Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Desenvolvimento e caracterização de dispersões sólidas amorfas de Praziquantel para uso pediátrico por hot melt extrusion e impressão 3D

Depuis 40 ans, le praziquantel (PZQ) est le traitement standard de la schistosomiase, une maladie parasitaire négligée qui touche plus de 250 millions de personnes dans le monde. Cependant, il n'existe pas de formulation pédiatrique adéquate sur le marché, ce qui conduit à une utilisation hors indication et à la division des comprimés commerciaux pour les adultes. Cette thèse s’articule autour du développement d'une dispersion amorphe solide (ASD) pour le PZQ afin d’améliorer certaines caractéristiques physico-chimiques (faible solubilité dans l'eau) et sensoriels (goût amer) de cet API. Des ASD contenant 35 à 50 % en masse d'API (systèmes binaires et ternaires) ont été produites par extrusion à chaud (HME) en utilisant un copolymère vinylpyrrolidone-acétate de vinyle (Kollidon® VA 64) comme support polymère. Les systèmes binaires sont constitués de PZQ et de Kollidon® VA 64. Afin de développer rationnellement des ASD hautement chargées en PZQ, la première étude de cette thèse porte sur la construction d'un diagramme de phase PZQ- Kollidon® VA 64, construit à partir d'une étude thermique de la recristallisation d'une ASD sursaturé (50 % PZQ), générée par séchage par pulvérisation. Les systèmes ternaires ont été formulés avec un tensioactif comme composant supplémentaire (5 % en masse), en utilisant deux types différents (Span ™ 20 et Kolliphor® SLS). Plusieurs techniques ont été utilisées pour caractériser les ASD produites (teneur en PZQ, propriétés thermiques, morphologie des particules, solubilité apparente, profil de dissolution et stabilité physique). Les ASD binaires et ternaires augmentent la solubilité apparente de la PZQ, plus précisément de 70 % à 90 % par rapport à la concentration d'équilibre dans l'eau à 37 °C. La cinétique de dissolution a également été améliorée, par exemple, 90 % de libération du médicament en une heure pour l’ASD ternaire contenant du SPAN 20 comme surfactant et 35 % en masse d'API. Le deuxième défi consiste à masquer le goût amer du PZQ. Des évaluations du masquage du goût (in vivo et in vitro) et des études pharmacocinétiques ont été réalisées avec des formulations sélectionnées. Des résultats positifs liés au masquage du goût amer pour les deux charges de PZQ (50 et 35 % en masse) ont pu être démontrés. Le troisième défi pour le PZQ à usage pédiatrique est le besoin d'un ajustement précis de la dose. Comme alternative pour surmonter le défi de l'ajustement des doses d'un médicament pédiatrique à base de PZQ pour les enfants, l'utilisation de la technologie d'impression 3D (FDM) avec alimentation directe de dispersions solides amorphes en poudre a été proposée. Nous avons pu démontrer la faisabilité d'obtenir des imprimés (printlets) avec deux doses différentes de PZQ (100 et 150 mg) en utilisant la technologie de FDM. Les printlets avec 35 % en masse de PZQ et SPAN 20 ont montré la meilleure performance de dissolution. Ce travail a démontré l'intérêt d’une dispersion solide amorphe ternaire contenant du PZQ sous forme de pellets ou de poudre pour l'impression 3D directe (FDM). Les principaux obstacles à la formulation du PZQ, tels qu'une faible solubilité du médicament, un goût inapproprié et des exigences de dosage élevées et variables, peuvent être surmontés en utilisant la combinaison de différents technologies (production d'ASD par HME et FDM comme technologie d'impression 3D).For the past 40 years, praziquantel (PZQ) has been the standard treatment for schistosomiasis, the neglected parasitic disease that affects more than 250 million people worldwide. However, there is no adequate paediatric formulation on the market, leading to off-label use and the division of commercial tablets for adults. This thesis focused on the development of a PZQ formulation based on solid amorphous dispersion (ASD) to solve physicochemical (low water solubility) and sensory (bitter taste) of PZQ active pharmaceutical ingredient (API) disadvantages. ASD with 35 to 50 w/w% API (binary and ternary systems) were produced by hot-melt extrusion (HME) using vinylpyrrolidone-vinyl acetate copolymer (Kollidon® VA 64) as a polymeric carrier. The binary systems consisted of PZQ and Kollidon® VA 64. To rationally develop ASD highly loaded with PZQ, the first study of this thesis focused on the construction of a PZQ- Kollidon® VA 64 phase diagram, constructed from a thermal study of the recrystallization of a supersaturated ASD (50 % PZQ), generated by spray drying. The ternary systems were formulated with a surfactant as an additional component (5 w/w%), using two different types (Span ™ 20 and Kolliphor® SLS). Several techniques were used to characterize the produced ASD (PZQ content, thermal properties, particle morphology, apparent