Bioequivalence of Two Perampanel Oral Suspension Formulations in Healthy Subjects: A Randomized Crossover Study

Abstract

Background and Objective

Perampanel has been approved for the adjunctive treatment of partial-onset seizures and primary generalized tonic-clonic seizures. The oral suspension formulation benefits patients who have difficulty swallowing tablets. The unavailability of an affordable generic perampanel oral suspension formulation increased the need for a cheaper bioequivalent alternative to the marketed reference product. The study aimed to assess the bioequivalence of two formulations of perampanel oral suspension (0.5 mg/mL) administered under fasting conditions focusing on providing a cost-effective and accessible alternative to current formulations.

Methods

This was an open-label, two-period, two-sequence, crossover, bioequivalence study conducted under fasting conditions. Healthy subjects were randomized to receive single doses of perampanel oral suspension (12 mg), Lepsiramp and Fycompa^® separated by a 6-week washout period. The maximum concentration and area under the concentration–time curve up to 72 h were the primary pharmacokinetic parameters used to assess bioequivalence.

Results

The geometric mean ratio of test to reference formulations and 90% confidence interval were 109.55 (99.49–120.64) for maximum concentration and 98.15 (90.68–106.23) for the area under the concentration–time curve up to 72 h_, which were within the 80–125% bioequivalence range. The adverse events were mild headache and dizziness.

Conclusions

The two oral suspension formulations were bioequivalent, safe, and well tolerated. This provides a beneficial affordable alternative for patients requiring non-tablet oral formulations.

Clinical Trial Registration

The ClinicalTrials.gov registration number is NCT06969963, retrospectively registered on 13 May, 2025.

Key Points

Both suspensions had similar absorption and exposure.

Both formulations were safe and well tolerated.

The generic suspension provides a cheaper accessible option for patients unable to swallow tablets.

Introduction

Epilepsy is a chronic non-communicable brain disease that affects approximately 50 million people worldwide. Most affected patients live in low-to-middle income countries and suffer from multiple psychological, physical, and social consequences, making the disease a significant health burden [1, 2]. Perampanel, a third-generation anticonvulsant, is classified as an AMPA receptor antagonist that targets α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors [3]. In 2012, the drug was approved in the USA as a once-daily oral therapy (adjunctive and monotherapy) for the management of focal-onset seizures with or without secondarily generalized seizures for patients with epilepsy aged 4 years and more in addition to its use as adjunctive therapy for primary generalized tonic-clonic seizures in patients aged 12 years and more [1, 4, 5].

Following oral administration, perampanel is readily absorbed without marked first-pass metabolism. Despite the administration of perampanel tablets with a high-fat meal having no impact on both the peak plasma concentration (C_max) and the total exposure (area under the plasma concentration–time curve up to infinity), the time to reach C_max (T_max) was delayed by approximately 1 hour in healthy subjects and reached 0.5–2 hours in patients with epilepsy. The drug is 95% bound to plasma proteins with an elimination half-life (t_1/2) of 105 hours. It is extensively metabolized via primary oxidation and sequential glucuronidation. Its metabolism is mediated mainly by cytochrome P450 3A and approximately 70% of the drug is recovered in the feces and 30% in the urine as a mixture of oxidative and conjugated metabolites. Perampanel pharmacokinetics show dose linearity over the range of 0.2–36 mg [5–7].

Bioequivalence studies are performed to allow interchangeability between different formulations with the same active pharmaceutical ingredients. Both reference and test formulations are tested using the same experimental design and conditions to confirm their equivalent bioavailability and that they have no significant difference in their rate and extent of drug absorption [8]. There is a constant demand for generic drugs, which are generally more affordable and cost effective while being equally as effective as the original products. The presence of an oral suspension formulation at a lower cost provides an advantage for patients who have difficulty swallowing the tablet formulation, such as children and elderly individuals [9]. Therefore, this study aimed to assess the bioequivalence of two formulations of perampanel oral suspension (0.5 mg/mL) administered under fasting conditions with a focus on providing a cost-effective, accessible, generic oral suspension as an alternative to the current marketed perampanel oral suspension formulations.

