Pharmaceutics and drug development

ANZCA syllabus:

Introduction:

Shelf life: Typically, this indicates the period during which a minimum of 90% of the
drug remains intact and available for delivery. (eg Sux 15 months @ 4-8 degrees)

Utility time: Time determined within which a drug should be administered once
reconstituted and or diluted for administration and is usually much shorter than the shelf
life. (eg Thiopentone within 24hrs if kept at room temperature, up to 7 days if
refrigerated)

Especially with regards to shelf life, the following mechanisms might shorten a drug’s
shelf life:
 Drug instability: = irreversible chemical reactions ( eg oxidation + hydrolytic
reactions) which result in loss of parent drug and production of degradation
products. Important factors here are: pH, temperature, addition of water,
exposure to light etc
 Incompatibility: eg concentration dependant precipitation and acid-base reactions.
 Maintenance of sterility: ie prevention of contamination (reason for preservatives
added).

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Methods to prolong a drug’s shelf-life:

 Temperature: keep at cool and constant temp (eg in fridge). With many drugs, a
10% increase in temperature may  degradation rates 2 – 5 fold.
 Intact packaging: - prevents exposure to contaminants as well as light.
 Light: - some drugs undergo  degradation if exposed to UV light (eg adrenaline,
IV paracetamol, droperidol), thus, store in amber ampoules.
 Water: - excluding water from the preparation may limit hydrolysis reactions in
certain drugs (those with following groups: carboxylic acid, phosphate esters,
amides, lactams and imines).
 Formulation: - decomposition occurs more slowly in powder or solid form.
 Oxidation: - excluding O2 from dosage forms, - adding antioxidants (sodium
bisulfate and sodium metabisulfate, ascorbic acid) eg = adrenalin
 pH: - drug reaction rates are generally less at intermediate pH values (4-8) c/f at
high or low pH’s. Buffers can be added to maintain required pH range.
 Preservatives: - to prevent or inhibit growth of microorganisms that may have
been introduced during manufacturing process. (eg = benzalkonium chloride,
chlorbutol, benzyl alcohol and parabens).
 Usage: - use drugs nearing their expiry dates first
 Other: - ensuring that no sorption phenomena occur with the container.

Drug Additives:

Common reasons for adding additives:

 Prevention of contamination
 Prevent degradation (ie maintain potency)
 Solubility: eg solvents (aqueous and non-aqueous), emulsifiers etc
 Other: - to modify tonicity, baricity, pH etc to prevent side effects of
administration eg irritation on injection, phlebitis etc.

Mechanism of action and side effects of common additives:

 Buffers: - usually added to maintain an intermediate range of pH’s to prevent

degradation.
- can be used to maintain pH in acidic range where other additives, such
as preservatives, are maximally active.
- pH manipulation to promote solubility / absorption: Most drugs are either weak bases or
weak acids, and the relationship between their pKa and the ambient pH, will determine their degree of
ionization and thus their solubility and degree of absorption. Some examples:
- NaHCO3 added to LA’s (weak bases) prior to administration, promotes the unionized form
  diffusion across neural sheaths/membranes.

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 - Na Carbonate (30mg) added to Thiopentone sodium to maintain pH 11 and
thus the enol form and to prevent precipitation as free acid.
Side effect: may cause precipitation if mixed with alkaline drugs
- NaOH added to Propofol to obtain pH 7.0
- NaOH and HCL added to Midazolam to maintain pH < 4.0 and thus water solubility
prior to injection (dynamic isomerism or tautomerism).
- Besylate (iodide salt) added to Atracurium to provide water solubility, pH 3,5 and
minimizes risk of spontaneous in vitro degradation.
- Citric acid, sodium phosphate and NaOH are added to Vecuronium to adjust pH.
- NaOH also added to Dantrolene to yield pH 9.5 after reconstitution (also 3g
mannitol in vials containing 20mg Dantrolene).

 Anti-oxidants: Most drugs undergo degradation by oxidation or hydrolysis,

especially in the presence of O2, UV-light or ions of heavy metals. This can be
prevented / minimized by protection from UV light (amber ampoules) or by
excluding O2 / CO2 from the ampoule ( eg Thiopentone at 0.8 atm nitrogen) or by
adding anti-oxidants.
Anti-oxidants : - prevent oxidation by combining with free radicals.
- Alpha tocopherol reducing agents divert oxidation because of
low redox potential.
- Ascorbic acid, Na + K salts of sulphurous acid are antioxidant
synergists that act as chelating agents and combine with heavy
metal ion catalysts ( eg Na metabisulfite added to adrenaline).

