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The objective of this investigation was to study the effect of induced vibrations on adhesive mixtures containing budesonide and salbutamol sulphate as active pharmaceutical ingredients (APIs) and Inhalacr 70 as carriers. A series of adhesive mixtures with varied fine concentrations (1–4%) was prepared for each API. Half of the adhesive mixture was stressed on a vibrating sieve under conditions resembling hopper flow. Based on scanning electron micrographs, it was concluded that Inhalacr 70 contains particles of two distinct shapes, one irregular with groves and valleys and the other more regular with well-defined edges. The dispersibility of the control and stressed mixtures was studied using a next generation impactor. The stressed mixtures containing 1 and 1.5% API displayed a significant reduction in fine particle dose (FPD) compared to the control. The reduction in FPD resulted from a loss of fines from the adhesive mixture during vibration and as a consequence of restructuring and self-agglomeration resulting in reduced dispersibility. However, no significant difference was observed for mixtures with larger weight fractions of fines (2 and 4% API) but these have a drawback of reduced fine particle fraction (FPF). It is concluded that vibrations induced on the adhesive mixtures during handling potentially have a significant effect on the dispersibility of the API and the total amount of drug delivered to the lungs. De två första författarna delar förstaförfattarskapet

Background: Sub-Saharan Africa (SSA) population is genetically diverse and heterogenous thus variability in drug response among individuals is predicted to be high. Cytochrome P450 (CYP450) polymorphisms is a major source of variability in drug response. This systematic review presents the influence of CYP450 single nucleotide polymorphisms (SNPs), particularly CYP3A4*1B, CYP2B6*6 and CYP3A5*3 on antimalarial drug plasma concentrations, efficacy and safety in SSA populations. Methods: Searching for relevant studies was done through Google Scholar, Cochrane Central Register of controlled trials (CENTRAL), PubMed, Medline, LILACS, and EMBASE online data bases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used. Two independent reviewers extracted data from the studies. Results: Thirteen studies reporting the influence of CYP450 SNPs on plasma concentrations, efficacy and safety were included in the final data synthesis. CYP3A4*1B, CYP3A5*5, CYP2B6*6 and CYP2C8*2 did not affect antimalarial drug plasma concentration significantly. There was no difference in treatment outcomes between malaria patients with variant alleles and those with wild type alleles. Conclusion: This review reports lack of influence of CYP3A4*1B, CYP3A5*3, CYP2C8*3 and CYP2B6*6 SNPs on PK profiles, efficacy and safety in SSA among P. falciparum malaria patients.

The tumor size ratio (TSR), time-to-tumor growth (TTG), and tumor growth rate (kG) are frequently suggested as model-based predictors of overall survival (OS) for different types of tumors. When the tumor metrics are applied in forecasting of the outcome for individual patients at an early stage, the tumor data might be sparse resulting in imprecise prediction. This simulation study aimed to investigate how the tumor follow-up data and estimation approaches influence the accuracy in the tumor size metrics and the predicted hazard of death for individual patients. Longitudinal tumor size and OS data were simulated using tumor growth inhibition and Weibull distribution models, respectively. Based on the model and increasing measurement durations, the accuracy (defined as 80–125% of the simulated “true” value) in individual metrics and hazard was computed. TSR week 6 (TSRw6) accuracy was adequate for 91% of the patients when tumor size was measured up to 12 weeks. For TTG and kG metrics, the highest accuracy observed was lower (43 and 77%, respectively) and occurred later (42 and 60 weeks, respectively). The simultaneous (joint) and sequential estimation approaches resulted in similar accuracies, however, in general, the sequential approach where individual tumor size parameters are fixed, demonstrated inferior estimation properties. The TSRw6 and the model-predicted tumor time course (absolute or relative change) had better forecasting properties than TTG or kG. The population pharmacokinetic (PK) parameters and data approach performed similarly or better than the simultaneous approach and had a better accuracy in estimating individuals' hazard of death than the individual PK parameters method. Title in thesis list of papers of Sreenath Madathil Krishnan: Bayesian forecasting of tumor size metrics and survival

Objectives: New drugs and methods to efficiently fight carbapenem-resistant gram-negative pathogens are sorely needed. In this study, we characterized the preclinical pharmacokinetics (PK) and pharmacodynamics of the clinical stage drug candidate apramycin in time kill and mouse lung infection models. Based on in vitro and in vivo data, we developed a mathematical model to predict human efficacy. Methods: Three pneumonia-inducing gram-negative species Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae were studied. Bactericidal kinetics were evaluated with time-kill curves; in vivo PK were studied in healthy and infected mice, with sampling in plasma and epithelial lining fluid after subcutaneous administration; in vivo efficacy was measured in a neutropenic mouse pneumonia model. A pharmacokinetic-pharmacodynamic model, integrating all the data, was developed and simulations were performed. Results: Good lung penetration of apramycin in epithelial lining fluid (ELF) was shown (area under the curve (AUC)(ELF)/ALI(Cplasma) = 88%). Plasma clearance was 48% lower in lung infected mice compared to healthy mice. For two out of five strains studied, a delay in growth (similar to 5 h) was observed in vivo but not in vitro. The mathematical model enabled integration of lung PK to drive mouse PK and pharmacodynamics. Simulations predicted that 30 mg/kg of apramycin once daily would result in bacteriostasis in patients. Discussion: Apramycin is a candidate for treatment of carbapenem-resistant gram-negative pneumonia as demonstrated in an integrated modeling framework for three bacterial species. We show that mathematical modelling is a useful tool for simultaneous inclusion of multiple data sources, notably plasma and lung in vivo PK and simulation of expected scenarios in a clinical setting, notably lung infections.

Proteins, and in particular whey proteins, have recently been introduced as a promising excipient class for stabilizing amorphous solid dispersions. However, despite the efficacy of the approach, the molecular mechanisms behind the stabilization of the drug in the amorphous form are not yet understood. To investigate these, we used experimental and computational techniques to study the impact of drug loading on the stability of protein-stabilized amorphous formulations. β-Lactoglobulin, a major component of whey, was chosen as a model protein and indomethacin as a model drug. Samples, prepared by either ball milling or spray drying, formed single-phase amorphous solid dispersions with one glass transition temperature at drug loadings lower than 40-50%; however, a second glass transition temperature appeared at drug loadings higher than 40-50%. Using molecular dynamics simulations, we found that a drug-rich phase occurred at a loading of 40-50% and higher, in agreement with the experimental data. The simulations revealed that the mechanisms of the indomethacin stabilization by β-lactoglobulin were a combination of (a) reduced mobility of the drug molecules in the first drug shell and (b) hydrogen-bond networks. These networks, formed mostly by glutamic and aspartic acids, are situated at the β-lactoglobulin surface, and dependent on the drug loading (>40%), propagated into the second and subsequent drug layers. The simulations indicate that the reduced mobility dominates at low (

Purpose Orally administered paclitaxel offers increased patient convenience while providing a method to prolong exposure without long continuous, or repeated, intravenous infusions. The oral bioavailability of paclitaxel is improved through co-administration with ritonavir and application of a suitable pharmaceutical formulation, which addresses the dissolution-limited absorption of paclitaxel. We aimed to characterize the pharmacokinetics of different paclitaxel formulations, co-administered with ritonavir, and to investigate a pharmacodynamic relationship between low-dose metronomic (LDM) treatment with oral paclitaxel and the anti-angiogenic marker thrombospondin-1 (TSP-1). Methods Fifty-eight patients treated with different oral paclitaxel formulations were included for pharmacokinetic analysis. Pharmacodynamic data was available for 36 patients. All population pharmacokinetic/pharmacodynamic modelling was performed using non-linear mixed-effects modelling. Results A pharmacokinetic model consisting of gut, liver, central, and peripheral compartments was developed for paclitaxel. The gastrointestinal absorption rate was modelled with a Weibull function. Relative gut bioavailabilities of the tablet and capsule formulations, as fractions of the gut bioavailability of the drinking solution, were estimated to be 0.97 (95%CI: 0.67–1.33) and 0.46 (95%CI: 0.34–0.61), respectively. The pharmacokinetic/pharmacodynamic relationship between paclitaxel and TSP-1 was modelled using a turnover model with paclitaxel plasma concentrations driving an increase in TSP-1 formation rate following an Emax relationship with an EC50 of 284 ng/mL (95%CI: 122–724). Conclusion The developed pharmacokinetic model adequately described the paclitaxel plasma concentrations for the different oral formulations co-administered with ritonavir. This model, and the established pharmacokinetic/pharmacodynamic relationship with TSP-1, may facilitate future development of oral paclitaxel.

