Browsing by Title

Conditional reimbursement was introduced in Finland in January 2017 as a temporary addition in the Finnish Health Insurance Act. An agreement can be made between a marketing authorisation holder (MAH) and the Pharmaceuticals Pricing Board. Conditional reimbursement status can be allowed for a medicinal product if the drug is addressing unmet medical need and there are uncertainties associated to the medicinal product considering i.e. therapeutic value or cost-effectiveness, when traditional reimbursement procedures are not suitable. Risk-sharing is an essential part of the agreements and the results are monitored. Types of agreements are divided into financial- and performance-based agreements. Conditional reimbursement in Finland has not yet been studied in a large extent since its introduction. The aim of this study was to create an overview of the medicinal products with conditional reimbursement in Finland, how the unmet medical need is addressed, and which treatment options are available. Also, benefits and risks of the different stakeholders of risk-sharing agreements (RSA), why these agreements are worth to implement, earlier experiences from the European Economic Area (EEA) countries and what pharmaceutical companies should consider prior to negotiations were investigated. A document analysis was performed for investigating the medicinal products with conditional reimbursement status in Finland. A systematic literature review was conducted for collecting information and earlier experiences of RSAs and managed entry agreements (MEA) in the EEA-countries. On February 1st, 2019 there was 19 medicinal products with conditional reimbursement in Finland. These drugs are successfully addressing unmet medical need. All stakeholders of RSAs encounter benefits and risks of these agreements but the MAH is the one carrying the largest responsibilities and risks. Risk-sharing agreements gained in popularity since the early 2000s in the EEA-countries. There is no golden standard for types of agreements made but MEAs are enshrined in legislation in most countries. The pharmaceutical company should as early as possible start shaping details and collect information of the product for which conditional reimbursement will be proposed to. Negotiations might be challenging, but the aim is an agreement in which both the MAH and the payer are content with. Finland is following a similar trend as other EEA-countries, since most of the medicinal products with conditional reimbursement are oncology medicines. The use of the drugs has been limited through reimbursement number codes for certain patients who are most likely to benefit from the treatment. Rationales for introducing RSAs in EEA-countries were similar, e.g. working with finite resources, improving access, reducing uncertainty and prices, managing budget impact and improving cost-effectiveness. It seems like Finland is unique by the temporary introduction of conditional reimbursement in legislation and in other countries it has been introduced as permanent. Starting the preparations early for negotiations could save time and resources. When a RSA is made and the medicinal product shows the benefits expected, this is the ideal situation where all stakeholders benefit.

The significance of OTC product sales has risen in pharmacies because of lower margins obtained from medicines and thus a fall in the revenue. Manufacturing enterprises must pay particular attention to the success of product launches to ensure that their products end up on pharmacy shelves instead of competitors. The study intended to determine if the known key factors of successful launch also apply when launching a product to pharmacy market and if any of these factors was thought to be the most important one from pharmacists' perspective. In addition it was researched if there would be some important factors to be considered exclusively in product launches to pharmacy market and which factors have the greatest impact on pharmacies decision making about the product selection. The study was conducted as a survey directed to pharmacists, in which just launched D-vitamin product Elivo Vahva+ D50 was used as an example product. As a second part of the study few participants were interviewed by e-mail. According to the study pharmacies are interested in products that fit their selection, in other words, they are proven to be effective and useful for customers. They should bring some added value to the existing selection, to be visually attractive, price-reasonable and with a large enough target group. Representative visits, product visibility in the media, as well as the customers demand have the greatest impact on pharmacies decision making about which products to include to the selection. In addition, belonging to a pharmacy chain often brings with it the obligation to keep certain products in the shelves. Least impact on the decision making was with the electronic newsletter and pharmacy events. Pharmacies profit margin, as well as the possible purchase discounts and OTC products compensation practices are also taken into account in selection decisions. It is important that the company invests in their representatives education and offer reliable product knowledge and sales arguments to pharmacies for example with personnel training or at least in the form of brochures. When deciding the timing of the launch, seasonal variations in sales as well as competitors market entries needs to be taken into account. If it's not possible to be the first in the market, the product needs to have a real added value compared to others.

