The pharmacy education in the country is a total disconnect between learning, training, and healthcare needs of the society. The profession of pharmacists goes well beyond mere drug dispensing to participate at all levels of the public health system. A roadmap needs to be chalked out to ensure a transformation in the profession of the pharmacist to shun the old and unproductive mindset and overhaul education, training and research approaches. There is need to harmonize pharmaceutical education with global standards where it is a recognised, critical and indispensable clinical profession. Unlike doctors, dentists and nurses, pharmacists are not considered as service cadre. General perception is that they are medicine traders. Moreover, the pharmacists are not seen in any uniform or white aprons either at chemist outlets or in hospitals. The faculty at pharmacy colleges do not interact with doctors. Pharmacists are not part of the decision making process to select the right medicines or in committees working on costing of drugs purchase. The current curricula is broadly industry oriented and has not changed in 80 years including the diploma course which was revised during the Education Regulation of 1991.They are still struggling for the recognition of their role that can help improve the health care system. Changes are required in quality pharmaceutical education meets the challenges and needs of the nation in the 21st century. The country failed to gain societal recognition of the pharmacy profession. The need of the hour is to ensure that quality of education is not sacrificed at the cost of quantity. Changes in the legislative framework that improve and maintain the high standards of the pharmacy profession in both educational and practice settings are lacking.
The profession of pharmacy is at a significant crossroads between its conventional drug-dispensing identity and a pioneering clinical role with health care provider status. Though a growing clinical pharmacy education system has been established in India, the developing pace is very slow. The main barriers facing clinical pharmacy education in India exist in the undergraduate educational system. First, the curriculum structure and content in clinical pharmacy programs needs to be improved to make it more practical and systematic.For example, courses are too elaborate and lack coherence and integrity from course to course and do not truly help students obtain practical clinical skills. Students lack sufficient opportunity to consolidate their theoretical knowledge in the earlier stages and find it difficult to adjust when they enter practice. There are still no well-designed assessment criteria for clinical pharmacy practice and little effective supervision when students are practicing in hospitals or other institutions. The more urgent need for pharmacy graduates is appropriate knowledge and skills in patient care. The demand for clinically trained pharmacists is therefore urgent. Cooperation between pharmacy colleges and hospitals must be strengthened, more faculty members with a clinical pharmacy background must be recruited, and hospital pharmacists must be involved in teaching college courses.
Federal legislation for pharmacy provider status is not a want, but a need for the reimbursement of patient care services that will not only demonstrate the importance of our profession but also provide financial benefits. With the snowballing demand for health care services by the increasing population and shortage of physicians, something will have to change. Pharmacists could be that defining factor for many companies and patients; however, we need to make our services and value known. Pharmacist provider status is just 1 piece of the colossal health care delivery system change puzzle. How will pharmacy practice evolve to meet the needs of the 21st-century health care system? That is up to us, and if we don’t take measures to define it in our terms, somebody may define it for us. The first step is the passage of federal provider status legislation.
Advertisements are freely appearing in social media convincing gullible public on Treatment of diseases like Cardiac diseases, Diabetis, Asthama etc for which claiming of cure is Prohibited under the Drugs & Magic Remedies (Objectionable Advertisements) Act.
Dispensing medicine is not just a mechanical transfer of materials from one person to the other.
It is the transfer of information with the material to ensure that the consumer adopts good technique in handling and storage and uses the medicine in the most appropriate way so that he is least harmed due to the side effects and at the same time derives optimized medication benefit that results in considerably lowered morbidity.
Corollary:
It should Be a habit in all patients to insist on correct and authentic information on each medicine he procures from a chemist shop or a hospital, as it is he who is using the medicine.
Chemist or hospital pharmacist cannot shirk his responsibility by telling 'Ask your doctor:.
If theChemist doesn't have an answer he should borrow time, collect the information and communicate.
At no cost and at no time the information can be refused by the dispensing professional as:
IT IS THE BASIC RIGHT OF THE PATIENT TO KNOW ABOUT WHAT HE IS CONSUMING.
The NPW 2016 is round the corner .
Educate and create awareness in the public on the need to have full information of their medicines.
Let them demand the service from the chemist and Hosp pharmacists.
#Practice in professional parlance means the service delivered by a professional all through till a logical end and One who delivers such a service is called Practitioner.
Ex. #LawPractice, #MedicalPractice, #AccountsPractice etc they serve their clients till logical end.
๐Where does the #PharmacyPractice fit in?
Or
๐Can storing, dispensing / selling drugs in a Pharmacy be called a Practice?
๐ What responsibility does a Pharmacist takes of the drug dispensed and the Patient after dispensing / sale?
Evidence based Medicine vs Evidence based Pharmacy / Pharmaceutical Care
Evidence-based medicine (EBM) uses the scientific method to organize and apply current data to improve healthcare decisions. Thus, the best available science is combined with the healthcare professional's clinical experience and the patient's values to arrive at the best medical decision for the patient. There are 5 main steps for applying EBM to clinical practice.
Defining a clinically relevant question
Searching for the best evidence
Critically appraising the evidence
Applying the evidence
Evaluating the performance of EBM
EBM starts with a clinical question. The clinical question is an issue which the health-care provider addresses with the patient. After the clinical question is formulated, relevant scientific evidence is sought, which relates to the clinical question. Scientific evidence includes study outcomes and opinions. Not all data has the same strength. Recommendations from an expert are not as robust as the results of a well-conducted study, which is not as good as the results of a set of well-conducted studies. Thus in evidence-based medicine, the levels of evidence or data should be graded according to their relative strength. Stronger evidence should be given more weight when making clinical decisions.
The evidence is commonly stratified into six different levels:
Level IA: evidence obtained from a meta-analysis of multiple, well-conducted, and well-designed randomized trials. Randomized trials provide some of the strongest clinical evidence, and if these are repeated and the results combined in a meta-analysis, then the overall results are assumed to be even stronger.
Level IB: evidence obtained from a single well-conducted and well-designed randomized controlled trial. The randomized controlled study, when well-designed and well-conducted, is a gold standard for clinical medicine.
Level IIA: evidence from at least one well-designed and executed non-randomized controlled study. When randomization does not occur, there may be more bias introduced into the study.
Level IIB: evidence from at least one well-designed case-control or cohort study. Not all clinical questions can be effectively or ethically studied with a randomized controlled study.
Level III: evidence from at least one non-experimental study. Typically level III evidence would include case series as well as not well-designed case-control or cohort studies.
Level IV: expert opinions from respected authorities on the subject based on their clinical experience.
All clinical studies or scientific evidence can be classified into one of the above categories. The clinician must then use their professional, clinical experience to extrapolate the scientific evidence as it applies to the specific patient. Most clinical studies have specific inclusion and exclusion criteria, as well as the specific population studied. More often than not, the patient being treated by the clinician will have one or more substantial differences from the population in the study. The medical provider must then use their clinical judgment to determine how the variations between the patient and the study population are important or not and how they affect applying the study results to the specific patient.
For example, a specific patient may be a 70-year-old female with a history of hyperlipidemia and a new diagnosis of hypertension, looking at hypertension treatment options. The clinician may find a good randomized controlled trial looking at medications to control hypertension, but the study's inclusion criteria were a population of 18 to 65-year-olds. Should the clinician ignore the results as the specific patient does not meet the study demographics? Should the clinician ignore the age difference between the specific patient and study population? This is where the clinical judgment helps bridge the gap between the relevant scientific evidence and the specific patient being treated.
