R e v is e d
GUIDELINES FOR
GOOD ST OR A GE P R A C T I C E S
        IN M EDIC A L ST ORES
            A ND H OSP IT A LS
 Central Administration of Pharmaceutical
Affairs, M inistry of H ealth And Pop ulation
   F aculty of Pharmacy , Cairo U niv ersity
        W   orld H ealth O rg aniz ation
                 Cairo - E g y p t
                      2 0 0 4
GSP - E g y p t
Cont r i b u t e r s - R e v i s e d E d i t i on
F ro m      C e n t r a l A d m in is t r a t io n o f P h a r m a c e u t ic a l A f f a ir s :
•        D r. Zeinab                Ebied, G eneral Manager, Technical Research
         and Training
•        D r. M o u s t af a I br                              ah im ,              G eneral                 Manager                  of
         Pharmaceutical Inspection
P h a r m a c e u t ic a l In d u s t r y E x p e r t s :
•        D r. R  eda S h o u k r y
•        D r. O s am a El -G h af f ar y
•         D r. A bdel A z iz A bdel R eh iem
U n d e r S e c r e t a r y o f S t a t e f o r P h a r m a c e u t ic a l A f f a ir s
•        D r. O     s am a El -K h o l y
C o n t r ib u t e r s -F ir s t E d it io n , 1 9 9 7
From Faculty of Pharmacy. Cairo University:
•         P r o f . D r . A hm e d A b d E l -B a r y , D e a n, p r o f e s s o r o f p ha r m a ce u t i cs a nd i ndu s t r i a l
         p ha r m a cy .
•        P r o f . D r . A l i a A . B a da w y , p r o f e s s o r o f p ha r m a ce u t i cs a nd i ndu s t r i a l p ha r m a cy .
•         D r . M o ha m e d S . E l -S a m a l i g y , p r o f e s s o r         o f p ha r m a ce u t i cs        a nd i ndu s t r i a l
         p ha r m a cy .
From M inistry of H ealth and Pop ulation:
•         D r . A b d E l -H a m i d A b d E l -A             z iz , fo r m e r      u nde r     s e cr e t a r y    o f   s ta te    fo r
         p ha r m a ce u t i ca l a f f a i r s .
•        D r . A l y M . E l -S ha r k a w y , he a d o f t he E g y p t i a n ho l di ng dr u g co m p a ny .
•        D r . G a m i l a M . M o s a , di r e ct o r o f dr u g co nt r o l de p a r t m e nt .
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                                                               TABLE OF CONTENTS
I . D E F I N I T I O N S A N D C O N C E P T S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
I I . P R E M I SE S A N D F A C I L I T I E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1
          B a s i c R e q u i r e m e n t s ..............................................................................................................1 1
          S a n i t a t i o n ..............................................................................................................................1 4
          H o u s e k e e p i n g ........................................................................................................................1 5
          F i r e P r e v e n t i o n .....................................................................................................................1 5
          W a r e h o u s e S i z e .....................................................................................................................1 6
          W a r e h o u s e S i t e S e l e c t i o n .....................................................................................................1 6
          W a r e h o u s e D e s i g n ................................................................................................................1 7
I I I . P E R SO N N E L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9
I V . SE C U R I T Y A N D SA F E T Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1
V . ST O R A GE P R O C E D U R E S A N D I N ST R U C T I O N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 4
          G e n e r a l P r i n c i p l e s ................................................................................................................24
          R e c e i p t o f I n c o m i n g M a t e r i a l s ............................................................................................26
          S t o r a g e o f A p p r o v e d P r o d u c t s ............................................................................................29
          S t o r a g e a t C l i n i c a l F a c i l i t i e s ................................................................................................30
          S p e c i a l S t o r a g e C o n d i t i o n s ..................................................................................................31
V I . ST O C K A R R A N GE M E N T                                                       R O T A T I O N A N D C O N T R O L .................................................3 2
          S t o c k R o t a t i o n a n d C o n t r o l .................................................................................................32
          A r r a n g e m e n t o f S t o c k ..........................................................................................................33
          C o n t r o l o f O b s o l e s c e n t a n d O u t d a t e d S t o c k ......................................................................33
V I I . D I SP A T C H                           A N D I SSU I N G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4
V I I I . ST A B I L I T Y F O L L O W -U P T H R O U GH C U R R E N T C H E C K -U P A N D
 I N SP E C T I O N O F P H A R M A C E U T I C A L P R O D U C T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6
I X . M A T E R I A L S A N D D R U GS R E Q U I R I N G SP E C I A L ST O R A GE C O N D I T I O N S . . . . . . . . . . . . 41
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                   I. DE F IN IT IO N S A N D C O N C E P T S
Storage: The term used to describe the safe keeping of starting
                  materials, packaging materials, components received
                  semi-finished, in-process and finished products awaiting
                  dispatch. The term is also applied for safe keeping of
                  materials and drug products in drug stores, pharmacies,
                  hospitals, etc., under the specified conditions.
Storage C on d i ti on s: The conditions specified for storing the
                  product e.g. temperature, humidity, container, etc.
Q u al i ty : The ability of a drug product to satisfy the users need.
Q u al i ty C on trol U n i t: Means any person or organizational element
                  designated to be responsible for the duties relating to
                  quality control.
M ateri al : A term used to cover stating materials, intermediate
                  products, packaging materials and components and
                  finished products.
Starti n g M ateri al : Any substance used in the manufacture of a
                  medicinal product ex cluding packaging materials.
I n term ed i ate P rod u c t: A partly processed material which must
                  undergo further processing before it becomes a finished
                  product.
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D osage F orm : Refers to the gross physical form in which a drug is
                   administered to or used by a patient.
D ru g P rod u c t: A dosage form containing one or more active
                   therapeutic ingredients along with other substances
                   included during the manufacturing process.
P ac k agi n g M ateri al : Any material used in the packaging of a
                   product. It does not normally include the outer
                   packaging or transit cases used for departmental
                   transportation or shipment of orders.
      a) Primary Packaging Material: A packaging material which is
                in direct contact with medicinal product.
      b) Printed Packaging Material: A packaging material which is
                imprinted with a tex t.
F i n i sh ed     P rod u c t: A medicinal product which has completed all
                   stages of manufacture, including packaging.
