Securing the supply of benzathine benzylpenicillin: a global perspective on risks and mitigation strategies to prevent future shortages.

Benzathine benzylpenicillin is a globally indispensable medicine. As a long-lasting injectable penicillin, it serves as the primary treatment for syphilis, group A streptococcal infections, rheumatic fever and rheumatic heart disease. A competitive market and low profit margins, compounded by limited visibility of demand, have resulted in a decreased number of active pharmaceutical ingredient (API) manufacturers. By 2016, only three Chinese API manufacturers remained, continuing to supply to the global market today. Recurring global shortages, a consequence of supply and demand imbalances, indicate underlying market risks. Therefore, the need for mitigation strategies is imperative.

Access to insulin: applying the concept of security of supply to medicines.

Security of supply of medicines is fundamental to ensure health for all. Furthermore, improving access to medicines is included in sustainable development goal 3. However, the concept of security of supply has mostly been applied to food, water and energy. Diversity of supply, vulnerability to disruption, expenditure, infrastructure, stability of exporting countries, ownership of production, price stability, access and equity, affordability, intellectual property, safety and reliability of supply, and countries' capacity to adapt to market changes are all elements of security of supply. Based on these elements, we assessed security of supply for insulin, since access to insulin is a global problem. We found that three multinational companies, in Denmark, France and Germany, control 99% of the value of the global insulin market. Prices and affordability of insulin and access to it vary considerably between countries. Some countries are vulnerable to insulin shortage because they import insulin from only one source. Many countries spend large amounts of money on insulin and costs are increasing. Some countries lack an adequate infrastructure for procurement, supply chain management and distribution of insulin. Applying the security of supply concept to insulin showed that diversification of suppliers needs to be fostered. Global health actors should adopt a security of supply approach to identify medicines that are susceptible to supply issues and address this concern by strategic promotion of local production, strengthening regulatory harmonization, and adding local products to the World Health Organization's programme on prequalification of medicines.

La sécurité de l'approvisionnement en médicaments est fondamentale pour garantir une bonne santé pour tous. De plus, l'amélioration de l'accès aux médicaments figure dans l'Objectif de développement durable n°3. Or, le concept de sécurité d'approvisionnement a jusqu'à présent été principalement appliqué aux aliments, aux boissons et à l'énergie. La diversité d'approvisionnement, la vulnérabilité face aux perturbations de la chaîne d'approvisionnement, les infrastructures, la stabilité des pays exportateurs, la propriété des moyens de production, la stabilité des prix, l'accès et l'équité, l'accessibilité des prix, la propriété intellectuelle, la sûreté et la fiabilité de l'approvisionnement ainsi que la capacité des pays à s'adapter aux évolutions du marché sont autant de notions inhérentes à la sécurité d'approvisionnement. À partir de ces éléments, nous avons évalué la sécurité d'approvisionnement pour l'insuline, étant donné que l'accès à l'insuline constitue un enjeu mondial. Nous avons constaté que trois multinationales (au Danemark, en France et en Allemagne) contrôlent 99% de la valeur du marché mondial de l'insuline. Les prix, leur accessibilité ainsi que l'accès à l'insuline varient considérablement d'un pays à un autre. Certains pays sont vulnérables face aux pénuries d'insuline, car ils n'importent l'insuline qu'auprès d'une seule source. De nombreux pays dépensent énormément d'argent pour l'insuline, et les coûts sont en augmentation. Certains pays n'ont pas d'infrastructures appropriées pour les achats, la gestion de la chaîne d'approvisionnement et la distribution de l'insuline. L'application du concept de sécurité d'approvisionnement à l'insuline nous a montré que la diversification des fournisseurs doit être encouragée. Les acteurs mondiaux de la santé devraient adopter une approche de sécurité d'approvisionnement pour identifier les médicaments susceptibles de connaître des problèmes d'approvisionnement et répondre à cet enjeu par la promotion stratégique d'une production locale, le renforcement de l'harmonisation réglementaire et l'ajout de produits locaux dans le programme de l'Organisation mondiale de la Santé sur la préqualification des médicaments.

La seguridad en el suministro de medicamentos es fundamental para garantizar la salud de todos. Además, la mejora del acceso a los medicamentos está incluida en el objetivo de desarrollo sostenible 3. Sin embargo, el concepto de seguridad en el suministro se ha aplicado principalmente a los alimentos, el agua y la energía. La diversidad del suministro, la vulnerabilidad a las perturbaciones, el gasto, la infraestructura, la estabilidad de los países exportadores, la propiedad de la producción, la estabilidad de los precios, el acceso y la equidad, la asequibilidad, la propiedad intelectual, la seguridad y la fiabilidad del suministro y la capacidad de los países para adaptarse a los cambios del mercado son todos elementos que se incluyen en la seguridad en el suministro. Con base en estos elementos, se ha evaluado la seguridad del suministro de insulina, ya que el acceso a esta es un problema mundial. Se ha descubierto que tres empresas multinacionales, en Dinamarca, Francia y Alemania, controlan el 99 % del valor de mercado mundial de insulina. Los precios y la asequibilidad de la insulina y el acceso a ella varían considerablemente de un país a otro. Algunos países son vulnerables a la escasez de insulina porque la importan de una sola fuente. Muchos países gastan grandes cantidades de dinero en insulina y los costes aumentan. Algunos países carecen de una infraestructura adecuada para la adquisición, la gestión de la cadena de suministro y la distribución de insulina. La aplicación del concepto de seguridad en el suministro a la insulina demostró que es necesario fomentar la diversificación de los proveedores. Los agentes de la salud mundial deberían adoptar un enfoque de seguridad en el suministro para identificar los medicamentos que son susceptibles de problemas de suministro y abordar esta preocupación mediante la promoción estratégica de la producción local, el fortalecimiento de la armonización de los reglamentos y la incorporación de los productos locales al programa de la Organización Mundial de la Salud sobre la precalificación de los medicamentos.

New perspectives on chinese herbal medicine (zhong-yao) research and development.

Synthetic chemical drugs, while being efficacious in the clinical management of many diseases, are often associated with undesirable side effects in patients. It is now clear that the need of therapeutic intervention in many clinical conditions cannot be satisfactorily met by synthetic chemical drugs. Since the research and development of new chemical drugs remain time-consuming, capital-intensive and risky, much effort has been put in the search for alternative routes for drug discovery in China. This narrative review illustrates various approaches to the research and drug discovery in Chinese herbal medicine. Although this article focuses on Chinese traditional drugs, it is also conducive to the development of other traditional remedies and innovative drug discovery.

Human follicular fluid heparan sulfate contains abundant 3-O-sulfated chains with anticoagulant activity.

Anticoagulant heparan sulfate proteoglycans bind and activate antithrombin by virtue of a specific 3-O-sulfated pentasaccharide. They not only occur in the vascular wall but also in extravascular tissues, such as the ovary, where their functions remain unknown. The rupture of the ovarian follicle at ovulation is one of the most striking examples of tissue remodeling in adult mammals. It involves tightly controlled inflammation, proteolysis, and fibrin deposition. We hypothesized that ovarian heparan sulfates may modulate these processes through interactions with effector proteins. Our previous work has shown that anticoagulant heparan sulfates are synthesized by rodent ovarian granulosa cells, and we now have set out to characterize heparan sulfates from human follicular fluid. Here we report the first anticoagulant heparan sulfate purified from a natural human extravascular source. Heparan sulfate chains were fractionated according to their affinity for antithrombin, and their structure was analyzed by 1H NMR and MS/MS. We find that human follicular fluid is a rich source of anticoagulant heparan sulfate, comprising 50.4% of total heparan sulfate. These antithrombin-binding chains contain more than 6% 3-O-sulfated glucosamine residues, convey an anticoagulant activity of 2.5 IU/ml to human follicular fluid, and have an anti-Factor Xa specific activity of 167 IU/mg. The heparan sulfate chains that do not bind antithrombin surprisingly exhibit an extremely high content in 3-O-sulfated glucosamine residues, which suggest that they may exhibit biological activities through interactions with other proteins.

Matrix metalloproteinases and their specific tissue inhibitors in menstruation.

The timely breakdown of extracellular matrix is essential for menstruation. Matrix metalloproteinases, which are able to degrade virtually all components of the extracellular matrix, are spatiotemporally expressed in the cyclic endometrium. The expression of most matrix metalloproteinases is regulated transcriptionally and their proteolytic activities are precisely controlled. The balance between matrix metalloproteinases and their specific tissue inhibitors is believed to be crucial for menstruation. This review focuses on the roles of matrix metalloproteinases and their tissue inhibitors in the initiation of menstruation and on the regulation of matrix metalloproteinase expression and activation. For example, the function of matrix metalloproteinases and their tissue inhibitors in endometrial re-epithelialization and angiogenesis during endometrial regeneration, when cell migration is facilitated to ensure endometrial repair, is discussed. This and other processes, although not fully resolved, serve to illustrate the involvement of matrix metalloproteinases and their tissue inhibitors in the process of menstruation.

Coordinate expression of anticoagulant heparan sulfate proteoglycans and serine protease inhibitors in the rat ovary: a potent system of proteolysis control.

During the reproductive cycle, ovarian follicles undergo major tissue-remodeling involving vascular changes and proteolysis. Anticoagulant heparan sulfate proteoglycans (aHSPGs) are expressed by granulosa cells during the development of the ovarian follicle. The function of aHSPGs in the ovary is unknown, but they might be involved in proteolysis control through binding and activation of serine protease inhibitors. To identify functional interactions between aHSPGs and heparin-binding protease inhibitors in the follicle, we have coordinately localized aHSPGs, antithrombin III, protease nexin-1, and plasminogen activator inhibitor-1 in the rat ovary during natural and gonadotropin-stimulated cycles. Anticoagulant HSPGs were visualized by autoradiography of cryosections incubated with 125I-antithrombin III, and protease inhibitors were assessed by immunohistochemistry and Northern blot hybridization. Anticoagulant HSPGs were expressed in follicles before ovulation, were transiently decreased in postovulatory follicles, and were abundant in the corpus luteum, mainly on capillaries. Anticoagulant HSPGs were colocalized with protease nexin-1 in follicles from the early antral stage until ovulation, with antithrombin III in the preovulatory stage and after ovulation, and with plasminogen activator inhibitor-1 in the corpus luteum. These data demonstrate that aHSPGs are critically expressed in the ovary to interact sequentially with protease nexin-1, antithrombin III, and plasminogen activator inhibitor-1 during the cycle. The specificity of these inhibitors is shifted toward thrombin inhibition in the presence of heparin, suggesting that aHSPGs direct their action to control fibrin deposition in the follicle. The occupation of aHSPGs antithrombin-binding sites by mutant R393C antithrombin III, injected in the ovarian bursa, decreased ovulation efficiency, further supporting the involvement of aHSPGs in the ovulation process.