 Antimicrobials (preservatives): are used in addition to sterile preparation and storage, and
heat sterilization. Selection of antimicrobials depends on the nature of the active drug, other
constituents and the container.
Examples: benzyl alcohol, chlorocresol, phenol, parahydroxybenzoic acid.
Common anaesth drugs: - Propofol: none or EDTA, Na metabisulfite or 2% benzyl alcohol
- Ketamine: Benzthonium chloride or none
- Lorazepam: 2% benzyl alcohol

 Solubilizing agents: (Solvents)

 Aqueous (water): - Advantages: tasteless, non-irritant, and pharmacologically inert.

- Problems: - many drugs = lipophylic and poorly soluble in H2O
- Many drugs unstable in H2O (hydrolysis)
- Easily contaminated by micro-organisms

 Non-aqueous solvents: Used for 2 reasons: - to solubilize lipophylic drugs

- to render stable solutions
Examples of non-aqueous solvents:
 Propylene glycol: used in formulations such as diazepam, GTN, phenobarb and
etomidate (newer formulation = emulsion like propofol).
Side effects = pain on injection +/- thrombophlebitis.

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 Benzyl alcohol: (in low [ ]’s = preservative = 2% = main use, eg diazepam,
midazolam) . In [ ]’s > 5% it is used as a solvent, but this use is limited due to
s/e’s + toxicity (vasodilation, myocardial depression, deaths in neonates). Also
has LA properties.
 Mannitol: 3g/vial added to 20mg dantrolene, + vecuronium to make it more
soluble + suitable for iv use.
Side effects: - osmotic diuresis  +/- dehydration + volume depletion ( the
osmotic diuresis may in fact help protect the kidneys in MH where dantrolene is
used = by “flushing” out plugs formed from the massive myoglobinuria)
 Emulsions: = a 2-phase system, consisting usually of a pair of immiscible liquids, one of
which is dispersed in the form of small droplets throughout the other. In order to 
stability of such an emulsion system, additives called “emulsifying agents” are added.
(Maintain droplets in dispersed phase and prevent coalescence). Eg’s are surfactants and
hydrocolloids. Effects are achieved via many processes, including forming physical or
chemical barriers around the dispersed droplets, or by imparting an electrical charge to
the external surface of the droplets so they repel each other.
Emulsions defined as being either: - oil-in-water (o/w) = where oil is the droplet.
- water-in-oil (w/o) =water droplets in oil

Of the commercial fat emulsions available, soya bean oil = most commonly used
in the emulsion of both propofol + diazepam, with purified egg yolk
phospholipids as the emulsifier. = Oil-in-water ( IntralipidR as used with Propofol: =
soybean oil 10% as the oil phase; glycerol 2.25% for tonicity; egg phosphatide 1.2% = emulsifier,
NaOH for pH ~7, EDTA = antimicrobial) Note: does not contain egg protein, which is from egg white. Most
people with “egg allergies” react to the protein in egg white.
Side effects of intralipid:
- May cause pain on injection or rarely thrombophlebitis
- May cause green urine or hair
-  Caloric load (fat = 9.3kCal/g) = esp in prolonged infusions + kids
- Supports bacterial growth (no preservative)
- Cost
- May contribute to “propofol syndrome” (acidosis, bradycardia, +/- death.
Mainly in children and? a functional palmoyl carnitine deficiency)

Other examples of emulsions / emulsifiers of historical interest:

 Cyclodextrans: used to solubilize lipophylic drugs. They are cyclic
oligosaccharides derived from starch. 3-D structure like a “hollow cone”, with a
hydrophilic exterior surface and a lipophylic interior surface into which individual
molecules can become incorporated. Such a configuration is NB for the
encapsulation of highly hydrophobic drugs, which can then be rendered soluble in
an aqueous solution. Eg = newer formulations of propofol…..
 Polyoxylated castor oils: eg Cremophor EL, now seldom used because of
serious anaphylactoid reactions (Originally used with propofol and propanidid)
 Other: Liposomes and medium chain triglycerides are alternative solvents used
for propofol

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 Miscellaneous problems with additives:

Neuraxial administered drugs: ( also see Anaesthesia, 2001, 56, p974 )

- Preservatives (ie antioxidants + antimicrobals) are implicated in

neurotoxicity / arachnoditis and drugs given by this route should be
preservative free. (The following additives are proven neurotoxic: alcohol,
phenol, formaldehyde, sodium –metabisulfite. The latter sometimes added to
adrenaline).
- Glycine: An inhibitory neurotransmitter. Drugs with glycine added should be
avoided via this route (agitation, incoordination, pain in animals) (Used as
solvent + antimicrobal with some drugs, eg remifentanil)

Adverse effects to drug additives in general:

Vast majority of additives used in pharmaceutical preparations are also widely used in the
food industry. Far more likely that pts will be exposed to a wider variety, and to greater
amounts, of these products due to ingestion of foodstuffs c/f the small amounts contained
in drugs.