B atc h : A specific quantity of a drug and/ or other material that is
                   intended to have uniform character and quality, within
                   specified limits, and is produced according to a single
                   manufacturing     order   during   the   same   cycle       of
                   manufacture.
 L ot: A batch, or a specific identified portion of a batch, having
                   uniform character and quality within specified limits, or,
                   in the case of a drug product produced by continuous
                   process. It is a specific identified amount produced in a
                   unit of time or quantity in a manner that assures its
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                  having uniform character and quality within specified
                  limits.
L ot N u m b er (C ontrol N umber or Batch N umber): Any distinctive
                  combination of letters, numbers, or symbols, or any
                  combination of them, from which the complete history of
                  the manufacture, processing, packing, holding, and
                  distribution of a batch or lot of drug product or other
                  material can be determined
M an u f ac tu re,      P roc essi n g,   P ac k i n g or H ol d i n g of   a D ru g
                  P rod u c t: includes packaging and labeling operations,
                  testing, and quality control of drug products.
C om p on en t: Any ingredient intended for use in the manufacture of
                  a drug product.
A c ti v e I n gred i en t: Any component that is intended to furnish
                  pharmacological activity or other direct effect in the
                  diagnosis, cure, mitigation, treatment, or prevention of
                  disease, or to affect the structure of function of the body
                  of man or other animals.
I n ac ti v e I n gred i en t: Any component other than an " active
                  ingredient" .
I n -P roc ess M ateri al : Any material fabricated, compounded,
                  blended, or derived by chemical reaction that is
                  produced for, and used in the preparation of the drug
                  product.
Stren gth :
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  i. The concentration of the drug substance (for ex ample
     weight/ weight, weight/ volume, or unit dose/ volume basis)
     and/ or
  ii. The potency, that is, the therapeutic activity of the drug
     product as indicated by appropriate laboratory tests or by
     adequately         developed     and   controlled     clinical      data
     (ex pressed, for ex ample, in terms of units by reference to a
     standard).
Stab i l i ty : The degree of resistance to chemical and physical
          changes. The efficacy of the preparation must remain
          constant (or change only within the limits specified by
          legal provisions) until the date of ex piration.
   a) C h emical S tab ility: The components making up the
       preparation should remain chemically unchanged, that is,
       their change should be within the specified limits.
   b) Ph ys ical s tab ility: The initial physical properties (shape,
       taste, solubility, crystalline form, disintegration              time,
       dissolution, colloidal properties, etc.) of the pharmaceutical
       preparation should remain unchanged, that is, their
       changes should be within the specified limits.
   c) Micro b io lo gical S tab ility: Sterility or resistance to the growth
       of microorganisms should remain unchanged. D uring
       storage, the efficacy of preservatives should change only
       within the specified limits.
   d) T h erap eu tic    S tab ility: The therapeutic effect of the
       pharmaceutical preparation should remain unchanged.
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       e) T o x ico lo gical S tab ility: There must be no significant change
                in the tox icity of the pharmaceutical preparation.
E x p i rati on D ate: The date placed on the immediate container label
                  of a drug product that designates the date through which
                  the product is ex pected to remain within specifications. If
                  the ex piration date includes only a month and a year, it
                  is ex pected that the product will meet specifications
                  through the last day of the month. K inetically it is the
                  time required for 10 %   of the material to disappear.
E x p i rati on D ati n g P eri od : The interval of time that a drug product
                  is ex pected to remain within specifications as detonated
                  from stability studies on a limited number of batches of
                  the product. The ex piration dating period is used to
                  establish the ex piration date of individual batches.
A c c el erated       T esti n g: (Stress Testing): Studies designed to
                  increase the rate of chemical or physical degradation of
                  a drug substance or drug product by using ex aggerated
                  storage conditions. The purpose is to determine kinetic
                  parameters, if possible, and/ or to predict the tentative
                  ex piration dating period.
Stab i l i ty     I n d i c ati n g A ssay : The assay which is sensitive and
                  selective to determine quantitatively the active ingredient
                  in the presence of its decomposition products.
Sh el f -Stab i l i ty : The stability of the drug or drug product at ambient
                  room temperature (15 - 35° C )
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O v erage: The ex cess quantity of drug that must be added to the
              preparation to maintain at least 10 0 %                  of the labeled
              amount during the ex pected shelf-life of the drug.
T em p eratu re C on trol : All following temperatures in D egrees
              C elsius.
C ol d P l ac e: The temperature does not ex ceed 8° C .
R ef ri gerator: The temperature is thermostatically controlled
              between 2° and 8° C .
F reez er: The temperature is thermostatically controlled to no higher
              than -10 ° C .
C ool P l ac e: The temperature is between 8° and 15° C .
W arm   P l ac e: Any temperature between 30 ° and 40 ° C .
R oom   T em p eratu re: The temperature is between 15° and 30 ° C .
E x c essi v e H eat: Any temperature above 40 ° C .
E x trem e T em p eratu re F l u c tu ati on s: The packaged drug product
              should be cycled through temperature conditions that
              simulate the changes that may be encountered once the
              drug product is in distribution.
Storage       T em p eratu res:   The      actual      storage          temperatures
              (numerical) used during stability studies should be
              specified.
E x trem es    of    T em p eratu re    an d    H u m i d i ty    in      P h arm ac y :
              Temperature above 40             ° and RH          above 70 %           are
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                  considered to be the ex tremes of temperature and
                  humidity respectively.
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                  II. P R E M IS E S A N D F A C IL IT IE S
Premises and other areas to be utilized for storage purposes
should comply with the prescribed minimum standards. They
should be located, constructed, serviced and maintained so as to
protect the stored materials, from all potentially harmful influences
such as undue variations of temperature and humidity; dust and
odor; entry of animals vermin and insects.
Basic Requirements
Facilities must be provided for:
    1. The safe and orderly receipt or dispatch of all materials,
        products or components.
    2. The safe sampling and cleaning of any incoming materials
        to prevent contaminating the areas of other material.
    3. Sufficient separation or segregation of pharmaceuticals,
        veterinary, food products, chemicals, disinfectants and
        cleaning materials to eliminate the risk of unacceptable
        chemical or organoleptic cross contamination.
