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BackgroundMannitol is considered the gold standard hyperosmolar agent to decrease intracranial pressure (ICP) after traumatic brain injury. However, solutions of mannitol may crystallise when exposed to low temperatures, for example at high altitude or during helicopter rescues. If crystals are observed, the container should be warmed, shaken and then cooled to body temperature before administration which is inappropriate in daily emergency practice. Several studies show that hypertonic saline solution (HTSS) is comparable or potentially superior to mannitol: furthermore HTSS might have less adverse effect than mannitol and does not crystallise with low temperature. HTSS only exists in 500 mL glass vials, unfit for emergency practices which need compact unbreakable packaging.PurposeTo provide for emergency practices a ready-to-use HTSS of 7.5% sodium chloride infusion bag.Material and methodsInfusion bags were produced by aseptic process using the BAXA® EM2400 compounder. Ingredients used were sterile sodium chloride 20% (AGEPS®) and water for injectable preparation (Bbraun®) filled in an ethyl vinyl acetate infusion bag of 100 ml. Bags were stored at room temperature without light protection. Microbiological stability was assessed by performing sterility and endotoxin tests. The physicochemical study was performed by determining visual aspect, osmolality, sodium and chloride concentration at 0, 30 and 90 days.ResultsNeither precipitate nor any change in colour was observed after 90 days. Ion concentrations remained unchanged with 1320 mM (+3%); 1290 mM (+1%); 1240 mM (−3%) and osmolality of the HTSS were found to be 2560 mosm/L (0%); 2420 (-6%); and 2350 mosm/L (9%) respectively at 0, 30 and 90 days. At each time point, all microbiological results were negative.ConclusionThe automated compounding ensures quality and safety of production for a ready-to-use HTSS of 7.5% sodium chloride with a best-before-date of 90 days. The stability study is still on-going.Reference and/or Acknowledgements1. Helmy A, Vizcaychipi M, Gupta AK: Traumatic brain injury: intensive care management. Br J Anaesth, 2007; 99: 32–42.No conflict of interest

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The German submission requires a comparison of the drug to be assessed with the appropriate comparative therapy (ACT). In contrast, for the NICE submission an economic evaluation is required beside the clinical evidence of all the drugs in the specific disease area. The assessment of vedolizumab was performed by the IQWiG for both indications simultaneously whereas NICE did the assessment for the two indications separately. The G-BA defined either adalimumab (ADA) or infliximab (INF) as ACT. As a direct comparison was not possible an indirect comparison was performed but the results were not considered by IQWiG due to different study design. No additional benefit was determined in both indications. By contrast network meta-analyses (NMA) were performed for the NICE submissions. Although NICE noticed that the NMA results are afflicted with uncertainties, vedolizumab was classified as cost-effective in both indications. ConClusions: The G-BA defined an ACT whereas the data of all drugs approved in disease areas are considered in the NICE submission. Indirect comparisons were not considered by IQWiG. In contrast, the results of the NMAs performed for the NICE submissions were discussed. The focus of the G-BA is on the assessment of the additional benefit against the ACT. That result is the basis for the price negotiation. By contrast, NICE is primarily interested in the cost-effectiveness of a drug.