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The Prescription Drug Marketing Act of 1987.

The Prescription Drug Marketing Act of 1987 is described, and its implications for hospitals and other health-care entities are discussed. The act, which became effective on July 21, 1988, is intended to reduce public health risks from adulterated, misbranded, and counterfeit drug products that enter the marketplace through drug diversion. The law provides that prescription drug products manufactured in the United States and exported can no longer be reimported, except by the product's manufacturer. It also establishes restrictions on sales of prescription drug products and samples. Samples of prescription drug products may be distributed only if a licensed prescriber requests them. Other distribution channels for samples specified in the law are permissible, provided records are maintained. Under the law, wholesale distributors must be licensed by the state and meet uniform standards. Penalties for violations of the law are also identified. According to FDA's advisory guidelines on the statute, the law will permit hospitals to return drug products, provided the return is made to the manufacturer or wholesaler and provided written notice is secured that the goods were received (for manufacturers) or the goods were destroyed or returned to the manufacturer (for wholesalers). The final chapter on drug diversion must await issuance of final FDA regulations.

Commerce↗

Risks of herbal medicinal products.

PURPOSE: Herbal medicinal products (HMPs) are again highly popular. Their current popularity renders the assessment of their safety an urgent necessity. METHOD: Narrative review using examples only. RESULTS: Constituents of HMPs can be toxic and numerous examples of liver, kidney or other organ damage are on record. All HMPs contain a range of pharmacologically active constituents, and users of HMPs often combine HMPs with prescribed drugs. Thus herb-drug interactions are a real possibility. In most countries, HMPs are not submitted to stringent regulation and control. Thus unreliable quality can be a problem. In particular, this poses a risk when HMPs are contaminated (e.g. with heavy metals) or adulterated (e.g. with prescription drugs). The medical literature holds numerous examples for all of these scenarios and some are used in this article to illustrate the above points. As this area is grossly under-researched, it is rarely possible to define the size of the problem. CONCLUSIONS: It is concluded that the widespread notion of HMPs being inherently safe is naive at best and dangerous at worst. More research is required to minimise the risk HMPs may pose to consumers' health.

Child↗

Kidney injury from alternative medicines.

In the developing world, up to 80% of the population uses traditional medicine for primary health care. In industrialized countries, adaptations of traditional medicine, termed "complementary" or "alternative" medicine (CAM), are used by a growing number of patients for preventive or palliative care. However, alternative medicine (AM) may be an important risk for the development of acute and chronic kidney injury because of several factors: nonconventional preparations rarely meet the required essential standards of consistency in composition and biological activity; many of these products contain undisclosed over-the-counter or prescription drugs or can be adulterated with hormones and glandular extracts; herbal preparations can be contaminated by pesticides and heavy metals; and because of errors in plant identification and confusing terminology, opportunities for mistakes and deliberate substitution can occur. Furthermore, there is a lack of reports of adverse events and drug interactions because of a lack of professional surveillance, and specific data on systemic and kidney toxicity are not easily available. Kidney injury/kidney syndromes caused by AM consist of acute tubular necrosis/toxicity (eg, Fanconi's syndrome), acute interstitial nephritis, papillary necrosis, hypertension, kidney stones, urinary retention, chronic tubulointerstitial nephritis with fibrosis, urinary tract carcinoma, and acute rejection of the kidney transplant. To improve the care for patients using AM, extension of physicians' knowledge about its possible hazards and toxicity is essential. This review deals with acute and chronic kidney toxicity caused by animal-, plant-, and mineral-based, nonconventional medicine and kidney failure caused by drug interactions with AM.

Complementary Therapies↗

Accidental intra-arterial drug injection successfully treated with Iloprost.

A 35-year-old drug abuser inadvertently injected adulterated heroin into her left femoral artery and presented with critical ischaemia of her left leg. Treatment with intravenous Iloprost, a stable prostacyclin analogue, combined with Heparin, produced a dramatic improvement in her circulation within 4 h.