    4. The safe storage of hazardous materials (pressurized
        gases, flammable solvents and ex plosive materials).
    5. The       storage   of   temperature-sensitive   materials      as
        appropriate in deep freezes, cold rooms or air conditioned
        areas.
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      6. The storage of cleaning equipment and materials
      7. Appropriate personnel service facilities such as toilets, etc.
      8. The safe charging of powered forklifts and trucks
      9. Secure storage of any controlled drugs (e.g. drugs of
             addictions, narcotics)
      10 . The separation or segregation of reception and dispatch
             facilities
      11. Effective lighting permitting all operations to be carried out
             accurately and safely.
      12. The safe storage of materials requiring dry or humidity
             controlled conditions.
      13. Racking and shelving must conform to the requirements of
             the G ood Manufacturing Practice (G MP).
      14. Max imum safe working loads should be displayed.
      15. To allow access for cleaning and to avoid harboring pests,
             racking should be positioned at least 0 .5 m form the walls
             of the warehouse and the bottom layer of pallets should be
             supported at least 0 .3 m above the floor.
      16. Forklift trucks should be provided with overhead protection
             against falling objects, and if used frequently in the open,
             weather protection and lighting.
      17. O nly electric powered (or hand operated) trucks should be
             used in enclosed spaces. D iesel powered Trucks should be
             avoided to decrease contamination
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18. Adequate washing facilities should be provided, including
       hot and cold water, soap or detergent, air driers or single
       service towels, and clean toilet facilities easily accessible to
       working areas.
1.         M a in S to r a g e A r e a .
2.       R e p a c k a g in g .
3.        C o ld R o o m .
4.     W a r e h o u s e D ir e c to r .
5.          P r o c u r e m e n t O ffic e .
6.      D ir e c to r o f S u p p ly (L o g is tic s ).
7.           F la m m a b le S u b s ta n c e s .
8.             S h ip p in g a n d R e c e iv in g .
9.              R e c e p tio n A r e a .
10 .          R e c o r d s a n d I n v e n to r y C o n tr o l.
11.               S te n o g r a p h y C le r k s .
12.              C o ffe e R o o m .
13.                 T o ile ts .
14.                C o n tr o lle d S u b s ta n c e s .
15.                  M a in E n tr a n c e a n d L o a d in g D o c k s .
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S anitatio n
G MP Regulations require:
      1. Any building used in the manufacture, processing, packing,
             or holding of a drug product shall be maintained in a clean
             and sanitary condition. Any such building shall be free of
             infestation by rodents, birds, insects, and other vermin.
             Trash and organic waste matter shall be held and disposed
             in a timely and sanitary manner.
      2. There shall be written procedures assigning responsibility
             for sanitation and describing in sufficient detail the cleaning
             schedules, methods, equipment, and materials to be used
             in cleaning the buildings and facilities. Such written
             procedures shall be followed.
      3. There shall be written procedures for use of suitable
             rodenticides, insecticides, fungicides, fumigating agents,
             and   cleaning    and    sanitizing   agents.   Such   written
             procedures shall be designed to prevent the contamination
             of equipment, components, drug product containers,
             closures, packaging, labeling materials, or drug products,
             and shall be followed.
      4. Sanitation procedures shall apply to work performed by
             contractors or temporary employees as well as work
             performed by full-rime employees during the ordinary
             course of operations.
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H o usek eep ing
    1. Premises and surrounding areas should be in a good
        appearance, be well maintained and must be kept in an
        orderly,   clean    and    hygienic    conditions   free     from
        accumulated waste.
    2. Buildings must be kept free of vermin, insects, birds and
        other pests. C ontrol treatments should be carried out
        according to written procedures by trained personnel using
        proven effective and safe procedures which do not
        contaminate the goods being held and should cover both
        the interior and ex terior of the building.
    3. Precautions must be taken to minimize the contamination
        of the store by dirty, damaged or unsuitable containers.
    4. W aste materials should be collected in suitable receptacles
        for removal to collection points outside the building and
        disposed of at regular and frequent intervals.
    5. Floor surface should be sealed to minimize the generation
        of dust and to facilitate cleaning.
F ire P rev entio n
        Accumulation of flammable trash, such as cartons and
box es, must not occur. Smokes alarms are inex pensive to install
and provide warning in case fire does break out. For fire
ex tinguishing, sprinkler systems are most effective. Their principal
drawback is that if accidentally set off they may ruin some stock. A
cheaper alternative is to place ex tinguishers suitable for chemical
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GSP - E g y p t
fires at frequent intervals throughout storage areas, although they
offer no protection unless someone is around to use them.
Employing night watchmen serves the dual purpose of responding
to fire alarms and protecting against theft.
W areh o use S iz e
The average takeoff of all clinical facilities for a given delivery
interval will determine the volume to be delivered down through the
system. Assume that 20 0 clinical facilities consume a total of 1,0 0 0
m3 during a three months interval, and that they are served by few
district warehouses, each of these must be capable of holding an
average of 250 m3 a piece plus room for safety stock; the central
warehouse must hold at least 1,0 0 0 m3 plus safety stock.
W areh o use S ite S el ectio n
In selecting the site of the warehouse, the following points should
be considered:
      1. Accessibility: Road is open the year round.
      2. U tilities: Site served by water and electricity.
      3. C ommunications: Reliable telephone service.
      4. D rainage: N either site nor surrounding area subject to
             flooding due to direct runoff or high water table.
      5. Size: U nimpaired entry and ex it for large vehicles.
      6. Security: Area not likely to invite intrusion or vandalism.
      7. Prox imity: G ood access to transport links, railways,
             highways.
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W areh o use D esig n
C ertain points should be considered in designing warehouse (Fig.
1.), the most important are the following:
    1. Easy Movement: U se one-floor layouts. Interior partitioning
        limits stock arrangement; if partitions are used, position
        walls and doors to promote easy movement.
    2. Air C irculation: U se of fans and forced ventilation prolongs
        shelf-life and improves working conditions.
    3. Bulk Storage on Pallets: This improves efficiency of stock
        handling; pallets are cheaper to construct than shelves and
        hold more stock for the amount of space they occupy; they
        facilitate air circulation and allow easier access to stock for
        cleaning.
