Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
1 [100%]
YAKUGAKU ZASSHI 129(11) 1385―1392 (2009) 2009 The Pharmaceutical Society of Japan 1385
―Regular Articles―
(Received March 18, 2009; Accepted July 29, 2009; Published online August 6, 2009)
The purpose of this study was to evaluate the incompatibility of ceftriaxone with calcium-containing products,
which had been the subject of an ALERT issued by the FDA. The in‰uence of calcium ion concentration, storage tem-
perature and shaking on the appearance and quantity of insoluble microparticles in mixtures of the two was examined
using a light obscuration particle counter and a stereomicroscope. Appropriate volumes of 2% (w/v) calcium chloride
solution were added to ceftriaxone sodium for injection (10 mg/ml) to make solutions with ˆnal calcium ion concentra-
tions of 0.52.5 mmol/l, and stored at 20° C, 25°
C, or 30°C. The number of insoluble microparticles increased on storage
when the calcium ion concentration of the sample was 2 mmol/l; it exceeded the permissible range at all temperatures
by 1 h. The microparticles had a greater diameter at higher temperatures, although fewer microparticles were observed.
The weight of precipitate increased as a function of both the calcium ion concentration and the temperature. The num-
ber of microparticles was also signiˆcantly increased by shaking. The number of microparticles in mixtures containing
1000 mg/ml ceftriaxone was signiˆcantly increased, even though concentrations of calcium ion was 1.25 mmol/l. Over-
all, not only calcium ion concentration, but storage temperature and shaking aŠected the extent of precipitation of
ceftriaxone with calcium.
Key words―ceftriaxone; calcium; incompatibility; insoluble microparticle; light obscuration particle counter;
stereomicroscope
e-mail: takahiro@mukogawa-u.ac.jp Fig. 1. Structural Formula of Ceftriaxone Sodium
hon p.2 [100%]
ing it a useful and commonly prescribed antibiotic.6) All procedures were carried out on a clean bench.
Ceftriaxone is usually administered via the same can- The number and size of microparticles were deter-
nula used for calcium-containing solutions. Koubo mined using a light obscuration particle counter
has previously reported the ceftriaxone-calcium KL-04 (RION Co., Ltd). The thresholds of micro-
precipitation increased with increasing calcium ion particle size were 1.3, 2.0, 5.0, 10.0, 20.0, 25.0, 40.0,
concentration and physical stimulation by infusion 50.0, and 100.0 mm. The volume of each sample was 5
pump aŠected the precipitation,7,8) but precipitation ml, and the mean value of three samples was calculat-
was observed with the naked eye and the in‰uence of ed. All instruments were washed with water for injec-
temperature was not examined. Precipitated particles tion to eliminate insoluble microparticles derived
of ceftriaxone and calcium, have a small diameter, from the devices. Gas bubbles in the sample solution
and are di‹cult to see with the naked eye in mixed so- were eliminated by standing for 2 min.
lutions, because the size of visible microparticles is 50 The results were evaluated according to the criteria
mm.9) Therefore, there is a possibility that such for the maximum number of insoluble microparticles
precipitated particles could accidentally be ad- in the 15th edition of the Japanese Pharmacopoeia.
ministered into human veins. Shoji and Nakagawa For injection preparations administered at a volume
suggested that the incompatibility of injection ‰uids of 100 ml, the tolerated number of insoluble
should be considered from the standpoint of not only microparticles with a diameter 10 mm or greater is 25
physical and chemical characteristics but also from a or less, and that of microparticles with a diameter 25
clinical viewpoint, and pointed out that insu‹cient mm or greater is 3 or less, per ml.
drug dosages may be due to the adsorption of the Method of Preparation
drug on the surface of the infusion bag or line.10,11) The in‰uence of calcium ion concentration 28,
Recently, there have been some reports of contamina- 56, 83, 111, 139 ml of 2% (w/v) calcium chloride so-
tion with insoluble microparticles at the time of am- lution were diluted up to 10 ml with ceftriaxone injec-
poule opening, observed using a light obscuration tion product (10 mg/ml) dissolved with isotonic sodi-
particle counter.12,13) um chloride solution, and the ˆnal calcium ion con-
In this study, the in‰uence of the temperature centrations adjusted to 0.5, 1, 1.5, 2, and 2.5 mmol/l.
which was not demonstrated in the previous article or The solutions were gently agitated and stored at 20° C,
FDA Safety Alert, was examined. And, the previous 25° C, or 30° C. The number of insoluble microparti-
studies related to incompatibility by measuring a cles was measured according to the method described
number of insoluble microparticles were examined in the previons section, both immediately after mixing
visually, a light obscuration particle counter was and 1, 3 and 6 h later. 139 ml of 2% (w/v) calcium
adopted to evaluate the incompatibility sensitively. chloride solution were diluted up to 10 ml with ceftri-
axone injection product (10 mg/ml) dissolved with
EXPERIMENTAL
isotonic sodium chloride solution, and the ˆnal calci-
Materials Rocephinfor injection containing 1 um ion concentrations adjusted to 2.5 mmol/l. The
g ceftriaxone (Lot No.; K251831, Chugai Phar- mixtures were observed visually and by stereomicro-
maceutical Co., Ltd. Tokyo, Japan), isotonic sodium scope (SZX10, Olympus Co., Ltd.), both immediate-
chloride solution 100 ml (Lot No.; 070625TA, Teru- ly after mixing and 3 and 6 h later.
mo Co., Ltd. Tokyo, Japan), and calcium chloride The measurement of precipitate weight 83, 111,
injection 2% (Lot No.; K6L70, Otsuka Pharmaceuti- 139 ml of 2% (w/v) calcium chloride solution were
cal Co., Ltd. Tokyo, Japan) were purchased for use diluted up to 10 ml with ceftriaxone injection product
in this study. (10 mg/ml) dissolved with isotonic sodium chloride
Measurement of Insoluble Microparticles Using a solution, and the ˆnal calcium ion concentrations ad-
Light Obscuration Particle Counter The em- justed to 1.5, 2, or 2.5 mmol/l. The solutions were
ployed method was essentially same as the `Insoluble gently agitated and stored at 20° C, 25° C, or 30°C for 6
Particulate Matter Test for Injection by Method 1. h. Samples were weighed after ˆltration and drying
Light Obscuration Particle Count Test' described in under reduced pressure.
the 15th edition of the Japanese Pharmacopoeia The in‰uence of shaking 69 ml of 2% (w/v)
(2006).9) calcium chloride solution were diluted up to 10 ml
hon p.3 [100%]
No. 11 1387
RESULTS
The In‰uence of Calcium Ion Concentration storage, and by 1 h after sample preparation, exceed-
The numbers of insoluble microparticles with di- ed the permissible range at all temperatures when the
ameters 10 mm or greater and 25 mm or greater deter- sample solution contained 2 mmol/l calcium ion.
mined at 1, 3 and 6 h after mixing calcium chloride At 3 h after sample preparation, the number of in-
solution with ceftriaxone injection, are shown in Figs. soluble microparticles exceeded the permissible range
2 and 3, respectively. Immediately after sample at all temperatures when the sample solution con-
preparation, the number of insoluble microparticles tained 1 mmol/l calcium ion. At 6 h after sample
in all samples was under the permissible limit. The preparation, the number of insoluble microparticles
number of insoluble microparticles increased on exceeded the permissible range in a few samples when
hon p.4 [100%]
No. 11 1389
DISCUSSION
Fig. 6. In‰uence of Shaking on the Number of Insoluble Microparticles with a Diameter 10 mm or Greater (A) and 25 mm or Greater
(B) Using a Light Obscuration Particle Counter
The in‰uence of shaking (120 cycles/min ) on the number of insoluble microparticles with a diameter 10 mm or greater (A ) and 25 mm or greater (B) (n=3±
S.D.). As analysed by two-way ANOVA with repeated measures; (▲) Ca: 1.25 mmol/l, 120 cycles/min, (◇) Ca: 1.25 mmol/l, without shaking, (■) Ca: 0 mmol/
l, 120 cycles/min.
Fig. 7. Number of Insoluble Microparticles with a Diameter Less than 10 mm (A) and 10 mm or Greater (B) in Low Concentrations
of Ceftriaxone in Isotonic Sodium Chloride Solution
The number of insoluble microparticles with a diameter less than 10 mm (A) and 10 mm or greater (B) in low concentrations of ceftriaxone in isotonic sodium
chloride solution (n=3 ±S.D.). 30 mg/ml(◇), 300 mg/ml (■), and 1000 mg/ml (▲) mixed and shaken at 120 cycles/min at 30° C. Tukey's HSD test; p <0.05;
p<0.01.
hon p.6 [100%]
ble microparticles arising due to precipitation with quencies can be increased under the in‰uence of
calcium was increased. The higher the storage temper- stirring.15) These studies suggest physical stimulation
ature, the fewer insoluble microparticles precipitated, aŠects the collision of insoluble microparticles caused
but the greater the weight of the precipitate. Thus, in by incompatibility, and new particles are formed in
the initial stage of the interaction between ceftriaxone the precipitation of ceftriaxone-calcium salt from su-
and calcium ion, insoluble microparticles with a small persaturated solutions. In a drop infusion using a
particle diameter precipitate; this is followed by ag- peristaltic infusion pump, local stirring and stimula-
gregation to form insoluble microparticles with larger tion may therefore encourage ceftriaxone-calcium
diameter. In other words, the total number of insolu- precipitation because the ˆngerboard of the pump
ble microparticles detected by the light obscuration frequently pushes the line of the infusion device.8,18)
particle counter decreased as the proportion of in- The in‰uence of the bubbles by the shaking is neglect-
soluble microparticles with a large particle diameter ed in this examination which evaluated for the num-
increased. The increase of particle diameter at higher ber of insoluble microparticles with a diameter 10 mm
temperatures seems to be due to aggregation of or greater. Because the number of insoluble micro-
precipitated insoluble microparticles. The observa- particles in the control solution which has not added
tions made using the stereomicroscope supported the calcium have not changed, and the gas bubbles 10 mm
ˆndings made using the light obscuration particle or greater was eliminated by standing for 2 min.19,20)
counter. The aggregation in perikinetic (diŠusive) The number of insoluble microparticles with a di-
systems, in general, is accelerated by increasing parti- ameter less than 10 mm in 30 mg/ml ceftriaxone with
cle and temperature.15) And, diŠusivities are propor- 1.25 mmol/l calcium chloride solution was decreased.
tional to the temperature based on Einstein The reason seems to be due to gas bubbles, which was
relation.16) It was thought that the particle diameter not removed before measurement. The incompatibili-
grew larger due to the aggregation at higher tempera- ty of ceftriaxone with calcium may occur immediately
ture, since diŠusivity increased the particle collision after the mixing, and is in‰uenced by the vibration of
based on the Brownian motion. The lower number of the supersonic wave. Gas bubbles 10 mm or greater in
insoluble microparticles at higher temperatures seems the sample solution were eliminated by standing for 2
to be diŠerences in the sedimentation rate for individ- min in this experiment. However, standing for 30 min
ual particles. In general, insoluble particles sediment to 1 h is necessary to eliminate 2 mm gas bubbles.19,20)
according to Stokes' Law.17) Since aggregated parti- There were no signiˆcant diŠerences of the number of
cles with larger diameter sediment with a compara- insoluble microparticles with a diameter less than 10
tively greater speed, there may be a risk of underes- mm between 3 h and 6 h after sample preparation.
timating the total number of microparticles suspend- And there were no signiˆcant diŠerences of the num-
ed in the sample solution when this includes particles ber of insoluble microparticles with a diameter 10 mm
with a comparatively large particle size. Therefore, it or greater among immediately after mixing and 3 and
would be an advantage to develop a method for mea- 6 h later. Therefore, the number of insoluble micro-
suring the number of insoluble microparticles by particles with a diameter less than 10 mm in 30 mg/ml
gradually stirring without generating bubbles. ceftriaxone with 1.25 mmol/l calcium chloride solu-
In our study, shaking increased the observed num- tion at 3 h after sample preparation might be
ber of insoluble microparticles signiˆcantly, suggest- decreased by eliminating gas bubbles which were not
ing that physical stimulation aŠects the precipitation eliminated immediately after making of the mixture.
of ceftriaxone with calcium. In the previous study for Symptomatic biliary sludge made of ceftriaxone has
the precipitation of calcium oxalate monohydrate frequently been observed in children.2123) There is
from supersaturated solutions,16) in any precipitation also a report in an adult without gall bladder
system there are two mechanisms for size enlarge- in‰ammation.24) In these experiments on the incom-
ment: growth, by which is meant the deposition of patibility of various concentrations of ceftriaxone iso-
ionic or molecular species on crystal surfaces, and ag- tonic sodium chloride solution with calcium-contain-
gregation, the process by which crystals collide, ad- ing products, the number of insoluble microparticles
here to each other, and form new, stable particles. In increased after mixing 1000 mg/ml of ceftriaxone,
orthokinetic (stirred) system, particle collision fre- simulating the ceftriaxone concentration in biliary
hon p.7 [100%]
No. 11 1391
sludge, with 1.25 mmol/l calcium isotonic sodium 5) FDA Update. Information for healthcare
chloride solution, simulating the postulated plasma professionals: Ceftriaxone (marketed as Roce-
calcium ion concentration. Therefore, the possibility phin and generics). Rockville: Food and Drug
of the precipitation of ceftriaxone in mixtures with Administration, Rockville, MD, USA, April
calcium-containing products in vitro and/or in vivo 21 (2009).