Adult↗

Thallium poisoning in cocaine abusers.

The users of illicit drugs is endangered by both unpredictable concentrations of the drugs and by unexpected adulterants that may be present. Cocaine has been adulterated or admixed with numerous substances, among them local anesthetics, amphetamine, phencyclidine, and strychnine. We report three cases of thallium poisoning following nasal insufflation of a substance that was believed to have been cocaine.

Abdomen↗

Foods--adulteration involving hard or sharp foreign objects; compliance policy guide; availability. Food and Drug Administration, HHS. Notice.

The Food and Drug Administration (FDA) is announcing the availability of a compliance policy guide (CPG) entitled "Foods--Adulteration Involving Hard or Sharp Foreign Objects." This CPG is intended to help FDA components and industry comply with FDA's internal enforcement process concerning foods that contain hard or sharp foreign objects.

Food Contamination↗

Systematic review: hepatotoxic events associated with herbal medicinal products.

BACKGROUND: Large proportions of patients use herbal medicinal products, and encouraging data in terms of effectiveness exist for some of these. One aspect, however, which is still largely under-investigated is the question of potential harm. AIM: To review the recent evidence on hepatotoxic events associated with the use of herbal medicinal products. METHODS: Systematic literature searches were performed on Medline, Embase, The Cochrane Library, Amed and Ciscom. To identify additional data, searches were conducted by hand in relevant medical journals and in our own files. The screening and selection of articles and the extraction of data were performed independently by the two authors. There were no restrictions regarding the language of publication. In order to be included articles were required to report data on hepatotoxic events associated with the therapeutic use of herbal medicinal products. RESULTS: Single medicinal herbs and combination preparations are associated with hepatotoxic events. Clinically, the spectrum ranges from transient elevations of liver enzyme levels to fulminant liver failure and death. In most instances hepatotoxic herbal constituents are believed to be the cause, while others may be due to herb-drug interactions, contamination and/or adulteration. CONCLUSIONS: A number of herbal medicinal products are associated with serious hepatotoxic events. Incidence figures are largely unknown, and in most cases a causal attribution is not established. The challenge for the future is to systematically research this area, educate all parties involved, and minimize patient risk.

Chemical and Drug Induced Liver Injury↗

Comparative evaluation of the flavonoid content in officinal Tiliae flos and Turkish lime species for quality assessment.

Lime flowers are used for various medicinal purposes in phytotherapy. Flavonoids, volatile oil and mucilage components are known as the active ingredients. In European Pharmacopoeia (EP), a simple thin-layer chromatographic (TLC) technique, which based on the analysis of the flavonoid composition was defined for the qualitative analysis of the drug. In this study, flavonoid composition in the flowers, bracts and leaves of the officinal species, Tilia platyphyllos were studied using a reversed-phase high performance liquid chromatographic (HPLC) technique, in order to develop a rapid, reliable and accurate method for quantitative analysis. The results were further compared with in those parts of two common species growing in Turkey, Tilia rubra and Tilia argentea. Results of the present study revealed that flavonoid composition of each lime species possesses a specific fingerprint HPLC chromatogram depending upon the parts used and evaluation of the data might be helpful in the quality assurance as well as determination of adulteration of the crude drug.

Chromatography, High Pressure Liquid↗

Thin-layer chromatographic screening procedure for undeclared synthetic drugs in Chinese herbal preparations.

A simple and rapid thin-layer chromatographic procedure was developed for the detection and presumptive identification of seventeen synthetic drugs previously reported as adulterants of Chinese herbal preparations. Depending on its complexity, the sample may be directly extracted into aqueous ethanol, or stepwise fractionated into acidic, basic, and neutral components. Extracts are analyzed on silica gel layers containing a fluorescent indicator with the aid of two solvent systems. Spots are visualized under short and long wavelength ultraviolet lights. The procedure was successfully tested on synthetic and commercial samples.

Chromatography, Thin Layer↗

Dietary supplements containing ephedrine alkaloids adulterated because they present an unreasonable risk; final rule.

