Annex 2

FIP–WHO technical guidelines: Points to consider in

the provision by health-care professionals of children-
specific preparations that are not available as authorized
products

1. Introduction and scope 89

1.1 Background 89
1.2 Purpose 90
1.3 Target audience and health-care settings 90
2. Glossary 90
3. Alternatives to compounding 92
3.1 Sourcing of a commercially-available (marketed) or manufactured product
if available 92
3.2 Dose rounding 93
3.3 Therapeutic alternatives 93
3.4 Manipulation of dosage forms 93
3.4.1 Tablet splitting 94
3.4.2 Tablet/capsule dispersion for oral administration 94
3.4.3 Crushing tablets/opening capsules and mixing powder with food or drink 95
3.4.4 Giving the injectable form by the oral route 96
3.4.5 Splitting suppositories 96
3.4.6 Rectal administration 97
3.4.7 General advice when changing the route of administration 97
4. Compounding 97
4.1 Good manufacturing practices aspects 97
4.2 Some potential problems 98
4.2.1 Oral liquids 99
4.2.2 Microbial contamination 100
4.3 Basic considerations 100
5. Information, availability and access 106
5.1 Standards of practice and guidelines 106
5.2 Formularies and compendia 106
5.3 Source and supply 106
5.4 Networks and information services 107
References 107
Appendix 1 Examples of therapeutic alternatives to extemporaneous formulations 109
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1. Introduction and scope

1.1 Background
Paediatric patients should have access to authorized, age-appropriate preparations
of medicines that can be administered safely and effectively. Nothing in this
document should detract from this objective. However, it is recognized that
such preparations are not always available and in such cases a safe and effective
alternative must be sought.
In the context of paediatric pharmacy practice, and for the purpose of
this document, compounding is the technique applied by pharmacists to produce
medicines from active pharmaceutical ingredients (APIs) or using authorized
medicines when no commercially available, authorized, age-appropriate or
adequate dosage form exists. Unless stated explicitly in this document, the
compounded medicine is assumed to be dispensed immediately after preparation
and not kept in stock. Compounding does not apply to reconstitution of
authorized medicines prior to dispensing. A clarification of the terminology of
preparation of medicines for children has been proposed by Ernest et al. 2012 (1).
The risks and benefits of compounding and of the alternatives should
be fully understood by practitioners. Practitioners who do not have appropriate
knowledge should seek advice.
Compared to the use of authorized medicines there are significant risks
associated with compounding; quality, safety and efficacy can rarely all be assured,
and many errors have been reported in the preparation of such medicines. In
some situations compounding of a medicine for a child may be the only option,
which may be supported by evidence of quality and occasionally evidence of
bioavailability by industry or other parties, such as academia. There may be
alternatives to compounding, which should also be considered, for example, use
of a commercially available therapeutic alternative or manipulation of authorized
dosage forms.
WHO Technical Report Series No. 996, 2016

This points-to-consider document is supported by a literature review

of the evidence available (2). An annex to the report contains an update on the
abstracts and papers published in 2010–2015.
This document is to be considered as a time-limited document that
addresses current needs for advice in the search for an alternative to an authorized,
age-appropriate dosage form. Wherever possible the guidance is informed
by the relevant evidence. However, the evidence base is weak or non-existent
in most situations. Consequently, the guidance is predominantly informed by
best practice, based on sound scientific and therapeutic principles and expert
consensus. Although the guidance takes the form of a working practical document
it is important to invite comment and input from interested practitioners so that
the guidance can be developed further in response to feedback. The document
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addresses mainly paediatric medicines for oral administration; comments and

proposals concerning other routes of administration are invited as well.

1.2 Purpose
The purpose of the document is to:
■■ provide evidence-based or best practice advice about alternatives to
compounding of medicines for paediatric patients;
■■ describe the main potential problems of compounding and educate
practitioners on how to avoid them;
■■ provide brief advice on compounding;
■■ reduce the risk of providing children-specific preparations without
informed knowledge.
The document will not reproduce guidance and standards that already
exist (e.g. good manufacturing practices (GMP) standards for facilities and
documentation). Where appropriate, reference is made to the relevant resources
and publications.

1.3 Target audience and health-care settings

The document is intended for a wide audience of health-care stakeholders
including:
■■ all practitioners involved in health care of the paediatric population
but mainly pharmacists, physicians, paediatricians and nursing staff;
■■ national medicines regulatory authorities and professional bodies,
e.g. national paediatric organizations and national pharmacy
associations;
■■ general hospitals and health clinics;
■■ specialized paediatric hospitals and primary care clinics;
■■ the pharmaceutical industry, given its role in providing information.
Pharmaceutical manufacturers can often provide useful information
on validated compounded formulas and other information relating to the
manipulations and specific characteristics of formulations.