Purpose Variability in cytochrome P450 3A4 (CYP3A4) metabolism is mainly caused by non-genetic factors, hence providing a need for accurate phenotype biomarkers. Although 4β-hydroxycholesterol (4βOHC) is a promising endogenous CYP3A4 biomarker, additional investigations are required to evaluate its ability to predict CYP3A4 activity. This study investigated the correlations between 4βOHC concentrations and hepatic and intestinal CYP3A4 protein expression and ex vivo microsomal activity in paired liver and jejunum samples, as well as in vivo CYP3A4 phenotyping (midazolam) in patients with a wide body weight range. Methods The patients (n = 96; 78 with obesity and 18 normal or overweight individuals) were included from the COCKTAIL-study (NCT02386917). Plasma samples for analysis of 4βOHC and midazolam concentrations, and liver (n = 56) and jejunal (n = 38) biopsies were obtained. The biopsies for determination of CYP3A4 protein concentration and microsomal activity were obtained during gastric bypass or cholecystectomy. In vivo CYP3A4 phenotyping was performed using semi-simultaneous oral (1.5 mg) and intravenous (1.0 mg) midazolam. Results 4βOHC concentrations were positively correlated with hepatic microsomal CYP3A4 activity (ρ = 0.53, p ρ = 0.30, p = 0.027), but not with intestinal CYP3A4 concentrations (ρ = 0.18, p = 0.28) or intestinal microsomal CYP3A4 activity (ρ = 0.15, p = 0.53). 4βOHC concentrations correlated weakly with midazolam absolute bioavailability (ρ = − 0.23, p = 0.027) and apparent oral clearance (ρ = 0.28, p = 0.008), but not with systemic clearance (ρ = − 0.03, p = 0.81). Conclusion These findings suggest that 4βOHC concentrations reflect hepatic, but not intestinal, CYP3A4 activity. Further studies should investigate the potential value of 4βOHC as an endogenous biomarker for individual dose requirements of intravenously administered CYP3A4 substrate drugs. Trial registration Clinical.Trials.gov identifier: NCT02386917.

Background: A critical step in tuberculosis (TB) drug development is the Phase 2a early bactericidal activity (EBA) study which informs if a new drug or treatment has short-term activity in humans. The aim of this work was to present a standardized pharmacometric model-based early bactericidal activity analysis workflow and determine sample sizes needed to detect early bactericidal activity or a difference between treatment arms.Methods: Seven different steps were identified and developed for a standardized pharmacometric model-based early bactericidal activity analysis approach. Non-linear mixed effects modeling was applied and different scenarios were explored for the sample size calculations. The sample sizes needed to detect early bactericidal activity given different TTP slopes and associated variability was assessed. In addition, the sample sizes needed to detect effect differences between two treatments given the impact of different TTP slopes, variability in TTP slope and effect differences were evaluated.Results: The presented early bactericidal activity analysis approach incorporates estimate of early bactericidal activity with uncertainty through the model-based estimate of TTP slope, variability in TTP slope, impact of covariates and pharmacokinetics on drug efficacy. Further it allows for treatment comparison or dose optimization in Phase 2a. To detect early bactericidal activity with 80% power and at a 5% significance level, 13 and 8 participants/arm were required for a treatment with a TTP-EBA0-14 as low as 11 h when accounting for variability in pharmacokinetics and when variability in TTP slope was 104% [coefficient of variation (CV)] and 22%, respectively. Higher sample sizes are required for smaller early bactericidal activity and when pharmacokinetics is not accounted for. Based on sample size determinations to detect a difference between two groups, TTP slope, variability in TTP slope and effect difference between two treatment arms needs to be considered.Conclusion: In conclusion, a robust standardized pharmacometric model-based EBA analysis approach was established in close collaboration between microbiologists, clinicians and pharmacometricians. The work illustrates the importance of accounting for covariates and drug exposure in EBA analysis in order to increase the power of detecting early bactericidal activity for a single treatment arm as well as differences in EBA between treatments arms in Phase 2a trials of TB drug development.

Cancer cell migration is a driving mechanism of invasion in solid malignant tumors. Anti-migratory treatments provide an alternative approach for managing disease progression. However, we currently lack scalable screening methods for identifying novel anti-migratory drugs. To this end, we develop a method that can estimate cell motility from single end-point images in vitro by estimating differences in the spatial distribution of cells and inferring proliferation and diffusion parameters using agent-based modeling and approximate Bayesian computation. To test the power of our method, we use it to investigate drug responses in a collection of 41 patient-derived glioblastoma cell cultures, identifying migration-associated pathways and drugs with potent anti-migratory effects. We validate our method and result in both in silico and in vitro using time-lapse imaging. Our proposed method applies to standard drug screen experiments, with no change needed, and emerges as a scalable approach to screen for anti-migratory drugs. The spatial positioning of cultured glioblastoma cells is used to estimate cell motility and drug effects from single end-point images in vitro.

Medication adherence is a key precondition of the effectiveness of evidence-based therapies. However, in real-life settings, non-adherence to medication is still very common. This leads to profound health and economic consequences at both individual and public health levels. The problem of non-adherence has been extensively studied in the last 50 years. Unfortunately, with more than 130,000 scientific papers published on that subject so far, we are still far from finding an ultimate solution. This is, at least partly, due to fragmented and poor-quality research that has been conducted in this field sometimes. To overcome this deadlock, there is a need to stimulate the adoption of best practices in medication adherence-related research in a systematic way. Therefore, herein we propose the establishment of dedicated medication adherence research Centres of Excellence (CoEs). These Centres could not only conduct research but could also create a profound societal impact, directly serving the needs of patients, healthcare providers, systems and economies. Additionally, they could play a role as local advocates for good practices and education. In this paper, we propose some practical steps that might be taken in order to establish such CoEs. We describe two success stories, i.e., Dutch and Polish Medication Adherence Research CoEs. The COST Action “European Network to Advance Best practices & technoLogy on medication adherencE” (ENABLE) aims to develop a detailed definition of the Medication Adherence Research CoE in the form of a list of minimal requirements regarding their objectives, structure and activities. We hope that it will help to create a critical mass and catalyse the setup of regional and national Medication Adherence Research CoEs in the near future. This, in turn, may not only increase the quality of the research but also raise the awareness of non-adherence and promote the adoption of the best medication adherence-enhancing interventions.

Purpose More than 15 years have passed since the first description of the unbound brain-to-plasma partition coefficient (Kp,uu,brain) by Prof. Margareta Hammarlund-Udenaes, which was enabled by advancements in experimental methodologies including cerebral microdialysis. Since then, growing knowledge and data continue to support the notion that the unbound (free) concentration of a drug at the site of action, such as the brain, is the driving force for pharmacological responses. Towards this end, Kp,uu,brain is the key parameter to obtain unbound brain concentrations from unbound plasma concentrations. Methods To understand the importance and impact of the Kp,uu,brain concept in contemporary drug discovery and development, a survey has been conducted amongst major pharmaceutical companies based in Europe and the USA. Here, we present the results from this survey which consisted of 47 questions addressing: 1) Background information of the companies, 2) Implementation, 3) Application areas, 4) Methodology, 5) Impact and 6) Future perspectives. Results and conclusions From the responses, it is clear that the majority of the companies (93%) has established a common understanding across disciplines of the concept and utility of Kp,uu,brain as compared to other parameters related to brain exposure. Adoption of the Kp,uu,brain concept has been mainly driven by individual scientists advocating its application in the various companies rather than by a top-down approach. Remarkably, 79% of all responders describe the portfolio impact of Kp,uu,brain implementation in their companies as ‘game-changing’. Although most companies (74%) consider the current toolbox for Kp,uu,brain assessment and its validation satisfactory for drug discovery and early development, areas of improvement and future research to better understand human brain pharmacokinetics/pharmacodynamics translation have been identified.

