Economical synthesis of γ-cyclodextrin catalyzed by oriented cyclodextrin glycosyltransferase displayed on bacterial polyhydroxyalkanoate nanogranules.

BACKGROUND: The advantages of γ-cyclodextrin (γ-CD) include its high solubility, ability to form inclusion complexes with various poorly water-soluble molecules, and favorable toxicological profile; thus, γ-CD is an attractive functional excipient widely used in many industrial settings. Unfortunately, the high cost of γ-CD caused by the low activity and stability of γ-cyclodextrin glycosyltransferase (γ-CGTase) has hampered large-scale production and application. RESULTS: This study reports the in vivo one-step production of immobilized γ-CGTase decorated on the surface of polyhydroxyalkanoate (PHA) nanogranules by the N-terminal fusion of γ-CGTase to PHA synthase via a designed linker. The immobilized γ-CGTase-PHA nanogranules showed outstanding cyclization activity of 61.25 ± 3.94 U/mg (γ-CGTase protein) and hydrolysis activity of 36,273.99 ± 1892.49 U/mg, 44.74% and 18.83% higher than that of free γ-CGTase, respectively. The nanogranules also exhibited wider optimal pH (cyclization activity 7.0-9.0, hydrolysis activity 10.0-11.0) and temperature (55-60 °C) ranges and remarkable thermo- and pH-stability, expanding its utility to adapt to wider and more severe reaction conditions than the free enzyme. A high yield of CDs (22.73%) converted from starch and a high ratio (90.86%) of γ-CD in the catalysate were achieved at pH 9.0 and 50 °C for 10 h with 1 mmol/L K+, Ca2+, and Mg2+ added to the reaction system. Moreover, γ-CGTase-PHA beads can be used at least eight times, retaining 82.04% of its initial hydrolysis activity and 75.73% of its initial cyclization activity. CONCLUSIONS: This study provides a promising nanobiocatalyst for the cost-efficient production of γ-CD, which could greatly facilitate process control and economize the production cost.

[Muscle relaxant and reversal practices and impact of reversal modalities on operating room and postoperative room duration - results of a Delphi study]. / Pratiques de curarisation/décurarisation et impact des modalités de décurarisation sur les durées en salle opératoire et SSPI ­ résultats d'une enquête Delphi.

OBJECTIVE: The objectives of this Delphi study are to describe muscle relaxant and reversal practices in France and to seek a consensus on the impact of the reversal method on the time spent in the OR and PACU. METHOD: A two-round Delphi survey was conducted on a panel of French anesthetists involved in colectomies, hysterectomies or bariatric surgery. The questionnaire was designed in collaboration with a scientific committee and was intended to assess neuromuscular blockade reversal techniques and their impact on time spent in the OR and PACU. The first round gathered data on practices and the second round sought a consensus for the time aspect. RESULTS: Overall, all participants (99%) monitored neuromuscular blockade, with a majority (82%) doing so continuously. Of the participants, 22% routinely used a reversal drug. The time saved in the OR or PACU with sugammadex varied between 1 and 43 minutes depending on the surgery and the neuromuscular blockade reversal method it was compared to. CONCLUSION: Although SFAR recommendations (French Society of Anesthesia & Intensive Care Medicine) were generally well followed, the use of neuromuscular blockade reversal drugs was observed to be not fully integrated into regular practice, despite the fact that more than half of patients were reported to have residual neuromuscular blockade post-surgery and that sugammadex is known to reduce time spent in the OR and PACU compared to other neuromuscular blockade reversal methods.

A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US.

INTRODUCTION: Sugammadex rapidly reverses the effects of rocuronium- and vecuronium-induced neuromuscular blockade (NMB), offering a more complete and predictable NMB recovery than cholinesterase inhibitors. Despite clinical benefits, cost pressures on hospital budgets influence the choice of the NMB reversal method. This study evaluated clinical and healthcare system payer's budget impacts associated with sugammadex in the US for routine reversal of moderate or deep rocuronium- or vecuronium-induced NMB in adults undergoing surgery. METHODS: A 1-year decision analytic model was constructed reflecting a set of procedures using rocuronium or vecuronium that resulted in moderate or deep NMB at the end of surgery. Two scenarios were considered for a hypothetical cohort of 100,000 patients: without sugammadex versus with sugammadex. Comparators included neostigmine (+glycopyrrolate) and no neuromuscular blocking agents (NMBAs). Total costs (in 2019 US dollars) to a healthcare system [net of costs of reversal agents and overall cost offsets via reduction in postoperative pulmonary complications (PPC)] were compared. RESULTS: A total of 9971 surgical procedures utilized rocuronium or vecuronium, resulting in moderate (91.0% of cases) or deep (9.0%) blockade at the end of surgeries. In the with sugammadex scenario, sugammadex replaced neostigmine in 4156 of 9585 procedures versus the without sugammadex scenario that used only neostigmine for NMB reversal. Introducing sugammadex reduced PPC events by 12% (58 cases) among the modeled procedures, leading to a budget impact of -$3,079,703 (-$309 per modeled procedure, or a 10.9% reduction in total costs). The results did not vary qualitatively in one-way sensitivity analyses. CONCLUSIONS: The additional costs of sugammadex for the reversal of rocuronium- or vecuronium-induced NMB could be offset by improved outcomes (i.e., reduced PPC events), and potentially lead to overall healthcare budgetary savings versus reversal with neostigmine or spontaneous recovery. This study provides insights into savings that can be obtained beyond the anesthesia budget, reducing the broader clinical and budgetary burden on the hospital.

Sugammadex versus neostigmine for routine reversal of rocuronium block in adult patients: A cost analysis.

STUDY OBJECTIVE: This report analyzes the comparative costs, efficacy and side effects of a newer, more expensive reversal drug, sugammadex, with its generic counterpart, neostigmine combined with glycopyrrolate, or no reversal agent when used routinely to reverse rocuronium-induced neuromuscular blockade in adult patients. DESIGN: Cost analysis. METHODS: We constructed a decision model to analyze the costs associated with the choice of reversal drug and differences in reversal time, occurrence of postoperative nausea or vomiting (PONV), and residual blockade requiring unplanned postoperative mechanical ventilation (UPMV). We selected variables that demonstrated meaningful differences in meta-analyses of published studies and/or had significant associated costs. We used data from local hospital system information, meta-analysis of published studies, and the general literature to construct base-case scenarios and sensitivity analyses. We performed the analysis from the perspective of a single hospital system. Costs were in 2019 U.S. dollars. RESULTS: Cost analysis suggested that reversal with sugammadex is preferable to neostigmine or no reversal drug when operating room (OR) time was valued at ≥$8.60/min (base case $32.49/min). Net costs of sugammadex were less than no treatment or neostigmine reversal when the probability of UPMV exceeded 0.019 and 0.036, respectively. Neither sugammadex nor neostigmine reversal was preferable to no treatment in a base-case analysis that considered the effect of the reversal agent on only drug and PONV costs, disregarding costs of OR time or UPMV. CONCLUSIONS: Routine reversal with sugammadex is preferable to choosing neostigmine or no reversal drug when accounting for potential savings in OR time. Sugammadex might also be a reasonable choice for patients at high risk of UPMV. If the cost of OR time is not considered, the analysis does not support the routine use of sugammadex in patients with perceived increased risk or solely to reduce PONV.

Chiral capillary zone electrophoresis in enantioseparation and analysis of cinacalcet impurities: Use of Quality by Design principles in method development.

