Accepted Manuscript

Review article

An overview of intestinal wafers for oral drug delivery

Kirsten Kirsch, Ulrike Hanke, Werner Weitschies

PII: S0939-6411(16)30396-4
DOI: http://dx.doi.org/10.1016/j.ejpb.2017.01.003
Reference: EJPB 12405

To appear in: European Journal of Pharmaceutics and Biophar-

maceutics

Received Date: 2 August 2016

Revised Date: 22 November 2016
Accepted Date: 5 January 2017

Please cite this article as: K. Kirsch, U. Hanke, W. Weitschies, An overview of intestinal wafers for oral drug
delivery, European Journal of Pharmaceutics and Biopharmaceutics (2017), doi: http://dx.doi.org/10.1016/j.ejpb.
2017.01.003

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Title Page
Our reference: EJPB 12405
Article reference: EJPB_2016_123
To be published in: European Journal of Pharmaceutics and Biopharmaceutics

Article title: An overview of intestinal wafers for oral drug delivery

Order of Authors: Dr Kirsten Kirsch*, Dr Ulrike Hanke*, Prof Dr Werner Weitschies*

Corresponding Author: Prof Werner Weitschies
Authors affiliations: * Ernst-Moritz-Arndt University Greifswald
Institute of Pharmacy
Department of Biopharmaceutics and Pharmaceutical Technology
Felix-Hausdorff-Strae 3
17489 Greifswald
Germany
Contact Information of Corresponsing Author:
Prof Dr Werner Weitschies
Ernst-Moritz-Arndt University Greifswald
Institute of Pharmacy
Department of Biopharmaceutics and Pharmaceutical Technology
Felix-Hausdorff-Strae 3
17489 Greifswald
Phone +49 3834 86-4811/13
Mail: werner.weitschies@uni-greifswald.de

1. Introduction
For drug delivery, oral intake is the most common and widely accepted procedure. However, many
active pharmaceutical ingredients (API) for example large biomolecules like peptides, proteins and
recombinant therapeutic agents typically have a very poor bioavailability after oral administration.
Reasons are for example low mucosal permeability for large and hydrophilic molecules, a narrow
absorption window at particular regions of the gastrointestinal tract (GIT), lack of stability in the
gastrointestinal environment resulting in a decomposition prior to its absorption and low dissolved
concentration of active ingredient in gastrointestinal contents [1, 2, 3]. One strategy to overcome
these problems is the usage of bioadhesive dosage forms. Bioadhesion is defined as the adhesion
of synthetic or natural macromolecules like polymers to biological tissue. A special type of
bioadhesion is mucoadhesion where the tissue is covered by mucus [4]. The process of
mucoadhesion is characterized by two steps: First, the initial contact between dosage form and
tissue surface, and second the formation of physical and chemical bonds like hydrogen bonds,
noncovalent and ionic interactions. Many theories try to explain mucoadhesion, for example the
electronic theory, the adsorption theory, the diffusion theory, the wetting theory, the fracture theory,
and the mechanical theory [4, 5, 6, 7]. Whereas the electronic theory argues with the formation of
electrostatic interactions between the mucoadhesive polymers and the intestinal mucus, the
absorption theory states the formation of hydrogen bonds and van-der-Waals interactions between
functional groups of the polymers and the intestinal mucus [4, 5, 6, 7]. The diffusion theory implies
that the polymer chains and the glycoproteins of the mucus interpenetrate each other and form
adhesive bonds [4, 5, 6, 7]. The wetting theory is applied for liquid systems and suggests that the
lower the surface tension of a polymer solution the greater the mucoadhesion, whereas the
fracture theory analyzes the adhesion force between solid materials. Considering the effect of
surface roughness of rough and porous materials, the mechanical theory is applied. Indeed,
mucoadhesive properties of dosage forms cannot be explained just by a single theory, but rather
as a combination of all of them [4, 5, 6, 7]. An example for mucoadhesive dosage forms are
wafers. In the literature there are many synonyms like (thin) film, melting film, thin strip or
(gastro)intestinal patch. In general wafers are defined as paperthin, flexible polymeric films which
are used as drug carriers, with a homogenous surface, an average size of 210 cm and a
thickness of 20500 m [8, 9].
Because of their different drug release rates and disintegration times, wafers can be classified into
rapid disintegrating, melt away, and sustained release wafers. Rapid disintegrating wafers
disintegrate within 3060 s and result in an immediate drug release, whereas melt away wafers
stick to the mucosa, disintegrate within 530 min and form a gelatinous, mucoadhesive depot at
the application site. Sustained release wafers attach to the mucosa as well and are characterized
by disintegration times of several hours and a continuous drug release, ideally zero order kinetics
[8]. Furthermore, the drug release rate and disintegration time is highly influenced by wafer
structure and polymer selection. Wafers can also be classified according to their structure into
singlelayered and multilayered wafers. Multilayered wafers consist of up to four layers, each with a
different function. Most frequently multilayerd wafers consist of some kind of a water-insoluble
layer, a drug-loaded layer, a mucoadhesive layer and an enteric, pH-sensitive layer. The selection
of a suitable wafer type and structure depends on the route of administration, application site,
indication and desired release profile. In table 1 the properties of different wafer types are
summarized.

Wafers can be applied to gastrointestinal, nasal, oral, buccal, rectal or vaginal mucosa. In studies
intestinal wafers were applied directly to mucosa after surgical incision or were swallowed packed
in enteric capsules. Wafers closely adhere to the intestinal mucosal tissue because of their
mucoadhesive properties and have an increased resistance time at the absorption site.
Furthermore, a large drug concentration gradient is created, resulting in a high drug flux at the
mucous membranes, which are well supplied with blood. All these conditions lead to an enhanced
drug absorption compared to conventional oral dosage forms. So following advantages of intestinal
wafers are mentioned in literature [4, 5, 10]:
- Prevention of breakdown of drugs by stomach acid and gastrointestinal enzymes
- Bypass first-pass effect because of direct uptake into systemic blood circulation
- Enhancement of bioavailability of oral administrated drugs and so dose reduction at equal
therapeutic effect
- Precise dosing at absorption site
- Reduction of gastrointestinal side effects
- Immediate drug absorption and rapid onset of action by rapid disintegrating wafers
- Simple and space-saving storage

However, no intestinal wafers are on the market at the moment. In studies intestinal wafers are
mainly used for the administration of active substances with either high first-pass effects, poor
bioavailability, high sensitivity for gastrointestinal enzymes and fluids or combinations thereof. In
addition, wafers are proposed for the delivery of active substances with an absorption window in
the upper small intestine. Especially sustained release wafers should enable an increased
retention time at the absorption window and consequently increased drug absorption.

2. The small intestine as an application site

Under fasting conditions the human small intestine is a mostly collapsed canal with a length of 3
6 m and an average diameter of about 2.5 cm. The small intestine can be divided into the three
major parts duodenum, jejunum and ileum. The surface is organized in villi, crypts, and microvilli,
which results in a very large surface. Furthermore, this surface is covered with mucus, which forms
a smooth surface. Mucus has many functions like protection against mechanical and chemical
damage of underlying intestinal epithelium, lubrication for the passage of objects, and as barrier for
pathogens [4, 7, 11]. Mucus thickness ranges from 50450 m (median 200 m) and is influenced
by hormonal, paracrine and neural stimulation as well as by inflammatory reactions and acids [7,
12]. Assuming a mean mucus thickness of 200 m this results in a total small intestinal mucus
volume of 1-2 L. Mucus mainly consists of high molecular weight glycoproteins and 90-98 % water.
Further ingredients are cholesterols, lipids, carbohydrates, inorganic salts, urea, enzymes and
amino acids [4, 5]. Allen et al. [12] identified three phases of intestinal mucus: 1) mucus stored in
epithelial cells, 2) adherent mucus on epithelium, and 3) mobile mucus, which is mixed with
intestinal content. The complete turnover of mucus varies between 1224 h [10]. However,
constant mucus turnover limits the retention of mucoadhesive dosage forms.
Small intestinal walls consist of several tissue layers (Fig. 1). The inner layer is the Tunica mucosa,
which is divided into Epithelium mucosa, Lamina propria and Muscularis mucosa.
Epithelium mucosa is a single squamous epithelium layer. The lamina propria is a connective
tissue layer and contains blood vessels, lymph vessels, and nerve fibers and by this is the
absorption site for nutrients and active pharmaceutical ingredients (API). Muscularis mucosa is a
thin muscle layer and consists of smooth muscle fibers. Similar to Lamina propria,
Tunica submucosa contains blood vessels, lymph vessels and nerve fibers. The following layer,
Muscularis propria, contains muscle layers. The outer layer, Tunica serosa, consists of adipose
tissue and collagen fibers [13].
Literature claims that the pH of the small intestine under fasting conditions is around pH 6 at pyloric
orifice and increases to pH 7-8 in deeper compartments [14, 15]. However, studies demonstrate
reasonable interindividual variability and fluctuations of small intestinal pH [16]. Furthermore, there
is a pH gradient between mucus surface and epithelial surface (pH 7) which is caused by the
production of carbonate ions in the proximal duodenum. This pH gradient decreases with
increasing distance from the pyloric orifice [12, 17].

The intestinal mucosa is known as a very good absorption site. Several research groups evaluated
the permeability of the small intestinal mucosa. Methods to quantify the permeability in vitro are for
example [18, 19, 20, 21]:
- Measurement of macromolecular flux across isolated GI segments in Ussing chambers,
- Determination of the effect of different factors on permeability of model substances in
monolayers of Caco-2 cells,
- Morphological measurement of tight junction components in mucosal biopsies,
- Everted intestinal sac model.
In vivo methods are for example [19, 22, 23]:
- PEG profiling to determine pore pathway (high capacity size and charge selective route) against
leak pathway (low capacity paracellular route)
- Open, semi open and closed perfusion in selected parts of the GIT with
single-balloon-technique or double-balloon-technique.

Hosoya et al. [24] compared the permeability of nasal, buccal, duodenal, jejunal, ileal colonic and
rectal mucosa of rabbits (male, Japanese white rabbits, 2.02.5 kg) with fluorescence-labeled
dextran (FD) of different molecular sizes using the Ussing chamber. Their results show the
following order of permeability rates of FD-4 (MW = 4400 Da): duodenum < jejunum < rectum <
ileum < colon < nose. For buccal mucosa no drug permeability was observed even after 4 h and it
was noticed that the permeability decreased with increasing molecular size. Toorisaka et al. [25]
determined the order of permeability for the small intestine of rats (male, Wistar rats, 7 weeks old)
using intestinal patches with fluorescein-isothiocyanate labeled insulin (FITC-insulin) and a
horizontal diffusion cell. Their results indicate an increase in permeability in the following order:
duodenum < ileum < jejunum. Van der Bijl and van Eyk [26] investigated the permeability of human
buccal, vaginal, intestinal and colonic mucosa. They used a flow-through diffusion cell, frozen
mucosa and substances of different molecular size like water (MW = 18 Da), arecaidine
(MW = 146 Da), arecoline (MW = 160 Da) and 17-estradiol (MW = 272 Da). The resulting order for
all drugs was intestinal < colon < buccal ~ vaginal mucosa. But Van der Bijl and van Eyk [26] used
vaginal mucosa of postmenopausal women. So they not considered the influence of hormones on
mucosa thickness and glycogen content and as a result the influence on permeability. As potential
reasons for different mucosal permeability and rates of drug absorption Alam et al. [18] named
variable presence of membrane transporters, different activity of transporters in intestinal
segments, variable amount of enzymes and also anatomical and physiological variations.
Additionally, the permeability of mucosa depends of course on the applied active substance.

3. Wafer formulation and preparation

For the preparation of intestinal wafers most research groups investigate multilayered wafers with
varying disintegration times. They consist of at least one active substance, one mucoadhesive
polymer and one plasticizer. Additionally, they can contain water-insoluble polymers, enteric,
pH-sensitive polymers, colors, fragrances, absorption enhancer, buffer substances and
preservatives. The mucoadhesive polymers used must be non-toxic and biocompatible. With
regard to the theories of mucoadhesion, various functional groups can have an effect on the
degree of polymer/mucus interaction. Studies suggest that mucoadhesive polymers are hydrophilic
networks that contain numerous polar, charged and/or hydrogen bond forming groups. Further, the
degree of flexibility of polymer chains, the molecular weight, and the polymer concentration are
important [5, 7, 9, 27]. Often applied polymers are poly(acrylic acid) (PAA), polyvinyl acid (PVA),
cellulose derivatives like hydroxypropyl methylcellulose (HPMC), hydroxypropyl cellulose (HPC),
hydroxyethyl cellulose (HEC) and sodium carboxymethylcellulose (SCMC), hydroxyethyl
methylacrylate, pectin, sodium alginate, chitosan and thiolated polymers [4, 5, 6, 10]. In order to
obtain smooth and flexible wafers the addition of plasticizer is usually required, such as
polyethylene glycol (PEG), glycerol and sorbitol. The concentration and combination of polymers
and plasticizer influence the drug release profile, the disintegration time, as well as the mechanical
properties of the wafer.
Intestinal wafers are most commonly prepared using solvent evaporation technique or direct milling
[5, 28]. In case of solvent evaporation technique each layer of the wafer is produced separately. All
ingredients of one layer are dissolved or dispersed in a solution/dispersion medium, which is cast
onto a release layer sheet or poured into a mold. In a subsequent drying step the medium is
evaporated at a defined temperature and time period. To achieve multilayered wafers the different
layers are connected by pressure, thermal bonding, an adhesive agent or they are casted onto
another interrupted by drying and/or lyophilisation steps.
In the direct milling method, all ingredients are homogeneously mixed and compressed to the
desired thickness and where applied, the produced wafers are completely or partly coated with a
water-insoluble and/or drug-impermeable layer [5].
Other methods mentioned in literature are hot melt extrusion, solid dispersion extrusion and
semisolid casting method [28].
The choice of preparation method depends on the selected active substance. Especially
biomolecules like peptides and proteins are fragile and temperature-sensitive. When using for
example solvent evaporation technique or hot melt extrusion a drying process is necessary, which
stresses the biomolecules and can induce partly or complete degradation. Consequently, control of
stability during the critical preparation steps, content uniformity and storage stability is
recommended. Possible detected decreasing of drug content could be corrected for example by
reduction temperature during drying process or optimization of storage conditions. However, only
Rajput et al. [30] which incorporated the low weight molecule glipizide in their wafer formulation
determined drug content uniformity. All other research groups announced in this review did not
consider stability of incorporated active substances in their wafer formulations and reference
dosage forms. So, it cannot be guaranteed that declared content is equal to applied dose.

As mentioned above different intestinal wafer structures are discriminated [29]. Examples are listed
below:
- Singlelayered wafers [30]
- Twolayered wafers [25, 31, 32, 33]
- Threelayered wafers [34, 35, 36, 37] and special types like drug-in-adhesive patches [38, 39],
microsphere patches [1, 40], and gated hydrogel patches [41]
- Fourlayered wafers [42, 43, 44] and special types like gastrointestinal mucoadhesive patch
system (GI-MAPS) [45, 46]
- Micro patches [3, 47]

Examples of different intestinal wafer structures are depicted schematically in figure 2. Most
studies focus on threelayered or fourlayered intestinal wafers. Fourlayered wafers mainly consist of
a water-insoluble/drug-impermeable backing layer, a drug-loaded layer, a mucoadhesive layer, and
an enteric, pH-sensitive layer. The water-insoluble layer contains ethyl cellulose (EC) or cellulose
acetate (CA) and should ensure the unidirectional drug transport, prevent drug release into
intestinal lumen, and protect drugs against enzymatic breakdown. The mucoadhesive layer
guarantees the adhesion to intestinal mucosa as well as prolonged retention time at the absorption
site resulting in a high drug concentration at intestinal mucosa. The enteric, pH-sensitive layer
consists of suitable excipients with pH dependent solubility, for example Eudragit L, Eudragit S
or hydroxypropyl methylcellulose phthalate (HP-55), and delays drug release until arrival of the
dosage form in the intestine. Threelayered wafers often consist of a water insoluble/drug
impermeable backing layer, a mucoadhesive layer, and an enteric, pH sensitive layer. Whereas,
the active substance is dissolved, suspended or incorporated as microspheres into the
mucoadhesive layer. A less often used threelayered wafer structure is the gated hydrogel patch.
These patches are constructed of a backing layer, a hydrogel-bilayer and a drug-loaded,
mucoadhesive layer. Because of different swelling of the bilayered structure these wafers curl up
upon contact to mucosa and fix itself in the intestine [41].
Further, intestinal patches can be built of two layers (water-insoluble layer and drug-loaded,
mucoadhesive layer) [25, 31, 32, 33].
Special types of wafers are micro patches which are characterized by a diameter of 50200 m
and a thickness of 225 m. Due to their size micro patches are thought to be large enough to
prevent endocytosis but small enough to migrate between intestinal villi. Micro patches are
produced of silicon dioxide, porous silicon and/ or polymethylmethacrylate (PMMA) [3, 47].

4. Wafer characterization
Wafer characterization is important to identify and select a wafer formulation during development
and to ensure constant quality during production. In table 2 parameters and methods are
summarized which are most frequently described to characterize intestinal wafers.

4.1 Appearance
Surface morphology, thickness and weight are important to control uniformity of dosage form and
to ensure a homogenous appearance. The thickness is determined using an automatic or
mechanical thickness tester and weight is investigated by weighing using suitable balances.
Surface morphology and homogeneity are controlled visually or by use of scanning electron
microscopy (SEM) [1, 9, 25, 30, 31, 37, 42, 48].

4.2 Mechanical properties

Suitable mechanical properties are necessary to withstand handling and application of wafers. So,
the folding endurance, the tensile strength and the elongation at break were determined to
characterize mechanical properties. Several authors used Texture Analyzer methods to assess
tensile strength and elongation at break. Tensile strength is the force that is required to break the
wafer. In order to calculate the tensile strength, the load at the breaking point and cross-sectional
area of the wafer are recorded. The elongation at break is calculated with elongation at breakpoint
and original length. Further parameters can be evaluated during mechanical studies like stress
strain curve and Youngs modulus, which is expressed as ratio of tensile strength and elongation at
break. All mechanical parameters are influenced among other things by polymer and/or plasticizer
selection as well as the mass ratio of these components within the formulation [49, 50].

4.3 Performance parameters

Performance parameters include parameters which influence drug stability and drug release.
Mucoadhesive properties are necessary to ensure the direct contact with the mucosa. They are
defined by the force between the mucoadhesive device and mucosal tissue. Mucoadhesion can be
determined by different approaches which are illustrated in figure 3. One approach is the flow
through model (Fig. 3B), consisting of a slope on which the mucosa is mounted. The
mucoadhesive device is attached to the mucosa and rinsed with a solution, and either the retention
time, the mass change of the device or the rinsed drug amount is measured as a function of time
[4]. A second approach is performed using a texture analyzer or modified microforce balance
(Fig. 3A). The wafer and mucosa are brought in contact for a defined time and the maximum force
required to break the adhesive bonding is recorded. Based on the results a force-distance curve
can be plotted, and depending on the direction in which the mucoadhesive formulation is separated
from the mucosa it is differentiated between shear, rupture and detachment force (Fig. 3C) [27, 51,
52].
Further, the ability of wafers to hydrate when coming into contact with intestinal mucus/mucosa is
relevant for their mucoadhesive properties and consequently for the drug release profile. A
commonly used parameter to quantify the hydration of dosage forms is the swelling index. It is
determined by weight gain of the dosage form submerged in different media.
Moisture content is an important issue regarding drug stability over time. It is typically determined
using Karl Fischer titration or drying loss.
In vitro dissolution models are used to evaluate the rate and amount of drug release and can be
split into animal dependent and animal independent models. For animal dependent models organs
or mucous membranes are extracted and incorporated into the experimental setup. An example for
that is the intestinal sac model [18, 27], which was introduced in 1954 by Wilson and Wiseman and
optimized by several research groups afterwards [21]. The extracted part of the intestine is
washed, everted, closed at one end and filled with a small amount of physiological medium.
Subsequently the intestinal sac is incubated in drug-containing medium and samples are taken
after defined time points. Advantages of this model are a large absorption surface and presence of
mucus layer, enzymes and transporters. A major disadvantage is the short survival time of the
tissues. Further examples of animal dependent models are diffusion chambers as the Franz cell
and the Ussing chamber. Standard USP apparatuses, originally designed for release and
dissolution testing of solid oral dosage forms, like the basket or paddle apparatus as well as
different kinds of beakers belong to the animal independent models [53]. However, most methods
for evaluation of drug release and absorption in use are not biorelevant because of aberrations
concerning the physiological pH and volume. Besides, direct application onto mucosa is not
considered. An opportunity to achieve a better adaptation to the situation in vivo using these
models might be the use of volumes comparable to those apparent in the upper GIT and
biorelevant media like simulated intestinal fluid (SIF) [53] or FaSSIF and FeSSIF buffer [2].
In vivo drug release studies are mainly performed in animal models like rat, dog, sheep, mouse
and rabbit. But the intestines of these animal models differ from human intestine in terms of
anatomy, physiology, and permeability. Wafers are either given orally or applied directly after
surgical incision on the intestinal mucosa. Subsequently, blood samples are taken and
pharmacokinetic parameters are determined. If applicable, also pharmacodynamics parameters
are measured. In vivo studies are important to evaluate influences of physiological factors like
condition of mucosa, pH at the application site, volume of the intestinal fluid, enzymatic and
hormonal status, and regional concentration of carriers, uptake transporters and efflux
transporters. Additionally, some research groups investigated tissue samples from the application
site by light microscopy and determined the compatibility of wafers.
Further, unidirectional drug release is tested [33, 40, 42, 54]. This is of importance as the drug
should be directly transported through mucosa into the systemic blood circulation and not be
diluted in intestinal fluids. To assess unidirectional drug release similar models are used as for
dissolution studies, for example the Ussing chamber.
Different methods for the quantification of these parameters have been described, however, due to
missing reference values and the lack of standardized monographs the comparison of different
formulations is critical.

5. Wafer performance
Intestinal wafers are used for the application of active substances that are usually given
intravenously (i.v.) or subcutaneously (s.c.) as well as substances which have a poor oral
bioavailability. In recent studies salmon calcitonin (sCT) [31] and insulin [25, 33, 36, 42, 48] are
primarily used as active substances, but also other peptides and proteins like leuprolide [32],
interferon alpha (IFN-) [35], erythropoietin (EPO) [37], and recombinant human granulocyte
colony-stimulating factor (G-CSF) [46] have been investigated. Additionally, low molecular weight
model substances like fluorescein, caffeine, metronidazole, and dextran with varying molecular
size are used [1, 38, 39, 43, 44, 54]. However, only dissolution of active substance and not the
uniformity of drug content was determined in most of these studies. So, a deviation between
declared and applied dose is possible resulting in a variability of absorption behavior after
application of dosage forms. Certainly, the majority of the reported studies are focused on the
relationship between drug absorption and wafer structure and/or formulation. The composition of
different wafers used for a selection of studies regarding intestinal wafers is summarized in table 3.
Eiamtrakarn et al. [45] investigated the influence of different pH-sensitive polymers on transit time,
retention time and effectivity of mucoadhesion of wafers in rat intestine. For this purpose the
authors used GI-MAPS with a pH-sensitive layer either prepared of HP-55, Eudragit L100 or
Eudragit S100. Each time ten wafers were administrated through a surgical cut into the stomach
near the pylorus. The rats (male, Wistar rats, 350 10 g) were sacrified after 1, 2, 3, 4, 5 or 6 h
and the wafers were localized after abdominal incision. It was observed that GI-MAPS with HP-55
adhered in duodenum and retained there for 3 h before migrating to deeper segments. Wafer
formulations with Eudragit L100 needed a transit time of 1-2 h to pass the duodenum and
adhered in the jejunum for 2 h, whereas formulations containing Eudragit S100 remained for 2 h
in jejunum and for further 4 h in the ileum. The authors state that because of the increased pH in
distal parts of the GIT, pH-sensitive polymers dissolve in different compartments and the wafers
showed varying transit times. In a subsequent study the influence of different pH-sensitive
polymers on drug release of the same wafer formulations was determined [46]. Wafers were orally
administrated to beagle dogs (male, 10-12.1 kg) using an enteric capsule. As model drug
substances fluorescein and G-CSF were used. The first appearance (ti) of fluorescein in blood
plasma, maximum plasma concentration (cmax), and time point of maximum plasma concentration
(tmax) were determined. All formulations provided comparable values for cmax. However, ti and tmay
were dependent on the pH sensitivity of the polymers. After administration of wafers containing
G-CSF total white blood cell count (WBC) was determined. The WBC had the highest increase
after administration of the wafer with Eudragit L100, followed by Eudragit S100 and HP-55. It
was assumed that one reason could be that wafers are not able to adhere to mucosa before the
pH-sensitive layer is dissolved. GI-MAPS containing Eudragit L100 showed about 70 % increase
of WBC count whilst a 400 % increase was observed after intravenous injection of the identical
dose of G-CSF. Unfortunately, the authors did not include G-CSF formulated as tablet or capsule
in this study in order to evaluate the superiority of wafer compared to conventional oral dosage
forms.
Indeed, Eiamtrakarn et al. [38, 39] compared the drug absorption from wafers with conventional
dosage forms in two different studies. Drug loaded mucoadhesive patches of 3 mm diameter were
administrated as enteric capsules to human volunteers. In the first study, a solution was used as
conventional dosage form with caffeine as model active substance [38]. Pharmacokinetic
parameters in fasted state and after food intake were compared. Under fasting state intake
conditions it was found that the wafers provided a decreased cmax, an increased tmax and a longer
retention time in blood plasma compared to drug solution. After food intake wafers yielded an
increased cmax, an only marginally increased tmax and an increased retention time. The comparison
of the wafer data between fasted and fed state provided that cmax and tmax increased with food
intake but the retention time decreased. The authors state that a reason for that could be the
interactions of mucoadhesive material with food. In the second study, Eaimtrakarn et al. [39]
determined the dissolution and absorption of fluorescein and FITC-dextran from threelayered
wafers and microcrystalline cellulose (MCC) tablets in vitro and in vivo. In vitro setups were
examined in paddle apparatus using 900 mL phosphate buffer pH 7.4 at 37 C, showing slower
drug release from wafers compared to tablets. One reason for this dissolution behavior could be
the formulation of the tablets with MCC only and the use of Carbopol 974P for preparation of the
drug-loaded layer of the wafers. But the authors do not discuss these results. It is to comment
critically that Carbopol 974P is utilized for preparation of extended release dosage forms because
it produces viscous gels after contact with aqueous liquids. In contrast, MCC is applied by
formulation of fast release dosage forms, because it quickly disintegrates after contact with
aqueous liquids. Additionally, the drug-loaded layer of the wafers is covered by a water-insoluble
layer of ethyl cellulose and a pH-sensitive layer of hydroxypropyl methylcellulose phthalate
(HP-55). This wafer formulation results in a delayed contact between drug-loaded layer of the
wafer and dissolution medium and a smaller contact area compared to the tablet. A more
comparable tablet formulation should be an extended release formulation which for example
consists of Carbopol 974P covered with HP-55.
For the in vivo setup beagle dogs (adults, 10.3-12.7 kg) and the same threelayered wafer
formulations and MCC tablets were used by Eaimtrakarn et al. [39]. The similar tendency of slower
release from the wafers compared to tablets was observed by the authors. Briefly, application via
wafers was associated with an increased area under the plasma concentration versus time curve
(AUC) and a 1.4-1.5 times longer residence time in blood plasma compared to conventional
tablets. A reason for that could be the increased retention time in the small intestine due to
mucoadhesive properties of the wafers. However, it has to be considered that Eaimtrakarn et al.
used different wafer structures, active substances, analytical methods, and species in all studies.
Anyhow, the results indicate that their wafers provide a continuous drug release over several
hours.
Threelayered wafers were also investigated by Ito et al. [35]. The wafers consisted of a
water-insoluble, a pH-sensitive and a drug-loaded layer, with IFN- as active substance. The effect
of different absorption enhancers (Gelucire 44/14, Labrasol and HCO-60), which were
incorporated into the drug-loaded layer, was investigated in vitro and in vivo. As reference an
IFN- solution as subcutaneous injection was used. All formulations yielded a complete drug
release within 30 min. The rate of release was depending on the absorption enhancer. The in vivo
studies were performed in rats (male, Wistar rats, 375-400 g), in which the wafers were
administrated after surgical incision directly into the small intestine and solutions were injected
subcutaneously, determining pharmacokinetic parameters in blood serum afterwards. The wafers
showed an increased cmax and a longer retention time compared to the application in solution.
Furthermore, wafers showed a higher relative bioavailability, which was explained with the
increased retention time in the small intestine enabling longer drug absorption.
The influence of contact area size between wafer and intestinal mucosa as well as the local drug
concentration gradient has been investigated by Teutinico et al. [32], using twolayered wafers
containing a drug-loaded, mucoadhesive and a water-insoluble layer. Leuprolide was used as the
active substance. The degree of drug permeation through intestinal rat mucosa was analyzed
using the Ussing chamber. The applied dose was constant and given either in solution or split up
into 2, 4, or 6 wafers. This study shows that wafers had an increased permeation rate compared to
solution. An explanation could be that wafers induced a much higher local drug concentration
gradient at the mucosa. Splitting the dose to 2, 4 or 6 wafers had no influence on the permeation
rate. Teutinico et al. [32] suggested a correlation between contact area size and drug
concentration.
In a study carried out by Gupta et al. [31] drug absorption from twolayered wafers, named intestinal
patches, was investigated using sCT as active substance. Intestinal patches consisting of a
drug-loaded, mucoadhesive and a water-insoluble, impermeable layer were used. The in vitro
dissolution in beaker filled with 10 mL phosphate buffered saline (PBS) pH 7.4 at room
temperature provided a cumulative release of 75 % of sCT within 5 h of incubation under slight
shaking. The main release started after about 3 h because of time-dependent swelling properties
and disintegration rates of the polymeric matrix. Drug transport through Caco-2 monolayer was
increased for wafers compared to solution.
Gupta et al. [31] performed also rat studies (adult, male, Sprague-Dawley, 275-300 g). The
twolayered wafers (3 mg sCT/kg) were administrated either after surgical incision or oral ingestion
of wafers filled into enteric capsules. Three control groups were included: placebo-wafer, direct
intestinal administration of sCT solution (3 mg/kg) and subcutaneous injection of sCT solution
(0.15 mg/kg). The pharmacokinetic and pharmacodynamic parameters determined in blood plasma
provided that the wafers which were orally administered as enteric coated capsule or directly
applied into the small intestine showed a higher cmax as well as a higher relative bioavailability
compared to intestinal instillation of the drug in solution. However, compared to subcutaneous
injection the wafer showed despite the 20times higher dose a lower cmax. The wafer formulation
showed a pharmacodynamic effect that was comparable to the subcutaneous injection and clearly
higher than the effect observed after intestinal instillation of the solution.
Kalavadia et al. [54] performed a pharmacokinetic study with twolayered wafers, named
gastrointestinal mucoadhesive patch (GMP), consisting of a drug-loaded, mucoadhesive and a
water-impermeable backing layer and using as active substance FITC-dextran which was
incorporated into the mucoadhesive layer either directly or as chitosan nanoparticles. The wafers
were filled into enteric capsules and orally administered to rabbits (New Zealand white rabbits,
1.00-1.25 kg). As a reference FITC-dextran solution was used. GMPs containing the FITC-dextran
nanoparticles showed a higher AUC and cmax compared to wafers where FITC-dextran was directly
incorporated. After oral administration in solution no active substance was detected in blood.

