Disposal practices for expired medicines

Irrespective of whether expired medicines have desired potency or not, they are toxic or not, it is legally and ethically not favourable to use them in clinical practice. But very often reports are on the contrary. The expired medicines get recycled with a new label showing fresh manufacturing and expiry date. The alleged kingpin, mastermind of a business of supply of expired medicines with a fresh label in Tamil Nadu, seems to have made an estimated Rs 100 crore in just 17 years of operation. Chennai police reported having seized expired drugs worth Rs 5.5 crore. Such drugs are found to be dumped in various places including Corporation dump yard to avoid police action. This is not an isolated case. While the expired medicines may not cause a serious health hazard to the public or to the environment, their improper disposal could be serious. Pilfering from a stockpile of waste drugs may result in expired drugs being diverted to the market for resale and misuse as incident described above. Expired medicines may come into the hands of scavengers and children if a landfill is insecure. Some of the issues relating to the inappropriate disposal of expired medicines are: ● Possibility of contaminating drinking water source or supply from the disposal place the leachate may get access to the water supply system. ● Disposal of non-biodegradable antibiotics, anti-neoplastics and disinfectants into the sewage system may kill bacteria necessary for treatment of sewage. Flushing of anti-neoplastics into water resource may damage aquatic life or contaminate drinking water. Discharge of large amount of undiluted disinfectants into the sewage system or water resources may too cause similar situation. ● Burning of the expired medicines at low temperature or in open containers results in release of toxic pollutants to the air. Ideally this should be avoided. ● Inefficient and insecure disposal may lead to recycling of the expired medicines. This is true especially when they are disposed in original containers.

Pharma Facts

GIT IMPORTANT POINTs

GI hormones: gastrin, CCK, GIP
-release, stimuli, action Gastrin
-stomach G cells (antrum) of parietal cells
-stimuli: protein, stomach distension, Ach
-action: stomach acid and motility

CCK
-SI parietal cells
-stimuli: FAs, peptides
-action: protein ezymes, gall bladder contractions

GIP
-SI parietal cells
-stimuli: acid
-action: inhibits stomach acid, boosts insulin

Smooth muscle contractile patterns: tonic, peristalsis, segmentation tonic: sustained smooth muscle contraction in sphincters

peristalsis: rapid waves of contraction pushes food to distal end

segmentation: back and forth mixing movement, slows food

Things that promote gastric emptying: -gastric distention
-fluidity of chymes
stimuli: gastrin, vagus nerve

Inhibition of gastric emptying: ENTEROGASTRONES from the SI:
secretin: bicarbonate
CCK: pancreatic enzymes, bile
GIP: decr stomach acid, insulin

Four conditions that influence absorption: permeability: water vs lipid soluble, large vs small, water itself
surface area: villi, micro villi
enterocyte replacement: produced in crypts, migrate up villi
luminal conditions: optimal pH for enzymes

Enzymes in carb digestion: maltase
sucrase
lactase
isomaltase

Enzymes in protein digestion:
stimuli, release, action Pepsin:
-simuli: gastrin, vagus
-stomach chief cels
-action: bd polypeptides

Pancreatic enzymes:
-enteropeptidase in brush border convert trypsin
-trypsin converts itself and chymotrypsin, elastase

Aminopeptidases:
-brush border and intracellular
-cleave single amino acids for di/tripeptides

Water soluble vs fat-soluble vitamins Water soluble:
-Vitamins B, C, folate
-require intrinsic factor from SI parietal cells

Fat-Soluble:
-Vitamins A, D, E, K
-diffuse passively

Gastric acid secretagogues:
(stimulate gastric acid production in the stomach) Acetylcholine
-vagus nerve
-action: gastrin, histamine release

Histamine
-Ach, gastrin stimuli
-from ECL cells (enterochromaffin-like)
-action: bind to H2 receptors on stomach parietal cells, cause H release

Gastrin
-Ach stimuli, gastric distention, protein
-action: histamine release, stomach motility

Mechanisms for mucosal protection Tight junctions: acid cannot penetrate
Mucus: secreted by surface and neck cells
Bicaronate: neutralizes acid
Prostaglandins:
-decreases acid secretion
-cytoprotective
-fluid secretions

Secretions of duct and acinar cells of the pancreas duct:
-exocrine (nerve) secretions
-bicarbonate

acinar:
-CCK: stimuli by FAs, peptides,
-an enterogastrone
-secrete pancreatic enzymes

GERD gastroesophageal reflux disease
-heartburn
-caused by poor tone of LES

Dumping Syndrome -caused by rapid movement of high-osmolarity chyme out of the stomach
-causes fluid secretion, low BP, and diarrhea