Finally, clinicians using evidence-based medicine must put all of the information in the context of the patient's values or preferences. The patient's values or preferences may conflict with some of the possible options. Even strong evidence supporting a specific treatment may not be compatible with the patient's preferences, and thus, the clinician may not recommend the treatment to the patient. Also, the treatment might not apply to the specific patient.
As an example, a patient may have a particular form of cancer. Level IA evidence may suggest life expectancy can double from 8 to 16 months with chemotherapy. The chemotherapy has significant side effects. The patient may find those side effects not acceptable and elect not to pursue chemotherapy secondary to the specific patient's preferences and values.
Once the clinical question is formulated, relevant scientific information is evaluated, and clinical judgment is used to apply the relevant scientific evidence to the specific patient and their values, the outcome must be evaluated. The final step is a re-evaluation of the patient and clinical outcome after application of the applied information. Did the intervention help? Were the outcomes as expected? What new information is obtained? How can this information be applied to future situations and patients?
Evidenced-based medicine starts with the clinical question and returns to the clinical question at the end to see to what effect the process worked. Without continuous re-evaluation, the medical provider will not be sure if their impact is positive or negative. Evidence-based medicine is a perpetual wheel of improvement rather than a one-time linear process.
The function of evidence-based medicine is to bring together three different entities: the patient's preferences, the healthcare professional's clinic judgment, and the best available, relevant, scientific information to provide improved medical care. [4]
There are numerous criticisms of evidence-based medicine [5][6][7][8][9]:
Publication Bias
Evidence-based medicine is based on published results, giving more weight to class I and II evidence. Many studies have shown that positive results are more likely to be published than negative results. This leads to a publication bias of positive result studies that can skew the available evidence. Additionally, studies funded by companies are more likely to get published to push for the use of the studied medication or device, which can also skew the available evidence.
Randomized, Controlled Trial Bias
Evidence-based medicine places the highest weight in randomized controlled trials. Although such randomized controlled trials may provide strong evidence, a randomized controlled trial may not always be possible or feasible. If a disease process has a very low prevalence, it may be extremely prohibitive or impossible to obtain a sufficient number of participants for a study.
For example, progeria is a rare disease with an incidence of around one in four to eight million live births and an average lifespan of 14 years. With a global population of around 7.6 billion and an annual birth rate of 18.5 births per 1,000 people per year, there would only be around 100 to 400 total individuals with progeria in the world. It is impractical to conduct a randomized controlled trial with so few patients and produce meaningful results.
As a second example, consider the ethical implications of randomized controlled trials. In a paper by Smith et al. (2003), they argue that we take for granted that parachutes help prevent injuries and save lives after a person jumps out of an airplane. This common-sense observation has not yet been studied and proven with a randomized controlled trial. The article argues that people should accept certain common-sense ideas, and randomized, controlled trials are not always necessary. After all, can researchers easily find evidence-based medicine purists who would be willing to sign up for a randomized, cross-over, placebo-controlled trial testing the utility of parachutes to decrease injuries or death after jumping out of an airplane?
Finally, there are many, many more clinical questions than there are randomized controlled trials. The many suitable questions for a well-designed and well-conducted randomized controlled trial far exceed the available resources to conduct the trials. We must admit that resources are limited, and spending time on every possible clinical question or configuration of clinical importance may not be practical or advisable. Research should rather devote such resources to focusing on higher-impact clinical questions.
Lag Time
A well-designed and well-conducted randomized controlled trial take time to design, carry out, and report. There can be significant changes in the medical landscape between when the trial is designed and initiated, and when the results are published. More than once, a study has sought to examine a chemotherapy regimen for specific cancer only for that chemotherapy regimen to be antiquated and supplanted by the time the trial results are published.
Values
Although patient values are explicit to the model of evidence-based medicine, many healthcare practitioners omit or minimize patient values. It is not uncommon for the healthcare provider to recognize the medical issue, perform the review, evaluate and assimilate relevant scientific information, and implement an intervention without considering the patient's values. It is easy for providers to be swept away in trying to implement the "best evidence" or "best practices" before understanding how these either fit or contradict the patient's values.
Evidence-based medicine provides a framework for applying the relevant scientific evidence to the patient's condition based on the patient's values using the clinician's clinical judgment to tailor the treatment for the patient. The goal of evidence-based medicine is to improve medical outcomes based on the highest quality evidence available. After the intervention is implemented, the outcome should be re-evaluated in the context of the clinical question to see what effect occurred. It can also be applied to a population to generate recommendations for the population-based on current medical evidence. Population recommendations are typically graded based on the underlying science behind the guidelines. Various grading schemes exist. These schemes rank recommendations from strong evidence (to support the guidelines) to poor or no evidence (to support the guideline with varying support levels in between).
Nursing, Allied Health, and Interprofessional Team Interventions
Evidence-based medicine provides a roadmap for clinicians to apply valid scientific evidence to the patient's condition based on the patient's values using the clinician's clinical judgment to tailor the treatment for the patient. The goal of evidence-based medicine is to improve medical outcomes based on the highest quality evidence available. Short term data evaluation indicates that EMB may be improving patient outcomes in certain disorders.
EVIDENCE BASED PHARMACY
Abstract
Introduction
Pharmacy is a very dynamic profession and the role of the pharmacist is improving with the expansion of the scope of services and the introduction of new subspecialties over time. Moving from being medication dispensers to outcome-oriented and patient-focused care providers; pharmacists will carry more responsibility and commitment to improve their knowledge and practice.
Being updated and evidence-based is a key tool to achieve effective pharmaceutical care services. The primary purpose of this article is to highlight the concept of “evidence based pharmaceutical care” as professional practice to improve the quality of pharmaceutical care.
Methods
Literature for relevant evidence was searched by Medline (through PubMed), Cochrane library using the keywords: pharmaceutical care, evidence-based and pharmacy practice. Also a manual search through major journals for articles referenced in those located through PubMed was done.
Results and discussion
There is strong data showing that pharmaceutical care lead to improvement in health outcomes and cost-effective therapy. More efforts, policies and qualified staff are needed to establish the “evidence-based pharmaceutical care” as new daily professional practice. Evidence to support pharmacists in their emerging role as care providers is available to improve the efficacy and quality of pharmaceutical care. Education and specialized training practicing evidence based approach are vital to prepare pharmacists to provide high quality pharmaceutical care.
Conclusion
As care providers, pharmacists are effective in providing high quality patient care and being members in multidisciplinary clinical teams is needed to give them the opportunity. Evidence based pharmaceutical care is a natural and logical emerging concept in the modern pharmacy practice to achieve high quality and more effective pharmaceutical care but still more efforts and resources are needed to promote new attitude toward more professional career.
Introduction
Personal experience or expert opinion alone is not enough to support health care decision. High quality research is the most accurate source of scientific evidence that can be used to identify and meet the patient health needs. In a recent survey of pharmacists, 90% held positive attitudes toward evidence based practice and 84% thought research findings were important to daily practice (Burkiewicz and Zgarrick, 2005). These results reflect the awareness of the pharmacists toward their profession as evidence-based practice and the desire to expand their role as researchers.
Pharmacy profession has improved to include the provision of cognitive services in addition to the traditional role of medication dispensing. Establishing evidence-based practice is important for pharmaceutical care services to be effective, updated and relevant to patients. Pharmacists must accept and actively participate in the research needed to establish the required evidence-base pharmaceutical care.