Methods

Study Population

All phases of the bioequivalence study were conducted at the Advanced Research Center (ARC), Cairo, Egypt, between January and April 2024. The study protocol was approved by the Independent Ethics Committee (IEC) of ARC on 17 February, 2024 (IEC No.: IEC_170224_01). The ClinicalTrials.gov registration number is NCT06969963, retrospectively registered on 13 May, 2025. All procedures conducted in the study involving human participants adhered to the ethical standards set by the institutional committee, the Guidelines for Good Clinical Practice of the International Conference on Harmonisation [10], and the 1964 Helsinki Declaration [11] along with its subsequent amendments or other comparable ethical standards. Prior to the initiation of the study procedures, written informed consent was obtained from all participants. The form was thoroughly explained to all participants prior to signing, ensuring they understood the nature, purpose, benefits, and potential risks of the study. Biological data and materials were used only for the specific purposes of the present study, maintaining the confidentiality of the subjects’ data.

The study was carried out on healthy male and female subjects aged 18–55 years with a body mass index of ≥ 18.5 to < 30 kg/m². In this study, subjects were recruited if they were in good health or had no clinically significant illness identified at the principal investigator’s discretion or through assessments, including medical history, electrocardiograms, vital signs, physical examinations, anthropometric measurements, and laboratory tests with negative test results for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and drug abuse. For female individuals, they consented to use an adequate contraception method during the study and for at least 30 days after the study. Subjects were excluded if they were allergic to the study medication, had signs or symptoms of organ dysfunction, had a history of severe diseases that have a direct impact on the study, had abnormal results of laboratory tests, had a history of drug or alcohol abuse, were heavy smokers, were pregnant or lactating, and used any systemic medications within 2 weeks or six elimination half-lives, whichever was longer.

Drug Products

In this study, the test product was Lepsiramp (perampanel 0.5 mg/mL) oral suspension (batch no. 23115001, expiry date: July 2025) manufactured by Global Napi Pharmaceuticals for Global Advanced Pharmaceuticals, Cairo, Egypt, compared to the reference product; Fycompa^® (perampanel 0.5 mg/mL) oral suspension (batch no. 142074, expiry date: September 2025) manufactured by Eisai GmbH, Edmund Rumpler, Germany. In vitro testing was carried out prior to the initiation of the clinical phase with the above-mentioned batches, which confirmed the in vitro pharmaceutical equivalence of both products.

Study Design

This was a single-center, open-label, randomized, single-dose, two-sequence, two-period, crossover, bioequivalence trial conducted under fasting conditions with healthy participants. The pre-randomization phase of the study consisted of a screening period (between day − 30 and day − 3) and baseline period 1 (day − 1, i.e., the day prior to drug administration in the first treatment period). Subjects who completed the pre-randomization phase and fulfilled the inclusion/exclusion criteria could enter the randomization phase. The randomization phase consisted of two periods separated by a 6-week washout period, followed by a follow-up period after the last dose of the study drug (day 46 of the study).

In each study period, the subjects were randomized in a 1:1 allocation to receive 24 mL of either the test or reference product under fasting conditions (TR-RT) (Fig. 1). The randomization plan was prepared considering the planned number of subjects calculated in the study protocol, number of treatments, and study design. The randomization was performed using the R statistical software (version 4.2.1).

Fig. 1.

Summary of perampanel oral suspension (0.5 mg/mL) bioequivalence study periods

Participants fasted for no less than 10 h overnight prior to receiving a single dose of perampanel. In the morning of each study period, fluids were not allowed 1 hour prior to the dose. Then, a single dose (24 mL containing 12 mg perampanel) of either the test or reference product was administered orally with 240 mL of water. One-hour post-dose, fluids administration was allowed again. In order to ensure consistency across treatment groups, all participants followed the same standardized diet during each study period, with food and beverages provided at the same time during each study period. The first and second meals were administered 4 and 8 hours after drug administration, respectively.

