Analysis of medicines returned to pharmacies for disposal and estimation of the cost due to medicine wasting.

Background: Studies have shown that waste medicines generate a significant cost for the national health system (NHS) in many countries. No data are available on costs and therapeutic classes of unused medicines in Italy.Objective: Conduct a quantitative and qualitative analysis of unused medicines returned for disposal to selected pharmacies in Rome, Italy, as well as to estimate the related costs for the NHS. Methods: Medicines returned to 4 pharmacies were collected for 8 months. Therapeutic class, number of remaining dosage units, remaining validity, and reimbursement by the NHS were analysed. The cost of reimbursed medicines was estimated on the prices provided by the Italian regulatory agency (AIFA). Results: The study sample consisted of 3219 medicine packages containing remaining dosage units, of which 72.4% had expired while 27.6% had not. The average remaining validity of unexpired medicines was 13 months. Medicines reimbursed by the NHS accounted for 73% of the total. Cardiovascular drugs and anti-infectives were the main therapeutic classes (17.2% and 15.2% of total packages, respectively), followed by gastrointestinal drugs, central nervous system (CNS) drugs, non-steroidal anti-inflammatory drugs (NSAIDs), and corticosteroids. The average of remaining dosage units found in the examined packages was 68% of the initial number of units. In terms of cost, antibiotics were the most relevant therapeutic class, followed by cardiovascular drugs, analgesics, corticosteroids, and NSAIDs. The estimated cost for the Italian NHS was € 200,656,780 per year. Conclusion: Waste medicines constitute a significant, but reducible cost for the NHS. The high prevalence of anti-infectives in the study sample appears to be a distinctive Italian characteristic and may be due to inappropriate prescribing. Policies aimed at reducing waste should improve prescriptive appropriateness and increase the variety of packaging size.

Amphetamine Modulation of Long-Term Object Recognition Memory in Rats: Influence of Stress.

Amphetamine is a potent psychostimulant that increases brain monoamine levels. Extensive evidence demonstrated that norepinephrine is crucially involved in the regulation of memory consolidation for stressful experiences. Here, we investigated amphetamine effects on the consolidation of long-term recognition memory in rats exposed to different intensities of forced swim stress immediately after training. Furthermore, we evaluated whether such effects are dependent on the activation of the peripheral adrenergic system. To this aim, male adult Sprague Dawley rats were subjected to an object recognition task and intraperitoneally administered soon after training with amphetamine (0.5 or 1 mg/kg), or its corresponding vehicle. Rats were thereafter exposed to a mild (1 min, 25 ± 1°C) or strong (5 min, 19 ± 1°C) forced swim stress procedure. Recognition memory retention was assessed 24-h after training. Our findings showed that amphetamine enhances the consolidation of memory in rats subjected to mild stress condition, while it impairs long-term memory performance in rats exposed to strong stress. These dichotomic effects is dependent on stress-induced activation of the peripheral adrenergic response.

Permitted Daily Exposure for Diisopropyl Ether as a Residual Solvent in Pharmaceuticals.

Solvents can be used in the manufacture of medicinal products provided their residual levels in the final product comply with the acceptable limits based on safety data. At worldwide level, these limits are set by the "Guideline Q3C (R6) on impurities: guideline for residual solvents" issued by the ICH. Diisopropyl ether (DIPE) is a widely used solvent but the possibility of using it in the pharmaceutical manufacture is uncertain because the ICH Q3C guideline includes it in the group of solvents for which "no adequate toxicological data on which to base a Permitted Daily Exposure (PDE) was found". We performed a risk assessment of DIPE based on available toxicological data, after carefully assessing their reliability using the Klimisch score approach. We found sufficiently reliable studies investigating subchronic, developmental, neurological toxicity and carcinogenicity in rats and genotoxicity in vitro. Recent studies also investigated a wide array of toxic effects of gasoline/DIPE mixtures as compared to gasoline alone, thus allowing identifying the effects of DIPE itself. These data allowed a comprehensive toxicological evaluation of DIPE. The main target organs of DIPE toxicity were liver and kidney. DIPE was not teratogen and had no genotoxic effects, either in vitro or in vivo. However, it appeared to increase the number of malignant tumors in rats. Therefore, DIPE could be considered as a non-genotoxic animal carcinogen and a PDE of 0.98 mg/day was calculated based on the lowest No Observed Effect Level (NOEL) value of 356 mg/m3 (corresponding to 49 mg/kg/day) for maternal toxicity in developmental rat toxicity study. In a worst-case scenario, using an exceedingly high daily dose of 10 g/day, allowed DIPE concentration in pharmaceutical substances would be 98 ppm, which is in the range of concentration limits for ICH Q3C guideline class 2 solvents. This result might be considered for regulatory decisions.