Marine organisms can be regarded as a diverse source of bioactive compounds with the possibility to discover novel drug lead molecules. Sea sponges produce bromine containing alkaloids, bromotyrosines, from which several are active against cancer. Some bromotyrosines have spirocyclic structure and the innate three-dimensionality and structural novelty of spirocycles make them an interesting option in drug design. Clavatadine C, extracted from sponge Suberea clavata, is a bromine containing spirocyclohexa-dienylisoxazoline alkaloid. It’s symmetric spirocyclic core can be viewed as a restricted derivative of open chain oximes, such as purpurealidin I, a bromotyrosine extracted from Pseudoceratina purpurea. Earlier work with purpurealidin I derivatives against melanoma cell line has had some promising results. Inspired by these earlier results, eight spirocyclic clavatadine C derivatives were synthesized according the published synthesis route. The activities of seven synthesized clavatadine C derivatives were tested on A375 melanoma cell line. All spiro derivatives were active with CC50 values ranging between 1.0 μM and 3.4 μM. Also, the activities of 10 earlier synthesized bromotyrosine derivatives were tested, from which four open chain oximes had CC50 values between 13.5 μM and 27.8 μM. Interestingly, the most active compounds were chlorinated and unhalogenated spirocyclic derivatives. In general, the spirocyclic compounds were 2- to 8-fold more active than the corresponding open chain oximes. The selectivity of active compounds was determined as cytotoxicity against Hs27 fibroblasts and by comparing the CC50 values of these two cell lines. The most selective compound was brominated derivative which had three times better selectivity against melanoma cells. The weak selectivity was consistent with the trend with open chain oxime analogs. Despite the selectivity issue, the improved activity of spirocyclic derivatives are promising and support for further investigation of marine-based spirocyclic bromotyrosine derivatives against melanoma.

Statins are a commonly used group of drugs that reduce the cholesterol levels in blood and have been shown to reduce cardiovascular morbidity and mortality. However, a considerable percentage of patients experience adverse effects during statin treatment. Statin adverse effects have been associated with genetic polymorphisms and drug-drug interactions that affect the elimination and active transport of these drugs. A more comprehensive knowledge of statin metabolism may be a step towards better management of statin treatments. Statin metabolism both in vivo and in vitro has been subject of study for years. In vitro incubation conditions may considerably affect the observed clearance, and results obtained with different methods or in different laboratories may not be directly comparable to each other. No single in vitro study on a wide panel of statins has previously been conducted. Six statins and some of their metabolites, fourteen compounds in total, were included in the study. The intrinsic clearance (CLint) of these molecules was investigated in vitro on human liver microsomes (HLM) and a panel of eleven cytochrome P450 (CYP) enzymes recombinantly expressed in E. coli. Observed CLint values for each compound in HLM and for each compound-CYP pair with observed depletion were calculated. The percentual contributions of each CYP enzyme to the metabolism of the compounds was calculated. The results obtained with recombinant CYP enzymes (rcCYP) were complemented with studies on HLM with specific chemical inhibitors of CYP enzymes. In this study the metabolism of statin lactones seemed to be faster than the metabolism of the corresponding statin acids. Atorvastatin lactone, 2-hydroxy atorvastatin lactone, 4-hydroxy atorvastatin lactone and simvastatin were extensively metabolized. Atorvastatin, 2-hydroxy atorvastatin, 3R,5S-fluvastatin, 3S,5R-fluvastatin, pitavastatin lactone and simvastatin acid showed intermediate metabolism. 4-hydroxy atorvastatin, pitavastatin, pravastatin and rosuvastatin rates of metabolism were below quantification limit. CYP3A4 had a major role in the metabolism of atorvastatin and its metabolites, simvastatin and simvastatin acid. CYP3A4 also had activity towards pitavastatin lactone. CYP2C9 had a high activity towards both 3R,5S-fluvastatin and 3S,5R-fluvastatin. CYP2D6 may play a part in the metabolism of pitavastatin lactone. CYP2C8 may have some activity towards simvastatin and simvastatin acid. The data is mostly in agreement with previous in vitro and in vivo studies regarding both the metabolism rate of statins and the contributions by different CYP enzymes to the metabolism of statins. Due to the screening nature of the study and some methodological constraints, these data should be considered as preliminary and require confirmation in further studies.