2. Glossary
The definitions given below apply to the terms used in these guidelines. They
may have different meanings in other contexts.
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active pharmaceutical ingredient (API). Any substance or mixture

of substances intended to be used in the manufacture or compounding of
a pharmaceutical dosage form and that, when so used, becomes an active
ingredient of that pharmaceutical dosage form. Such substances are intended
to furnish pharmacological activity or other direct effect in the diagnosis, cure,
mitigation, treatment or prevention of disease, or to affect the structure and
function of the body.
authorized dosage form. A pharmaceutical dosage form that has been
authorized by the competent authority to be marketed for the treatment of
specific indications.
beyond-use date. The date after which a compounded preparation should
not be stored, transported or used; the date is determined from the date or time
the preparation is compounded. It is also known as the expiry date.
compounding. Preparation under the supervision of a pharmacist
following national legislation of an unlicensed medicine to meet the specific
needs of a patient when no suitable authorized dosage form is available. This
may involve preparation from the authorized dosage form or from the active
pharmaceutical ingredient and usually involves addition of excipients to produce
an acceptable product.
dispensing pharmacy. The pharmacy receiving the prescription for
a patient and providing the pharmaceutical preparation to the patient. For
compounded medicines, the dispensing pharmacy is not necessarily the
compounding pharmacy.
dose rounding. Amending a dose that has been calculated accurately
on the basis of body weight or surface area to correspond with an amount of
the dosage form that is easy to measure and administer. Account of therapeutic
index should be taken before rounding the dose.
excipient. A substance or compound, other than the active pharmaceutical
ingredient and packaging materials, that is intended or designated to be used in
WHO Technical Report Series No. 996, 2016

the manufacture or compounding of a pharmaceutical product.

expiry date. The date after which a compounded preparation should not
be stored, transported or used; the date is determined from the date or time the
preparation is compounded. It is also known as beyond-use date.
good manufacturing practices. A system of practice and processes to
assure the quality and safety of manufactured pharmaceutical products, specified
in, for example, WHO guidelines.
labelling information. Information to the user provided on the container
or package label or in the patient information leaflet.
manipulation of a dosage form. Authorized dosage forms may be
manipulated (or modified), often at the point of administration, to provide the
appropriate dose (e.g. by segmenting tablets) or to facilitate administration (e.g.
by crushing a tablet and adding to food).
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pharmaceutical dosage form. The physical form in which a medicine

is presented; the name of a dosage form combines its physical form and the
intended route of administration, e.g. a tablet (to be swallowed), oral suspension
(liquid suspension of solid particles intended for oral intake and swallowing).
route of administration. The way in which a medicine is given to
a patient, e.g. oral administration (administration via the oral route), rectal
administration (administration to the rectum), parenteral administration
(administration via the blood, muscular or subcutaneous routes).
summary of product characteristics. Summary of product characteristics
approved by the competent authority. The information may alternatively be
presented in the container or package label.
verification. A process of providing any type of adequate evidence,
e.g. new (bio)analytical data, from the literature or by referencing to existing
practices to support that the proposed modification will not change the
pharmaceutical characteristics of the original preparation in a way that will
negatively impact the safety and/or efficacy of the medicine.

3. Alternatives to compounding
Before deciding to compound, consider possible alternatives that will give the
greatest assurance of clinical effectiveness and safety.
The main alternatives to compounding are described below.

3.1 Sourcing of a commercially-available (marketed)

or manufactured product1 if available
A marketed, authorized, age-appropriate finished pharmaceutical preparation
should always be sourced when available. Where appropriate and in accordance
with the national regulations, this could include:
–– off-label use of a medicine authorized in the country where the
medicine is to be dispensed;
–– (off-label) use of an imported product authorized in the country
of origin;
–– use of a manufactured product made in authorized facilities in the
country where the medicine is to be dispensed.

  This includes products prepared to GMP standards, for example, at an accredited hospital manufacturing
1

unit.
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The logistics of supply, costs and access are obvious factors that might
present obstacles, but practitioners should liaise with suppliers, importers and
regulatory authorities to access these products if possible.
Importation of products may be expensive, and reputable suppliers should
be used to avoid spurious/falsely-labelled/falsified/counterfeit (SFFC) medicines.
Quality assurance systems should be in place, for example, to ensure that recall
systems are available and that information is provided in the local language.
The use of compounded products for children should not be justified
on the grounds that they are cheaper than marketed products. Other
options,  including local manufacture in accordance with GMP standards,
should be investigated.

3.2 Dose rounding

If the dose prescribed does not correspond to a dosage form that is commercially
available, consider whether the dose can be suitably amended while maintaining
safety and efficacy.
The therapeutic index of the medicine and patient characteristics need
to be considered before making a decision.
Some medicine doses are calculated accurately on the basis of body
weight, yet the therapeutic index is such that one dose can be used for a broad
age and weight band. Consult the WHO Model formulary for children.2

3.3 Therapeutic alternatives

If a medicine is prescribed in a formulation that is not available, e.g. in an age-
appropriate form, consider the possibility of using a commercially available
medicine with a similar therapeutic action, which is available in a more suitable
form. Examples are presented in Appendix 1.
WHO Technical Report Series No. 996, 2016

3.4 Manipulation of dosage forms

In situations where the prescribed dose is different from what is marketed, or
there are administration-related difficulties, the possibilities for manipulation
of a dosage form as outlined below can be considered. Formularies or
manufacturer’s information, if available, and the labelling or the summary of
product characteristics (SmPC) should be consulted.
A report with evidence-based guidelines on the manipulation of
medicines to obtain the required dose for children was published by the

  Available from: http://apps.who.int/medicinedocs/en/m/abstract/Js17151e/.

