PHARMA PERSPECTIVES AND INSIGHTS ISSUE 48 2022 www.pharmafocusasia.com Building a Biomedical Diagnostic Research Hub in Asia Pharma Consumables Supply Chain Ensuring resilient and reliable in future EXECUTIVES SPECIAL ISSUE
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Executives Special Issue Pharma perspectives and insights
We took our first steps in 2005 and have, since then, successfully marched towards the launch of 47th issue. In this journey, we came across many changes and tried our best to serve our audience and clients creating the best possible platform increasing their visibility and facilitating outreach to the audience. Starting with a bi-annual publication, we transitioned to quarterly editions and supplemented the print magazine with e-newsletter. We have come a long way with the core objective of delivering the most insightful content covering the latest in the pharma industry.
Ensuring resilient and reliable in future Ben Wylie, Senior Product Manager, ChargePoint Technology
L Shamithra M Sigera, Manchester Fungal Infection Group, Core Technology Facility, Grafton Street, University of Manchester; Department of Mycology, Medical Research Institute
Adrija Hajra, Internal Medicine Physician, currently affiliated with Montefiore Medical Center/Albert Einstein College of Medicine
c. Department of Biochemistry and Chemistry, La Trobe Institute for Molecular Science, La Trobe University
Fausto Artico, Global R&D Tech Head and Director of Innovation and Data Science, GSK
a. College of Medicine and Public Health, Flinders University
Massachusetts College of Pharmacy and Health Sciences University
Elide Zingale, University of Catania
MANUFACTURING
David W Denning, Manchester Fungal Infection Group, Core Technology Facility, Grafton Street, University of Manchester; Global Action for Fungal Infections
Kevin Harrigan, Director of Innovation and Engineering, GSK
Sakshi Piplania,b, David A. Winkler c,d,e*, Nikolai Petrovsky a,b*
Leonardo L G Ferreira, Researcher, São Carlos Institute of Physics (IFSC) - University of São Paulo (USP)
36 Anti-fungal Resistance Magnitude of the problem and impact
Rajendra Talele, Pharmaceutical Professional
Luca Soraci, Geriatrician and a Research Assistant, Laboratory of Pharmacoepidemiology and Biostatistics National Institute for Research and Care of the Elderly (IRCCS INRCA)
How to select the CRO for a clinical trial
25 Role of miRNAs in Neurodegeneration In disease causing mechanisms and tools of biomarker discovery and therapeutics
CLINICAL TRIALS
41 Nanocrystal Technology Applied to the Treatment and Diagnosis of Neurodegenerative Diseases
INFORMATION TECHNOLOGY
EXECUTIVES SPECIAL ISSUE
Bidisha Roy, Department of Biological Sciences, Rutgers University
Maria Elsa Gambuzza, Italian Ministry of Health, Luca Soraci
e. School of Pharmacy, University of Nottingham
23 Building a Biomedical Diagnostic Research Hub in Asia
Josué de Moraes, Professor, Guarulhos University
Angela Bonaccorso, Researcher, Department of Drug and Health Sciences, University of Catania
STRATEGY
Awani, Consultant
47 Recent Advances and Future Prospects of Treatment of Pulmonary Hypertension
50 Learn from your Metrics Using Operational Data to Improve Operations in ManufacturingPharmaceuticalandQCLabsMatteoBernasconi,
54 Ensuring Efficiency in Packaging Process should be a top Priority for Pharma Packaging Companies
56 Current and Future Outlook of Pharmacogenomics in Paediatric Asthmatic MedicationsChristyLim,
Ronny Priefer, Massachusetts College of Pharmacy and Health Sciences University
13 COVID WalkingVaccinesaroundproblems and solutions
16 How to Use Pharmacogenomic Information to Reduce the Risk of Experiencing Adverse EventsGiovanniFurlan, Fellow, International Society of Pharmacovigilance
20 Innovation for the Elimination of Neglected Tropical Diseases
Paul Kippax, Pharmaceutical and Food Sector Director, Malvern Panalytical
64 Which Technologies you Need to Use, and for What, to be Successful with your Teams in Pharma 4.0
d. Monash Institute of Pharmaceutical Sciences, Monash University
Siddharth Shah, Director, Bharat Rubber Works
61 Using Analytical Technology to Guide Generic Drug Development
Maurizio Luongo, CEO, A. Menarini Asia-Pacific Holdings Pte Ltd. (Menarini Asia-Pacific)
06 Pharma Consumables Supply Chain
b. Vaxine Pty Ltd
10 Outsourcing Clinical Trials
44 Pharmacogenomic Evaluation in Lung ADiseasesgrowing need
Research Associate, University of St.Gallen Gian-Andri Steiger, Bernasconi, M., Research Associate, University of St.Gallen Marten Ritz, Post-doctoral Researcher, University of St.Gallen Thomas Friedli, Director, Institute of Technology Management
32 Computational Repurposing of Drugs and Natural Products Against SARS-CoV-2
CONTENTS
Rosario Pignatello, Full Professor, Pharmaceutical Technology and Legislation, University of Catania
RESEARCH & DEVELOPMENT
Adriano D Andricopulo, Full Professor, São Carlos Institute of Physics (IFSC) - University of São Paulo (USP)
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The pharmaceutical industry has undergone considerable upheaval over the last two years due to the COVID19 pandemic, exposing previously unknown vulnerabilities that need to be addressed.
Ensuring resilient and reliable in future
For the pharmaceutical industry, managing supply chain risk has never been a higher priority. This is particularly true when it comes to ensuring a reliable supply of consumables - whether ingredients for drug formulation, materials for device and packaging manufacture, or for single-use technology (SUT) for production lines.
8 PHARMA FOCUS ASIA ISSUE 48 - 2022
STRATEGY
At the height of the first wave of COVID-19 cases in spring 2020, a number of developments caused disruption in the industry. The closure of factories and export restrictions intro duced from countries which produce significant portions of the world’s active pharmaceutical ingredients (APIs) and excipients, caused considerable disrup tion to drug manufacturers across the globe.Inaddition, measures designed to control travel to minimise inter-country transmission, combined with a rapid rise in cases in the global freight sector, posed challenges to companies. They resulted in an interruption of essential transport of ingredients, raw materials, as well as consumable production line equipment across the globe. This led to a significant increase in lead times for the supply of essential consumables that impacted on manufacturing productivity,
How to de-risk the consumables supply chain
The COVID-19 pandemic revealed critical gaps in consumables supply chains and created anxiety as managers scrambled to assure continuity. Learning from the last 24 months is critical if we are to ensure the pharmaceutical supply chain is more resilient and reliable in future.
Understanding the last 24 months
In this article, Ben offers pharma company procurement teams three top tips to finding a trusted consumables supplier to ensure the security and integrity of their supply chain. The author offers advice on questions to ask suppliers, including suppliers of single-use manufacturing equipment, to ensure that they are satisfied that their partners can continue to deliver material when they need it. The author highlights the steps ChargePoint Technology has taken to ensure that they remain a reliable and trusted partner even during these unprecedented times.
In this article Ben Wylie, Snr Product Manager at ChargePoint Technology will explore these issues, providing his view on how risk-based approaches to purchasing/specifying consumables rela tive to product, process and supplier can help de-risk this critical supply chain and help drug programme managers sleep better at night.
Ben Wylie, Senior Product Manager, ChargePoint Technology
Pharma Consumables Supply Chain
While the events of 2020 demonstrated weaknesses across pharmaceutical supply chains, they also showed that some segments are more susceptible than others. One such is the highly potent active pharmaceutical ingre dient (HPAPI) sector, and not simply because of issues sourcing HPAPIs or theirHPAPIs,ingredients.dueto their potent nature, require specialist manufacturing processes and production line equip ment. This is vital to minimise the risk of operating staff being exposed to hazard ous compounds and to prevent crosscontamination between compounds.
Conflicts are also leading to a rise in energy and commodity prices, which may well have a knock-on effect for manufacturing productivity within the pharmaceutical industry, as well as on global supply chains.
Many HPAPI processing lines make use of SUT transfer components, such as single-use Split Butterfly Valves (SBVs) and chargebags, to ensure optimum containment. These offer particular advantages to manufacturers, as they minimise cleaning and wash down requirements, making it possible to minimise contamination risk while enhancing production line efficiency.
The work of SUT manufacturers to mitigate against supply issues during the first wave of COVID-19 offers a number of important lessons for the rest of the industry as it looks to build a more resil ient consumables supply chain capable of handling ongoing uncertainty.
to encourage companies to onshore theirAssupplies.discussed earlier, a heavy reliance on JIT delivery for many commodities also posed an issue when transport networks were disrupted.
Stock up on essentials
With this in mind, it is recommended to take steps to build an inventory of any essential ingredients or consum able equipment, and explore ways of expanding Where companies are supply ing markets overseas, it may be advis able to explore ways of building stocks of finished goods within those markets to ensure they can deliver even when there are international shipping delays.
Diversifying networks
A standard pre-COVID-19 supply chain features a number of weak points that can act as a single point of failure. The industry’s reliance on a single global region for much of its API supply, for example, made it vulner able when factories in that part of the world paused operations due to COVID lockdowns. This is one reason why some national governments have tried
Sterile processing lines are similarly exposed. Manufacturers need to main tain suitable cleanroom environments when processing sterile products, such as parenteral drugs, while also maximising line productivity. To achieve this, many make use of specialist asep tic SBVs and other SUTs due to their combination of optimum aseptic integrity and reduced cleaning and validation requirements.AswithHPAPIs, it is imperative that they are able to source their equipment from reliable suppliers with their own robust supply chains to safeguard
Some sectors more affected than others
It is no surprise then that many companies across the pharmaceutical industry have taken steps to rethink their consumables supply chains. Not just consumables suppliers, but drug devel opers and contract development and manufacturing organisations (CDMOs) are exploring how to de-risk in order to further enhance the reliability and quality of the support they provide their customers in the future.
While there seems to be light at the end of the tunnel with regards to COVID19, the related economic uncertainty continues, with implications for the phar maceutical supply chain. As more coun tries open up, we are seeing demand outstripping supply in the pharmaceuti cal sector and in other industries, lead ing to rising prices and extended lead times on new orders of consumables of all stripes.
against any unforeseen disruption to international trade.
The pandemic showed that to ensure a stable and reliable supply of these single-use components during future economic uncertainty, suppliers and pharmaceutical companies need to have effective contingency plans in place to secure their supply chain.
The steps to enhancing the robust ness of their consumables supply:
As shown by the experience of many SUT manufacturers, having a ready supply of raw materials or essential components can help mitigate the impact of any delays in new deliveries, enabling them to continue manufactur ing and supply customers.
9www.pharmafocusasia.com
leading to delays in the delivery of vital medicines around the world.
Lessons for the future
Identify vulnerabilities
EXECUTIVES SPECIAL ISSUE
Relying on a single company for an essential supply is also a potential liability highlighted during pandemic. If the company fails and ceases opera tions, then that can cause considerable delays.Tobuild
a more resilient supply chain in the future, it is important for compa nies to identify such single points of failure in their own operations, as well as the risk of failure, so they can take steps to address them.
Seeking more than one supplier for essential goods, and working with partners from across the globe can help address the single points of failure identified during the first step. Working with only local partners is not an option for some essential materials or SUTs, as they may not be produced domesti cally. Nor is it always desirable — it is possible a local market may experience supplyCreatingshortages.aglobal network can ensure access to all of the high-qual ity consumables as and when they are
More for information, please visit Product Filtering | Powder Transfer Systems | ChargePoint (thecharge point.com).
resilience further down the supply chain, helping to support the wider pharmaceu tical industry in creating a more robust, secure and certain future.
of suppliers beyond individual compa nies or single regions is an important way of preventing the creation of single points of failure, so they can continue to supply customers.
STRATEGY
A rapid response
needed. Multi- or dual-sourcing can also help to enhance the flexibility of supply, helping businesses to respond more rapidly to issues with individual partners.
It is important to work with partners that have a reputation for reliability and quality. They must be able to offer you a consistent service and deliver the high
Pharma companies don’t need to take responsibility for this preparation entirely on their own shoulders — they should work with suppliers that are doing the same and securing their own networks. Such suppliers create
With these frailties in mind, rapid action has been needed on the part of SUT suppliers to safeguard their customers.
est standard materials and components to help you ensure you can operate consistently.Inaddition, it is important to seek out suppliers that you can be confident will continue to operate for the long term. Exploring suppliers’ financial health before making any agreement can help give you the peace of mind that they can be relied on for the long haul.
Partner with reliable suppliers
Finally, it is crucial to seek out and work with partners that are reliable and have the capacity to support manufacturers in achieving their supply chain security goals.Itis
During the first wave of COVID-19 in particular, many suppliers of SUTs took steps to minimise their exposure to potential points of failure, such as just-in-time (JIT) deliveries. Maintaining adequate levels of essential raw mate rials, and building stocks of finished components within key overseas markets, have been important ways of addressing this issue. It ensured that manufacturers could continue to manufacture their components and deliver them to customers without disruption.
BEN WYLIE is the Senior Product Manager at ChargePoint. He joined ChargePoint in 2005 and is responsible for the day-to-day and strategic management of the product portfolio, including the development of the ChargePoint single-use solutions. Ben has 14 years of experience in Pharma with a focus on marketing and product management of powder processing and containment handling.
Time to shield yourself from economic uncertainty
BIOAUTHOR
advisable to work with consum ables suppliers that have, themselves, taken steps to enhance the robustness of their supply chains, whether through diversification, the introduction of multisourcing or the building up of stock. Asking potential partners about their own supply chains, and about their global operating footprint, can help manufacturers understand whether they will be able to complement and boost their own efforts.
Another step taken by SUT manu facturers has been to try to expand their footprint beyond their core markets, establishing new sites within their customers’ geographies. Given that countries such as the US and India have been incentivising their domestic pharmaceutical sectors to localise or “onshore” their supply chains, establishing local sites can help SUT manufacturers address customers’ concerns about relying on imports.SUTmanufacturers have also begun reconsidering their own supply chains to optimise their resilience, and to support customers in achieving the same goal. Diversifying their network
Dual- or multi-sourcing is also another key measure taken by a grow ing number of SUT and other consum ables manufacturers. Multi-sourcing describes a supply planning system that can intelligently choose between alternate sources of supply. While not without its own complexities and chal lenges, this approach has the potential to allow SUT manufacturers to respond in real time to disruption, enabling them to switch from an affected supplier to one that is able to continue to deliver.
10 PHARMA FOCUS ASIA ISSUE 48 - 2022
While the economic turmoil from COVID19 looks to be settling down in many parts of the world, there are other devel opments that have the potential to pose challenges for the global economy, and for the pharmaceutical industry in 2022 andItbeyond.isimportant for pharmaceutical companies to prepare now to ensure their essential supplies, not just of raw materials, but of SUTs and other key components, are secure and sourced from reliable partners so that they can continue to operate.
Working with suppliers that have a global operating footprint, with sites and operations in multiple countries, can also optimise the robustness of supply chains, as they will be less vulnerable to localised or regional supply challenges.
Clinical Trials are an integral part of drug development and are often outsourced to third parties clinical research organisations (CROs) for execution. The selection of a CRO for a trial is usually based on certain parameters. An experienced CRO can complete the trials smoothly, while a non-experienced CRO may worry the sponsor. All CROs are good but not necessarily all are experienced and capable to handle your specific trial requirements, even your preferred CRO. Any negligence in trial design, planning, or conduct jeopardises the outcome of the trial results. Therefore, the selection of a CRO or an outsourcing partner is critical and challenging. It’s both a science and an art. To master this process, the selector or the team at the sponsor company should define clear objectives and expectations from the clinical trial. These objectives and expectations should be documented, which may be used to evaluate CROs. As such, there is no universal checklist or a gold standard checklist for selecting the CROs, but certainly, there are a few common parameters which can help make the final decision. This article lists the common parameters which can be used as per the requirements of your specific studies, because like every molecule, every study is different. .
Rajendra Talele, Pharmaceutical Professional
12 PHARMA FOCUS ASIA ISSUE 48 - 2022
enough bandwidth to execute the trial. Many times, the sponsors are clear about the objectives and expectations from the trial, and they ask the selected CRO to design a study around those objectives and expectations. However, when the spon sors are not clear on the objectives or the expectations from their clinical trials, they ask the CRO to study and design the trial accordingly. Therefore, in either case, it is important to select an experienced, and eligible CRO to undertake a clinical trial project. This makes the selection of the CRO and the outsourcing of the clinical trial a critical and crucial affair.
cule. Often, clinical trials are outsourced to CROs, may be end-to-end or a part of the study depending on the sponsor’s need. The sponsoring company outsources trials due to two primary reasons:(a)either the sponsor company does not have the required expertise to design, plan and execute a trial, or (b) does not have
The outsourcing of the clinical trial is challenging, and it is a skill. It is a process and not a one-time half an hour event. However, few sponsors think of outsourcing as an event and without a thorough evaluation of the CRO, make their decision in haste. Often such spon sors regret their selection which was based on selective criteria. The selection of the wrong outsourcing partner not only jeopardises the prospect of the molecule but also attracts a lot of trouble shoot ing which demands the sponsor’s time. To avoid such regrets and troubleshoot ing, the sponsor must clearly document the objectives and expectations of the proposed clinical study. This would help in evaluating the CROs and while there are no universal checklists, there are a few parameters and flags to look out for while making the selection. We will discuss these below, but before enlisting
How to select the CRO for a clinical trial
Clinical trials are an integral part of drug development that decide the outcome of the newly developed or the newly formulated medicines. A well designed, planned and executed clinical study can bring success to an average drug molecule too, and a poorly designed or executed study can kill a promising mole
CLINICALOUTSOURCINGTRIALS
CLINICAL TRIALS
EXECUTIVES SPECIAL ISSUE
the criteria, let’s understand ‘outsourcing’. However, before enlisting the criteria for selection of the CRO, let's understand the outsourcing Outsourcingprocess.usually starts when the medical or the outsourcing team is informed about the molecule and/or therapeutic category and the development timelines. Once this information is made available to the respective sponsor, the team studies the molecule, understands earlier data, and does an insightful litera ture search. Once all this data/informa tion is available, the team decides the objectives, expectations and timelines for completion of the clinical phase. In the next step, the team starts searching the list of experienced CROs who can plan and execute the study in the given time frame. This is a general process and not necessarily followed by every company. Some of the smaller sponsor companies or generic companies start by searching for the CROs as soon as they decide on the molecule or the therapeutic area, and expect CROs to study, do the literature search and design the study. While search ing the CROs, the sponsor team usually follows a fixed pattern, such as either:(a) approaching their preferred CROs, or (b) contacting known CROs having worked with them in past, or (c) contacting CROs suggested by a peer group or friends, or (d) Google the experienced CROs for the specific therapeutic area. Through these methods, the team gets the names of CROs, but not necessarily the ’right-fit’.
How doesone select the ‘correct CRO’ for the study?
1. Understanding the objectives/ expectation, service required and the timelines for the study:
The first step before we start searching for a CRO is answering a few questions
However, due to time constraints, teams select the CRO from the list with limited knowledge. Every CRO indeed presents their best capabilities and expertise and promises completion of the study in the given time frame. A very common scenario which might have worked well in past for many of the projects. However, one can not befortunate all the time or necessarily have a well experienced CRO partner. Therefore, to avoid any error in identify ing and selecting a CRO it’s important to follow the well-defined procedure and checklist.
2. Have the list of CROs:
The identification of the list of experi enced CROs and the understanding of the objectives or the expectations for the study can go in parallel. Once the name of the molecule and the therapeutic area are known one can easily start identify ing the experienced CROs using various methodssuch as preferred vendor, refer rals, secondary research or by the help of the search engines or specialised search engines which provide the ’right-fit’ list of CROs as per the requirements of the project. It is important to have a ready list of dependable CROs as it saves time when we are ready with all our understanding of the study of the product.
3. Understanding the service capabilities of identified CROs:
Once the list of the CROs is available, study them using their website or infor mation available in the public domain, without contacting them directly. It is important to evaluate the service capabili ties of the identified CROs and evaluate them based on required services from them. Not all the CROs have all service capabilities to offer, and if the project demands end-to-end services then restrict your focus only to the CROs providing such services, or have multiple CROs with expertise in their respective domain.
After defining objectives, expecta tions, timelines, and understanding
In any development program, the selec tion process of the CRO starts after receiving the name of the molecule, the therapeutic area, and the overall develop ment timelines. The timelines for clinical development are derived based on the overall development timelines. In absence of a universal checklist for the selection of the CROs, one can use the following parameters proposed by the experienced CRO and the sponsor’s personnel. These are general parameters and need to be redefined according to the need of indi vidual project requirements.
13www.pharmafocusasia.com
including: what do we want from our study? and why are we doing this study? There may be different reasons for doing the study: to evaluate the safety and effi cacy both, or only efficacy, promotional study, to find the superiority over the comparator, to find the equivalence with the comparator, etc. Besides answering this, the sponsor needs to identify services that are to be outsourced. It is possible that few of the services required by the project can be done in-house, and/or only a few of those needs expertise from the CRO. Alternatively, could the entire project be outsourced? And lastly, the sponsor needs to define the completion timelines.
CLINICAL
b. Understanding of the required therapeutic area
Investigational sites are the backbone of clinical trials because completion of the trial is largely dependent on the enrolment of the trial subjects and the collection of accurate data. Therefore, CROs having a good database of investi gational sites and good rapport with the Investigators can easily execute the site and complete the study in the given time frame. Hence there should be questions seeking information on investigational sites and the rapport with the investiga tors in the RFP document.
TRIALS
Pricing though may not be or should not be the only deciding factor in the selection of a CRO, but it is important to have a detailed pricing structure from the CRO. It is important to understand where the CRO service charges are visà-vis the market. As every CRO has a different way of presenting the pricing data, but to have a fair comparison between CROs the RFP document should have the questions designed uniformly, so that all CROs can answer with identical understanding.
Ask service providers to provide their detailed service capabilities, including the number of employees, training of the employees, technology software in use, and overall experience. If the project is a planned multi-country project, ask the CRO about its capabilities to manage the study in different countries to understand the geographical coverage and knowledge of the CRO.
Mr Talele is a Post Graduate of Pharmacy (M. Pharm) and MBA from the University of Pune, has also completed the Sr. Management 3TP MBA program at IIM-Ahmedabad.
the capabilities of the identified CROs, prepare a blinded study synopsis and start contacting the identified CROs. Send them the blinded synopsis along with the request for proposal (RFP) document containing questions. It is important that all the CROs should be asked the same questions and should be evaluated on the same parameters. One can derive the questions based on the following parameters:
This is the most important criterion for evaluation of the CRO. Every CRO proclaims that they have experience in all therapeutic areas. It's possible to have the experience, but not necessar ily the understanding of the required therapeutic area. Having experience and understanding are two different param eters. When the safety of the molecule is under discussion, an understanding of the therapeutic area is critical to avoid safety reporting errors. Therefore, proper questions need to be added to the RFP document to evaluate the therapeutic area understanding of the CRO.
To understand the workload of the exist ing staff it is important to know and ask for some information on the exist ing projects maintaining confidentiality because every CRO works on optimum resource utilisation.
Rajendra Talele is a Pharmaceutical professional having over 30 years of experience in the Pharma drug development industry. His career includes multiple executive-level positions, Board Members, SBU Heads, President, Directors and Country heads of various MNC and Indian CRO companies. Currently, he is the Chief Executive Officer (CEO) of EviaSearch, www.eviasearch.com a search engine designed for the Pharmaceutical Industry and creating an ecosystem of connecting various Pharma service providing industries with their potential clients, the Pharmaceutical Industry.
a. Details on the service capabilities
document should have adequate ques tions on the technological capabilities of the CROs.
14 PHARMA FOCUS ASIA ISSUE 48 - 2022 BIOAUTHOR
It is important to understand the financial situation of the CRO because usually, the clinical study runs for a longer duration and changing CRO in between due to financial troubles would be difficult for the sponsors. Hence questions on financial stability such as how long the CRO is working in this space, existing clients, past clients, financial partners, etc. need to be asked in the RFP document.
i. Financial Stability
j. Pricing
Conclusion
Selection of the CRO can be a complex process if they are allowed to present their capabilities without defining your require ments. This is because every CRO has its way to showcase its capabilities, expertise, team strength, and pricing. However, if the sponsor can define the expectations and requirements in a RFP document the selection process becomes easy and faster. The presented list for parameters is just an example and is required to be modified as per the project demand.
g. Existing running projects
c. Information on investigational sites and relationships with the investigators
f. Statement of purpose (SOP) documents SOPs are the guiding documents for the execution of the study, though the SOPs are categorised as confidential documents, one can ask for a list of SOPs from the CROs. Hence, the RFP should have ques tions on the list of SOPs for completing the required services.
e. Quality management system (QMS) Quality Management System varies from CRO to CRO and is mainly derived from the operational process and understanding of the process. Therefore, our expecta tions regarding quality need to be defined clearly in the RFP document so that all CROs will have a similar understanding of the requirements.
h. Software and other tools used Technology plays an important role in the collection, compilation and analysis of various types of data in clinical trials. Technology assures timely completion of the clinical study. Therefore, the RFP
The CRO project manager is a key coordi nator between Investigators, CRO senior management and the sponsor, whereas the project management is the process detailing the flow from the project plan ning to project completion. Therefore, while selecting a CRO one should criti cally evaluate the project management process, the experience of the project managers, and challenging situations/ risks handled by the project managers.
d. Project management capabilities
ously naturally infected and vaccinated individuals.Consequently, even if the general opinion that mass vaccination against SARS-CoV-2 contributes to eliminate the transmission of the virus, the world is not yet positioned to end the pandemic emergency.Among the several causes affecting the vaccine effectiveness, there are:
• reduced protective effectiveness in older age groups;
Luca Soraci, Geriatrician and a Research Assistant, Laboratory of Pharmacoepidemiology and Biostatistics National Institute for Research and Care of the Elderly (IRCCS INRCA)
Although the vaccines currently approved to prevent the infec tion caused by the severe acute respiratory syndrome coronavirus 2(SARSCoV-2) —known as coronavirus disease 2019 (COVID-19) — and emerging vari ants, have shown to greatly reduce the rates of serious illness and death, they appear not fully effective at preventing the infection and disease, and long COVID can arise, even after a mild or asymp tomatic coronavirus infection. Indeed, as showed by SARS-CoV-2 infection surveillance and vaccination registry data, numerous fully vaccinated people exposed to SARS CoV-2 developed COVID-19. These cases are called vaccine break through infections, although vaccinated people develop symptoms that tend to be less severe than those experienced by unvaccinated people. In any case, people with vaccine breakthrough infections can be contagious and the virus can spread from them to other people.
• mutations in virus sequences, that lead to mutated clusters in the structural proteins;
COVID Vaccines Walking around problems and solutions
A recent study shows that, despite a prior infection can protect against SARSCoV-2 reinfections, emerging variants can infect and/or reinfect both previ
A comparative analy sis recently performed by Fiolet T. et al., shows that all vaccines represent safe and
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The current vaccines developed against Severe Acute Respiratory Syndrome Coronavirus 2(SARS-CoV-2) have been shown not be enough to counter act the pandemic of corona virus disease 2019 (COVID-19). Further studies and vaccination strategies are required to both improve lasting immunological response, and allowing in the meantime a rapid development and a large-scale production.
• efficacy differences, related both to population or geography and to locally circulatingConsequently,variants.the long-lasting protection against SARS-CoV-2 infec tion, through specific antibody and T-cell responses elicited by the current vaccina tion or natural infection, represents a global concern.
Maria Elsa Gambuzza, Italian Ministry of Health
The ACE2 is a multifunctional protein that plays a crucial role in several mechanisms, including:
• regulation of renin-angiotensin, kinin-kallikrein systems, and amyloid peptides;
Anyway, one of the main roles of ACE2 is to bind and inactive the potent
effective tools to prevent severe COVID19, hospitalisation, and death against all variants of concern, even if the quality of evidence greatly varies, depending on the vaccines considered. However, the Authors claim that the main questions remain the need of a booster dose, the waning immunity, and the not last long duration of Moreover,immunity.thecurrent vaccines appear not able to elicit an oral mucosal immunity, thus failing in limiting virus acquisition upon its entry through this route. In fact, the induction of mucosal front-line immunity has the potential to mitigate current and future respiratory virus epidemics and pandemics. In addi tion, since mucosal immunity maxim ises the individual protection against breakthrough infections, it contributes to decrease the disease severity and the risk for virus transmission upon infec tions
At light of these considerations, since that both S protein of SARS-Cov-2 and
Among these, there are the virus nucleocapsid components and the membranegly coprotein, that have been reported to exhibit both pathogenic and immunogenic properties.
However,etc.in my opinion, the main problem consists in the particular conformation of the protein S selected, as protective antigen, both in live or inert, attenuated immunogens, or as protein translated from mRNA-based vaccines.
Altogether,. the immune response elicited by current COVID-19 vaccines, including both T-cell responses and neutralising antibody production, could be improved, within certain limits, by optimising the primary antigen sequence, the doses, the adjuvants, the immu nisation regimes, the manufacturing processes,
At the same way, in biological systems, in addition to antibodies target ing antigens, all biomolecules, includ ing enzymes catalysing their substrates, regulatory proteins binding DNA, and receptor-ligand complex systems, specifi cally recognise each other through the so-called mechanism “lock and key”. The ligand recognition can be very specific, allowing the binding to only a small part of an antigen or ligand (known as the epitope), and discriminating between highly similar epitopes.
In addition, S protein has been shown to share sequences similar to alveolar lung surfactant proteins, and this molecular mimicry can represent one of the main mechanisms of SARS-Cov-2 infection responsible for inducing the production of self-reactive antibodies in infected host Ref. Letter from Editor: On the molecular determinants of the SARSCov2 attack - Clinical Immunology 215 (2020)Consequently108426.In any case, the limited immunogenic properties of the S protein used in COVID vaccines could be mainly due to any conformational similarity to Ang-II, and this similarity could explain both the numerous cases of infection occurring among the regularly vacci nated people and the number dramati cally increasing of subjects who have been infected from SARS-Cov-2 for a secondThistime.hypothesis can be easily tested by analysing, in a detailed and comparative manner, the conformational dynamics and the protein sequence alignment, to identify specific regions of similarity between S protein, Ang-II and other endogenous components, including surfactantAltogether,proteins.these considerations should address the current studies both to further investigate the molecular characteristics of S protein potentially associated to its low immunogenicity and to identify other immunogenic SARSCoV-2Theepitopes.reverse vaccinology approach allowed to select a further list of SARSCoV-2 antigens as promising candidates for vaccine development.
vasopressine peptide angiotensin II (Ang II) by removing the C-terminal pheny lalanine residue to yield Ang1–7.This conversion inactivates the vasoconstrictive action of Ang II and yields a peptide that acts as a vasodilatory molecule.
• amino acid homeostasis regulation;
Mucosal COVID-19 vaccines represent a promise and challenge, mainly due to the needlefree administration, and the ability to induce both mucosal (IgA) and circulating (IgG and IgA) antibod- ies, as well as T-cell responses.
As above discussed, the S protein shows a high binding affinity both to the angiotens in converting enzyme 2 (ACE2) receptor and to soluble ACE2.
• transport of neutral amino acids;
At the same way, the complex immune sensory system is able to discrim inate self- from non-self-antigens, and autoimmune diseases represent the result of the breakdown in any of the mecha nisms that maintain unresponsiveness to self (a state known as self-tolerance).
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In particular, membrane glycopro tein, which is the most abundant viral
In natural infections, when an immu nocompetent animal is exposed to a T-dependent microbial antigen, it will develop an array of antibodies that each bind to a separate epitope of the antigen.
• interaction with integrins.
the human protein Ang-II, are capable of selectively recognising and binding the ACE 2 receptor, it can be supposed that S protein shares any sequence identity region with Ang-II.
RESEARCH & DEVELOPMENT
According to antigen-antibody inter action theory, it is known that antibodies recognise antigens based on their structure as well as content.
phage particle that can be administered in an aerosolised form by inhalation. A combinatorial approach for liganddirected pulmonary delivery as a unique route for systemic targeting in vaccination showed to elicit, both in mice and nonhuman primates, a systemic and specific humoral response.
represent a promise and challenge, mainly due to the needle-free administration, and the ability to induce both mucosal (IgA) and circulating (IgG and IgA) antibod ies, as well as T-cell responses. Mucosal immune responses could also contribute to reduce the frequency of asymptomatic SARS-CoV-2 positive individuals, who represent an important factor in trig gering and sustaining infection chains.
Luca Soraci works as a geriatrician and a Research Assistant at the Laboratory of Pharmacoepidemiology and Biostatistics at the National Institute for Research and Care of the Elderly (IRCCS INRCA), Italy. He has been collaborating in several studies concerning the role of SARS-CoV-2 and impact of COVID-19 in older patients with frailty and multimorbidity, as well as vaccination strategies for protecting such frail individuals. Other fields of interest include study of chronic kidney disease, multimorbidity, anticholinergic drug burden, and frailty.
protein in SARS-CoV-2 and plays a crucial role in viral pathogenesis, has been reported to have a highly immu nogenic domain, mainly consisting in its C-terminal region.
In conclusion, the most efficient strategy to combat the current pandemic COVID-19 and save millions of human lives worldwide remains active immunisa tion. To date, current vaccines have been shown to reduce both mortality and the incidence of severe COVID19. Since, there are still some aspects, concern ing their efficacy, immunogenicity and safety to be focused, the future studies will have toanalyse and comparegenetic variants andmutations, and evaluate the conformational similarity degree between the viral S proteins and the human ACE2 receptor and other endogenous proteins, in addition to identify additional immu nogenic epitopes and develop other alter native vaccines.
phage display technol ogy can represent an inexpensive and versatile tool for large-scale screening methodology for the identification of potential vaccine candidates against SARS-Cov-2 as well as other microbial infections.Theability to produce combinatorial peptide libraries with a highly diverse pool of randomised ligands, allows screen ing and selecting, through an affinity selection-based strategy called “biopan ning”, a wide variety of targets with high antigenicity and immunogenicity. Also, peptide libraries can be panned against the antiserum of convalescent individu als, in order to identify both additional protective virus antigens and novel peptidomimetics of pathogen-related epitopes. Combined with bioinformatic approaches capable of identifying immu nogenic epitopes, this strategy provides a promising framework for developing a more effective SARS-Cov-2 vaccine.
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In addition, specific non-structural polyproteins (NSP), including NSP3, NSP4, and NSP6, involved in the viral adhesion and host invasion, appear to exhibit high protective immunogenic ity. Currently, NSPs represent one of the most promising alternative COVID-19 vaccine candidates, since they have already been successfully used to induce protec tive immunity against other pathogens, including flaviviruses, hepatitis C virus, and
Phage display vaccines are obtained by expressing multiple copies of an antigen on the surface of immunogenic phage particles, thereby eliciting a powerful and effective immune response.
Maria Elsa Gambuzza works in Italian Ministry of Health. Maria has Degree in Biology and Postdegree in Medical Microbiology and Virology; Environmental Parassitology with PhD in: “Clinical Neuroscience; “Microbial Biotechnology“” Work’s medicine”.
It is also hoped that efforts towards the development of mucosal vaccines consisting in peptide-directed phage particles leading to secretory IgA anti body production can provide a very strong first line of defense, by prevent ing the virus entry into the mucosa. It is becoming increasingly clear that local mucosal immune responses, that include, in addition to IgA antibod ies, local mucosal IgG production, and cytotoxic T lymphocyte activation, are very important for protection against COVID-19 disease. However, one of the main challenges in designing phage display vaccines consists into assure that, following the insertion of the different SARS-CoV-2 antigen epitopes into the phage particles, the structure of these peptides is maintained intact as in the original three-dimensional conformation. Therefore, mucosal COVID-19 vaccines
Recent advances consider the possi bility of producing a peptide-directed
Peptide-basedHIV-1.
References are available www.pharmafocusasia.comat
In addition, the phage-based vaccines can represent a valid strategy for vaccine design, due to being highly stable under harsh environmental conditions, and potent adjuvant capacities.
Maria has an experience in international prophylaxis of infectious diseases and management of pandemic emergencies. She has done research activities in molecular mimicry, and innovative vaccine strategies.
BIOAUTHOR
• Genes that influence disease suscepti bility or progression. Variants of these genes can become therapeutic targets.
• Genes not directly involved in the drug’s pharmacology that can alter an “off-target” protein. In this instance idiosyncratic reactions (e.g., immune mediated adverse reactions) can occur
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RESEARCH & DEVELOPMENT
How to Use Pharmacogenomic Information to Reduce the Risk of Experiencing Adverse Events
Multiple genetic and non-genetic factors can increase the risk of experiencing an adverse reaction: the example of warfarin
Giovanni Furlan, Fellow, International Society of Pharmacovigilance
These genetic variants are estimated to account for 15 per cent-20 per cent of the different desirable and undesirable responses that patients have following drug intake and for some drugs they can account for up to 95 per cent of interindividual variability.
It is rare that one single gene variant is responsible for altering the metabolism of a drug or for causing an idiosyncratic adverse reaction. More often, as in the case of warfarin, (a drug used for the prevention of thrombosis and thrombo embolism) multiple genetic and environ mental factors are involved. This drug is of particular interest since it has a narrow therapeutic index, the inter-individual variability of the dose required to achieve the required therapeutic effect can vary up to 20 times and an excessive dose increases the risk of bleeding, while a subtherapeutic dose increases the risk thromboembolism.Toidentifywhich genetic variants are of importance, boththe metabolic steps and the mechanism of action of warfarin need to be considered.
As shown in figure 1, warfarin is a racemic mixture, and the S-enantiomer is more potent in inhibiting vitamin K epoxide reductase (VKORC1) as compared to the R-enantiomer. (Note: VKORC1 reduces vitamin K, an essential
ciated with pharmacokinetic altera tions and might require a drug dose adjustment
Genetic testing can be used to reduce the risk of experiencing adverse reactions. Seldom is one single gene responsible for altering a drug’s benefitrisk balance. This is more often due to multiple genetic and non-genetic factors, thus increasing the complexity and limiting the utility of a widespread use of pharmacogenomics. Widespread use of genotyping and artificial intelligence can overcome these limits.
• Genes that code for proteins that are intended or unintended drug targets and other pathways related to a drug’s pharmacological effect. Variants of these genes can shift the relationship between the drug dose and its effect, thus requiring a change in the admin istered drug dose
Pharmacogenomics is the study of the genes, their structure, func tion, polymorphisms, transcrip tion, and translation, how they interact with each other and with environment. The main goal of pharmacogenomics is to understand how genetic variants can alter a drug’s benefit-risk balance. Genetic differences that are likely to be of most relevance to drugs and that can alter their benefit-risk balance pertain to four broad •categories:Genesthat affect proteins involved in the metabolism of a drug, its active metabolites, or their transport. Variants affecting these genes are mainly asso
Polymorphism The presence of variant forms of a DNA sequence
GLOSSARY
inhibitortranscriptaseReverse
Therapeutic index The ratio of the amount of a drug that causes a therapeutic effect to the mount that causes toxicity
A class of drugs that inhibit an enzyme (called reverse transcriptase) that syntheses DNA from an RNA template. This enzyme is necessary to viruses that insert a copy of their RNA into the host cell they invade.
Transcription The biological process of copying a segment of DNA into messenger RNA
Gene variant A change in the most common DNA sequence
Factors that influence the need for genetic testing
Enantiomer Either of the two molecules that are the mirror image of each other (and that form a racemic mixture)
ing should be performed and for which variants. To answer this question, the strength of evidence associating an allele to an adverse event and the expected consequences of the adverse reaction need to be determined. Therefore, it is necessary to evaluatethe severity and seriousness of the adverse event associ ated with the genetic variants, since, for example, it is not worthwhile to investi gate the contribution of a genetic poly morphisms to a mild localised erythema associated with a drug used for cancer. Other aspects that have to be considered are the magnitude of the adverse event increased frequency, the probability with which a genetic test will indicate the patients have the genetic variant of inter est among those who actually have the variant (i.e., the analytical sensitivity), the accuracy with which a genetic test predicts the clinical disorder (i.e. the clinical validity of testing)and the differ ent frequencies in the various ethnicities of all the genetic variants contributing to an adverse event.All these factors contribute to the genetic test positive predictive value that tells us what is the probability that a patient taking the drug of interest and with a positive test for a specific genetic allele will experience the adverse event.
TERM DEFINITION
cofactor of gamma-glutamylcarboxylase, the enzyme that converts hypofunctional clotting factors to functional). It is, there fore, not surprising that genetic variants affecting cytochrome 2C9 (CYP2C9), the enzyme that metabolises the S-enantiomer, have a greater influence in altering the dose of warfarin that is needed to achieve the therapeutic effect as compared to genetic variants of CYP1A2 and 3A4, since these cytochromes are responsible for the metabolism of the less potentR-enantiomer. The variability in the needed warfarin dose is partially explained by the more than 60 known variants affecting CYP2C9 and, even if not all these variants are important, their prevalence varies from one ethnicity to another. CYP2C9 *2 variant, for exam ple, requires a lower warfarin dose, but its frequency is around 13-14 per cent in Caucasians and less than 1 per cent in Asian patients.CYP2C9*5,*6,*8 and *11 polymorphisms also require a lower warfarin dose, but their prevalence varies from 10 per cent in Africans to less than 1 per cent in Caucasians. There is another variant in a non-coding region of CYP2C9DNA that requires to reduce warfarin dose only in African Americans. The reason is not clear, but it could be that only in this population this vari ant is inherited together with another polymorphism that affects cytochrome metabolism.Anothervery important genetic poly morphism reduces by twofold the expres sion of VKORC1 and, therefore, requires a lower dose of warfarin. The frequency of this allele is around 90 per cent in Asiatic patients, while it is only around 10 per cent in African Americans. Also, the gene coding for CYP4F2, that metabolises reduced vitamin K to hydroxy vitamin K, has a variant(CYP4F2*3) that lowers the concentration of this cytochrome thus increasing active vitamin K concentration and requiring a higher warfarin dose. As for the previously detailed variants, also this allele has a different prevalence in different ethnicities: it is presence ranges from 24 per cent in Caucasians to 7 per cent in African Americans.
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Since many genetic variants can influ ence the effect of a drug and it would be unpractical and expensive to perform genetic testing for all the involved alleles, the logical question is when genetic test
Allele A gene’s variant
Translation The biological process of synthesizing a protein from messenger MRNA
Human leukocyte antigen A gene that codes for proteins responsible for the regulation of the immune system
Odds ratio A statistical measure of the association between two events.
Finally, calumelin, a protein that inhibits gamma-glutamyl carboxylase, is characterised by a variant that requires African Americans to take a lower warfarin dose to achieve the targeted therapeutic effect.The multitude of variants that influ ence the required warfarin dose and whose prevalence varies in the different ethnici ties, explains why traditional dosing algo rithms, that only look at CYP2C9 *2 and *3 together with the above mentioned VKORC variant, might not be optimal for all patients regardless of their ethnicity. Algorithms should rather be adapted to consider which variants can influence the required drug dose in the various ethnici ties. However, more precise dosing algo rithms should also consider non-genetic factors. In fact, in the case of warfarin also elderly age, high weight, amount of vitamin K taken with the diet, drugdrug interactions involving the drug and tobacco smoking alter the required dose.
Racemic mixture A mixture of two molecules that mirror images of each other and that are not superimposable
RESEARCH & DEVELOPMENT
Not all adverse reactions are character ised by a complex interplay of multiple genetic and non-genetic factors as is the case of Abacavir,warfarin.is a reverse transcriptase inhibitor indicated for human immunode ficiency virus infection (HIV). It can cause a hypersensitivity syndrome characterised by respiratory, gastrointestinal disorders and rash. In patients who are rechallenged with abacavir after having experienced a hypersensitivity syndrome, this adverse reaction can be fatal. A study in about 1900 patients showed that avoiding abacavir in patients with human leuko cyte antigen (HLA)-B*57:01 variant eliminated immunologically confirmed hypersensitivity reactions. In this study, the test negative predictive value was100 per cent: this meant all the patients that had a negative genetic test did not experi
The more genetic and non-genetic variants contribute to an adverse event, the less it is likely the genetic variant of interest will cause an adverse event: therefore, its positive predictive value will be low.
ence the adverse reaction. Considering an overall prevalence of HLA-B*57:01 variant of 6 per cent and being the posi tive predictive value of the test of 47.9 per cent,it has been calculated that 25 patients need to be screened to avoid one case of abacavir induced hypersensitiv ity syndrome.Therefore, the medicine’s Summary of Product Characteristics requires that before taking abacavir all patients are screened for HLA-B*57:01 variant; patients who are found to carry this allele should not be treated with abacavir.Avery different example is that of flucloxacillin, a medicine used to treat bacterial infections. The strongest known genetic association for drug-induced liver injury is that between flucloxacillin and HLA-B*57:01 (the odds ratio of the asso ciation is 80). The genetic test accurately identifies the patients who have the vari ant, but flucloxacillin drug induced liver injury occurs (luckily) in only 8.5 out if 100,000 patients who take the drug and the positive predictive value of the test for the HLA-*B57:01 allele is of 0.12 per cent. It has been calculated that around 13,500 patients need to be screened to
As for abacavir, also for flucloxacillin, the answer can be found in the medicine’s Summary of Product Characteristics: HLA-B*57:01 variant is only mentioned in section 4.8 ‘Undesirable Effects’ where
Examples of genetic testing utility
Genetic testing clinical utility is there fore being pondered: what is the balance of benefits and risk associated with using a test in everyday practice, including its ability to inform clinical decision making and prevent adverse reactions.
avoid one case of drug induced liver injury and due to the low positive predictive value of the test, only 1 out of about 830 patients who take flucloxacillin and have the HLA-B*57:01 variant will suffer from drug-induced liver injury.Considering that the prevalence of the HLA-B*57:01 vari ant is relatively high (in Caucasians, for example, it is of around 7 per cent) and that only a small fraction of patients with the variant will experience drug-induced liver injury due to flucloxacillin, it has to be decided if these patients should take the medicine or if they should be denied flucloxacillin. Another non-trivial point to examine is the cost-effectiveness of screening around 13,500 patients to avoid one case of liver injury.
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21www.pharmafocusasia.com
AUTHOR BIO
Giovanni Furlan has more than 20 years’ pharmacovigilance experience. He has overseen pharmacovigilance medical, operational and compliance activities and has managed, merged, and developed
However,needs.
EXECUTIVES SPECIAL ISSUE
meaning of their genetic characteristics will look for information in the web and will easily fall prey to those who want to sell improbable remedies for their risk factors or, even worse, who have political agendas.
each patient suffering from a pathology. Therefore, the benefit-risk balance of a drug could be assessed based on indi vidual
The effect of a genetic variant on an adverse reaction varies from being the most important risk factor to being only a minor contributor. In the future, it is possible that all the gene variants affect ing the efficacy and safety of a drug and how they interact with the environment will be known. The human population could all be genotyped, and the genotype
like everything pertaining to this world, there will also be some cons. For example, the data on the genetic characteristics of a person could be hacked and used to discriminate some individuals. Health insurance companies might require access to individuals’ geno type, and the cost of health insurance could be higher for subjects with genes predisposing to certain pathologies. Will everyone really want to know, through the analysis of our genotype, what is our risk of suffering from a pathology, or will this only increase people’s anxi ety? Finally, it is uncertain if everyone
References are available www.pharmafocusasia.comat
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A look in the future of personalised medicines: pros and cons
it is stated there is evidence that the risk of flucloxacillin induced liver injury is increased in patients who carry the abovementioned allele. However, since very few carriers of the allele will develop liver injury, routine screening for the variant is not recommended.
RESEARCH & DEVELOPMENT
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agreed goals, especially for protozoan and helminthic NTDs. Unfortunately, drug research and development (R&D) for highly prevalent NTDs such as schistoso miasis, human African trypanosomiasis, Chagas disease and leishmaniasis, has, for decades, been characterised for insufficient funding and low-technology approaches. This paradigm has recently changed given the rising of initiatives that involve notfor-profit organisations, universities, and pharma companies. Among these partnerships we can cite the NTD Drug Discovery Booster, the Lead Optimization Latin America (LOLA),the WIPO Re: Search project, and the Welcome Trust for NTD drug discovery programme, the first two being administered by the Drugs for Neglected Diseases initiative (DNDi). These programmes have proven invaluable to catalyse drug R&D for NTDs by integrating medicinal chem istry and parasite biology and allowing multi-parameter optimisation (MPO) of high-quality hits and lead compounds. Despite these efforts, innovative products have not been regularly developed and approved for NTDs. The few products that have recently been approved for these conditions are known or repurposed drugs, new formulations, or combination chemotherapies.Thecaseofleishmaniasis is emblem atic. Leishmaniasis is caused by more than 20 species of Leishmania parasites and affects 700,000 to 1 million people each year. Chemotherapy for this NTD is complex, costly, lengthy, and can cause severe adverse effects. Most drugs require intravenous or intramuscular administra tion by highly skilled health professionals
Innovation for the Elimination of Neglected Tropical Diseases
Adriano D Andricopulo, Full Professor, São Carlos Institute of Physics (IFSC) - University of São Paulo (USP)
Leonardo L G Ferreira, Researcher, São Carlos Institute of Physics (IFSC) - University of São Paulo (USP) Josué de Moraes, Professor, Guarulhos University
The World Health Organization (WHO) roadmap on neglected tropical diseases (NTDs) for 2021-2030 highlights the pivotal role of pharmaceutical innovation in the control and elimination of these conditions. However, sustained funding for well-structured and innovation-oriented drug discovery programmes, especially in the postCovid-19 era, is a necessary condition for the translation of the roadmap goals into concrete achievements.
Neglected tropical diseases (NTDs) affect more than one billion people worldwide. Although this group of 20 infectious conditions corresponds to 11 per cent of the global disease burden, no innovative drugs have been developed in this field. The World Health Organization (WHO) has played a
central role in raising global awareness on the subject. Recently, WHO launched its roadmap on NTDs for 2021-2030, which highlights the advances made over the past years and sets the strategies to eliminate these diseases by 2030. According to this agenda, pharmaceutical innovation will be central for the achievement of the
Another condition that requires urgent attention is Chagas disease. Approximately 6-7 million people worldwide are infected with Trypanosoma cruzi, the causative agent of this disease. Although endemic in 21 countries in Latin America, Chagas disease has spread to North America, Europe, Africa, and Eastern Mediterranean and Western Pacific countries, exposing 75 million people to the risk of infection. The two drugs available to treat Chagas disease are benznidazole and nifurti mox, and in 2017, the FDA approved a formulation of benznidazole for children. These compounds bear a nitroheterocy cle and cause severe adverse effects that lead to poor treatment compliance among patients; additionally, they are effective only in the acute stage of the disease. Two compounds, fexinidazole and DNDi
EXECUTIVES SPECIAL ISSUE
6148, are undergoing translation phase IIa and phase I tests, respectively, and new benznidazole regimens are in clinical development. Important programmes for Chagas disease and leishmaniasis have been led under the NTD Drug Discovery Booster and LOLA initiatives in collabora tion with pharmaceutical companies. To date, these programmes have advanced several hits to proof-of-concept (PoC) tests for Chagas disease, and one molecule has been forwarded to preclinical investiga tions for Causedleishmaniasis.byTrypanosoma brucei gambi ense and T. b. rhodesiense, HAT affects remote communities in sub-Saharan Africa. Continued programmes for disease control have significantly reduced the number of new cases to fewer than 1,000 in 2019. However, the disease reemerged with epidemic proportions after several occasions on which it was thought to be controlled. This is an important remark since 65 million people are still at risk of infection. The WHO roadmap preconises the interruption of
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in hospital settings. Most agents available to treat leishmaniasis, such as ampho tericin B, pentavalent antimonials, and paromomycin, are outdated and highly toxic. The most recent drug, miltefosine, was approved by the US Food and Drug Administration (FDA) in 2014 and is the only oral therapy for the disease. Among the targets to reach the WHO roadmap goals for leishmaniasis is the discovery of more effective and easily administered treatments, since there are no vaccines or drugs for pre-exposure prophylaxis. Fortunately, the drug R&D pipeline for leishmaniasis includes seven molecules in the translation phase, three new treatments in clinical development, and two new therapies under registration. Additionally, known molecules under clinical inves tigation are Regardingandnate(NCT04799236),(NCT04515186),(NCT03084952),18-methoxycoronaridinemeglumineantimoniatepentavalentantimonysodiumstiboglucowithallopurinol(NCT04699383),pentoxifylline(NCT02530697).biologicals,ChAd63-KHis
in clinical phase II as a vaccine candi date for the treatment of leishmaniasis (NCT03969134). Moreover, a combina tion of the already used antileishmanial drugs miltefosine and paromomycin are under clinical development.
RESEARCH & DEVELOPMENT
Leonardo L G Ferreira holds a master’s degree and a Ph.D. in Biomolecular Physics from the University of Sao Paulo (USP), and a post-doctoral degree in Medicinal Chemistry (USP). He is researcher at the São Carlos Institute of Physics (IFSC-USP) and has experience in Medicinal Chemistry and Drug Design.
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some species, praziquantel displays low efficacy against juvenile parasite stages, a property that likely contributes to the failure of praziquantel to cure parasitic infections.Consequently, there is a need for new drugs that act equally against adult and juvenile worms. Interestingly, a series of potent compounds against both the adult and juvenile schistosomes from Salvensis & London School of Hygiene & Tropical Medicine have been handed over to Merck to progress the programme towards drug development for treat ing schistosomiasis. Praziquantel was included in the WHO Model List of Essential Medicines for Children, but the absence of an oral formulation for the youngest children is an obstacle in preventive chemotherapy; favourably, research on a paediatric formulation is ongoing by the Pediatric Praziquantel Consortium. Furthermore, the reduced efficacy of praziquantel has been reported, and its use on a large scale raises fair concerns that resistance can emerge. Due to the limitation of this approach, and since no other alternative has reached the market, the WHO calls for the development of novel therapeutic interventions in its roadmap to elimi nate schistosomiasis as a public health problem by 2030.
good news is the progression of some drug candidates to advanced clinical trials, and the identification of novel molecular targets that can be explored in HAT drug discovery programmes. Remarkably, fexi nidazole, which is a molecule discovered in the 1980s, has been introduced as the first oral drug for the therapy of HAT caused by T. b. gambiense.
On the other hand, progressing lead compounds from the early discovery phases has been challenging for Chagas disease. Many gaps in the parasite-host interplay still need to be closed for this NTD. Many difficulties have also been faced in schistosomiasis research, which has not resulted in leads that are suit able for advanced discovery stages. An important aspect in this regard is that compounds that target both juvenile and adult worms are critical for the elimina tion of Theschistosomiasis.rigorousTarget Product Profiles (TPPs) and the high investment required to carry out trials on different sites are major challenges to conduct clinical devel opment studies for NTDs. These difficul ties will need to be addressed in the global agenda set for 2021-2030. Fortunately, solid drug discovery efforts are ongo ing for NTDs, which can now rely on innovation-oriented campaigns based on high-quality chemical matter, technology, and human resources. Especially after the crisis caused by the Covid-19 pandemic, consistent funding is critical to achieve the highly aspiring goals of the WHO roadmap and, hopefully, eliminate the NTDs in the foreseeable future.
Josué de Moraes holds a Ph.D.in Parasitology and a post-doctoral degree in Biotechnology (University of São Paulo). He is a professor of Parasitology and Infectious Diseases at Guarulhos University, has experience in antiparasitic drug discovery, and coordinates the Center for Neglected Diseases Research.
HAT transmission by 2030, which means zero cases. Unfortunately, poorly efficient and remarkably toxic molecules such as suramin, pentamidine, melarsoprol, eflo rnithine, and nifurtimox remain in use in HAT chemotherapy. On the upside, the European Medicines Agency (EMA) gave a positive opinion on fexinidazole in 2018 and the FDA approved the drug in 2021 as the first oral treatment for T. b. gambiense HAT. The molecule was rediscovered in a screening campaign led by DNDi and Sanofi; the company (Hoechst AG at the time) interrupted the development of the compound in the 1980s. In addition, fexinidazole for T. b. rhodesiense and acoziborole for T. b. gambienseare under clinical devel opment.Schistosomiasis is an NTD caused by an intravascular flatworm (blood flukes) of the genus Schistosoma. Approximately 10 per cent of the world’s population is at risk of infection. Schistosomiasis treatment and control depend almost entirely on a single drug, praziquantel, which has been used on a large scale for decades. Endemic in 78 countries, schistosomiasis affects poor rural commu nities but has spread to urban areas and tourists visiting endemic areas. The ongo ing WHO strategy for endemic areas is to reduce morbidity, prevalence, and transmission through mass drug admin istration. In 2020, at least 246 million people required preventive treatment with praziquantel, yet only 66 million were reported to have been treated. Although effective against all schisto
Adriano D Andricopulo holds a Ph.D. in Organic Chemistry (Federal University of Santa Catarina) and has postdoctoral experience in Medicinal Chemistry (University of Michigan). He is a full professor at USP, has experience in Medicinal Chemistry and Drug Design, and coordinates the Laboratory of Medicinal and Computational Chemistry (LQMC).
BIOAUTHOR
The interplay enabled by the current partnerships has allowed, for the first time, the incorporation of forefront technologies for NTD drug discovery. These efforts have resulted in promising compounds undergoing preclinical and clinical devel opment, mainly for leishmaniasis. Another
back in November 2011. Over the past decade, the island-nation’s positioning has changed from just a pharmaceutical manufacturing outpost to an international biomedi cal hub that encompasses the entire innovation and manufacturing value chain.
Menarini Asia-Pacific is just over a decade old, having established its regional headquarters in Singapore
MAURIZIO LUONGO CEO, A. Menarini Asia-Pacific Holdings Pte Ltd. (Menarini Asia-Pacific)
Building a Biomedical Diagnostic Research Hub in Asia
2. Why the need to launch a biomarker research arm?
Menarini Biomarkers (A. Menarini Biomarkers Singapore Pte Ltd) was founded with the mission of
1. Tell us more about Menarini Biomarkers, Singapore. Why set up an R&D operation in Asia instead of Europe or North America?
25www.pharmafocusasia.com EXECUTIVES SPECIAL ISSUE
Globally, there remains an unmet need for advanced research in health care biotechnology and diagnostics. Singapore’s reputation for quality research and development (R&D), supportive operating environment, and talent pool made it an easy deci sion when deciding where to build our first diagnostics research arm in the world.
Beyond the SingHealth partnership, Menarini Biomarkers is also collab orating with the KK Women's and Children's Hospital, Singapore Eye Research Institute, and Singapore General Hospital to develop singlecell based diagnostic platforms for applications in the immuno-oncology
team will continue to place strong emphasis on advancing highly specialised and scientifically valuable fields through close collabo rations with academic and medical institutions to elevate the standard of healthcare not only in Asia, but globally.
26 PHARMA FOCUS ASIA ISSUE 48 - 2022
BIOAUTHOR
RESEARCH & DEVELOPMENT
This patented technology can surpass any prenatal testing technology currently available in the market. It is a next-generation non-invasive clinical prenatal test (CB-NIPT) that can detect pathogenic microdeletions and micro duplications in the foetal genome. The test can be conducted as early as the first trimester (10 weeks) to give an indication of potential diseases that can be treated in utero or immedi ately after birth. This avoids the crucial delay between disease discovery and treatment. Previously, in some cases, diseases were only formally diagnosed well into early childhood.
Thefield.
The Biomarkers team have developed a technology that enables the isola tion of rare cells taken from the blood of pregnant women. These rare cells are released from the unborn foetus and can provide the entire genome of a baby from the isolated foetal cells alone.
3. Are there any current use applications you can share to contextualise the work underway?
In the years to come, the team anticipates increased demand for CB-NIPT, owing to the rising aver age maternal age, as women choose to give birth later in life. Increased literacy rates, financial stability, and awareness of genome sequenc ing are also empowering women
In his role as Chief Executive Officer, Maurizio ensures the smooth operations of Menarini in the region. A veteran marketing professional, he was previously appointed as Corporate Consumer Health Business Unit Director of Menarini Consumer Health, where he drove the distribution expansion of the portfolio. Prior to joining Menarini, Maurizio worked in various industries with companies including Angelini, Tigi Italia Healthcare, L’Oreal and Saritel SpA.
identifying, developing, and validating new biomarkers on circulating human cells for applications in diagnostics.
specialises in patho genic single-cell isolation that enables scientists to pinpoint specific disease markers, also known as biomarkers. The identification and selection of path ogenic single cells from blood samples is incredibly useful in disease treatment, as it helps healthcare practitioners narrow therapies down to target cells.
Pregnant women face complex health care journeys, undergoing different tests at various gestational stages and this does not necessarily include genetic testing. At the same time, an increasingly educated segment of the population wish to understand the potential health risks carried in their babies’ genes without undergoing invasive tests.
There is a current healthcare gap in precision medicine surrounding the fields of early disease prediction and disease control, particularly related to precision rare-cell isolation, analy sis, and disease diagnosis. Menarini Biomarkers uses single-cell analysis to provide clinicians with new tools for early detection, tracking disease progression, and the measurement of real-time responses to innovative Thetherapies.R&Dteam
to demand access to world-class healthcare.
4. Looking ahead, what are your plans for Biomarkers in the next five years?
Last October, Menarini Biomarkers signed a Memorandum of Understanding with the SingHealth Duke-NUS Maternal and Child Health Research Institute (MCHRI) to develop the first non-European based interna tional medical hub for non-invasive testing in prenatal care.[1]
This article highlights the relevance of studying brain-enriched miRNAs, the mechanisms underlying their regulation of target gene expression, their dysregulation leading to progressive neurodegeneration, and their potential for biomarker marker and therapeutic intervention. This article has been written to emphasize ways for the effective diagnosis and prevention of these neurodegenerative disorders in the near future.
Neurodegenerative diseases such as Alzheimer’s disease (AD), Parkinson’s disease (PD), Huntington’s disease (HD), and Amyotrophic lateral sclerosis (ALS) are a group of age-related progressive disorders initiated by the neuronal loss that even tually leads to cognitive and movement disorders. These diseases are thought to be caused by alterations to protein-coding genes. Non-coding RNAs participate in translational regulation and comprise 95 per cent of total human cellular RNAs (Figure 1)
MicroRNAs
long and fixed in the 3' untrans lated section. Mature miRNA are formed in the effector complex to act as a post-transcriptional regu lator with its target mRNA. Each miRNA comprises of a seed region
Role of miRNAs Neurodegenerationin
27www.pharmafocusasia.com EXECUTIVES SPECIAL ISSUE
Bidisha Roy, Department of Biological Sciences, Rutgers University
that is highly conserved and comprises of an area between 2 to 8 nucleotides. This region spans from the 5’ to 3’ end of the miRNA and has a perfect complementarity match with the 3’UTR of the target mRNA.
Figure 1: PostmortemContol and AD brain - (A, B) represents post mortem formalin fixed human brain whole (A) or hemi segments of the human brain from control patients (B). (C, D) represents post mortem formalin fixed human brain whole (C) or degenerated shrunk hemi segments of the brain (D) from AD patients.
Neurodegenerative diseases
MicroRNAs are small, non-coding RNA molecules transcribed from RNA polymerase II and III. MicroRNAs are 22 nucleotides
PostmortemContol and AD brain - (A, B) represents post mortem formalin fixed human brain whole (A) or hemi segments of the human brain from control patients (B). (C, D) represents post mortem formalin fixed human brain whole (C) or degenerated shrunk hemi segments of the brain (D) from AD patients.
In disease causing mechanisms and tools of biomarker discovery and therapeutics
Alzheimer’s Disease affects about 60 per cent of age dependent dementia cases amongst elderly people. This neurode generative disorder is associated with loss in neuronal tissue, memory, impaired cognitive functioning, and impaired learning. The exact cause of AD is still unknown but prior research shows that there are two biomarkers strongly associ ated with AD. The first biomarker, tau, is a microtubule-associated protein that promotes vesicle transportation. In AD, hyper phosphorylation of tau causes it
Role of microRNAs in neurodegenerative diseases
Molecular, genetic and biochemical components that aid in the identi fication and analysis of pathological processes in the human body are referred to as biomarkers. They can be used as tools to assess the different stages of diseases, especially the early or preclini cal stages. Detection of biomarkers
to lose its affinity to other molecules. Consequently, this hyper phosphoryl ated tau develops a stronger affinity for other tau molecules and cause them to adhere together to form Tau aggregates. Increased levels of Tau aggregates lead to a decrease in neuronal communica tion, due to microtubule instability. Tau is a microtubule binding protein and phosphorylation of Tau lead to its dissociation from the microtubules, thereby destabilizing the microtubule assembly. This eventually lead to defec tive axonal transport and impaired synaptic transmission across neurons in a neuronal circuit. The second biomarker is amyloid- , which is a product of the APP (amyloid- precursor protein), and is known to form amyloid- plaques in AD patients. Research studies show that there is another biomarker in addition to hyper-phosphorylated Tau and amyloidplaques, known as miRNAs. Several research investigations discuss the pres ence of miRNAs circulating within the blood and cerebrospinal fluid. Most of these miRNAs have experimentally vali dated targets, known to be important in regulating various pathological processes in the neurons leading to AD (Figure 3). On the other hand, certain miRNAs have been shown to have altered levels in blood plasma, cerebrospinal fluid, or post- mortem brain tissues in AD patients. Additionally, there are various molecular players modulated by miRNAs
Figure 2: Biogenesis of microRNA - Various steps of mature microRNA formation and mode of gene regulation in the various cellular compartments of the neuron.
28 PHARMA FOCUS ASIA ISSUE 48 - 2022
in other neurodegenerative diseases like Parkinson’sDisease (PD), Huntington's Disease (HD) and Amyotrophic Lateral Sclerosis (ALS). The miRNA target gene sche matic diagram (Figure 4) highlights some of the important genes whose levels post-transcriptionally modified miRNAs, leading to alteration of various vital cellular functions of the neurons. This eventually leads to their degenera tion (Figure 3).
Extensive research, led to the under standing that small noncoding miRNAs played an important role in fine-tuning the genome. Complex networks in the brain are formed by the usage of tran scriptome in wide range of combina tions. Modulation of expression of thou sands of genes is achieved by specific miRNAs controlling the target mRNA expression, leading to various physi ological processes. Primary transcripts of miRNA are synthesised by RNA polymerase from miRNA genes. These transcripts are processed in the nucleus by the Drosha enzyme to produce a hairpin-like precursor miRNA (premiRNA). The pre-miRNA is transported from the nucleus to the cytoplasm by exportin. In the cytoplasm, the premiRNA undergoes shearing by dicer to form the mature miRNA. Ago 1 and Ago2 (Argonaute-1 and Argonaute-2) proteins, mature miRNA containing RISC (RNA induced silencing complex) binds to the 3'UTR of target mRNA. This leads to post-transcriptional inhibi tion or degradation of the target mRNA. Neuronal degeneration onset begins due to dysregulation in Dicer, Drosha, and RISC complexes leading to disruption of miRNA biogenesis and defective cellular processes (Figure 2)
Gene Regulatory network of miRNAs in AD - Network depicting the modula tion of various genes affecting function of Tau and Amyloid beta by different microRNAs leading to Alzheimer’s disease. [Adapted from Roy et al., Genes (Basel), 2022, (6)] (Figure 4).
MicroRNAs as biomarkers
Biogenesis of microRNA -Various steps of mature microRNA formation and mode of gene regulation in the various cellular compartments of the neuron.
Gene Regulatory network of miRNAs in other neurodegenerative diseasesNetwork depicting the modulation of various genes by different microRNAs, affecting neuronal function in PD, HD and ALS. [Adapted from Roy et al., Genes (Basel), 2022]
RESEARCH & DEVELOPMENT
EXECUTIVES SPECIAL ISSUE
Figure 3: Gene Regulatory network of miRNAs in AD - Network depicting the modulation of various genes affecting function of Tau and Amyloid beta by different microRNAs leading to Alzheimer’s disease. [Adapted from Roy et al., Genes (Basel), 2022, (6)]
Figure 4: Gene Regulatory network of miRNAs in other neurodegenerative diseases - Network depicting the modulation of various genes by different microRNAs, affecting neuronal function in PD, HD and ALS. [Adapted from Roy et al., Genes (Basel), 2022]
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Disease 158 RESEARCH & DEVELOPMENT
CSF samples can be a useful methodology for detecting circulating disease specific or associated miRNAs. Despite few ongoing stud ies, further research and more easily viable, cost effective and user friendly applications or methodologies are needed for implementing miRNAs as biomarkers for AD. The application of CSF to detect miRNAs is highly recom mended in comparison to blood. Blood samples are easily obtained at a low-cost and low risk. However, the molecular profile generated from blood and CSF samples can vary, as there is a possibil ity of additional factors being found in the blood (which are absent from the brain), due to blood’s systemic circula tion properties. Cerebrospinal fluid, on the other hand might be a more reliable biomarker, because it is protected by the blood brain barrier, which reduces unreliable biological factors that may influence the miRNA composition in AD or any other brain disorder. Internal and external factors influencing miRNA levels, include genetic variation, age, gender, race, inflammatory status, lifestyle, methodologies or techniques used to process samples and measure miRNA levels. MicroRNA concen tration levels may vary in serum and
Figure 5: Table listing the miRNAs found as potential biomarkers in Alzheimer’s disease– The table lists the various techniques and tissue samples used for measuring miRNA levels in AD patient samples and can serve as potential strategies for biomarker studies in clinical diagnostics. USEDTECHNIQUE ALTERED MIRNA IDENTIFIED DISEASENEURODEGENERATIVECAUSED REFERENCE Microarray Analysis miR-12 Alzheimer's Disease 9, 151
Disease 156
MicroRNAs as therapeutics
Alzheimer's
Technology
Alzheimer's
in the early stage of any disease may enable patients to receive early ther apy. MicroRNA has been advocated as a possible biomarker for different types of diseases regarding diagnosis and treatment. These diseases include, neurodegenerative diseases such as AD and different types of cancer (lung carcinoma, gastric cancer, oesopha geal cancer, breast cancer, colorectal cancer). A widespread methodology used in miRNA biomarker study is the utilisation of their levels in the cerebrospinal fluid (CSF) as a mini mally invasive detection tool for preclinical markers for central nervous system diseases like AD, lymphomas and gliomas. Circulating miRNAs in the body fluids, showing statistically signifi cant alteration levels, have been widely accepted as an important diagnostic factor in miRNA biomarker research in many diseases, including AD. Several research groups used different human patient samples (serum, peripheral blood mononuclear cells, cerebrospinal fluid) and different techniques (to measure circulating microRNAs) (Figure 5).
Table listing the miRNAs found as potential biomarkers in Alzheimer’s disease– The table lists the various techniques and tissue samples used for measuring miRNA levels in AD patient samples and can serve as potential strat
Overview: Delivery of miRNA into the central nervous system, is very challeng
Nanostring let-7d-5p, let-7g-5p, miR-15b-5p, miR-142-3p, miR-191-5p, miR- 301a-3p, and miR-545-3p
Microarray + qRT-PCR miR-15a
plasma samples, within the same person. Research study have shown that differ ent types and concentrations of miRNA were found in blood, plasma, serum and exosome samples. Thus, a care ful analysis of data from these various samples should be done as a downstream processing protocol in every biomarker study. Additionally, precaution should be taken in the process of analysing the downstream data, for understand ing the statistical significance and the relevance of the data in biomarker studies. The variation of miRNA meas urement requires a more standardised protocol, such as consistent sample preparation, statistical calculations, and systematic analysis of unvarying miRNA levels. In summary, miRNA biomarker research has the potential in understanding the pathogenesis of these age related neurodegenerative disease and deciphering the underlying regula tory molecular mechanisms leading to their clinical manifestations. As a step forward, miRNA biomarker research in a more detailed and comprehensive manner might help us to monitor and diagnose these diseases at the earlier pre-clinical stage.
and
let-7b
egies for biomarker studies in clinical diagnostics.Usageof
MiR-98-5p, miR-885-5p, miR-4833p, miR-342-3p, miR-191-5p and miR-let-7d-5p miR-128/miR-491-5p, miR- 132/miR-491-5p, and miR- 874/miR-491-5p, miR-134/miR- 370, miR-323-3p/miR-370, and miR-382/miR-370
Disease 157
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Mild Cognitive Impairment 152
SequencingRNA
Alzheimer's Disease 153
Alzheimer's
qRT-PCR miR-27a-3p
Disease 155
Alzheimer's
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Liposomes
Lipoplexes: Formed by cationic liposomes that self- assemble in the presence of RNA due to the electrostatic interaction between the positively charged lipids and the negatively charged RNA molecules.
1) Reduce the efflux of drugs out of the BBB. 2) Entrap both hydrophilic and lipophilic drugs. 3) W eakly immunogenic and biodegradable. 4) Protects the encapsulated therapeutic agent against rapid enzymatic degradation. 5) High versatility and flexibility in the surface modification with target recognition molecules. 6) Minimizing unwanted inactivating effects of the body and improving the biodistribution of the encapsulated drug to specific cells. 7) Low elimination by the liver and spleen, increases the circulation time of therapeutic agents in the bloodstream and improves the bioavailability of encapsulated molecules for therapeutic action.
1) Controlled drug release and high drug loading still remain challenges with dendrimers. 2) Their cytotoxicity increases proportionally with the generation number.
Figure 6: Non-viral methods of delivery – Various methods of non-viral mode of delivery in the central nervous system are listed in this table, along with their strengths and weaknesses, aiding in understanding the best strategy for miRNA delivery to the brain for effective neuro-therapy.
Cyclodextrins
1) Naturally derived materials with the ability to deliver therapeutic agents across the BBB. 2) Cyclodextrins have been investigated intensely in the targeted delivery of small therapeutic molecules due to their nontoxicity and not producing immune stimulation
1) It can induce inflammatory effects and unwanted interaction with negatively charged serum proteins, which can lead to opsonization and clearance of the lipoplex
Polymeric Nanoparticles
WEAKNESSES
1) Derived from intraluminal vesicles and are released from the plasma membrane; contain proteins, lipids, and miRNAs that can mediate various signaling functions; CNS-derived exosomes are released into physiological biofluids such as CSF and blood. 2) Exosomes can be used as diagnostic tools and have reduced immunogenicity and toxicity.
1) Possible effects of nucleic acids and proteins derived from dendritic cells and carried with the exosomes on the target cell need to be further explored.
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1) High cellular toxicity.
1) Efficient internalization of RNA via membrane fusion with the host cell, and high rate of endosomal release of RNA after entering the cell.
Dendrimers (Composed by repetitive units of branched molecules; ability to control their structure)
1) High biodegradability, biocompatibility, nonallergic, low immunogenicity, and lack of or low cytotoxicity, higher stability in biological fluids and protection of the RNA against degradation by RNases, reduced nonspecific biodistribution, encapsulate large amounts of genetic material (high drug-binding capacity), and high delivery efficacy, facilitate the cellular uptake via endocytosis.
1) High versatility to incorporate multiple molecules in the peripheral end groups. 2) Improve solubility, pharmacokinetics, and biodistribution of the therapeutic agents. 3) High loading capacity and transfection efficiency. 4) Low toxicity and immunogenicity; triggering endosomal escape and release RNA into the cytoplasm. They are cleared rapidly by the bloodstream, preventing ‘long-term’ accumulation in nontargeted organs, such as kidneys, lungs, and liver, reducing potential side
1) Traditional liposomes have low transfection efficiency into cells due to their lack of surface charges. 2) Nonspecific uptake, and unwanted immune response. 3) Usually heterogeneous in size owing to interactions between water molecules and the hydrophobic groups of lipids, and sometimes the large size of the liposomes produces microembolisms giving a false impression of brain uptake. 4) Conventional liposomes, composed of cholesterol and phospholipids, suffer from high plasma clearance and low transport
Polymeric micelles : Amphiphilic copolymers composed by a hydrophobic core and hydrophilic surface.
1) Easy to formulate, incorporated at different sites in micelles. 2) Small particle size that allows escaping from the reticuloendothelial system. 3) Enhanced drug solubility, drug pharmacokinetics, and biodistribution; high physical stability.
1) Enhanced penetration for a number of useful drugs, using this non-viral delivery system would also open the BBB to potentially toxic substances.
NONVIRAL DELIVERY SYSTEMS STRENGTHS
Exosomes
ing due to the presence of blood brain barrier (BBB). The BBB prevents the accumulation of bio-active compounds in the CNS, thereby posing as a limi tation for transfection efficiency for miRNA mimics or miRNA inhibitors introduction. To increase the transfec tion efficiency of these miRNAs and as an aid in their blood- brain barrier cross ing, two strategies have been formulated. In the first strategy, the restoration of the suppressed miRNA is achieved by introduction miRNA mimics (agonists). In the second method, the miRNA levels are lowered by inhibiting their activ ity by using anti-miR agents (antago nists). Depending on the therapeutic requirement, these strategic methods of either, increasing the expression of miRNA or lowering their levels, can be used effectively to modulate the levels of disease specific miRNAs in ameliorating the clinical manifestations of these neurodegenerative diseases. The methods required to suppress the function of microRNAs are anti-miRs oligonucleotide (AMOs), antagomirs, miRNA sponges, locked nucleic acids (LNA) anti-miRs and miR-masks. The methods required to enhance the activ ity or expression levels of miRNAs are by inducing miRNA expression vectors and miRNA mimics. Therapeutic appli cation of miRNAs-based agents poses towards an encouraging and optimistic path towards the initiative of finding a cure for various neurodegenerative disorders, including the ones rooted
Small packaging capacity, leads to severe limitations on the therapeutic cargo size.
32 PHARMA FOCUS ASIA ISSUE 48 - 2022
Figure highlight some of the widely used viral vectors delivery into the CNS
virus (AVV) Viral vectors are currently being used more frequently
WEAKNESSES
vantages associated with their meth odologies.
Small packaging capacity, which places severe limitations on the therapeutic cargo size.
for gene
and the advantages and disadvantages associated with their methodologies. RESEARCH & DEVELOPMENT
RNA-based therapeutics is emerging as potential drugs in various clinical fields, including neurodegeneration. RNA based therapeutics have yielded extremely positive results. However, these results do not include miRNAbased therapeutic strategies targeting against AD pathology. Patisiran, the first siRNA drug was approved by the FDA in 2018 for the treatment of heredi tary transthyretin-mediated amyloido sis. In this methodology, siRNA was packaged in lipid nanoparticles and directed to the liver, where it targeted the mRNA of transthyretin and blocked the production of the mutant protein. Treatment for spinal muscular atrophy (SMA) was approved in 2016 using a 2 -O-2-methoxyethyl phosphorothio ate-modified Antisense oligonucleotide (ASO). Splicing of SMN2 mRNA was inhibited by the ASO, thereby increas ing the amount of functional SMN2 protein, which could rescue the loss of SMN1 phenotype by compensat ing for the loss of SMN1 Another RNA-based therapy (zolgensma) was approved by the FDA for SMA, where a functional copy of SMN1 gene is delivered using an adenoviral AAV9 delivery system. Translational inhibi tion of tau mRNA using an ASO-based strategy (NCT03186989, BIIB080,
VIRAL DELIVERY SYSTEMS STRENGTHS
Adenoviral
RNA Based Therapeutics in Neurodegeneration:
7: Viral methods of delivery – T his table
Viral methods of delivery – This table highlight some of the widely used viral vectors for gene delivery into the CNS and the advantages and disad
deep in the central nervous system, due to these following properties: easier manufacturing methods, bio-safety, simplicity, potency and effectiveness and optimum duration of gene expression silencing. Within the context of brain delivery, the distribution of miRNAbased therapeutics and their effectiveness can also be influenced by the route of delivery. To overcome this issue, two methods have been applied for drug transport across the BBB, namely invasive and non-invasive approaches. The invasive approaches include Intra cerebro-ventricular infusion, intrath ecal, convection-enhanced delivery, and the disruption methods of BBB integrity. The non-invasive approaches include lipid-mediated drug transport, systemic intravenous administration, intranasal delivery, and strategies using nano-Differentsystems. and efficient carrier systems have been developed and applied in gene therapy trials to promote the transport and delivery of miRNAsbased therapeutics into the brain, increasing their accumulation in the site of interest, enhancing the silencing potency, thereby making these kinds of RNA therapeutics more effective. In a simple way, delivery methods can be divided into two categories, non-viral (Figure 6) and viral systems (Figure 7).
The transgene does not integrate into the host genome but remains episomal, leading to stable and sustained expression in the brain for at least up to a year; direct infusion into brain parenchyma results in gene transfer to a broad range of cell populations, including neurons, astrocytes, microglia, and oligodendrocytes.
Adeno-associated in the CNS. They are neurotrophic, can exist stably with a low rate of genomic integration, exhibit no pathogenicity or cytotoxicity,can be manufactured at high titers and at high purity, high efficiency in vivo delivery.
Alzheimer's Disease
Nanostring Technology let-7d-5p, let-7g-5p, miR-15b-5p, miR-142-3p, miR-191-5p, miR-301a-3p, and miR-545-3p
Alzheimer's Disease
USEDTECHNIQUE
CSF let-7b
Blood Plasma
ALTERED MIRNA IDENTIFIED
Microarray Analysis miR-12
SPECIMENSTISSUE USED
Serum RNA Sequencing and MiR-98-5p, miR-885-5p, miR-483-3p, miR-342-3p, miR-191-5p and miR-let-7d-5p
IONISMAPTRX), is currently in a clini cal phase I/II trial study. With respect to the miRNA-targeted pharmaceutical gallery, numerous ongoing clinical trials (CDR132L, Cardior Pharmaceuticals GmbH; RG012, Genzyme /Sanofi / Regulus Therapeutics; MRG-106, MRG-110, MRG-201, miRagen / Viridian Therapeutics; TargomiRs) are being continued. However, none of these trials are targeted for AD therapy. In the spectrum of neurodegenerative disorder, MRG-107, a miR-155 inhibi tor has been pre-clinically tested and validated by miRagen Therapeutics against ALS.
Alzheimer's Disease
Alzheimer's Disease
Peripheral mononuclearbloodcells (PBMCs)
Serum + CSF qRT-PCR miR-27a-3p
References are available www.pharmafocusasia.comat
DISEASENEURODEGENERATIVECAUSED
Alzheimer's Disease
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Mild Cognitive Impairment
Blood Plasma miR-128/miR-491-5p, miR-132/miR-491-5p, and miR-874/miR-491-5p, miR-134/miR-370, miR-323-3p/miR-370, and miR-382/miR-370
gies are key issues to be resolved. Even though a large number of miRNA-based companies are being acquired by major pharmaceutical companies to help find a novel category of drugs, the appli cation of miRNA therapeutics in AD is lagging behind other diseases areas such as cancer, which has approximately 30 times more new molecular targets in clinical trials than AD. Technology improvisation, aggressive monetary investment, and research develop ment in the field of neurodegenera tive disorders such as AD, are needed to bridge the gap between promising initial bench side miRNA research and clinical application.
Serum + CSF Microarray + qRT-PCR miR-15a
Alzheimer's Disease
therapeutics is a developing field in comparison to other oligonucleotide based therapeutics, like siRNA and ASO. Therefore it is essential to conduct a more detailed, comprehensive basic research to characterise how miRNAs target molecular and cellular path ways in neurodegenerative diseases. Additionally, a systematic mapping of the on- and off- target toxic effects of miRNA based gene regulation should also be considered while designing miRNA based therapies. These factors serve as important prerequisites for effective clinical application of miRNA in treatment of AD and other neurode generative disorders. Additionally, better methods of targeted brain delivery and additional investigation of the toler ability of miRNA restoration strate
AUTHOR BIO Bidisha Roy currently a postdoctoral associate and teaching instructor, in the Department of Biological Sciences, Rutgers University, Newark. She has previously, held postdoctoral fellow positions at the Department of Neurology, UTHSC, Memphis, TN; Department of Pathology, Friedman Brain Institute, Icahn School of Medicine, Mount Sinai, New York; Department of Neurology, University of Texas Medical Branch, Galveston, Texas. Education: Ph.D. (2009)Biology (Neurobiology, genetics, biochemistry, molecular and cell biology), National Centre for Biological Sciences, Tata Institute of Fundamental Research, Bangalore, India; M.Sc. (2002)Biotechnology, Jawaharlal Nehru University, New Delhi, India; B.Sc. (2000)Microbiology, University of Delhi, New Delhi, India. Research interests: Molecular mechanisms underlying neurodegeneration, neurodegenerative and neurodevelopmental disorders, drug screening and therapeutics, lysosomal dysfunction in disease and cell biology of neurodegeneration, neural development, circuit formation, and function.
Till now, even though various clini cal trials are ongoing to test miRNAbased therapeutics against several peripheral diseases, none have been attributed for the treatment of AD. However, gemfibrozil, a previously FDA-approved drug for decreasing cholesterol and lipids, has undergone a phase I trial to evaluate its ability to increase miR-107 levels for the prevention of AD in cognitive health and MCI individuals (NCT02045056). Gemfibrozil was found to be a safe drug, in inducing a change in miR-107 plasma levels, decreasing A 42, pTAU, A 42/ pTau ratio, brain atrophy, and plasma TNF levels in the treated patients. However, these studies did not reach a statistical significance. MiRNA-based
EXECUTIVES SPECIAL ISSUE
e. School of Pharmacy, University of Nottingham
b. Vaxine Pty Ltd
c. Department of Biochemistry and Chemistry, La Trobe Institute for Molecular Science, La Trobe University
d. Monash Institute of Pharmaceutical Sciences, Monash University
Sakshi Piplania,b, David A. Winklerc,d,e*, Nikolai Petrovskya,b*
The SARS-CoV-2 pandemic has required new methods for rapidly developing effec tive vaccines and drugs to treat COVID-19 patients. There are approximately 12,000 existing drugs, approved natural products, and clinical trials candidates whose safety in man has already been established. Computational repurposing of these drugs, where mathematical methods are used to simulate their interactions with key proteins in the virus, is a rapid way to find new treatments for SARS-CoV-2.
Introduction
SARS-CoV-2ProductsDrugsRepurposingComputationalofandNaturalAgainst
RESEARCH & DEVELOPMENT
34 PHARMA FOCUS ASIA ISSUE 48 - 2022
The SARS-CoV-2 pandemic has required the development of new methods for rapidly developing effective vaccines and drugs to treat COVID19 patients. There are approximately 12,000 existing drugs, approved natural products, and clinical trials candidates whose safety in man has already been established. Computational repurposing of these drugs, where mathematical methods are used to simulate their interactions with key proteins in the virus, is a rapid way to find new treatments for SARS-CoV-2.
The COVID-19 pandemic caused by the SARS-CoV-2 virus has infected at least 500 million people and has killed almost 7 million, both numbers likely to be underestimates. There has been a massive mobilisa tion of scientific research efforts around the world to understand the origin and structure of the virus, and to develop effective vaccines and drugs to treat patients with COVID-19, the illness caused by the virus. While rapid progress has been made in a rela tively short space of time in both vaccines and thera peutics, the treatment options for patients severely ill with COVID-19 remain limited. Unfortunately, traditional development of new drugs takes of the
a. College of Medicine and Public Health, Flinders University
Blue color highlights the interacting residues in the binding pocket.
35www.pharmafocusasia.com
Red color is the drug inside the binding pocket
order of 10-15 years, which is unaccept ably long for pandemics when drugs are needed as soon as possible.
Blue color highlights the interacting residues in the binding pocket Grey color is the protein
properties and limitations of the soft ware, the results obtained can be unre liable at best and meaningless at worst. Considerable understanding of the structural biology of the targets and the operational parameters of the docking software is required to achieve robust results, as was reviewed very recently.
While most widely used molecular docking software is easy to run, these studies have varied enormously in qual ity and outcomes because, without full understanding of the protein target
One approach to drug discovery that can be productive in very short time frames is the repurposing of existing drugs. Already approved drugs, natural products, and drugs already in clinical trials for other indications have all been tested for safety in man and could be used ‘off label’ for emergency use in a pandemic. The principle behind our in silico antiviral drug screening approach is that all drugs hit targets other than those for which they are designed, this off-target activity is the origin of most drug side-effects. This off-target activ ity has also been exploited in the seren dipitous discovery of several blockbuster drugs such as Viagra and Minoxidil (both originally antihypertensive drug candi dates). While all 12,000 or so repurposing candidates could in principle be tested experimentally for activity against virus targets or in vitro, it is much faster and cheaper to use computational methods to achieve this. This realisation caused an unprecedented surge in publications where we and others have used molecu lar docking to identify promising drugs that could bind to the dozen or more viable target proteins in SARS-CoV-2.
Red color is the drug inside the binding pocket
Fig2: Surface binding representation of Doultegravir with helicase.
EXECUTIVES SPECIAL ISSUE
Grey color is the protein
In the studies summarised below, rigorous computational methods were used to identify potentially useful COVID-19 drug candidates for repur posing. This involved a combination of validated molecular docking meth ods (that calculate the orientation and binding energy of drugs to binding sites in proteins), and molecular dynamics methods (that allow for protein and drug flexibility and calculate more accurate binding poses and energies) to identify the most promising drugs and natural products for treating COVID-19. Most importantly, rigorous quality control measures were applied at every step in the process to ensure the quality of the target predictions.
Fig1: Surface binding representation of Paritaprevir with RdRp
searches disclosed that >30 per cent of our predicted repurposing candidates for all three SARS-CoV-2 protein targets have experimental validation data, a very impressive validation rate for the computational methods employed.
setdrughigh-throughputtoscreeningaretorevolutionisepandemicdrugdiscoveryefforts.
Red color is the drug inside the binding pocket Blue color highlights the interacting residues in the binding pocket.
In approachessilico
RESEARCH & DEVELOPMENT
and has a reported in vitro SARS-CoV-2 IC50 of 18.8 µM, and CC50 >20 µM.
Fig3: Surface binding representation of Simeprevir with MPro.
36 PHARMA FOCUS ASIA ISSUE 48 - 2022
Given the function of SARS-CoV-2 RdRp to bind RNA, its binding site is large. Most of the repurposed drugs in the list of 20 best binders we predicted had relatively large complex structures and substantial ligand flexibility. Antiviral drugs accounted for half of this list, the remaining compounds in being mostly natural products or their derivatives. These were of particular interest given their relative novelty and molecular diver sity. Interestingly, our computational screen identified ivermectin as fitting snugly into the RdRp binding pocket. Ivermectin and other avermectins and milbemycins are broad-spectrum antipara sitic macrocyclic lactones that have shown inconsistent activity against SARS-CoV-2. Ivermectin has been widely touted as a drug against COVID-19, although the debate around its use has become highly politicized. It is interesting, therefore, that our unbiased screening methods identified Ivermectin as one of its top hits. Digoxin is a widely used cardiac drug used to treat heart arrythmias and cardiac failure and has a large complex structure that fitted well into the RdRp binding pocket. It exhibited potent in vitro antiviral effects against SARS-CoV-2 in Vero cells (IC 50 37 nM). Another tightly binding natural product, silibinin, is a flavonolignan that is the major active constituent of silymarin, a standardised extract of the milk thistle seeds. It can function as an antioxidant, antineoplastic drug, and hepatoprotectant. Rapamycin, a macrolide antifungal metabolite with immunosuppressant activity that also bound tightly to RdRp, is currently in COVID-19 clinical trials. Other highly ranked natural products from our in silico screens included: carbetocin, a synthetic analogue of oxytocin;eribulin, a fully synthetic macrocyclic ketone analogue of the marine natural product halichondrin B, a potent anti-mitotic anticancer agent; novobiocin, a DNA gyrase and bacterial type IIA topoisomerase inhibitor; and
SARS-CoV-2 Mpro inhibitors
Mpro is a key protease essential to SARS-CoV-2 function. We therefore screened drug libraries for compounds that might bind and inhibit Mpro . Several of the top ten best binding drug candidates were antiviral agents sime previr, sofosbuvir, lopinavir, ritonavir and remdesivir. The more interesting candidates had similar binding affini ties and were of diverse activity classes. These were bemcentinib (AXL receptor kinase inhibitor), montelukast (leukot riene receptor antagonist), ergotamine and mergocriptine (ergot alkaloids with adrenergic and dopaminergic receptor agonist activities). Bemcentinib shows in vitro activity against SARS-CoV-2 with 10-40 per cent protection at 50µM in Vero cells and an IC 50 of 100nM and CC50 of 4.7µM in Huh cells. Indeed, it is already an investigational treatment for COVID-19 , with a phase 2 trial underway. Montelukast another inter esting hit has been shown to produce a significant reduction in SARS-CoV-2 infection in elderly asthmatic patients
Grey color is the protein
SARS-CoV-2 RdRp inhibitors
Three key protein targets essential for the function of SARS-CoV-2 were used to screen a large library of ~12,000 small molecule drug candidates. The targets were the main protease of the virus, Mpro or 3CLpro, the RNA -dependent RNA polymerase (RdRp, essential for viral replication), and the helicase (also part of the virus’ replicative machinery). The docking calculations were validated by redocking drugs into the relevant protein binding sites to recapitulate the binding poses in the experimental structure. The calculations were run on large GPU clus ter machines generously made available during the pandemic by Oracle Cloud Systems. The top 80-100 drug candidates identified by the docking calculations were subjected to molecular dynamics calculations to improve the estimates of the relative binding energies of drugs to proteins, and their binding poses in the protein active sites. Subsequent literature
BIOAUTHOR
Sakshi Piplani is a Senior Bioinformatics Scientist skilled in Structural Bioinformatics, Data Analytics, Machine learning. She uses computational modelling of immuogenic receptors, discovery of potential new drugs/ lead compounds through machine learning and virtual screening. She also uses computers to simulate protein structures, and identify their functions.
ergotamine and related ergot alkaloids also predicted by us and others to bind several SARS-CoV-2 molecular targets, including the main protease, Mpro.
EXECUTIVES SPECIAL ISSUE
37www.pharmafocusasia.com
David A Winkler is Professor of Biochemistry &Chemistry at La Trobe University. He applies computational chemistry, AI, and machine learning to design drugs, agrochemicals, nanomaterials, and biomaterials. He is ranked 227th of 81,000 medicinal chemists worldwide and has written >250 journal articles and book chapters and his H index is 54.
The twenty molecules with the best predicted helicase binding affinity can be broadly characterized as contain ing one or more hydrophobic aromatic moieties linked to another polycyclic moiety containing hydrogen bond donors or acceptors. These molecules come from diverse drug classes, with antiviral agents making up 25 per cent of the hits and antihistamines and antip sychotics also being well represented. The most interesting non-antiviral agents identified by the study were hesperidin(citrus flavanone glycoside), rutin (flavonol glycoside), conivaptan (vasopressin inhibitor), aprepitant (NK1 antagonist), manidipine (Ca channel blocker, anti-hypertensive), aminoquinuride (trypanocidal agent), antrafenine (analgesic anti-inflamma tory), epirubicin (anticancer intercala tor), dicoumarol (anticoagulant), flus pirilene (antipsychotic), fexofenadine (antihistamine), astemizole (antihista mine), sertindole and pimozide (antip sychotics). Of these manidipine exhibits broad-spectrum antiviral activity, with SARS-CoV-2 IC50=2µM in HUH7 cells and 7.5µM in Vero cells. Tipranavir also exhibits a relatively broad spectrum of antiviral activity, inhibiting replica tion of SARS-CoV-2 in VeroE6 cells. Fluspirilene activity against SARSCoV-2 was reported to be 3.1µM in Vero E6 cells, mirroring the activity of fluspirilene against MERS-CoV and SARS-CoV in Vero E6 cells of 7.5µM and 6.0µM, respectively. Astemizole had an EC 50 of 1µM against SARSCoV-2 in Vero E6 cells and 4.9µM and 5.5µM against MERS-CoV and SARS respectively.
Nikolai Petrovsky is Professor of Medicine at Flinders University, Director of Endocrinology at Flinders Medical Centre and Research Director of Vaxine, an Adelaide-based biotechnology company focused on vaccine development. He has been awarded over 50 million dollars in vaccine grants including from the US National Institutes of Health. In addition to authoring over 200 peer-reviewed research papers he is an inventor on multiple vaccine patents, and most recently developed the Covax-19/SpikoGen® vaccine against COVID-19 that in October 2021 received emergency use authorization in Iran, making it the first recombinant protein COVID-19 vaccine in the world to receive approval, and the first successful human vaccine developed in Australia in the last 40 years.
Conclusions
Computational screening methods prom ise fast and reliable identification from libraries of existing drugs, clinical trials
candidates, and approved natural products of compounds that may have useful activ ity against SARS-CoV-2. The three stud ies summarised here show that docking methods are capable of reliably predicting the binding pose of drugs to structures of virus target proteins. Complementary MD simulations performed on the repur posing candidates with the highest dock ing scores provide more reliable relative binding affinities of these drugs for the targets, allowing the docking hits to be ranked for activity. This is a very rapid and efficient way to screen for potential anti-viral drug activities.
The fact that >30 per cent of the top 80-100 repurposing candidates we identified have experimental activ ity against the target and/or the virus, with several already in clinical trials for treating COVID-19 shows the compu
SARS-CoV-2 Helicase inhibitors
tational predictions were highly reliable. Therefore, the 70 per cent of repurposing candidates identified by these studies that have not yet been assessed for in vitro or in vivo activity could provide a rich resource of potentially useful drugs for treating COVID-19. As these are gener ally applicable, platform methods, they are equally suitable for identifying repur posed drugs to treat neglected tropical diseases, or viral infections and future pandemics.[5]We are seeing the begin ning of an era where experimental high throughput drug screens will comple ment structural biology-based and machine learning methods to provide faster, more efficient, cheaper, and more robust methods for repurposing existing drugs or discovering new ones. References are available www.pharmafocusasia.comat
MagnitudeInfections of the problem and impact ANTI-FUNGAL RESISTANCE
Fungi are ubiquitous in nature and cause disease in humans, animals, and, especially, plants. The range of human fungal infection varies from superficial infections (pityriasis, athlete’s foot, ring worm, nappy rash, and many others), allergic disease (chronic sinusitis and fungal asthma), chronic infections (chronic pulmonary aspergillosis and the NTD mycetoma as examples) to
Anti-fungal resistance is increasing, with the global spread of the multi-drug resistant Candida auris since 2008, increasing rates (up to 95 per cent) of azole resistance in Aspergillus fumigatus and the emergence of a new species of Trichophyton in India which is terbinafine resistant. Accurate and rapid diagnosis of most fungal infections is now possible with nonculture based tests, allowing tailoring of both antibacterial and anti-fungal therapy, but culture and susceptibility testing are required to detect resistance. New anti-fungal agents are being developed, but not fast enough to address this problem without minimising empirical anti-fungal therapy in patients and reduction in azole fungicides in crops.
L Shamithra M Sigera, Manchester Fungal Infection Group, Core Technology Facility, Grafton Street, University of Manchester; Department of Mycology, Medical Research Institute
Anti-fungals and resistance
Anti-fungals are used to prevent and treat fungal infections in humans, animals, and plants. Moreover, they play an impor tant role in material preservation and food safety [Verweij, P.E., et al. 2020].
RESEARCH & DEVELOPMENT
Microscopic view of Aspergillus terreus
severe life-threatening invasive infec tions (cryptococcal meningitis, invasive aspergillosis, candidaemia, mucormy cosis, etc). Some of these are recurrent infections (vaginal candidiasis) and some fungal infections are contagious. Globally, over 300 million people are threatened by serious fungal infections. Invasive fungal infections are associated with high mortality even with effective anti-fungal management: Cryptococcal meningitis; >50 per cent in the devel oping world and 15-20 per cent in the USA, invasive aspergillosis;~30 per cent mortality in leukaemia and >90 per cent in liver failure, invasive candidi asis; ~40 per cent mortality even with treatment [ GAFFI ].
crops such as rice, wheat, maize, pota toes, and soybeans. The list includes most high-value crops (coffee, bananas, cacao, mangos, and spices). Moreover, food becomes non-edible when fungi produce mycotoxins, commonly in if poorly stored. Fungi are major patho gens of trees, such as chestnut blight, ash dieback, and many others, impacting attempts to ameliorate global warm ing and incurring major economic loss. More species extinctions are attribut able to fungi than any other infectious group, notably many frog species in recent years. Fungal disease leads to decreased biodiversity and indirectly contributes to global warming.
David W Denning, Manchester Fungal Infection Group, Core Technology Facility, Grafton Street, University of Manchester; Global Action for Fungal
38 PHARMA FOCUS ASIA ISSUE 48 - 2022
Fungal infections go beyond humans — invading plants, insects, and animals. Fungi infect and destroy food crops reducing food production. It is esti mated that one-third of all food crops are destroyed by fungi annually (Fisher et al., 2012). They have a high impact on global nutrition and the economy by affecting the most widely consumed
Different classes of anti-fungals act on different targets, inhibiting fungal growth or killing them. A limited number of
Fungal disease of humans, animals, and plants
IV Invasive candidiasis and candidaemia
Drug resistance fungi
Amphotericin B IV topicaland
Griseofulvin Oral Tinea corporis and capitis
All forms of aspergillosis and endemic fungal infections Prophylaxis in leukaemia
Anti-fungal resistance might be either intrinsic or acquired. Naturally, some fungi are not killed by certain anti-fungals, and they are called intrinsically resistant to that anti-fungal. The second group is usually susceptible but alters their susceptibil ity over time with the presence of anti-fungals and becomes non-responders; Is called acquired resistance. Most of the antifungal resistance is acquired [Denning, D.W., 2022].Interestingly,
Refractory oropharyngeal and oesophageal candidiasis
Terbinafine Oral Tinea corporis and capitis
Empirical therapy in febrile neutropenia
Voriconazole Oral, IV Invasive and chronic aspergillosis, some rare moulds
39www.pharmafocusasia.com
EXECUTIVES SPECIAL ISSUE
anti-fungals are currently available for use (Table 1) and new anti-fungals come onto the market at a snail’s pace. Fungi have large genomes and are very adaptable. Both intrinsic (primary) resistance and secondary (acquired) resistance are well-known. Multiple strategies have been described in different fungi to resist the effect of anti-fungals, including modification of drug-acting sites or voiding the drug out of the fungal cell by efflux as 2 common examples. Many researchers continue to identify new mechanisms of anti-fungal resistance, and in many fungi, several mechanisms coexist in individual cells. Resistance in fungi is both increasing in incidence and increas ingly detected. Certain resistant fungi are already widespread across the globe [Denning, D.W., 2022].
Prophylaxis in acute lymphoblastic leukaemia
Salvage therapy for the treatment of invasive and chronic aspergillosis and mucormycosis
Onychomycosis (fungal nail infection) due to dermatophytes
Empiric therapy in febrile neutropenia
Itraconazole Oral, IV* Treatment for vaginal candidiasis
Oral, IV Cryptococcal meningitis induction therapy, Neonatal candidiasis, Candida endocarditis, and endophthalmitis, other rare refractory fungal infections
Fluconazole Oral, IV Treatment for vaginal candidiasis
Oropharyngeal and esophageal candidiasis (mucosal candidiasis), Treatment and maintenance therapy for Prophylaxiscryptococcosisinleukaemia, HSCT, and intensive care
Invasive candidiasis and Induction therapy of cryptococcal meningitis, endemic fungal infections
Table 1:Systemic anti-fungal agents and their primary indications
Second-lineMucormycosisfor invasive aspergillosis
Second-line invasive and chronic pulmonary aspergillosis
Oropharyngeal and esophageal candidiasis (mucosal candidiasis. Fungal skin and nail infections
An antifungal susceptibility plate of Candida species. The strain is susceptible (S) to amphotericin B (AP, seen at 5:00 with a large zone of inhibition) compared to fluconazole (FCA, seen at 11: 00 with a smaller zone of inhibition).
Posaconazole Oral, IV Prophylaxis of fungal infections in haemat opoietic stem cell transplant (HSCT) recipients and acute leukaemia
Flucytosine
ANTI-FUNGAL ROUTE PRIMARY INDICATIONS
anidulafungin)caspofungin,(micafungin,Echinocandins
03 parapsilosisCandida
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02 Candida tropicalis Resistant to the azoles have been reported Present on the skin, gut, genitourinary and respiratory tracts of humans. Harmless in healthy people
A major concern in transplantation, leukaemia, severe influenza and Covid-19, and high doses of corticosteroid.
Common environmental fungi occurring on decaying organic matter Resistant to most anti-fungals, except amphotericin B, posaconazole and isavuconazole Uncontrolled diabetes and corticosteroids are major risks.
08
01 Candida auris Multidrug resistance /pan anti-fungal resistant Identified since 2008 in all continents of the world.
Highly resistant to terbinafine and less susceptible to itraconazole Contaminates the environment and causing infection in household and other close contacts Common in India and now seen across the world Causes extensive ringworm, with strong inflammatory component
Some species are highly resistant to most anti-fungal agents It has a neurotropic nature
Causes oral candidiasis, VVC, blood, and deep-seated organsin people with a suppressed immune system Very strong biofilm producer
some of these fungi exhibit resistance to multiple anti-fungals, and some of them are resistant to almost all the available anti-fungals or to a complete class, such as pan-azole resistance. Table 2 shows the most frequently observed resistant fungi, and Table 3 to which anti-fungal fungus is resistant to.
Scedosporium spp Fungi occur on decaying organic matter (sewage, contaminated water, and urban soil)
06 Mucorales
07
Common mould and spores in the air are inhaled regularly Azole resistance driven by azole fungicide use in crops, increasing. Causes a wide range of infections (chronic lung disease, invasive aspergillosis, allergic disease).
Causes nail infections, kerat,itis and bloodstream infection (in leukaemia). Important plant pathogen, causing root rot and stem canker
RESEARCH & DEVELOPMENT
Causes subcutaneous infection infections, asymptomatic pulmonary colonization in cystic fibrosis patients, and severe invasive infections such as brain abscess and infective endocarditis. It is particularly involved in the near-drowning syndrome
Usually resistant to azole anti-fungal agents and resistance develops while on treatment; occasional echinocandin Aresistancecommon problem in recurrent vaginal candidia sis Systemic Candida infections including bloodstream infections Systemic infections are often nosocomial, as fluconazole breakthrough
NO. RESISTANT FUNGI COMMENT
05 fumigatesAspergillus
How anti-fungal resistance develops
indotTrichophytonineae
09
Human skin - adapted fungus, newly described in 2020 in India
Can persist in the environment irrespective of common cleaning and disinfection methods. Causes severe fungal infections including bloodstream infections
Fusarium spp. Fungi occur on decaying organic matter and water supply Resistant to most anti-fungals.
Table 2: Common fungal species with increasingly documented anti-fungal resistance
Resistance to the azoles and echinocandins reported (China, South Africa) Present on the skin as a commensal, hospitals spread disease through the hands of health staff Causes blood and deep-seated organs and infections associated with prosthetic devices and indwelling catheters This species can form biofilm
Misuse and overuse of anti-fungals, inadequate infection control in the healthcare sector, poor medical facili ties, and lack of awareness are blamed for the emergence and spreading of anti-fungal resistance.
Expansion of preventive and therapeu tic use of anti-fungals contributes to the growth of anti-fungal resistance. Repeated drug exposure in the form of prophylaxis or long-term therapy is often associated with the emergence of resistance. When fungi are exposed to suboptimal concen trations, drug-resistant fungal strains are
A cause of hospital-acquired infections and difficult to control outbreaks. Outbreaks have been reported in India, Italy, Florida, and California
04 Candida glabrata Presents in the GI tract, mouth, and genital area.
Acute severe infections often of the nose, sinuses and penetrate the brain, and lungs.
How to prevent anti-fungal resistance
Anti-fungals have been used widely in the agriculture sector to prevent fungal infections in crops. Azole-based agricultural fungicides are a cornerstone of the crop protection market(including prochloraz, difenoconazole, propicona zole, hexaconazole and tebuconazole) [Darwin, J., et al. 2015]. However, the wide use of fungicides in agriculture is closely linked to creating environmental niches for fungi (Aspergillus in particu lar) to become resistant. Agricultural fungicides which share similar molecular targets with systemic azole anti-fungals are reported to cause the selection of resistant fungal species. [Verweij, P.E., et al. 2020] [Denning, D.W., 2022].
Anti-fungals play a pivotal role in the treatment of human fungal infections and a successful therapeutic outcome
Amphotericin B Fluconazole Itraconazole Voriconazole Posaconazole Echinocandin Terbinafine Candida auris + ++ ++ + + + NA A calidoustus + ++ ++ ++ ++ NA NA Fusarium solani + ++ ++ + NA ++ NA Scedosporium spp NA ++ + NA + + NA prolificansLomentospora ++ ++ + + + + NA C tropicalis + + + + + NA NA Candida parapsilosis NA + NA NA NA + NA C glabrata + ++ NA NA NA + NA fumigatusAspergillus + ++ + + + NA NA Mucorales NA ++ + ++ NA ++ NA Trichophyton spp. NA NA NA NA NA NA ++
EXECUTIVES SPECIAL ISSUE
With the rising at-risk population, the requirement for new strong antifungals is growing. However, the devel opment of new powerful anti-fungals is at a slow pace. Moreover, some anti-fungals show a limited spectrum of activity. Consequently, it is vital to curb anti-fungal resistance because so few anti-fungals are currently avail able, with only a few new molecules in development.Moreover,low, and middle-income countries commonly have only some of the quality anti-fungals available in high-income countries. A rising inci dence of resistant strains there is not manageable in many of these countries.
The emergence and spread of resistant fungi is now a widespread and global threat. Consequently, we all must fight this problem together, linked with antibacterial resistance countermeasures. A multifaceted approach at the healthcare level, community level, and industry level is necessary.Thehealth care sectors in each coun try can contribute to the containment of resistant fungi through meticulous screening by culture, species identifica tion, and susceptibility testing. Good infection control measures are essential, including air protection measures for vulnerable patients. The incorporation of anti-fungal stewardship programs (including rapid diagnostics to mini mise unnecessary antibacterial or antifungal therapy) into routine practice will minimise the emergence and spread of resistance among fungi.
Meanwhile, scientists are continu ing to develop new laboratory tests to detect resistant fungal infections. Such novel methods will need clinical trials to demonstrate their worth, and these trials need public Epidemiologicalfunding. research and surveillance are also key to under standing the emergence and spread of anti-fungal resistance. The gathering of data on anti-fungal resistance through
41www.pharmafocusasia.com
selected. This may be observed among the patients with chronic fungal infec tions who are supposed to take prolonged anti-fungal treatment courses. Some of these patients show poor compliance with drug regimens (often linked with toxicity or poverty) allowing for the selection of resistance fungi. For example, increased use of azole for prophylaxis and long-term use of azole in chronic conditions are linked with azole resistance in Aspergillus species [Verweij, P.E., et al. 2020].
Why we need to prevent antifungal resistance
mandates effective anti-fungal treat ment. Emerging and spreading antifungal resistance make existing antifungals ineffective. The only oral class of anti-fungals for Aspergillus infections is the azole, and so pan-azole resistance commits patients to intravenous therapy only. Even common fungal infections become harder to treat resulting in severe infections and death. Since a few classes of anti-fungals are available, the emer gence of drug resistance severely limits the therapeutic options while multi-drug resistance and pan drug resistance anni hilate almost all options. In addition, patients with resistant fungal infections require specific expensive management and prolonged hospital stay.
Table 3: Fungal species with their resistant anti-fungals; ++ Highly resistant to anti-fungals, + some resistance, NA = not active or used
Rajasingham, R., Smith, R.M., Park, B.J., Jarvis, J.N., Govender, N.P., Chiller, T.M., Denning, D.W., Loyse, A. and Boulware, D.R., 2017. Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis. The Lancet Infectious Diseases, 17(8), pp.873-881.
IA in COPD populations 760,017 – 2,272,322 cases annually, 45-70 per cent mortality when diagnosed and treated
Cryptococcal meningitis 223,100 cases in HIV/AIDS annually, 15-70 per cent mortality when treated
Denning, D.W., Pleuvry, A. and Cole, D.C., 2011. Global burden of chronic pulmonary aspergillosis as a sequel to pulmonary tuberculosis. Bulletin of the World Health Organization, 89, pp.864-872.
FUNGAL INFECTION
3-21/100,000 globally (ie>750,000) with ~45 per cent annual mortality treated
BIOAUTHOR
42 PHARMA FOCUS ASIA ISSUE 48 - 2022
David W Denning is an infectious diseases clinician with expertise in fungal diseases. He serves as the Chief Executive of Global Action For Fungal Infections (GAFFI) and Professor of Infectious Diseases and Global Health at the University of Manchester, UK. He leads LIFE (Leading International Fungal Education (http://fungaleducation.org/), which is focused on improving patient outcomes through online education and the Aspergillus Website (www.Aspergillus.org.uk). GAFFI (www.GAFFI. org) advocates for universal access to fungal diagnostics and antifungal therapies. He is also a member of the SEARO Task Force on Antimicrobial Resistance (AMR).
Centers for Disease Control and Prevention. Invasive Candidiasis Statistics https:// www.cdc.gov/fungal/diseases/candidiasis/invasive/statistics.html Accessed April 20, 2022.
Pre-COVID-19, 140 /million in India (170,000), with ~45 per cent mortality treated.
Fungal keratitis 1.0 to 1.4 million eyes affected annually, at least 60 per cent blindness and ~10 per cent loss of eye
WHO.Mucormycosis (covid-19)/mucormycosis.https://www.who.int/india/emergencies/coronavirus-disease-AccessedApril202022
137 million women affected in any one year
Brown, L., Leck, A.K., Gichangi, M., Burton, M.J. and Denning, D.W., 2021. The global incidence and diagnosis of fungal keratitis. The Lancet Infectious Diseases, 21(3), pp.e49-e57.
Hammond, E.E., McDonald, C.S., Vestbo, J. and Denning, D.W., 2020. The global impact of Aspergillus infection on COPD. BMC pulmonary medicine, 20(1), pp.1-10.
Recurrent candidiasisvulvovaginal
Table 4: Incidence or prevalence of several serious fungal infections, in which anti-fungal resistance compromises therapy
of addressing crop fungal pathogens utilised.
RESEARCH & DEVELOPMENT
References are available www.pharmafocusasia.comat
GLOBAL BURDEN REFERENCE
Mucormycosis
L Shamithra M Sigera is a Sri Lankan who is currently attached to Manchester Fungal Infection Group as a research fellow for the completion of overseas postgraduate training in medical mycology. She did her undergraduate medical training at the University of Kelaniya, Sri Lanka. She then completed internship in General Surgery and Paediatrics and worked as a Medical Officer in Paediatrics. She has a special interest in medical mycology.
Chronic aspergillosispulmonary
Candidemia
strongly associated with the develop ment of anti-fungal resistance in the skin fungus Trichophyton and should be avoided. Azole fungicide use should be minimised and alternative means
Denning, D.W., Kneale, M., Sobel, J.D. and Rautemaa-Richardson, R., 2018. Global burden of recurrent vulvovaginal candidiasis: a systematic review. The Lancet infectious diseases, 18(11), pp.e339-e347.
~ 3 million affected in any one year, 20 per cent 1 year mortality, 50 per cent five year mortality
anti-fungal resistance surveillance (hospital, and environmental) programs aids in mapping resistance trends. Resistance should be sought not only in the healthcare sector but also in agricul ture settings. Surveillance of anti-fungal resistance should be a global enterprise, and databases of anti-fungal resistance openly shared. In addition, financial and technical assistance for low-resource countries should be provided to identify and contain resistant fungal species. The expansion of infrastructure for tracing and testing anti-fungal resistance and for surveillance programs should be a priority.The consumption of anti-fungals in a responsible manner will help to curtail this issue. As a community, we should avoid sub-therapeutic doses of anti-fungals (and poorly bioavailable generic preparations) which are more likely to select resistant strains. Overthe-counter anti-fungal treatment is
1 051 787 cases
Nanocrystal Technology Applied to the Treatment and Diagnosis of Neurodegenerative Diseases
Poor bioavailability of many approved and yet-to-be-approved drugs for the treatment of brain disorders represents a pharmaceutical challenge. Despite the high pharmacological activity, limited water solubility leads to poor absorption and sub-therapeutic drug concentrations at the target site. The formulation of drug nanocrystals (NCs) emerges as a promising approach for different administration routes to enhance the brain delivery of hydrophobic drugs.
obstacle in the development of new therapies is often the poor solubility of many drugs in the research pipeline. Almost 90 per cent of them have a little or no water solubil ity. The term 'poor solubility' applies when the maximum concentration of drug dissolved in water is <10 mg/mL; a molecule is defined as 'insoluble' at a maximum dissolved concentration of 0.1 mg/mL. Water solubility affects dissolution in aqueous fluids and thus the
Nanocrystals technology
Drug NCs are solid drug particles in the nanometer range surrounded by a stabiliser layer. If prepared as aqueous suspension, they can also be called nanosuspensions. The choice of the stabiliser is important since it can influence the physico-chemical properties of the formulation and its in vivo behaviour. Many stabilisers act as absorption promoters improving the bioavailability of the drug.
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Elide Zingale, University of Catania Angela Bonaccorso, Researcher, Department of Drug and Health Sciences, University of Catania Rosario Pignatello, Full Professor, Pharmaceutical Technology and Legislation, University of Catania
bioavailability of the molecule. A common consequence is an increased required dosage or repeated administrations to reach the wished therapeutic concentra tions. Many of these molecules belong to classes II and IV of the Biopharmaceutical Classification System (BCS) and are suitable to be designed as NCs. In fact, nanonisation is one of the simplest and most effective strategies to increase the solubility, dissolution and bioavailability performance of these drugs.
An
Nanocrystals for nose-to-brain delivery
considered a useful approach to improve the antioxidant molecule bioavailability intended for Parkinson's treatment. In fact, many studies concern the develop ment of NCs based on antioxidants such as schisanterin, resveratrol, quercetin and ginkolide B. Schisanterinin particular is a Chinese herb which has been extensively studied for its antioxidant properties and its ability to reduce dopaminergic loss. The problem is always its poor oral availability and reduced solubility. Chen et al. demonstrated an increased bioavailability of schisanterin NCs and its neuroprotective efficacy.
The treatment of psychotic patients, most of whom are elderly, involves longterm treatment with repeated adminis trations, and often patient compliance and adherence to therapy are very low. Using of long-lasting nanocrystal formu lations of aripiprazole, for instance, has been approved by FDA by intramus cular injection. Buccal films based on aripriprazole NCs have been designed to improve the ease of therapy and opti mise the controlled release of the drug. Nanosuspensions of risperidone showed a much higher bioavailability than the marketed drug Risperidal®. One of the most used molecules in the treatment of Alzheimer's is donepezil. Its use in the form of oral tablets (Aricept®) causes gastric injuries that can be avoided afterintramuscular administration. However, the latter causes problems of poor patient compliance. Mittapelly et al. formulated donepezil NCs for intramuscular use that avoid gastroin testinal toxic effects and allow a longterm release of the drug.The design of NCs was also aimed at the treatment of demyelinating diseases, brain tumours and infections. An area of research that has been the subject of much interest and has produced optimistic results in recent years is the delivery of systems to the brain via the nasal cavity. The nose-to-brain route has proved success ful in preclinical models with various nanocrystal-based pharmaceutical forms, ranging from gels to sprays, powders
In the landscape of brain delivery, drug NCs are increasingly being studied for the treatment of neurodegenerative disorders. In particular, their develop ment in Parkinson's disease is one of the most studied areas. One of the main causes of this disease is an increase in oxidative stress and the production of free radicals. NCs technology can be
The nasal route is the only direct access of drugs to the brain by a non-invasive route. Intranasal drug administration allows drugs to be transported to the brain via two direct routes: the trigemi nal and the olfactory nerves, by over coming the BBB drawback. Due to the small volume of formulation that can be instilled into the nasal cavity, this route is limited to those drugs that are very potent at low concentra tions. Highly concentrated NCs may be a useful approach for this route. Antipsicotics such as zotepine, or donepezil, a molecule widely used in the treatment of Alzheimer's disease, have found many benefits in terms of increased bioavailability when adminis tered as nanosuspensions by this route. One obstacle may be the mucociliary clearance: increasing the mucoadhesion of the formulation,by means of viscous or in situ gelling formulations, so that the drug remains longer in the nasal cavity, may be a valid strategy. Hao et al. reported the use of a gelling system consisting of resveratrol NCs in deacety lated gellan gum gel that becomes a gel in the presence of cations in the nasal cavity. This strategy, in combi nation with nose-to-brain administra tion, resulted in a 400 per cent higher brain bioavailability compared to the neat drug.
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and solutions. The indications in which nanocrystal-based products for the noseto-brain pathway have emerged most strongly are neurodegenerative diseases such as Parkinson's and Alzheimer's. The projects involve the transport via this route of antioxidant molecules or molecules of industrial interest already conventionally used in the treatment of these diseases.
Nanocrystal strategy can improve drug bioavailability. In accordance with Noyes-Whitney’s theory, the decrease in drug particles size, resulting in an increase of surface area, leads to a higher dissolution rate of the drug in aque ous media. This ultimately enhances its bioavailability. NCs can be applied to different routes of administration, among which the oral route is the most popular. They can also be processed and delivered in any pharmaceutical form: suspensions, tablets, powder, sprays, eye drops, buccal adhesive films and hydrogels.
The lack of effective treatments for neurodegenerative diseases is mainly due to the presence of the blood-brain barrier (BBB), which protects the central nervous system (CNS) from foreign substances and drugs. Fortunately, nanotechnology offers brain targeting opportunities. The fact that NCs consist of 100 per cent drug makes them highly concentrated formulations, reducing the frequency of repeated dosing. The difficulty of drug transport into the brain could be bypassed by their small size. Moreover, the stabilisers used, such as Tween 80 in combination with D-tocopheryl polyethylene glycol succi nate (TPGS), aids Apo-E uptake of these systems and recognition by LDL recep tors. This initiates a receptor-mediated transcytosis and internalisation through the BBB. This also allows to avoid the recognition by opsonins and the attack by the immune system, overall leading to high concentrations of drug in the brain tissues.
Nanocrystals in brain diagnostic NCs are also widely studied for diagnos tic applications. Fluorescent semicon ductor-based on NCs are employed for
Nanocrystals in neurodegenerative diseases:
RESEARCH & DEVELOPMENT
these nano-drugs into different pharma ceutical final forms leads to a growing interest in NCs technology, especially for drug delivery to the brain. NCs drugs could be considered promising candidates for the high drug loading and the possibility of maintaining a very potent therapeutic action, particularly useful in the treatment of neurodegener ative diseases. This particular application of NCs drug is currently investigated, as indicated by the growing studies in this field and the increasing number of approved drugs on the market.
Marketed nanocrystals for brain diseases
deficit hyperactivity disorder (ADHD) are Ritalin® and Focalin®.
AUTHOR BIO
Angela Bonaccorso is a researcher at the Department of Drug and Health Sciences (University of Catania). She completed her International PhD in Neurosciences in 2017. Her research interests lie in the design and optimization of nanosystems through the quality by design approach focusing on drug delivery to the Central Nervous System by nose-to-brain delivery. She is author of 27 scientific articles published in international peer-reviewed journals. She attended national and international congresses and she is member of A.D.R.I.T.E.L.F; SCI; CRS Italy Chapter.
Elide Zingale is a PhD student in Neuroscience at University of Catania (Italy) under the supervision of Prof. Rosario Pignatello. She received her Master's degree in Pharmacy in 2020. During her thesis, she frequented the laboratory of Pharmaceutical Technology (University of Catania)and the Italian Research Council (CNR) with a study on the “Optimization of curcumin nanocrystals by DoE for nose-to-brain delivery”. At the end of 2020 she worked for one years in a project in collaboration with pharmaceutical company on the development of lipid nanoparticles for the ocular delivery of molecules of industrial interest. Now she is focused on a doctoral project on "Development of different nanocarriersloaded with Sirt-1 agonists for the treatment of degenerative eye diseases".
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Rosario Pignatello is full professor of pharmaceutical technology and legislation at the University of Catania (Italy). He is at present the Director of the Department of Drug and Health Sciences of the same university. He is coauthor of about 160 scientific papers dealing with pharmaceutical technology and innovative drug delivery systems, in particular for ophthalmic application. He is the scientific responsible of NANO-i, the Research Centre for Ocular Nanotechnology, and of CERNUT, the Research Centre on Nutraceuticals and Health Products of the University of Catania.
The importance of NCs has grown over the last decade with the global sector market increasing million by 2028 compared to 2021, with an unexpected compound annual growth rate (CAGR) during the same period. NCs, due to their structural simplicity and highly scalable manufacturing processes, have the potential to revolutionise the thera peutic and diagnostic fields and their application is bound to emerge in a near future. The simplicity of NCs composi tion and the possibility of transforming
Emend® was the first drug approved by the FDA in 2003 based on NCs formulation. This nanosuspension of aprepitant NCs acts centrally to inhibit chemotherapy-induced vomit ing. Subsequently, three long-acting injection (LAI) antipsicoticdrugs in the same class were approved. These extended-release depot formulations represented a revolution in the treatment of schizophrenia. In fact, one of the main problems is non-adherence to ther apy with poor patient compliance and repeated dosing. In particular, Aristada Initio®, Invega Sustenna® and Xeplion® are FDA-approved NCs medicines for the treatment of schizophreniain which the bioavailability of aripiprazole is improved. Zyprexa Relprevv®, based on olanzapine pamoate NCs, was also approved by FDA formulation for the parenteral treatment of schizophrenia. Two psychostimulant products based on methylphenidate and used in attention
Conclusions:
EXECUTIVES SPECIAL ISSUE
high-resolution cellular imaging, as well as for tumour targeting or visualisation of vascular damages. The main difference between fluorescent NCs and drug-based NCs is their chemical composition: the former are composed of inorganic materi als (gold, cadmium telluride, cadmium selenide and iron oxide), whereas drug NCs contain organic (polymeric) stabi lisers and Amongdrugs.themost widely used NCs in this field are rare-earth NCs made of elements of the lanthanide series such as erbium, ytterbium and europium. Perovskite NCs have recently aroused interest in diagnostics. They consist of a general formula, ABX3, in which A is a monovalent cation, B is a divalent metal cation and X is usually a halide. These systems have proven to be useful in the diagnostics of brain areas, with an optimal emission spectrum at 1700 nm.Ultimately, NCs have been used to prepare biosensors to assess adrenaline release or simulate synapses.
References are available www.pharmafocusasia.comat
RESEARCH & DEVELOPMENT
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(WHO ). Despite the growing health and wellness centricity across countries, respiratory conditions have not received the attention they need. If at all they do then it’s more for infectious conditions like Tuberculosis. But when wellness is looked at holistically, healthy lungs and lung health is paramount for over all health and wellbeing. According to WHO, respiratory illnesses lead to over 10per cent disability adjusted life years (DALYs), are second only to cardiovas cular conditions such as Stroke in terms of fatality and constitute to 5 of the 30 leading causes of death (WHO ). Current awareness and efforts are mainly directed towards control of indoor and outdoor air pollution and awareness generation around the major respiratory indications such as chronic obstructive pulmonary disease (COPD), asthma, tuberculosis and lung cancer. The need, however, is two fold, covering the whole gamut of lung diseases in awareness generation includ ing rare conditions like Interstitial lung diseases and increased focus on R&D for the understanding of these diseases and evaluating new lines of treatment powered by Pharmacogenetics,Pharmacogenomics.whichrefers to the variability in an individual’s response to drug therapies (NCBI ), has been receiv ing increased attention for many thera peutic conditions and holds immense
Awani, Consultant
Infact, non-communicable diseases, such as chronic respiratory diseases are among the biggest reasons for fatality
More than one billion people are impacted by chronic and acute lung diseases globally.
More than 1b people are impacted by chronic and acute lung diseases globally. Despite the growing health and wellness centricity across countries, respiratory conditions have not received the attention they need. Current need is two folds, covering the whole gamut of lung diseases in awareness generation including rare conditions like Interstitial Lung Diseases and increased focus on R&D for the understanding of these diseases and evaluating new lines of treatment powered by Pharmacogenomics.
EvaluationPharmacogenomicinLungDiseases A growing need
Similarly).
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Lungs are a vital organ for survival, pumping over 20,000 breaths in a day, they keep all the body organs alive by infusing the required amount of oxygen. Studies indicate that upto four million people die prematurely due to chronic respiratory diseases (Annals of
How can pharmacogenomics help
Traditionally, pharmacogenetics considered drug response as mono genic, following the Mendelian principles. Over time multifactorial genetic influences were looked at in Pharmacogenetics, such as the influence of environment, and this widened the horizon. Pharmacogenetics now also considers variability in gene expression which may arise due to other factors such as drug induced variation, rather than a mutation. With systematic and procedural advances pharmacogenet ics evolves into the wider discipline of pharmacogenomics. Pharmacogenomics helps identify the underlying genetic causes of common diseases, which implies that new and more precise drug targets can be identified. This further implies therapies with not just improved drug safety but also better efficacy. Once the right drug targets are determined, patients can be categorized into different genetically defined classes by virtue of race or population sub-groups with a particular gene. These are groups that are likely to have similar reaction to a drug. Lung conditions such as the Interstitial lung diseases (ILD) can bene fit significantly with Pharmacogenomics given the observed variability in patient outcomes with current standards of care (PubMed , ResearchGate ).
ILD constitutes a set of heterogeneous, inherited, lung conditions, which show significant variation in response to thera pies. Also referred to as Fibrotic intersti tial lung diseases (ILDs), these conditions are associated with high mortality rate, tend to have an unpredictable disease course but also have clinical features that frequently overlap (PubMed ). The disease susceptibility and progression both have genetic association. With the applica tion of pharmacogenomics, the genetic factors that influence the response to treatment, can be understood. Drug metabolism and disease activity are both influenced by different genetic factors. Several genetic associations have been established for conditions like Idiopathic Pulmonary Fibrosis (IPF), one of the Interstitial lung diseases and the most common fibrotic lung disease, with the application of genomic technology. Several studies have indicated the suscep tibility to IPF and also mortality to be
associated with certain genes. Studies have also indicated toxicity and severe adverse drug reactions with the current standard lines of treatment in conditions such as IPF – a patient suffering from IPF and treated with Azathioprine developed severe alveolar haemorrhage (European Respiratory Journal ). The potential that Pharmacogenomics holds is not just in avoiding situations of such ADRs but also identifying the right drug and dose for each patient for improved efficacy in conditions such as IPF.
IPF is a chronic condition with unknown etiology and high rates of mortality. With the application of the principles of Pharmacogenomics, an individual's molecular data and the 'omics' data (viz genomic, proteomic, epigenomic) can be used for identify ing strategies for disease prevention and management. The Pharmacogenomic concepts can be applied to both the sporadic and familial forms of IPF and offers significant hope for better disease outcome through effective and timely predictions and overall disease manage ment. This approach holds significant potential in not just personalizing treat ment for IPF patients but also identifying the need for lung transplant. Over time cumulative data from such approaches can help in stratifying patients basis their omics data and planning the right disease management approaches for them (PubMed
potential for transforming the state of healthcare globally. The underlying principles of inheritance as envisaged by Gregor Johann Mendel remain and the variability occurs due to several genetic and non-genetic factors. The genetic factors could be like gene mutations. Studies indicate that genetic factors could contribute to as much as 95per cent of the variability in treatment response (NCBI ).
Lung diseaseepidemiology
in COPD, inhaled corti costeroids are commonly prescribed but patient outcomes and even Adverse Drug Reactions tend to vary with the same therapy for patients because of known genetic linkages (PubMed ).
Besides other lung conditions, Pharmacogenomics holds great poten tial in lung cancer treatment as well. Chemotherapy in Lung Cancer is known to substantially improve overall survival as also progression-free survival. However, ADRs and even mortality is known post chemotherapy and patient outcomes show significant variation. Thereby there is need for individual specific dose and
EXECUTIVES SPECIAL ISSUE
Global Health ). Different lung condi tions have varying prevalence across the globe. Prevalence of Interstitial lung diseases (ILD) has been noted to range from 6.3 to 71 per 100,000 people. In North America and Europe, Idiopathic Pulmonary Fibrosis and Sarcoidosis are the most prevalent forms of ILD observed. There is wide varia tion observed in the prevalence of ILD alone.For instance in countries of Asia like India and Pakistan, Hypersensitivity Pneumonitis has relative higher frequency. In some other countries such as Belgium, Canada and Saudi Arabia, connective tissue disease ILD has relative higher prevalence. This significant variation in prevalence of ILDs is not a reflection of the actual prevalence in the underly ing population but also represents the differences in disease classification. Lack of standard ontologies and lack of glob ally representative data or comparative epidemiological studies on ILD are all opportunity areas for enabling global effort in disease management.
Genetic association of lung diseases
RESEARCH & DEVELOPMENT
Lung diseases fail to receive the atten tion and concerted global effort that they deserve despite the disease burden. The global spread of lung diseases varies still chronic respiratory diseases are among the leading causes of fatality globally. The
Pharmacogenomics offers great hope for several lung diseases which tend to have variable outcomes with tradi tional lines of treatment and also lead to high mortality. With the leverage of Pharmacogenomics based diagnostic tests, underlying genetic causes of lung diseases can be determined. With this approach new and more precise drug targets can be identified such that overall effectiveness of treatment can be improved with better safety results. Patients can also be strati fied into sub-groups based on multiple parameters such as race, genetic make-up; this is especially important considering that genetic factors can lead to upto 95per cent variability in treatment response. The benefit of Pharmacogenomics lies in not just capturing the genetic effect but also considering other factors such as the impact of environment or drug induced variability in gene expression which may otherwise be construed as mutation.
The economic value in pharmacogenomic evaluations
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BIOAUTHOR
Lung diseases such as IPF have been shown to have genetic linkage. This holds good not just for the familial form but also the sporadic form of IPF. Pulmonary fibrosis is observed to be caused by mutations in surfactant proteins. Some studies have indicated mutations in telomerase in individuals of families suffering from IPF. Infact even in cases of sporadic IPF, shortened telomeres have been observed. Studies have also indicated that a variant in mucin 5B, predisposes individuals to IPF and this has been observed in individuals with both the familial and sporadic types. This further implies that even sporadic is trig gered by existing genetic predisposition (PubMed , PubMed ). Environmental factors, cigarette smoking, exposure to metal fumes and wood dust exposure, all exacerbate the risk of developing IPF but the disease still has a genetic predis position. The same is evident through its familial aggregation. Pulmonary fibrosis is known to occur in many rare genetic disorders, a fact that further reinforces this.Other forms of ILD which may have genetic origin include –Lymphangioleiomyomatosis (LAM), Nonspecific interstitial pneumonia (NSIP), Pulmonary alveolar proteinosis (PAP) and BesidesSarcoidosis.ILDs,many other rare lung conditions have a genetic asso ciation. Chances of developing COPD or Emphysema increase in individuals with Alpha-1 Antitrypsin deficiency, a genetic condition. Cystic Fibrosis and Pulmonary Arterial Hypertension (PAH) are also know to have genetic association (Cleveland Clinic ).
treatment basis pharmacogenomic evalu ation for personalised care and better outcomes. Pharmacogenomic studies have indicated variation in tolerability and response to chemotherapeutic agents used in the treatment of lung cancer (PubMed ).
On closer evaluation it can be surmised that Pharmacogenomic assessment in lung diseases offer economic benefit as well alongside the promise for a better quality of life for the patient. Prevalence of genetic variance, cost of the Pharmacogenomic test as also cost of choosing the wrong treatment are the primary factors that can help assess the economic viability of pharmacogenomics. The fact that Pharmacogenomics may hold potential for improved drug effec tiveness and reduced ADRs for various lung conditions, impinges on the over all cost effectiveness of the treatment. Additionally, it may help with reduced toxicity in drug development which is a big reason for Pharma companies as well to focus on Pharmacogenomics. It will be important to determine the clinical effectiveness of Pharmacogenomics for different lung conditions, esp in compari son to the standard lines of treatment before its widespread adoption can be envisaged.Savings would be realised by elimina tion of costs due to a failed treatment.
Conclusion
In a study done using retrospective health claims data of Asthma patients, the pharmacogenomic evaluation in clinical practice was assessed. The study investigated alternate clinical strategies for establishing how potential costs can be offset. Annualised per patient cost was evaluated under two approaches, not testing any patient or testing all patients on the likelihood of a non-responsive genotype. The study observed that while upfront pharmacogenomic testing costs for Asthma patients may be high, this is offset by avoiding costs of non responsive treatments (Research Gate ).
overall spread of Interstitial lung diseases (ILD) or the diseases constituted within ILD shows marked difference across countries. This can be ascribed to not just a difference in population and their genetic makeup but an important reason is also the lack of standard definitions and ontologies for classifying these diseases.
Awani is a consultant with 18 years of experience in Life Sciences and Healthcare industry. She is a Biotechnology major and has worked with several leading Pharma clients in providing research and analytics services.
Recent Advances and Future Prospects of Treatment of Pulmonary Hypertension
Group 1 Pulmonary arterial hypertension (PAH)
Currently,outcomes.there are several thera peutic options available. But there are drugs under trial, and they are presently being evaluated for PHTN treatment. In addition, the recent coronavirus infection 2019 (COVID-19) pandemic has initiated a new interest in PHTN management among health care providers. COVID19infection has been shown to worsen
Chronic obstructive pulmonary disease
Patients with PHTN may present with multiple systemic involvement and symptoms masking the underly ing problem. A high index of clinical suspicion is needed as it is a frequently missed diagnosis due to the non-specific early signs and symptoms. It is necessary to review the management of PHTN as there are still some areas regarding the management of PHTN that need further research and clinical evidence to show positive
Pulmonary hypertension is defined as increase in pressure of the blood vessels of the lungs. The mechanism of developing pulmonary hypertension is complex. Recently it has been noted that COVID-19-affected patients are at risk of having pulmonary hypertension. There are already multiple available treatments for this condition. In addition, recent advancements are going on in the treatment of pulmonary hypertension.
Group 4 Chronic pulmonarythromboembolichypertension (CTEPH)
Group 2 Pulmonary hypertension secondary to left-sided heart disease
WHO GROUP CLINICAL GROUP
Idiopathic, Heritable, Drug or toxin-induced
Group 5 Pulmonary hypertension with unclear or multifactorial etiologies
CAUSE
In general, the treatments for PHTN are directed toward the underlying etiology.
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Hematologic disorders, systemic disorders, metabolic disorders, miscellaneous conditions
To fully understand the rationale behind the pharmacotherapeutic options and their benefits, it is essential to discuss the pathophysiology of PHTN. Persistent vasoconstriction, endothelial dysfunction and hyperplasia, remodeling and fibrosis of the pulmonary vasculature, and in-situ thrombosis of the blood vessels contribute to the development of the PHTN. In addition, overproduction of endothelin, reduced nitric oxide production and reduced prostacyclin levels change the delicate balance between the vasocon strictor and vasodilator mechanisms in the pulmonary vasculature. In PHTN, however, the balance is tilted in favor of the vasoconstrictor mechanism at the expense of the vasodilators. This imbal ance perpetuates the underlying disease process, and they form the basis of phar macotherapeutic intervention in PHTN. Undoubtedly, the development of PHTN is multifactorial. Therefore, it isn't easy
Adrija Hajra, Internal Medicine Physician, currently affiliated with Montefiore Medical Center/Albert Einstein College of Medicine
pre-existing PHTN. COVID-19 is also anticipated to be a significant etiology of PHTN in the coming years due to the long-term sequala of lung fibrosis associated with the infection.
Table 1: WHO classification of PHTN based on pathophysiology
Left ventricular dysfunction
Group 3 Pulmonary hypertension due to lung diseases and/or hypoxia
Pulmonary hypertension (PHTN) is defined by mean pulmonary arterial pressure >20mmHg at rest (or > 30mmHg on exertion). The World Health Organization (WHO) has classified PHTN into five groups.
Complication of pulmonary embolism
Pathogenesis
Recently the COVID-19 pandemic has raised concern for PHTN as a future complication for COVIDaffected patients. Increased production of cytokines such as interleukin (IL)-1, 2, 6, 10, tumor necrosis factor – (TNF- ), and monocyte chemoattractant protein-1 (MCP-1) in the setting of COVID19pneumonia leads to oxidative stress and subsequent damage to the pulmonary vessels. In addition, the residual effects of the above mechanism can lead to vascular remodeling resulting in PHTN.
Animal studies
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Available treatment
The therapeutic target of PHTN has evolved through various animal stud ies. The result of the studies has guided further clinical trials to find out the efficacy of different treatment options. Mutations of transforming growth factor B (TGF B), bone morphogenic protein receptor 2 (BMPR-2), activinlike kinase type 1 receptor (ALK1), and mothers against decapentaplegic homolog 9 (SMAD 9), endoglin gene,
MANUFACTURING
caveolin 1, serotonin transporter gene have shown a role in the pathogenesis of PHTN. Targeting those genes to treat PHTN is an emerging field of develop ment for future treatments for PHTN. Animal studies have shown that 14 days of sacubitril/valsartan treatment has improved the hemodynamic and histological status of PHTN by inhib iting the renin-angiotensin-aldosterone system, increasing natriuretic peptides, and by the anti-inflammatory effect of sacubitril/valsartan. The positive results from the animal studies are the forerun ners of future therapeutic options for PHTN patients.
The endothelial receptor antago nists Bosentan, Ambrisentan, and Macitentan, are noted to be beneficial in PHTN. Intravenous prostacyclin is another treatment option. Triggering the prostacyclin receptor stimulates pulmonary vasodilation resulting in a decrease in the pressure in the pulmo nary vessels. Phosphodiesterase type 5 (PDE5) inhibitors have been shown in clinical trials to improve six-minute walk distance and hemodynamics in PHTN patients. In October 2013, the Food and Drug Administration approved Riociguat to treat adults with PHTN. It is also approved for treating adults with chronic thromboembolic pulmonary hypertension (CTEPH), which is persistent or recur ring following pulmonary endarterectomy. Another medication for the treatment of PHTN is Selexipag, an oral, selective, and long-acting non-prostanoid agonist of the prostacyclin receptor. Waxman et al. showed that Treprostinil, initially approved for group 1 PHTN, can be used to treat PHTN in patients with ILD. Inhaled Treprostinil improved exercise capacity from baseline. Thrombogenesis has been proposed to play a role in developing PHTN use of anticoagulation may play
Several medications are already available for the treatment of the PHTN. Voltagegated calcium channel blockers (CCBs) are indicated for patients with PHTN who show a positive response to vaso reactivity testing. A positive response to vasoreactivity testing is defined as a decrease in the mPAP by 10 mm of Hg to an absolute value of less than 40 mm of Hg after administering a short-acting vasodilator agent such as inhaled O2.
to pinpoint a single factor that causes the PHTN as there are multiple factors contributing to the pathogenesis of PHTN that make the treatment challenging.
Future potential treatment for PHTN: In rodent models, mineralocorticoid receptor antagonists have a promising role in preventing or reversing PHTN and right ventricular failure. Decreasing circulating estrogen by inhibiting the conversion of androgens to estrogen using the aromatase inhibitor anastrozole and inhibition of the estrogen receptor with tamoxifen inhibited PHTN in animal models. Tyrosine kinase inhibitors can attenuate platelet-derived growth factor signaling and reduce calcium-sensing receptor expression. This makes the kinase inhibitors to be an effective treatment for PHTN. Inhibition of histone deacetylase and Keratin-1 have the potential to reverse the changes in pulmonary vasculature and PHTN. The role of hypoxia-inducible factor (HIF)2 in the initiation and development of PHTN has been an area of future research. 5-hydroxytryptamine (5-HT) pathway inhibition, activation of vasoactive intes tinal peptide (VIP) pathway, pyruvate dehydrogenase kinase (PDK) inhibitors, and targeting the mechanistic target of rapamycin (mTOR) are some areas of limited knowledge that can prove their benefit in the treatment of PHTN in the near future. Results from meta-analysis have shown that stem/progenitor cell therapy is associated with significantly improved pulmonary haemodynamics in animal models. Future studies have scope for exploration of this field.
BIOAUTHOR
Managing patients with PHTN should always be a multidisciplinary decision. There are already different options avail able for the treatment of PHTN. In addi tion, newer studies are coming up to show the potential therapeutic benefit of the new drugs/molecules in the management of the PHTN.
There are treatment options avail able for PHTN, which include nonpharmacologic management. Treatment of sleep-related disorders using continuous positive airway pressure and non-invasive ventilation helps patients with PHTN. The prevention of nocturnal hypoxemia helps alleviate the development of precap illary PHTN. Advances in percutaneous technology opened new possibilities for the management of PHTN. Interventional procedures including balloon atrial septo stomy, transcatheter Potts shunt, balloon pulmonary angioplasty, and pulmonary artery denervation have shown promising results in haemodynamic and functional improvements in PHTN patients.
for patients with COVID-19 infection. Hopefully, the gliflozins will be a future possible treatment option for PHTN, particularly for COVID-19 patients.
and the treatment more difficult. Finding a guideline for treating these patients is often not easy. Most of the clinical trials have excluded patients with a combina tion of etiologies for PHTN, and thus treatment of these patients is not evidencebased. Dealing with PHTN in patients with idiopathic pulmonary fibrosis (IPF) is also not straightforward. Recently, a multi-centre, international, double-blind, randomised, placebo-controlled, phase 2b study did not show any treatment benefit after adding sildenafil to pirfeni done versus pirfenidone plus placebo up to 52 weeks in patients with advanced IPF and risk of PHTN. More studies are required to find an optimum solution for these complex patients.
Challenges for treatment of PHTN
Conclusion
Adrija Hajra is an Internal Medicine physician, currently affiliated with Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA. Her research interests are heart failure, pulmonary hypertension, diabetes, hyperlipidemia with special focus on cardiac complications in COVID-19 patients.
EXECUTIVES SPECIAL ISSUE
a role in PHTN patients. However, clini cians should be careful about possible interactions of anticoagulation medication with other anti-PHTN drugs. The drug interaction can increase the bleeding risk for patients with PHTN. Sotatercept is a fusion protein that binds activins and growth differentiation factors to balance growth-promoting and growth-inhibit ing signalling pathways. Humbert et al. reported that treatment with sotatercept reduced pulmonary vascular resistance among patients with PHTN.
We cannot ignore the fact that there are still multiple challenges associated with PHTN management. Patients can have multiple types of PHTN together. For example, patients may have heart disease, chronic obstructive pulmonary disease, and connective tissue disorders. The pres ence of multiple co-morbidities makes the pathogenesis of the PHTN complex
As mentioned before, special attention is required for people with COVID19 infection as they are at high risk of developing PHTN. For the COVID-19 patients with pulmonary hypertension, inhaled nitric oxide improved blood oxygenation and decreased pulmonary vascular pressure. Puk et al. have shown that endothelin receptor antagonists, phosphodiesterase 5 inhibitors, rioc iguat, and prostacyclin could help treat PHTN in COVID-19. Clinicians must be cautious while following up on patients with COVID-19 as a low threshold to diagnose PHTN in these patients is important not to miss the complication. Studies are going on to show the effects of sodium-glucose transporter inhibitors to improve pulmonary vascular resistance
Management of PHTN in COVID-19 patients
References are available www.pharmafocusasia.comat
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Matteo Bernasconi, Research Associate, University of St.Gallen Gian-Andri Steiger, Research Associate, University of St.Gallen Marten Ritz, Post-doctoral Researcher, University of St.Gallen Thomas Friedli, Director, Institute of Technology Management
Data-based identification of improvement potentials: An example in the area of pharmaceutical manufacturing
The possibility of identifying the right levers to improve, based on a holisti cally comparison against peers, is a key
Operational excellence (OPEX) is the philosophy summarising numerous technical and social practices aiming at improving operations. However, the complexity of the practices and multiplicity of the initiatives hinders to always identify and set the most promising priorities.
Using Operational Data to Improve Operations in ManufacturingPharmaceuticalandQCLabs
importance of jointly analys ing the manufacturing facility’s maturity and performance was outlined in the article The Link between Plant Performance & Maturity – Seeing the whole picture. The St. Gallen Model for OPEX depicts the synergies between technical & social sub-systems (Friedli & Bellm, 2013) and serves as backbone of the OPEX benchmarking, which has been supporting pharmaceutical companies in
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(Ritz, 2022). In the case of pharmaceu tical industry, QC can strongly affect operations (Barbarite & Maslaton, 2008; Friedli et al., 2018)) and QC labs have been moved under the spotlight form the FDA in the recent years (FDA, 2016, 2022; Friedli et al., 2019). The QC lab benchmarking, which was presented in the article Benchmarking Pharmaceutical Quality Control Labs – Holistically assess Operational Excellence in Pharmaceutical Companies, supports firms in improving lab processes to systematically progress in operations along the entire value chain.
identifying potentials for improvement since 15 years. As discussed in the arti cle St. Gallen OPEX Benchmarking for Pharmaceutical Manufacturing Sites –Measure Yourself Against the Best but Do It Right, the benchmarking helps to support continuous improvement in manufacturing. However, to advance in the lean journey, an end-to-end consid eration of the value chain is required to systematically identify bottlenecks
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Being able to take decisions based on data and measured situations can improve the efficacy of the strategic initiatives. The St. Gallen manufacturing and quality control (QC) benchmarking programmes support pharmaceutical companies with a rich base of information needed to inform their decision making processes.
This article discusses two practical examples of how data driven improve ments can be initiated and derived from a benchmarking. Firstly, an example from the manufacturing and OPEX benchmarking is presented. Secondly, a project that emerged based on QC lab benchmarking results is illustrated and discussed. Finally, the benefits of data driven decision are highlighted.
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The OEE is composed as a sum of three elements: OEE availability, OEE perfor mance and OEE quality (see Figure 1).
The St. Gallen team analysed the situ ation and identified that the low OEE was mainly driven by high down times. These
Data-driven improvement actions are not solely a topic in the field of manufactur ing. Also St. Gallen’s dedicated Quality Control (QC) Benchmarking is inten sively used for the systematic definition of improvement strategies. In the following a practical example, how lab specific and company-wide improvement actions may be derived, will be presented.
such as pharma, have still good potential in improving OEE (Friedli et al., 2013).
Figure 1: OEE Calculation
The link between good maintenance practices and good quality is well estab lished in manufacturing literature (Cua et al., 2001; McKone et al., 2001), neverthe less some very quality oriented industries,
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The result workshop provides the possibility to better understand the link between plant maturity and performance, by deep diving into the individual matu rity items and key performance indi cators. For example, during a bench marking we observed a situation of high Total Productive Maintenance (TPM) maturity but low TPM outcome perfor mance across all participating facilities of the production network. The low TPM performance was mainly driven by a low level of Overall Equipment Effectiveness (OEE).
Data to action: How benchmarking data allows the derivation of improvement actions in the field of quality control labs.
In the presented case, the QC lab benchmarking was individually conducted for 15 different sites of the company. The overall performance based on the sites’ KPIs showed significant differences among the various QC labs within the corpora tion. Besides the actual performance the labs’ maturity levels were assessed using specific enabler questions in addition. Those questions aim at assessing how advanced the respective process struc tures and management approaches in
Setting the focus on TPM maturity and performance, in this case, was very rele vant because of two reasons. On the one hand, TPM is the first pillar on which companies should concentrate to progress in achieving OPEX. In fact, TPM prac tices guarantee a stable equipment which is fundamental to allow for stable and reliable processes before finally reducing inventories to increase efficiency. On the other hand, all participating sites form this companies were suffering from the same conditions irrespective of the manu factured types of products. The systematic OEE performance problem across the manufacturing network provides the ideal setting for a corporate initiative targeting the issue not only in one plant but across the sites and therefore contributing to the stability of the equipment in the whole organisation (Figure 1).
element to define and start strategic improvement initiatives. As a balanced approach for performance and maturity calculation, the OPEX benchmarking report provides the basis to make a meaningful comparison and define the next steps. In the general procedure, a benchmarking can be further enriched by a structured result workshop, in which the operations team receives further insights from the results and guidance to act on the results. In the case of multiple facilities participating in the assessment, the sites are compared, and the network intern-learnings are highlighted and discussed. This facil itates the recognition of site-specific capabilities and the knowledge sharing within the manufacturing network.
can be divided in two categories: planned (setup & cleaning) and unplanned (break down, etc.). Thanks to the workshop, the team was able to deep dive into the maturity of the TPM practices and link them back to the low performance due to downtimes. Analyses revealed that unplanned downtimes were not the main driver of the low OEE, the setup & cleaning was the cause. TPM practices showed a high maturity in the category of housekeeping but a very low maturity in setup time reduction. Thus, the low performance in OEE (especially setup & cleaning) can be improved by focusing on the blank spots of the maturity and better training as well as better schedul ing of the setup times. The workshop provided the unique opportunity to take a closer look to the results, investigate the cause-and-effect relationship of the low performance findings, and discuss the most suitable initiatives to target the problem. One initiative, for example, is focusing on improving the whole plan ning/scheduling.
The OEE availability represents the percentage of the time that the equipment has operated over the scheduled time. The OEE performance denotes the amount produced by the ideal cycle time over the available time in which the equipment was producing. The OEE quality shows the percentages of outputs without defects as percentage of the overall inputs.
Figure 2: Maturity assessment of 15 corporate labs
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A subsequent project has been initi ated to systematically identify successful practices that already exist in the lab’s network and at facilitating the corre sponding knowledge transfer among all labs. Thereby, one strives for an optimal use of existing improvement opportuni ties.
necks had been identified. This was the initial impact assessment (IIA) and the root cause investigation (RCI).
The maturity levels of the 15 sites reflected the variability in the respec tive performance levels (cf. Figure 2). Especially the sub-categories Housekeeping, Process Management and Standardisation & Simplification showed a significant variability in maturity, while having an overall high degree of maturity on the corporate level. This indicated that certain successful practices already exist in those fields among some labs, while other QC labs have a significant improvement potential in the same field (Figure 2).
Havingoverdue.thisresults in mind, a more flexible setup of local guidelines was advised that allows the consideration of a site’s complexity in implementing global standards. The set IIA deadline should be feasible for all sites. Otherwise, there is an inherent risk of evasive operational behaviour with negative consequences such as the previously mentioned increase in reoccurring deviations and CAPAs overdue.These examples show how patterns in benchmarking data can be analysed, their root-causes be identified and conse quently lead to effective and practical improvement actions.
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field of action that had been identified during the QC benchmarking was the site’s handling of quality events. Especially in the share of CAPAs overdue and reoccurring deviations, mayor differ ences had been observed. Consequently, the event handling process was analysed on both, the corporate and site level. The overall event handling process was defined in detail in a global standard operating procedure. When examining the local translation and implementation of that global SOP, two distinct bottle
When analysing the benchmark ing data, it became apparent that one of the major challenges for QC labs is the complexity they face. Large varia tions in the number of different tests to be performed and fluctuating test volumes inhibit the standardisation of lab layouts and the associated processes. Furthermore, the labs face the problem of limited available floor space. Having this challenge in mind, five labs were selected for the further analysis. The labs were selected according to their maturity levels. Three labs with a comparably high maturity and two with a rather low level of maturity had been selected for further on-site investigation and documentation of the status quo. The idea behind that selection was to enable a knowledge trans fer from advanced to less advanced labs and consequently make effective use of existing successful practices which then should result in an increase of the overall maturity and performance on a corpo rateAnotherlevel.
For the initial impact assessment for example, a hard deadline of three days was defined by the global SOP. This deadline did not account for local specif ics of the different sites. In dedicated site interviews it was noticed that depend ing on the complexity of the different sites, the three days are not sufficient for a profound IIA. In this respect, two phenomena had been observed. Firstly, in some labs IIAs had been performed on rather superficial level. This resulted then regularly in rather ineffective RCIs and CAPAs, considerably increasing the share of reoccurring deviations. Secondly, some other labs tended to perform a profound IIA, which often resulted in overdues in complex sites. This resulted consequently in backlog and started a vicious cycle that leads to growing shares of CAPAs
Data is the basis for all improvement initiatives. It provides one with a holis tic picture of the status quo, allow ing the identification of improvement potentials. The systematic identifica tion, adaption and implementation of successful practices contributes signifi cantly to a company’s journey towards operational excellence. Continuous improvement requires that deficien
the QC labs are. All enablers are scien tifically derived and proven to have a direct impact on the labs’ overall outcome performance levels. The enabler questions are structured in three main categories; namely the Maintenance & Quality System, the Planning & Steering System and the Management System. All three categories are again divided in total 13 subcategories. Due to their proven posi tive effect on performance, the enablers act as a starting point and toolbox for defining particular improvement initia tives. Further information about the QC benchmarking approach can be found in article in issue 47 / 2022.
Gian-Andri Steiger is a research associate at the University of St.Gallen. At the Institute of Technology Management, he works in the Operational Excellence team with a special focus on the pharmaceutical industry. Currently, his academic research focuses on quality assurance excellence in the pharmaceutical industry.
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In the next journal issue, the St. Gallen team will conclude their article series with a summary of the operational excellence research field in the context of the pharmaceutical industry and provides an outlook to futures trends and current research activities in that field.
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Matteo Bernasconi is a research associate at the University of St.Gallen. At the Institute of Technology Management, he works in the Operational Excellence team with a special focus on the pharmaceutical industry. Currently, his academic work concentrates on preventive risk quality management and data-driven decision-making.
Marten Ritz is a post-doctoral researcher at the University of St.Gallen. At the Institute of Technology Management, he leads global collaboration projects to support pharmaceutical companies in developing KPI strategies and implementing quality metrics programs. His academic research focuses on aligning OPEX initiatives across manufacturing and QC lab in pharmaceutical production.
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Thomas Friedli is a director at the Institute of Technology Management. He leads a division of 14 PhD students and two post-docs. His research areas include strategic management of production companies, management of industrial services, and operational excellence. He is editor, author and co-author of numerous books and articles.
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cies are made visible and the effec tiveness of improvement actions is verifiable. This article thereby showed two distinct examples for how improvement initiatives may be built based on benchmarking data. St. Gallen’s holistic approach on measuring performance allows companies to define strategically improvement initiatives that lead to stable and long-lasting enhance ment of a company’s performance.
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vaccine is a difficult process that requires years of development time and millions of dollars in research funds to complete. Pharmaceutical manufacturers are faced with many obstacles once they've
The pharmaceutical industry is one where decades of innovation lead to one new product, like a drug or vaccine. It’s common knowledge that the development of a critically vital drug or
The Repercussions of COVID-19 on the Pharmaceutical Packaging Industry
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formulated a new drug or vaccine. One of the obstacles is the packaging of these newly developed drugs. When it comes to packaging, there are several critical steps that go into ensuring that a prod uct reaches the end-user in very good condition. Pharmaceutical manufactur ers often have many options when it comes down to picking the correct type of packaging solutions that can protect their product to ensure uncompromised quality along with maximum safety and efficacy. A lot of the time, the success or failure is usually determined right at this stage. There are many factors that can be taken into account such as shelf life, homogeneity of drug formulations and composition, as well as patient safety and delivery control considering it may require controlled temperatures for efficacy.
Starting with the outbreak of the COVID19 pandemic, the pharmaceutical packag ing sector suffered a significant setback. The supply chain was severely disrupted, and the rapid increase in demand posed difficulties for both manufacturers and packaging solution providers alike. An important problem was the inability to dispatch supplies during this period due to a lack of available global logistical facilities. Aside from that, supplementary industries to the pharmaceutical industry, such as the manufacture of packaging materials for pharmaceuticals, had not yet been placed under the purview of vital services. Slowly, but steadily, the
Ensuring Efficiency in Packaging Process should be a top Priority for Pharma Packaging Companies
Covid-19 drastically impacted the way pharma packaging functioned. The overnight entire supply chain was heavily fractured across the globe and at the same time demand for healthcare products skyrocketed due to panic amongst the public. There is no scope of mistake when it comes to packaging critical drugs, especially rubber stoppers. It is a test of all our compliances, quality and proficiency in producing critical components to protect drugs and maintain their safety and efficacy. We are now witnessing a robust change in the working environment with demand planning, Quality, Innovation, Supply chain as well as storage. India is the new powerhouse of pharmaceutical packaging. It is time to increase capacity for quantity and quality production.
Siddharth Shah, Director, Bharat Rubber Works
Packaging of Critical Drugs: How Rubber Stoppers Play a Huge Role
Indian pharmaceutical manufacturing is third in volume, leading to an indus try nickname of "The Pharmacy of the World." Supply chain constraints during the pandemic forced pharmaceutical manufacturers to seek out solutions with quicker turnaround times. Localisation worked as a big push towards this change, transforming India into a world pharma packaging center. Domestic producers were also forced to seek effective pharma ceutical packaging solutions due to the pandemic, and they rapidly learned that the local pharma packaging industry was more than capable of satisfying local and global requirements for pharmaceutical packaging. The production and packag ing of COVID-19 vaccine was a product that received significant attention from both Indian and international manufac turers, serving as validation for Indian pharmaceutical packaging companies at large. Thus, the fortunes of India's phar maceutical packaging business changed substantially, for the better, in the last 24 months.TheIndian pharmaceutical packaging businesses provide solutions for a broader range of pharmaceutical products than merely the COVID-19 vaccines. In fact, what has been observed over the last few years is that the demand for non-COVIDrelated drugs has surged by a factor of per cent. This has ensured that the phar
and stoppers were under enormous pres sure to manufacture items in a timely and high-quality manner while adhering to strict quality standards. Stakes were high as there was no COVID-19 vaccine without the right packaging. The fact that Indian pharmaceutical packaging industry could ensure adequate and high-quality packaging solutions during the pandemic has further catapulted their image and importance in the global pharmaceuti cal space. This has helped them garner a good reputation, not just as the largest producers of pharmaceuticals but also as one of the largest providers of high-quality packaging solutions to the pharmaceutical industry worldwide.
As a result of the pandemic, there were acute shortages of some important pharmaceuticals. As a result of the high demand for these drugs, many people were forced to purchase medicines from black market dealers who sold counterfeits that came in significantly lower quality than what they were substituting. Several counterfeits entered the market to fill this resulting supply gap and take undue advantage of the situation. This was a major source of concern for producers, merchants, end-users, and all other players in the ecosystem. Fortunately, modern communication methods, increased reli ance on digital verification, as well as a
Pharmaceutical packaging solutions in this field have a greater obligation to produce high-quality solutions because vaccines and other critical drugs have the potential to save millions of lives. Having said that, preserving these critical drugs and vaccine integrity across the supply chain can be difficult without the proper packaging solutions. There are two crucial components to consider when it comes to packaging these: the first is glass vials, which are all designed to have a very low moisture vapor transmission rate, and the second is rubber stoppers. During the pandemic, the producers of these vials
industry was able to adapt and restore normalcy throughout the supply chain as a result of government policies and actions designed to transform these services into vital services. However, there were some important shifts during this period. COVID-19 paved the way for a more prominent localisation approach, which had a significant impact on phar maceutical packaging. As a result of the COVID-19 pandemic, Indian pharma ceutical packaging contractors got an opportunity to actively enter and compete in a growing global packaging market.
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maceutical packaging industry has seen significant growth and demand, not just for COVID-19 related drug packaging but also for the other essential medications in constant demand. Given this reality, it's common to find an alliance between pharmaceutical producers and pharma ceutical packaging companies during all phases of development. Aside from that, the sector has gained a great deal of knowledge about operational strategy, particularly in the area of raw material procurement since it is vital for them to stay profitable and maintain the price point advantage. Through the use of smart supply chain management and realistic market forecasting, the sector is on track to grow at previously unheard-of rates.
The Pharmaceutical Packaging Industry Has Undergone Significant Changes
Pharmaceutical Packaging as a Solution to Combat Counterfeiting
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Packaging That is Centered on the Customer is Essential.
As previously said, pharmaceutical packaging is vital in ensuring access to pharmaceuticals and medicine, and in a country known as "The Pharmacy of the World," the local pharmaceutical packaging business plays an even more critical role than it did prior to the current crisis. As more pharmaceutical businesses rely on medications and medication produced in India, this presents a new set of constraints as well as opportunities for innovation. When developing devices for new pharmaceuticals, the pharmaceuti cal packaging industry must first satisfy a specified benchmark before moving on to the next step. This step is carried out
to ensure the safety and preservation of the medication under various circum stances. This test should also be specific to the drug's identity and conform to worldwide and regional regulatory stand ards. Additional requirements include: Regular quality control inspections are required to guarantee that this system is not tampered Additionally,with.the Consumer Product Safety Commission (CPSC) has estab lished a set of guidelines that must be rigorously adhered to at all times. Today, there are very few things available on the market that are not packaged in a way that is child-resistant. This is particularly true in the case of medications. Product and packaging teams are also concentrat ing on ergonomic solutions that are effi cient at the logistics end while also being more consumer-centric in their design. All things considered, pharmaceutical packaging is an essential component of pharmaceutical supplies throughout the world. With more localisation and manu facturing taking place within the country, the scope and quality of local pharmaceu tical packaging are becoming increasingly important for sustained growth across the pharmaceutical industry.
No matter the type of medication, it’s crucial to make sure an appropriate phar maceutical packaging is used to seal and maintain the safety, efficacy and quality of the medicines at all times. This is exactly why global pharmaceutical companies are eager to work with India's most reliable pharmaceutical packaging manufacturers and see what they offer as appropriate solutions to their pharmaceutical packag ing conundrums.
A young stalwart of Bharat Rubber Works, Siddharth Shah has been the Director of the company since 2018. Mr. Shah joined Bharat Rubber Works after completing his bachelor’s in Banking and Wealth Management from the University College of Dublin in 2018. He has also completed his Diploma in Marketing from Kaplan. As the director of the company, Mr. Shah is responsible for overall growth and company operations. Since his arrival at the family-owned business, Mr. Shah has taken the company to another level, allowing Bharat Rubber Works to become a leading manufacturing solutions provider to the healthcare industry.
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Packaging is an essential part of fighting counterfeit drugs in the phar maceutical industry because it can serve as both a way to identify and authenticate medications and a way to protect the medication itself. This problem of coun terfeit medicines can be easily avoided by including pharmaceutical packaging solutions in the manufacturing process as early as possible. Packaging companies worldwide, including India, are actively developing trace and track technology solutions, which incorporate advanced blockchain technology to create an atmos phere of assurance, security, and trust for all stakeholders at all stages of the manufacturing and distribution processes.
There are many ways that a packag ing solution provider can be proactive when it comes to tackling counterfeiting drugs or medication. By actively fighting against counterfeit drugs, manufacturers and suppliers of medicine will experience a much-needed reduction in black market trade and positively impact consumers' health and safety. In turn, fighting coun terfeit drugs directly helps foster the phar maceutical industry's growth.
Building best-in-class customer experi ences is vital since it is a discipline that has the potential to revolutionize entire sectors. Customers' needs are becoming increasingly important to the best-in-class
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India is gaining the much-needed recog nition for its pharmaceutical packaging supplies capabilities and is growing consid erably at the global level. Less than 40 percent of the country's businesses in this industry have reached a point where they are able to offer their customers products that are highly customizable. In today's world, customer-centricity is one of the most difficult aspects of any business to execute. Some companies emphasize giving their customers what they want, when they want it, and even how they want it. The same is true for pharmaceuti cal packaging businesses in India.
organizations, which is allowing them to organize their businesses around them. By providing customers with simple, differ entiated, safe and effective experiences, a company may unleash great value by increasing client loyalty while simultane ously lowering leakage and churn. Having said that, the Indian pharmaceutical pack aging business is still in its growing phase when it comes to developing solutions. A significant amount of emphasis is still placed on the fact that the majority of packaging companies in the domain are striving to make every packaging collateral as customer-centric as possible. It is fair to say that customer-centric packaging will be critical to the future success of the pharmaceutical sector, and as time goes on, more and more companies will begin to take this into consideration when designing their goods.
swift action by influential opinion leaders assisted in the fight against counterfeits.
So, what is the future of the Indian Pharmaceutical Packaging Industry?
Current and Future Outlook of Pharmacogenomics in Paediatric Asthmatic Medications
treatment and highlights the importance of optimising a patient’s response to drug therapy while minimising adverse reac tions. Although most studies have looked more closely at children, there have been no clinically relevant findings that have warranted specific therapeutic recommen dations.Commonly researched medica tions include beta-2 agonists, inhaled corticosteroids (ICS), and leukotriene modifiers (LTM).
Classified as bronchodilators, beta-2 agonists are categorised into two groups:
Figure 1: Beta-2 Agonists Mechanism of Action. Adapted from 1.
Christy Lim, Massachusetts College of Pharmacy and Health Sciences University Ronny Priefer, Massachusetts College of Pharmacy and Health Sciences University
Nearly 300 million people worldwide are affected by asthma, which, left untreated or uncontrolled, decreases quality of life and increases the risk of developing chronic obstructive pulmonary disease (COPD). More than half of these asthma cases origi nate from childhood. Shortness of breath, tightness, and wheezing are just a few of the symptoms caused by asthma. Although robust evidence supports the efficacy of current treatment options, approximately 100 million additional asthma cases are expected by 2025. Despite recommenda tions by the Global Initiative for Asthma (GINA) guidelines, up to 70 per cent of patients are still unable to find proper symptom relief. While the lack of adher ence and improper diagnosis have been implicated, genetics may also play a role. With widespread intra-variability among medication responses, pharmacogenom ics has an emerging place in asthmatic
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Beta-2 agonists
Current treatment options for asthma, a respiratory condition often stemming from childhood, include beta-2 agonists, inhaled corticosteroids, and leukotriene modifiers. Despite recommendations by the Global Initiative for Asthma, a substantial number of patients are unresponsive to treatment. Paediatric pharmacogenomics could allow for potential preemptive screening, thus improving patient outcomes.
Unlike amino acid position 16, conflicting reports in response to SABA therapy at amino acidposition 27 on the receptor have limitedany significant associations. Alghoshaby measured bronchodilator response by FEV1/ forced vital capacity (FVC) and FEV1 whereas Giubergia utilized change in FEV1 over thirty days. While the former found greater improvements with the Gln27Glu variants, the latter found a decrease in responsiveness. A study conducted by Elbahlawanon 31 African American children found that those with the Glu27Glu treated with albuterol needed additional medication for symptom control. These contradic tory results provide no clear association at position 27 and bronchodilation in response to SABA.
1, Billington, C.K.; Penn, R.B.; Hall, I.P. Agonists. Handb. Exp.Pharmacol.2017, 237, 23–40
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Figure 2: ICS Mechanism of Action. Adapted from 2
Inhaled Corticosteroids (ICS)
Arg16Arg genotype displayed a decline in responsiveness to long-term treatment.
The adrenergic receptor is encoded by the ADRB2 gene and is found on chromosome 5q31-32, an area highly associated with asthma. Position 16 and 27 are two amino acid locations thought to modulate down regulation and airway responsiveness. Choudhry et al. discov ered that the presence of Arg at position 16 produced the greatest bronchodilation compared to Gly16Gly when adminis tered albuterol in the Puerto Ricans. Although the study included both Puerto Rican and Mexican children, no genetic association was found among Mexican children. Martinez et al. reported that Arg16Arg and Arg16Gly were more likely to produce greater bronchodila tion compared to Gly16Gly when given albuterol. Similar studies by Salah on Egyptian children and Finkelstein on multiethnic children also found favour able results with Arg16Arg in response to albuterol. Both studies found reduced responses in those with Arg16Gly and Gly16Gly genotypes. In contrast, a study conducted by Carroll et al. found that children with the Gly16Gly variation showed a better response, to albuterol, compared to those with the Arg variants. Similarly, Giubergia observed changes in desensitisation over four weeks among some Argentinian children treated with albuterol and reported those with the
GINA guidelines currently recommend using as needed SABA or ICS -formo terol for children who only require rescue therapy. A low dose of ICS in conjunction with a SABA is recommended as control ler therapy for children ages 6-11.ICS work to improve asthma symptoms by decreasing mast cells, cytokines, COX-2, etc thereby decreasing inflammation (Figure 2). FDA indicated to reduce asthma attacks, ICS not only reduce respiratory swelling but also reduce morbidity in both children and adults. Although the risk of systemic exposure is minimal due to their route of adminis tration, side effects such as osteoporosis, glaucoma, and metabolic disturbances are not negligible, especially when used for an extended period (Figure 2).
short-acting beta agonists (SABAs) and long-acting beta agonists (LABAs). Examples of these include albuterol and formoterol, respectively. Commonly utilised in respiratory distress, these agonists induce bronchodilation and relax smooth muscles by binding to the adrenergic receptor located in the lungs. The activation of G-protein coupled receptors (GPCR) causes an increase in cAMP concentration, decreases intracel lular calcium and in turn, relieves asthma symptoms (Figure 1).
SABA and ADRB2 Variations
Tantisira conducted a genome-wide association study (GWAS) and identified the glucocorticoid-induced transcript 1 (GLCCI1) gene and the SNPs, rs37972 and rs37973. Although little is known about GLCCI1, those homozygote for the mutant T allele at SNP, rs37972, yielded a poorer response to ICS compared to those who were heterozygote (CT) or homozy gote (CC). Conversely, Vijverberg saw no association with individuals having SNP, rs37972 and ICS response in Northern European children. It was concluded that
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Organic anion transporter poly peptide 2B1 (OATP2B1) are drug transporters responsible for reuptake of various substrates in the liver, intes tine, and kidney. Solute carrier organic anion transporter family member 2B1 (SLCO2B1) encodes for these transport ers. Mougey found that those with the SNP, rs12422149 GG genotype demon strated greater improvement at three and six months compared to the those with the AG genotype. Similarly, a study by Li with 50 asthmatic Chinese children displayed lower montelukast clearance if possessing the SLCO2B1 rs12422149 GG genotype, compared to either GA and AA. Due to increased plasma concentra tions, children with the GG genotype found better symptom relief when given montelukast. Although CYP2C8 varia tions were also investigated in this study, no associations with montelukast response were found.