Pharmacokinetic Analysis

In each study period, a total of 22 blood samples (5 mL each) were collected in EDTA-treated tubes according to the following sampling schedule (pre-dose [t = 0], 0.25, 0.5, 0.75, 1, 1.25, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 8, 10, 12 [day 1], 24 [day 2], 48 [day 3], and 72 hours [day 4] post-dose). Any deviation from the nominal sampling times was accurately recorded and the calculations of the pharmacokinetic (PK) analysis were performed based on the actual time of blood sampling. Samples were collected over 24 h via a cannula inserted into the forearm vein of the subjects. Samples were collected at 24, 48, and 72 hours through venipuncture. After collection, the blood samples were immediately centrifuged for 5 min at 3500 rpm at 4 °C using a PRO-analytical centrifuge (Centurion Scientific Limited-PRO-Analytical CR2000; PRO Analytical Cooling, Chichester, UK). After centrifugation, plasma samples were transferred into labeled plastic tubes that were then stored at the trial site at −80 °C pending analysis.

A non-compartmental PK analysis was performed using Phoenix WinNonlin version 8.3.4 (Certara, NJ, USA) to estimate the primary and secondary PK parameters. The primary PK parameters, which reflect the rate and extent of drug absorption, included C_max and the area under the plasma concentration–time curve up to 72 h (AUC_0–72). The AUC was truncated up to 72 h for perampanel and AUC_0–72 was used instead of area under the plasma concentration–time curve up to infinity because of the long half-life of the drug [4]. The secondary PK parameters included the T_max, area under the plasma concentration–time curve up to infinity, and terminal t_1/2. The elimination rate constant (k_e) was estimated from the slope of the logarithmic concentration versus the time plot. The t_1/2 was calculated using the equation t_1/2 = Ln (2)/kel.

Bioequivalence Evaluation

The primary outcome was the assessment of the bioequivalence of test and reference products. According to the US Food and Drug Administration guidance for bioequivalence, the PK parameters of interest for dose suitability were the drug systemic exposure parameters, AUC_0–t, and C_max [12]. The linear trapezoidal rule was used to calculate the area under the concentration–time curve. The median value and range were calculated for T_max. For the rest of the PK parameters, the geometric mean, after log-transformation of the data, in addition to the arithmetic mean were calculated. For AUC_0–72 and C_max parameters, the geometric mean ratio (GMR%) and their corresponding 90% confidence interval (CI) were calculated for comparisons between both test and reference products in each study period. The two formulations were considered bioequivalent if the 90% CI of the test to reference GMR of AUC_0–72 and C_max did not exceed the bioequivalence acceptance boundaries of 80.00–125.00% [12].

Bioanalytical Method

Bioanalysis was performed at ARC, Cairo, Egypt. Liquid chromatography coupled with tandem mass spectrometry was performed using Acquity UPLC/XEVO TQD Triple Quadruple Mass spectrometry (Xevo TQD, Dublin, Ireland). A quantitative assay for perampanel in human plasma was achieved using a fully validated bioanalytical method.

Chromatographic separation was accomplished by Acquity UPLC BEH C₁₈ (50 × 2.1 mm, 1.7 μm) at a column temperature of 45 °C with a flow rate of 0.3 mL/min. The mobile phase was (10 mM of ammonium formate and 0.1% formic acid): acetonitrile (55:45 v/v). Deuterated perampanel (perampanel-d5) was used as an internal standard for quantifying perampanel.

The mode used for detecting the ions was multiple reaction monitoring by monitoring the transition pairs of m/z 350 to 219 for perampanel and m/z 355 to 220 for perampanel-d5. The calibration curves were linear covering the range of 3–400 ng/mL for perampanel. The precision and accuracy values for the lower limit of quantification were acceptable, with accuracy that ranged from 94.55 to 105.13%. This bioanalytical method was validated following Food and Drug Administration guidance for industry on bioanalytical method validation in terms of selectivity, precision, accuracy, linearity, calibration curve, stability, and carry-over [13, 14].