Adverse reactions can be:

- Dose related: uncommon (at risk = neonates, TPN, long term
Iv drug Rx, and indwelling pump systems)
- Allergic / hypersensitivity nature (eg: sodium metabisulfate is a combined
preservative / antioxidant that is commonly used in food stuffs. Sometimes
added with adrenaline. Allergic reactions fairly common against it)

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 Isomerism

Definition: Isomers are two or more compounds that have the same atomic composition
( ie chemical formula), but different structural arrangement, often with different
properties.

Classified into :

 Structural isomers ( same atomic composition, but different bond structure, aka "constitutional")

 Stereoisomers: (same atomic composition and same bond structure, but different spatial arrangement
of atoms or functional groups eg around a chiral atom; aka "spatial isomers")
- Enantiomers: ( = stereoisomers that are non-superimposable mirror images of each other)
- Diastereomers ( = stereoisomers that are not mirror images of each other)

 Structural isomers:

These compounds have the same chemical formula, but different chemical bond structures ( ie their
atoms are arranged differently ).

May be subdivided into:

 Chain (skeletal) isomers: main carbon chain differs b/w the isomers
 Positional isomers: main carbon chain is the same b/w the isomers (functional groups or
constituents in different positions attached to main carbon chain)
 Tautemerism: Dynamic isomerism (below)

Examples:
- Isoflurane and Enflurane (positional). Have similar type actions, ie general
anaesthesia.
Most of the volatiles* also have chiral atoms and thus have stereoisomers as well.
* Exception = sevoflurane
- Promazine and promethazine (chain) Have different actions (antipsychotic vs
antihistamine).

Tautomerism (aka “dynamic isomerism”)

= where 2 structural isomers exist in equilibrium. Shift of equilibrium = pH dependant.

Examples:

 Thiopentone: After reconstitution in syringe, = in ionized enol (water soluble: HS-C) form =
pH 11  once injected into blood ( pH 7.4 ) becomes the highly lipophylic keto form (S=C).

 Midazolam: In ampoule ( pH < 4 ) = open ring = hydrophilic  at pH 7.4 ring closure =

highly lipid soluble.

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 Stereoisomers:
These compounds have the same chemical formula as well as the same chemical bond structure but
have different spatial orientations. Two types are found:
Enantiomers and diastereomers

 Enantiomers: (aka optical isomers)

Enantiomers are non-superimposable mirror images of each other. For a substance to be able to
be an enantiomer, it needs to have a special atom, called a chiral atom (aka a centre of 3-
dimensional asymmetry). These chiral atoms are in many/most cases carbon.

Around these chiral atoms, the attached atoms differ in their spatial orientation between
enantiomers so that they form non-superimposable mirror images of each other. The possible
number of isomers is given by: 2n (where n = number of chiral atoms)

Each enantiomer has the ability to rotate the plane of polarized light to either:
- the right ( + , dextro, d )
- to the left ( - , laevo, l )

Above classification according to the rotation of polarized light, has now been largely superseded
by the R / S –system (R =rectus or right, and S =sinistra or left).
The R and S describe the configuration of the atoms around the chiral atom.
The R-enantiomer has its atoms arranged in a clockwise manner according to set rules re its mw
(vice-versa for S-enantiomers). Furthermore, a R(+) isomer rotates light to the right whereas a
R(-) rotates light to the left (clear as mud!).

Each enantiomer may have very different effects to those of its mirror image. The fact that such
closely related molecules may have different effects is further proof in support of the receptor
theory.

A racemic mixture, is one containing equal amounts of the enantiomers and has no optical
activity. (The component enantiomers are often referred to as “race mates”)

 Diastereomers:
They have the same chemical formula and bond structure but differ from each other in their
spatial orientation and are not mirror images of each other.
They generally arise due to: (1) more than one chiral atom present or
(2) are geometric isomers.