Amiodarone biokinetics, the formation of its major oxidative metabolite and neurotoxicity after acute and repeated exposure of brain cell cultures.

The difficulty in mimicking nervous system complexity and cell-cell interactions as well as the lack of kinetics information has limited the use of in vitro neurotoxicity data. Here, we assessed the biokinetic profile as well as the neurotoxicity of Amiodarone after acute and repeated exposure in two advanced rodent brain cell culture models, consisting of both neurons and glial cells organized in 2 or 3 dimensions to mimic the brain histiotypic structure and function. A strategy was applied to evidence the abiotic processes possibly affecting Amiodarone in vitro bioavailability, showing its ability to adsorb to the plastic devices. At clinically relevant Amiodarone concentrations, known to induce neurotoxicity in some patients during therapeutic treatment, a complete uptake was observed in both models in 24 h, after single exposure. After repeated treatments, bioaccumulation was observed, especially in the 3D cell model, together with a greater alteration of neurotoxicity markers. After 14 days, Amiodarone major oxidative metabolite (mono-N-desethylamiodarone) was detected at limited levels, indicating the presence of active drug metabolism enzymes (i.e. cytochrome P450) in both models. The assessment of biokinetics provides useful information on the relevance of in vitro toxicity data and should be considered in the design of an Integrated Testing Strategy aimed to identify specific neurotoxic alerts, and to improve the neurotoxicity assay predictivity for human acute and repeated exposure.

In vitro kinetics of amiodarone and its major metabolite in two human liver cell models after acute and repeated treatments.

The limited value of in vitro toxicity data for the in vivo extrapolation has been often attributed to the lack of kinetic data. Here the in vitro kinetics of amiodarone (AMI) and its mono-N-desethyl (MDEA) metabolite was determined and modelled in primary human hepatocytes (PHH) and HepaRG cells, after single and repeated administration of clinically relevant concentrations. AMI bioavailability was influenced by adsorption to the plastic and the presence of protein in the medium (e.g. 10% serum protein reduced the uptake by half in HepaRG cells). The cell uptake was quick (within 3h), AMI metabolism was efficient and a dynamic equilibrium was reached in about a week after multiple dosing. In HepaRG cells the metabolic clearance was higher than in PHH and increased over time, as well as CYP3A4. The interindividual variability in MDEA production in PHHs was not proportional to the differences in CYP3A4 activities, suggesting the involvement of other CYPs and/or AMI-related CYP inhibition. After repeated treatment AMI showed a slight potential for bioaccumulation, whereas much higher intracellular MDEA levels accumulated over time, especially in the HepaRG cells, associated with occurrence of phospholipidosis. The knowledge of in vitro biokinetics is important to transform an actual in vitro concentration-effect into an in vivo dose-effect relationship by using appropriate modelling, thus improving the in vitro-to-in vivo extrapolation.

Interactions between prebiotics, probiotics, polyunsaturated fatty acids and polyphenols: diet or supplementation for metabolic syndrome prevention?

The metabolic syndrome can be prevented by the Mediterranean diet, characterized by fiber, omega-3 polyunsaturated fatty acids and polyphenols. However, the composition of the Mediterranean diet, which can be viewed as a natural multiple supplement, is poorly controlled, and its beneficial effects poorly predictable. The metabolic syndrome is associated with intestinal dysbiosis and the gut microbioma seems to be the main target and player in the interactions occurring between probiotics, prebiotics, omega 3 polyunsaturated fatty acids, and polyphenols. From the reviewed evidence, it is reasonable to manage growth and metabolism of gut microflora with specific prebiotics and polyphenols. Even though the healthy properties of functional foods and nutraceuticals still need to be fully elucidated, available data suggest that well-designed supplements, containing the better ratio of omega-3 polyunsaturated fatty acids and antioxidants, specific probiotic strains, and selected polyphenols and prebiotics, could be useful in metabolic syndrome prevention and treatment.

Serum depletion, multidrug resistance and fluorescent probes: methodological implications in free radicals evaluation.

Intracellular probes used for oxidative burst evaluation could be a substrate of the multidrug resistance proteins (MDR), which may cause misinterpretation of experimental data. We aimed to study the effect of the culture condition and of the MDR-interfering antioxidant quercetin on free radical measurement in serum depleted HCT-8 cells and chick embryo hepatocytes. Serum depletion and/or quercetin affected the traffic of 2',7'-bis(carboxyethyl)-5,6-carboxyfluorescein (BCECF) and calcein. The comparative results obtained with 2',7'-dichlorofluorescein (DCF) and with the plasma-membrane probe C11-BODIPY 581/591 [4,4-difluoro-5-(4-phenyl-1,3-butadienyl)-4-bora-3a,4a-diaza-s-indacene-3-undecanoic acid], suggest caution in the use of intracellular probes to evaluate oxidative stress in vitro.

Effects of peroxyl radicals on contractility of rabbit aorta and guinea pig atria.

BACKGROUND: High-fat meals may lead to hypotension, oxidative stress and increases of lipopolysaccharide (LPS). Contrasting results have been reported after treatment of isolated tissues with hydrogen peroxide and LPS, whereas the effects of peroxyl radicals, involved in the propagation reaction of lipoperoxidation, have not been investigated previously. AIM: In the present study, we aimed to evaluate the effects of peroxyl radicals on the contractile responses in isolated rabbit aorta and guinea pig atria. METHODS AND RESULTS: We treated isolated guinea pig atria, rabbit aorta strips and rings with 2,2'-Azobis (2- amidinopropane) dihydrochloride (AAPH). AAPH did not affect isoprenaline-induced contraction in guinea pig atria, whilst it dose-dependently reduced the contractile responses induced in rabbit aorta strips by cumulative doses of adrenaline (ADR) and induced an endothelium-independent relaxation of noradrenaline (NA)-contracted aorta rings. The effects of KCl-induced and BaCl2-induced contractions were small. Furthermore, alkalinization with NH4Cl of NA-contracted aorta rings significantly reduced the vasodilatatory activity of AAPH. CONCLUSION: The present study suggests that peroxyl radicals induce acute functional alterations on vascular contraction through intracellular pH regulation. This finding could be related to the documented after meal increase in oxidative burst and endotoxin and the related hypotension.

The NOP receptor involvement in both withdrawal- and CCk-8-induced contracture responses of guinea pig isolated ileum after acute activation of κ-opioid receptor.

In isolated guinea-pig ileum (GPI), the κ-opioid acute withdrawal response is under the control of several neuronal signaling systems, including the µ-opioid, the A(1)-adenosine and the CB(1) receptors, which are involved in the inhibitory control of the κ-withdrawal response. After κ-opioid system stimulation, indirect activation of µ-opioid, A(1)-adenosine and CB(1) systems is prevented by the peptide cholecystokinin-8 (CCk-8). In the present study, we have investigated whether the NOP system is also involved in the regulation of the acute κ-withdrawal response. Interestingly, we found that in GPI preparation, the NOP system is not indirectly activated by the κ-opioid receptor stimulation, but instead this system is able by itself to directly regulate the acute κ-withdrawal response. Specifically, our results clearly highlight first the existence of an endogenous tone of the NOP system in GPI, and second that it behaves as a functional anti-opioid system. We also found that, the NOP receptor system is involved in the regulation of the CCk-8-induced contracture intensity, only when in the presence of the κ-opioid receptor stimulation. This effect seems to be regulated by an activation threshold mechanism. In conclusion, the NOP system could act as neuromodulatory system, whose action is strictly related to the modulation of both excitatory and inhibitory neurotransmitters released in GPI enteric nervous system.

Biphasic regulation of the acute µ-withdrawal and CCk-8 contracture responses by the ORL-1 system in guinea pig ileum.

The cloning of the opioid-receptor-like receptor (ORL-1) and the identification of the orphaninFQ/nociceptin (OFQ/N) as its endogenous agonist has revealed a new G-protein-coupled receptor signalling system. The structural and functional homology of ORL-1 to the opioid receptor systems has posed a number of challenges in the understanding the often competing physiological responses elicited by these G-protein-coupled receptors. We had previously shown that in guinea pig ileum (GPI), the acute µ-withdrawal response is under the inhibitory control of several systems. Specifically, we found that the exposure to a µ-opioid receptor agonist activates indirectly the κ-opioid, the A(1)-adenosine and the cannabinoid CB(1) systems, that in turn inhibit the withdrawal response. The indirect activation of these systems is prevented by the peptide cholecystokinin-8 (CCk-8). In the present study, we have investigated whether the ORL-1 system is also involved in the regulation of the acute µ-withdrawal response. Interestingly, we found that in GPI preparation, the ORL-1 system is not indirectly activated by the µ-opioid receptor stimulation, but instead the system is able by itself to directly regulate the acute µ-withdrawal response. Moreover, we have demonstrated that the ORL-1 system behaves both as anti-opioid or opioid-like system based on the level of activation. The same behaviour has also been observed in presence of CCk-8. Furthermore, in GPI, the existence of an endogenous tone of the ORL-1 system has been demonstrated. We concluded that the ORL-1 system acts as a neuromodulatory system, whose action is strictly related to the modulation of excitatory neurotrasmitters released in GPI enteric nervous system.