2

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Manipulation of Drugs Required in Children (MODRIC) research group in

2013 (3).
The practitioner should bear in mind that manipulation, such as tablet
splitting, tablet/capsule dispersion, or tablet crushing and mixing with food
or drink, may increase the potential for inaccurate dosing and may affect the
efficacy, stability and bioavailability of the dosage form, in particular when mixed
with food or drink. Excipients that are safe for adults may not necessarily be so
for children.
When medicines are mixed with food or drink, including breast milk
for very young children, an unpleasant tasting mixture may cause aversion in
the child. In addition, the compatibility of the product with the food, drink or
breast milk will need to be taken into account. Where a child shows signs of
refusal or aversion other options should be considered.

3.4.1 Tablet splitting

Not all tablets should be split. In general, those with a sustained-release or
enteric coating should not be split, but it may be possible to split tablets with
a sustained-release matrix. Formularies or manufacturer’s information, if
available, and the product label or SmPC should be consulted.
Some tablets allow splitting, either by breaking, if scored, or by using a
tablet cutter designed for the purpose. If the child is able to take solid dosage
forms safely, a tablet segment can be given; otherwise it can be dispersed or
mixed with food or drink as described below in section 3.4.3.
Tablets without a score line cannot, in general, be split into uniform
segments meeting relevant uniformity requirements. Information about possible
splitting of such tablets may however be provided in the SmPC or on the label.
Tablet splitting was reviewed by Freeman et al. (2012) (4).
Consider on a case-by-case basis whether splitting of tablets might lead
to toxicity or reduced effect as a result of inaccurate dosing or an effect on the
release profile. This is especially important in situations where the API is potent
or has a narrow therapeutic index, if there is a lack of appropriate information,
or if an accurate dose cannot be assured.
Consideration should be given to splitting tablets with an appropriate
commercial tablet splitter in the pharmacy. If possible, tablets with score lines
and uniform distribution of the API should be sourced and information sought
on the stability of segments. If carers are cutting segments, they should be given
a suitable tablet splitter and receive adequate instruction on the method for
preparing and storing tablet segments.

3.4.2 Tablet/capsule dispersion for oral administration

It may be possible to disperse immediate-release tablets or the contents of
capsules in water or another liquid. If the tablet disperses, the tablet or a fraction
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of it can be dispersed in a small volume appropriate for the child concerned and
the whole dose given when a suspension is formed, or mixed with a flavoured
vehicle if required. To ensure that the whole dose is administered the measuring
device should be rinsed and the resulting solution or suspension administered.
It is necessary to consider the impact of dispersion and the risk of interactions
with the vehicle on the bioavailability.
Conventional tablets do not disperse readily but some form a suspension
within a short time. Soluble tablets and dispersible tablets disintegrate and
dissolve or disperse within a short time in water at room temperature.
If the tablet disperses in a known volume of water to form a stable
suspension, a fractional dose can be appropriately measured with a syringe. As
extraction of soluble API from the tablet may be incomplete, the suspension
should be shaken or stirred before measuring the dose and not filtered unless
it has been established that the API is fully dissolved. Dose uniformity of
the prepared suspension cannot be assured and the risk of overdosing or
underdosing must be considered. This may depend on the volume of prepared
suspension that is to be extracted for administration. Any such tablet (whether
a dispersible or conventional-release tablet) compounded to a dispersion
or solution should be administered immediately after preparation and the
remainder should be discarded.
When the dispersion is intended for tube feeding, parameters such as
particle size, viscosity, dosing volume and compatibility of the oral preparation
with the tube material should be considered. Dispersions may be too viscous or
may contain large particles that can mean that administration by feeding tube
is not feasible. Adsorption of API to the tube material results in inappropriate
dosing; this concern is most relevant for lipophilic and low-dose potent APIs.
WHO is promoting the use of flexible solid oral dosage forms such as
dispersible tablets (5). Custom-made dispersible tablets for paediatric dosing
should be used wherever possible but it is still necessary to ensure that carers
WHO Technical Report Series No. 996, 2016

understand how they are to be administered.

3.4.3 Crushing tablets/opening capsules and

mixing powder with food or drink
The practice of crushing tablets or opening capsules and adding the powder to a
palatable drink or sprinkling it onto solid food has been reviewed (6). Although
common, there may be little evidence to support the efficacy and safety of this
practice since stability and bioavailability may be altered. With the exception
of multiple-unit preparations, which can be opened and administered without
affecting efficacy and safety, modified-release tablets and capsules cannot be
crushed or opened without affecting bioavailability and/or stability, and this
should therefore not be done. Insoluble tablet excipients are in suspension and
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may compromise product appearance, whereas soluble excipients may alter

stability, for example, by changing the pH of the preparation.
In the case of potent APIs, consider the risks associated with handling of
powdered material to parents or carers.
In general, the decision on whether to crush tablets should be based on
bioavailability and acceptability studies. Information should be sought from
manufacturers (e.g. the label or SmPC and website) and formularies whenever
possible. The process is acceptable only if bioavailability is not affected by food or
drink, and the product has to be used immediately to minimize stability problems.
It is difficult to ensure that a complete dose has been taken and the
practice of nurses and carers handling powdered medicines may present health
concerns. Tablet dispersion may be a simpler, more reliable and potentially
safer method.
Liquid-filled capsules should generally not be opened since it is difficult
to remove and measure the total contents.

