Browsing by Title

Background and objectives: Documenting and processing of dispensing errors at both organizational and national levels is one of the basic preconditions for effective medication risk management. Since the most recently accomplished national register research of dispensing errors in Finland, there have been several changes in the medication dispensing process that advance medication safety. Thus, the previous study does not provide an up-to-date picture of the current situation. The primary objective of this study was to find out the trends in dispensing errors that were reported to the Finnish Pharmacy Association's registry of dispensing errors in 2015–2019. The secondary objective was to identify risk factors expository to dispensing errors in the dispensing process and to review the measures utilized by community pharmacies to prevent dispensing errors. Materials and methods: The retrospective registry study, in which the register of dispensing errors maintained by the Finnish Association of Pharmacists for the period from 1 January 2015 to 31 December 2019, was analyzed. Cases that did not fulfil the definition of a dispensing error (n=829) were removed from the original data (n=17763). In addition, clear errors (n=2130) were corrected in the data and cases (n=499) that were initially insufficiently entered in the register were added. 17433 dispensing errors were included in the study. The data was analyzed using Microsoft Excel. The number, qualities, prescription types, observers, therapeutic harms and contributory factors of the dispensing errors were investigated in the data. The most common groups of medicinal substance, high-alert medications and risk factors in the medication dispensing process were identified in the data. In addition, interventions reported by community pharmacies to prevent dispensing errors were collected from the data. Results: The number of cases reported to the dispensing error register has decreased annually (2015 n=3913, 2016 n=3795, 2017 n=3708, 2018 n=3578, 2019 n=2439). The most common types of dispensing errors are incorrect strength (51 % of all the reported dispensing errors) and incorrect quantity or package size (14 %). Slightly more than a half (51 %) of the reported dispensing errors were noticed by medicine users. The percentage of electronic prescriptions in dispensing errors has increased and is clearly the most common prescription type in dispensing errors (2015: 79 %, 2016: 84 %, 2017: 93 %, 2018: 96 %, 2019: 95 %). The majority of dispensing errors occurred with cardiovascular medicines (29 %) and medicines affecting the nervous system (26 %). 7 % of dispensing errors caused therapeutic harm to the medicine user. As a result of dispensing errors, 21 medicine users were hospitalized. 13 % of dispensing errors occurred with high-alert medications (n=2244). The high-alert medications were involved in one-third (n=7) of dispensing errors that led to hospitalization. Factors related to the employee (25 %), similar packaging (19 %), and similar medicine name (15%) were most commonly considered to be the main contributory factors for the occurrence of the dispensing errors. The risk factors identified in the medicine dispensing process were related to the pharmacy system, the characteristics of the prescription, the storage method of the medicine and the characteristics of the medicine packaging. In the automated dose dispensing process, the risk of dispensing error increased if changes had to be made to the dose dispensing order. The risk factors for automated dose dispensing were related to the pharmacy system and the characteristics of the prescription. The community pharmacies had mentioned taking measures to prevent dispensing errors in one-fifth (21 %) of the reported cases. In addition to developing their own operations, community pharmacies saw cooperation with other healthcare professionals as an important factor in preventing medication errors. In addition, community pharmacies reported exposing properties for dispensing errors of pharmaceutical products and systems to pharmaceutical companies and providers of pharmacy systems and automated dose dispensing. Conclusions: Trends, risk factors of the dispensing process and interventions to prevent dispensing errors can be identified in the dispensing errors reported to the Finnish Association of Pharmacists’ dispensing error registry. The dispensing error register provides valuable information on dispensing errors at the national level, but it is no longer able to fulfil completely the current medication safety needs. In the future, the role of the pharmacy as a promoter of medication safety should be perceived as more comprehensive. In the development of medication safety, special attention should be paid to the risk factors of the dispensing process, the high-alert medications and to new risks arising from the increase of electronic prescriptions and automated dose dispensing. In addition, cooperation between pharmacies and other healthcare professionals and the medication safety culture of pharmacies should be further strengthened.