1.1. What is “pharmaceutical care”?
According to the definition of Hepler & Strand pharmaceutical care is “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life” (Hepler and Strand, 1990). Pharmaceutical care is based on a relationship between the patient and the healthcare providers who accept responsibility to provide care to the patients. Pharmaceutical care involves the active participation of both the patient and the health care provider in drug therapy decisions.
Pharmaceutical care involves three major functions: identifying potential and actual drug related problems; resolving actual drug-related problems; and preventing drug related problems. Although there are different trends, such as clinical pharmacy services, cognitive services, medication management, medication review, they all share the same philosophy and objectives, namely “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life” (Roughead et al., 1990).
Pharmaceutical care activities include medication dispensing, providing drug information, patient counseling, drug monitoring, parenteral nutrition preparation, adverse drug reaction monitoring, medication reconciliation, drug protocol/guideline development, medical rounding with the health care team, and performing admission drug histories. Practicing these activities by evidence-based approach will improve the quality of the provided services.
Pharmacists need training and support to develop and improve their practical skills to provide comprehensive pharmaceutical care (Schommer and Cable, 1996).
To be effective, pharmaceutical care needs to be adopted by majority of pharmacists in their daily work. Many barriers limit the implementation of the pharmaceutical care principles. To identify and solve these barriers well designed research is needed (Farris and Kirking, 1993a, Farris and Kirking, 1993b).
1.2. Evidence based practice
There is an increasing awareness of the need for healthcare professionals to adopt an evidence-based approach to their daily practice. Practicing pharmacy in an evidence based manner will enhance professional skills of the pharmacist with improved patient care. The concept of evidence-based pharmaceutical care requires training and education starting from undergraduate level. Pharmacy students need to be educated how to professionally apply science in patient care. Special training on research principles, literature review and evidence based approaches is very important to prepare the pharmacists to practice the evidence based pharmaceutical care efficiently.
2. Methods
A literature review was performed by searching Medline database through PubMed for relevant articles including meta-analyses, systematic reviews, review articles, randomized and non-randomized trials, as well as case reports. Search keywords were as follows: evidence-based pharmacy, patient care, pharmacist, pharmaceutical care, and pharmacy practice. Web-based searching and backward citation tracking were conducted for context and additional citations.
3. Results and discussion
3.1. Search results
There are strong data showing that pharmaceutical care is effective and led to improved patient care with more cost-effective therapy in both in- and outpatient settings. Many studies and reviews demonstrated the efficacy of the pharmaceutical care programs as described below. Research describing the term “evidence-based pharmaceutical care” is limited in the literature.
3.2. Data findings
3.2.1. Inpatient pharmaceutical care
The literature proving the beneficial role of the pharmacist in inpatient care is strong and abundant (Shekelle et al., 2013). A comprehensive systematic review of inpatient pharmacy services was conducted and summarized in a Technology Assessment report in 2013 by the Agency for Healthcare Research and Quality titled, “Making Healthcare Safer II: an Updated Critical Analysis of the Evidence for Patient Safety Practices”.
The report stated that the totality of the literature (delineated in evidence tables) shows that pharmacist-provided care enhances the patient safety and improves outcomes. Later in the report, they focus on medication reconciliation and found that pharmacists significantly decreased emergency department visits and hospitalizations within 30 days of discharge (Shekelle et al., 2013).
Services provided by pharmacists in hospitals were found to be highly cost-effective in a database analysis of 1016 hospitals (Bond et al., 2000). In all, 6 services significantly reduced costs, including drug use evaluation, drug information, adverse drug reaction monitoring, drug protocol/guideline development, medical rounding with the health care team, and performing admission drug histories. As staffing was increased for clinical pharmacists, total cost of care decreased (Bond et al, 2000)
3.2.2. Outpatient pharmaceutical care
In 2010, a comprehensive systematic review of 298 studies evaluating the impact of pharmacist-provided direct patient care in ambulatory settings found significant benefits in achieving hemoglobin A1c, LDL cholesterol, and blood pressure targets in addition to reducing adverse drug events (Chisolm-Burns et al., 2010). These intermediate health outcome benefits result from enhanced patient knowledge about medications, increased medication adherence, and improved quality of life as a result of pharmacist-provided services (Chisolm-Burns et al., 2010).
In a systematic review of 15 randomized controlled trials in 9111 outpatients with diabetes published in 2012, the use of pharmacist medication management, educational interventions, feedback to providers, and patient reminders had a significant effect on systolic blood pressure, diastolic blood pressure, total cholesterol, LDL cholesterol, and body mass index versus standard of care (Santschi et al., 2012).
Similar benefits were seen in a systematic review of hyperlipidemia patients treated by pharmacists, where markers of lipid control were markedly improved (Charrois et al., 2012). In July 2013, the impact of pharmacists, specifically on geriatric care, was assessed in a meta-analysis of 20 studies (Lee et al., 2013). Pharmacist-provided care resulted in significant improvements in hospitalizations, medication adherence, combined therapeutic outcomes (blood pressure, INRs, etc), and combined safety end points (falls, adverse events, and number of unnecessary drugs being used) (Lee et al., 2013).
3.2.3. Evidence-based pharmaceutical care
The concept “evidence-based pharmaceutical care” has been mentioned as a term in 2008 (Gaebelein and Gleason, 2008) and it has been defined in 2009 as ‘‘the responsible provision of evidence-based medication-related care for the purpose of achieving definite outcomes that improve patients’ quality of life” (Aburuz, 2015). EBPC evolves the application of the current best up to date pharmacy research to provide effective pharmaceutical services to patients. Like other health care disciplines, implementation of EBPC mainly involves four sequential steps (Weng et al., 2013): first, framing a clear question based on a clinical problem; second, searching for relevant evidence in the literature; third, critically appraising the validity of contemporary research; and fourth, applying the findings to clinical decision-making.
4. Discussion
From the literature review results it is clear that pharmaceutical care achieves a brilliant and innovative step in improving the pharmacy practice to be more professional and effective health care service. Changing practice from dispensing to care providing system requires major changes in education and training of the pharmacists that should be started early from undergraduate level and continues throughout their carrier.
Commitment and dedication of the pharmacists toward self improvement and professionalism should be enforced and encouraged since this will build up the future of the pharmacy practice.
As any other health care discipline to be effective, pharmaceutical care needs to be evidence-based practice that is systemic, well organized and updated. Being systemic implies input, process and output. This flow will also be subjected to continuous corrections and modifications through feedback step (pharmacists need to measure and monitor their contribution to health care for the ultimate benefit of the patient). In order to ensure standards of practice, pharmacists must be willing to assess their knowledge and audit their practice to determine the effectiveness of their interventions.
Evidence-based pharmaceutical care is a dynamic daily practice that is updated according to new and emerging evidence of high quality research and this represents the feedback loop in this system.
To simplify the concept; pharmaceutical care services can be subdivided into direct services that are provided directly to the patient (ex. patient counseling) and indirect services like any other pharmacy service that eventually will help the patient (ex. therapeutic drug monitoring).
4.1. Example
In the anti-coagulation clinic the pharmacist is in direct contact with the patients who are treated with warfarin. Pharmacists are using written brochures to counsel the patients about the proper use of warfarin but during the routine patient satisfaction survey it had been noticed that some patients still do not understand the basic information regarding warfarin use.
Now we have identified the problem, the root cause analysis would be a good option or we can use the PICO method. The next step is to review the literature to figure out the best evidence based approach to be applied in order to achieve effective and convenient patient counseling. By literature search it was found that there is evidence suggesting that weekly scheduled phone consultations increased awareness regarding warfarin use and this resulted in decreased risk of hospitalization for an adverse event associated with anticoagulation (Ibrahim and Saber-Ayad, 2013). Consequently the pharmacy team decided to apply the weekly phone consultations as warfarin counseling tool in addition to the conventional written (warfarin booklet) educational brochures, and to follow the effect of the new counseling program on the proper usage and understanding of warfarin using patient satisfaction measurement tool. In this example evidence-based approach is used to provide pharmaceutical care to patient on warfarin.
Implementation of EBPC can improve the quality of the pharmaceutical care services and encourage the pharmacists to be involved in the health care systems as both practitionersc107 and researchers. Barriers to the implementation of the use of evidence in clinical decision-making can generally be summarized as problems in identifying, assessing, interpreting, and applying best evidence to practice.
Some potential barriers may hinder the implementation of an evidence base approach; these barriers can be categorized as personal or environmental factors. Personal factors include: Attitude and perception toward EBPC, time (due to a heavy clinical load), basic knowledge, skills in critical appraisal, skills in literature searching, clinical incorporation. Environmental factors are those barriers related to system adopted by the health institution like lack of support and reward, inadequate library and evidence based resources and lack of specialized training courses (Weng et al., 2013).
5. Conclusion
Health care interventions can no longer be based on opinion or individual experience alone. Scientific evidence, built up from good quality research, is used as a guide, and adapted to each individual patient’s circumstances. As a new innovative concept evidence-based pharmaceutical care seems promising practice to improve the quality of the pharmaceutical care. We encourage all health system pharmacists to adapt, disseminate and promote this new concept to improve the pharmacy profession. More focused studies are needed to establish and market this concept as a daily pharmacy practice.
I think this should be done : " A bridge course for connecting Pharm D and MBBS". This shall allow to produce talents and experts who have amalgamated, comprehensive knowledge of all the 3 most important aspects of healthcare which are medicine( for diagnosis of disease), pharmacy( for authentic knowledge of medications for prescription writing) and surgery (of course for operations). This has to definitely improve and enhance quality of patient-care manyfolds . Why we shall always follow USA or western setups of education and service systems? They are good no doubt, as they are rich countries with large budgets for healthcare; but sometimes we must take initiatives and become leaders and provide path-breaking or a new-path setting grounds for others to follow.
Therefore I wrote a mail to secretory of MCI (secretary@mciindia.org), requesting for the same. It goes as follows:
Respected Sir/Madam,
I
am currently pursuing 2nd year of PharmD (Post baccalaureate), which is
a relatively a new curriculum started by PCI since 2008 and which is
clinically oriented pharmacy. Up till now pharmacy in India was industry
oriented i.e. pharmacist was more into manufacturing,sales,research of
discovery of novel molecules and invention of formulations etc.But now
with the advent of PharmD, it has become clinically oriented i.e. now a
pharmacist is given an opportunity, allowed and equipped to play a role
in direct patient care, giving pharmaceutical care. Madam, PharmD
syllabus framed by PCI contains many pharmacy related subjects along
with the subjects which are present in common in both MBBS and PharmD
curriculum, i.e. subjects like anatomy and physiology (a lot lesser of
it is there in PharmD), Pathophysiology, Biochemistry, Microbiology,
Pharmacology, Biopharmaceutics (a lot more of
it is there in PharmD). Madam, I have a great respect for MBBS course
and for physicians and surgeons. And I am currently 29 year old man.
This is to ask you whether its feasible/ possible that a new
course/curriculum may be framed and started by MCI within two to three
years, which can bridge this gap between PharmD and MBBS.That is, a
bridge-course(of 3years duration) which shall allow a PharmD graduate to
be certified as MBBS,upon successfully completion of such a course.
This may bring a new input, perspective and vision in patient care,
to MBBS/physician as well as provide an opportunity, encourage, help fulfil
dreams and strong aspirations of human beings like me, who wish to
study such a curriculum, get a medical license, be a physician and
earnestly want to play that very role in the healthcare system, at this
stage and age of our lives. May all this come into effect for the
2014-2015 session.
Hoping for an encouraging, enlightening and positive reply on this request from you.
Yours truly,
Samrat Paul
Pharmacist A HealthCare professional? If so why pharmacy course is not?.
Has the Pharmacy education been got included in National Health Education Manual?
The BCS characterizes drugs into four classes according to their US FDA solubility and permeability as depicted in Figure 1. In 2000, the US FDA promulgated the BCS system as a science‐based approach to allow waiver of in vivo bioavailability and bioequivalence testing of immediate‐release solid oral dosage forms for Class 1 high solubility, high‐permeability drugs when such drug products also exhibited rapid dissolution.1 This waiver is based on a triple‐tier rationale where: (a) high solubility insures that drug solubility will not limit dissolution, and thus absorption, (b) high permeability insures that drug is completely absorbed during the limited transit time through the small intestine, and (c) rapid dissolution insures that the gastric emptying process is the rate‐limiting step for absorption of highly soluble and highly permeable drugs.5 Drug sponsors are allowed to use mass balance, absolute bioavailability, or human intestinal perfusion studies to demonstrate high permeability.1 The US FDA Guidance, however, also recommends possible methods not involving human subjects including in vivo or in situ intestinal perfusion in a suitable animal model, and/or in vitro permeability methods using excised intestinal tissues or monolayers of suitable epithelial cells,1,5 usually the Caco‐2 cell system. However, some studies have shown that in vitro cellular permeability criteria recognized in the US FDA's BCS guidance may not always correctly predict the extent of drug absorption in humans.6-8
The Biopharmaceutics Classification System (BCS) as defined by the US FDA1 after Amidon et al.2
In 2010, the European Medicines Agency (EMA) revised its bioequivalence guideline stating that demonstration of complete absorption in humans is preferred for biowaiver of BCS Class 1 drug applications rather than measures of high permeability.9 The criterion for complete absorption in the EMA Guideline is ≥85% measured extent of absorption in humans based either on absolute bioavailability or mass balance studies.9
The correlation between intestinal permeability rate and the extent of absorption in humans came from the results of in vivo studies with 34 drugs and endogenous substances, where a good correlation was observed between jejunal permeability from human intestinal perfusion studies and the fraction of the oral dose absorbed in humans.10 However, in these early human intestinal perfusion studies, no drugs were investigated that subsequently showed a discordance between cellular system permeability rates and the extent of absorption in humans. It is now generally recognized by the US FDA, the EMA, and the research scientists in the field that high cellular permeability rates do correctly predict a high extent of absorption.5 Discordance is essentially only found for some nonmetabolized drugs exhibiting low cellular permeability rates but complete absorption.5
The role of BCS in drug development is facilitating the possibility of obtaining a waiver of in vivo bioequivalence studies for drug products, where the regulatory agencies recognize the drug as BCS Class 1 and where the dissolution rate of the new drug product meets the rapid dissolution criteria of the regulatory agencies. This is definitely a simplifying and cost saving procedure in drug development. However, there is no predictive benefit to BCS. Studies in humans must be carried out to show that the drug achieves complete absorption (≥90% for US FDA and ≥85% for EMA, although the US FDA has indicated informally that ≥85% may be appropriate for a biowaiver). Yet, as stated above, cellular studies exhibiting high‐permeability rates can give sponsors confidence that a high‐solubility compound will meet the extent of absorption criteria of the regulatory agencies before obtaining actual extent of absorption measures in humans. Since the promulgation of the US FDA BCS Guidance in 2000, a number of new possible class boundaries have been proposed for additional biowaivers. For example, the EMA will grant biowaivers for BCS Class 3 drugs with high solubility but limited absorption.9 In addition, a World Health Organization (WHO) Technical Report11 suggests that biowaivers may be appropriate for so‐called BCS Class 2a drugs, weak acids that exhibit low solubility only at low pH. The WHO recommended criteria for such drug products would be rapid dissolution at pH 6.8 and a similar dissolution profile to the innovator product at pH 1.2, 4.5, and 6.8. Like the EMA, the WHO Technical Report also recommends biowaiver eligibility for Class 3 very rapidly dissolving drug products that contain no inactive ingredients that are known to alter GI motility and/or absorption.11However, at this time only BCS Class 1 drugs are eligible for a biowaiver of in vivobioequivalence from the US FDA1 and BCS Class 1 as well as some Class 3 drugs by the EMA.9
BDDCS
As described above, the purpose of BDDCS is to predict drug disposition and potential drug–drug interactions in the intestine and the liver with an emphasis on defining which drugs would be amenable to enzymatic‐only and transporter‐only disposition and drug–drug interactions, as well as where transporter–enzyme interplay may be important. Recent reviews from the Benet Lab12-14 have defined these enzymatic, transporter, and transporter‐interplay characteristics with potential transporter effects following oral dosing as depicted in Figure 2. The recognition of the correlation between BCS intestinal permeability and BDDCS extent of metabolism by Wu and Benet3 preceded an explanation for these findings. We hypothesize now that high‐permeability‐rate compounds are readily reabsorbed from the kidney lumen and from the bile, facilitating multiple accesses to the metabolic enzymes. For example, consider the BCS/BDDCS Class 1 drug letrozole. This completely oral available drug is primarily eliminated by metabolism via CYP3A4 and CYP2A6 enzymatic processes with less than 4% of the dose excreted unchanged in the urine. However, letrozole is only 60% bound to plasma proteins and thus it might be expected, based on glomerular filtration rate and fraction unbound, that renal clearance could approach 48 mL/mL. Yet the total clearance for letrozole is only 40.5 mL/min with less than 4% excreted unchanged. Thus, this high‐permeability compound is reabsorbed in the kidney tubules (and possibly from the bile) with the major route of elimination being metabolic processes. The rationale for the correlation between intestinal permeability rate and the extent of metabolism appears to be based on the fact that high‐permeability‐rate compounds are reabsorbed from potential unchanged drug excretion routes in the body and thus can only be eliminated through metabolism. This hypothesis then led us to conclude that the measure of high‐permeability rate in making the BDDCS assignment need not necessarily be a human biological membrane or membrane surrogate, but that passive permeability in any appropriate membrane model may provide the correct assignment. This topic will be discussed further below.
Transporter effects predicted by BDDCS following oral dosing.12
THE USE OF BDDCS FOR DRUGS ALREADY ON THE MARKET
Table 2 lists six potential uses of BDDCS in characterizing drugs that have already reached the market. The text below provides greater detail for each of these six potential uses.
Table 2. The Use of BDDCS for Drugs on the Market
Predict potential drug–drug interactions not tested in the drug approval process.
Predict the potential relevance of transporter–enzyme interplay.
Assist the prediction of when and when not transporter and/or enzyme pharmacogenetic variants may be clinically relevant.
Predict when transporter inhibition by uremic toxins may change hepatic elimination.
Predict the brain disposition.
Increase the eligibility of drugs for BCS Class 1 biowaivers using measures of metabolism.
For drugs already in the market, BDDCS provides potential predictability of drug–drug interactions that had not been anticipated or tested in the drug approval process. For example, our laboratory recognized that atorvastatin was a BDDCS Class 2 drug exhibiting extensive metabolism and poor solubility. Thus, as shown in Figure 2, we recognized that atorvastatin may potentially exhibit a drug–drug interaction with inhibitors of hepatic uptake transporters. We first demonstrated in cellular and isolated perfused rat liver studies15 that atorvastatin, as well as its two active hydroxylated metabolites, were substrates for human and rat organic anion transporting polypeptides (OATPs) and that inhibition of OATP uptake would decrease atorvastatin metabolism. We then carried out whole animal studies in rats to confirm this finding in intact animals.16 We then demonstrated in healthy volunteers that a single intravenous (i.v.) dose of rifampin, a potent OATP inhibitor would significantly increase the total area under the curve (AUC) of atorvastatin acid by 6.8 ± 2.4‐fold and that of 2‐hydroxy‐atorvastatin acid and 4‐hydroxy‐atorvastatin acid by 6.8 ± 2.5‐fold and 3.9 ± 2.4‐fold, respectively.17 Of course, once recognizing that atorvastatin and its active metabolites are substrates for OATP1B1, then it would logically follow that genetic variants in this transporter would affect atorvastatin pharmacokinetics, as has been demonstrated.18 Thus, BDDCS is also useful in predicting where pharmacogenetic variants can yield meaningful drug disposition changes.
In a further study, we demonstrated that inhibiting the hepatic uptake transporter for glyburide would also significantly increase its AUC and that blood glucose levels were lower than those observed after dosing with glyburide alone.19 Glyburide is primarily a substrate of OATP1B3, which does not exhibit significant changes in activity with genetic variants, and therefore, one would suspect that a pharmacogenetic study of the transporter would not yield significant changes. However, glyburide is a substrate for CYP2C9, with known disposition changes for the genetic variants of this enzyme.
It is important to recognize that the BDDCS characterization of transporter effects and transporter enzyme interplay as depicted in Figure 2 does not predict that every drug in each class will display the effects listed. Rather, BDDCS predicts what transporter effects may occur, and which may not, and what should be tested. As an example, the Class 2 drug felodipine is a CYP3A substrate, but not a substrate for P‐glycoprotein (P‐gp), and we used it as our control in examining Class 2 drug efflux transporter–enzyme interplay.20Furthermore, one cannot be sure that a cellular transporter–enzyme interaction will translate into an in vivo clinically relevant interaction, even when the in vitro Ki values suggest that the interaction needs to be tested. As an example, numerous publications concerning the pharmacogenomics of warfarin have shown that accounting for the genetic variants of CYP2C9 and VKORC1 plus other patient parameters can only explain about 55% of the variability observed for this drug in patient populations.21 Because warfarin is a Class 2 drug, we asked could it be a substrate for an uptake transporter, and if so might knowledge of this transporter genotype increase the predictability? Rat and human hepatocyte studies22 showed that warfarin appeared to be a substrate for OATP uptake that could be inhibited by rifampin, which might account for an approximately 30% change in AUC. The in vitro interaction was of the same magnitude as what we had observed in vitro for glyburide. We then carried out a human study22 that showed that there was no significant increase in warfarin blood concentrations in the presence of the OATP inhibitor rifampin.
Recently, the US FDA has recommended that studies in renal failure patients be carried out even for drugs where renal elimination of unchanged drug is minimal.23 This recommendation comes about in part based on a finding that was related to the development and characterization of BDDCS. Previous studies of changes in drug metabolism in renal failure patients for drugs primarily eliminated by hepatic metabolism were thought to be related to the effects of uremic toxins as either potential inhibitors or down regulators of metabolic enzymes. However, this could be tested in vitro and was shown not to occur in many cases. We began to recognize that previously unexplained effects of renal disease on hepatic metabolism can result from accumulation of substances (toxins) in renal failure that modify hepatic uptake and efflux transporters,24-26 and that this mechanism could explain why BDDCS Class 2 drugs could demonstrate changes in metabolism in renal failure, whereas this would not be observed for BDDCS Class 1 drugs when in vitro uremic toxins did not alter microsomal metabolism.
To demonstrate the relevance of the potential effect of uremic toxins in patients, we compared the pharmacokinetics of oral and i.v. erythromycin in patients with end stage renal disease versus healthy volunteers.27 Erythromycin is a BDDCS Class 3 drug that is primarily eliminated unchanged in the bile. It is a substrate for hepatic uptake transporters that we had previously shown can be inhibited by uremic toxins.25 We demonstrated that the hepatic clearance of erythromycin in end stage renal disease patients was decreased by 31% (p = 0.01) and that bioavailability was increased 36%. Because we had given the drug both i.v. and orally, we calculated that there was no change in the fraction of the oral dose absorbed multiplied by the potential gut availability (Fabs·Fg). This would be expected even though erythromycin, a Class 3 BDDCS drug is a substrate for an intestinal uptake transporter, as it is not possible for the uremic toxins to be present in the intestine. Thus, the BDDCS allows investigators to predict the potential effect of uremia on hepatic metabolism and biliary excretion.
To facilitate use of the BDDCS system for making predictions for drugs on the market, we recently compiled the BDDCS classification for 927 drugs, which include 30 active metabolites.28 Of the 897 parent drugs, 707 (78.8%) drugs are administered orally. Where the lowest measured solubility was found in the literature, this value was reported for 72.7% (513) of these orally administered drugs. Measured values are reported for the percentage excreted unchanged in the urine, log P and log D 7.4, when available. For all 927 compounds, the in silico parameters for predicted log solubility in water, calculated log P, polar surface area, and the number of hydrogen bond acceptors and hydrogen bond donors for the active moiety are also provided, thereby allowing comparison analyses for both in silico and experimentally measured values. We showed that when comparing the in silico parameters across the four classes, there is a distinct difference between Class 2 and Class 3 compounds. However, surprisingly the log P and solubility in silico parameters for the Class 1 drugs appear to be intermediate between those for Class 2 and Class 3 and not very different than the parameters for the Class 4 drugs. We note this failure of in silicoparameters to efficiently predict whether a drug will be Class 1, believed by many to be the most desirable because of high solubility and high permeability, versus Class 4 drugs that are low solubility and low permeability.
Most recently, we have shown that the prediction of brain disposition of orally administered drugs may be improved using BDDCS.29 It is generally believed that high log P, high permeability, and lack of P‐gp efflux are desirable characteristics for central nervous system (CNS) drug candidates to become marketed CNS drugs.30-32 From the literature, we were able to identify 153 marketed drugs that met three criteria: (a) central or lack of central pharmacodynamics effects were known, (b) the BDDCS class was identified, and (c) information was available as to whether the drug was or was not a substrate for P‐gp. About 98% of BDDCS Class 1 drugs were found to be markedly distributed throughout the brain; this includes 17 BDDCS Class 1 drugs known to be P‐gp substrates. Thus, we expand upon the transporter effects listed in Figure 2 for Class 1 drugs. We now believe that transporter effects are minimal, and clinically insignificant, for Class 1 drugs in the gut, liver, and brain, and suspect that this is also true for the kidney. Recognition that BDDCS Class 1 drugs that are P‐gp substrates will still yield central effects allowed us to decrease the number of compounds incorrectly predicted from in silico parameters in terms of disposition from the 19%–23% employing previous methods30,31,33 to less than 10%.29 This finding of a lack of a clinically significant effect of P‐gp on brain disposition of BDDCS Class 1 drugs has marked implications for predicting drug disposition and effects of new molecular entities (NMEs), as will be described in the last section of this report.
Finally, there is also an application to BCS biowaivers inherent in the BDDCS Classification System. Benet et al.34 recognized that for 29 drugs where measured human intestinal permeabilities were available, the extent of metabolism correctly predicted high versus low permeability for 27 of 29 (or 93%) of the measured human intestinal permeabilities in terms of BCS. Thus, Benet and coworkers recommended that regulatory agencies add the extent of drug metabolism (i.e., ≥90% metabolized for US FDA and ≥85% metabolized for EMA) as an alternate method for determining the extent of drug absorption in defining Class 1 drugs suitable for a waiver of in vivo studies of bioequivalence. The authors propose that the following criteria be used to define the ≥90% metabolized for US FDA marketed drugs: “Following a single oral dose to humans, administered at the highest dose strength, mass balance of Phase I oxidative and Phase II conjugative drug metabolites in the urine and feces measured as either unlabeled, radioactive‐labeled or nonradioactive‐labeled substances, account for ≥90% of the drug dose. This is the strictest definition for a waiver based on metabolism. For an orally administered drug to be ≥90% metabolized by Phase I oxidative and Phase II conjugative process, it is obvious that the drug must be absorbed.” In their 2010 revised bioequivalence guidance,9 EMA incorporated this recommendation. US FDA scientists have also supported this recommendation,5 although no formal written guidance change has been issued.
THE ROLE OF BDDCS IN THE DRUG DEVELOPMENT OF NMEs
Although BDDCS can be used for characterizing disposition of drugs already on the market, as detailed in Table 2 and in the text above, the goal of BDDCS was to predict and characterize drug disposition for NMEs.3 Table 3 lists those uses and the text below is a prescription for utilizing BDDCS with NMEs.
Table 3. Additional Uses of BDDCS for New Molecular Entities and its Role in Drug Development
Predict the major route of elimination of an NME in humans (metabolism vs. excretion of unchanged drug in the urine and bile).
Predict the relevance of transporters and transporter–enzyme interplay in drug disposition as detailed in Figure 2 and Table 2.
Predict central or lack of central effects.
Predict the effects of high‐fat meals on the extent of bioavailability.
For an NME, it would be most useful to predict its BDDCS class before any studies in humans, animals, or even cellular systems. The recognition of the correlation between intestinal permeability rate and extent of metabolism allows prediction of BDDCS class for an NME to be based on passive membrane permeability.35 Initially, we proposed to follow the BCS permeability rate measure in the Caco‐2 cellular system using metoprolol, but now more preferably labetalol, as the cutoff between high and low permeability compounds. However, because we now believe that it is the passive permeability that is the predictive parameter, we suggest that even studies with an artificial membrane such as parallel artificial membrane permeability assay (PAMPA) will provide a reasonable prediction of BDDCS Class 1 and Class 2 versus BDDCS Class 3 and Class 4 using labetalol as the cutoff marker. We evaluated35 the permeability results for 21 drugs studied by three different PAMPA models (a lipid/oil/lipid trilayer, a biomimetic, and a hydrophilic filter membrane PAMPA assay). For these 21 drugs, the human extent of absorption and metabolism was known. In this evaluation, the extent of absorption or metabolism was defined as being low or high if it was less than 30% or ≥90%, respectively. Permeability was defined as being low or high if it was less than 2.0 or ≥3.5 × 10−6 cm/s, respectively, based on a marked differentiation using these cutoffs for 19 of the 21 drugs. The high PAMPA permeability for all three models accurately predicted BCS ≥90% absorption very well and only slightly less accurately BDDCS metabolism. However, for low PAMPA permeability, although the system very accurately predicted poor BDDCS metabolism, the systems only correctly predicted absorption 25% of the time. On the basis of these data, we suggest that passive transcellular drug permeability in an artificial membrane may reasonably predict extensive versus poor human metabolism.35 Note that we are not suggesting that the permeability rate cutoffs listed above are numbers that may be translated to other laboratories. They are just the values from our in vitro permeability rate analyses used to attempt to differentiate the 21 drugs for which human in vivo permeability rate measures and extent of metabolism have been reported.