Artificial intelligence (AI) is becoming an integral part of drug discovery. It has the potential to deliver across the drug discovery and development value chain, starting from target identification and reaching through clinical development. In this review, we provide an overview of current AI technologies and a glimpse of how AI is reimagining preclinical drug discovery by highlighting examples where AI has made a real impact. Considering the excitement and hyperbole surrounding AI in drug discovery, we aim to present a realistic view by discussing both opportunities and challenges in adopting AI in drug discovery.

Purpose The current study aimed to illustrate how a non-linear mixed effect (NLME) model-based analysis may improve confidence in a Phase III trial through more precise estimates of the drug effect. Methods The FULFIL clinical trial was a Phase III study that compared 24 weeks of once daily inhaled triple therapy with twice daily inhaled dual therapy in patients with chronic obstructive pulmonary disease (COPD). Patient reported outcome data, obtained by using The Evaluating Respiratory Symptoms in COPD (E-RS:COPD) questionnaire, from the FULFIL study were analyzed using an NLME item-based response theory model (IRT). The change from baseline (CFB) in E-RS:COPD total score over 4-week intervals for each treatment arm was obtained using the IRT and compared with published results obtained with a mixed model repeated measures (MMRM) analysis. Results The IRT included a graded response model characterizing item parameters and a Weibull function combined with an offset function to describe the COPD symptoms-time course in patients receiving either triple therapy (n = 907) or dual therapy (n = 894). The IRT improved precision of the estimated drug effect compared to MMRM, resulting in a sample size of at least 3.64 times larger for the MMRM analysis to achieve the IRT precision in the CFB estimate. Conclusion This study shows the advantage of IRT over MMRM with a direct comparison of the same primary endpoint for the two analyses using the same observed clinical trial data, resulting in an increased confidence in Phase III.

Introduction The organic cation transporter 3 (OCT3, SLC22A3) is ubiquitously expressed and interacts with a wide array of compounds including endogenous molecules, environmental toxins and prescription drugs. Understudied as a determinant of pharmacokinetics and pharmacodynamics, OCT3 has the potential to be a major determinant of drug absorption and disposition and to be a target for drug-drug interactions (DDIs). Goal The goal of the current study was to identify prescription drug inhibitors of OCT3. Methods We screened a compound library consisting of 2556 prescription drugs, bioactive molecules, and natural products using a high throughput assay in HEK-293 cells stably expressing OCT3. Results We identified 210 compounds that at 20 μM inhibit 50% or more of OCT3-mediated uptake of 4-Di-1-ASP (2 μM). Of these, nine were predicted to inhibit the transporter at clinically relevant unbound plasma concentrations. A Structure-Activity Relationship (SAR) model included molecular descriptors that could discriminate between inhibitors and non-inhibitors of OCT3 and was used to identify additional OCT3 inhibitors. Proteomics of human brain microvessels (BMVs) indicated that OCT3 is the highest expressed OCT in the human blood-brain barrier (BBB). Conclusions This study represents the largest screen to identify prescription drug inhibitors of OCT3. Several are sufficiently potent to inhibit the transporter at therapeutic unbound plasma levels, potentially leading to DDIs or off-target pharmacologic effects.

BACKGROUND AND INTRODUCTION: The dispersible tablet formulation (DTF) of pretomanid has been developed to facilitate future use in children. This work aimed to assess the pharmacokinetics (PK) and relative bioavailability of the DTF compared to the marketed formulation (MF) and the potential influence of dose. METHODS: Pretomanid DTF was investigated in a single-dose, randomized, four-period, cross-over study, with 7 days of washout between doses. Forty-eight healthy volunteers were enrolled and randomized into one of two panels to receive doses either in the fasted state or after a high-fat meal. Each volunteer received doses of 10, 50, and 200 mg DTF, and 200 mg MF pretomanid. Blood samples for pharmacokinetic assessment were drawn following a rich schedule up to 96 h after each single dose. The study data from the panel receiving the high-fat meal were analyzed using a nonlinear mixed-effects modeling approach, and all data were characterized with noncompartmental methods. RESULTS: A one-compartment model with first-order elimination and absorption through a transit compartment captured the mean and variability of the observed pretomanid concentrations with acceptable precision. No significant difference in bioavailability was found between formulations. The mean absorption time for the DTF was typically 137% (86-171%) of that for the MF. The bioavailability was found to be dose dependent with a small positive and larger negative correlation under fed and fasted conditions, respectively. CONCLUSION: Using data from a relative bioavailability study in healthy adult volunteers, a mathematical model has been developed to inform dose selection for the investigation of pretomanid in children using the new dispersible tablet formulation. Under fed conditions and at the currently marketed adult dose of 200 mg, the formulation type was found to influence the absorption rate, but not the bioavailability. The bioavailability of the DTF was slightly positively correlated with doses when administered with food. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04309656, first posted on 16 March 2020.

Pulmonary drug delivery has been used for decades to treat local diseases like asthma. When using the pulmonary route to deliver drugs, several important lung features are being used, such as a large surface area available for absorption, high organ vascularization, and a thin blood-alveolar barrier. Pulmonary drug delivery systems on the market are formulations with a rapid release, which leads to a high drug concentration initially and a prompt decline in concentration shortly thereafter. This could cause unfavourable adverse effects or toxicity to the lung tissue at the onset of the release and could also result in decreased efficacy. To overcome these challenges, there is a need to develop controlled release drug delivery systems to improve the therapeutic effectiveness of inhaled drugs. When a drug is inhaled, the drug particles will deposit in the lung, and the drug needs to dissolve in the lung fluids before the drug is available for uptake locally or in the systemic circulation. The absorption inhaled drug thus depends on the dissolution of the drug particles in the lung fluid. As a result, it could be possible to prolong the duration of the drug effect, by prolonging the time it takes for the dissolution of the drug particles. Due to this, in vitro methods analysing the dissolution of the drug particles in the lung are of high relevance for the development of novel pulmonary drug delivery systems. It is therefore of high importance that the dissolution profiles that are measured are well understood. The overall aim of this thesis was to evaluate and characterise an in vitro dissolution method (Transwell system) for assessment of novel pulmonary drug delivery systems, with a focus on future controlled release systems. A developed mechanistic model was used to analyse experimental dissolution data and to predict which process was the rate limiting step in the obtained profiles. The developed mechanistic model provided the same rank order as the Weibull fit, however the model provided additional detailed understanding of the used dissolution process and setup. In addition, two novel controlled release drug delivery systems, mesoporous silica particles and hyaluronic based hydrogels, were successfully analysed using this in vitro dissolution system. Both delivery systems showed a promising aerosolization and control over the release profiles. Finally, the micellar contribution to diffusion of poorly soluble inhaled drugs during in vitro dissolution was defined and validated using the obtained in vitro dissolution profiles. Physiologically based biopharmaceutics modelling tools were successfully established for Bud, BDP and FP using the diffusivity values taking into account the micellar contribution of the surfactant.