The purpose of this systematic review is to investigate the usage of artificial intelligence in the pharmaceutical industry in the fields of pharmaceutical manufacturing, product development, and quality control. Today, developing and getting a new drug on the market is time-consuming, ineffective, and expensive. Artificial intelligence is seen as one possible solution to the problems of the pharmaceutical industry. From 734 articles 77 academic study articles were included. Included articles showed artificial neural networks to be the most used artificial intelligence method between 1991 and 2021. The search was conducted from three databases with the following inclusion criteria: studies using AI in either pharmaceutical manufacturing, product development or quality control, English as the language, and Western medicine-based pharmacy as a branch of science. This systematic literature review has three main limitations: the possibility of an important search word missing from the search algorithm, the selection of articles according to one person's assessment, and the possible narrow picture of the used artificial intelligence methods in the pharmaceutical industry, as pharmaceutical companies also research the subject. The use of artificial intelligence in product development has been studied the most, while its use in quality control has been studied the least. In the studies, tablets were a popular drug form, while biological drugs were underrepresented. In total, the number of studies published increased over three decades. However, most of the articles were published in 2020. Nearly half of the articles had some connection to a pharmaceutical company, indicating the interest of both the academy and pharmaceutical companies in the use of artificial intelligence in manufacturing, product development, and quality control. In the future, the efficacy of artificial intelligence, as well as its limitations as a method, should be investigated to conclude its potential to play a key role in reforming the pharmaceutical industry. The results of the study show that a wave of artificial intelligence has arrived in the pharmaceutical industry, however, its real benefits will only be seen with future research.

Nicotinic acetylcholine receptors are ion channel receptors that consist of five subunits and have an important role in modulating neurotransmitter release in the central nervous system. The literature review part of this thesis presents an overview of the structure, function and diverse subunit composition of nicotinic receptors and reviews the scientific literature on their function as modulators of neurotransmitter release. Relevant literature on the role of the nicotinic receptors of the striatum, the hippocampus and the prefrontal cortex in the modulation of the release of dopamine, glutamate, GABA, acetylcholine, noradrenalin and serotonin is reviewed. Finally, a summary for each of the brain areas and some conclusions are presented. The experimental part of this thesis consists of a series of experiments, where the ability of morphine to activate the presynaptic nicotinic receptors modulating dopamine release in the mouse striatum was investigated based on opioid-nicotine-interactions reported earlier. The possible effect of morphine was studied by measuring the release of radiolabeled dopamine from perfused synaptosomes prepared from mouse striatum. In addition, the effect of nicotine was studied to confirm the correct functioning of the method and to obtain data for comparison with the morphine results. Both nicotine and morphine elicited the release of [3H]dopamine from striatal synaptosomes. The release of [3H]dopamine elicited by morphine was blocked by nicotinic antagonists, suggesting that the effect of morphine was mediated by nicotinic receptors. Use of the selective antagonist α-conotoxin MII revealed that the effect of morphine, similar to nicotine, was mediated in part by α6β2* receptors and in part by other receptors, possibly α4β2*. In addition, the opioid antagonist naloxone blocked the effects of both nicotine and morphine, likely via direct antagonism of nicotinic receptors. However, the concentrations of morphine and naloxone needed for affecting [3H]dopamine release were very high, which suggests that the clinical relevance of the effects described here is likely to be small. The involvement of opioid receptors was deemed to be unlikely but, along with possible non-specific effects by high concentrations, could not be completely ruled out.

Most bacteria live as biofilms (99%), which is a population of cells attached to a natural or artificial surface and encased in self-produced exopolysaccharide matrix. The extracellular polymeric substances (EPS) in the matrix can vary greatly between species in chemical and physical properties, but primarily it consists of water, polysaccharides, proteins, nucleic acids and absorbed nutrients from the surrounding area. Biofilm formation appears to be a survival strategy of bacteria and the main purpose of the biofilm matrix is to protect the bacteria. In nature, biofilms have been found in variety of different environments, including humans. Bacterial biofilms demonstrate a decreased susceptibility to antimicrobial agents and several mechanisms have been proposed to be involved in this tolerance. One of the reasons why chronic infections develop is that the immune response fails to remove the biofilm. Most of the bacterial infections currently in developed countries are biofilm related and these infections are often recalcitrant and difficult to eradicate with available treatments. In addition to chronic infections, the treatment of acute infections is shadowed by increasing problems with highly resistant bacteria. The presence of dormant persisters in biofilms accounts for their tolerance to antimicrobials and likely are responsible for latent and chronic infections, such as tuberculosis. Persistence is not primarily an active mechanism of antibiotic tolerance, but a dormant state of the bacteria avoiding the mechanism of action of most antibiotics. Persisters form stochastically only in small numbers, and more relevant physiological explanation is related to the stress responses of the cells. Persisters are distinguish phenotypic variants of the normal population and it is not a heritable feature, as no mutations occur. The dormant, persistent state of the bacteria is largely responsible for the multidrug tolerance of recalcitrant infections. Biofilm cause various diseases in humans, as bacteria are able to attach to practically any surface, such as teeth, heart valves, lungs, middle ear, artificial prosthetics and instruments. Biofilms growing on prosthetic joints can cause also serious infections, which are painful for the patient with high risks for complications, expensive and laborious to replace. Biofilm infections are difficult to treat and a huge burden in the healthcare. Many acute infections can be cured with conventional antibiotic therapies, but this is not case with recalcitrant, chronic infections. B. cenocepacia belongs to the B. cepacia complex (Bcc) which consist of 20 closely related and phenotypically similar species. This species was chosen for this study because of its natural tolerance to antibiotics and ability to form biofilms easily. This species causes fatal lung infections in cystic fibrosis patients, and there is no treatment for it other than inadequate combination antibiotic treatment and lung transplant. In this thesis, a promising method was developed and validated for detecting anti-persister activity against B. cenocepacia. The assay is based on measuring the levels of ATP present in the cultures after treatment and it can be used quantify remaining persisters using B. cenocepacia biofilms. Utilizing the method validated, it was confirmed that mitomycin C is an effective anti-persister compound against highly tolerant B. cenocepacia biofilms even at low concentrations. Doxycycline was found to be ineffective against B. cenocepacia biofilms, although the bacteria are susceptible to it in planktonic form, and ciprofloxacin was proved to be effective at very high concentrations.

