespective of the responses observed in the BAT. CONCLUSIONS: The impact of thermal processing on the capacity of peanuts to trigger basophils seems highly divergent between patients and cannot be predicted using SDS-PAGE or IgE binding. BAT can be considered a complementary tool for the evaluation of food allergenicity.

Component-resolved allergy diagnosis by microarray: potential, pitfalls, and prospects.

Diagnosis of IgE-mediated allergies is not always straightforward, as traditional tests can yield equivocal or negative results and provocation tests are hampered by several practical and ethical limitations. During the last decades two new in vitro techniques have entered the field of allergy diagnosis, that is, flow-assisted analysis of allergen-specific activated basophils and component-resolved diagnosis (CRD). This review focuses on component-resolved allergy diagnosis by microarray that has evolved from recent advances in molecular allergology and biochip technology. The technique allows a comprehensive analysis of individual sensitization profiles with multiplexed purified and recombinant allergens within a single run using only a minute amount of serum, providing information that largely exceeds the output from current sIgE capturing tools. Actually, multiplexing allows identification of diagnostic patterns that may facilitate the formulation of diagnostic algorithms. Although CRD by microarray sounds promising, the diagnostic performance requires further intensive assessment before it can enter mainstream application. In our opinion, the technique should currently be considered a complementary diagnostic tool rather than a first-line choice.

Vanishing tumour of the colon ascendens due to acquired type II C1-inhibitor deficiency.

We present a patient with recurrent bouts of angioedema of the lips, throat and extremities with a negative familial history for angioedema. Laboratory results confirmed an angioedema due to acquired C1-INH deficiency (or acquired angioedema, AAE). As AAE can result from underlying disease, further investigation toward malignancy was initiated. A CT-scan of the abdomen disclosed a circumferential tumour of the proximal segment of the colon ascendens which disappeared by the time an ileocolonoscopy was executed. Angioedema of the bowel has been widely reported in hereditary angioedema, whereas it is anecdotal in AAE.

Macadamia nut allergy: 2 case reports and a review of the literature.

We report on 2 patients with anaphylaxis rom Macadamia nut. Temporal relationship between consumption of the nut strongly suggested the diagnosis. Clinical suspicion was supported by the presence of positive specific IgE and/or the positive skin test and/or and the basophil activation test.

Component-resolved diagnosis from latex allergy by microarray.

BACKGROUND: A positive specific IgE (sIgE) result for latex does not always mirror the clinical situation and is frequently found in individuals without overt latex allergy. OBJECTIVE: We sought to investigate the potential of component-resolved diagnosis (CRD) of latex allergy by microarray and to assess whether the technique allows discriminating genuine allergy from asymptomatic sensitization. METHODS: Twenty-six healthy controls without a history of latex allergy with a negative latex sIgE and skin test, 22 latex-allergic patients with a compelling history of latex allergy with a positive latex sIgE and prick test and 20 latex-sensitized individuals with a frequent asymptomatic exposure to natural rubber latex-containing devices with a negative latex skin test but a positive sIgE were also included. CRD was performed with the ImmunoCAP ISAC microarray and traditional singleplexed ImmunoCAP. RESULTS: In all patients, the diagnosis of latex allergy could be established by the combination of recombinant latex components present on the microarray (Hev b 1, Hev b 3, Hev b 5 and Hev b 6.02). Over three-quarters of our patients were sensitized for Hev b 5 and/or Hev b 6.02. Some patients also displayed reactivity for Hev b 1 and/or Hev b 3. In contrast, none of the individuals sensitized to natural rubber latex or control individuals demonstrated IgE reactivity for rHev b 1, rHev b 3, rHev b 5 or rHev b 6.02. Three-quarters of the patients sensitized to latex displayed a positive microarray result for recombinant latex profilin (rHev b 8). In contrast to the results obtained by traditional ImmunoCAP for bromelain, almost no sensitization for cross-reactive carbohydrates was demonstrated by bromelain spotted on the microarray. CRD by traditional singleplexed ImmunoCAP showed highly comparable results. CONCLUSION: CRD by microarray is a reliable tool for diagnosing latex allergy. In addition, the technique allows discrimination between genuine allergy and sensitization. CRD by microarray can improve the diagnosis of IgE-mediated latex allergy by discriminating between genuine allergy and sensitization. CRD by microarray is a reliable tool to diagnose latex allergy. In addition, the technique allows discrimination between a genuine allergy and simple sensitization.

