838848

research-article2019
PMTXXX10.1177/8755122519838848Journal of Pharmacy TechnologyLawson et al

Research Report
Journal of Pharmacy Technology

Comparative Stability of Oral Vitamin

2019, Vol. 35(3) 105­–109
© The Author(s) 2019
Article reuse guidelines:
K Liquids Stored in Refrigerated sagepub.com/journals-permissions
DOI: 10.1177/8755122519838848
https://doi.org/10.1177/8755122519838848

Amber Plastic Syringes journals.sagepub.com/home/pmt

Sarah Lawson, BS1, Paul Lewis, PharmD, BCPS (AQ-ID)2,

Gina Peacock, PhD3, and Stacy Brown, PhD1

Abstract
Background: Compounded vitamin K oral liquids may be useful in some patient populations, or when an appropriate
solid dosage form is not available. While vitamin K oral liquid is typically prepared with sterile water for injection
(SWFI), other compounding agents may be more palatable. Objective: To evaluate stability of compounded vitamin K
liquids in SWFI, Ora-Sweet, simple syrup, cherry syrup, and SyrPalta stored in amber plastic oral syringes. Methods:
Five types of compounded vitamin K liquids were prepared in triplicate—Ora-Sweet, simple syrup, cherry syrup,
SyrPalta, and SWFI without flavoring; aliquoted into amber plastic oral syringes; and stored in a laboratory refrigerator
(4.9°C to 5.4°C). On study days, 3 syringes from each batch were removed, diluted to assay concentration, and
compared with a freshly prepared US Pharmacopeia reference solution. The samples and reference were analyzed
using a previously validated high-performance liquid chromatography–ultraviolet method. Product stability was defined
as 90% to 110% labeled amount. Results were further compared using a 2-way ANOVA (analysis of variance; P = .05)
with post hoc Tukey’s correction for multiple comparisons. Results: Vitamin K in SWFI, SyrPalta, and cherry syrup
was stable for 21 days, 7 days, and 24 hours, respectively, under refrigeration in amber plastic oral syringes. Vitamin
K in Ora-Sweet and simple syrup demonstrated high within-day variability and low potency. Statistically significant
differences were detected between the SWFI formulation and all other vehicles. Conclusion: Vitamin K in SWFI is
appropriate for longer-term storage of unit-dosed vitamin K; however, SyrPalta and cherry syrup may be used for
short-term storage or immediate administration of vitamin K.

Keywords
beyond-use date, stability, vitamin K, HPLC, vehicles, syringes

Introduction Concerns with availability of this tablet, lack of dosing

Vitamin K (phytonadione) is commonly utilized in warfa-
rin reversal, with a preference on the oral route when
reversal is not medically urgent.1,2 Patients with interna-
tional normalized ratios (INRs) greater than 10 without
significant bleeding can be managed with vitamin K at
doses of 2.5 to 5 mg. While the American College of Chest
Physicians no longer recommends vitamin K for patients
with INRs between 4.5 and 10, low doses (1-2.5 mg) of
vitamin K can be considered in patients with greater risk
of bleeding.3,4 Low doses appear to have similar efficacy
as higher doses and perhaps with less warfarin overcorrec-
tion.5,6 Additional studies have explored the possibility of
using low-dose vitamin K supplementation in conjunction
with warfarin as a means of stabilizing anticoagulation
control.7-9 Despite the need for low-dose oral vitamin K,
there remains only a single manufacturer and a single
strength (Mephyton 5 mg tablet).10
options for treatment requiring less than 5 mg, and delivery
options for patients unable to swallow whole tablets have
led researchers to explore alternative dosing strategies using
the 10 mg/mL injectable emulsion.11,12 Vitamin K can be
given orally using the undiluted injectable formulation;
however, this is not ideal due to the potential for medication
errors involving incorrect route of administration and inac-
curacies of measuring small doses, particularly in pediatric
patients.11 Vitamin K oral liquid diluted to 1 mg/mL using
1
East Tennessee State University, Johnson City, TN, USA
2
Johnson City Medical Center, Johnson City, TN, USA
3
Shenandoah University, Winchester, VA, USA
Corresponding Author:
Stacy Brown, Department of Pharmaceutical Sciences, Gatton College
of Pharmacy, East Tennessee State University, Box 70594, Johnson City,
TN 37614-1708, USA.
Email: browsd03@etsu.edu
106 Journal of Pharmacy Technology 35(3)
sterile water for injection (SWFI) has demonstrated concen-
trations greater than 90% for at least 105 days when stored
under refrigeration.13 However, the unpleasant taste of vita-
min K in SWFI makes this vehicle suboptimal.
Commonly used sweetening agents include Ora-Sweet,
simple syrup, cherry syrup, and SyrPalta. Ora-Sweet is one
of the most common commercial sweetening agents, and it
is buffered to a pH of 4 to 4.5 to help prevent degradation
through oxidation.14 Of note, Ora-Sweet contains preserva-
tives (potassium sorbate and methylparaben) but does not
contain alcohol.15 Simple syrup has been previously reported
as a suitable vehicle for vitamin K oral liquid and has a
slightly higher pH (4.5-5.0) compared with Ora-Sweet.11,15
Additionally, simple syrup is considered “self-preserving”
by nature of the high sucrose content.15 Cherry syrup is the
most acidic vehicle included in this study (2.7-3.1).16
SyrPalta has a pH of 4.7 and contains preservatives (sodium
benzoate, benzalkonium chloride) and alcohol (0.2%).17
The purpose of this study is to evaluate the stability and
beyond-use-dating for vitamin K 10 mg/mL injectable
emulsion compounded into 1 mg/mL oral liquid of vitamin
K in SWFI, Ora-Sweet, simple syrup, cherry syrup, and
SyrPalta, stored in amber plastic oral syringes. Beyond-use-
date (BUD) is defined as 90% to 110% potency, relative to
initial value. The US Pharmacopeia (USP) has historically
established the ±10% as an acceptable range for stability
investigations, which has been the benchmark for previous
stability investigations involving vitamin K oral liquids.18
Published data regarding storage of oral vitamin K solu-
tions in SWFI in syringes serves as the control for this
study.13 While SWFI is the vehicle most associated with
compounded vitamin K oral solution, its palatability is
problematic, thus possibly prompting pharmacists to taste-
mask with flavored agents. This study investigates the suit-
ability of a diverse set of compounding vehicles for their
suitability toward preparing vitamin K oral liquids.
Methods
This study uses a validated quantitative stability-indicating
high-performance liquid chromatography (HPLC) and
ultraviolet (UV) detection assay.13 In brief, a Shimadzu
HPLC System with XR upgrade was used for all chromato-
graphic measurements (Shimadzu Scientific, Kyoto,
Japan). The system was equipped with column oven, in-
line degasser, and auto-sampler. Gradient separation was
achieved on a Waters X Bridge C18 (3.5 µm, 4.6 × 150
mm) column (Waters Corporation, Milford, MA), main-
tained at 40°C. The UV detector was maintained at 263 nm,
and an injection volume of 1 mL was used. HPLC-grade
denatured ethanol (Alfa Aesar, Ward Hill, MA) at 0.7500
mL/min was used for the mobile phase. The vitamin K ref-
erence standard was of USP grade (United States
Pharmacopeia, Rockville, MD).
Preparation of Vitamin K Oral Formulations
Thirty plastic amber syringes of 1 mg/mL vitamin K solu-
tion were prepared in SWFI with standard pharmacy com-
pounding procedures. The preparation used 10 mg/mL
vitamin K injectable emulsion (Hospira, Lake Forest, IL;
Lot # 75-273-EV; Expiration September 1, 2018). Each mil-
liliter of the Hospira emulsion contains phytonadione (10
mg), polyoxyethylated fatty acid derivative (Polyoxyl 35
castor oil, 70 mg), dextrose, hydrous (dextrose monohy-
drate, 37.5 mg), benzyl alcohol (9 mg) added as preserva-
tive, and hydrochloric acid, to achieve a pH of 6.3 (5.0-7.0).
Twenty milliliters of SWFI (Baxter Health Corporation,
Deerfield, IL; Lot # 670084P; Expiration June 2019) were
added to an empty amber glass bottle. Five milliliters of the
vitamin K emulsion from glass ampules were drawn up
through a 5-µm filter straw and injected into the amber glass
bottle, and additional SWFI was added sufficient to make
50 mL total volume. The solution was then divided into
thirty 1-mL aliquot samples using amber plastic oral
syringes (PRECISEDOSE Dispenser with cap, Medisca,
Plattsburgh, NY), and capped. Samples were retained and
analyzed for time 0 concentration, and the remaining
syringes were stored in the laboratory refrigerator (4.9°C to
5.4°C). The same process was repeated using Ora-Sweet
(Perrigo, Minneapolis, MN; Lot# 6437494; Expiration
October 2019), cherry syrup (Humco, Austin, TX; Lot#
A20550; Expiration November 2020), simple syrup
(Humco, Austin, TX; Lot#A27070; Expiration October
2020), and SyrPalta (Humco, Austin, TX; Lot# A26908;
Expiration September 2019). Table 1 summarizes the prop-
erties of the aforementioned compounding vehicles.
Samples were retained and analyzed for time 0 concentra-
tion, and the remaining syringes were stored in the labora-
tory refrigerator (4.9°C to 5.4°C).
Stability Investigation
On each day of sampling (0, 1, 2, 4, 7, 14, 21, 30, 60, and
90) 3 syringes from each of the compounds tested were
removed from refrigerated storage and the contents mixed
with 1 mL ethanol. All samples (including USP reference
standard) were filtered through a 0.22-µm polytetrafluoro-
ethylene membrane prior to analysis. Filter material suit-
ability was assessed by investigating solvent compatibility
and filtering blank ethanol and compounding agents to
assess the potential for interfering peaks by HPLC. The
temperature of the refrigerator was recorded each day
using a digital thermometer probe. Recovery of vitamin K
in the compounded samples was quantified against a USP
reference standard, diluted to 0.5 mg/mL in HPLC-grade
water. Each sample was injected in duplicate for n = 6
injections for each compounded batch per sampling day.
Assay results were based on the area under the curve of the
Lawson et al 107

Table 1.  Properties of Compounding Vehicles Investigated for the Preparation of Vitamin K Oral Liquids.14-17,21-22,26.

Product Preservatives pH Osmolality Viscosity

Cherry syrup Sodium benzoate 2.7-3.1 6165 mOsm/kg NT
Ora sweet Methyl paraben and potassium sorbate 4.0-4.5 3240 mOsm/kg 71.9 cps
Simple syrup Methyl paraben 4.5-5.0 NT NT
SWFI N/A 5.0-7.0 (5.5) 0 mOsm/kg 1 cps
SyrPalta Sodium benzoate, benzalkonium chloride, and alcohol 4.7 NT NT

Abbreviations: NT, not tested; cps: centipoise; SWFI: sterile water for injection; N/A, not available.

Table 2.  Summary of Stability Investigation Data for 1 mg/mL Vitamin K Oral Liquids Prepared in SWFI, Ora-Sweet, Simple Syrup,
Cherry Syrup, and SyrPalta Stored in Amber Plastic Syringes Under Refrigerated Conditionsa.

Compounding Vehicle
Time of
Storage (Days) SWFI Ora-Sweet Simple Syrup Cherry Syrup SyrPalta
0 98.03 ± 3.70 92.72 ± 9.88 86.81 ± 0.54 94.52 ± 0.75 93.57 ± 1.53
1 97.18 ± 2.58 94.14 ± 6.26 89.18 ± 3.87 93.36 ± 2.86 94.54 ± 2.55
2 99.66 ± 1.89 90.77 ± 9.15 89.54 ± 2.00 91.44 ± 3.59 93.33 ± 2.52
4 95.38 ± 3.60 90.41 ± 14.85 87.22 ± 9.57 93.82 ± 3.91 94.18 ± 2.63
7 95.91 ± 2.18 87.24 ± 12.25 85.42 ± 3.29 91.80 ± 6.95 91.19 ± 1.54
14 95.28 ± 3.52 79.27 ± 8.69 85.22 ± 1.64 92.09 ± 2.46 91.08 ± 1.72
21 93.98 ± 6.99 79.03 ± 19.55 86.23 ± 5.15 90.36 ± 2.77 90.59 ± 2.99
30 86.29 ± 6.30 75.90 ± 19.48 77.02 ± 2.01 87.69 ± 6.21 87.66 ± 5.78
60 84.13 ± 4.40 75.90 ± 10.20 67.68 ± 1.80 65.25 ± 3.75 76.70 ± 0.98
90 84.27 ± 8.88 64.38 ± 21.30 59.18 ± 15.76 62.82 ± 20.96 74.48 ± 15.10
a
Data (percent recovery ± standard deviation) reflect triplicate samples on each day of analysis, injected in duplicate (n = 6).