The lower respiratory infection tuberculosis (TB) has been the leading cause of death for centuries causing millions of deaths worldwide. The development of antibiotic therapy has reduced the morbidity and mortality during the 20th century, at least in the developed countries. However, tuberculosis is still the world's second leading cause of death from infectious diseases. Although TB can be treated and even cured with drug therapy, the treatment is extremely long and requires 6-9 months constant drug therapy. This prolonged treatment causes poor patient compliance, which is usually the reason for the selection of drug resistant and often multidrug (MDR-TB) or even extensively drug-resistant (XDR-TB) TB bacteria. Limitations of available therapies and the emergence of drug-resistant strains have intensified the search for new drugs from natural sources. Marine micro- and macro-organisms have proven to be an excellent source of structurally unique biologically active natural products. EU FP7 -funded MAREX project, launched in 2010, aims at identifying new biologically active compounds from marine sources. This Master's thesis was carried out as a part of the MAREX project. The aim of this study was to optimize and validate a reproducible method to determine antimicrobial activity of natural products against Mycobacterium smegmatis, which is a widely used non-pathogenic surrogate model for TB. In the present study, spectrophotometric microplate assay was optimized and validated using existing antibacterial agents ciprofloxacin and rifampicin as reference compounds. The assay was performed on 96-well plate by using two detection techniques, absorbance measurement and a colorimetric indicator, for the antibacterial MIC end-point determination. The results obtained by the described methods were compared with each other in order to achieve the most optimal assay conditions. The quality control parameters S/B, S/N and Z' factor were used in order to determine the optimal experimental conditions for the assay. Obtaining reliable results with the turbidimetric method required incubation for two days in the case of ciprofloxacin, and for five days with rifampicin. Colorimetric measurement led to similar results as the turbidimetric measurement for both of the reference compounds. The method was further used for the screening of a group of marine extracts. None of the 21 samples tested showed significant activity against M. smegmatis.

The aged are the biggest age group of using psychotropics. The most used ones of these drugs are hypnotic and sedatives that consists mainly of benzodiazepines and related drugs. However, the aged are extremely sensitive for these drugs that are also noted as potentially inappropriate drugs for the aged in the national, but also in the various international recommendations and care guidelines. Despite the care guidelines, benzodiazepine compounds are usually used for years and often concomitantly. Research material of this longitudinal, observational study with two cohorts was collected from structured interviews at two similar acute wards in Pori City Hospital during one month in 2015. The research protocol of an early similar study which was conducted in 2004 was followed. Results of the two studies (2004 and 2015) were compared. Interviews were conducted among patients aged ≥ 65 years. Users of benzodiazepines or related drugs (2004: n=38, 2015: n=32) were further interviewed. The aim of this study was to compare the characteristics of the usage of benzodiazepine compounds in the aged between the years 2004 and 2015. In particular the medicines information sources and amount of information on these drugs i.e. knowledge on adverse drug reactions was studied and compared. Additionally a systematic review was conducted to explore the current evidence on interventions to rationalize the use of benzodiazepines and related drugs in the aged. In 2004, 54% of the interviewed patients (n=64) were using benzodiazepine compounds. However, in 2015 there were 34% (n=36) using. In 2015 regular usage of these drugs was decreased and irregular usage (given on an as-needed basis) was increased compared to the year 2004. None of the patients used long-acting benzodiazepines in 2015. Medicines information is provided notably more by doctors and pharmacies to 2004, but still the information focused more on benefits of drug other than adverse drug reactions. However, the patients' knowledge about the adverse drug reactions of benzodiazepine compounds has increased. The patients got presented adverse drug reactions known on mean of five in the year 2015, while the same value in 2004 was three. In the both years, the most of the patients were aware of the dependence these drugs may cause. The usage of benzodiazepine and related drugs in the aged has become better, but there is still need to improve multi-professional cooperation and applicate new interventions for rationalize the usage of benzodiazepinecompounds.