Safety Evaluation

During the whole study period, all participants were monitored and observed closely for drug safety. The principal investigator asked the participants every hour if they experienced any adverse events in addition to informing them to promptly report any unfavorable adverse events they might experience during the study. In addition, vital signs, including blood pressure, pulse rate, respiratory rate, and temperature, were measured pre-dose and at 2, 6, 12, and 72 h post-dose. By the end of the study period, a complete blood count was performed on all subjects included in the study. In cases where adverse events occurred, the principal investigator assessed each adverse event in terms of seriousness, severity (mild, moderate, or severe), and drug causality. As the drug has a moderate influence on the ability to drive and use machines and may cause dizziness and somnolence, subject alertness was checked during each study period before leaving the trial site [6].

Statistical Analysis

The sample size was calculated using R software (version 4.2.1) based on published data of intra-subject variability for C_max of perampanel of 19.35% [15], significance level (α) of 5%, power of 80%, and also taking into account the dropouts and exclusions to guarantee the reliability of the statistical results. Two one-sided tests for bioequivalence were used and the 90% CIs for the difference between the means of drug formulations were calculated for the PK parameters of perampanel using log-transformed data. The non-parametric Wilcoxon signed-rank test was used for T_max for the two formulations, and P < 0.05 was considered statistically significant. To evaluate the sequence, treatment, and period effects, an analysis of variance test was conducted on the C_max and AUC_0–72 parameters and their log-transformed values. This analysis allowed for a comprehensive examination of potential variations related to the sequence of administration, treatment received, and specific period under consideration.

Results

Study Population

A total of 26 subjects were randomized, enrolled, and completed the study. The eligible subjects were adults of both sexes (19 male individuals and 7 non-pregnant, non-lactating female individuals) with a mean age of 31.04 ± 8.97 years, a mean height of 167.19 ± 9.14 cm, a mean body mass index of 26.37 ± 2.67 kg/m², and a mean weight of 73.73 ± 9.81 kg. The demographic and baseline characteristics of the included subjects are summarized in Table 1.

Table 1.

Summary of demographics and baseline laboratory parameters

Parameter (unit)	Value	Parameter (unit)	Value
Age (years)	31.04 ± 8.97	Blood urea (mg/dL)	24.38 ± 7.64
Height (cm)	167.19 ± 9.14	Creatinine (mg/dL)	0.78 ± 0.17
Weight (kg)	73.74 ± 9.81	Sodium (mEq/L)	140.69 ± 1.46
BMI (kg/m2)	26.38 ± 2.72	Potassium (mEq/L)	4.79 ± 0.52
Hb (g/dL)	13.94 ± 1.29	Total bilirubin (mg/dL)	0.41 ± 0.22
RBCs (106/mm3)	5.14 ± 0.44	ALP (U/L)	80.27 ± 17.86
Hct (%)	41.35 ± 3.43	Total protein (g/dL)	7.69 ± 0.36
Platelet count (103/mm3)	265.54 ± 63.24	Cholesterol (mg/dL)	171.73 ± 28.4
WBCs (103/mm3)	6.6 ± 1.95	Triglycerides (mg/dL)	123.04 ± 66.77
Random blood glucose (mg/dL)	88.73 ± 10.03	HDL-cholesterol (mg/dL)	45.77 ± 9.28
ALT (U/L)	22.15 ± 9.87	LDL-cholesterol (mg/dL)	101.42 ± 20.14
AST (U/L)	21.42 ± 6.59

Data are presented as mean ± standard deviation

ALP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, BMI body mass index, Hb hemoglobin, Hc hematocrit, HDL high-density lipoprotein, LDL low-density lipoprotein, RBCs red blood cells, WBCs white blood cells

Pharmacokinetics

The PK analysis comprised 26 subjects who completed both treatments and had sufficient plasma perampanel concentrations for a PK evaluation. The mean plasma concentration–time profiles of perampanel following oral administration of 24 mL of lepsiramp (test) 0.5 mg/mL oral suspension and 24 mL of Fycompa^® (reference) 0.5-mg/mL oral suspension to 26 Egyptian healthy subjects under fasting conditions are presented in Fig. 2. Following the administration of test and reference formulations to 26 healthy subjects, the mean C_max of perampanel was 379.67 ± 113.59 and 345.44 ± 95.74 ng/mL, respectively, AUC_0–72 was 10310.01 ± 3012.19 and 10417.85 ± 2602.39 ng.h/mL, respectively, and the median (range) T_max was 1.78 (0.5–4.5) and 2.30 (0.75–4.5) hours, respectively. The summary of the primary and secondary PK parameters for both the reference and test products is presented in Table 2.