A clean area is an area isolated from its environment to prevent contamination of final product during aseptic processing. The clean area can be divided into four different grades from A to D, which all have different cleanliness standards. Grade A is the highest grade where preparing products that are not terminally sterilized must be performed. Airlocks are located between different grades to prevent free airflow, and enable necessary precautions, such as putting on protective garments and disinfecting material surface. These procedures reduce risk of contamination of the higher grade. The purpose of this study was to create a protocol to help evaluate material disinfection and transfer processes in the hospital pharmacy of Turku University Central Hospital and to determine surface bioburden of material stored in the grade C area. Surface samples of the examined material were taken in accordance with in-house guidelines by using contact plates and swabs depending on the surface of the material examined. After incubation, colony forming units were counted. Samples were taken from primary packages of ingredients and equipment stored in grade C area, as well as from material transfer boxes and cut flush plastic folders used in the clean area. Samples were taken both before and after routine disinfection of this material. 45 % of the samples taken before disinfection were contaminated. The lowest contamination rates were observed from items made from glass and those that were stored in their secondary package. In five plates grew more than 25 colonies, of which two had biofilm covering the whole surface of the plate. These samples were taken from larger plastic items, such as an infusion bag and a plastic folder. High bioburden is possible on the surface of material stored in grade C clean room, despite precautions. 25 % of the samples taken after routine disinfection were contaminated with a maximum of two colonies per plate. Despite disinfection, viable microbes may remain on the surface of material. Material with risk of high bioburden were selected for the protocol. Items were disinfected and transferred to grade B area as a simulation of normal processes. Different operators performed the protocol a total of eight times. 14 % of samples were contaminated with a maximum of two colonies per plate, except for one plate with 15 colonies. This repetition exceeded the limits set for the protocol. One repetition had zero contaminated samples. The bioburden of material surface after disinfection is affected by operators, cleanliness of the grade C area, and manipulation of the storage. A high bioburden increases risk of unsuccessful disinfection, and recontamination is possible in a non-sterile environment. Bacillus and Staphylococcus -species were identified from the samples taken during the protocol. Bacillus-species are usually isolated from soil, can tolerate harsh and low nutrient environments, and can form spores. Staphylococcus-species are part of the human skin microbiome. Microbes inside clean area are originated from personnel or surface of material transferred there. Material surface bioburden creates a contamination risk of aseptically prepared products, and thus material transfer and disinfection are critical stages during aseptic processing.

Throughout the history, there has been a wide selection of drugs developed for therapy of cardiovascular diseases (CVD). Despite a broad spectrum of different therapeutic strategies to deaccelerate and try to reverse the progression of cardiovascular diseases has been achieved, only a modest amelioration of the health of the CVD patients was achieved, as the mortality remains high by being the cause of nearly one in every three deaths yearly, myocardial infarction being involved in majority of these cases. Novel solutions are being studied to overcome this problem, one of them being nanoparticles, which may provide potential solution by carrying drugs to the desired location. Microfluidics technique may further improve the properties of nanoparticles, being a platform that allows the production of homogenous and repeatable batches that are non-dependent by the operator using it. In this thesis, it is described how microfluidics-based preparation of spermine-functionalised acetalated dextran nanoparticles co-loaded with a trisubstituted isoxazole and curcumin perform in physicochemical and in vitro experiments, in order to evaluate their potential in the application of ischemic myocardial injury therapy.