Pharmaceutical contaminants in waste and surface waters have been recognized as an emerging risk to environmental health. Bioaccumulation of pharmaceuticals increases the risk of adverse effects in off-target species, as the chemical concentration within the organism exceeds the concentration of the surrounding environment. An organism’s ability to metabolize foreign organic compounds influences the likelihood of bioaccumulation. Current methods for predicting bioaccumulation in aquatic organisms are labour intensive or too simplistic to cover the variety of chemical and physiological processes involved and may lead to over or underestimations of environmental risk. A promising approach to improve bioaccumulation predictions, without the need of excessive animal testing, is to incorporate in vitro biotransformation data into computational models. The primary aim of this study was to assess whether selected pharmaceuticals (diclofenac, gemfibrozil, haloperidol, levomepromazine, levonorgestrel, sertraline and risperidone), that are well metabolized in humans through key biotransformation pathways, are metabolized by rainbow trout (Oncorhynchus mykiss) liver enzymes under physiologically relevant conditions (11°C, pH 7.8). A secondary aim was to produce fish in vitro intrinsic clearance (CLint, in vitro) data, that could potentially be used as input in computational models to predict bioaccumulation. In vitro biotransformation was studied using a single vial approach according to the Organisation for Economic Co-operation and Development (OECD) Test Guideline 319B: Determination of in vitro intrinsic clearance using rainbow trout liver S9 sub-cellular fraction (RT-S9). Depletion of the test compounds were measured during a 3-hour incubation period. High-performance liquid chromatography with ultraviolet detection (HPLC–UV) was used for qualitative and quantitative analysis of the samples. Levomepromazine, levonorgestrel and sertraline showed significant substrate depletion compared to negative controls while gemfibrozil, haloperidol, and risperidone did not seem to be metabolized. The results for verapamil were inconclusive. Levomepromazine displayed a higher in vitro intrinsic clearance rate (26 ml/h/g liver) than diclofenac (6.2 ml/h/g liver). These results are in accordance with previous studies and support the notion that a direct comparability between fish and human metabolism cannot be assumed, highlighting the need of fish in vitro biotransformation studies. The apparent lack of in vitro metabolism of risperidone, haloperidol, and gemfibrozil combined with their lipophilicity suggest that they are more likely to accumulate within rainbow trout, compared with the compounds that showed depletion during the assays, although repetitions and additional studies are needed to confirm this.

Biological medicines are gaining ground in drug therapy. However, biological medicines are considerably expensive. Top ten drugs that caused the most drug reimbursement expenses included six biological drugs in Finland in 2017. A biosimilar is a biological medicine which is highly similar to another biological medicine (the reference medicine) that has already approved. Biosimilar prices are cheaper than the original medicines because their clinical development program does not have to be as extensive. A wide use of biosimilars save costs for both the patient and society without changing the effectiveness of drug therapy. The aim of this study is to investigate the automatic substitution of biological drugs containing the same active ingredient, especially from the point of view of medication safety. The study was conducted as a systematic literature review. Literature search was carried out by using Pubmed and Scopus databases. The literature was also searched manually from references of the articles and from the industry experts. The literature search produced a total of 454 articles after the deletion of duplicates. A title, abstract and full text screening was conducted by two independent researchers. All in all, 65 articles met the inclusion criteria of the study. As no studies were found on the automatic substitution of biological medicines from the point of view of medication safety, it was decided to include in the study original studies investigating the substitution of biological drugs from the point of view of doctors (n=8), pharmacists (n=3), patients (n=1) and various stakeholders (n=2). The original studies were all surveys except one study. In addition, the review included statements of various medical associations and organizations (n=23), descriptive reviews (n=27), and expert views (n=2) on the automatic substitution of biological drugs. According to the results of the original studies (n=13), it can be stated that automatic substitution is not considered generally acceptable. Doctors consider it is very important that the pharmacist informs them if substitution occurs. They also think it’s critical that doctors should be able to prevent substitution. Patients are also sceptical about the substitution of biological drugs. The quality of the original studies was assessed by the generalizability of the research results. The generalizability of the results of the original studies is weak due to the methodological shortcomings of the studies. Although the automatic substitution of biological drugs is legal in some countries, such as in France and in Australia, it has not been studied from the point of view of medication safety. In order to be safe to implement automatic substitution of biological medicines, more should be investigated on the subject. From the point of view of medication safety, healthcare professionals and patients will need further target group education on biosimilars. In addition, it should be clarified what kind of education the healthcare professionals and patients would need if the automatic substitution of biological medicines was to be realized.