solubility, dissolution profile, and physical stability). All binary and ternary ASD increased the PZQ apparent solubility, more specifically, 70 % to 90 % more than the equilibrium concentration in water at 37°C. The dissolution kinetics was also improved, for example, 90 % of drug release in one hour for the ternary ASD containing SPAN 20 as a surfactant and 35 wt% of API. The second challenge is to mask the bitter taste of PZQ. Taste masking assessments (in vivo and in vitro) and pharmacokinetics studies were performed with selected formulations. Positive results related to masking the bitter taste for both PZQ load (50 and 35 wt%) could be demonstrated. The third challenge for paediatric PZQ is the need of accurate dose adjustment. As an alternative to overcome the challenge of adjusting the doses of a paediatric medicine based on PZQ for children, the use of 3D printing technology (FDM) with direct feeding of powdered amorphous solid dispersions was proposed. We could demonstrate the feasibility of obtaining printlets with two different doses of PZQ (100 and 150 mg) using ternary ASD. The printlets containing 35 wt% of API load and SPAN 20 showed the best dissolution performance. This work demonstrated the interest of ternary ASD containing PZQ in the form of pellets or powder for compressed 3D printing. The main obstacles in the formulation of PZQ, such as low drug solubility, inappropriate taste, and high and variable dosage requirements, can be overcome using the combination of different technologies (production of ASD by HME and FDM as SD printing technology)

Development and validation of particle size distribution methodology by laser light scattering of the active pharmaceutical ingredient efavirenz

Submitted by Gilvan Almeida ([email protected]) on 2016-12-15T12:51:21Z No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 16.pdf: 15962120 bytes, checksum: cf60c03c2bf3664f6f59ca02502aac2f (MD5)Approved for entry into archive by Michelle Lanzellote ([email protected]) on 2017-02-08T13:08:48Z (GMT) No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 16.pdf: 15962120 bytes, checksum: cf60c03c2bf3664f6f59ca02502aac2f (MD5)Made available in DSpace on 2017-02-08T13:08:48Z (GMT). No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 16.pdf: 15962120 bytes, checksum: cf60c03c2bf3664f6f59ca02502aac2f (MD5) Previous issue date: 2013Fundação Oswaldo Cruz. Instituto de Tecnologia em Fármacos/Farmanguinhos. Rio de Janeiro, RJ, Brasil.Nas formas farmacêuticas sólidas, a biodisponibilidade de um fármaco está ligada a sua dissolução e esta, por sua vez, tem relação com a distribuição granulométrica. Além disso, a distribuição granulométrica pode impactar diretamente nos processos de fabricação e na qualidade do medicamento. Atualmente, a técnica de espalhamento de luz laser tem sido amplamente utilizada na análise da distribuição granulométrica. Embora os equipamentos sejam relativamente simples ao manuseio, há a necessidade de um desenvolvimento adequado de metodologia (contemplando diversos pontos) a fim de garantir resultados confiáveis, robustos e precisos. A ISO 13320 (2009) trata da técnica de distribuição granulométrica por espalhamento de luz laser e as farmacopeias referenciam a ISO 13320 na descrição dos métodos e dos parâmetros técnicos, inclusive na validação. O objetivo deste trabalho foi desenvolver e validar a metodologia de distribuição granulométrica por espalhamento de luz laser do insumo farmacêutico ativo (IFA) efavirenz, o qual é um fármaco de baixa solubilidade e alta permeabilidade (SCB classe II) e, segundo documento da World Health Organization (WHO) de 2011, o sucesso de formas farmacêuticas de efavirenz depende, dentre outros fatores, da caracterização adequada do IFA, sendo destacada a importância do conhecimento de sua distribuição granulométrica. Foram utilizadas 5 amostras de efavirenz de 3 fabricantes diferentes (A, B e C): EFZ-A1 e EFZ-A2 (etapa de desenvolvimento); EFZ-A3, EFZ-B1 e EFZ-C1 (etapa de validação). As amostras foram avaliadas por microscopia ótica (MO) e microscopia eletrônica de varredura (MEV). A análise de distribuição granulométrica por espalhamento de luz laser foi realizada no equipamento Mastersizer 2000 (Malvern Instruments), utilizando o módulo Hydro 2000S. As amostras foram previamente dispersas em 10 mL de solução contendo tensoativo e submetidas a ultrassom. Os tensoativos avaliados foram: polissorbato 20, 40, 60, 80 e 85, Triton X-100, LSS, CTAC e Igepal® 630CA. O procedimento de validação foi baseado na repetibilidade do sistema, repetibilidade da metodologia e precisão intermédia. A análise microscópica mostrou que todas as amostras apresentam morfologia semelhante. Os polissorbatos 40, 60 e 80 foram os tensoativos que apresentaram melhor desempenho na análise. No final do desenvolvimento, foram definidos os seguintes parâmetros para a análise de distribuição granulométrica do