3.4.4 Giving the injectable form by the oral route

Oral administration is possible for some injections. If the injectable form of
the API is the same as the oral form (for example, labetalol hydrochloride,
ondansetron hydrochloride) it can be assumed that the API will be absorbed
enterally from the injectable formulation. However, as the API is in solution,
more rapid absorption and higher peak levels may occur than would result
from the slower absorption from a solid oral dosage form. When evaluating
whether an injection is suitable for oral use, specialist advice, e.g. consultation
with a medicines information centre in the region, should be sought because
there are important factors which must be considered, e.g. first-pass effect, oral
bioavailability, gastric acidity (e.g. effect on stability), pH effects (e.g. precipitation
of soluble salts of weak acids) and palatability.
Injections may contain excipients that may have undesirable effects in
some patients, e.g. propylene glycol and ethanol. The pH of some injections may
be high or low and they should therefore not be given orally, or alternatively
should be diluted before administration to avoid irritation. The taste of the
injectable form may not be known and may not be acceptable. Advice should be
sought from the manufacturer and from experts to assist in deciding whether
the injectable form can be administered orally.

3.4.5 Splitting suppositories

There is little information available on the accuracy with which suppositories
can be  split. Splitting is usually associated with major problems with regard
to accurate dosing and is therefore generally discouraged. Most commercially
available suppositories are formulated as suspensions, which means that
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sedimentation of the solid API particles may occur during solidification of

the suppository; therefore, if suppositories need to be split, this should be
done lengthwise.
Therapeutic index and the consequences of over- or underdosing should
be taken into account when determining whether it is safe to split suppositories.
If possible, this should be done in the pharmacy.

3.4.6 Rectal administration

There may be opportunities to give oral or injectable dosage forms by rectal
administration (7).

3.4.7 General advice when changing the route of administration

Whenever a change of the route of administration for an authorized medicine
is considered, advice should be sought from formularies and the literature and
even from specialists. In general, altering the route of administration results in
a different pharmacokinetic profile introducing a high risk of dosing errors and
may compromise safety and efficacy. Hence, this practice is generally discouraged.

4. Compounding
4.1 Good manufacturing practices aspects
The dispensing pharmacy receives the prescription for a patient and provides
the pharmaceutical preparation to the patient. For compounded medicines the
dispensing pharmacy is not necessarily the compounding pharmacy. Regardless
of where the product is compounded the dispensing pharmacy is responsible
for ensuring the safety and quality of the product.
When a batch of non-authorized medicine is prepared, including for
stock, the preparing pharmacy or hospital unit should meet – depending on a risk
WHO Technical Report Series No. 996, 2016

assessment – the GMP or good pharmacopoeial practices (GPhP) requirements

pertaining to personnel, premises and equipment, quality assurance system,
documentation and product dossier. Further, an authorization by the competent
authority to carry out operations may be needed, in accordance with the
national legislation. In this respect, one should refer to the relevant international
and national guidance and to other guidelines, including WHO guidelines on
GMP (8, 9), the Pharmaceutical Inspection Co-operation Scheme (PIC/S) GPP
Guide to good practices for the preparation of medicinal products in healthcare
establishments (10) and corresponding national guidelines.
When compounding is a one-off event, the intended prescription should
be prepared for an identified individual patient for immediate dispensing. In
such cases requirements may be less strict. Nevertheless, certain requirements
need to be met:
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■■ the preparing pharmacy should have appropriate premises

and equipment;
■■ the pharmacist and staff, or entitled persons, must have sufficient
training and background for compounding;
■■ access to relevant literature (e.g. pharmacopoeias, formularies,
handbooks and scientific journals) and the Internet must be
available;
■■ general instructions for the preparation of each dosage form
should be available;
■■ a record on each preparation should be retained showing the
calculations, key processing and packaging steps, and also including
the name of the person responsible for each step.

4.2 Some potential problems

In some situations, for example, if the method of preparation and the stability of
an oral liquid are well documented, e.g. if compounding has been supported by
evidence of quality, stability data and occasionally evidence of bioavailability
by industry or other parties, such as academia, and all facilities and ingredients
are available, it may be less pressing to seek an alternative to compounding. On
the other hand, if there are no stability data and, for example, the API forms a
caking suspension in the only available excipients (e.g. a syrup), an alternative
must be considered to ensure safe and effective treatment.
In any case, the decision on how to prepare and/or provide an unlicensed
preparation should be based on an assessment of risks and benefits of the dosing
strategy. On a case-by-case basis, potential benefits from their use should be
weighed against all possible risks arising from preparation and administration
of such medicines. Even in cases where the compounded preparation can be
considered a verified formulation, the impact of compounding on bioavailability
may not be known.
Formulation of a compounded medicine is associated with a number of
potential problems that may impact on its safety and effectiveness. Awareness of
the relative complexity of the formulation and of the things that can go wrong
will help to avoid such problems. Guidance on compounding has been published
(e.g. 11). A review of extemporaneous compounding is also available (12).
Consideration must be given to the properties of the API (e.g. aqueous
solubility, pH effect on solubility, particle size, polymorphism) and stability
of both API and the compounded formulation, i.e. chemical, physical and
microbiological instability.
Care must also be taken in the selection of excipients and their safety
in relation to the age of the child as well as any possible adverse effects of the
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“inactive” components of the preparation should be considered. The use of

preservatives, ethanol and sugars must be carefully considered. Some guidance
and literature references on the formulation can be found in Development of
paediatric medicines: points to consider in formulation (5).