Background: Pharmaceuticals are a big part of healthcare expenditures. Advancements such as the sequencing of the human genome and technical methods has led to the development of more advanced drugs. Aim: The aim of this study was to explore the trends in new drug development areas and the costs of drugs in different therapy areas. Method: To do this, data from the Swedish Medical Products Agency, e-Hälsomyndigheten and the 20 biggest pharmaceutical companies regarding new approved drugs during a 20-year period, costs and new chemical entities in late development stage has been analyzed. Results: Each year, between 20 and 60 new drugs are approved. New chemical entities are most prevalent in the ATC-group L, which includes oncology and immunomodulating drugs. Innovation is also seen in group J, antiinfectives. The cost of drugs has increased during the study period, especially for oncology drugs. In the coming years, we can expect the introduction of even more oncology drugs, as mostdrugs in later development phases are expected to be classified in this group. Conclusion: Over the studied period, the most innovative therapeutic group has not changed but rather grown. The cost of drugs has also grown, possibly because of more new drugs introduced but also due to expanded indications and larger patient groups. It is hard to see a future where oncology drugs are not the biggest cost since in the coming years, many of the expected new drugs will fall into the same category.

Colonic mucus plays a key role in colonic drug absorption. Mucus permeation assays could therefore provide useful insights and support rational formulation development in the early stages of drug development. However, the collection of native colonic mucus from animal sources is labor-intensive, does not yield amounts that allow for routine experimentation, and raises ethical concerns. In the present study, we developed an in vitro porcine artificial colonic mucus model based on the characterization of native colonic mucus. The structural properties of the artificial colonic mucus were validated against the native secretion for their ability to capture key diffusion patterns of macromolecules in native mucus. Moreover, the artificial colonic mucus could be stored under common laboratory conditions, without compromising its barrier properties. In conclusion, the porcine artificial colonic mucus model can be considered a biorelevant way to study the diffusion behavior of drug candidates in colonic mucus. It is a cost-efficient screening tool easily incorporated into the early stages of drug development and it contributes to the implementation of the 3Rs (refinement, reduction, and replacement of animals) in the drug development process.

The subtilisin-like macrocyclase PatGmac is produced by the marine cyanobacterium Prochloron didemni. This enzyme is involved in the last step of the biosynthesis of patellamides, a cyanobactin type of ribosomally expressed and post-translationally modified cyclic peptides. PatGmac recognizes, cleaves, and cyclizes precursor peptides after a specific recognition motif comprised of a C -terminal tail with the sequence motif-AYDG. The result is the native macrocyclic patellamide, which has eight amino acid residues. Macrocyclase activity can be exploited by incorporating that motif in other short linear peptide precursors, which then are formed into head-to-tail cyclized peptides. Here, we explore the possibility of using PatGmac in the cyclization of peptides larger than the patellamides, namely, the PawS-derived peptide sunflower trypsin inhibitor-1 (SFTI-1) and the cyclotide kalata B1. These peptides fall under two distinct families of disulfide constrained macrocyclic plant peptides. They are both implicated as scaffolds for drug design due to their structures and unusual stability. We show that PatGmac can be used to efficiently cyclize the 14 amino acid residue long SFTI-1, but less so the 29 amino acid residue long kalata B1.

In this work, simulations of intestinal peristalsis are performed to investigate the intraluminal transport of macromolecules (MMs) and permeation enhancers (PEs). Properties of insulin and sodium caprate (C10) are used to represent the general class of MM and PE molecules. Nuclear magnetic resonance spectroscopy was used to obtain the diffusivity of C10, and coarse-grain molecular dynamics simulations were carried out to estimate the concentration-dependent diffusivity of C10. A segment of the small intestine with the length of 29.75 cm was modeled. Peristaltic speed, pocket size, release location, and occlusion ratio of the peristaltic wave were varied to study the effect on drug transport. It was observed that the maximum concentration at the epithelial surface for the PE and the MM increased by 397 % and 380 %, respectively, when the peristaltic wave speed was decreased from 1.5 to 0.5 cm s−1. At this wave speed, physiologically relevant concentrations of PE were found at the epithelial surface. However, when the occlusion ratio is increased from 0.3 to 0.7, the concentration approaches zero. These results suggest that a slower-moving and more contracted peristaltic wave leads to higher efficiency in transporting mass to the epithelial wall during the peristalsis phases of the migrating motor complex.

Schizophrenia is a severe psychiatric disorder affecting approximately 20 million people worldwide. The disease consists of positive symptoms e.g. hallucinations, negative symptoms such as anhedonia, and cognitive deficits, e.g. impaired episodic memory. Most of the currently available treatment options for schizophrenia only target the positive symptoms, possess severe side effects and do not work for a large group of patients. In this thesis, the unique antipsychotic drug lumateperone and adjunctive treatment of sodium nitroprusside (SNP) to sub-maximal doses of conventional antipsychotic drugs are investigated in preclinical tests as novel treatment options for schizophrenia In paper I we showed that SNP enhances the antipsychotic-like effect of a sub-effective dose of risperidone in the conditioned avoidance response (CAR) test in rats. Moreover, by using microdialysis we showed that SNP significantly enhances risperidone-induced dopamine release in the rat medial prefrontal cortex (mPFC) but not in the nucleus accumbens, indicating that adjunct SNP could be used to improve the efficacy of antipsychotic drugs, while reducing their dose and subsequently lower the risk of side effects. In paper II we used microdialysis combined to the behavioral novel object recognition test in rats to show that the release of both dopamine and norepinephrine is increased in the ventral hippocampus in response to a novel object, suggesting that dopamine and norepinephrine may play a crucial role in recognition memory. In paper III we showed that SNP significantly enhanced the antipsychotic-like effect of sub-effective doses of olanzapine in the CAR test, but not of clozapine, this could be explained by the developed tolerance towards clozapine after repeated administrations. In paper IV we used enzyme-coated microelectrode arrays to show that lumateperone significantly increased cortical glutamate release in the mPFC of anaesthetized rats. By using electrophysiology, we also show that lumateperone facilitates NMDA and AMPA-mediated currents in a dopamine D1 dependent manner in layer V/VI pyramidal neurons in the mPFC of rats. Moreover, lumateperone increases dopamine release in the mPFC of freely moving rats as shown by using microdialysis. These mechanisms may improve cognitive deficits and contribute to the clinically demonstrated antidepressant effects of lumateperone. Taken together, these results show that lumateperone is a promising novel treatment option for schizophrenia, and that adjunct SNP treatment may allow for improved efficacy at maintained or even reduced dosage of conventional antipsychotic medication.

Solute carriers consist of over 400 genes and 66 subfamilies and are the largest group of membrane bound transporters. They facilitate movement of many molecules through cells and organelles and are crucial for upholding many key functions in the human body. They are also involved in the pathophysiology of several diseases. The sodium-coupled neutral amino acid transporter family (SLC38) consists of 11 known transporters classified into system A and system N. They are responsible for influx and efflux of amino acids in different tissues, and the broad majority are expressed in various brain regions. The transporters are involved in gamma-aminobutyric acid (GABA)/glutamine metabolism, liver metabolism, the mammalian target of rapamycin pathway, among many other pathways and mechanisms. This study quantitatively investigates the mRNA expression of the transporters in human nerve cells from differentiation day 0 to 30, with the main focus being on the Golgi/ER localized SLC38A10. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was used to run quantitative assays on nerve cells from day 0, 5, 10, 15 and 30 in nerve cell differentiation, with histone variant H3.3 and Ribosomal Protein L13a as housekeeping genes. It was found that the genes SLC38A1, A2, A3, A8 and A10 had relatively similar expression patterns in the nerve cell tissues tested. No expression was detected for SLC38A5, A6, A9 and A11. SLC38A4 had no clear expression pattern in the nerve cell tissues, although expression was detected in some assays, which was not expected in nerve cells. SLC38A10 demonstrated the highest expression, and lowest expression levels were seen for SLC38A4. SLC38A1, A2, A3, A8 and A10 had highest expression in day 0 nerve cells. These results indicate that precursor neurons could be most suitable to use for knockout studies of SLC38A10, as well as for SLC38A1, A2, A3 and A8, as these cells demonstrated the highest levels of expression of these genes. Further studies are encouraged into the expression levels of the SLC38 transporters, their roles in the human body and disease pathophysiology, and, ultimately, their potential as drug targets.