efavirenz, por espalhamento de luz laser: 50% de agitação (1750 rpm), 50% de ultrassom, polissorbato 80 [0,02% (p/v)] como tensoativo e tempo de dispersão da amostra no equipamento antes da medição igual a 10min. Na etapa de validação, os coeficientes de variação ficaram dentro dos limites previamente estabelecidos para as amostras EFZ-A3, EFZ-B1 e EFZ-C1, nos quesitos repetibilidade do sistema, repetibilidade da metodologia e precisão intermediária.In solid pharmaceutical forms, the bioavailability of a drug is related to its dissolution, which is, in turn, related to the particle size distribution. Besides, the particle size distribution can directly impact in the manufacturing processes and in the quality of the drug. Nowadays, the laser light scattering technique is widely used in the analysis of particle size distribution. Although the equipment is relatively simple to handle, there is a need for an adequate development of methodology (contemplating several points) to ensure reliable, robust and accurate results. The ISO 13320 refers to the particle size distribution by laser light scattering technique, and the pharmacopoeias refer to the ISO 13320 in the description of methods and technical parameters, even for validation. The purpose of this study was to develop and validate the methodology of particle size distribution by laser light scattering for the efavirenz active pharmaceutical ingredient (API), which is a drug with low solubility and high permeability (BCS class II) and, according to a document from the World Health Organization (WHO) (2011), the success of pharmaceutical forms of efavirenz depends, among other factors, on the appropriate characterization of the API, being highlighted the importance of knowing their size distribution. Five samples of efavirenz, from three different manufacturers (A, B and C), were used: EFZ-A1 and EFZ-A2 (development stage); EFZ-A3, EFZ-B1 and EFZ-C1 (validation stage). The samples were evaluated by OM and SEM. The analysis of particle size distribution by laser light scattering was performed on the equipment Mastersizer 2000 (Malvern Instruments), using the Hydro 2000S module. The samples have been previously dispersed in 10 mL of a solution containing surfactant and subjected to ultrasound. The evaluated surfactants were: polysorbate 20, 40, 60, 80 and 85, Triton X-100, SLS, CTAC and Igepal ® 630CA. The validation procedure was based on the repeatability of the system, the repeatability of the methodology, and on intermediate precision. The microscopic analysis showed that all samples presented similar morphology. The polysorbates 40, 60 and 80 were the surfactants that showed better performance in the analysis. At the end of development, the following parameters have been defined for the analysis of size distribution by laser light scattering of efavirenz: 50% agitation (1750 rpm), 50% ultrasound, polysorbate 80 [0.02% (w/v )] as surfactant, and dispersion time of the sample in the equipment before measurement equal to 10 minutes. In the validation stage, the coefficients of variation of repeatability of the system, repeatability of the methodology, and intermediate precision were within the previously established limits for all analyzed samples (EFZ-A3, EFZ-B1 and EFZ-C1)

Desenvolvimento e caracterização de dispersões sólidas amorfas de Praziquantel para uso pediátrico por hot melt extrusion e impressão 3D

For the past 40 years, praziquantel (PZQ) has been the standard treatment for schistosomiasis, the neglected parasitic disease that affects more than 250 million people worldwide. However, there is no adequate paediatric formulation on the market, leading to off-label use and the division of commercial tablets for adults. This thesis focused on the development of a PZQ formulation based on solid amorphous dispersion (ASD) to solve physicochemical (low water solubility) and sensory (bitter taste) of PZQ active pharmaceutical ingredient (API) disadvantages. ASD with 35 to 50 w/w% API (binary and ternary systems) were produced by hot-melt extrusion (HME) using vinylpyrrolidone-vinyl acetate copolymer (Kollidon® VA 64) as a polymeric carrier. The binary systems consisted of PZQ and Kollidon® VA 64. To rationally develop ASD highly loaded with PZQ, the first study of this thesis focused on the construction of a PZQ- Kollidon® VA 64 phase diagram, constructed from a thermal study of the recrystallization of a supersaturated ASD (50 % PZQ), generated by spray drying. The ternary systems were formulated with a surfactant as an additional component (5 w/w%), using two different types (Span ™ 20 and Kolliphor® SLS). Several techniques were used to characterize the produced ASD (PZQ content, thermal properties, particle morphology, apparent solubility, dissolution profile, and physical stability). All binary and ternary ASD increased the PZQ apparent solubility, more specifically, 70 % to 90 % more than the equilibrium concentration in water at 37°C. The dissolution kinetics was also improved, for example, 90 % of drug release in one hour for the ternary ASD containing SPAN 20 as a surfactant and 35 wt% of API. The second challenge is to mask the bitter taste of PZQ. Taste masking assessments (in vivo and in vitro) and pharmacokinetics studies were performed with selected formulations. Positive results related to masking the bitter taste for both PZQ load (50 and 35 wt%) could be demonstrated. The third challenge for paediatric PZQ is the need of accurate dose adjustment. As an alternative to overcome the challenge of adjusting the doses of a paediatric medicine based on PZQ for children, the use of 3D printing technology (FDM) with direct feeding of powdered amorphous solid dispersions was proposed. We could demonstrate the feasibility of obtaining printlets with two different doses of PZQ (100 and 150 mg) using ternary ASD. The printlets containing 35 wt% of API load and SPAN 20 showed the best dissolution performance. This work demonstrated the interest of ternary ASD containing PZQ in the form of pellets or powder for compressed 3D printing. The main obstacles in the formulation of PZQ, such as low drug solubility, inappropriate taste, and high and variable dosage requirements, can be overcome using the combination of different technologies (production of ASD by HME and FDM as SD printing technology).Depuis 40 ans, le praziquantel (PZQ) est le traitement standard de la schistosomiase, une maladie parasitaire négligée qui touche plus de 250 millions de personnes dans le monde. Cependant, il n'existe pas de formulation pédiatrique adéquate sur le marché, ce qui conduit à une utilisation hors indication et à la division des comprimés commerciaux pour les adultes. Cette thèse s’articule autour du développement d'une dispersion amorphe solide (ASD) pour le PZQ afin d’améliorer certaines caractéristiques physico-chimiques (faible solubilité dans l'eau) et sensoriels (goût amer) de cet API. Des ASD contenant 35 à 50 % en masse d'API (systèmes binaires et ternaires) ont été produites par extrusion à chaud (HME) en utilisant un copolymère vinylpyrrolidone-acétate de vinyle (Kollidon® VA 64) comme support polymère. Les systèmes binaires sont constitués de PZQ et de Kollidon® VA 64. Afin de développer rationnellement des ASD hautement chargées en PZQ, la première étude de cette thèse porte sur la construction d'un diagramme de phase PZQ- Kollidon® VA 64, construit à partir d'une étude thermique de la recristallisation d'une ASD sursaturé (50 % PZQ), générée par séchage par pulvérisation. Les systèmes ternaires ont été formulés avec un tensioactif comme composant supplémentaire (5 % en masse), en utilisant deux types différents (Span ™ 20 et Kolliphor® SLS). Plusieurs techniques ont été utilisées pour caractériser les ASD produites (teneur en PZQ, propriétés thermiques, morphologie des particules, solubilité apparente, profil de dissolution et stabilité physique). Les ASD binaires et ternaires augmentent la solubilité apparente de la PZQ, plus précisément de 70 % à 90 % par rapport à la concentration d'équilibre dans l'eau à 37 °C. La cinétique de dissolution a également été améliorée, par exemple, 90 % de libération du médicament en une heure pour l’ASD ternaire contenant du SPAN 20 comme surfactant et 35 % en masse d'API. Le deuxième défi consiste à masquer le goût amer du PZQ. Des évaluations du masquage du goût (in vivo et in vitro) et des études pharmacocinétiques ont été réalisées avec des formulations sélectionnées. Des résultats positifs liés au masquage du goût amer pour les deux charges de PZQ (50 et 35 % en masse) ont pu être démontrés. Le troisième défi pour le PZQ à usage pédiatrique est le besoin d'un ajustement précis de la dose. Comme alternative pour surmonter le défi de l'ajustement des doses d'un médicament pédiatrique à base de PZQ pour les enfants, l'utilisation de la technologie d'impression 3D (FDM) avec alimentation directe de dispersions solides amorphes en poudre a été proposée. Nous avons pu démontrer la faisabilité d'obtenir des imprimés (printlets) avec deux doses différentes de PZQ (100 et 150 mg) en utilisant la technologie de FDM. Les printlets avec 35 % en masse de PZQ et SPAN 20 ont montré la meilleure performance de dissolution. Ce travail a démontré l'intérêt d’une dispersion solide amorphe ternaire contenant du PZQ sous forme de pellets ou de poudre pour l'impression 3D directe (FDM). Les principaux obstacles à la formulation du PZQ, tels qu'une faible solubilité du médicament, un goût inapproprié et des exigences de dosage élevées et variables, peuvent être surmontés en utilisant la combinaison de différents technologies (production d'ASD par HME et FDM comme technologie d'impression 3D)

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.13Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt