The precipitation of phenytoin sodium injection provoked by mixing with infusion fluids renders its use in clinical practice difficult, as rapid intravenous (i.v.) push and i.v. infusion are supposed to be avoided. As some of its aspects remain unclear, this study tried to elucidate this precipitation mechanism. In particular, this study focused on the significant precipitation induced by glucose infusion fluid. The precipitation provoked by 5% glucose infusion fluid was obviously different from the precipitation that accompanied simple pH reduction, in terms of the growth mode and morphology of crystals. In addition, the effect of glucose was partially unrelated to pH reduction. NMR measurements including a two-dimensional nuclear Overhauser effect spectroscopy (2D-NOESY) spectrum indicated the specific interaction between glucose and propylene glycol, which is incorporated into phenytoin sodium injection as a solubilizing agent. These results led to the conclusion that this interaction was crucial for the precipitation of phenytoin, as it diminished the solubilizing effect of propylene glycol, resulting in the enhancement of the crystallization of phenytoin. The determination of phenytoin solubility in aqueous solutions at different pH values revealed that phenytoin incorporated in the admixture could be dissolved completely, as long as the injection was diluted with saline or water. These findings offer a profound insight into the formulation design of phenytoin sodium injection and its use in clinical practice.Key words phenytoin; precipitation; glucose infusion fluid; propylene glycol; 2-dimensional nuclear Overhauser effect spectroscopy Phenytoin sodium injection is indicated for the control of status epilepticus of the grand mal type and for the prevention and treatment of seizures that occur during neurosurgery. As phenytoin is a weak-acid drug (pK a =8.3) 1) with low solubility at biological pH values, 2,3) phenytoin sodium injection is prepared using an organic cosolvent consisting of 40% (v/v) propylene glycol and 10% (v/v) ethanol, with the pH adjusted to 12.The intravenous (i.v.) administration of phenytoin sodium has long represented a dilemma. The rate of administration is strictly limited; the delivery of the injection is recommended at a rate not exceeding 50 mg/min, 4) as a rapid i.v. push has a risk of serious adverse effects on the cardiorespiratory system.5-7) In contrast, the addition of phenytoin sodium injection to an i.v. infusion is not recommended because of its low solubility and resultant precipitation; this means that continuous infusion should be avoided.Many reports in the literature describe precipitation occurring by mixing phenytoin sodium injection with various infusion fluids. [8][9][10][11][12][13][14][15] The reduction in pH that accompanies the dilution with the infusion fluids is widely recognized as the principal cause of the precipitation; 16,17) the pH of the admixture is reduced once the phenytoin sodium injection is diluted in an excessive amount of infusion fluids. ...