BACKGROUND: Hereditary angioedema (HAE) is caused by low levels of or defects in C1 inhibitor. Although disease activity may be modified by prophylaxis, emergency treatment, treatment for comorbidities, and oral contraceptives, the extent of their use is unclear. OBJECTIVE: To investigate trends in the use of disease-specific and interfering drugs in patients with HAE compared with the general population in Sweden. METHODS: In a nationwide, longitudinal study, 239 patients with HAE and 2 383 controls were compared with the Prescribed Drug Register (2005e2019). These data reflect rates of dispensed prescriptions from pharmacies in Sweden. RESULTS: Attenuated androgens were used by approximately 10% of patients with HAE. The number of individuals treated with prophylactic plasma-derived C1 inhibitor increased during this period to reach almost 25% in men and 35% in women in 2019. Tranexamic acid was prescribed to 5% to 15% of patients, primarily children and young adults. Rates of prescriptions for icatibant, an emergency medication, showed a steady increase since its introduction in 2010, in particular among middle-aged women, suggesting poorly controlled disease. The use of di-uretics, calcium channel blockers, and gestagens was more common in patients with HAE than in controls, whereas angiotensin-converting enzyme inhibitors were rarely collected. CONCLUSIONS: Despite concerns regarding side effects, approximately 10% of patients with HAE received attenuated androgens for long-term prophylaxis. The common use of emergency medication also suggests poorly controlled disease in many patients, highlighting the need for increased focus on prophylactic treatment.

Background Discrepancies in medication lists are common and can contribute to drug-related problems. This study was performed before the implementation of the National Medication List in Sweden, an intervention expected to improve the accuracy of medication lists. Aim The aim of the study was to examine the number and type of discrepancies in the medication list from pharmacies in Sweden. The secondary aim was to describe the information sources Swedish patients used as their medication lists and how confident they were with the information. Method Structured interviews were conducted with patients at 13 community pharmacies in Sweden during the period October 5, 2020, to April 16, 2021. The printed medication list was reviewed together with the patient to identify any discrepancies and missing information. Results A total of 327 patients were included in the study (response rate 51%). The printed medication list from pharmacies was the most common information source for patients to know which medications to use. Two thirds (n = 215) of the patients had at least one discrepancy among their prescriptions and 32% (n = 106) were missing at least one prescription medication. Among all prescriptions (n = 2567) 10% (n = 264) were non-current prescriptions, 9% (n = 238) were duplicates and 3% (n = 88) had the wrong dose. The proportion of prescriptions with discrepancies differed between drug-groups. Conclusion The discrepancies described in this study can have serious consequences, and results provide a baseline for studies after the implementation of the National Medication List.

Bakgrund: Paracetamol är ett av de mest kända och använda läkemedlet över hela världen för analgetisk och antipyretisk effekt. Paracetamol är ett receptbelagt läkemedel men säljs även receptfritt. Läkemedlet anses vara säkert under graviditet och därför kan den användas så länge den rekommenderade dosen inte överskrids. Hur paracetamol verkar är det inte klarlagt än idag däremot finns det en del hypoteser och teorier Syfte: Syftet med litteraturstudien är att, med hjälp av djurstudier, undersöka hur en tidig exponering av paracetamol ger neurologiska negativa effekter under hjärnutvecklingen. Metod: Artikelsökning till litteraturstudien gjordes i databasen Pubmed genom sex sökningar där 12 artiklar kunde besvara studiens frågeställning. Sökningen följde exkluktions kriterierna: humana studier, paracetamol har antingen en positiv eller ingen påverkan på hjärnutvecklingen, paracetamols påverkande på framtida sexuella samt reproduktionsbeteende som ses i vuxen ålder. Artiklarna som inkluderades var från och med år 2016–2022, ett undantag gjordes dock vid sökning 5 och 6 där artiklar inkluderades från 2014–2022. Resultat: Paracetamol exponering under tidig hjärnutveckling har visat minskade koncentrationsnivåer av monoaminer, dess metaboliter och aminosyror i olika hjärnregioner. Dessa förändringar har kopplats till neurofysiologisk och kognitiv försämring som försämrad minne och inlärningsförmåga. Även oxidativ stressindex har ökat efter paracetamol exponeringen vilket associerades med inducerad oxidativ stress. Antioxidanterna superoxiddistumas och glutation minskade också vilket ökade de skadliga radikalerna i kroppen vilket ökade den oxidativa stressen. Slutsats: Slutligen kan en slutsats dras om en tidig paracetamol exponering. Läkemedlet har visat neurotoxiska effekter under tidig hjärnutveckling vilket har i in vivo studier visat ökad oxidativ stress, abnormitet i kognitiva funktioner och risk för neuropsykiatriska dysfunktioner. Därmed bör försiktighetsåtgärder och rekommendationerna kring paracetamol användningen under graviditet iakttas och nödvändigt utvärderas av läkare som farmaceuter och läkemedelsverket.

Gambling disorder (GD) is a behavioral addiction characterized by persistent and recurrent gambling behavior that disrupts personal, social or professional life. Studies have revealed that GD shares many features with alcohol and substance use disorders, but little is known about potential unique features in GD and to what extent characteristics are shared. One shared feature is reward-related decision-making and individuals with GD display deficits in decision-making. The rat gambling task (rGT) has been developed to enable preclinical studies of reward-related decision-making and underlying neurobiological mechanisms. The aim of this thesis was to explore individual differences in decision-making strategies in the rGT and underlying behavioral phenotypes and neurobiology. Paper I: three groups with different decision-making strategies in the rGT were identified: the strategic, risky and safe group. The rGT strategies were shown to be stable over time, even after multiple interruptions and other behavioral testing. Rats with risky rGT strategies had higher voluntary alcohol intake but not elevated sexual behavior. Naltrexone treatment resulted in an overall lowered motivation in the rGT but had no effect on choice behavior. Paper II: individual differences in gambling strategies were found in the rGT and corresponding strategy groups were replicated from Paper I. Moreover, brain functional connectivity was assessed using resting-state functional Magnetic Resonance Imaging. Differences in rGT strategies were associated with connectivity in regions in or associated with brain reward networks. Paper III: levels of neurotransmitters and metabolites were explored using matrix-assisted laser desorption/ionization mass spectrometry imaging in selected brain regions. The strategy groups were revealed to differ in levels of neurotransmitters and metabolites in regions of importance for decision-making and reward. Paper IV: decision-making strategies in humans, using the Iowa gambling task, and in rats, using the rGT, were explored. Results showed that most humans and rats learned to favor the advantageous choices and showed similar variability in individual choice preferences during end performance. This thesis has provided new information about individual decision-making strategies in the rGT and associations with other reward-related behaviors as well as neurobiology. Characterization of the strategy groups indicates a shared underlying mechanism between rGT strategies and alcohol intake but not natural rewards. Neurobiological differences in regions important for reward processing were also revealed. Lastly, similar variability in individual choice preference was found in humans and rats and it is concluded that both clinical and preclinical research would benefit from more detailed analyses on individual variations in decision-making.

Contains fulltext : 292507.pdf (Publisher’s version ) (Open Access) A milestone in the development of novel antituberculosis drugs is the demonstration of early bactericidal activity (EBA) in a phase IIa clinical trial. The significant variability in measurements of bacterial load complicates data analysis in these trials. A systematic review and evaluation of methods for determination of EBA in pulmonary tuberculosis studies was undertaken. Bacterial load quantification biomarkers, reporting intervals, calculation methods, statistical testing, and handling of negative culture results were extracted. In total, 79 studies were identified in which EBA was determined. Colony-forming units on solid culture media and/or time-to-positivity in liquid media were the biomarkers used most often, reported in 72 (91%) and 34 (43%) studies, respectively. Twenty-two different reporting intervals were presented, and 12 different calculation methods for EBA were identified. Statistical testing for a significant EBA compared with no change was performed in 54 (68%) studies, and between-group testing was performed in 32 (41%) studies. Negative culture result handling was discussed in 34 (43%) studies. Notable variation was found in the analysis methods and reporting of EBA studies. A standardized and clearly reported analysis method, accounting for different levels of variability in the data, could aid the generalization of study results and facilitate comparison between drugs/regimens.