Pancreatitis -inflammation of the pancreas
-block pancreatic enzyme secretion, causing maldigestion and malabsorption

Celiac's disease -gluten allergy
-causes decrease in surface area of the upper small intestine by destruction of enterocytes/villi

Chron's disease -caused by inflammation of the lower small intestine (ileum)
-can be caused by malabsorption of bile salts after fat digestion, which enter the colon and cause colonic irritation, fluid secretion, and diarrhea

Pernicious Anemia -caused by lack of intrinsic factor secreted from stomach parietal cels, resulting in malabsorption of vitamin B12
-results in impaired RBC formation, and nerve health

Peptic Ulcers -H.pylori bacteria can survive the acidic environment of the stomach, by producing urease enzymes that create ammonia (basic), protective shell around it
-causes inflammation in the stomach, creating ulcers

Cystic Fibrosis -defect CFTR, preventing Cl transport into the lumen
-less fluid secretion, and more mucus
-blocks pancreatic enzymes secretion, resulting in maldigestion

Pharma Facts

For drugs that require administration
on an empty stomachStop enteral feeding for 1-2 hrs before and after dosing if the tube is placed in the stomach Levothyroxine (Eltroxin),Rifampin (Rimactane)
Phenytoin (Epilog) and carbamazepine (Tegretol),Warfarin (Marevan),Floroquinolones ,Theophylline

Warfarin
Vitamin K directly blocks warfarin’s effects when given in doses of 140
to 500 mcg/day.Foods rich in Vit K : green tea, green vegetables (broccoli, spinach and lettuce), liver, lentils, peas, cauliflowerand cabbage)
Floroquinolones
Bind with divalent cations ( calcium and Magnesium )and should not
be given within 2 hours before or after them.

Drugs may affect GIT absorption of other medications
Sodium bicarbonate caps
May reduce absorption of ketoconazole,digoxin and iron.(space 2 hrs before and after).
Succralfate (Gastrofait)
May reduce absorption of phenytoin,digoxin,tetracyclines ,quinolones ,salicylate ,allopurinol and theophylline .(space 2 hrs).

reduce absorption of levothyroxine (Eltroxin) ,spacing is ineffective so we should use other agent for stress ulcer prophylaxis.
Antacids
(Al containing antacids) ex: Mucogel,Epicogel May reduce absorption of phenytoin,digoxin,tetracyclines ,quinolones ,iron,ACE inhibitors ,acetaminophen, NSAIDs ,allopurinol and theophylline .(space 2 hrs).

reduce absorption of levothyroxine (Eltroxin) ,spacing is ineffective so we should use other agent for stress ulcer prophylaxis.
Calcium containing antacids (Ca carbonate (calcimate))
Ca carbonate reduce assorption of tetracyclines , floroquinolones,phenytoin,iron,ACE inhibitors ,acetaminophen and levothyroxine (space 2 hrs).
sodium polystyrene sulfonate (sorbisteril):
separate dosing from other orally administered medicines by at least 3 hours. That time should be increased to 6 hours for patients with gastroparesis or other conditions resulting in delayed emptying of food from the stomach into the small intestine.
Osmolality
Many commercial liquids have
osmolalities well over 1000
mOsm/kg.. Diarrhea,
cramping, abdominal distention,
and vomiting may occur after
administration of hyperosmolar
products through the feeding
tube.

Aluminium hydroxide (Mucogel) syrup,Acyclovir syrup,Azithromycin (Zithromax) syrup,Carbamazepine (Tegretol) syrup,Dexamethasone syrup,Digoxin syrup,Diphenhydramine (Avil) syrup,Ibuprofen (Brufen) syrup, (Gaptin ) syrup.
Ferrous sulphate syrup.Fluconazole (Diflucan) syrup.Furosemide (Lasix) syrup.
Lactulose syrup.Leviteracetam (Tiratam) syrup.Metochlopramide (Prempran) syrup.
Potassium chloride syrup.Phenytoin (Epilog) syrup.Trimethoprime-sulphamethoxazole (Sutrim) syrup.

These effects may be
reduced by diluting medication
with by ratio1:5 or 1:10 of sterile water
before administration.
Inactive ingredients or excipients
in liquid products may also cause side effects when given enterally.
-Many sweeteners, including sorbitol,mannitol, lactose, saccharin,
and sucrose, may cause or worsen diarrhea in up to 50% of patients.
Syrups have sorbitol:
Tegretol (carbamazepine),Trimethoprime-sulfamethoxazole(sutrim),Ranitidine (Zantac),Valproic acid (Depakine),Domperidone(Motilium)