4.2.1 Oral liquids

Deterioration of an oral liquid may be a result of chemical, physical or
microbiological instability which can lead to a subtherapeutic dose of the
medicine, exposure to toxic degradation products or ingestion of unacceptable
numbers of microorganisms. It is important for pharmacists, clinicians and
nursing staff to be aware of potential problems caused by instability and
microbial contamination to ensure that any medicine used is effective and safe.
APIs in compounded liquids may be susceptible to chemical reactions
leading to degradation. Publications reporting the stability of compounded
paediatric preparations include a review by Glass and Haywood 2013 (13). The
most common reactions are hydrolysis, oxidation and reduction. Usually  the
reaction rate or type is influenced by pH. Other factors that may increase
the  rate of reaction include the presence of trace metals which catalyse the
oxidation of captopril, methyldopa or exposure to light, which catalyses the
oxidative degradation of 6-mercaptopurine. The rate of chemical degradation
usually increases with temperature.
The API in the preparation may be totally or partially in solution or
predominantly in the solid state as a suspension. APIs in solution are more
susceptible to chemical degradation than APIs in the solid state (i.e. suspensions);
thus suspensions of acetazolamide and chlorothiazide are more stable than
solutions. However, it cannot be assumed that a compounded suspension
is always more stable than a solution. In a suspension, an equilibrium exists
between the API in the solid state and an API in solution, and even though
the amount of API dissolved may be minimal, the conditions could be optimal
WHO Technical Report Series No. 996, 2016

for degradation. Furosemide is a notable example: it undergoes hydrolysis in

acidic conditions where the solid state is predominant, but is much more stable
at alkaline pH where it is totally in solution.
Preparations made from tablets contain excipients such as binders
and disintegrating agents in addition to the API. These excipients may reduce
chemical stability by changing the pH to a value at which more rapid degradation
occurs. This probably explains why amiloride solution prepared from pure API
is more stable than an oral liquid prepared from tablets.
Hygroscopicity and/or moisture-sensitivity of the API also play a key
role in degradation. These characteristics of the API(s) should be understood
before compounding from a tablet to a liquid form. A common example of such
an API is tenofovir disoproxil fumurate.
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Dispersions and suspensions of medicine with low therapeutic index

require special consideration with regard to efficient resuspension to avoid
medication error.

4.2.2 Microbial contamination

Microbial growth in an oral liquid may cause a foul odour and turbidity and
adversely affect palatability and appearance. High titres of microorganisms
may be hazardous to health especially in very young or immunocompromised
patients. By-products of microbial metabolism may cause a change in the pH
of the preparation and reduce the chemical stability or solubility of the API.
Microbial contamination during preparation must be minimized by using clean
equipment, water of adequate quality and by avoiding contaminated raw materials
and containers. If sodium benzoate or benzoic acid are used as antimicrobial
preservatives, the final pH must be less than 5 so that the active unionized form
is predominant. Consequently the API must also be stable at this pH.
Many factors can reduce the effectiveness of the preservative, including
use of contaminated materials, chemical degradation, binding of preservative to
suspending agents or tablet excipients, incorrect storage or unhygienic use of the
final product.

4.3 Basic considerations

■■ Quality of API and excipients
It is important to ensure that the API and the excipients meet
pharmacopoeial standards with regard to both identity and purity.
The choice of excipients should be restricted to those that have
been used in authorized medicines intended for the same route of
administration and at similar concentrations.

■■ Consider use of an authorized dosage form as a starting point

It may be safer and more effective to crush tablets or use the
contents of hard capsules with an appropriate suspending vehicle
than to prepare medicines from an API and excipients. There are
many formulations available with a validated shelf life but sourcing
of suspending agents may be difficult and/or expensive.
There might be instances when a pharmacist crushes a number
of tablets or opens a number of capsules, dilutes the powder with a
suitable excipient and doses the powder in ready-to-use single-dose
sachets. Before doing so, consider the stability of the preparation,
including stability with respect to humidity and exposure to air.
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■■ Consult literature and guidelines if available

Use a validated formulation whenever possible (i.e. based on
literature, stability studies and guidelines). Consult product
information and the latest national and international guidelines
and/or a specialist information centre if possible.
■■ Potential medication error
Medication errors in preparing compounded medicines occur often,
and some have resulted in serious harm to patients or even in death.
The potential for medication error must be recognized and steps
taken to minimize the risk. As a minimum, this will include the use
of a worksheet listing the formulation ingredients and the identity of
the ingredients; quantities, calculations and measurements should
be double-checked by trained personnel and signatures provided.
The pharmacist responsible should check the final product and label
against the signed worksheet, ingredients and prescription.
■■ Exercise caution in extrapolating from other formulations
Caution is required when extrapolating the formulation from a
published study or formulary. Formulations made from APIs may
be more stable than formulations made from solid dose forms and
vice versa. Tablet and capsule excipients can increase or decrease
the stability of the API in an oral liquid preparation. The salt form
of the API used in a published study could be different to the form
locally available and this may affect its solubility, bioavailability
and stability. Consult publications and pharmacopoeias, and seek
specialist advice, if possible.
Similarly, the results of a published study using an API mixed
with a commercial suspending base cannot generally be extrapolated
WHO Technical Report Series No. 996, 2016

to a situation where the same API is mixed with a simple base of

syrup or glycerol.
Formulations for compounded medicines based on APIs and
crushed tablets are not interchangeable.
■■ Dose uniformity may be a problem – explain the importance of
shaking prior to use
If the API is poorly soluble in water, uniformity of dosing may be a
problem and a suspending agent will be required. Always check that
the finished preparation resuspends under in-use conditions and
explain the importance of resuspension by shaking to patients or
their carers.
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As excipients and other formulation components can affect

solubility, all compounded liquid formulations should be shaken
prior to administration. Some of the API may not be in solution
even if it is highly soluble in water. The only exception would be if
the preparation is made from pure API and it can be assured that
the entire API is in solution.
Suppositories have sometimes been melted and recast
into smaller moulds. This option is associated with a risk of
recrystallization and of affecting the distribution and solubility of the
API, resulting in over- or underdosing. Further, re-melting may affect
degradant levels. Re-melting is therefore generally discouraged.
■■ Exceptionally, when no published formulation is available
When no published formulation is available the pharmacist must
assess the risks associated with the different options and use his or
her knowledge and experience to formulate a product taking into
account the need to:
–– obtain information on the physicochemical properties of the
API if available.
If possible, obtain basic physicochemical information about
the API, especially its aqueous solubility at the expected pH of
the final preparation. This allows a judgement to be made as to
whether an API solution or suspension is formed at a particular
dose-relevant concentration.
–– test the physical characteristics before using the preparation to
treat a patient.
FPPs of the same medicine may vary worldwide, especially
with respect to the content of excipients. Such differences can
influence the safety, efficacy and acceptability of the preparation.
Basic performance tests should be done before the preparation is
used in a patient, particularly on formulations prepared for the
first time. Tests include ease of resuspension and pouring, degree
of caking on storage, and observation of physical behaviour
and characteristics.
–– consider risk of microbial growth.
All compounded liquid formulations are highly susceptible to
microbial growth. Oral liquids that are not adequately preserved
will support rapid growth of bacteria and fungi especially at warm
to hot temperatures and can pose hazards to patients especially
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those who are immunosuppressed. An antimicrobial preservative

should be included if the final product is likely to be used beyond
2–3 days, even when it is stored under refrigeration.
The effects of the addition of the preservative on interactions
between pH, stability and effectiveness of the preservative should
be carefully taken into account.
Compounded liquids should be prepared under conditions
that minimize the introduction of microbial contaminants.
■■ Use appropriate final containers
Final containers and closures should be clean and free from dust and
other residues. Use of new containers is recommended. Containers
that are reused should be thoroughly washed, rinsed with sterile or
freshly boiled water and dried. Light-protective (e.g. dark plastic or
amber glass) containers should generally be used.
Consider the use of a light-protective wrapping such as foil if
a light-protective container is not available. When selecting the final
container, consider the interactions between the container and the
product, for example, the possibility of adsorption to plastic containers.
■■ Dosing device
For liquid preparations, the feasibility of appropriate dosing should
be confirmed bearing in mind that not all dosing devices may allow
delivery of the required volume. Most compounded liquids should
be shaken prior to administration and this may introduce entrapped
air in the liquid, which could cause problems with accurate
measurement of small volumes.
■■ Consider in-use storage
In-use storage conditions may vary considerably from those in a
WHO Technical Report Series No. 996, 2016

published study or formulary recommendation. Always consider

whether it will be possible to store and use the preparation
under the optimal conditions described in the study; usually
refrigeration, protection from light and minimal possibility of in-use
contamination. If these conditions are not possible locally it can be
assumed that the preparation will be less stable and more susceptible
to microbial growth. Reduce the shelf life according to professional
judgement. If possible, obtain expert advice.
■■ Expiry date
It is recommended that each compounded preparation be given an
expiry date assigned in a conservative way and taking into account
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API-specific and general stability documentation and relevant

literature when available.
When an authorized medicine is used as the source of the
API, stability information can be obtained from the manufacturer.
Otherwise, applicable information on stability, compatibility
and degradation of ingredients, and use has to be sought in the
literature.
Stability may be formulation-dependent and is likely to change
with any manipulation of the product. Most studies base their
expiry date recommendation on chemical stability but do not
address possible physical or microbiological spoilage which may be
significant during actual use of the product. Whereas compounded
preparations will normally be freshly prepared, the storage and shelf
life during use need to be considered, in particular if it becomes
impractical to prepare the product immediately prior to dispensing
each time it is needed.
The assignment of an expiry date serves to ensure suitability for
use and will encourage regular fresh preparations. It also allows the
practitioner to regularly review the patient’s use of the preparation.
The following aspects should be considered when determining
an expiry date:

–– nature of the API and its degradation mechanisms;

–– dosage form and its components;
–– potential for microbial proliferation in the preparation;
–– container in which the preparation is packaged;
–– expected storage conditions; and
–– the intended duration of therapy.

The in-use conditions, for example, access to a refrigerator

for storage, should be taken into account when establishing the
expiry date.

■■ Give clear instructions to caregivers and patients

The instructions given to caregivers and patients may include
instructions on storage, resuspension, changes in taste, smell,
appearance, adverse effects and other pharmaceutical advice.
Compounded dosage forms are sometimes added to a small
amount of liquid (e.g. water or juice) or sprinkled onto small
amounts of food. Consideration should be given to the effect of food
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on bioavailability and to the risk that only part of the dose will be
swallowed. Provide parents and carers with appropriate information.
If an oral syringe or other measuring device is used it is
important to check the technique to ensure that the correct dose
is administered. Advise the use of clean measuring devices and
explain how to avoid contaminating the preparation when preparing
the dose.
■■ Label information
In addition to dosage instructions, include at least the following
information, subject to national regulations for the labelling of
medicines:
–– if applicable, the name of the pharmaceutical preparation;
–– the route of administration;
–– the name(s) of the API(s) and excipients of known
pharmacological action, and adverse effects, e.g.
antimicrobial agents, antioxidants;
–– if the preparation is a liquid, give the concentration(s) of
the API(s), e.g. in mg/mL, and the amount or volume of
the preparation in the container;
–– if the preparation is a solid, give amount(s) of the API(s) in
each dose and the number of doses in the container;
–– reference or batch number (or date of preparation);
–– expiry date (“do not use after ...”);
–– any special storage conditions and handling precautions
that may be necessary, e.g. “to be shaken before use”, “shelf
life during use”;
WHO Technical Report Series No. 996, 2016

–– the pharmacy name and contact information;

–– name of the patient.
Consider adding pictograms to supplement the label
information, e.g. for “to be shaken well” and “store in the refrigerator”.
■■ Document concerns and share information
Practitioners are encouraged to maintain a dialogue with regulatory
bodies and international agencies and networks about problems
and concerns associated with the preparation and availability of
age-appropriate medicines for children. The sharing of solutions to
problems is also important.
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5. Information, availability and access

A number of networks, websites and other resources are available which provide
information on standards of practice, formulas for compounded preparations,
manufacturers, suppliers of oral liquid formulations and responsive information
services. These should be consulted by practitioners and regulators to enable
them to provide the safest and most effective treatment options for children who
require an age-appropriate formulation.

5.1 Standards of practice and guidelines

Some national, regional and international guidelines for extemporaneous
formulations and medicines administration to children have been published.
Consulting these documents may assist in forming local policies on practice and
educational activities for practitioners.

5.2 Formularies and compendia

Formularies and compendia may be helpful in providing formulation advice and
general advice on dosage manipulations. The information in these formularies
may be difficult to transfer to a local situation where the base ingredients (e.g.
commercial suspending bases, antimicrobial preservatives, pure API powder)
are not readily available.
In addition to formularies and compendia, information can be sought in:
–– the eMixt database (www.pharminfotech.co.nz), which provides
comprehensive information for all settings and environments;
–– Handbook of extemporaneous preparations (11), which contains
formulations and associated stability summaries for oral liquid
preparations;
–– Improving medicines for children, by the Council of Canadian
Academies, which contains a comprehensive review of paediatric
medicines (14);
–– The International Journal of Pharmaceutical Compounding,
which is a general source of information. It is a subscription-only
journal, but the contents can be searched on the journal’s website
(http://www.ijpc.com).

5.3 Source and supply

A database of sources and prices of medicines for children has been compiled by
the United Nations Children’s Fund (UNICEF) (15) and the UNICEF catalogue
(https://supply.unicef.org) provides examples without being exhaustive.
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Countries may also have their own database to use to find suppliers of
age-appropriate formulations for paediatric use.

5.4 Networks and information services

–– Local, national and international medicines information centres
may respond to questions about formulation. One example is
the WHO Paediatric medicines Regulatory Network (PmRN)
(http://www.who.int/childmedicines/paediatric_regulators/en/).
Partnerships and twinning arrangements between hospitals in
poorly-resourced countries and developed countries can be explored
and are often beneficial.
–– Questions can be posted via the eMixt website (www.pharminfotech.
co.nz).
–– Sharing of information and advice on paediatric formulations
should be explored whenever possible.
–– International discussion lists can be useful for posting questions on
formulations and their archives can be searched for previous questions
and answers. Examples include eDrug and INDICES (accessed via
www.asksource.info/resources/essentialdrugsorg).

References
1. Ernest TB, Craig J, Nunn A, Salunke S, Tuleu C, Breitkreutz J, et al. Preparation of medicines for
children – a hierarchy of classification. Int Journal Pharm. 2012;435(2): 124–30. doi: 10.1016/j.
ijpharm.2012.05.070.
2. Nunn T, Hill S, Secretary, WHO Expert Committee on the Selection and Use of Essential Medicines.
Report for WHO on findings of a review of existing guidance/advisory documents on how
medicines should be administered to children, including general instructions on extemporaneous
WHO Technical Report Series No. 996, 2016

preparations and manipulation of adult dosage forms. Geneva: World Health Organization;
2011 (working document QAS/11.400 – available on request) (http://www.who.int/medicines/
areas/quality_safety/quality_assurance/Review-findings-PaediatricMedicnesAdmin_QAS11-
400Rev1_22082011.pdf, accessed 20 November 2015).
3. MODRIC. Manipulation of drugs for children – a guideline for health professionals. Liverpool:
Alder Hey Children’s NHS Trust (http://www.alderhey.nhs.uk/wp-content/uploads/MODRIC_
Guideline_FULL-DOCUMENT.pdf, accessed 20 November 2015).
4. Freeman MK, White W, Iranikhah M. Tablet splitting: a review of weight and content uniformity.
Consult Pharm. 2012;27(5):341–52. doi: 10.4140/TCP.n.2012.341.
5. Development of paediatric medicines: points to consider in formulation. In: WHO Expert
Committee on Specifications for Pharmaceutical Preparations: forty-sixth report. Geneva: World
Health Organization; 2012: Annex 5 (WHO Technical Report Series, No. 970).
6. Anon. Crushing tablets or opening capsules: many uncertainties, some established dangers.
Prescrire Int. 2014; 23(152): 209–11, 213–14.
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7. Smith S, Sharkey I, Campbell D. Guidelines for rectal administration of anticonvulsant medication