    4. Easy Maintenance: Floors should be graded and drains
        placed to catch runoff; provide well-spaced faucets.
    5. Systematic     Arrangement     of     Stock:   Frequently     used
        arrangements are by therapeutic/ pharmacological class,
        clinical indications, level of service, and alphabetic
        sequence. Array stock in the same order that products
        appear on standard requisitions
    6. C old C hain Maintained: V accines require special cold
        storage arrangements. C old rooms, refrigerators, and
        freezers should be protected from power cuts by backup
        generators.
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        7. Secure Storage Area for C ontrolled Substances: N arcotics
                  must be stored in areas with restricted access.
        8. Protected Storage Area for Flammable Substances: Ether,
                  alcohol, and fuels are best stored in out-buildings.
                  O therwise the storage room should seal tightly, be well
                  ventilated and be insulated with fireproof material.
        9. Fire             Prevention                 Measures:         D o       not        allow       trash    to
                  accumulate; provide smoke alarms, fire ex tinguishers and
                  a night watchman.
                          Fig. (2) T e m p e r a t u r e R e q u ir e m e n t s f o r v a c c in e s t o r a ge
                               L e v e l:                     C e n tr a l              R e g io n a l          L o c a l
        V A C C IN E
                              S to r a g e T im e :        6-1 8 m o n t h s            3m o n th s           1 m o n th
      M e a s le s
                                                                      -1 5 ° C t o -2 5 ° C
       O r a l P o lio
        D P T *
         T e ta n u s *                                                              + 4 ° C to + 8 ° C
          B C G
      * N e v e r F r e e z e D P T o r T e ta n u s
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                                      III. P E R S O N N E L
1. Personnel who carry out supervision and/ or controlling
    functions   should      possess   the    necessary    integrity,
    knowledge, ex perience and qualification.
2. Each store should employ sufficient staff of a quality and
    ex perience appropriate with their individual responsibilities
    and the operations carried out.
3. Staff must be given specific authority, facilities and training
    to discharge their responsibilities effectively.
4. Staff should be medically ex amined before being employed
    and at such subsequent times as may be required by
    national authorities.
5. Before being employed an applicant' s background should
    be investigated. Staff with convictions for theft or drug
    abuse should not be employed.
6. Protective clothing must be worn by persons working in
    warehousing areas. Safety-hats must be provided for
    people working within racking areas. W here staff have to
    work under ex tremes of temperature (e.g. cold room)
    appropriate clothing should be provided.
7. D rinking, eating and smoking must not be permitted in any
    part of the premises ex cept those designated for that
    purpose and adequately separated from storage areas.
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      8. Staff must maintain high standards of personal hygiene
             and cleanliness. D irect contact between raw materials or
             products and operators hands must be avoided whenever
             possible.
      9. The           personnel   should    have    the   basic   knowledge
             concerning.
                  a. Types of materials and dosage forms to be
                        handled.
                  b. Materials that require specific storage conditions.
                  c.    Types of storage conditions.
                  d. Types         of    stability   (physical,     chemical,
                        microbiological, tox icological and therapeutic).
                  e. Ex piration date.
                  f.    Stress storage conditions.
                  g. Sampling.
                  h. Q uality control and quality assurance
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                                                        GSP - E g y p t
                 IV . S E C U R IT Y A N D S A F E T Y
1. The cost of security precautions should be related to the
    social environment in which the facility is situated and the
    value and nature of the goods used. W here large or
    significant quantities of valuable materials are held or
    where theft is prevalent, 24 hour security coverage should
    be provided.
2. Security arrangements with respect of poisons and habit-
    forming drugs should at least meet the standards laid down
    in the relevant legislation.
3. Stock control procedures should be sufficiently tight to
    ensure that significant loss by theft can be detected.
4. Arrival and departure of visitors to the warehouse must be
    controlled. The right to inspect all persons including
    employees, contractor staff and visitors entering or leaving
    the site should be reserved and random searches should
    be cashed out.
5. Safety and risk reduction measures, which must include
    procedures for the handling, transportation, usage and
    disposal of highly flammable liquids, tox ic and corrosive
    materials, must comply with the appropriate guide to be
    safe working.
6. Fire fighting precautions must include:
                                                                    21
GSP - E g y p t
             a. The training of selected staff to form a fire fighting team
                  capable of using effectively the equipment available in
                  the site.
             b. The routine maintenance and testing of fire fighting
                  alarms, detection systems, and sprinkler alarms.
      7. Fire ex its, corridors, walk-ways, doorways and other points
             requiring immediate access must be clearly defined and
             kept free from obstruction and litter. Regular fire evacuation
             drills must be carried out.
      8. W alk-in refrigerators and similar facilities must be equipped
             with safety devices for operators and must not be fitted with
             self locking doors which cannot be opened from within. The
             internal light must be manually operated from within the
             refrigerator.
Saf ety c on trol s f or f l am m ab l e storage areas i n c l u d e:
      a.          Electrically conductive floor.
      b.          Raised door sill.
      c.          Ex plosion-proof light fix tures.
      d.          Blow-out wall.
      e.          Forced draft vapor take-off.
                       i. At floor level.
                       ii. N ear the ceiling.
22
                                                           GSP - E g y p t
    f.      Rate-of-temperature-rise fire alarm.
    g.      Fire alarm monitored at fire station or continuously
            manned control board.
    h.      Switches for lights and vapor take-off fans located
            outside the room.
    i.      Supply of safety cans for dispensing fluids.
    j.      Alcohol storage located in this area meets Treasury
            regulations.
    k.      H eavy safe for storage of nitro compounds and other
            ex plosives.
O perations relating to the manufacture, processing, and packing of
penicillin shall be performed in facilities separate from those used
for other drug products for human use.
                                                                       23
GSP - E g y p t
                             V . S T O R A G E P R O C E DU R E S
                                        A N D IN S T R U C T IO N S
G eneral P rincip l es
      1. Factors to be taken in consideration for proper storage
             a.   Sanitation.
             b.   Temperature.
             c.   L ight.
             d.   Moisture.
             e.   V entilation.
             f.   Segregation.
      2. Materials must be stored under conditions which minimize
             deterioration, contamination, or damage. They must be
             stored         under   conditions     compatible       with    their
             recommended storage requirements of temperature and/ or
             humidity and where necessary, to comply with legal
             requirements, under secure or segregated conditions.
      3. Appropriate temperatures are:
             a.   For materials labeled " s to re in ref rigerato r" , they should
                  be stored at temperature between 2° and 8° C .
24
                                                           GSP - E g y p t
   b.   For materials labeled " s to re in a co o l p lace" , they
        should be stored at a temperature between 8° and 15°
        C .
   c.   For materials labeled " s to re in f reez er" , they should be
        stored at a temperature not higher than -10 ° C .
   d.   In the absence of more stringent storage requirements
        pharmaceutical products and raw materials should be
        stored at an average over any month of below 25° C
        with the max imum usually below 30 ° C        and above 4°
        C . Materials should be protected from direct sunlight.
4. Temperature or humidity controlled environments must be
   equipped with suitable indicators, recorders and/ or failure
   warning devices which must be checked at appropriate
   intervals    and     the     results    recorded.      Recording
   thermometers should be used. Temperature in uncontrolled
   storage areas holding raw materials or products should
   also be monitored.
5. Temperatures should be measured at different levels in the
   warehouse and if necessary storage of sensitive materials
   should be restricted to locations in the warehouse where
   they will be protected from ex treme conditions.
6. There must be an appropriate formal stock control system
   which record the receipt, location and issue of materials
   and facilitate proper stock rotation and reconciliation. The
   stock control procedure should ensure that materials with
   the shortest life are used first unless there is a conscious
                                                                       25
GSP - E g y p t
             decision that for a special reason an alternative priority has
             to be applied.
      7. Materials and products should be inspected at specified
             intervals to ensure that containers are properly closed,
             labeled, and that there is no evidence of serious damage or
             deterioration in the containers or their contents and that the
             stock rotation system is functioning correctly.
Receip t o f I nco ming M aterial s
See figure 3
      1. U pon receipt, each incoming delivery should be checked
             against the relevant documentation and physically verified
             by label description, type and quantity, against the relevant
             purchase order information.
      2. The consignment should be ex amined for uniformity and if
             necessary should be subdivided according to supplier’ s lot
             numbers especially if the delivery comprise more than one
             batch.
      3. All      containers    should     be   carefully   inspected   for
             contamination and damage and if necessary they should
             be cleaned or set aside for further investigation.
      4. Records should be retained for each delivery. They should
             include the description of the goods, quality, quantity,
             supplier, supplier’ s batch number, the date of receipt.
      5. Samples should be taken only by appropriately trained and
             qualified personnel strictly in accordance with written
26
                                                        GSP - E g y p t
   sampling    instructions.     The     samples    should         be
   representative of the batch from which they were taken.
6. The recommended product related storage conditions, for
   ex ample,   type   of    container,   temperature,   humidity,
   protection from light etc., should be maintained throughout
   the period of storage.
7. Secure measures should be taken to ensure that rejected
   materials cannot be used and they should be stored
   separately form other materials.
8. W hen necessary, to minimize contamination of the storage
   area, incoming materials must be cleaned, repacked or
   over wrapped where large quantities of materials in poor
   quality containers have to be handled. If it is neither
   possible to have the material supplied in more suitable
   containers nor practical to repack the material, it should be
   held in segregated area.
                                                                    27
GSP - E g y p t
       Fig. (3 ) I n s p e c t io n C h e c k l is t f o r D r u g R e c e ip t s
        A L L          S H I P M E N T S - C o m p a r e p h y s i ca l s t o ck w i t h s up p l i e r ' s i n v o                     i ce a n d
       o rig in       a l p ur ch a s e o r d e r / co n t r a ct . N o t e d i s cr e p a n ci e s o n t h e R e ce i v i n g R          e p o rt
       − N               um b e r o f co n t a i n e r s d e l i v e r e d
       − N               um b e r o f p a ck a g e s i n e a ch co n t a i n e r
       − V               i s i b l e e v i d e n ce o f d a m a g e s ( d e s cr i b e )
         − q           ua n t i t y i n e a ch p a ck a g e
         − C            o r r e ct d r ug ( d o n ' t co n f us e g e n e r i c n a m e s a n d b r a n d n a m e ), d o s a            g e fo rm
                   ( t a b l e t , l i q ui d , e t c.), d o s e ( m i l l i g r a m s , % , co n ce n t r a t i o n , e t c.)
       −          T a k e a s a m p le fo r te s tin g
       −            P r e s e n ce o f un i q ue i d e n t i f i e r s i f r e q ui r e d ( M i n i s t r y o f H e a l t h s t a m     p , e t c.)
       T A B L E T S - F o r e a ch s h i p m e n t , t a b l e t s o f t h e s a m e d r ug a n d d o s e s h                          o ul d b e
        co n s i s t e n t . T h e f o l l o w i n g ch a r a ct e r i s t i cs s h o ul d b e ch e ck e d
        − Id e n t i ca l s i z e , s h a p e , co l o r ( s h a d e o f co l o r m a y v a r y f r o m b a t ch t o                     b a t ch )
       − M a r k i n g s ( s co r i n g , l e t t e r i n g , e t c.) s h o ul d b e i d e n t i ca l o n a l l t a b l e t s
       − N o e v i d e n ce o f s p o t s , p i t s , ch i p s , b r e a k s , un e v e n e d g e s ,                                    cr a ck s ,
                 e m b e d d e d o r a d h e r e n t f o r e i g n m a t t e r , s t i ck i n e s s .
       − N o o d o r up o n o p e n i n g a s e a l e d b o t t l e ( e x ce p t f l a v o r e d t a b l e t s a n                       d th o s e
                  w i t h a ct i v e i n g r e d i e n t s n o r m a l l y h a v i n g a ch a r a ct e r i s t i c o d o r )              a n d n o
                   o d o r a f t e r b e i n g e x p o s e d t o r o o m a i r f o r 2 0 -3 0 m i n ut e s .