cannot be excluded, even in adults. 6) Chugai Pharmaceuticals. Drug Interviewform
According to the FDA Alert,4) deaths due to in- ``ROCEPHIN FOR INJECTION 1 g''
soluble ceftriaxonecalcium precipitation in the lungs (2008).
and the kidneys have occurred in newborn and 7) Koubo B., J. New Rem. & Clin., 48, 133145
premature babies following administration of higher (1999).
dosages of ceftriaxone and higher concentrations of 8) Koubo B., J. New Rem. & Clin., 55, 870886
calcium-containing medium. The temperatures at (2006).
which this occurred were probably higher than nor- 9) ``Japanese Pharmacopoeia,'' 15th ed., Hiro-
mal room temperature. It is also conceivable that the kawa Book Co., Tokyo, 2006, pp. B565575.
precipitation of ceftriaxone with calcium may occur 10) Shoji T., Nakagawa Y., Gekkanyakuji, 38,
in adults receiving total parenteral nutrition from an 31473156 (1996).
infusion pump. 11) Shoji T., Nakagawa Y., Iyakujournal, 35,
11551164 (1999).
CONCLUSIONS
12) Kawasaki Y., Matsuka N., Okada T.,
Precipitation of insoluble microparticles occurred Yokoyama N., Kawashima R., Sendo T.,
in mixed solutions of ceftriaxone and calcium-con- Gomita Y., J. Jpn. Soc. Hosp. Pharm., 43,
taining products. The amount of precipitation de- 927930 (2007).
pended on the calcium ion concentration, tempera- 13) Kawasaki Y., Matsuka N., Yokoyama N.,
ture, storage time, and shaking. The precipitate could Kawashima R., Okada T., Sendo T., Gomita
not be redissolved in water, even after agitating Y., J. Jpn. Soc. Hosp. Pharm., 43, 11981201
strongly. (2007).
Overall, not only calcium ion concentration, but 14) Rochephin Prescribing Information, Roche
storage temperature and shaking aŠected the extent Pharmaceuticals USA, 2008.
of precipitation of ceftriaxone with calcium. Ceftri- 15) Rolli áe S., Sundmacher K., Langmuir, 24,
axone has a prolonged biological half-life and may 1334813358 (2008).
remain in circulation for a comparatively long time, 16) Hounslow M. J., Bramley A. S., Paterson W.
with a concomitant risk of incompatibility even at low R., J. Colloid Interface Sci., 203, 383391
concentrations of calcium ion. (1998).
17) Sunada H., ``Textbook of Pharmaceutics,''
REFERENCES
eds. by Yotsuyanagi T., Danjo K., Yamamoto
1) Robinson L. A., Wright B. T., Am. J. Hosp. A., Nankodo Co., Ltd., Tokyo, 2007, p. 44.
Pharm., 39, 120121 (1982). 18) Koubo B., ``Chushayaku touyohou no kihon
2) Knowles J. B., Cusson G., Smith M., Sitrin to kufuu,'' Medical Tribune Inc., Tokyo,
M. D., J. Parenter. Enteral Nutr., 13, 209213 2001, p. 59.
(1989). 19) Aoyama T., ``RION technical information
3) FDA Safety Alert. Hazards of precipitation 667,'' RION Co., Ltd., (2000).
associated with parenteral nutrition. Food and 20) ``The Japanese Pharmacopoeia Technical In-
Drug Administration, Rockville, MD, USA, formation,'' ed. by Society of Japanese Phar-
April 18 (1994). macopoeia, JIHO, Inc., Tokyo, 2006, p. 199.
4) FDA Safety Alert. Information for healthcare 21) Palanduz A., Yalçin I., Tonguç E., G äuler N.,
professionals: Ceftriaxone (marketed as Roce- Oneç U., Salman N., Somer A., J. Clin.
phin). Rockville: Food and Drug Administra- Ultrasound, 28, 166168 (2000).
tion, Rockville, MD, USA, September 11 22) Bor O., Dinleyici E. C., Kebapci M., Aydogdu
(2007). S. D., Pediatr. Int., 46, 322324 (2004).
hon p.8 [100%]
23) Ozturk A., Kaya M., Zeyrek D., Ozturk E., 24) Bickford C. L., Spencer A. P., Pharmacother-
Kat N., Ziylan S. Z., Acta Radiol., 46, 112 apy, 25, 13891395 (2005).
116 (2005).