Sensitization profiles in birch pollen-allergic patients with and without oral allergy syndrome to apple: lessons from multiplexed component-resolved allergy diagnosis.

BACKGROUND: Component-resolved diagnosis (CRD) using microarray technology has recently been introduced into the field of clinical allergology. OBJECTIVE: To further validate the use of CRD by microarray technology in allergy diagnosis. METHODS: Thiry-seven patients allergic to birch pollen were included. The discriminative value of apple-specific IgE (sIgE), recombinant Mal d 1 (rMal d 1) sIgE, apple skin prick test and rMal d 1 on the microarray was assessed between patients with a birch-related oral allergy syndrome to apple (OAS(+), n=20) and healthy control individuals (HC, n=8) without a history of inhalant allergies or apple-induced OAS. An additional comparative analysis was carried out with individuals allergic to birch pollen allergy without OAS (OAS(-); n=17). RESULTS: rMal d 1 coupled to the microarray constitutes a discriminative marker between OAS(+) and HC with a sensitivity 95% and a specificity of 100%. However, in parallel with the traditional sIgE assay, 15 out of 17 OAS(-) individuals (88%) also displayed IgE reactivity to rMal d 1 coupled to the microarray. OAS(-) individuals are more frequently sensitized to mite (about three to four times), cat and dog dander (about two to three times) and grass pollen (about 1.5 times) as compared with OAS(+) patients. CONCLUSION: At first glance, CRD by microarray seems to be a reliable instrument in the diagnosis of apple-mediated OAS in birch pollen allergy. However, for discriminating between sensitization and a real allergy, micro-arrayed rMal d 1 offers no advantage over conventional quantification of rMal d 1 sIgE. Most interestingly, within a single run, birch pollen-allergic patients without OAS to apple were shown to display a broader sensitization to classical inhalant allergens than birch pollen-allergic patients with an apple-related OAS.

Angioedema beyond histamine: an educational case series.

Angioedema constitutes an important clinical problem that can cause significant morbidity and mortality. Correct management requires a prompt recognition and treatment of the acute event and identification of the underlying cause. Many cases are caused by non-allergic reactions and do not result from mediator release by degranulating mast cells and basophils, but are related to accumulation of plasma and tissue bradykinin. This case series aims primarily to describe some important causes of non-allergic bradykinin-induced angioedema. Particular emphasis is put on clinical particularities, differential diagnosis, diagnostic approach and correct therapeutic management, as bradykinin-mediated angioedema is unresponsive to antihistamines.

Pretreatment of pigments to prepare liquids for enteric coating.

Film coating fluids commonly contain different pigments. The objective of this work was a study of the distribution of these particles in the coating film. Different pretreatment forms (pigment suspension, pigment paste and untreated pigments) were applied. They were incorporated into a Eudragit L 30 D-55 dispersion. The surface roughness and the mechanical properties of the free films indicated, that the most homogeneous film was obtained with the pigment paste. The homogeneity of the film was investigated by mechanical testing. The protective effect of the coating did not vary with the application of pigments in different forms, but the appearance of the coated tablets underwent a considerable change.

[Neurolymphomatosis. Subacute sensorimotor polyneuropathy as a first sign of non-Hodgkin's B cell lymphoma]. / Neurolymphomatose. Subakute sensomotorische Polyneuropathie als Erstmanifestation eines Non-Hodgkin-B-Zell-Lymphoms.

We report on a 65-year-old patient with subacute painful sensorimotor polyneuropathy with distal leg muscle palsy and initially presenting with bilateral leg edema. Electrophysiologic testing showed an axonal lesion pattern with acute denervation. Nerve biopsy demonstrated neurolymphomatosis as an initial manifestation of a non-Hodgkin's B cell lymphoma.