        C A P S U L            E S - C a p s ul e s s h o ul d b e i n s p e ct e d f o r t h e s a m e ch a r a ct e r i s t i cs a s
       t a b l e t s . In       a d d i t i o n , t h e f o l l o w i n g s h o ul d b e ch e ck e d :
       − N o e               v i d e n ce o f h o l e s i n t h e ca p s ul e
       − N o e              m p t y ca p s ul e s
       − N o o                p e n o r b r o k e n ca p s ul e s
       P A R E N T E R A L S (In je                  c ta b le s ) - A ll p ro d              uct s f o r i n j e ct i o n ( IV l i q ui d s ,
        a m p o ul e s , d r y s o l i d s f o r      r e co n s t i t ut i o n , s us p e   n s i o n s f o r i n j e ct i o n , e t c.) s h o ul d
         b e ch e ck e d f o r t h e f o l l o w        in g :
       − C l a r i t y o f s o l ut i o n           ( s o l ut i o n s s h o ul d b e        fre e fro m       un d i s s o l v e d p a r t i cl e s ,
                w ith in p e rm itte d lim             i t s ).
       − Dr y s o l i d s i n t e n d e d                f o r us e i n i n j e ct a b l e   s o l ut i o n s s h o ul d b e e n t i r e l y f r e e
                 fro m v is ib le fo re ig n            p a r t i cl e s
       − E v i d e n ce o f l e a k a g e                 fro m th e im m e d ia te          co n t a i n e r ( b o t t l e , a m p o ul e , e t c.)
28
                                                          GSP - E g y p t
S to rag e o f A p p ro v ed P ro d ucts
  1. All stored products should be accurately documented
      particularly with respect to product name, batch number,
      ex piry date and quantity.
  2. C omprehensive records should be maintained of the
      receipt and issue of all products.
  3. Products should be protected from ex cessive climatic
      conditions during storage and transit, such as heat, frost,
      moisture and direct sunlight.
  4. Products should not be distributed if they are approaching
      the end of their life. There must be a written policy laying
      down the remaining shelf-life after which products must not
      be distributed other than under ex ceptional circumstances.
  5. Picking stock should be stored to facilitate stock security,
      rotation, order assembly and dispatch.
  6. The picking and assembly areas should be organized to
      minimize the distance traveled by operators. The general
      environment should be of a high standard and well lit.
  7. H andling of goods should be kept to a minimum on
      grounds of high efficiency and safety. In large facilities the
      provision of mechanized order assembly system should be
      considered.
  8. There should be a laid down procedure for the checking of
      assembled orders.
                                                                      29
GSP - E g y p t
S to rag e at C l inical F acil ities
             The basic characteristics of good storage space at clinical
facilities are the same as for warehouses. Storerooms require
ready access, good circulation, dryness, and security. In most
cases, the smaller quantities of drugs stored will permit use of
shelving. Products are arranged in convenient manner and in the
order they appear on requisitions. L arge labels placed on the
shelves with each product facilitate recognition.
             The Storekeeper and assistant storekeeper alone have
access to the storeroom. A " D u tch D o o r" arrangement, in which the
top half of the door opens, while the bottom remains closed, keeps
out unauthorized persons and permits easy communication.
             At lower level facilities such as rural health posts, clinical
personnel frequently perform all supply management activities. It is
seldom the case, however, that medical aux iliaries or community-
based workers receive specific training for this. The result is that
the quality of supply handling and storage conditions deteriorates
as one move to the periphery of the delivery system.
             Training programs for clinical personnel who will handle
supplies should include specific courses of instruction in the
following subjects:
            Setting up a storeroom and good storage practices
            U se of stock control forms including requisitions, stock
             records, and prescriptions
            C old chain procedures, including the use and preventive
             maintenance of refrigerators.
30
                                                              GSP - E g y p t
S p ecial S to rag e C o nd itio ns
        Some categories of supplies require special storage
conditions. These include vaccines, narcotics, and combustibles.
V accines require both refrigerators and freezers.
        N arcotics and other controlled substances should be kept
in secure locking rooms with only one entrance. The keys should
be kept in a secure place, preferably a safe. O nly the warehouse
director and one other person should have access to them.
        C ombustibles such as alcohol, ether, and fuels must be
stored in special rooms. A small, separate out-building is preferable
since it virtually guarantees that fire will not spread throughout the
warehouse. If a special building is not available, the room used to
store these supplies must be fireproof and well-ventilated.
                                                                          31
GSP - E g y p t
                         V I. S T O C K A R R A N G E M E N T
                           R O T A T IO N A N D C O N T R O L
S to ck Ro tatio n and C o ntro l
      1. C omprehensive records should be maintained showing all
             receipts and issues of materials according to batch
             number.
      2. Periodic       stock   reconciliations   should     be   performed
             comparing the actual and recorded socks. In any event this
             should be performed when each batch is totally used up.
      3. All significant stock discrepancies should be subjected to
             investigation as a check against inadvertent mix -ups and
             wrong issues.
      4. Issues should normally observe the principle of stock
             rotation (first-in first-out) especially where ex piry dated
             materials are concerned.
      5. Partly used containers of materials should be securely re-
             closed to prevent spoilage and/ or contamination during
             subsequent storage. D amaged containers should not be
             issued but should be brought to the attention of the
             organization responsible for quality control.
32
                                                            GSP - E g y p t
A rrang ement o f S to ck
W ithin warehouses and storerooms, drugs are arranged according
to a specified organizational principle. Therapeutic/ pharmacological
class, clinical indication, alphabetic order, and level-of-use are
commonly used. W ithin the warehouse itself as well as in clinical
facilities, use of the therapeutic/ pharmacological classification
produces good results, perhaps because it provides a frame of
reference within which workers can easily recognize individual
products. L evel-of-use can be combined with this approach by
using preprinted Requisition/ Issue Tickets for each type of facility.
W ith this system, drugs are arranged in the warehouse by their
classes in the same order as they appear on the Requisition/ Issue
Ticket. W orkers move along the rows of pallets packing only the
type and quantity of drugs shown on the Ticket - a greater range of
products for hospitals, a lesser range for dispensaries. A final
check before sealing the box es assures that aux iliaries have not
requested unauthorized drugs (e.g., morphine for backaches).
C o ntro l o f O b so l escent and O utd ated S to ck
        All stocks should be checked regularly for obsolescent and
degraded materials. Materials with an ex pired shelf life should be
destroyed unless an ex tension of shelf life is granted following the
satisfactory results or re-analysis. All due precautions should be
observed to preclude issue of outdated materials.