The Food and Drug Administration issued a final regulation declaring dietary supplements containing ephedrine alkaloids adulterated under the Federal Food, Drug, and Cosmetic Act (the act) because they present an unreasonable risk of illness or injury under the conditions of use recommended or suggested in labeling, or if no conditions of use are suggested or recommended in labeling, under ordinary conditions of use. The agency took this action based upon the wellknown pharmacology of ephedrine alkaloids, the peer-reviewed scientific literature on the effects of ephedrine alkaloids, and the adverse events reported to have occurred in individuals following consumption of dietary supplements containing ephedrine alkaloids. The final Rule was published in the Federal Register, Volume 69, Number 28, Pages 6787-6854 on February 11, 2004. This rule that became effective on April 12, 2004 is now included in the Code of Federal Regulations (21CFR Part 119). This report includes the Table of Contents of the full Federal Register publication and selected sections and tables from that publication.

Adrenergic Agents↗

Analytical aspects of drugs of natural origin.

The current importance of drugs of natural origin and their different phytotherapeutical preparations are mentioned. Analytical aspects related to vegetable drugs and their extracts are discussed. An overview is given on procedures used for the isolation of reference compounds, sample preparation for high-performance liquid chromatographic analysis, identification of vegetable drugs and detection of adulterants. The different approaches currently employed for the standardization of extracts are presented. The various aspects are discussed with the aid of illustrative examples.

Chromatography, High Pressure Liquid↗

Implementing a research agenda for complementary and alternative medicine.

Complementary and alternative medicine (CAM) consists of diverse clinical interventions that are practiced because of their popularity rather than the prior demonstration of safety and efficacy required for conventional agents. CAM therapies can be grouped into five categories: biologically based therapies, manipulative and body-based interventions, mind-body interventions, "energy" therapies, and alternative medical systems. The present evidence that individual CAM interventions are efficacious is largely anecdotal, but hundreds of small trials have yielded positive results. For a few modalities, existing data are either very encouraging or else sufficient to conclude that they are ineffective. CAM interventions are presumed to be safe, yet they may not be, particularly in the case of botanical agents with inherent toxicities, significant drug interactions, or potent adulterants. The public health questions regarding CAM can only be addressed through a research agenda that defines which interventions have favorable therapeutic indices. Implementation of this agenda involves adequate characterization and standardization of the product or practice, with rigorous investigation to demonstrate its safety, mechanism of action, and efficacy.

Biomedical Research↗

Amphetamine detection during toxicology screening of a university medical center patient population.

The frequency of detection of "amphetamines" (amphetamine and/or methamphetamine) in the toxicology tests of a university medical center patient population was evaluated by retrospective review of the results of 2,900 toxicology test profiles performed on urine during the year 1986-87. Ten percent of these (291 cases) were positive for either amphetamine alone or amphetamine in conjunction with methamphetamine--a substantial increase from the 3% noted in 1978 at this medical center. Amphetamines were detected predominantly in males (164 cases). The most common age range for the entire series was 21 to 30 years (61% of cases). The typical user was a 27 year old Caucasian man who used amphetamines alone or in combination with at least one other drug with about equal frequency. The sympathomimetic amines (ephedrine, phenylpropanolamine, and pseudoephedrine) were the most frequently associated category of other drugs, perhaps reflecting either adulteration of the amphetamines with these compounds or concurrent ingestion of over-the-counter preparations containing these agents. Requests for those toxicology tests which subsequently revealed amphetamines mostly originated in the emergency room (30% of cases) although 25% originated on the trauma service and 17% on the obstetrics service. Twelve percent of cases occurred in neonates, presumably reflecting transplacental transmission of amphetamines detected in mothers that were studied simultaneously. Amphetamine and methamphetamine were detected together 84% of the time. Analysis of amphetamines should be an integral part of toxicology testing performed on a university medical center patient population.

Adolescent↗

Drug-testing methods and clinical interpretations of test results.