chromatographic peak for vitamin K using a UV absor-
bance of 263 nm. The concentration-versus-time profiles
for each syringe were evaluated using a 2-way analysis
of variance (ANOVA, P of .05 and a Tukey’s multiple-
comparisons posttest) using GraphPad Prism, version 7.04
(La Jolla, CA). The investigation involved refrigerated
storage, for a duration of 90 days, to exceed the 14-day
default BUD recommended by the USP chapter <795> for
water-containing oral formulations.19
Results
The stability investigation data are collated in Table 2,
showing the percent recovery, based on the USP reference
material. Of the vehicles tested, SWFI was the most suitable
vehicle for longer-term storage of unit-dosed vitamin K.
The 1 mg/mL vitamin K in SWFI, when stored in amber
plastic oral syringes, remains within the acceptable 90% to
110% range for 21 days. The SyrPalta preparation demon-
strated the next highest BUD of 7 days, with 1 syringe (2
injections) falling outside the 90% potency at the 14-day
time point. Cherry syrup allowed for very limited stability,
with a BUD of 24 hours. By the 48-hour time point, 2 of the
3 cherry syrup samples were below the 90% potency cutoff.
For the vitamin K oral liquids prepared in simple syrup and
Ora-Sweet, the recovery of vitamin K was not within
acceptable limits, even on the day of compounding. The ini-
tial recovery for vitamin K in simple syrup was only 86.8%.
Similarly, the preparation in Ora-Sweet was not at accept-
able potency on the day of compounding (92.7 ± 9.9%).
While the average recovery in these samples exceeded
90%, the variability between samples suggests a lack of
homogeneous distribution of drug through the vehicle.
These data are summarized graphically in Figure 1.
Statistically significant differences were detected
between the SWFI preparation and all other vehicles in a
2-way analysis of variance (ANOVA) with Tukey’s multi-
ple comparison posttest (P of .05). This difference was most
pronounced between SWFI and Ora-Sweet and SWFI and
simple syrup (both P < .0001). Cherry syrup was also
vastly different from SWFI (P = .0002), and the difference
between SWFI and SyrPalta was less pronounced, yet still
significant (P = .0442).
Discussion
Vitamin K 1 mg/mL in SWFI remained within the accept-
able 90% to 110% range for 21 days and is the most suitable
for longer term storage of unit-dosed vitamin K. The
SyrPalta preparation demonstrated a BUD of 7 days, which
108 Journal of Pharmacy Technology 35(3)
Figure 1.  Percent recovery of vitamin K in various oral
solutions during the course of a 90-day stability investigation.
Data points are an average of 3 samples injected in duplicate (n
= 6), and error bars represent standard deviation.
makes it a reasonable option for adding a flavorant to unit-
dosing of a vitamin K oral liquid. Cherry syrup preparation
demonstrated as BUD of 24 hours, suggesting immediate
use only. Preparations containing simple syrup or Ora-
Sweet did not demonstrate acceptable stability at any point
and should not be used. While common practice in pediatric
wards may assume that taste masking in foods or other
agents is universally acceptable, our data indicate that this
is not the case with oral vitamin K.20
Using the injectable form of the drug to prepare an
extemporaneous compound, as opposed to the pulverized
tablet, helps minimize aerosolization exposure during
compounding.6 Other studies have attempted to explore
the stability of vitamin K with other sweeteners. One of
the first such studies compounded the vitamin K emulsion
in Cremophor EL.12 Despite a reported shelf life of 6
months, this compound is not commonly adopted due to
the requirement of nitrogen sparging and the undesirable
allergic-type reactions associated with the Cremophor EL
vehicle.2 More recently, the University of Michigan Health
System suggested a BUD of 104 days and 111 days for 1
mg/mL vitamin K in SWFI and in simple syrup, respec-
tively.11 However, this report cites Canadian sources using
a different product, and unpublished communications with
Sandoz Canada.2,11
Several factors appear to affect the potency and stability
of vitamin K in different vehicles. The increased stability
and homogeneity of SyrPalta compared to Ora-Sweet and
the syrups investigated may be due to the presence of addi-
tives. SyrPalta contains multiple preservatives such as
sodium benzoate, benzalkonium chloride, and alcohol.17
Alcohol contributes to the lower viscosity of SyrPalta, and
it is known to enhance the solubility of the vitamin K. The
pH of cherry syrup is 2.7 to 3.1, and previous forced degra-
dation studies showed a loss of 54% potency of vitamin K
after just 1 hour in 1 M HCl, indicating that vitamin K is
highly unstable in acidic solutions.13,16 The initial low
potency of vitamin K in simple syrup suggests that drug did
not disperse well. This is potentially due to the viscosity of
the simple syrup and the viscosity of the vitamin K causing
limitations in the ability of these 2 substances to be mixed
together adequately with the vitamin K suspended in the
simple syrup. The pH of simple syrup (4.5-5.0) is similar to
the pH of SWFI (5.5); thus, pH is not likely a factor in the
lower potency of the vitamin K in simple syrup.21,22 Previous
reports indicate that oral vitamin K could be prepared in
simple syrup, but the details of that preparation are not dis-
closed, and the reference notes of the use of a non-US prod-
uct.11 Ora-Sweet combined with vitamin K was not an
acceptable vehicle due to the large variation in potency
among the samples, which indicated that the distribution of
vitamin K in Ora-Sweet was not homogeneous. The nonho-
mogeneous mixing could have been due to the viscosity of
the vehicle, which is a physical barrier to dissolution.
Unlike SyrPalta, simple syrup and Ora-Sweet do not con-
tain an alcohol component, which may help interface the
vitamin K emulsion with the aqueous vehicle.
The possibility of storing the oral liquid in unit-doses
adds a layer of convenience and is common practice in many
hospital pharmacies.23 When drug solutions are carefully
preloaded into unit-dosed syringes, the requirement for pre-
servatives, compared with a multi-dose solution, should be
reduced due to lower risk of environmental contamination.12
Because of exposure to the plastic components of the
syringes, preloading drug solutions in unit-doses is not with-
out risk, especially with more lipophilic active pharmaceuti-
cal ingredients. The stability results in dosing syringes is far
less than previously reported, suggesting that unit-dosing in
amber plastic syringes shortens the BUD. Vitamin K is lipo-
philic, rendering it susceptible to adsorption to plastics.23 In
an investigation of dexamethasone, diazepam, diatrizoate,
and nitroglycerin solutions stored in amber plastic syringes,
the more lipophilic dexamethasone and diazepam experi-
enced the largest decreases in potency during the 30-day
study period.23 Steroid drugs and calcitriol have also shown
affinity for plastics, such as polyvinyl chloride and polypro-
pylene (PPE).24,25 The syringes used in this study were PPE;
thus, our data suggest that hydrophobic interactions between
the vitamin K and PPE surface may contribute to decreasing
drug concentrations over time.
Conclusions
Stability of vitamin K containing oral liquid is highly
dependent on compounding agent. In this study, several
commonly used agents were found unsuitable for the prepa-
ration of oral vitamin K solution. Vitamin K in SWFI
appears to be the most appropriate vehicle for longer-term
storage of unit-dosed vitamin K. Vitamin K 1 mg/mL solu-
tions containing SyrPalta and cherry syrup may also be
Lawson et al 109
appropriate for more immediate use with BUDs of 7 days
and 24 hours when stored in amber syringes under refriger-
ated conditions. Because the stability of vitamin K oral
solution differs between reports in amber glass bottles and
oral syringes, vitamin K has the potential to adsorb to PPE.
Extrapolation of stability data to formulations or conditions
not previously studied is not recommended.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Project support was provided by the Gatton College of Pharmacy,
Department of Pharmaceutical Sciences. USP reference standard
and analytical column was provided by Dunn School of Pharmacy,
Shenandoah University.
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