In conclusion, most of these studies demonstrated that wafers are superior compared to
conventional oral dosage forms like tablets and solutions, but they present no superiority compared
to parenteral administration. Further, the studies indicate that wafers are suitable for oral
biomolecule delivery. Despite, some research groups used low molecular weight substances like
fluorescein, caffeine and metronidazole to compare drug absorption after application of wafers and
reference dosage forms. It is to consider that their results may not be representative for peptides
and proteins as high weight biomolecules are most likely absorbed by other mechanism.
As main reasons for the improved drug absorption the authors discuss different factors. These
factors include direct contact of the wafer with intestinal mucosa, high local concentration gradients
resulting in increased drug transport, a prolonged retention time at the site of application and by
this an extension of the time available for drug absorption and the absence of dilution of active
substances in the gastrointestinal fluids.

6. Concluding remarks
Wafers are preferentially investigated to overcome the main problems faced by oral delivery of
difficult APIs for example large biomolecules like peptides, proteins and recombinant therapeutic
agents as poor bioavailability and large variability. Several studies in different species including
humans prove their efficacy as oral dosage form and their principal suitability for delivery of model
substances and oral biomolecules. However, the critical issue of high variability has still to be
addressed. Furthermore, available studies mainly focus on intestinal, sustained release wafers and
authors do not control whether the wafer is in contact with the application site or not.
Consequently, more research is necessary in terms of controlling and ensuring the intestinal
performance with respect to drug delivery rates as well as the control of the location and duration
of mucosal adhesion.

Conflict of interest
The authors report no conflict of interest.

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Figure captions
Figure 1: Schematic drawing of cross-section of the small intestinal wall of humans (modified after
[13]).

Figure 2: Examples of different intestinal wafer structures shown in cross-section.

Figure 3: Methods for the evaluation of mucoadhesive properties. (A) texture analyzer; (B) flow
through method; (C) peeling off methods (C1 shear, C2 rupture, and C3 detachment).
Table 1: Overview of wafer types, properties and preferred application sites (modified after [8, 9]).
Type Rapid disintegrating Sustained release
Meltaway wafer
Parameter wafer wafer
Surface (cm) 2-10 2-10 2-4
Thickness (m) 20-70 50-500 50-250
Multilayered, often with
Structure Single- or multilayered Single- or multilayered water-insoluble
backing layer
Oral (lingual, Oral (lingual,
Oral (lingual,
Application site sublingual, buccal), sublingual, buccal),
sublingual), vaginal
vaginal, intestinal vaginal, intestinal
Site of action Local and systemic Local and systemic (Local) and systemic
Maximum: 60 s
Formation of a
(special type: quick
Disintegration time mucoadhesive gel Maximum: 5-10 h
dissolving wafer
depot within 5-30 min
max. 10 min)

Table 2: Parameters and methods to characterize intestinal wafers

Parameter Methods References
Appereance
- Visual
Color, transparency, - Light microscopy
[1, 9, 25, 31, 42, 48]
surface morphology - Fluorescence microscopy
- Scanning electron microscopy (SEM)
Uniformity of mass (mg) - Balance [9, 43]
Content Uniformity [30]
Thickness (m or mm) - Micrometer [1, 9, 30, 37]
Mechanical properties
- Texture Analyzer
- Instron Tensile Strenght Tester
- Instron 5848 Microtester
- Instron Universal Testing Instrument

Tensile strenght (MPa), Expanding wafer at a defined speed and determining load (F, N)
elongation at break and elongation (l1) at rupture point [9, 30, 54]
(mm or %)
load )
a)
cross section mm )

elongation mm)
1
original leng t mm)
Folding endurance in mano - folding repeatedly in one place until break [1]
Performance parameters
Determining weight gain after submerging in medium
[9, 30, 34, 41, 42, 43, 48,
Swelling index S mg) initial mg)
s ollen a er 51]
initial mg)
- Arizona Instruments VaporPro System
- Karl Fischer titration
Moisture content (% (w/w)) [9, 30, 54]
- Loss on drying (storage in a desiccator)
- Thermogravimetric analysis