Fig. 2.

Mean plasma concentration–time profile of the perampanel 0.5-mg/mL oral suspension following oral administration of 24 mL of both Lepsiramp (test) and Fycompa^® (reference) to healthy subjects under fasting conditions. hr hour

Table 2.

Summary of PK parameters of perampanel following administration of a single oral dose of Lepsiramp oral suspension (test) and Fycompa^® (reference) products in Egyptian healthy volunteers

PK parameter, unit	Test	Reference
Cmax, ng/mL	379.67 ± 113.59	345.44 ± 95.75
Clast, ng/mL	101.69 ± 45.62	101.82 ± 38.31
Tmax, h	1.5 (0.5–4.5)	2.5 (0.75–4.5)
AUC0–72, ng·h/mL	10310.01 ± 3012.19	10417.85 ± 2602.39
AUC0–inf ng·h/mL	30586.71 ± 24982.08	33370.68 ± 33620.29
t1/2, h	112.36 ± 99.09	130.42 ± 147.03
Ke, h−1	0.01062 ± 0.01	0.00982 ± 0.007

Data are presented as mean ± standard deviation, except for T_max, which are median (range)

AUC_0–72 area under the plasma concentration–time curve up to the 72 h, AUC_0–inf area under the plasma concentration–time curve up to infinity, C_last the last quantifiable plasma concentration, C_max maximum plasma concentration, K_e elimination rate constant, PK pharmacokinetic, t_1/2 elimination half-life, T_max time to reach C_max

Bioequivalence and Statistical Analysis:

The results of the bioequivalence evaluation of the two formulations are presented in Table 3. The GMR% of test to reference formulations for perampanel and 90% CI were 109.55 (99.49–120.64) for C_max and 98.15 (90.68–106.23) for AUC_0–72, which were both within the predefined acceptance bioequivalence range of 80.00–125.00. The intra-subject variability CV% of perampanel was 12.73% for AUC_0–72 and 19.35% for C_max. It has been shown that there was no statistically significant difference between treatments for logarithmically Ln-transformed C_max, and AUC_0–72 (P = 0.1184, and P = 0.6898, respectively, analysis of variance). There was no period or formulation effect on ln (AUC_0–72), and ln (C_max) [P > 0.05], indicating that there were no significant differences between the two formulations in AUC and C_max by two one-side t test (TOST). A statistically significant sequence effect was observed ln (AUC_0–72), and ln (C_max) [P < 0.05]. Using a non-parametric test, no significant difference was observed between test and reference formulations regarding T_max (P = 0.0694, Wilcoxon signed-rank test).

Table 3.

Bioequivalence evaluation of perampanel after single oral dose administration of 24 mL of test product (T) Lepsiramp 0.5 mg/mL oral suspension versus 24 mL of reference product (R) Fycompa^® 0.5 mg/mL oral suspension under fasting conditions

PK parameter	Geometric means		GMR% test/reference	90% CI	P value	CVws
	Test Lepsiramp	Reference Fycompa®
Cmax (ng/mL)	364.36	332.595	109.55	99.49–120.64	0.1184	19.35%
AUC0–72 (ng·h/mL)	9891.47	10078.05	98.15	90.68–106.23	0.6898	12.73%

AUC_0–72 area under the concentration–time curve up to 72 hours, CI confidence interval, C_max peak plasma concentration, CV_ws within-subject coefficient of variation, GMR% geometric mean ratio percentage, PK pharmacokinetic

Safety Evaluation

During both study periods, all reported adverse events were mild, related to the study drug, and no serious adverse events were experienced. A summary of the adverse events related to the drug product is presented in Table 4. In the first study period, only six subjects experienced adverse events, including dizziness (4/26, 15.38%), headache (1/26, 3.84%), and nausea (1/26, 3.84%). In the second study period, only three subjects experienced adverse events, including headache (1/26, 3.84%), nausea (1/26, 3.84%), and hallucinations (1/26, 3.84%). During the follow-up period, the complete blood count results showed that only seven patients experienced adverse events, including low hemoglobin levels (6/26, 23.08%), low red blood cell counts (2/26, 7.69%), and low white blood cell counts (1/26, 3.85%). All these complete blood count-related adverse events were mild except for one subject who experienced a moderate decrease in hemoglobin levels, for which he was prescribed the appropriate medication by the end of the study. All vital signs including blood pressure, pulse rate, respiratory rate, and body temperature were normal during both study periods.