3, Mougey, E.; Lang, J.E.; Allayee, H.; Teague, W.G.; Dozor, A.J.; Wise, R.A.; Lima, J.J. ALOX5 polymorphism associates with increased leukotriene production and reduced lung function and asthma control in children with poorly controlled asthma.Clin. Exp. Allergy 2013, 43, 512–520
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ALOX5 encodes for 5-lipoxygenase (5-LO) and is found on chromosome 10q11.21. 5-LO is involved in the conversion of arachidonic acid into LTA4 and is the rate limiting step in leukotriene synthesis (Figure 3).Klotsman was able to identify five ALOX5 variants associated with montelukastresponsive ness. However, only two of the five vari ants were found to be significant for favorable outcomes, SNP rs4987105 TT and rs4986832 AA. Conversely, Telleria recognized five copies of the transcrip tion factor binding sequence GGGCGG (rs59439148)in the ALOX5 promoter region as the major allele. Homozygote wild types (5/5) and heterozygotes (5/4) produced favourable responses to montelukast, while the 4/4 repeats produced unfavourable responses. These children demonstrated higher rates of exacerbation and required more doses of their rescue inhaler (Figure 3).
Leukotriene Modifiers (LTM)
2, Barnes, P.J. Inhaled Corticosteroids. Pharmaceuticals2010, 3, 514–540
Figure3: Leukotriene Modifiers Mechanism of Action. Adapted from 3
the mutant T allele was not associated with an increased risk when treated with budesonide. In contrast, Huang found associations in the GLCCI1 gene among Chinese children with SNPs, rs37969 GG, rs37972 CC, and rs37973 AA producing favourable changes measured by maximal mid-expiratory flow.
Variations among cytochrome p450 (CYP) 3A4, 3A5, and 3A7, which are involved in fluticasone metabolism, were assessed in a study conducted by Stockmann involving a group of Caucasian children. CYP3A5 and CYP3A7 were found to have no asso ciation, however, CYP3A4*22 children displayed better asthma control due to the reduced activity of this metabolic enzyme, leading to increased therapeutic outcomes. However, this was not seen in a follow-up study of 64 Caucasian children treated with beclomethasone. Observed in this study were CYP3A5 *1/*1, *1/*3, and *3/*3 variations, with the *3/*3 variant displaying the greatest responsiveness based on asthma control scores. It may be recommended that children with the CYP3A4 *22 initiate therapy with fluticasone. Children with CYP3A5 *3/*3 may be advised to avoid beclomethasoneregimens.
Leukotriene modifiers are typically considered when symptoms are uncon trolled by ICS and/or bronchodilators. As seen with previous medications, genetic differences and inter-patient variability also affect a child’s response when given LTM, such as zileuton and montelukast. Although this class may be favoured due to oral administration, nearly half of all children have reported mental status changes like depression and hallucinations. Thus, identifying variants associated with positive LTM response can benefit children who cannot gain symptom control with bronchodilators and ICS.
Christy Lim is a PY4 pharmacy student at the Massachusetts College of Pharmacy and Health Sciences University-Boston. Her research interests include pharmacogenomics in both adult and paediatric populations.
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Ronny Priefer is a Full Professor of Medicinal Chemistry and Dean of Graduate Studies at the Massachusetts College of Pharmacy and Health Sciences University-Boston with over 90 peer-reviewed publications. Additionally he is a serial entrepreneur, with five start-up companies and over half a dozen patents.
Outlook
for the translation of genotype to pheno type, with the common goal of develop ing the best course of treatment for each individual child. Although preemptive pharmacogenomic testing for asthma is not currently recommended, the hope
for universal testing at an early age has the potential to eliminate prolonged medication trial and error.
References available www.pharmafocusasia.comat
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The cost effectiveness and increased quality of life due to pharmacogenomic testing in adults has been clearly demon strated for those who are genetically inclined to show a reduced response to ICS. Although no research has been conducted in the paediatric population for the same outcomes, identifying chil dren who may also be predisposed to ICS unresponsiveness can encourage provid ers to initiate LTM therapy sooner. This would eliminate the trial and error of increasing doses of a medication class that the patient will likely fail. Additionally, drug transporters and CYP450 enzymes have potential to guide clinicians when selectingUnfortunately,medications.limitations in many of these studies include the small sample size, unstandardised outcome measures, and lack of diversity. With recent discus sions on race and ethnicity, there is a need for further stratification based on genetic ancestry. Larger paediatric asth matic studies could improve confidence
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Product deformulation is a crucial but challenging process for the development of generic products. This article will discuss how deformulation uses analytical technologies to decode the physicochemical formation of a drug and provide insight into how its composition might affect drug efficacy and safety in vivo.
The constituents of any drug product fall into one of two categories: excipients and APIs. Excipients can sometimes be added to a drug formulation to act simply as a bulking agent to help with achieving a consistent concentration of API in each dose. However, excipients can also be functional agents, improving the stabil ity of the drug and altering its delivery to the patient. Examples of this include controlled-release agents, stabilisers and surface-active agents, which can alter how and how quickly an API reaches and is absorbed by its target tissues.
Using DevelopmentGuideTechnologyAnalyticaltoGenericDrug
Unveiling the blueprint
Guiding the workflows associated with generic drug development, the FDA’s Critical Path Opportunities for Generic Drugs emphasises the need for compa nies to adopt a Quality-by-Design (QbD) approach (1), which demands a thorough understanding and control of the variables impacting product and process behaviours. To accomplish this, developers must gather extensive infor mation about the innovator drug, and generate data using a variety of in vitro analytical methods.
As
These methods help developers create a comprehensive blueprint that captures the complexity of a drug prod uct’s constituents and how these interact, creating a microstructure which ensures the stability and effective delivery of the drug. With these critical material attrib utes at hand, developers can begin to design a generic product and, in some cases, may even consider reformulating the product in the hope of improving its clinical efficacy and/or safety profile.
develop generic alternatives as drug prod ucts approach or pass patent expiration.
In this article, we will examine the use of analytical technologies in generic drug development focusing on the exam ple of Morphologically-Directed Raman Spectroscopy (MDRS), to show how these techniques can help drug devel opers decode both the formulation and manufacturing processes of RLDs.
The(RLDs).reverse engineering of an RLD— product deformulation—is a critical step in the development of more accessible and less expensive generic versions. Deformulation relies on analytical tech nologies to not only tease apart the phys icochemical properties of an innovator drug and its constituent parts—its active pharmaceutical ingredients (APIs) and excipients—but also offer drug develop ers insights into how the innovator RLD was manufactured. Such information is vital to drug companies competing to
63www.pharmafocusasia.com EXECUTIVES SPECIAL ISSUE
Paul Kippax, Pharmaceutical and Food Sector Director, Malvern Panalytical
Developers use technologies such as laser diffraction and analytical imaging to both characterise and differentiate the excipients from other RLD components and one another, information vital to generic development and possible refor mulation. When exploring reformula tion, developers rely on these analytical technologies to ensure that efforts to improve one feature of a drug were not deleterious to other features.
is the case in most scientific disci plines, the most common way to determine how something works is to break it down, identify and quantify its component parts and then see how they work together to function as a whole. This is true for understanding the metabolism of a cell, for understanding the synthesis of a chemical, and in the pharmaceutical industry, for understanding the formu lation and function of reference listed drugs
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And finally, these analytical tech nologies also provide developers with invaluable insights into the processes used to manufacture the innovator prod uct. For example, API shape features such as elongation offer clues as to the manufacturing methods used to produce the final product: if analytical imaging shows small, almost spherical particles rather than long needle-shaped parti cles, developers can be more confident that micronization has been used during manufacture of the RLD product. Such information can be critical to the devel opment of a generic product, as using the wrong processing technique can result in APIs with different surface area and dissolution rates to the innovator prod ucts, which can significantly impact the generic’s bioequivalence. Likewise, shape differences can influence the flow and compressibility of the generic product, for example, in tablet formulation, which may impact the quality (content uniform ity) and Again,performance.fromabusiness perspective, a better understanding of the practices required to build a bioequivalent generic also helps companies to identify areas in which they lack technological and
By applying the Quality by Design approach in their generic drug development projects, scientists ensure that rigorous design principles are used consistently across the entire process, thereby ensuring the quality of the final product. Central to these principles are the use of analytical technologies that provide a foundation from which developers can engineer generic drugs that match the therapeutic characteristics of the innovator drug.
amounts of the API, whereas the branded product contained comparatively higher quantities of fine API particles. Even though the generic product contained a higher percentage of the active ingre dient, the morphology of the branded product’s API particles could accelerate its dissolution in the body and therefore improve absorption.
[from morphologically-directed-raman-spectroscopy]https://www.malvernpanalytical.com/en/products/technology/image-analysis/
In parallel, developers also use char acterisation techniques to evaluate the active substance(s) and help them under stand physical and functional features like particle shape and size distributions, chemical identity, and crystal structure. Such features provide insights into the efficacy and stability of the final drug product.Forexample, the size and shape of API particles can have a significant impact on the dissolution rate of a drug, directly influencing how the API is absorbed into the blood stream in order to trigger its therapeutic effect. Similarly, developers need to understand the polymorphic form of an API, as the nature of its crystal structure can also have a significant impact on dissolu tion rate and bioavailability. And from a business perspective, differences in solid form can impact questions relating to intellectual property and patents.
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production capabilities and therefore might wish to seek development or manufacturing partners and collaborators.
One technology that allows developers to extract both morphological and chemical data about the multiple constituents of any drug—i.e., active phar maceutical ingredients (APIs) and excipients—is MDRS®, which combines the insights of automated analytical imaging and Raman spectroscopy.
Understanding Morphologically-Directed Raman Spectroscopy (MDRS)
Morphologically-Directed Raman Spectroscopy (MDRS) in practice
Experts have also used MDRS to identify the sources of counterfeit drugs by comparing their unique chemical signatures to the innovator drugs.
To highlight its value in deformulation studies, researchers have used MDRS to analyse commercially available treat ments—a branded therapy and its generic equivalent—to identify differences in particle size distribution between the two products. The researchers noted that the generic drug contained higher total
In another experiment, researchers used the Raman spectroscopy function of MDRS to evaluate whether a sample of an API included more than one poly morphic form. Such information can be
Using the analytical imaging function of MDRS, developers can scan dispersed product samples and capture images of individual particles to under stand distributions in particle shape and size. The Raman spectroscopy function then allows developers to differentiate and quantify the chemical constituents and compare the individual spectra against a reference spectral library to chemi cally identify them.
which in this case, they determined to be1: 9 representing polymorph A and polymorphResearchersB.
Alongside these chemical insights, developers are also using these analytical technologies to find clues explaining how the innovator products were originally manufactured. This opens the door for them to replicate that production process within their own companies, facilitating access to less expensive, equivalent or possibly superior generic therapies.
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Breaking through
produced more elongated particles than when the same API was micronized (green). [from: wp141209deformulationworkflowosd,https://www.malvernpanalytical.com/en/learn/knowledge-center/whitepapers/Figure8]
Paul Kippax leads the business development and marketing team at Malvern Panalytical as Pharmaceutical and Food Sector Director. He has a PhD in colloid science from the University of Nottingham and joined Malvern Panalytical in 1997 – developing an in-depth understanding of how material characterisation techniques can address key industry challenges.
polymorphs. They can then use this information to identify API particles as one polymorph or the other and quan tify the relative abundance of the two,
As shown in Figure 1, the research ers found that although most peaks are recorded at the same Raman shift for either polymorphic form, clear spectral differences between wave numbers 1100 and 1300 highlight the presence of two
Figure 1: Using Raman spectroscopy on an API sample, researchers identify the presence of two polymorphic forms (white shaded area). [from: Figurewp141209deformulationworkflowosd,https://www.malvernpanalytical.com/en/learn/knowledge-center/whitepapers/Figure6]2:Byusinganalyticalimaging,researchersshowedthattapmilling(red)anAPI
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critical in RLD deformulation as it can significantly impact drug behaviour in vivo. Thus, companies will often formu late an innovator drug using the most stable polymorphic form to reduce the risks associated with polymorphic trans formation during manufacture and stor age (Figure 1).
have also used the analytical imaging function of MDRS to obtain morphological data about an API. As discussed earlier, such informa tion can be very useful in determining how a product was manufactured and thereby informing the reverse-engineering process. As shown in Figure 2, the same API produced with tap milling resulted in much more elongated particles than when it was produced using micronisa tion (Figure 2).
As drug product patents continue to expire and companies continue to push to develop generic versions, efforts to break down innovator products into detailed physicochemical blueprints will only increase. And the growing complexity of these therapies will continue to challenge the analytical technologies needed for generic drug development. Using newer technologies such as MDRS, drug developers are achieving a highly detailed understand ing of the constituent components of drug products and probing deeper into the mechanisms by which drug composi tion impacts therapeutic features such as drug efficacy and safety.
Emerging technologies can help you automate processes in ways believed impossible just five years ago. Furthermore, many pharma compa nies are accelerating their digital transforma tion journey, pairing up their use of emerging technologies with other methodologies like Agile, DevOps, Extreme Programming, etc. But what could be some of the most promising emerging technologies you and your teams can use to accelerate your digital transformation journey? And how do they work or why are they so promising? In this short article, we provide a quick overview of the emerging technologies we think are most useful to you and your teams in pharma. You do not need to have a technical background or know how they work. We will make them easy to under stand. In addition, we will provide some quick examples and explain where you can start to leverage them inside your company. Doing what we say, you will create some quick wins that will generate business value, unlock more funds for you and your teams, and increase your probability of career progression.
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Fausto Artico, Global R&D Tech Head and Director of Innovation and Data Science, GSK
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Kevin Harrigan, Director of Innovation and Engineering, GSK
Introduction
We live in a volatile, uncertain, complex and ambiguous (VUCA) world. Things will continue to change faster and faster. The question is not anymore about if you and your company will be disrupted but when (and how). Therefore, you need to continuously be on the lookout for new, emerging technologies that could be used by you to generate competitive advantage and by your competitors to disrupt the market. Many such emerging technologies might not be mature enough, but you need to assess them anyway. In fact, to be ahead of your competitors, you and your teams need to understand these technologies and start to build internal capabilities(e.g., acquire talent, run experiments, create support ecosystems) now. This will allow you to quickly scale up their adoption inside your organisation as they enter their growth and maturity phases.
Which Technologies you Need to Use, and for What, to be Successful with your Teams in Pharma 4.0
3D PRINTING: It provides the ability to code what you want the machine to build for you. It is also called 'additive manufacturing’ because the machine adds layer upon layer of material to create the physical objects you want. The type of personalisation you can achieve with 3D printing is enormous. 3D printing is still far from being mature enough to allow you to create ad-hoc manufacturing components or personalised medicines. However, it is maturing and some important governmental initiatives, especially in the USA, are creating synergies between university and industry, especially in the manufacturing sector, to accelerate the capabilities it can offer. The most promising usage of such technology in the Pharma sector is for creating highly personalised implants and so your bioengineering departments are potential good collaborators in working with you to experiment with it.
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is important as more and more systems become impossible to manage using only conscious capabilities. AI is also important for quickly reacting to unexpected events that could take time for a human being to recognise but which could be easily stopped and/or taken care of by software systems. However, remember always to embed monitoring capabilities so that such systems can ask for human interven tion if the situation drifts too much from a baseline and/or the systems recognise the situation to be too different from any of the ones used for their training.
ARTIFICIAL INTELLIGENCE (AI): AI can automate many processes, thereby reducing the need for human intervention and achieving scalable cost savings. AI
AUGMENTED REALITY (AR): AR over lays information on your vision field to revolutionise the way you execute root cause analyses. This is especially true in manufacturing where equipment has many mechanical components. For exam ple, using smart glasses with AR allows people to quickly discover handles and other machine parts that seem to be in the wrong positions as well as to verify wear and tear of many small components
Interesting Emerging Technologies
ANALYTICS: It is so pervasive that you can use it everywhere. From executing simple statistical methods to visualising results in dashboards, your Fausto Artico, Global R&D Tech Head and Director of Innovation and Data Science, GSK Kevin Harrigan, Director of Innovation and Engineering, GSK teams have an unlimited number of ways to use analytics to discover and show drifts, deviations, trends, etc. It can also be used to generate new insights on why adverse events happen (e.g., deviations). This is important because operators and users struggle to make sense of all the informa tion available. Analytics can help them prioritise what to focus on, independently of which part of the organisation they work in (e.g., drug discovery, clinical trials, manufacturing, supply chain or commercialisation).
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MACHINE LEARNING : The ability of a machine to learn new things and generate insights using pre-codified rules is going to become a huge source of competitive advantage. A new algorithm is difficult to copy or understand if your competi tors do not have access to its code. The more you create flexible rules provid ing strong statistical evidence that the models they create are reliable, resilient and robust, the more you can be success ful in solving many different challenges in the whole Pharma pipeline. This is due to the generic nature of the rules and the fact that you can create them for generic abstractions of problems that seem different superficially (e.g., manufacturing problems vs drug discovery problems) but are similar from the mathematical point of view (i.e., symbols and the need to discover in automated ways the rela tionships and dynamics between them).
QUANTUM COMPUTING (QC): The most promising applications of QC in Pharma are probably those used to determine how proteins fold, thus aiding in the discovery of new drugs. There are still big limita tions on the hardware side, but progress and workarounds are moving fast on the software side. Promising QC sub-fields in which we could see breakthroughs are the ones characterised by Quantum classifiers. Such classifiers could soon be able to scan huge amounts of genomic data in very short amounts of time and verify if a subject is affected by a specific disease or has a propensity to become affected. Compared to other emerging technologies, for QC you probably need a small team of people that could be difficult to find. To minimise cost, try to hire somebody with a Computer Science, Statistics, Mathematics and Physics back ground. If you cannot find anybody with all these backgrounds, then hire several people to cover all the bases.
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BLOCKCHAIN: Transparency is a critical feature for building trust. Blockchain will become very important in Supply Chain because it allows you to trace in a fully transparent way the provenance of all the source materials. It will also become extremely important in the crea tion and execution of smart contracts. Smart contracts will save huge amounts of time for legal departments. Contracts that can be 'assembled’ using pre-estab lished clauses for different geographi cal zones will probably be the first ones to be created in automatic ways using Blockchain as the underlying founda tional technology.
CYBERSECURITY: It is important to minimise the possibility for malicious people to execute actions that are against the integrity of systems and the wellbeing of users and patients. However, cybersecurity can go a step further and be used to design future systems lever aging security principles from day one.
DATA SHARING: The huge need to innovate in this field has created plenty of opportunities. This is true especially if the systems you design and implement need to work in geographical zones that have different legal systems and regulations. It will also be important to: 1) create systems that are able to share data but that can also mask, for privacy reasons, important information in automated ways (e.g., people in some geographical zones cannot access some data or people access ing clinical trial data cannot deanonymise patients); 2) allow users to grant, but also revoke at any moment, access to their data; and 3) make sure sensitive information does not get copied and is destroyed in a timely fashion after the end of contracts. You and your teams can start to build basic masking capabilities first (e.g., mask addresses and names). When you have become more experi enced in understanding the difficulties and nuances of creating a privacy system for data sharing at the local level, you can move to more complex activities like very
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granular policy creation (e.g., policies based on attributes and not roles) and code systems that ensure their performant enforcement at scale.
that are difficult to analyse by the human eye. Because the precision and accuracy of such solutions is heavily dependent on Computer Vision capabilities, make sure to have at least a Deep Learning expert in your teams when you build or buy AR solutions.
REAL WORLD DATA: Government initiatives are making it easier to get data that can be used to design new clinical
However, to be ahead of your competitors, you and your teams need to understand these technologies and start to build internal capabilities now.
This is important because, in the future partnership ecosystems, more components will be designed and coded by different companies. Having each component providing its own cybersecurity capa bilities minimises the possibility, after penetration, for attackers to 'spread’ to other components and execute unauthor ised actions. You and your teams can get in touch with the perimeter and security teams and start to use cybersecurity for creating monitoring systems able to detect anomalous users' behaviours.
BIG DATA (BD): The ability to ingest, clean, link, contextualise and harmonise many disparate data sources is becoming incredibly important. This will become easier as BD capabilities become more mature. The number of tools and plat forms available in the marketplace allows you to leverage graphical user interfaces and so even non-technical people can simply drag and drop boxes and connect them to create data pipelines that in the background execute all the typical BD operations. Thanks to BD, your work ers and partners save huge amounts of time accessing all the data and have it organised using agreed upon formats and schemas. You can use BD capabilities in any part of your company and on any project where it would be practically impossible to manually collate, check and update the deluge of information the existing systems are constantly generating.
Kevin graduated with a BSAE in aerospace engineering from Pennsylvania State University. During his collegiate career he gained experience in a co-opposition with Capital One Financial as a Data Analyst at in Richmond, Virginia. It was this experience that afforded him the opportunity to find passion in data munging, applied statistics, and programming. Following graduation, he accepted a full time offer in their newly formed Digital Enterprise Organization, expanding his technical and analytical knowledge in areas such as distributed computing, clickstream analytics, multivariate testing, anomaly detection, and propensity modeling.
Often it is a software capability, contrary to what many people think. You install a software on laptops and other devices. The software starts to track the actions that people execute. Later, after having collected data for some time, the soft ware discovers and finds commonalities and differences in how people execute actions and standardise them creating push button macros that people can use to not have to manually repeat the common parts of the actions. This capa bility is important especially if some parts of some procedures should be repeated always in the same exact way for regula tory and compliance reasons. In addition, the macros save a great deal of people’s time, and such time is easily transform able into cost savings that senior execu tives can readily understand, and which scale up quickly as the adoption of the software increases.
operate and multiple sub-groups in the “community” they create can observe what each single sensor is doing, or claims to be doing, and help it to determine through voting methodologies if it is healthy. Such capability is important for maintenance people, especially in manufacturing where machines can have thousands of sensors (i.e., bioreactors).
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VIRTUAL REALITY (VR): Educational purposes or regulatory processes, you can use VR to train people on many things. For example, some young opera tors must be able to use and manage complex equipment for discovering new drugs in early stage discovery or producing products in manufacturing. Such equipment can easily cost tens of millions of dollars. Human errors need to be minimised because they would easily cost tens of million dollars to your company due to missed target submission deadlines and/or regula tory fines. Using VR to train people before introducing them to the real processes can greatly decrease the prob ability of misuse of such equipment. You can create digital twins, especially for highly mechanical systems for which the science is very well known, and have people, through VR, run what-if scenarios on how to use the equipment in different situations and conditions (even the rare, anomalous ones).
trial studies or accelerate drug discovery. The datasets made available through such initiatives are important because they are usually a ‘common denominator’ that companies can use in their collaborative efforts. The standards used to create such datasets are determined a priori. Such initiatives facilitate the adoption of such standards (e.g., schemas and formats) inside companies. This also means that if at a later stage companies decide to share their data, integration and sharing will happen quickly. You and your teams should leverage such rich datasets. This is true even if the reliability of the data sources cannot be easily checked and/or the replicability of the results is difficult to verify due to the lack of metadata that explains the protocols used to generate the data.
Fausto has two PhDs. As a Physicist, Mathematician, Engineer, Computer Scientist, and High-Performance Computing (HPC) and Data Science expert, Fausto has worked on key projects at European and American government institutions and with key individuals, like Nobel Prize winner Michael J. Prather. After his time at NVIDIA corporation in Silicon Valley, Fausto worked at the IBM T J Watson Center in New York on Exascale Supercomputing Systems for the US government (e.g., Livermore and Oak Ridge Labs).
WEARABLES: The new generation of wearable devices is easily configurable and can stream seamlessly and constantly a considerable number and type of biomarkers. These new devices can do this using bluetooth, Internet or lowpower, wide area networks (LoRaWan). This opens unprecedented possibilities in clinical trials. Before doctors had to manually take and record biomarkers from patients with a very low sampling frequency. Thanks to the new genera tion of wearable devices, you can now monitor patients 24/7 and do not have to wait any time before receiving the data from your patients or doctors. Therefore, leveraging such devices, you can generate much richer datasets for each patient and take clinical trial actions much faster.
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Summary
SMART SENSORS: As the number and complexity of systems increase, the abil ity of sensors to 'talk with’ and “observe” each other is fundamental. Sensors are becoming capable of collaborating with each other thanks to their augmented capabilities to interconnect and work together (i.e., Internet of Things). Working together, they can create base lines for the environment in which they
ROBOTIC PROCESS AUTOMATION:
In this VUCA world, it is important that you invest some time and money in exploring and assessing new emerging technologies on an ongoing basis. Doing so, by the time some of these technologies become mature, you and your team will have built the knowledge and confidence necessary to leverage them in larger and more complex projects. Such projects will be critical for you to generate a competi tive, and in a considerable number of cases, sustainable, long-term advantage for your organisation.
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CLINICAL
Novo Nordisk
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