The aim of this research was to evaluate the use of microfluidic paper-based devices (µPAD) in drug analysis. Micro total analysis systems (µTAS) channels are in the range of a few micrometers and are capable of performing all steps of a chemical analysis. The advantages of miniaturization are lower sample consumption and faster analysis time. µTASs are usually fabricated of glass, silicon or polymers and their fabrication requires cleanroom facilities and specific equipment. Paper offers an inexpensive and versatile substrate for µTASs. Paper wicks liquids and no external pumps are required. µPADs advantages over µTAS are its ease of use and inexpensive and simple fabrication. µPADs are fabricated by patterning hydrophobic barriers in hydrophilic paper. There are several fabrication methods for µPADs such as photolithography, cutting and methods based on the application of wax (etching, wax printing, wax dipping). In this research wax printing was selected as the fabrication method because it's simple, rapid and inexpensive. Wax was printed using Xerox Phaser 8560DN solid ink printer. After printing the wax was melted through the paper by heating the paper at 150 °C for 120 seconds on a hotplate. Thus the wax creates a hydrophobic barrier on the hydrophilic paper which channels the liquids flow. Owing to papers anisotropic nature the wax also spreads horizontally in the paper when heated, thus reducing the wax patterns resolution and making the pattern coarse. Wax printing is an inexpensive and simple fabrication method suitable for fabricating µPADs. Also liquids flow velocity and methods for controlling the flow rate were studied. By knowing the flow velocity, one can assure that the analytes and reagents reach the reaction site. Controlling the flow velocity enables the use of multiphase reactions or the use of multiple simultaneous reactions on the µPAD. The liquid flow velocity can be controlled by changing the hydrophilic channels width, reducing the average pore size by melting a layer of wax inside the hydrophilic channel or by changing the surface tension or viscosity of the liquid used. Colorimetric assays are the most commonly used detection methods in µPADs, but also electrochemical sensing and detection methods based on fluorescence are used. In this study direct and indirect fluorescence detection methods were studied. In the detection method based on direct fluorescence, fluorescein and coumarine derivates were studied. In indirect fluorescence amino acids fluorescamine conjugates, which were created in the paper, were studied. Level of the analytes detected in direct fluorescence detection was 10-13 mol in the range of visible light and 10-12 mol in the range of UV-light. Level of the amino acids fluorescamine conjugates detected in indirect fluorescence detection was 10-9 mol. According to our results the fluorescence based detection methods used in this study are suitable for drug analysis on µPADs.

Microcrystalline cellulose is a compactable, versatile, and popular excipient in tableting. Microcrystalline cellulose is produced using acid hydrolysis where most of the amorphous areas are removed and the crystalline part is left. Particle size affects most on the functionality of microcrystalline cellulose and that can be altered by changing the duration of acid hydrolysis or the drying method. The aim of this Master’s thesis was to compare new microcrystalline materials produced using energy efficient methods, to commercial Avicel-powders. The used formulation consisted of microcrystalline cellulose, hydroxypropyl methylcellulose, magnesium stearate and dried colloidal silicon dioxide. Due to the small particle size of AaltoCell™ samples it was not possible to use it for direct compaction, but with wet granulation this was successful. The tablets were tested by the standards of European pharmacopoeia and the tablets from wet granulated Avicel PH-101, AaltoCell™ sample B and C passed all the tests. Probably the problem with the rejected formulations was poor flowability, which caused poor reproducibility in the experiments with direct compressed tablets. The wet granulated Avicel PH-101 produced the best tablets with the used formulation.