Although we believe it is quite easy, and using high‐throughput methods, to predict with good accuracy Class 1 and Class 2 versus Class 3 and Class 4 assignment of an NME, it is not easy to differentiate high solubility from low solubility. The major impediment is that the BDDCS (and BCS) solubility criterion is based on the highest marketed dose strength. Of course, for an NME such knowledge may be years away from the compounds initial evaluation. Therefore, we propose following the recommendation of Pfizer scientists36 to use a solubility cutoff of 200 ฮผg/mL (i.e., 50 mg highest dose strength) in the initial evaluation. Thus, compounds with a lowest solubility over the pH range 1–7.5 being greater than 200 ฮผg/mL would be assigned Class 1 or Class 3 and those with a lowest solubility less than 200 ฮผg/mL would be assigned Classes 2 and 4. As we have noted previously,28in silicopredictions of solubility are not very reliable and thus we also recommend following the Pfizer protocol36 of utilizing a high‐throughput equilibrium solubility assay for NMEs in simulated gastric fluid at pH 1.2 and in 50 mM phosphate buffer pH 6.5, for the initial assignment. Thus, very early in the drug development of an NME, using only in vitro methods to assign BDDCS class, sponsors will be able to predict the major route of elimination of an NME in humans (metabolism versus excretion of unchanged drug in the urine and bile) and predict the relevance of transporters and transporter–enzyme interplay in drug disposition. If an NME is BDDCS Classes 1 or 2, the drug should exhibit good absorption, but not necessarily good bioavailability. In contrast, if the NME is BDDCS Classes 3 or 4, then good absorption will only be achieved if the NME is a substrate for an intestinal uptake transporter or possibly small enough to pass through intestinal pores.
There is a marked difference in the BDDCS class distribution of drugs on the market as opposed to NMEs. We previously estimated the distribution for NMEs based on all recently synthesized medicinal compounds. In Figure 3, we depict the distribution of oral immediate‐release drugs on the market versus small molecule NMEs, the latter percentages determined from a data set of Professor Oprea37 encompassing 28,912 medicinal chemistry compounds tested for at least one target and having affinities of micromolar or less concentrations. Although 40% of oral immediate‐release marketed drugs are Class 1, only 18% of NMEs fall in this category. This difference is primarily related to Class 2 drugs, where 33% of marketed oral immediate‐release products are found versus 54% of NMEs. As can be seen in Figure 3, quite similar numbers between marketed drugs and NMEs are found for Classes 3 and 4. That is, in essence, NMEs are becoming larger, more lipophilic and less soluble, with time in the drug discovery paradigm.
Distribution of 698 oral immediate‐release drugs on the market28 and NME percentages from a data set of 28,912 medicinal chemistry compounds tested for at least one target and having affinities at micromolar or less concentrations37using BDDCS criteria.
Early characterization of the BDDCS class of an NME offers information related to all those characteristics listed in Table 2 for drugs on the market. Of particular relevance, early in drug development, may be the information related to potential brain distribution as described in our recent publication.29 That is, if central effects for an NME are not desired, then a BDDCS Class 2 compound that is a substrate for brain efflux transporters would be preferable to a highly soluble BDDCS Class 1 NME. On the contrary, sponsors should recognize that if the NME was, in fact, BDDCS Class 1, then brain distribution and potential central off‐target effects cannot be avoided even if the compound is shown to be a substrate for brain efflux transporters.
BDDCS classification may also allow predictions regarding food effects for orally dosed drugs. The AUC and bioavailability of many drugs are greatly affected by concomitant food intake and the US FDA recommends that high‐fat meals (800–1000 cal; 50%–65% from fat, 25%–30% from carbohydrates, 15%–20% from protein) may be used in food effect studies in humans.38 Many factors are believed to contribute to these food effects, including changes in gastric emptying time, bile flow, pH of the intestine, splanchnic blood flow, and gut wall metabolism. A variety of evidence exists supporting food effects on transporters as well, as described by Custodio et al.39 In general, high‐fat meals have no effect on the extent of absorption of BDDCS Class 1 drugs, increase AUC for BDDCS Class 2 drugs, decrease AUC for BDDCS Class 3 drugs, with insufficient data to show a general trend for Class 4 drugs. However, the multiplicity of factors affecting absorption in the presence of food make it more difficult to have a uniform response, and I estimate that the accuracy of the food effect predictions above is only approximately 70%.
It is now been 17 years since Amidon et al.2 published the theoretical basis for the BCS. According to Thompson Reuters (formerly ISI) Web of Knowledge, this paper has now been referenced more than 1350 times and is the most highly cited paper in the pharmaceutical sciences. The impact of this paper has been substantial leading to an US FDA guidance1 and as befits the high citation rate, the paper has led to many other discoveries in the pharmaceutical sciences. Today, all new drugs approved by the US FDA and the EMA contain information related to the BCS classification of the molecule and its drug product. Although the purpose of BCS is to characterize drugs for which products of those drugs may be eligible for a biowaiver of in vivo bioequivalence studies, there is no inherent predictability of this characteristic, as the categorization is based on experimental results. This simple categorization of drugs into four classes has spawned many further approaches in drug product analysis. BDDCS is one of those derivative approaches. Wu and Benet3 recognized that the great majority of BCS Class 1 and Class 2 drugs were eliminated in humans predominantly by metabolic processes, whereas the great majority of BCS Class 3 and Class 4 drugs were predominantly eliminated unchanged either in the urine or bile. In 7 years since the BDDCS publication,3 it has also received a significant citation history, now over 350. BDDCS was developed with the purpose of predicting drug disposition and drug–drug interactions, both for drugs on the market and NMEs. Very recently, Professor Amidon has characterized the 2005 BDDCS paper3 as advancing and conceptualizing “a new era of molecular ADME.”40 He has very graciously written, “I believe this 2005 BDDCS paper is a seminal concept in development in the field of molecular ADME of drugs and will have a profound impact on drug discovery and development in the 21st century, and eventually human health and quality of life.”40 I certainly hope that he is correct and in this commentary have attempted to lay out the significant role that BCS has played in drug development and the potential for the role that BDDCS may play.
Importantly, the system was designed around
oral drug delivery since the majority of drugs are, and remain,
orally dosed. Waivers, permission to skip in vivo bioequivalence
studies, are reserved for drug products that meet certain
requirements around solubility and permeability and that are
also rapidly dissolving.
More and more however, the industry is using the BCS as a tool
in drug product development. As a simple example, BCS can
be used to flag drugs that should not be tested clinically unless
appropriate formulation strategies are employed (Figure 1). A
BCS Class II compound for instance, permeable but relatively
insoluble, would likely not be a good clinical candidate without
the use of enhanced formulation techniques aimed at increasing
solubility or rate of dissolution. This sort of data-informed formulation
approach is a distinguishing feature of Particle Sciences
and other leading groups. Various schemes exist that attempt to
funnel a given API towards particular drug delivery techniques
depending on, among other things, the API’s BCS category.