A capillary electrophoresis method for the simultaneous determination of the enantiomeric purity and of impurities of the chiral calcimimetic drug cinacalcet hydrochloride has been developed following Quality by Design principles. The scouting phase was aimed to select the separation operative mode and to identify a suitable chiral selector. Among the tested cyclodextrins, (2-carboxyethyl)-ß-cyclodextrin and (2-hydroxypropyl)-γ-cyclodextrin (HPγCyD) showed good chiral resolving capabilities. The selected separation system was solvent-modified capillary zone electrophoresis with the addition of HPγCyD and methanol. Voltage, buffer pH, methanol concentration and HPγCyD concentration were investigated as critical method parameters by a multivariate strategy. Critical method attributes were represented by enantioresolution and analysis time. A Box-Behnken Design allowed the contour plots to be drawn and quadratic and interaction effects to be highlighted. The Method Operable Design Region (MODR) was identified by applying Monte-Carlo simulations and corresponded to the multidimensional zone where both the critical method attributes fulfilled the requirements with a desired probability π≥90%. The working conditions, with the MODR limits, corresponded to the following: capillary length, 48.5cm; temperature, 18°C; voltage, 26kV (26-27kV); background electrolyte, 150mM phosphate buffer pH 2.70 (2.60-2.80), 3.1mM (3.0-3.5mM) HPγCyD; 2.00% (0.00-8.40%) v/v methanol. Robustness testing was carried out by a Plackett-Burman matrix and finally a method control strategy was defined. The complete separation of the analytes was obtained in about 10min. The method was validated following the International Council for Harmonisation guidelines and was applied for the analysis of a real sample of cinacalcet hydrochloride tablets.

A quality by design-based approach to a capillary electrokinetic assay for the determination of dextromepromazine and levomepromazine sulfoxide as impurities of levomepromazine.

Using a quality by design approach, a capillary electrophoresis method for the simultaneous determination of dextromepromazine and the oxidation product levomepromazine sulfoxide in levomepromazine was developed. The analytical target profile was defined that the method should be able to quantify 0.1% of both impurities with a precision of ≤10%. Hydroxypropyl-γ-cyclodextrin was used as chiral selector. The critical process parameters cyclodextrin concentration, buffer pH and concentration as well as temperature and applied voltage were studied using a fractional factorial resolution V+ design for defining the knowledge space. A central composite face centered design was used as response surface methodology for deriving the design space by Monte Carlo simulations. The selected working point was a 100mM citric acid buffer, pH 2.85, containing 3.6mg/mL hydroxypropyl-γ-cyclodextrin, a temperature of 15°C and a voltage of 25kV. Robustness was estimated using a Plackett-Burman design. The method was subsequently validated in the relative concentration range of 0.1%-1.0% of the impurities for a solution containing 0.25mg/mL levomepromazine. The method was applied to the determination of the purity of the reference substance of the European Pharmacopoeia and of the drug in a commercial injection solution.

Half dose sugammadex combined with neostigmine is non-inferior to full dose sugammadex for reversal of rocuronium-induced deep neuromuscular blockade: a cost-saving strategy.

BACKGROUND: Sugammadex reverses the effect of rocuronium more rapidly and effectively than neostigmine, at all levels of neuromuscular blockade (NMB). However, its cost is prohibitive. The combination of half dose sugammadex with neostigmine would be non-inferior to full dose sugammadex for the reversal of deep NMB. This approach would reduce the cost of sugammadex while preserving its efficacy. METHODS: Patients were randomly allocated to receive sugammadex 4 mg/kg (Group S) or sugammadex 2 mg/kg with neostigmine 50 µg/kg and glycopyrrolate 10 µg/kg (Group NS) for reversal of rocuronium deep NMB. The primary outcome was the percentage of patients who recovered to 90% Train of Four (TOF) ratio within 5 min. The non-inferiority margin was set at 10%. RESULTS: Twenty eight patients were enrolled in each group. The number of patients who reached 90% TOF ratio within 5 min was 27 out of 28 (96%) in group S versus 25 out of 28 (89%) in group NS by intention-to-treat (difference: 7%, 95% CI of the difference: -9% to 24%). The number of patients who reached 90% TOF ratio within 5 min was 26 out of 26 (100%) in group S versus 23 out of 25 (92%) in group NS by per-protocol (difference: 8%, 95% CI of the difference: -6% to 25%). CONCLUSIONS: Sugammadex 2 mg/kg with neostigmine 50 µg/kg was at worst 9% and 6% less effective than sugammadex 4 mg/kg by intention-to-treat and by per-protocol analysis respectively. Hence, the combination is non-inferior to the recommended dose of sugammadex. TRIAL REGISTRATION: Clinicaltrials.gov NCT 02375217 , registered on February 11, 2015.

Operating room discharge after deep neuromuscular block reversed with sugammadex compared with shallow block reversed with neostigmine: a randomized controlled trial.

OBJECTIVE: To determine if reversing a deep or moderate block with sugammadex, compared with a shallow block reversed with neostigmine, reduces the time to operating room discharge after surgery and the time spent in the postanesthesia care unit. DESIGN: A randomized controlled trial. SETTING: Monocentric study performed from February 2011 until May 2012. PATIENTS: One hundred consenting women with American Society of Anesthesiologists grade I or II were randomized into 2 groups. INTERVENTION: Laparoscopic hysterectomy was performed under desflurane general anesthesia. For the neostigmine (N) group, 0.45 mg · kg-1 rocuronium was followed by spontaneous recovery. A 5-mg rescue bolus was administered only if surgical evaluation was unacceptable. At the end of surgery, 50 µg · kg-1 neostigmine with glycopyrrolate was administered. For the sugammadex (S) group, a higher intubating rocuronium dose (0.6 mg · kg-1) was followed by 5-mg boluses each time the train-of-four count exceeded 2. Sugammadex (2-4 mg · kg-1) was administered to reverse the block. All patients were extubated after obtaining a train-of-four ratio of 0.9. MEASUREMENTS: The duration between the end of surgery and operating room discharge and the time spent in the postanesthesia care unit. MAIN RESULTS: The time till operating room discharge was shorter and more predictable in group S (9.15±4.28 minutes vs 13.87±11.43 minutes in group N; P=.005). The maximal duration in group S was 22 minutes, compared with 72 minutes in group N. The time spent in the postanesthesia care unit was not significantly different (group S: 47.75±31.77 minutes and group N: 53.43±40.57 minutes; P=.543). CONCLUSION: Maintaining a deep neuromuscular block during laparoscopic hysterectomy reversed at the end of the procedure with sugammadex enabled a faster and more predictable time till operating room discharge than did the classical combination of a shallower block reversed with neostigmine.

Do we really need sugammadex as an antagonist of muscle relaxants in anesthesia?

PURPOSE OF REVIEW: Sugammadex is a selective relaxant-binding agent that is designed to encapsulate rocuronium and chemically similar steroidal muscle relaxants such as vecuronium. This review summarizes recent information on the use of sugammadex in clinical practice. RECENT FINDINGS: The main advantages of sugammadex when compared with conventional anticholinesterase agents are a much faster recovery time and its unique ability to reverse rapidly and efficiently, for the first time, deep levels of neuromuscular blockade. However, there is paucity of evidence-based studies on the benefit of deep neuromuscular block, and then routine administration of sugammadex to reverse any level of block, for example, during laparoscopic surgery. It appears that reduction of costs depends mainly on organizational factors. Finally it must be remembered that sugammadex only works with steroidal nondepolarizing muscle relaxants; therefore neostigmine should not be withdrawn because it is the only reversal agent effective against atracurium or cisatracurium. SUMMARY: Sugammadex offers a significantly faster and more predictable recovery profile than neostigmine. It is now possible to reverse rapidly and efficiently any level of neuromuscular blockade and to avoid the risk of adverse events because of residual paralysis such as critical respiratory events during recovery from anesthesia.

A PK-PD model-based assessment of sugammadex effects on coagulation parameters.