In the present paper, major issues related to drug testing are discussed. For example, drug-testing techniques measure the presence of a drug or drugs but are not sophisticated enough to measure impairment from drug use. Moreover, it is difficult to determine the route of drug administration, quantity or frequency, as well as when the drug was taken, on the basis of the laboratory results. Selection of the drug to be tested should depend on the local availability of the drug, its abuse potential and clinical effects, as well as on the availability of analytical technology and expertise in testing and in interpreting laboratory results. The most sophisticated drug-testing approach is gas chromatography coupled with mass spectrometry (GC/MS), which is regarded as a "gold standard"; it is used in confirmatory testing. Typically, GC/MS is preceded by a rapid immunoassay method to eliminate the majority of the "negative" samples. Despite the existence of sophisticated drug-testing methods, it is still possible to obtain incorrect test results. Such results may be caused by the presence of interfering substances or adulteration of the urine sample. A number of techniques can be employed to reduce the likelihood of obtaining erroneous results and to detect adulterated urine samples. A "positive" drug finding can have a serious impact on the livelihood of an individual, therefore, persons conducting such tests should adhere to the strictest standards of laboratory performance. Only qualified and experienced individuals with proper laboratory equipment should perform these analyses. The standards of laboratory performance must meet local legal and forensic requirements. Access to patient samples and laboratory records must be restricted in order to prevent the tampering of samples and results. In order to maintain confidentiality, the results must be communicated only to the medical review officer. Chain-of-custody documents and all file so that they can be examined in case of a legal challenge. The laboratory must have a complete record on quality control. Finally, specific initial and confirmatory testing requirements should be met.

Bias↗

[Study on allele-specific diagnostic PCR of the traditional Chinese medicines of the deers].

AIM: To develop a convenient and accurate method of DNA molecular marker for the identification of traditional Chinese medicines made of deers, consisting of pilose antler, penis and testis, tendon and foetus. METHODS: Based on the analysis of DNA sequence of mitochondrial Cyt b gene from original animals of both genuine crude drugs, Cervus nippon and Cervus elaphus, and adulterants, a pair of allele-specific primers named as ILu01-L and ILu01-H were designed for distinguishing geniune crude drugs of deers from their adulterants. RESULTS: The results of diagnostic PCR annealing at 64 degrees C for original animals showed that a 365 bp fragment was only amplified from DNA templates of Cervus nippon and Cervus elaphus. For the identification of medicinal materials total of 43 samples from 6 packages were tested under the same reaction conditions except for DNA templates extracted from these crude drugs. Only 9 samples mentioned above was shown to generate positive amplificon. The result indicate that of 8 samples from 1 package of pilose antler and only 1 sample of deer tendon was genuine crude drug. After that, 3 amplified fragments selected randomly were performed with sequencing analysis with the purpose of verifying the results from diagnostic PCR. Data from sequencing confirmed the reliability of diagnostic PCR identification. CONCLUSION: The diagnostic primers designed in the present study were highly specific for Cervus nippon and Cervus elaphus, and they could be used for the authentication of traditional Chinese medicines made from the deer. The quality of the crude drugs of the deer in the current market is a problem and more effective quality control for these traditional Chinese medicines is urgently needed.

Alleles↗

Effects of oxidizing adulterants on detection of 11-nor-delta9-THC-9-carboxylic acid in urine.

