Background and Importance Status epilepticus requires an emergent treatment as continuous epileptic activity results in increased pharmacoresistance, morbidity and mortality. Topiramate leads to a control of status epilepticus in 70% of the patients who showed no response to first-line treatments. As there are no parenteral formulations available, topiramate tablets are administered via enteral feeding tube. This is problematic in an emergency setting because pharmacokinetics are unpredictable and rapid therapeutic drug levels are essential. Aim and Objectives The aim of this work is the development of a parenteral formulation of topiramate of 200 mg with a stability of at least 3 months to allow the production in a hospital pharmacy for a stock at the intensive care unit (ICU). Material and Methods Due to poor solubility, different intravenous (IV) formulations were developed for stability and practicability testing: 4 mg/ml and 8 mg/ml with 0.025 M phosphate buffer as ready to use solutions and 20 mg/ml single dose vials with meglumine, a solubility enhancer. A stability study was conducted at time points 0 and 3 months evaluating the concentration of topiramate of three different batches with LC-MS, the pH, the clarity and colouring of the solution according to the European pharmacopoeia. The different formulations were tested during storage at room temperature and at 2–8°C. Results All three formulations of topiramate (4 mg/ml, 8 mg/ml and 20 mg/ml) passed the stability requirements and exhibited a concentration of 100.7%, 101.2%, and 104.4% respectively after 3 months at room temperature and 106.3%, 101.7% and 99.5% respectively at 2–8 °C. There were no significant pH changes and the colour and clarity of the solution remained clear and colourless. Conclusion and Relevance Our results are in line with Cloyd's extrapolated stability data, that topiramate 7 mg/ml with 0.1M phosphate buffer is stable for 1.5 years at 5°C with a concentration of at least 90% topiramate. We demonstrated that topiramate parenteral solution is stable at room temperature for at least 3 months, which is favoured in a hospital setting. Therefore, the hospital pharmacy's production unit can provide the ICU with a stock of an IV formulation of topiramate and the stability study will be continued. References and/or Acknowledgements Conflict of Interest No conflict of interest.

Background: We assessed the capacity of epidermal growth factor receptor (EGFR)-targeted immunoliposomes to deliver cargo to brain tumor tissue in patients with relapsed glioblastoma harboring an EGFR amplification. We aimed to assess the tolerability and effectiveness of anti-EGFR immunoliposomes loaded with doxorubicin (antiEGFR ILs-dox) in glioblastoma multiforme patients. Patients and methods: Patients with EGFR-amplified, relapsed glioblastoma were included in this phase I pharmacokinetic trial. Patients received up to four cycles of anti-EGFR ILs-dox. Twenty-four hours later, plasma and cerebrospinal fluid (CSF) samples were obtained. In addition, we also treated three patients with anti-EGFR ILs-dox before resection of their relapsed glioblastoma. Doxorubicin concentrations were measured in plasma, CSF, and tumor tissue. Safety and efficacy parameters were also obtained. Results: There were no or negligible levels of doxorubicin found in the CSF demonstrating that anti-EGFR ILs-dox are not able to cross the bloodebrain barrier (BBB). However, significant levels were detected in glioblastoma tissue 24 h after the application, indicating that the disruption of BBB integrity present in high-grade gliomas might enable liposome delivery into tumor tissue. No new safety issues were observed. The median progression-free survival was 1.5 months and the median overall survival was 8 months. One patient undergoing surgery had a very long remission suggesting that neoadjuvant administration may have a positive effect on outcome. Conclusions: We clearly demonstrate that anti-EGFR-immunoliposomes can be targeted to EGFR-amplified glioblastoma and cargodin this case doxorubicindcan be delivered, although these immunoliposomes do not cross the intact BBB.