Acute withdrawal induced by adenosine A-receptor activation in isolated guinea-pig ileum: role of opioid receptors and effect of cholecystokinin.

OBJECTIVES: In isolated guinea-pig ileum, the mu-opioid acute withdrawal response is under control of several neuronal systems, including the kappa-opioid and the A(1)-adenosine systems, which are involved in the mu-withdrawal response inhibitory control. After mu-opioid system stimulation, indirect activation of both kappa-opioid and A(1)-adenosine systems is prevented by the peptide cholecystokinin-8 (CCk-8). Guinea-pig ileum exposed to A(1)-adenosine agonist (CPA), shows a withdrawal contracture precipitated by the A(1)-adenosine antagonist (CPT). We investigated this response. METHODS: We investigated the involvement of the opioid system in the A(1)-adenosine acute withdrawal response in guinea-pig ileum, the potential induced cross-dependence between the A(1) and the opioid system and also the interaction between the CCk-8 and A(1) systems. KEY FINDINGS: We found that in the guinea-pig ileum preparation exposed to CPA, mu- and kappa-opioid antagonists increased the withdrawal response to CPT. Tissues exposed to CPA showed a contractile response to the opioid receptor antagonist naloxone only after complete removal of the A(1)-agonist. In the presence of CPA, the response to CCk-8 was inhibited while a significant increase in CPT response intensity was observed. CONCLUSIONS: In guinea-pig ileum, stimulation of the A(1) system indirectly activates both mu- and kappa-opioid systems; this indirect activation is significantly, albeit not completely, antagonised by CCk-8. Cross dependence between A(1) and opioid systems was also observed.

Inhibitory control of the acute mu-withdrawal response by indirectly activated adenosine A1 and kappa-opioid systems in the Guinea-pig ileum; reversal by cholecystokinin.

In the isolated guinea-pig ileum (GPI), the acute mu-opioid withdrawal response is inhibited by the kappa-opioid system, indirectly activated by the opioid agonist; yet, other inhibitory mechanisms are probably operating. On the other hand, cholecystokinin (CCK-8) strongly enhances the withdrawal response. In this study, we have shown that the adenosine A1 antagonist 8-cyclopenthyl-1,3-dimethylxantine (CPT) increased the withdrawal response in dermorphin/naloxone (NLX) tests but lacked any effect if the withdrawal tests were carried out in presence of CCK-8. In tissue preparations coming from a same animal both CPT and the kappa-opioid antagonist, nor-binaltorphimine (BNI), increased the intensity of the withdrawal responses; the effects of the two antagonists were additive. The intensity of withdrawal contractile responses in presence of CCK-8 was similar to those obtained in presence of the two antagonists. Tissue preparations tested with dermorphin/CCK-8/NLX and then washed out yielded contractile responses when subsequently challenged with CPT, BNI or BNI+CPT, with a percentage markedly higher than the percentage of the response to NLX challenge. BNI+CPT also increased the intensity of the response to NLX challenge. These data suggest that acute exposure of GPI to dermorphin induces the activation of both the adenosine A1 and kappa-opioid systems, which in turns inhibit the mu-withdrawal response. CCK-8 antagonises the inhibitory effect of the indirectly activated systems.

Involvement of the cannabinoid CB1 receptor in the opioid inhibition of the response to cholecystokinin and acute withdrawal response.