in children. Paediatr Perinatal Drug Ther. 2001;4(4):140–7.
8. WHO good manufacturing practices: main principles for pharmaceutical products. In: WHO Expert
Committee on Specifications for Pharmaceutical Preparations: forty-eighth report. Geneva: World
Health Organization; 2014: Annex 2 (WHO Technical Report Series, No. 986).
9. Good manufacturing practices for pharmaceutical products. In: Quality assurance of
pharmaceuticals. WHO guidelines, related guidance and GXP training materials. Geneva: World
Health Organization; 2015 CD-ROM.
10. Pharmaceutical Inspection Co-operation Scheme. PE 010-3 Guide to good practices for the
preparation of medicinal products in healthcare establishments. PICS; 2014 (http://www.
picscheme.org/bo/commun/upload/document/pe-010-4-guide-to-good-practices-for-the-
preparation-of-medicinal-products-in-healthcare-establishments-1.pdf, accessed 20 November
2015).
11. Jackson M, Lowey A. Handbook of extemporaneous preparation: A guide to pharmaceutical
compounding. London: Pharmaceutical Press; 2010.
12. Patel VP, Desai TR, Chavda BG, Katira RM. Extemporaneous dosage form for oral liquids.
Pharmacophore. 2011;2(2):86–103.
13. Glass BD, Haywood A. Liquid dosage forms extemporaneously prepared from commercially
available products – Considering new evidence on stability. J Pharm Sci. 2006;9(3):398–426.
14. Council of Canadian Academies. Improving medicines for children in Canada. Ottawa: The Expert
Panel on Therapeutic Products for Infants, Children, and Youth; 2014 (http://www.scienceadvice.
ca/uploads/eng/assessments%20and%20publications%20and%20news%20releases/
therapeutics/therapeutics_fullreporten.pdf, accessed 20 November 2015).
15. Sources and prices of selected medicines for children, including therapeutic food, dietary vitamin
and mineral supplementation – 2nd edition. Geneva: UNICEF/WHO; 2010 (http://www.who.int/
medicines/publications/sources_prices/en/, accessed 20 November 2015).

Further reading
The International Pharmacopoeia, fifth edition; 2015. Available online and CD-ROM version) (http://
who.int/medicines/publications/pharmacopoeia/en/index.html).
Kastango ES, Trissel LA, Bradshaw BD. An ounce of prevention: Controlling hazards in extemporaneous
compounding practices. Int. J Pharm. Compounding. 2003;7(5):401–16.
Pharmaceutical development for multisource (generic) pharmaceutical products. In: WHO Expert
Committee on Specifications for Pharmaceutical Preparations: forty-sixth report. Geneva: World
Health Organization; 2012: Annex 3 (WHO Technical Report Series, No. 970) (http://www.who.int/
medicines/areas/quality_safety/quality_assurance/en/).
Pharmaceutical Inspection Co-operation Scheme (http://www.picscheme.org/). In particular the
following documents can be downloaded free of charge: PE 009-9 (Part I); PIC/S GMP guide (Part I:
Basic requirements for medicinal products); PE 010-3 Guide to good practices for the preparation of
medicinal products in healthcare establishments.
Report of the Informal Expert Meeting on Dosage Forms of Medicines for Children. Geneva:
World Health Organization; 2008 (http://www.who.int/selection_medicines/committees/expert/17/
application/paediatric/Dosage_form_report DEC2008.pdf).
The WHO Model formulary for children. Geneva: World Health Organization; 2010 (http://www.who.
int/selection_medicines/list/WMFc_2010.pdf).
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Appendix 1
Examples of therapeutic alternatives to extemporaneous
formulations

Required Possible alternative Notes

(available)
diclofenac oral naproxen oral suspension; The alternatives are available
liquid (tablet) ibuprofen oral liquid in some countries.
enalapril oral liquid captopril oral liquid Captopril oral liquid is not
(tablet) (losartan oral suspension) available in all countries.
Captopril has a shorter
duration of action than
enalapril. Enalapril tablets can
be crushed and suspended
in water immediately before
use. Captopril tablets can be
easily dispersed in water.
Losartan may be appropriate
for hypertension.
ibuprofen oral paracetamol oral liquid For pain and fever but not as
liquid (tablet) an anti-inflammatory.
levamisole oral albendazole chewable tablet;
liquid (tablet) mebendazole oral liquid;
pyrantel oral liquid
lisinopril oral liquid ramipril oral liquid
WHO Technical Report Series No. 996, 2016

(tablet)
omeprazole oral esomeprazole granules;
liquid (capsule) lansoprazole orodispersible
tablet
praziquantel oral niclosamide chewable tablet Niclosamide can also be
liquid (tablet) crushed and mixed with water
to form a vanilla paste.
sertraline oral liquid fluoxetine oral liquid
(tablet)

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Table continued
Required Possible alternative Notes
(available)
tinidazole oral metronidazole oral liquid Very few reasons why
liquid (tablet) tinidazole should be
preferred over metronidazole.
ciprofloxacin/ ciprofloxacin/hydrocortisone
dexamethasone ear drops
ear drops

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