Background Cleaning of technical equipment should remove residues of products and cleaning agents, as well as avoid microbial contamination.1 In hospital pharmacies multipurpose equipment is used for the manufacture of different pharmaceutical preparations. Suitable well-documented cleaning procedures are necessary to guarantee patient safety by avoiding cross-contamination of drugs. Purpose Effective cleaning procedures should be developed and validated for multipurpose and drug-contaminated equipment used in the solution production e.g. stirrers, tanks, tubes and filling systems. As a final result the contamination risk of all possible production lines could be assessed. Material and methods Focusing on direct product contact our multipurpose equipment was grouped into nine critical and 11 uncritical systems. For seven of nine critical systems, a validated cleaning process did not exist and had to be developed. The validation covered the cleaning status immediately at the end of production (t0) and after a 24 hours' dirty-hold time (t24). Naphazoline nitrate was defined as the worst case active component of our solutions portfolio. The analytical (1/1000 dose criteria) and microbiological residue limits were calculated.1 The HPLC method for the quantitative analysis of naphazoline nitrate was validated.2 Based on a risk assessment evaluating the potential of contamination, the number of validation runs for each unit of equipment was defined. The analytical and microbiological results were quantified for each system. To assess the whole process the residues of all production lines at t0 and t24 were summarised. Results An effective cleaning procedure was evaluated for each system and validated at t0 and t24. Each unit of equipment and all possible production lines met the analytical residue limits at t0, and at t24 with the exception of the tubes. The microbiological requirements were fulfilled for the clean-room zones D and C. Conclusion The tube surface consists of polytetrafluoroethylene and has to be cleaned immediately after the end of the production (t0). All other systems are almost completely made of stainless steel and can be cleaned until t24. The cleaning validation of the solution production was the first process in our hospital pharmacy which was completely validated including a dirty-hold time. References and/or Acknowledgements 1. GMP-Guideline, Annex 15: Qualification and Validation. 2. ICH-Guideline, Topic Q2(R1): Validation of Analytical Procedures. No conflict of interest

Currently, the University Hospital Basel is running an outpatient parenteral antibiotic therapy (OPAT) program which uses elastomeric infusion pumps for continuous application of certain antibiotics. To prepare piperacilline (PIP)/tazobactam (TAZ) pumps in advance, the original brand is used (Tazobac®), as recommended by several guidelines. This study aims to investigate whether a generic brand shows sufficient stability under the following conditions in the OPAT program: manufacturing pumps in advance, storing them refrigerated and administrating them at elevated temperatures (37 °C), when pumps are placed close to the patient's body. The stability of two different pump compositions was evaluated to examine the influence of an additional buffer (as contained in Tazobac®) on the chemical stability of the PIP/TAZ solution. Preparation and sampling of solutions in pumps: a total of six pumps were prepared, each containing 12/1.5 g PIP/TAZ in 0.9% sodium chloride. Three of the six pumps were buffered using 17 mL of 4% sodium citrate. All pumps were filled up to 240 mL using 0.9% sodium chloride. A sample was drawn immediately thereafter. The pumps were kept in the refrigerator for seven days and then kept outside for one hour before a second sample was taken. After keeping the pumps for additional 12 hours at 37 °C, a third sample was taken and then samples were drawn every three hours for up to 12 hours, while keeping the pumps at 37 °C. Samples were frozen and analyzed within seven weeks. Assay: a validated HPLC method was used to determine drug concentration. The method employed a reversed phase C18 column (ACE RP 18.3 μm 4.0 × 75 mm, Fa LCC), with retention time of PIP at 7.3 minutes and TAZ at 2.3 minutes and a detection wavelength of 230 nm. Mobile phase consisted of a phosphate buffer adjusted to pH 5.5 and methanol. The initial concentration was defined as 100% and subsequent concentrations were calculated as percentages of the initial concentration. Acceptance criteria for stability were defined as 90–110% of initial concentration. The lowest concentration of PIP for the generic pumps was 89% and of TAZ 92%. The lowest concentration for PIP and TAZ for the generic pumps with buffer was 94% and 95% respectively. The buffer shows a positive effect on stability of PIP and TAZ in elastomeric pumps prepared with the generic brand. The stability was proven under simulated OPAT conditions. The savings of switching from Tazobac® to the generic brand are estimated to outweigh the expenses of buffering the pumps.

