the preparation of
`A STERILE SOLUTION OF MANNITOL
`
`by LOUIS P. JEFFREY and KENNETFI H. FISH, JR.
`
`• ACUTE KIDNEY FAILURE HAS PROVED A SERIOUS AND
`sometimes fatal complication of certain kinds of sur­
`gery. An exhaustive search for a means of preventing
`this kidney failure during surgery was carried out by
`a research team in the Eldridge H. Campbell Surgical
`Research Laboratory at the Albany Medical College.
`This team found that mannitol was remarkably effec­
`tive in preventing kidney failure. As a result of their
`work, the Department of Surgery of the Albany Medi­
`cal Center Hospital began administering mannitol to
`patients undergoing operations where the risk of kid­
`ney shutdown was high. In the past, it was not un­
`common to find that 20 to 25 surgical patients each
`year would require artificial kidney treatment because
`their kidneys stopped functioning. In 1961, thanks to
`mannitol, there were no cases of acute kidney failures
`following surgery at this Hospital.^
`
`Background
`
`At the time this procedure was being instituted the
`Department of Pharmacy was carr^'ing in stock man­
`nitol injection,- commercially available as a 25 percent
`solution packaged in a 50 ml. ampul. This was ac­
`ceptable for most cases since mannitol is administered
`intravenously in doses as high as 100 grams or more. In
`using this concentration undiluted, the fluid volume is
`kept to a minimum, which has a distinct advantage.
`There are occasions when this product is added to an
`intravenous solution, such as dextrose injection 5 per­
`cent. This could be done without significantly affecting
`the pharmacological aspects of either the mannitol or
`the large volume parenteral solution. This is one ad­
`vantage of the high concentration of mannitol in man­
`nitol injection.
`The injection can be administered, undiluted or
`directly intravenously. Large doses can be given in a
`short time with a minimum fluid volume introduced.
`Mannitol is also used as a diagnostic agent for kid­
`ney function.^
`
`Physical Characteristics
`
`Mannitol, official in N.F. XI, is a hexahydric alcohol
`which is rather widely distributed in the tissue fluids of
`
`LOUIS P. JEFFREY, M.S., is Director of Pharmacy and
`Central Supply, Albany Medical Center Hospital, Al­
`bany, New York. KENNETH H. FISH, JR., B.S., is Su­
`pervisor, Division of Bulk Pharmaceutical Develop­
`ment, Department of Pharmacy, Albany Medical Cen­
`ter Hospital, Albany, New York.
`
`American Journal of Hospital Pharmacy Vol 20 MAY 1963
`
`various plants. It is obtained from manna and other
`natural sources by means of hot alcohol extraction. In
`purified form, it is a white, crystalline powder, odorless
`and having a sweetish taste. It melts between 165 and
`167°C. One gram dissolves in about 5.5 ml. of water
`(18 percent solubility). It is obvious that a 25 percent
`solution is a supersaturated one.
`Under certain conditions it is possible to prepare a
`solution containing a larger amount of solute than is
`necessary to form a saturated solution. This may occur
`when a solution is saturated at one temperature, the
`excess solid solute removed, and the solution cooled.
`The solute present in solution, even though it may be
`less soluble at the lower temperature, does not always
`separate from the solution and there is produced a
`supersaturated solution. Such solutions may be made
`to deposit their excess of solute in one of the follow­
`ing ways: by vigorous shaking; by scratching the side
`of the vessel in contact with the solution; by intro­
`ducing into the solution a small crystal of the solute; or
`by reducing the temperature of the solution to a great
`extent.
`This information gives us some idea of the physical
`characteristics of mannitol injection 25 percent. Under
`normal conditions, it is a stable solution. But during
`shipping, handling, and storage of the injection, ex­
`treme temperatures and conditions may prevail. Be-
`
`Kenneth H. Fish, Jr. prepares the
`equipment for the filtration
`process of mannitol solution
`
`255
`
`MYLAN INST. EXHIBIT 1115 PAGE 1
`
`MYLAN INST. EXHIBIT 1115 PAGE 1
`
`

`

`cause of the extreme conditions to which the injection
`was exposed during shipping many ampuls were re­
`ceived which contained large crystals. Rough handling
`or low temperature may have caused the precipitation
`to occur. Nevertheless, the problem existed and steps
`• were taken to rectify it.
`Upon receiving a shipment, it was necessary to open
`each case and each box to visually inspect the ampuls.
`I'he ampuls which contained crystals were set aside for
`return. Idie greatest problem arose in the late fall and
`during the winter months, when practically every
`amptil received contained large clumped crystals of
`mannitol.
`We decided to follow the recommendation of the
`manufacturer who suggested that ampuls, in which
`crystals were evident, be warmed to body temperature
`in water. We found that if the crystals were large and
`formed a solid mass at the base of the ampul, it was
`impossible to redissolve them using this method. After
`a review of the literature and several personal in­
`quiries, we decided to re-autoclave the ampuls. This
`did not adversely affect the color of the mannitol solu­
`tion and, if crystals were present, they would easily re-
`dissolve. This method was instituted as a procedure in
`: the Pharmacy and it gave us the assurance that no am-
`
`PraporaMon
`
`ALBANY MEDICAL CENTER HOSPITAL
`DEPARTMENT OF PHARMACY
`BULK COMPOUNDING RECORD
`
`FORMULA
`
`.
`
`Cm/ml
`
`v'
`
`Mada by
`Mada by
`Mada by
`Mada by
`
`Tim*
`Tim*
`Tim*
`Tim*
`
`•
`•
`
`-
`-
`
`Chsckad by
`
`Ocla
`Ocla
`Ocla
`Ocla
`
`Flllad by
`Flllad by
`Flllad by
`
`Flllad by Flllad by
`Flllad by
`
`Containar
`Containar
`Containar
`
`Containar Containar
`Containar
`
`Sixa
`Sixa
`Sixa
`
`Sixa Sixa
`Sixa
`
`Saal
`Saal
`Saal
`
`Saal Saal
`Saal
`
`No. Unili
`No. Unili
`No. Unili
`
`No. Unili No. Unili
`No. Unili
`
`Tim#
`Tim#
`Tim#
`
`Tim# Tim#
`Tim#
`
`Data
`Data
`Data
`
`Data Data
`Data
`
`Inipactad by Inipactad by
`
`
`
`Del* Del*
`
`Lobalad by Lobalad by
`
`Lobalad by
`
`• •
`
`•
`
`Tima Tima
`
`Tima
`
`Dola Dola
`
`Dola
`
`•
`
`.
`
`•
`
`
`
`. .
`
`]
`:
`i
`
`1
`
`
`i| i|
`
`!l !l
`
`1!
`
`Lobal No. Lobal No.
`
`Lobal No.
`
`LABORATORY DATA
`
`STERILIZATION DATA
`
`Dote
`
`Method
`
`Temperofyre
`
`Exposure
`
`Dlepeiltlon ol
`Vicli
`
`Mlice11ar)eout_
`Bacteriology
`
`R*iacrs_i
`
`Control
`To »tock_
`
`Totoi
`
`pH Before sierilixoiioi
`After tlerilizalion
`
`Sterility
`
`Checked by.
`
`256
`
`Pharmacist Everett C. McBride adjusts
`temperature of hot plate in the
`preparation of the mannitol
`filtration process
`
`puis containing crystals would be dispensed. However,
`this procedure was quite time-consuming. One way for
`us to have circumvented this problem would be to or­
`der a large amount of mannitol injection in the early
`fall and maintain it under suitable conditions through­
`out the winter. This procedure would have involved
`the allotment of large areas of valuable storage space
`which was not readily available. Also, there were
`many times when the demand for the preparation
`which we placed on the pharmaceutical manufacturer
`was so great that it could not be met.
`
`Method of Preparation
`
`Because of the many difficulties we were having in
`this area, we decided to investigate, the possibility of
`preparing mannitol injection. The task was assigned
`to the Division of Research, Control and Development
`of the Department of Pharmacy. The initial step was
`to find a procedure. When we were not able to find any
`references to a specific procedure for compounding, we
`proceeded to develop our own.
`Some of the problems incurred in the manufacture
`of a solution of mannitol 25 percent are described in
`the following paragraphs. Since this preparation is a
`supersaturated solution, it was necessary to heat the
`water to boiling to effect solution of the crystals. If the
`solution were allowed to cool in a container which was
`not tightly sealed, small amounts of water would be
`lost through evaporation. Crystals of mannitol then
`formed in the beaker. Upon cooling, the solution did
`not contain the labeled quantity. The supersaturated
`solution was prepared by adding boiling water to the
`mannitol in a flask, and then stoppering the flask
`
`MYLAN INST. EXHIBIT 1115 PAGE 2
`
`MYLAN INST. EXHIBIT 1115 PAGE 2
`
`

`

`tightly. The solution was cooled and brought to
`volume.