Bleach, nitrite, chromate, and hydrogen peroxide-peroxidase are effective urine adulterants used by the illicit drug users to conceal marijuana-positive results. Methods for detecting nitrite and chromate are available. Effects of other oxidizing agents that could possibly be used as adulterants and are difficult to detect or measure are presented in this report. Urine samples containing 40 ng/mL of 11-nor-delta9-THC-9-carboxylic acid (THC-acid) were treated with 10 mmol/L of commonly available oxidizing agents. Effects of horseradish peroxidase of activity 10 unit/mL and extracts from 2.5 g of red radish (Raphanus sativus, Radicula group), horseradish (Armoracia rusticana), Japanese radish (Raphanus sativus, Daikon group), and black mustard seeds (Brassica nigra), all with 10 mmol/L of hydrogen peroxide, were also examined. After 5 min, 16 h and 48 h of exposure at room temperature (23 degrees C) the specimens were tested by a gas chromatographic-mass spectrometric method for THC-acid. A control group treated with sodium hydrosulfite to reduce the oxidants, was also tested to investigate the effect of oxidizing agents on THC-acid in the extraction method. THC-acid was lost completely in the extraction method when treated with chromate, nitrite, oxone, and hydrogen peroxide/ferrous ammonium sulfate (Fenton's reagent). Some losses were also observed with persulfate and periodate (up to 25%). These oxidants, and other oxidizing agents like permanganate, periodate, peroxidase, and extracts from red radish, horseradish, Japanese radish and black mustard seeds destroyed most of the THC-acid (> 94%) within 48 h of exposure. Chlorate, perchlorate, iodate, and oxychloride under these conditions showed little or no effect. Complete loss was observed when THC-acid was exposed to 50 mmol/L of oxychloride for 48 h. Several oxidizing adulterants that are difficult to test by the present urine adulterant testing methods showed considerable effects on the destruction of THC-acid. The time and temperature for these effects were similar to those used by most laboratories to collect and test specimens. In several cases, the loss of THC-acid was > 94%.

Armoracia↗

Final rule declaring dietary supplements containing ephedrine alkaloids adulterated because they present an unreasonable risk. Final rule.

The Food and Drug Administration (FDA, we, our) is issuing a final regulation declaring dietary supplements containing ephedrine alkaloids adulterated under the Federal Food, Drug, and Cosmetic Act (the act) because they present an unreasonable risk of illness or injury under the conditions of use recommended or suggested in labeling, or if no conditions of use are suggested or recommended in labeling, under ordinary conditions of use. We are taking this action based upon the well-known pharmacology of ephedrine alkaloids, the peer-reviewed scientific literature on the effects of ephedrine alkaloids, and the adverse events reported to have occurred in individuals following consumption of dietary supplements containing ephedrine alkaloids.

Alkaloids↗

Analysis of morphine and codeine in samples adulterated with Stealth.

Stealth is an adulterant used to avoid detection of drug abuse. The product does have an effect on the ability to detect several drugs of abuse, including the opiates morphine and codeine. It has previously been shown that low concentration (2500 ng/mL morphine) samples adulterated with Stealth tested negative by both Roche OnLine and Microgenics CEDIA immunoassays, but those spiked with higher concentrations (6000 ng/mL of codeine and morphine glucuronide) were positive. Initial results showed confirmation analysis was also sometimes negatively impacted by this adulterant. Urine samples were spiked with 6000 ng/mL of codeine and/or morphine glucuronide to assess the effect of Stealth. Each individual sample was split into separate aliquots. One aliquot of each was adulterated with Stealth following package directions. The samples were then tested by immunoassay and gas chromatography-mass spectrometry (GC-MS). The control and adulterated aliquots were positive by both immunoassays. Results of GC-MS analysis of the Stealth-adulterated aliquots following standard procedures using deuterated internal standards proved unsuccessful in several cases. In 4 of 12 cases (33%), neither the drugs nor internal standards were recovered despite repeated attempts. In one other sample, recovery was dramatically reduced, making accurate quantitation impossible, whereas the unadulterated aliquots of the same samples posed no problem with recovery. Addition of sodium disulfite to the aliquots prior to extraction allowed recovery of the drugs and internal standards from all samples. Analysis of the samples showed the concentration of morphine and codeine decreased in some by as much as 17 and 30%, respectively. In other cases, there was essentially no difference in the concentration seen before and after adulteration, with or without disulfite treatment. Unless the initial concentration of opiate is near the cutoff, samples containing opiates are likely to be immunoassay positive, it is important to consider this procedure as an option for samples that screen positive but the opiates and their respective internal standards are not recovered for GC-MS analysis.

Codeine↗