Objective: Duchenne muscular dystrophy (DMD) is the most common and one of the most severe muscular dystrophies presenting with rapidly progressing muscle wasting and premature death. Reduced neuronal nitric oxide synthase (nNOS) activity is thought to be important for the pathophysiology of DMD. In this prospective, open-label, single center proof-of-concept pilot study, we aimed to increase the intramuscular NO concentration to improve the mitochondrial energy metabolism using a novel approach with a combination of l-arginine and metformin.

The pharmacokinetics and pharmacodynamics of a highly concentrated cyclodextrin-based intranasal (i.n.) midazolam formulation containing the absorption-enhancer chitosan were studied in 12 healthy volunteers and compared with intravenous (i.v.) midazolam. The pharmacodynamic (PD) effects were assessed using quantitative electroencephalography (EEG). Maximal plasma concentrations of 63 and 110 ng/ml were reached at 8.4 and 7.6 min after 3 and 6 mg i.n. midazolam, respectively. After 5 mg i.v. and 6 and 3 mg i.n. midazolam, the times to onset of significant EEG effects in the beta 2 band (18-25 Hz) were 1.2, 5.5, and 6.9 min, respectively, and the times to loss of response to auditory stimuli were 3.0, 8.0, and 15.0 min, respectively. A sigmoid maximum-effect (E-max) model indicated disequilibrium between plasma and effect-site concentrations, with equilibration half-lives of 2.1-4.8 min. The observed pharmacokinetic-PD (PK-PD) properties suggest that i.n. midazolam deserves to be evaluated as an easy and noninvasive method of administering a first benzodiazepine dose, e. g., in out-of-hospital emergency settings with no immediate i.v. access.

(CIM), which has been attributed to chronic muscle membrane depolarisation. The aim of this study was to investigate muscle membrane properties by measuring velocity recovery cycles (VRCs) of muscle action potentials in the early stage of experimental sepsis. VRCs chart the changes in velocity of a muscle action potential in the wake of another, and provide an indirect indication of the afterpotentials following the muscle action potential. Hence, they are strongly dependent on membrane potential. Methods: Twenty-five anesthesized pigs were randomized to either fecal peritonitis (n = 11) or to non-septic controls (n = 14). Multi-fibre responses to direct muscle stimulation through needle electrodes were recorded from the front leg immediately before induction of peritonitis as well as 6, 18 and 24 h thereafter. Latency changes were measured as conditioning stimuli were applied at inter-stimulus intervals of 2–1000 ms. Relative refractory period (RRP) and maximal supernormality (SN) were assessed. Results: In septic animals, RRP was increased by 38% (P < 0.05) and SN was reduced by 22% (P < 0.05) 24 h after induction of peritonitis compared with baseline measurements. The effect of increased RRP and reduced SN in the sepsis group was already apparent 6 h after induction of peritonitis, whereas in the non-septic controls there were no significant differences over time. The changes in SN in the sepsis group were significantly correlated with muscle oxygenation and with serum potassium levels. Conclusion: VRC changes in the sepsis group corresponded to muscle membrane depolarisation, which seems to be an important factor in the pathogenesis of CIM. Muscle membrane depolarisation was most likely caused by muscle hypoperfusion. VRCs provide a practicable mean for monitoring muscle membrane changes and may allow an early diagnosis of CIM.