Numerous recent studies have reported major functional interactions between cannabinoid and opioid systems. These interactions can be studied in the myenteric plexus-longitudinal muscle isolated preparations. We had previously shown that in the guinea-pig ileum (GPI), the opioid acute withdrawal response is under the inhibitory control of several systems; mu-opioid agonist exposure indirectly activates the kappa-opioid system; conversely, exposure to a kappa-opioid agonist indirectly activates the mu-system; the indirectly activated opioid system inhibits the withdrawal response. The adenosine A1 system is also indirectly activated by opioids and it inhibits the withdrawal response. We had also shown that indirect activation is prevented or antagonized by cholecystokinin (CCK-8). In GPI preparations briefly exposed to the mu-agonist, dermorphine (DERM) and then challenged with naloxone (NL), the cannabinoid CB1 antagonist, SR141716 (SR), increased the withdrawal responses to NL, but only did so in presence of a kappa-opioid and an adenosine A(1) antagonist. Under similar experimental conditions, SR also enhances the kappa-opioid withdrawal response. In opioid agonist/CCK-8/NL tests, SR antagonized the inhibition of the tissue response to CCK-8 induced by the mu- or kappa-opioid agonist and increased the kappa-withdrawal response, but not the mu-withdrawal response. However, the dose-response curve against dermorphine inhibition of the response to CCK-8 was bell-shaped and the highest SR concentration also significantly decreased the mu-withdrawal response. In preparations exposed to dermorphine or to the kappa-agonist, U-50,488H, the cannabinoid agonist WIN 55,212-2 increased the opioid-induced inhibition of the tissue response to CCK-8 and decreased the NL-induced responses. These results show that opioid exposure may also activate the cannabinoid CB1 system, which leads to an inhibition of the opioid acute withdrawal response. This phenomenon and the antagonistic effect of SR on the opioid-induced inhibition of the response to CCK-8 suggest that reciprocal interaction between opioid and cannabinoid systems are operating in the enteric nervous system.

Effects of insulin-induced acute hypoglycemia and normoglycemic hyperinsulinemia on the retinal uptake and ocular metabolism of glucose in rabbits.

Glucose is the principal metabolic substrate for the retina in mammals, being essential for maintaining the functional activity of the retina; it can be supplied to the tissue by both vitreous humor and blood. Yet, the impact of hypoglycemia on retinal glucose metabolism has been poorly investigated. We have therefore studied the effects of acute insulin-induced hypoglycemia on the glucose uptake and metabolism in the retina, by analyzing the hypoglycemia-induced changes in the ocular distribution and metabolic fate of [3H]-2-deoxy-D-glucose (2-DG) and [14C]-D-glucose, both injected in the vitreous body. Rabbits were rendered hypoglycemic by subcutaneous injection of insulin (0.8 and 1.2 IU/kg). Insulin-induced hypoglycemia increased both retinal [3H]-radioactivity levels and retina to vitreous humor ratio of [3H]-radioactivity levels ([3H]-[R/VH]). Radio-chromatography showed that hypoglycemia did not induce any change in the retinal conversion of 2-DG to 2-DG-6-phosphate, but increased the conversion of [14C]-D-glucose to [14C]-lactate. Normoglycemic hyperinsulinemia caused no change in either retinal [3H]-radioactivity levels or [3H]-[R/VH] while decreasing retinal [14C]-radioactivity levels and retina to vitreous ratios of 14C-radioactivity levels. These results indicate that acute hypoglycemia increases the uptake rate of glucose by the retina and suggest that normoglycemic hyperinsulinemia may decrease retinal lactate, possibly stimulating its removal from the retina.

Intestinal motility disorder induced by free radicals: a new model mimicking oxidative stress in gut.

Literature data suggest that the inflamed intestine may be subjected to a considerable oxidative stress. Therefore, the aim of the present study was to simulate the oxidative stress in the gastrointestinal tract and to explore its effect on intestinal motility. This was attained by treating isolated segments from the rabbit jejunum and from the guinea pig ileum with 2,2'-Azobis (2-amidinopropane) dihydrochloride (ABAP), which generates peroxyl radicals by thermal decomposition. Treatment of intestinal segments with ABAP reduced the muscarinic cholinergic response to acetylcholine in both preparations and induced a dose-dependent inhibition of the spontaneous contractions in the jejunum, also in the presence of tetrodotoxin. ABAP was found to inhibit the contractile response induced by BaCl(2) in guinea pig ileum preparations. This effect was not dose-dependent and it was reversed by Bay-K 8644, which activates voltage operated L-type calcium channels. The rapid and reversible effects of ABAP suggest that it might directly affect L-type calcium channels before lipoperoxidation induction. In conclusion, the results of the present study show that ABAP could be a useful tool to simulate early contractility dysfunctions mediated by oxidative stress.