1) More than one chiral atom:

Maximal number of possible isomers possible = 2n (where n = number of chiral atoms). This holds
true if the chiral centres are different or non-equivalent. If the chiral centres are identical (equivalent)
the number of isomers is reduced (molecular symmetry, eg atracurium has 4 chiral atoms and in
theory should have 16 isomers, but due to molecular symmetry only has 10).

Tramadol for example has two different chiral atoms and thus 4 isomers possible (see over, two are
optical isomers of each other and two are diastereomers)
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2) Geometric isomers: ( a.k.a. Cis-trans isomerism )
= a special form of diastereomerism that refers to the arrangements of paired atoms
or groups around a double C bond (or around a rigid C single bond in a ring structure).

Cis refers to both substituents being on the same side of the double bond and trans where
they are one on the opposite side.
Geometric isomers are not usually optically active, unless they have chiral atoms. They
do have different physical + chemical properties though. Eg’s = atracurium, mivacurium.

Stereoisomers in clinical practice:

Because the different constituent enantiomers ( or diastereomers) of the same main drug may have
different effects and or side effects, this have potential implications with respect to drug formulation.
Following are examples of commonly used drugs:

- S (+) ketamine produces more anaesthesia and amnesia (wanted) than the
R (-) isomer and also has less emergence phenomena (unwanted) as well as
faster recovery (wanted).
- Thiopentone: Given as racemic mixture ( the S(-) = more potent, but shorter t1/2 )
- Levobupivacaine similarly has fewer side effects ( esp cardiac: CC:CD 5:1) than the
traditional racemic preparation ( already prepared as such for use).
- Morphine: has 5 chiral centres (thus 32 isomers possible). Only the
l-morphine are stereoselectively synthesized for use, as its d-enantiomer has
no opioid/analgesic effects ( ie opioid receptors = highly stereoselective).
Likewise, the opioid antagonistic effects of l-naloxone = 10 000 times more
than the d form.
- Tramadol: Chemical structure = consistent with 2 pairs of isomers (n=2).
(1R,2R) (1S,2S) (1R,2S) and (1S,2R) tramadol. The last 2 are not mirror images (ie =
diastereomers). Only the 1st 2 enantiomers used:(1R,2R)(+)-tramadol has greater affinity
for u + delta receptors and a more potent inhibitor of 5-HT uptake (and enhances its
release). (1S,2S)(-)-tramadol = potent inhibitor of NA uptake. Both produce central
antinociception and may display synergism. Analgesia: 40% opioid + 60% non-opioid.
- Adrenaline (and noradrenaline): the R(-) or l-isomer usually used ivi, as it is 50-500
times more potent than the d-isomer. The racemic mix (dl) adrenaline is sometimes used
for croup in nebulized form (50% potency, but longer duration than l on its own when
given in the respiratory tract, thus less rebound phenomena).
- Isoflurane: Still presented as a racemic mix, but evidence exist that the S(+) form has
higher potency with less CVS depressive effects. This fact supports the receptor theory
for volatiles.

Examples of drugs available as single stereoisomer: d-tubocurarine,

l-hyoscine (= scopolamine), cisatracurium, S(-) ropivacaine, l-adrenaline, R(+)-
etomidate, S(-) bupivacaine (= levobupivacaine), S(+) Ketamine, l-morphine

Examples of racemic preparations: bupivacaine, adrenaline, ketamine, thiopentone,

isoflurane, atropine, tramadol, the volatiles.

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Examples of mixtures of more than two stereoisomers: Atracurium and mivacurium
Note: Atracurium has 4 chiral atoms and thus potentially 16 enantiomers, however, only
10 exist because of molecular symmetry (some chiral centres identical).
One of these 10 isomers = cisatracurium and is available for commercial use ( same
kinetics as atracurium, but 4-5 times more potent and is CVS more stable and has
minimal histamine release).

Approval of new drugs for research and clinical use (Australia):

Drugs are classified as therapeutic goods under the Therapeutic Goods Act 1989 and
Regulations made there under and cannot be supplied in Australia unless they are
exempted goods or have been entered in the Australian Register of Therapeutic Goods
(ARTG).
The ARTG is a a computer data base established under the Therapeutic Goods Act of
1989 in which most therapeutic goods have to be entered prior to supply. It is an offence
to knowingly supply drug product in Australia for use in humans unless the goods are
registered, listed or exempt.