Exposure-response analyses of sugammadex on activated partial thromboplastin time (APTT) and prothrombin time international normalized ratio (PT(INR)) were performed using data from two clinical trials in which subjects were co-treated with anti-coagulants, providing a framework to predict these responses in surgical patients on thromboprophylactic doses of low molecular weight or unfractionated heparin. Sugammadex-mediated increases in APTT and PT(INR) were described with a direct effect model, and this relationship was similar in the presence or absence of anti-coagulant therapy in either healthy volunteers or surgical patients. In surgical patients on thromboprophylactic therapy, model-based predictions showed 13.1% and 22.3% increases in respectively APTT and PT(INR) within 30min after administration of 16mg/kg sugammadex. These increases remain below thresholds seen following treatment with standard anti-coagulant therapy and were predicted to be short-lived paralleling the rapid decline in sugammadex plasma concentrations.

Pharmacokinetics of sugammadex 16 mg/kg in healthy Chinese volunteers.

OBJECTIVE: Elimination of sugammadex occurs predominantly via the kidneys, with the majority of the drug excreted unchanged in the urine. To date, most studies with sugammadex have been performed in non-Asian populations. The objectives of this open-label study were to determine the pharmacokinetics (PK) and safety of single-dose sugammadex (16 mg/kg) in healthy Chinese adult volunteers. METHODS: 12 Chinese subjects (6 male; 6 female) received intravenous sugammadex (16 mg/kg) as a 10-second bolus infusion. Blood samples were collected pre-sugammadex and at regular intervals up to 24 hours post-sugammadex for PK assessment. Safety was assessed via AEs, vital signs, electrocardiogram, and laboratory parameters. RESULTS: Following sugammadex 16 mg/kg infusion, peak sugammadex concentration was 197 µg/mL, clearance was 99.7 mL/min, and apparent volume of distribution at equilibrium was 10.5 L. Plasma sugammadex concentrations showed a polyexponential decline over time, with an overall geometric mean (CV%) terminal half-life of 145 minutes (17.9%) (139 minutes (17.7%) for males; 152 minutes (18.6%) for females). No influence of gender on the PK of sugammadex was observed. Three subjects experienced an adverse events (AE) (dysgeusia of mild intensity), which was considered possibly or probably related to sugammadex. There were no clinically significant changes in vital signs, electrocardiography or laboratory parameters. CONCLUSION: PK of sugammadex (16 mg/kg) was characterized in healthy Chinese subjects. Overall between-subject variability on clearance and apparent volume of distribution was ~ 10%. Sugammadex was generally well tolerated.

A doubly alkynylpyrene-threaded [4]rotaxane that exhibits strong circularly polarized luminescence from the spatially restricted excimer.

The Sonogashira coupling of γ-CD-encapsulated alkynylpyrenes with terphenyl-type stopper molecules gave a doubly alkynylpyrene-threaded [4]rotaxane. The rotaxane showed only excimer emission, with a high fluorescence quantum yield of Φf =0.37, arising from the spatially restricted excimer within the cavity of the γ-CD. The excimer emission suffered little from self-quenching up to a concentration of 1.5×10(-5) M and was circularly polarized with a high glum  value of -1.5×10(-2) . The strong circularly polarized luminescence may result from the two stacked pyrenes existing in the rotaxane in an asymmetrically twisted manner.

R-α lipoic acid γ-cyclodextrin complex increases energy expenditure: a 4-month feeding study in mice.