The gold standard for pharmacometrics modeling, along with its modeling format, is currently NONMEM. In order to use other software, there is often a manual step of converting a model from one format to another, which is both time-consuming and causes manual errors. This project aimed to solve this problem by creating a conversion- and validation tool from NONMEM to two formats: nlmixr2 and RxODE2. These are both, unlike NONMEM, freely available and integrated into R. This was done by integrating the two tools (conversion and validation) into the program Pharmpy, which can extract model information from NONMEM's model format. For conversion, the model was read into Pharmpy and then, part by part, converted to the respective model format. The associated validation compared the predictions of the respective programs to see if they differed significantly from each other. The project showed that this type of conversion is possible, but the programs showed a greater difference than expected. Part of this can be explained by a rounding of parameter values in Pharmpy, but further analysis also indicated fundamental differences in the determination of the predictions between the programs. Larger differences in predictions are for instance oftentimes equidistant from the actual observation, meaning the predictions are presumably calculated differently. While not disproving the converted model, smaller discrepancies between the programs would indicate a more confident validation. In summary, the developed tools are considered useful for models where Pharmpy supports parsing of the model. If not for complete conversion, then at least for partial conversion with manual correction, which is also an improvement over an entirely manual workflow.

Background: Type 3c diabetes is a form of diabetes that a patient can develop secondary to diverse pancreatic complications. The blood sugar of these patients is highly fluctuating and can be very hard to handle. In a previous project a new diabetes-diary was developed to, alongside other work at the department, promote the patients’ learning about blood sugar and insulin treatment postoperatively after newly debuted diabetes due to total panctreatectomy. The diary has however not been tested and the efficiency of it in regards to the patient’s learning about blood sugar and insulin treatment is still unknown. Aim: To investigate how the new diabetes diary and the overall work at the department promotes the patients’ learning about blood sugar and insulin during the postoperative period after a total pancreatomy. Method: A feasibility study was made using a qualitative method. Data was collected through 5 focus group interviews with nurses and nursing assistants separately between September and December 2022 at Karolinska Universitetssjukhuset in Huddinge, Stockholm. The data were analyzed using thematic content analysis. Results: The new diabetes diary could not be evaluated due to shortage of patients. The analysis of the interviews with the nurses and the assistant nurses indicated inadequate routines and the participants desired more education from different professions. Opinions of the participants on the new diary were positive in regards to the structure and visual appeal. Interventions and support from the clinical pharmacist were valued by the participants. The communication between nurses and assistant nurses was not perceived as optimal. Conclusion: This feasibility study show that a longer study period is required to answer the preset aim of the study. Patient data could not be collected and evaluated due to shortage of patients. Interviews with the staff indicated that more uniform routines, internal education and improved communication may improve patients’ learning about diabetes control. However, this needs further evaluation in future studies where the diabetes diary is actually tested.

Aims: Increasing concentrations of dietary sugar results in a linear accumulation of triglycerides in male Drosophila, while inducing a U-shaped obesity response in their offspring. Here, using a combination of proteomics and small RNA (sRNA) sequencing, we aimed at understanding the molecular underpinning in sperm for such plasticity.Results: Proteomic analysis of seminal vesicles revealed that increasing concentrations of dietary sugar resulted in a bell-shaped induction of proteins involved in metabolic/redox regulation. Using stains and in vivo redox reporter flies, this pattern could be explained by changes in sperm production of reactive oxygen species (ROS), more exactly mitochondria-derived H2O2. By quenching ROS with the antioxidant N-acetyl cysteine and performing sRNA-seq on sperm, we found that sperm miRNA is increased in response to ROS. Moreover, we found sperm mitosRNA to be increased in high-sugar diet conditions (independent of ROS). Reanalyzing our previously published data revealed a similar global upregulation of human sperm mitosRNA in response to a high-sugar diet, suggesting evolutionary conserved mechanisms.Innovation: This work highlights a fast response to dietary sugar in mitochondria-produced H2O2 in Drosophila sperm and identifies redox-sensitive miRNA downstream of this event.Conclusions: Our data support a model where changes in the sperm mitochondria in response to dietary sugar are the primary event, and changes in redox homoeostasis are secondary to mitochondrial ROS production. These data provide multiple candidates for paternal intergenerational metabolic responses as well as potential biomarkers for human male fertility. Funding Agencies|Swedish Research Council [2015-03141]; Ragnar Soderbergs foundation; Knut and Alice Wallenberg foundation [2015.0165]

Cyclotides are an intriguing class of structurally stable circular miniproteins of plant origin with numerous potential pharmaceutical and agricultural applications. To investigate the occurrence of cyclotides in Sri Lankan flora, 50 medicinal plants were screened, leading to the identification of a suite of new cyclotides from Geophila repens of the family Rubiaceae. Cycloviolacin O2-like (cyO2-like) gere 1 and the known cyclotide kalata B7 (kB7) were among the cyclotides characterized at the peptide and/or transcript level together with several putative enzymes, likely involved in cyclotide biosynthesis. Five of the most abundant cyclotides were isolated, sequenced, structurally characterized, and screened in antimicrobial and cytotoxicity assays. All gere cyclotides showed cytotoxicity (IC50 of 2.0-10.2 mu M), but only gere 1 inhibited standard microbial strains at a minimum inhibitory concentration of 4-16 mu M. As shown by immunohistochemistry, large quantities of the cyclotides were localized in the epidermis of the leaves and petioles of G. repens. Taken together with the cytotoxicity and membrane permeabilizing activities, this implicates gere cyclotides as potential plant defense molecules. The presence of cyO2-like gere 1 in a plant in the Rubiaceae supports the notion that phylogenetically distant plants may have coevolved to express similar cytotoxic cyclotides for a specific functional role, most likely involving host defense.

Contains fulltext : 293463.pdf (Publisher’s version ) (Open Access) BACKGROUND: Linezolid is an effective, but toxic anti-tuberculosis drug that is currently recommended for the treatment of drug-resistant tuberculosis. Improved oxazolidinones should have a better safety profile, while preserving efficacy. Delpazolid is a novel oxazolidinone developed by LegoChem Biosciences Inc. that has been evaluated up to phase 2a clinical trials. Since oxazolidinone toxicity can occur late in treatment, LegoChem Biosciences Inc. and the PanACEA Consortium designed DECODE to be an innovative dose-ranging study with long-term follow-up for determining the exposure-response and exposure-toxicity relationship of delpazolid to support dose selection for later studies. Delpazolid is administered in combination with bedaquiline, delamanid and moxifloxacin. METHODS: Seventy-five participants with drug-sensitive, pulmonary tuberculosis will receive bedaquiline, delamanid and moxifloxacin, and will be randomized to delpazolid dosages of 0 mg, 400 mg, 800 mg, 1200 mg once daily, or 800 mg twice daily, for 16 weeks. The primary efficacy endpoint will be the rate of decline of bacterial load on treatment, measured by MGIT liquid culture time to detection from weekly sputum cultures. The primary safety endpoint will be the proportion of oxazolidinone class toxicities; neuropathy, myelosuppression, or tyramine pressor response. Participants who convert to negative liquid media culture by week 8 will stop treatment after the end of their 16-week course and will be observed for relapse until week 52. Participants who do not convert to negative culture will receive continuation phase treatment with rifampicin and isoniazid to complete a six-month treatment course. DISCUSSION: DECODE is an innovative dose-finding trial, designed to support exposure-response modelling for safe and effective dose selection. The trial design allows assessment of occurrence of late toxicities as observed with linezolid, which is necessary in clinical evaluation of novel oxazolidinones. The primary efficacy endpoint is the change in bacterial load, an endpoint conventionally used in shorter dose-finding trials. Long-term follow-up after shortened treatment is possible through a safety rule excluding slow-and non-responders from potentially poorly performing dosages. TRIAL REGISTRATION: DECODE was registered in ClinicalTrials.gov before recruitment start on 22 October 2021 (NCT04550832).