In vitro and ex vivo:
dissolution,
(unidirectional) drug
transport,
drug permeability
In vivo drug absorption
Mucadhesion
Tissue histology
Storage stability
- USP apparatus 2 Paddle [38, 39]
- USP apparatus 1 Basket [30]
- Beaker method [31, 34, 36, 42, 43]
- Caco-2 monolayer [31]
- Different, partly modified diffusion cells and dialysis cells [1, 25, 32, 35, 40, 41, 42,
43, 48, 54]
Measuring pharmacokinetic and pharmacodynamic parameters
[30, 33, 35, 36, 37, 38, 39,
in blood where wafer is applicate after surgical intervention or
44, 46, 54]
through swallowing
- Modifizied mikroforce/torsion balance and Texture Analyzer:
Measuring load that is required to break bond between wafer
and mucosal tissue
- Flow Through Method: Placing wafer on tissue, rinsing tissue
by medium and determining retention time and/or rinsed drug
amount
- USP apparatus 3 - rotating cylinder: Measuring retention time [1, 7, 25, 31, 33, 41, 42,
on cylinder in medium 43, 44, 45, 48, 51, 54]
- Rheometer: Dissolving/ dispersing wafer in mucus/mucin
solution and measuring viscosity
- Atomic Force Microscopy (AFM): Determing change in surface
roughness due to polymer binding to mucosa
- In vivo: Determination of retention and/or transit time in the
small intestine after surgical incision
- (Light)Mikroskopy
[33, 35, 37, 48]
- Different cell assays
Storage at different conditions and evaluation of appearance
[1, 9]
and drug content

Table 3: Studies focusing on intestinal wafers (*n.a. not available)

Backing Mucoadhesive pH-sensitive
Author/Year API Middle layer
layer layer layer
Singlelayered wafer
[30] Glipizide - HPC, PEG 400 - -
Twolayered wafers
Fluorescein-
Carbopol 934 P-NF,
[54] Isothiocyanate EC, TEC - -
PEG
(FITC)-dextran

Calcitonin, salmon Carbopol 934,
[31] EC - -
(sCT) pectin, SCMC (1:1:2)
Fluorescein-
Isothiocyanate Chitosan, HEC, HPC,
[25] EC - -
(FITC)-labeled CMC or Carbopol
insulin
[32] Leuprolide n.a.* n.a.* - -
Chitosan-EDTA,
drug-loaded
[48] Insulin EC, glycerin
Chitosan-grafted
nanoparticles

Carbopol 934,
[33] Insulin EC - -
pectin, SCMC (1:1:2)
Threelayered wafers

Eudragit L1005
Salmonella Eudragit L100
Dried bacterial 5 (1:1) blend,
[55] typhimurium Stamm 55 (1:1) blend, -
cell film TEC, Cholesty-
SL3261 TEC
ramine

- Bifidobacterium Eudragit L100
breve 55 (1:1) or
[34] - HPMC -
- Salmonella Eudragit -EC
typhmurium blends, TEC

Carbopol 940,
EC, HPMC, pectin, PEG,
[1] Metronidazole - CAP, PEG
HCO-60 drug-loaded
microspheres
 PCP-cysteine
Eudragit
[36] Insulin EC conjugate, -
L100-55
glutathione, mannitol

1. Labrasol , SLS

2. Gelucire 44/14,

Pharmasol Eudragit L100,
[37] Erythropoietin (EPO) CA, TEC -
3. HCO-60 , TEC
citric acid, gelati

1. Gelucire 44/14
2. Labrasol, SLS

Interferon alpha 3. HCO-60 , Eudragit L100,
[35] CA, TEC -
(IFN-) citric acid TEC
4. Gelucire 44/14,
Pharmasol
- acid orange 8
[41] - bovine serum PHEMA PVA, Carbopol 934 PMAA, PHEMA -
albumin (BSA)

- Fluorescein Carbopol 974P, CA,
[39] EC - HP-55
- FITC-dextran HCO-60

Carbopol 974P-NF,
Eudragit L100,
[38] Caffeine EC HCO-60 , sodium -
PEG 400
salicylate
Cross-linked
- Sulforhodamine B
Carbopol 934, bovine serum
[40] - Phenol red EC -
pectin albumin
- Dextran
microspheres

Continuation of Table 3.
Backing Mucoadhesive pH-sensitive
Author/Year API Middle layer
layer layer layer
Threelayered wafers
HA-Cym,
cross-linked
HA-Cym and
PVA with
[42] Insulin HA-Cym, PVA uncross-linked -
glutaraldehyde
PVA
as crossing
agent
Fourlayered wafers
Lactose, starch,
PCP-Cys, mannitol,
[44] FITC-Dextran EC con ectioners Eudragit L100
glutathione
sugar
Lactose, starch,
Ch-GSH, unbound
[43] FD4 EC con ectioners Eudragit L100
GSH
sugar

drug-loaded Eudragit L100,
- Fluorescein Hiviswako 103,
[45, 46] EC, TEC cellulose Eudragit S100
- G-CSF PEG400
membrane or HP-55 , TEC

API-Active pharmaceutical ingredient, CACellulose acetate, CAPCellulose acetate phthalate, Ch-GSHChitosan-Glutathione,

ECEthyl cellulose, G-CSF-recombinant human granulocyte colony-stimulating factor, HA-CymHyaluronic acid cysteamine,
HCOhydrated castor oil, HECHydroxyethyl cellulose, HPHydroxypropyl methylcellulose phthalate, HPCHydroxypropyl
cellulose, HPMCHydroxypropyl methylcellulose, SCMCSodium Carboxymethyl cellulose, PCP-Cy Polycarbophil-Cysteine,
PEGPolyethylene glycol, PHEMA-Polyhydroxyethylmethacrylate, PMAA-Polymethylmethacrylate, PVAPolyvinyl alkohol, SLS
Sodium laurylsulfate, TECTriethyl citrate
Graphical abstract