Phases of human drug trials:

Clinical drug trials are experiments conducted in humans to assess the effects, efficacy
and/or safety of a drug.

 phase 0 : literature review. Animal studies to estimate LD50

 phase 1 : drug is administered to small numbers of volunteers ( 20 – 100). They are
usually healthy, but may be patients. The purpose of this phase is to determine
pharmacological activity, tolerance, pharmacokinetic data and safety. These should be
carried out in a laboratory appropriately equipped for the specialized monitoring and the
high degree of surveillance required. Data from phase 1 should identify the preferred
routes of administration for following trials.

 phase 2 : This involve the 1st trials of the drug in hundreds of supervised patients
suffering from the disorder for which the drug is intended. The purpose is to determine
efficacy as well as safety. These trials are usually conducted by investigators regarded as
specialists in the particular disorder and its treatment. Several doses of the drug are often
used to establish the therapeutic range and the maximum tolerated dose.

 phase 3 : Involves extended trials involving thousands of patients, multicentre, RCT’s

undertaken by experienced clinical investigators when data from phase 2 studies indicate
that the drug has potential benefit which outweighs possible hazards. The purpose is to
ascertain whether the drug confers clinical benefit in the disease states for which
effectiveness is claimed for, with an acceptable incidence and nature of adverse effects.

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 phase 4 : Once state approval to market the drug has been obtained, the drug is
monitored for safety amongst a large number of patients amongst the actual conditions of
use. Because of the small number of pts in the ph 1-3 trials, many low incidence adverse
effects are not detected until ph 4, which has no fixed duration. Ph 4 research should be
distinguished from marketing research, sales promotion studies and routine post
marketing surveillance for adverse drug reactions, as these do not require prior ethical
committee approval.

In Australia there are 2 ways of initiating a clinical trial of new drugs, or new uses of
existing drugs. The clinical trial notification scheme (CTN) and the clinical trial
exemption scheme (CTX). The choice of scheme to follow lies firstly with the sponsor
and then with the individual Institution Ethics Committee (IEC), following the NHMRC
Statement on Ethical Conduct in Research Involving Humans (1999) and the Voluntary
Code of Conduct of Clinical Trials in Australia ( as well as background of the Nuremburg
Code, Declaration of Helsinki and the CIOMS and WHO International Ethical Guidelines
for Biochemical Research Involving Human Subjects).
Contentious items of the Helsinki Decleration relate to whether every research participant
should give informed consent in writing, whether developing nation research participants
should be provided with developed nation standard of health care and whether placebos
can be used, even when an effective therapy exists, so long as research participants do not
die or are not disabled.
Since May 1991 there have been no restrictions to applying for clinical trials in
conjunction with applicants for registration of a drug.

Variations in drug nomenclature:

(Note: these are all the generic names and not trade names)

 Adrenaline = epinephrine ( same for noradrenaline)

 Isoprenaline = isoproterenol
 Paracetamol = acetaminophen (USA)
 Pethidine = meperidine ( USA )
 Thiopentone = Thiopental (USA)
 Salbutamol = albuterol (USA)
 Lignocaine = lidocaine (USA)
 Amethocaine = Tetracaine (USA)
 Cinchocaine = dibucaine (USA) (amide LA, used to determine inhibition of
plasmacholinesterase activity to give dibucaine number. Benzoyl choline used as
substrate)

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 Addendum:

Terminology around solutions, emulsions and colloids:

Solution: Is a liquid mixture in which the minor component (the solute) is uniformly
distributed within the major component (the solvent). It is a one-phase system.
Examples: Crystalloids

Colloid: Is a homogeneous non-crystalline substance consisting of large molecules or

ultramicroscopic particles of one substance dispersed through a second substance
(continuous phase). It is a two-phase system and includes emulsions. The particles do not
settle, and cannot be separated out by ordinary filtering or centrifuging like those in a
suspension.
Examples: Gels, starches

Emulsion: Is a mixture of two or more liquids that are normally immiscible (unmixable
or unblendable) owing to liquid-liquid phase separation. Emulsions are part of a more
general class of two-phase systems of matter called colloids. Surfactants or emulsifiers
needed to ensure fine dispersion of one liquid through the other. Usually specified as
either oil:water or water:oil, depending on the more dominant phase.
Examples: IntralipidR.

Suspension: A suspension is a heterogeneous mixture in which the solute particles do not

dissolve, but get suspended throughout the bulk of the solvent, left floating around freely
in the medium. Particles can settle over time and/or be separated out by ordinary filtering.
Examples: Muddy water, flour in water, sand particles suspended in water.

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