Still, most approaches remain fragmented in their methodology,
ignoring commercially and biologically important factors.
The BCS can however, when integrated with other information
provide a tremendous tool for efficient drug development. One
school of thought, very much endorsed by Particle Sciences, is
that first in human (FIH) drug dosage forms should be designed
to maximize bioavailability and that the FIH dosage form should
be a logical step towards commercialization and not simply a
stop gap to facilitate data acquisition. This makes sense both
economically and ethically.
For BCS Class I molecules, FIH formulations are
straightforward and may consist of essentially the neat API.
However, for other compounds, effective dosage forms present
greater challenges. Although designed originally to classify
APIs as to their oral bioavailability, properly augmented, the
BCS can be used as a key component of an algorithm to guide
drug delivery system design for any route of administration.
This notion has been elaborated on by a number of authors .
The Biopharmaceutical Classification System
Briefly, the BCS places a given API in one of four categories
depending on its solubility and permeability as they pertain
to oral dosing (Figure 1). A drug substance is considered
“highly soluble” when the highest clinical dose strength is
soluble in 250 mL or less of aqueous media over a pH range of
1–7.5 at 37 °C. A drug substance is considered to be “highly
permeable” when the extent of the absorption (parent drug
plus metabolites) in humans is determined to be ≥90% of an
administered dose based on a mass balance determination or
in comparison to an intravenous reference dose . Permeability
can be determined a number of ways but is most often done
using Caco-2 cell lines, an assay that lends itself to high
throughput automation. In this system, a monolayer of cells is
grown and drug permeation from the drug donor (apical side)
to the acceptor (basolateral side) compartments is assessed,
usually by using a direct UV or LC-MS assay. Potential issues
with Caco-2 based systems range from variation (from in
vivo) in transport mechanisms to drug interactions with the
apparatus itself. Commercial companies focused on this
assay have developed multiple approaches to alleviate these
issues but a review is beyond the scope of this paper and the
reader is encouraged to contact the various suppliers. As a
drug candidate moves up the development ladder, developers
will often confirm and refine their BCS assessments with
increasingly complex in vivo models.
An important subtlety here is that the BCS accounts for
potency in that solubility and permeability are relative to
clinical dose. Again, oral dosing is assumed in the testing
design. So, for example, a compound that has poor absolute
solubility might paradoxically be classified as “highly soluble” if
it were a highly potent compound and the whole clinical dose
was soluble in 250 mL.
BCS and Dosage Form Trends
It is commonly recognized that most new drugs present
formulation challenges. In fact, older drugs as compared
to newer ones have higher solubilities in general. One
reference noted that BCS Class II compounds as a percentage
of compounds under development had increased from 30%
to 60%. BCS Class I compounds have fallen correspondingly
from 40% to 20% over that same period . In practice, low
solubility is the most common theme encountered. In our own
experience the majority of compounds formulated at Particle
Sciences on the behalf of our clients have low to no aqueous
solubility (Figure 2). It should be noted that not every drug
is classified the same by each investigator. The variability can
be due to a number of things including the way permeability
is measured. As above, in vivo permeability is impacted by,
among other things, drug transporters. Both uptake and efflux
transporters exist and can contribute to the differences seen by
the various techniques.
.
For the majority of APIs a solid oral dosage form (SOD) is
the preferred option. Sometimes the physicochemical and physiologic mechanisms do not allow this and alternatives are
pursued such as suspensions or oral solutions. Other times,
the target and other factors dictate that a non-oral dosage
form is most sensible. Examples include the local delivery of
female hormones (i.e., gels and dissolving film strips), nasal
allergy preparations (i.e., nasal aerosols or dry powders), ocular
therapeutics (i.e., implants) and combination products (i.e.,
intravaginal rings, intrauterine devices, and stents) aimed at
prolonged drug release. In all these cases, even though not
orally dosed, the concepts inherent in the BCS can be important
tools in dosage form design. Particle Sciences offers these and
more delivery options.
Formulation Approach
Having a predefined system in which one can make decisions
based on data is necessary for efficient drug development.
Inputs into such a system include, in addition to BCS class, a
detailed solubility profile, polymorph status, desired dosage
form, target dose and dosing regimen, drug stability, excipient
compatibility and knowledge of transporter and metabolic
pathways. Non-technical factors that, as a practical matter, need
to be considered are such things as cost, intellectual property
and distribution chain limitations. Integration of these into a
methodical systematic approach will maximize the chances of
a successful outcome. As R&D dollars become ever scarcer,
it becomes increasingly evident that early consideration of as
many factors as possible is the most efficient way to proceed.
This is true independent of the route of administration. In
practice, this leads to the strategy of getting to FIH as quickly
as possible with a formulation strategy that accounts for both
physicochemical properties and physiologic influences.
A complete set of algorithms covering the four classes and all
possible dosage forms is well beyond the scope of this article.
However, a few fundamental principles can be covered. First,
it is critical to characterize your compound. Understanding the
basic behavior of a given compound in various solvents and
across a range of pHs is fundamental to designing a dosage
form. For instance, a compound soluble only at lower pHs
will require a different formulation than one freely soluble
at, for example, pH 7. Likewise, a soluble but impermeable
compound will require yet another strategy. Very importantly,
this is true whether one is administering the drug, for example,
IV or orally. The implications to formulation are different for
the different routes of administration but the fact that these
properties need to be accounted for is universal. It is important
that the drug developer or the CRO be equipped with a range
of technologies to address the various patterns that emerge.
Nothing wastes more time and money than trying to fit a drug
to a specific preordained delivery technology.
Armed with the proper set of tools one can rapidly narrow
down the potential approaches. For the most part, all drug
delivery strategies are trying to control drug exposure.
Most often, one is trying to maximize it over time and/or
concentration but frequently goals also include extended
release and/or site specific delivery. In addition to the delivery goals, other functions are often required such as API
stabilization or taste masking as two examples. In short, no one
formulation approach will ever satisfy all or even a substantial
portion of drug delivery demands.
For oral drug delivery, a simplified summary of approaches
based on properties might look like Table 1. Each approach
must then be tailored to meet the other demands of that
particular API and desired product profile.
If formulation conditions dictate that a non-oral dosage
form be used, similar charts exist for virtually all routes of
administration. Each route of administration will of course have
different options but they are all ruled by the interplay of the
drug’s physicochemical properties and the local and systemic
physiology they encounter.
Concluding Remarks
Independent of the final dosage form, ideal drug development
involves an iterative process of setting goals, performing
formulation work and developmental stage appropriate testing.
Early on, for example, after physicochemical evaluations are
complete, screening BCS testing and early polymorph screens
might be performed. After thorough preformulation including
solubility and stability testing, early formulations might again
be screened for their impact on dissolution or bioavailability.
This approach is repeated such that at each inflection point
data is gathered to support the development plan. In this way,
FIH is achieved most efficiently and in such a way as to insure
clinically relevant data is obtained.
1 Chi-Yuan Wu and Leslie Z. Benet, Predicting Drug Disposition via
Application of BCS: Transport/Absorption/Elimination Interplay and
Development of a Biopharmaceutics Drug Disposition Classification System,
Pharmaceutical Research, January 2005, 22(1), 11-23.
2 http://www.fda.gov/AboutFDA/CentersOffices/cder/ucm128219.htm
3 M. Sherry Ku, Use of the Biopharmaceutical Classification System in Early
Drug Development, AAPS J., March 2008, 10(1), 208–212