Background: Patient harm is a global problem that causes hundreds of millions of hospitalizations every year. Part of the problem is medicinal harm, many of which are preventable. One way to improve rational treatment is the use of clinical pharmacists within healthcare. By conducting medication reviews medical related problems can be identified and actions set in before further harm is made. Those directly impacted by any complication are the patients, yet in Sweden studies have focused on experiences of health personnel. To promote person-centered care, it is therefore important to focus on patients’ point of view. Aim: To explore inpatients’ knowledge about and experiences with clinical pharmacists. Method: Individual semi-structured interviews with inpatients from a Swedish hospital. The patients had met with a clinical pharmacist earlier in the day and were asked questions related to that meeting. Interviews were audio-recorded, transcribed, and qualitative analyzed withthematic analysis. Results: In total 20 patients were interviewed from four different wards: 55 % were female and the average age was 75 years (41-89 years). Four main themes were identified: 1) Earlier knowledge about clinical pharmacists; 2) Pharmacists integration into care; 3) Personal traits of a pharmacist; and 4) Patient benefit of the meeting. Conclusion: Inpatients’ knowledge about clinical pharmacists is low and few expect to meet one during hospitalization. Still, the general impression is mostly positive, and patients appreciate both the person and the context. Future research should focus on how to promote clinical pharmacists to increase patient awareness and their involvement in care.

The pharmaceutical development process starts with patient populations and their unmet therapeutic needs. Traditional pharmaceutical manufacturing of solid oral dosage forms is based on the strategy of one-size-fits-all. This is problematic, especially for patient populations with high patient-to-patient variability, as in pediatrics. Historically, pharmaceutical development has focused on the adult population, neglecting the therapeutic needs unique to children. As a result, there is a lack of age-appropriate formulations—available in acceptable dosage forms and suitable dosage strengths—for safe and efficient drug therapies for children. To address this, additive manufacturing, more commonly known as three-dimensional (3D) printing, has emerged as a flexible manufacturing platform for production of dosage forms based on patient needs. Interest in 3D printing for pharmaceutical production has grown rapidly; however, to date the research has mainly focused on water-soluble drugs not in need of more advanced drug delivery systems to enable oral absorption. The overall aim of this thesis was therefore to develop lipid-based drug delivery strategies for poorly soluble drugs to be 3D printed into personalized solid oral dosage forms. In the first part, an observational study was performed at a pediatric oncology ward, together with analysis of the age-appropriateness of the oral medications. Administration through enteral feeding tubes was identified as the main reason for manipulation of the solid dosage forms. Furthermore, active pharmaceutical ingredients requiring age-appropriate, personalized dosage forms were identified. In the next part, emulsion gels from emulsified lipid-based formulations stabilized by surfactants (surfactant-stabilized emulsion gels) or solid particles (Pickering emulsion gel) were developed to incorporate a poorly water-soluble model compound. The rheological properties of the emulsion gels were investigated. The developed emulsion gels were successfully 3D printed into solid oral dosage forms by semi-solid extrusion (SSE). In the last part, central quality control attributes, including both the printable formulation and the 3D-printed tablets, were studied in the 3D-printing method developed for one of the emulsion gels. The SSE 3D-printed tablets complied with standardized uniformity tests for both mass and drug content and demonstrated high dose accuracy and short-term storage stability. To conclude, a method for SSE 3D printing of emulsion gels into lipid tablets was developed with promising potential for personalized dosing of lipophilic drugs in a clinical setting.

Background: In older age polypharmacy is common due to a higher rate of chronic diseases. Taking multiple medications can result in drug related problems resulting in higher health care costs. OptiMEDs is an information and communications technology (ICT) guided medication review program that was created to improve the quality of the prescription of medicines in elderly. A pilot study of OptiMEDs was performed in 3 nursing homes in Belgium during 2019-2020. Aim: To update the explicit criteria behind OptiMEDs and to make the tool more specific. Method: Through a literature search of explicit criteria of potentially inappropriate prescribing (PIM-lists), newer versions published between 1st of January 2018 – 31st of October 2022 were sought. Redundancy of alerts was reduced by removing all the double alerts of PIMs. To minimize the number of alerts issued by the tool, several approaches to exemptions from and exclusion to PIMs were tested. To evaluate the improvement, results from the previous and new rule base were compared using the same dataset from the OptiMEDs feasibility trial. Results:OnlyonePIM-list(Beer’scriteria)hadanewversion,resultingin45PIMsbeingadded to the database and 33 PIMs were removed. Removal of the duplicates resulted in a database with 594 PIMs. With the OptiMEDs data set; The amount of patients having a PIM decreased with 25.1 % when removing EU(7)-list as a source. The amount of patient having at least one candidate for deprescribing decreased with 10.4 % when only keeping the deprescribing.org and RTCs as a source. Conclusion: The update probably made OptiMEDs more user-friendly as the number of PIMs decreased and the number of medications candidated for deprescribing decreased. However, an important further update is still needed, which is to include the clinical-based PIMs.

The gastrointestinal mucus is a hydrogel lining the luminal side of the gastrointestinal epithelium. Mucus is vital for gut homeostasis because it protects the epithelium from the noxious external environment. However, from a drug delivery perspective, drugs have to permeate through the mucus to reach the epithelium; therefore, mucus might pose a barrier to drug absorption. Most of the information about mucus derives from fundamental studies performed on rodents. However, information from larger preclinical animal species is highly warranted for improving study designs and guiding better interpretation of data from preclinical assessments. Furthermore, improved understanding of the nature of the gastrointestinal mucus would enable the development of in vitro mucus models with increased biorelevance. These could then be implemented in drug absorption assays to improve the (bio)predictability. Well-informed in vitro mucus models would enable quick and less variable screening of drug candidates in the early drug development stages. Finally, these models would contribute to reduction, refinement, and replacement (the 3Rs) of animal usage in the drug development process. This thesis aims to improve our understanding of the nature of gastrointestinal mucus and its impact on drug absorption. For this purpose, mucus from the complete gastrointestinal tract of pigs and dogs was characterized and the diffusion of physicochemically diverse FITC-dextrans through colonic mucus was studied, both ex vivo and in vitro. The characterization of the gastrointestinal mucus focused on properties relevant for drug absorption and revealed the physiological characteristics, composition, and structural profiles from the various gastrointestinal regions. The findings pointed towards substantial differences between small intestinal and colonic mucus in both species and served as the basis for developing artificial colonic mucus models for drug permeation assessments. Porcine and canine artificial mucus models were developed and validated against the respective native secretions in terms of structural properties and demonstrated their potential to capture the key diffusion patterns of FITC-dextrans observed in native colonic mucus. Overall, this work provided insights into key properties of mucus from large preclinical species and validated tools for the assessment of the impact of mucus on drug absorption.