Background: Antibiotics have been an important factor in the dramatic decrease of infectious disease mortality in the 20th century. Bacteria are, however, very quick to respond to the changes in their environment because of their short life cycle. Thus, the development of bacterial antibiotic resistance is a natural consequence of the enormous worldwide antibiotic use. The current situation is that the antibiotic resistance develops faster than novel antibiotics are found and developed. The three main resistance strategies of Gram-negative bacteria are: modification of the antibiotic target, enzymatic inactivation of the antibiotic and reduce of the intracellular antibiotic concentration by changing the function of the outer membrane. To decrease the intracellular antibiotic concentration bacteria use efflux pumps. RND efflux pumps are the most important family of efflux pumps regarding antibiotic resistance. They typically function as a part of a tripartite structure which allows the efflux of antibiotics to the extracellular space. Multiple inhibitors have been developed against RND efflux pumps but none has reached the clinical stage of drug development. Objectives: Development and testing of a 384-well plate method for screening efflux pump inhibitors for E. coli (BAA1161) efflux pumps. Methods: Verifying that the absorbance measurement is a sensitive enough method for measuring the bacterial (BAA1161) growth in 384-well plate format. The antibiotic chosen to be used in the screening method was piperacillin and the positive control efflux pump inhibitor was mefloquine. Determining the minimum growth inhibiting concentrations (MICs) of piperacillin and mefloquine in 96- and 384-well plate formats. Verification of the synergistic growth inhibitory effect of piperacillin and mefloquine with the checkerboard method in 96- and 384-well plate formats. Determining the positional effect in the 384-well plate. Determining the highest DMSO concentration without effect on the growth of BAA1161. Screening of 126 natural compounds in 384-well plates to test the developed method. Screening was done in quadruplicates based on the growth inhibitory effect of the natural compounds when combined with piperacillin. Dose-response assay was conducted in combination with and without piperacillin with the compounds that showed growth inhibiting effect during screening. Results and discussion: Absorbance measurement was sensitive enough method for measuring the BAA1161 growth in the 384-well plate. MIC value of mefloquine was 32 μg/ml in both plate formats. Piperacillin’s MIC was 1024 μg/ml in the 96-well plate, but on the 384-well plate there was variation in the MIC. Piperacillin and mefloquine showed synergistic effect on BAA1161 growth inhibition in the checkerboard assays. Positional effect could not be determined, because of the variation in the BAA1161 growth inhibition effect of piperacillin. This randomly occurring phenomenon were piperacillin inhibited BAA1161 growth completely or almost completely with sub-MIC concentration was encountered in all the subsequent experiments in the 384-well plate format. One possible reason for this phenomenon, occuring in the 384-well plate format, could be piperacillin heteroresistance of BAA1161 strain. In the test screen, four compounds, which all included gallic acid ester, showed promising activity. These compounds were: epigallocatechin gallate, hamamelitannin, isopropyl gallate and octyl gallate. In the dose-response assay, hamamelitannin’s and octyl gallate’s effect was synergistic with piperacillin. Conclusions: The developed method can be used to screen novel efflux pump inhibitors. However, to increase the reliability of the method, further optimization is required to eliminate the variability in the effect of piperacillin. When plate format of a method is changed, factors which could affect the functionality of the method in the new format should be carefully assessed. Based on the test screed, gallic acid esters are interesting compounds which combined effects with antibiotics should be studied in the future experiments.

Population is aging. Within aging the morbidity and the use of medicines increase. Polypharmacy and the physiologic changes related to the ageing expose to medication-related problems. This has to be taken into consideration when planning the care of the elderly. Multiprofessional cooperation is seen as a solution to optimize the medicines' use among the aged people. Finnish Medicines Agency (Fimea) has started a network with local multiprofessional health care teams. The aim of the network is to make a national guideline for multiprofessional cooperation and optimizing the medicines' use among the aged people. The objective of the study was to clarify multiprofessional working models to optimize the medicines' use that had been carried out or planned by the teams belonging to the network. The models can work as examples when creating standardized practices to multiprofessional cooperation in Finland. Factors that promote or prevent multiprofessional cooperation and the problems of optimizing the medicines' use were clarified as were the possible solutions to solve them. Factors to strengthen cooperation and its effects were clarified on the basis of experience of the multiprofessional teams. As a material of the study were the interviews (n=15) of health care professionals (n=55) invited to Fimea's multiprofessional network. Fimea had collected the material that consists of group discussions (n=10), pair interviews (n=3) and individual interviews (n=2). The interviews that had been recorded were transcribed and analyzed by using a combine of inductive and deductive content analysis. A theoretical framework in the study was multiprofessional teamwork and networking. According to the interviews, multiprofessional cooperation in optimizing the medicines' use among the aged has been carried out in Finland in both public and private health care. The interviewees think that the most important way to optimize the medicines' use is clear division of tasks and responsibilities. Adding more pharmacists to all over the public health services and fostering the role of the community pharmacies as a part of the health care are seen as solutions. Multiprofessional meetings and education can break barriers between different professionals. The most common problems are the challenges related to economic limitations and to the busy work. There are problems in IT systems and information transfer. At the individual level, the most common problems seem to be in communication and the attitudes. The interviewees' experience is that successful multiprofessional cooperation increases medication safety and improves patients' state. The work of all the professions is faciliatated and burden of the public health service decreases. Lighter medication reviews could be used to find the patients who benefit from the comprehensive medication review. Information transfer and the currency of patients' medication should be secured with functioning IT systems. The results of the study can be utilised when developing multiprofessional practices to optimize the medicines' use. More study is needed to show the profitability of medical reviews, dose dispensing and other services.