`Great care should be exercised in handling this
`solution since crystals form quite easily. Introduction
`of foreign objects {e.g. a glass rod) or just pouring the
`solution, may cause the crystals to be "shocked out."
`After working with this solution for quite sometime, we
`concluded that there were too many obstacles for us
`to solve in working with this high concentration. To
`resolve the problem created by the supersaturation of
`the mannitol solution, we varied the percent of chemi­
`cal until we, achieved a concentration with which we
`found that it was easy to work. We consulted with the
`members of the medical staff concerning a desirable
`concentration. It was concluded that a 20 percent solu­
`tion of mannitol was the optimum concentration which
`presented the least number of problems. The 20 per­
`cent solution was of low enough concentration to vir­
`tually eliminate the problems of precipitation during
`manufacturing process. It was still high enough to as­
`sume the concentration needed in surgical and medical
`procedures. Heat is still required to prepare a 20 per­
`cent solution of mannitol, but crystallization did not
`occur during the handling of the solution. The deci­
`sion to prepare a 20 percent solution also made it rela­
`tively easy for the nursing and medical staff to calcu­
`late dosage. The solution was to be packaged in 50
`ml. vials, thus each vial contained 10 grams of manni­
`tol. The final product maintained an essential element
`of the preparation—the highest possible concentration
`in the least amount of fluid volume.
`Although Mannitol N.F. was used, there was present
`a significant amount of insoluble contaminants in the
`chemical. This created another problem. In the small
`volume parenteral procedures, we use the Millipore
`
`Pharmacists Fay Peck, Jr. (left) and
`Kenneth Fish, Jr. discuss problems
`involving filtration of the mannitol solution
`
`f^fr-1-'
`
`STERILE SOLUTION OF MANNITOL
`
`REFRACTOMETER READINGS
`
`(ARBITRARY SCALEl
`
`Figure 1. Refractometer Readings versus Percentage of
`Mannitol in Aqueous Solution at 25^0.
`
`filter.-' The porosity in the filter disc is 0.45 microns.
`This is small enough to remove from tlie solution prac­
`tically any insoluble material. This was the case with
`the mannitol solution, which contained enough in­
`soluble particles to cause the filter to become clogged
`after only a few hundred milliliters had passed through
`it.
`This problem of impurity was discussed by corres­
`pondence with the chemical manufacturer and a re­
`quest was made for a more highly purified grade of
`chemical. We were informed that the only available
`grade was the one which we had purchased, and that
`this grade meets the N.F. requirements. Since a more
`refined powder was not available, we attempted to
`solve the problem through technicological methods.
`The solution proved to be relatively simple. After the
`mannitol solution was made, it was filtered throiwh a
`
`Equipment used in preparing the mannitol
`solution is checked by Pharmacist.^
`Everett C. McBride and Kenneth H. Fish, Jr.
`
`American Journal of Hospital Pharmacy Vol 20 MAY 1963
`
`257
`
`MYLAN INST. EXHIBIT 1115 PAGE 3
`
`MYLAN INST. EXHIBIT 1115 PAGE 3
`
`

`

`medium porosity, fritted disc funnel.® This proce­
`dure served as a preliminary filtration step and a large
`percent of the insoluble material was removed. The
`solution was then passed through the Millipore filter
`and no clogging occurred.
`
`Procedure
`
`The last of the problems concerned the procedure in
`filling the mannitol solution into vials. It was noted
`that a cool solution would at times "throw out" crys­
`tals when it was filled into a cool vial. To circumvent
`this, the solution was filled, while warm, into vials that
`had been recently autoclaved. No precipitation took
`place using this procedure.
`1 he following is the formula for mannitol injection
`209r.
`
`Mannitol Powder N.F. (98%)
`Water for Injection, to make
`
`204 Gm.
`1000 ml.
`
`1 he inannilol is accurately weighed and dissolved in water
`I'or injection, which has been previously heated to 80°C. The
`solution is allowed to cool to approximately 50°C. and the
`volume is adjusted if liecessary. The solution is then filtered
`through a medium porosity, fritted disc funnel. The vacuum
`bottle into which the mannitol solution is filtered
`rests on a
`hot-plate which has the temperature adjustment set at 60°C.
`I his keeps the solution warm so that crystals are not likely
`to form. This step is repeated, exactly, during the second fil­
`tration process using the Millipore filter. The filtered
`solu­
`tion is kept warm. The vacuum bottle is attached to the
`•automatie pipetting machine^ and the solution recirculated
`through the filter. This step assures that no dust particles or
`other impurities remain in the solution. After the solution
`has been recirculated several times, it is ready to be filled
`into vials. The 50 ml. vials, which have been properly washed
`and
`treated, should be autoclaved and allowed
`to cool
`slightly. Fifty-five (55) ml. of the warm solution is pipetted
`into each yial. The vials are capped with a one piece tear-
`away aluminum seal, crimped and autoclaved at 12I°C. for
`15 minutes.
`
`Procedure for Control
`
`After the vials are autoclaved they are packed into
`a case and sent to a quarantine area. One vial is sent
`to the-Bacteriology Laboratory for a sterility test. Two
`vials are sent to the Pharmacy Control Laboratory
`where the preparation is checked on these points.
`1. /;H—6.3 to 7.3 (N.F. XL 1960)
`2. Quality—qualitative tests for mannitol (N.F. XI
`1960)
`3. Refractive Index'—19 to 21
`4. Assay—the refractive index reading provides a
`reliable assay.' The readings on the arbitrary scale have
`a direct relationship to the percent of mannitol in
`solution. (See Figure 1)
`5. Stability—One sample is held as a control. It is
`observed for several weeks to check stability.
`6. Sterility—The Bacteriology Laboratory sends to
`the Department of Pharmacy a report on the sterility
`
`258
`
`of the products. The media used were fluid
`collate and fluid Sabouraud media.®
`7. Pyrogens—The distilled water used for making
`the solution is pyrogen tested periodically.
`
`thiogly-
`
`If the mannitol injection meets all the specifications
`listed above, it is then released from quarantine. The
`vials are now visually inspected and those containing
`any macroscopic contamination are discarded. The re­
`maining vials are labeled and delivered to the stock
`room. All compounding and control statistics are en­
`tered on the Bulk Compounding Record and this
`card is filed for future reference.
`
`Summary and Conclusion
`
`If mannitol solution 20 percent is to be prepared,
`certain steps must be followed to develop and prepare
`an acceptable product. The mannitol is dissolved in hot
`water and kept warm. It is filtered through a medium
`porosity fritted disc funnel and then through a Milli­
`pore filter. The solution is filled while warm into pre­
`heated vials. This procedure is easy and effective. The
`possibility of crystallization occurring is practically
`eliminated.
`The medical and surgical staff at this hospital have
`found mannitol injection 20 percent to be suitable in
`all cases in which mannitol is indicated. We now have
`control over the supply of mannitol injection, and the
`hospital is never without an adequate supply in stock.'
`The reserve which we have is stable and there is no
`problem with storage. The manufacture of this prep­
`aration is also economical.
`Perhaps the most gratifying and satisfying conclu­
`sion to this work was the fact that the Department of
`Pharmacv has rendered a valuable service to the pa­
`tients, physicians, and nurses at the Albany Medical
`Center Hospital. With the addition of this valuable ad­
`junct to their armamentarium, we have assisted the
`medical staff in their effort to control acute renal
`failure.
`
`Notes and References
`
`1. Albany Medical Center Hospital, Annual Report,
`2. Merck Sharp and Dohme, Division of Merck and Com­
`pany, Inc., West Point, Pa.
`3. Remington's Practice of Pharmacy, Martin and Cook,
`11th Edition 1956, Mack Publishing Company, pp. 636-637!
`4. Ibid.: p. 143.
`5.. Millipore Filter, "Pyrex Filter Holder," Catalogue No.
`XX10 047 00, Millipore Filter Corporation, Bedford, Mass.
`6. Buchner-type funnel, with fritted disc. "Pyrex" brand
`glass (Corning No. 36060), Will Corporation, Box 1050
`Rochester 3, N. Y.
`'
`7. Brewer Automatic Pipetting Machine, Baltimore Bio-
`logieal Laboratory, Inc., 1640 Gorsuch Avenue, Baltimore
`18, Md.
`8. American Optical Company, Buffalo, New York, Hand
`Refractometer, Series 25-A.
`9. U.S.P. XVI, page 856.
`
`MYLAN INST. EXHIBIT 1115 PAGE 4
`
`MYLAN INST. EXHIBIT 1115 PAGE 4
`
`