Funding: This clinical trial was conducted within PanACEA, which was part of the European and Developing Countries Clinical Trials Partnership (EDCTP) 1 programme [project code IP. 2007.32011.012 (HIGHRIF)] and the EDCTP2 programme supported by the European Union (grant number TRIA 2015-1102-PanACEA). Biomarkers are quantifiable characteristics of biological processes. In Mycobacterium tuberculosis, common biomarkers used in clinical drug development are colony forming unit (CFU) and time-to-positivity (TTP) from sputum samples. This analysis aimed to develop a combined quantitative tuberculosis biomarker model for CFU and TTP biomarkers for assessing drug efficacy in early bactericidal activity studies. Daily CFU and TTP observations in 83 previously patients with uncomplicated pulmonary tuberculosis after 7 days of different rifampicin monotherapy treatments (10–40 mg/kg) from the HIGHRIF1 study were included in this analysis. The combined quantitative tuberculosis biomarker model employed the Multistate Tuberculosis Pharmacometric model linked to a rifampicin pharmacokinetic model in order to determine drug exposure-response relationships on three bacterial sub-states using both the CFU and TTP data simultaneously. CFU was predicted from the MTP model and TTP was predicted through a time-to-event approach from the TTP model, which was linked to the MTP model through the transfer of all bacterial sub-states in the MTP model to a one bacterial TTP model. The non-linear CFU-TTP relationship over time was well predicted by the final model. The combined quantitative tuberculosis biomarker model provides an efficient approach for assessing drug efficacy informed by both CFU and TTP data in early bactericidal activity studies and to describe the relationship between CFU and TTP over time. Publisher PDF

Introduction and Hypothesis: Patients with overactive bladder (OAB) often undergo prolonged treatment with one or more oral OAB medications. OnabotulinumtoxinA (onabotA), a type A botulinum toxin, may provide an appropriate alternative to oral treatments in patients intolerant of or refractory to one or more oral OAB medications. The GRACE study demonstrated real-world benefits of onabotA treatment for OAB in patients refractory to oral medications. This exploratory post hoc analysis of data from the GRACE study aims to determine if treatment history impacts benefit from treatment with onabotA. Methods: This is a subanalysis of the GRACE study, a prospective observational study (NCT02161159) that enrolled patients with symptomatic OAB inadequately managed by at least one oral OAB medication. Patients had a treatment history of one or more anticholinergics (AC) and/or β-3 adrenoreceptor agonists (β-3) for relief of OAB; results were stratified according to treatment history. Patients in this analysis elected to discontinue oral medications upon treatment with onabotA. Safety was followed for 12 months in all patients that received at least 1 dose of onabotA; efficacy was determined over a 12-week period. Results: Compared to baseline levels, significant reductions in urinary incontinence (UI), urgency, micturition, and nocturia were noted as early as 1 week and were sustained at 12 weeks, regardless of the type and number of oral medications taken before treatment with onabotA. At 12 weeks post-onabotA, the mean change from baseline UI episodes/day for those with a treatment history of only one AC was −2.4 (n = 43, p ≤ 0.001); more than one AC, −2.4 (n = 52, p ≤ 0.001); one β-3, −3.3 (n = 12, p < 0.05); at least one AC and at least one β-3, −3.2 (n = 56, p ≤ 0.001). Pad and liner use was significantly decreased at 12 weeks post-onabotA across all treatment history groups. Reductions in diaper pant use varied, with less of a reduction in patients with a treatment history of more than one AC compared to patients with a history of at least one AC and one β-3 (p < 0.05) or those with a history of only one AC (p < 0.05). Overall, a total of 253/288 of patients (88%) reported improvements on the treatment benefit scale 12 weeks after treatment with onabotA, regardless of type and number of prior oral medications. In the population of patients that received at least one dose of onabotA (N = 504), 57 adverse events were reported in 38 patients (7.5%); 9 were serious (1.8%). Urinary retention was reported in 5 patients (1.0%); 1 was severe (0.2%). Symptomatic urinary tract infection was reported in 2 patients (0.4%). Conclusions: In this exploratory post hoc analysis of real-world data from the GRACE study, there were few significant differences in outcomes based on the type and number of prior oral medications. Thus, patients who are refractory to one or more oral OAB medications may benefit from earlier treatment with onabotA.

Acetylbenzylfentanyl, benzoylbenzylfentanyl, 3-fluoro-methoxyacetylfentanyl, and 3-phenylpropanoylfentanyl are fentanyl analogs that have been reported to the European Monitoring Centre for Drugs and Drug Addiction in recent years. The aim of this study was to identify metabolic pathways and potential biomarker metabolites of these fentanyl analogs. The compounds were incubated (5 mu M) with cryopreserved hepatocytes for up to 5 h in vitro. Metabolites were analyzed with liquid chromatography-quadrupole time of flight-high-resolution mass spectrometry (LC-QTOF-HRMS). The experiments showed that acetylbenzylfentanyl, benzoylbenzylfentanyl, and 3-phenylpropanoylfentanyl were mainly metabolized through N-dealkylation (forming nor-metabolites) and 3-fluoro-methoxyacetylfentanyl mainly through demethylation. Other observed metabolites were formed by mono-/dihydroxylation, dihydrodiol formation, demethylation, dehydrogenation, amide hydrolysis, and/or glucuronidation. The experiments showed that a large number of metabolites of 3-phenylpropanoylfentanyl were formed. The exact position of hydroxy groups in formed monohydroxy metabolites could not be established solely based upon recorded MSMS spectra of hepatocyte samples. Therefore, potential monohydroxy metabolites of 3-phenylpropanoylfentanyl, with the hydroxy group in different positions, were synthesized and analyzed together with the hepatocyte samples. This approach could reveal that the beta position of the phenylpropanoyl moiety was highly favored; beta-OH-phenylpropanoylfentanyl was the most abundant metabolite after the nor-metabolite. Both metabolites have the potential to serve as biomarkers for 3-phenylpropanoylfentanyl. The nor-metabolites of acetylbenzylfentanyl, benzoylbenzylfentanyl, and 3-fluoro-methoxyacetylfentanyl do also seem to be suitable biomarker metabolites, as do the demethylated metabolite of 3-fluoro-methoxyacetylfentanyl. Identified metabolic pathways and formed metabolites were in agreement with findings in previous studies of similar fentanyl analogs. Funding Agencies|Eurostars-2 Joint Programme (European Commission) [E! 113377]; European Unions Horizon 2020 research and innovation program; Swedens Innovation Agency VINNOVA [2019-03566]; Strategic Research Area in Forensic Sciences (Strategiomradet forensiska vetenskaper) at Linkoeping University

The blood–brain barrier (BBB) poses major challenges to drug delivery to the CNS. SFTI-1 and kalata B1 are cyclic cell-penetrating peptides (cCPPs) with high potential to be used as scaffolds for drug delivery. We here studied their transport across the BBB and distribution within the brain to gauge the potential of these two cCPPs as scaffolds for CNS drugs. In a rat model, SFTI-1 exhibited, for a peptide, high extent of BBB transport with a partitioning of unbound SFTI-1 across the BBB, Kp,uu,brain, of 13%, while only 0.5% of kalata B1 equilibrated across the BBB. By contrast, kalata B1, but not SFTI-1, readily entered neural cells. SFTI-1, but not kalata B1, could be a potential CNS delivery scaffold for drugs directed to extracellular targets. These findings indicate that differences between the BBB transport and cellular uptake abilities of CPPs are crucial in the development of peptide scaffolds.

Background: There are some health care centers in Region Västmanland that always turn a profit, and other health care centers which always go at a loss. Aim: The aim of this study was to analyze the potential reasons as to why the same health care centers always profit, and the other health care centers always go at a loss under year 2022. Methods: A cross-sectional study with register data for the year 2022 was used as a method. The analysis was performed by aggregating different indicators and measures. For example, the age and sex of the patients, socioeconomic status, morbidity, and number of listed patients that the health centers have. Two different therapy areas were chosen for deeper analysis - diabetes and atrial fibrillation. Medicines for these diagnoses have the highest cost for the health centers. In addition to this, differences between the health care centers in prescribing of over-the-counter medicines and in selection of generic drugs were also considered. Results: The results show that the three health centers that lost the most had 29 percent higher costs per diabetes patient of the more expensive diabetes drugs compared to other three health centers that always make a profit. The health centers that had the largest loss had higher costs of Lyrica, a more expensive drug compared to other bioequivalent drugs, than the other health centers. The health centers that lost the most had older patients, and more patients who were socioeconomically disadvantaged. Two of the health centers that lost the most had higher CNI scores, which means that the patients at these health centers had a lower socio-economic status. In conclusion, the health care centers that lost the most had the highest diabetes costs, especially from the more expensive drugs and they had also more older patients.