                                                                        33
GSP - E g y p t
                          V II. DIS P A T C H A N D IS S U IN G
      1. The allocation and shipping of products should be made
             only after the receipt of a written sale order.
      2. Results for dispatch procedures should be established
             depending on the nature of the product and after taking into
             account any special precautions to be observed. The
             shipping container should offer adequate protection from all
             ex ternal influences, and should be indelibly and clearly
             labeled.
      3. D ispatch documents should be retained indicating:
                  •     D ate of dispatch.
                  •     C ustomer name and address.
                  •     Product name and quantity sent.
All documentary records should be readily accessible and be kept
in a secure place.
In Medical Stores:
      1. W hen requisition/ issue tickets (R/ I) arrive, shipping clerks
             review them to see that the types and quantities of supplies
             correspond to the needs of the warehouse or clinical facility
             requesting them. The clerks initial approval and send the
             R/ I to the Inventory C ontrol U nit. There, stock clerks review
             the availability of the supplies requested. They note any
34
                                                       GSP - E g y p t
   low inventory levels and send the R/ I to the D irector. The
   D irector reviews the document, taking into account the
   stock clerks’ notations. H e may delete items, modify
   quantities, or approve the R/ I as it is. H e then returns the
   document to the Inventory C ontrol U nit. There, the clerks
   post the Stock Record C ards and send all copies of the R/ I
   to the Pharmaceutical Store Room. Eventually, when
   Shipping and Receiving provides a signed copy of the R/ I
   verifying that the shipment has been made the stock clerks
   change the pencil entries to ink.
2. The   C hief   Storekeeper       supervises   preparation       of
   shipments. As a clinical pharmacist, he is the only person
   authorized to make substitutions. W ithin the store room,
   supplies are arranged in the order that they appear on the
   Requisition/ Issue. Ticket. The store men loose-pack
   supplies in cartons. W hen issuing drugs, an important
   principle is to issue those drugs with the nearest ex piration
   date first. The Assistant Storekeeper is responsible for this
   and for posting the Bin C ard.
                                                                   35
GSP - E g y p t
            VIII. STABILITY FOLLOW-U P TH R OU G H C U R R E N T
       C H E C K -U P AN D IN SP E C TION OF P H AR M AC E U TIC AL
                                                      P R OD U C TS
             The stability of a pharmaceutical product can be defined as
the ability of its formulation, in a specific container-closure system,
to remain within the defined physical, chemical, microbiological,
therapeutic, and tox icological specifications till the end of the stated
dating,           under   defined   storage   conditions.   Protection   of   a
pharmaceutical product may be viewed from two perspectives:
      1. It is necessary to provide protection for the dosage form
             from the environment, by controlling product’ s storage and
             distribution conditions.
      2. Products should be well packaged to protect the end user
             from the product itself. In this sense security packaging or
             temperature resistant packaging ex hibits a dual protection
             role. The protection function of packaging provided the
             major vehicle for optimization of the elements of storage
             and security. The cG MP include two acts controlling drug
             stability and G ood Storage Practice (G SP).
36
                                                                 GSP - E g y p t
                A ct 5 . 5 3 :
                D rug storage should be regularly checked for
                cleanliness      and     good    order,   and    for
                misplaced, deteriorated, or out-dated stock.
                A ct 5 . 5 4 :
                D rug     products     should   be   stored   under
                conditions       which   minimize     deterioration,
                contamination, spillage, or breakage.
Accordingly, current inspection at appropriate time intervals should
be done to verify:
    1. Proper selection of storage conditions according to that
        stated on products label.
        The following world-wide climatic zones are assigned.
        Zone 1: Temperate climate
        Zone II: Mediterranean-like and subtropical climate
        Zone III: H ot, dry climate, dry regions
        Zone IV : H ot, humid climate, tropics.
        In Egypt the climate, varies with season and place, roughly
        corresponding to climates of zones II, and IV           round the
        year.
                                                                             37
GSP - E g y p t
             Both temperature and relative humidity (RH ) determine the
             ex act climate for drug storage.
      2. C urrent recording and occasionally validation of monitoring
             equipment (thermometers, hygrometers, etc.) to insure
             proper climate adjustment.
      3. Pharmacist should be aware that deterioration of drug
             products may happen even before their ex piration. This
             may occur perhaps due to improper storage or the fact that
             the product may require critical storage conditions not
             stated on the label e.g.:
                  •   Sorbitol discolors rapidly when stored in metal
                      containers.
                  •   Sodium metabisulfite gets ox idized rapidly by
                      frequent container opening
H ence, inspection should include frequent product ex amination to
detect signs of product deterioration which differ according to the
dosage form, where deterioration may be physically detected as
follows:
I- P a r ent er a l S ol u t i ons a nd O r a l S ol u t i ons :
a. Slight gradual discoloration.
b. Swirly precipitation.
c. W hiskering: pinhole at ampoule tip that leaks solution which
precipitates or crystallizes solid matter.
d. C louding
38
                                                                 GSP - E g y p t
e. Fading of color
II- D i s p er s e S y s t em s :
a. C ake sedimentation (suspension).
b. C reaming and cracking (emulsions)
c. D iscoloration.
III. S em i -S ol i d s (O intments, creams, gels and suppositories)
a. C hange in consistency and feel to touch
b. Syneresis.
c. Phase-separation.
d. D iscoloration.
e. Surface crystal growth.
f. H ardness.
IV S ol i d D os a g e F or m s :
a. Surface chipping or pitting (plain tablets).
b. D eformation (C apsules).
c. Increased hardness.
d. D iscoloration.
e. C olor fading (colored tablets).
f. C hipping of coat.
                                                                             39
GSP - E g y p t
      4. In this respect the trained pharmacist, should be aware
             (during inspection) that drugs mostly susceptible to
             hydrolytic, ox idative, or photolytic decomposition should be
             carefully ex amined for deterioration. D rugs susceptible to
             hydrolysis are those containing, -C O O -C O N H -, lactone or
             lactame group. Most vitamins, hormones, enzymes are
             highly sensitive to ox idation and photodecomposition.
      5. The integrity of packing and packaging of dosage form is
             one of the important tacks of inspection pharmacist as
             these protect the drug in a tailored fashion.
      6. After each inspection, products showing any signs of
             instability should be subjected to sample analysis to insure
             product activity.
40
                                                           GSP - E g y p t
                           IX . M A T E R IA L S A N D DR U G S
                     R E Q U IR IN G S P E C IA L S T O R A G E
                                                 C O N DIT IO N S
1. M e d i c a l G a s e s
            G as cylinders should be stored under cover, and not
subjected to ex tremes of temperature. Areas where they are stored
should be clean, dry, well ventilated and free of combustible
materials. They should be stored vertically and secured to prevent
falling. Storage arrangements should permit segregation of different
gases and of full/ empty cylinders and permit rotation of the stock.
Flammable gases should be segregated from ox ygen and other
ox idizing gases. Storage arrangement for gas-mix ture should be
such as to avoid separation of the mix ture into its component
gases.
2. A e r o s o l s
Aerosols should be stored in a clean separate area away from heat
and sunlight. Because the container contents are under pressure,
filled containers must be checked for weight loss over the
ex piration dating period. For contents under pressure, the label
should carry out do not ex pose to heat or store at a temperature
above 49° C . K eep out of children reach.
3. C r e a m s
                                                                       41
    GSP - E g y p t
                 C reams can be destroyed under ex treme temperature
    fluctuations; hence they should be stored at temperature above 10 °
C        and not ex ceeding 30 ° C . If the creams are opened and diluted,
they should not be kept more than 14 days to avoid microbial
contamination.
    4 .O p h th a lm ic S o lu tio n s a n d D r o p s
                 They should be stored according to the conditions specified
    on the label. After opening they should not be used for more than
one month at home and not more than 15 days in hospitals.
    5. C a p s u l e s
                 Ex tremes of humidity and temperature should be avoided.
    H igh humidity (> 60 %         RH   at 21° C   to 24° C ) produce more lasting
    effects on the capsule shell, since as moisture is absorbed, the
capsules become softer, tackier and bloated. If temperature is
increased the capsule shells may melt and fuse together. H igh
temp > 40 ° in a dry place may cause cracking of the capsule shell.
Therefore, capsules should be stored in an air-conditioned area in
which the humidity does not ex ceed 45%                  RH at 21° C to 24° C .
                 Empty hard gelatin capsules, generally range in moisture
content between 12 to 15% . Below 10 %                     moisture content, they
become brittle and may shrink to the point of not fitting in the filling
equipment. Above 16% , size problems in the filling equipment, plus
a loss of mechanical strength, may be encountered. Ex posure to
either heat or moisture ex tremes can distort empty capsules to the
ex tent that they can not be handled by automatic filling machines.
    6. S u p p o s i t o r i e s
    42
                                                                                      GSP - E g y p t
            Suppositories should be protected from heat, preferably
stored in the refrigerator. Polyethylene glycol suppositories and
suppositories enclosed in a solid shell are less prone to distortion at
temperature slightly above body temperature. G lycerinated gelatin
suppositories should be protected from heat, moisture, and dry air
by packaging in well sealed containers and stored in a cold place.
7 .E m u ls io n s a n d S u s p e n s io n s
            Emulsions and suspensions should be stored at a
temperature between 15° C                    and 30 ° C . H igh and low temperature
may destroy the system and cause separation.
8. V a c c i n e s
            D PT and Tetanus should not be stored in a freezer .They
should be stored at cold place (3-8° C ). Also BC G                          should be stored
in a cold place (3-8° C ). Measles and oral polio should be stored in
a freezer (-25° C to -15° C ).
9. R a d i o p h a r m a c e u t i c a l s
            Storage          of      radiopharmaceuticals                must     take         into
consideration the chemical state of the radioactive drug, the
quantity and type of radiation involved, and any special storage and
stability      requirements.             For     ex ample,         gaseous       or      volatile
radiopharmaceutical should be kept in specially vented areas,
whereas certain other radioactive drugs require refrigeration.
Storage conditions are normally specified in product package
inserts. In addition, appropriate shielding must be used for storage
areas to minimize personnel ex posure.
10 . D r u g s R e q u i r i n g S p e c i a l S t o r a g e C o n d i t i o n
                                                                                                  43
GSP - E g y p t
        a.        Aminophyline Injection: Protected from light, discolored
                  product not to be used.
        b.        Aspirin Tablets: In moisture proof containers, avoid moist
                  conditions.
        c.        Epinephrine Solution: Protected from light, ophthalmic
                  solutions should be in small volumes, discolored products
                  not used.
        d.        Idox uridine Solution: Protected from light, in completely
                  filled containers.
        e.        Ergometrine and Ergotamine Solutions: Filled containers
                  with minimum headspace, protected from light.
        f.        G lyceryl Trinitrate Tablets: In water proof non-plastic
                  containers.
        g.        H eparin Injections: At temp not ex ceeding 25° C , in
                  refrigerators (2-8° C ), freezing is avoided.
        h.        Insulin Injections: In refrigerators (2-8° C ), freezing should
                  be avoided.
        i.        C arbamazipine Tablets: In cool dry place in tightly closed
                  containers. Tablets readily lose as much one third of their
                  activity when stored in humid environment and the tablet
                  become harder and dissolution is impaired.
        j.        N ystatin Preparations: In dark cool place, in tightly closed
                  containers.
44
                                                         GSP - E g y p t
k.   Phenothiazine Preparations: Protected from light in tightly
     closed containers.
l.   Riboflavin Tablets: Protected from light in tightly closed
     containers.
m.   Sulfacetamide Solution: In dark tight containers with
     minimum headspace.
n.   O x ytocin Injections: In amber colored containers with
     minimum headspace in refrigerator (2-8° C ).
o.   N oradrenaline Injections: In dark filled containers, if color
     change to brown the preparation is not to be used.
p.   V egetable and Animal D rugs: Protected from insect
     infestations or microbiological contaminations by means
     of suitable agents or processes that leave no harmful
     residues. Mycotox in detection such as aflatox ins B1 and
     B2 should be performed on crude drugs before use,
     because of the carcinogenicity of these mycotox ins.
q.   Mannitol Injections: Should be stored at a temperature
     not less than 20 ° C . If crystallization occur, heat to
     dissolve before use.
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