3029 Background: Immunoliposomes (ILs) combine antibody-mediated tumor recognition with liposomal delivery and, when designed for target cell internalization, provide intracellular drug release in order to increase specificity and efficacy of the encapsulated drug. In animal studies we have shown the ILs approach to be active and promising when targeting the epidermal growth factor receptor (EGFR). Methods: ILs were modularly manufactured under GMP conditions with Fab' fragments from MAb C225 (cetuximab), covalently linked to pegylated liposomes containing doxorubicin (PLD). This first in man single-center phase I clinical trial of anti-EGFR ILs-dox was designed for patients (pts) with various solid tumors, overexpressing EGFR (DAKO EGFR pharmDx-test). ILs-dox was administered i.v. q 4 weeks at a doxorubicin (dox) dose of 5, 10, 20, 30, 40, 50 and 60 mg/m2, 3 pts per dose level, for a maximum of 6 cycles. In addition to weekly safety monitoring, echocardiography was performed q 2 cycles, and pharmacokinetic assessments during cycle 1. The primary objective of this study was the establishment of MTD; secondary objectives included PK, tumor response, and time-to-progression. Results: After failure of standard treatments 26 pts were included between January 2007 and May 2010. Median age was 62 years, WHO PS-0 in 3, PS-1 in 19 and PS-2 in 4 pts. Most common histologies included pancreatic, H&N, colorectal and urothelial cancer. Two cases of neutropenia, defined as a dose limiting toxicity, occurred on dose level 7 (= 60 mg dox/m2). On all lower doses the compound was very well tolerated, e.g. skin toxicity grade 1 in 2 pts, no hand-foot-syndrome, no alopecia, no cardio-toxicity, no cumulative toxicity. Therefore, 50 mg dox/m2 was defined as the maximum recommended dose for further phase II development. Best response to treatment included 1 CR, 1 PR and 8 SD lasting 2-12 mo (median 5.75 mo). Mean total dox half-life was calculated to be 31.0 h (+/- 7.6 h) and for the attached monoclonal antibody fragment of C225 17.7 h (+/- 4.3 h), respectively. Conclusions: Anti-EGFR dox-loaded ILs are safe and well tolerated up to 50 mg dox/m2. Clear evidence of clinical activity was observed warranting further evaluation in phase II trials.

P>Background and objective:Judicious use of antibiotics is essential considering the growth of antimicrobial resistance and escalating costs in health care. This intervention study used treatment guidelines to improve antibiotic therapy by changing prescribing practice.Methods:A before-after intervention study was performed in a 550-bed tertiary care teaching hospital in Switzerland, with an additional follow-up analysis 1 year later. The pre-intervention phase included chart analysis of current antibiotic use in 100 consecutive patients from the representative medical and surgical wards included in the study. Treatment guidelines were defined, taking into account published guidelines, the local antibacterial sensitivity of the pathogens, and the hospital antibiotic formulary defined by the drug and therapeutics committee. The guidelines were presented to the medical residents on a pocket card. They were informed and educated by the pharmacist (intervention). In the post-intervention phase immediately after the instruction, and in the follow-up phase 1 year later, a prospective analysis of antibiotic prescription was performed by chart review of 100 antibacterial treatments in consecutive patients to detect changes in antibiotic prescribing (treatment) and to determine whether these changes were sustained.Results:The pre-intervention review of antibiotic use showed the need for therapy improvements in urinary tract infections (UTI) and hospital-acquired pneumonia (HAP). In the post-intervention phase 100% of UTI were treated as recommended, compared to 30% before the intervention (P < 0 center dot 001). The follow-up analysis showed a decrease in guideline adherence to 39% in patients with UTI. Before implementation of the clinical guidelines, HAP was inappropriately treated like community-acquired pneumonia (CAP). Immediately after the intervention, 50% of HAP patients were treated as recommended, and 1 year later (follow-up phase) 56% of HAP patients received the recommended antibiotic medication. This change in prescription practice was significant (P < 0 center dot 05).Conclusion:Antibiotic treatment guidelines for the infections most commonly occurring in hospitalized patients resulted in a significant increase in appropriate antibiotic use. The program was successful in changing prescription practice and achieved a sustained optimization of HAP therapy. Implementing, teaching and monitoring treatment guidelines can have a major impact on patient care.