OBJECTIVE: A high-fat diet (HFD) affects energy expenditure in laboratory rodents. R-α lipoic acid cyclodextrin (RALA-CD) complex is a stable form of lipoic acid (LA) and may improve energy expenditure. The aim of this study was to determine the effect of RALA-CD on energy expenditure and underlying molecular targets in female laboratory mice. METHODS: Female C57BL/6J mice were fed a HFD containing 0.1% LA for about 16 wk. The effects on energy expenditure, gene and protein expression were assessed using indirect calorimetry, real-time reverse transcriptase polymerase chain reaction, and Western blot, respectively. RESULTS: Supplementing mice with RALA-CD resulted in a significant increase in energy expenditure. However, both RALA per se (without γ-cyclodextrin) and S-α lipoic acid cyclodextrin did not significantly alter energy expenditure. Furthermore RALA-CD changed expression of genes encoding proteins centrally involved in energy metabolism. Transcriptional key regulators sirtuin 3 and peroxisome proliferator-activated receptor-γ, coactivator 1 alpha, as well as thyroid related enzyme type 2 iodothyronine deiodinase were up-regulated in brown adipose tissue (BAT) of RALA-CD-fed mice. Importantly, mRNA and/or protein expression of downstream effectors uncoupling protein (Ucp) 1 and 3 also were elevated in BAT from RALA-CD-supplemented mice. CONCLUSION: Overall, present data suggest that RALA-CD is a regulator of energy expenditure in laboratory mice.

[Assessment of sugammadex use efficiency and safety for neuromuscular block reversion].

Blockade of neuromuscular conductivity is a considered one of basic part of a patient protection in a concept of a balanced multicomponent anesthesia. The controlled neuromuscular paralysis in a combination of a sedation, an analgesia and a hyporeflection not only provides comfortable conditions to surgeons for carrying out surgeries, but also allows to manage a gas exchange, blood circulation and a metabolism in a patient. However in clinical practice there is such complication after application of muscular relaxant (not depolarizing) as a residual curarization. The residual curarization is interfaced to deterioration of the respiratory answer to a hypoxemia, swallowing dysfunction that significantly increased risk of aspiration and risk of postoperative pulmonary complications. Until recent time acetylcholinesterase inhibitors or prolonged ALV before spontaneous regression of the neuromuscular block were applied in clinical practice for the purpose of restoration of adequate neuromuscular conductivity and elimination of a residual curarization. However there are number of the circumstances limiting application of preparations of this group including it is related with rather high frequency of side effects and lack of efficiency at the deep neuromuscular block. Today in an arsenal of the anesthesiologist there was the latest chemical - sugammadex. Sugammadex realizes a new approach to restoration of the neuromuscular conductivity.

The influence of unrestricted use of sugammadex on clinical anaesthetic practice in a tertiary teaching hospital.

This retrospective casenote audit involving 374 patients requiring intubation for an anaesthetic found that when the availability of sugammadex became unrestricted, its use increased from 7.1 to 65.3% (P <0.0001) of all muscle relaxant reversals, while neostigmine use decreased from 59.6 to 12.5%. Rocuronium use decreased slightly (90.8 to 79.2%, P=0.006) but vecuronium use increased (2.1 to 8.3%, P=0.02). Cisatracurium and suxamethonium use were unchanged. Total rocuronium dose (55.9 ± 24.1 vs 60.4 ± 22.3 mg) and the number of doses (1.9 ± 1.48 to 1.96 ± 1.27) were unchanged, but the time between the last dose and reversal decreased (91.7 ± 68.1 to 62 ± 52.4 minutes, P=0.0002). There appeared to be no change in postoperative nausea and vomiting, or post-anaesthesia care unit time or oxygen saturation levels. Anaesthetic theatre time fell from 143.5 ± 85.8 to 120 ± 71.2 minutes (P=0.01) and remained significant when adjusted for confounding variables (ratio of means 1.17, 95% confidence interval 1.03 to 1.34, P=0.02), although inferences in relation to causality are limited by the retrospective and observational design of the study. Hospital stay also appeared to fall (4.2 ± 3.5 to 3.4 ± 3.0 days, P=0.035), but was not statistically significant when adjusted for confounding variables (ratio of means 1.04, 95% confidence interval 0.89 to 1.2, P=0.59). These observations suggest that the unrestricted availability of sugammadex will change how steroid-based neuromuscular blocking drugs are used and reversed, but further research is needed to determine if patient outcomes will improve.