Table 4.

List of adverse events with relation to the drug product (0.5-mg/mL oral suspension)

Study drug	Adverse events	No. of subjects (%)	Severity	Causality assessment	Drug attribution
Reference product (Fycompa®)	Headache	1 (3.85%)	Mild	Not serious	Possibly related
	Dizziness	2 (7.69%)
Test product (Lepsiramp)	Headache	1 (3.85%)
	Nausea	2 (7.69%)
	Hallucinations	1 (3.85%)
	Dizziness	2 (7.69%)

Discussion

The perampanel oral suspension formulation was approved in 2016 for the adjunctive treatment of partial-onset seizures as well as primary generalized tonic-clonic seizures in patients aged 12 years and older. Being a beneficial route of administration for children who have difficulty swallowing tablet formulations, it has been approved for children aged 4 years and older with the same dosing recommendation as for adults [16]. The unavailability of an affordable generic oral suspension formulation of perampanel in the Egyptian market prompted the conduct of this study to evaluate Lepsiramp, a generic version of Fycompa^® 0.5 mg/mL oral suspension, for regulatory approval. It has been reported that epilepsy is more prevalent among children and elderly individuals than among adults [17, 18]. Therefore, the presence of an oral suspension formulation is likely to have added value for pediatric and elderly patients with epilepsy who may be in need of a non-tablet oral formulation [19].

In line with the Egyptian Drug Authority guidance for the approval of bioequivalent generic products [20], this study was conducted on 26 healthy Egyptian volunteers under fasting conditions with a 6-week washout period to evaluate the bioequivalence of 12 mg of perampanel in a lepsiramp oral suspension formulation when compared to Fycompa^®, with the consequent approval of lepsiramp in the Egyptian market. The 6-week washout period was chosen based on the long t_1/2 of perampanel (~105 h) [5–7]. Regulatory guidelines recommend a washout of at least five half-lives to avoid carryover effects in crossover designs [12, 21]. Extending the washout to approximately ten half-lives (~6 weeks) provided a conservative margin to ensure complete elimination of perampanel before the subsequent dosing period, thereby minimizing any risk of PK carryover and strengthening the validity of the bioequivalence assessment. It has been observed that the 90% CI of the GMR for C_max and AUC_0–72 met the prespecified bioequivalence acceptance criteria (80.00–125.00%), indicating the bioequivalence of 12 mg of perampanel in the two oral suspension formulations. This finding is in accordance with a previously published bioequivalence study of perampanel, which confirmed the bioequivalence of single doses of perampanel 12 mg in both tablet formulations with an equivalent dose of the oral suspension formulation [22].

Both formulations showed favorable safety and were well tolerated by all enrolled subjects throughout the whole study period. The most commonly reported adverse events were headache and dizziness. However, all reported adverse events were mild in severity, except for one subject who had a moderate decrease in hemoglobin and received the appropriate medication. The vital signs, physical examinations and electrocardiogram findings were normal throughout the study period. No serious adverse events were reported and none of the adverse events required discontinuing any of the study subjects from the study. In agreement with these results, the favorable safety profile was observed among Japanese healthy volunteers receiving bioequivalent 12-mg fine granules and 12-mg oral tablets of perampanel [19]. In addition, consistent safety results and acceptable tolerability were observed among patients experiencing focal seizures or generalized tonic-clonic seizures and receiving a once-daily oral tablet formulation of perampanel [23–26].

Conclusions

The two oral suspension formulations containing 12 mg of perampanel, Lepsiramp and Fycompa^®, were bioequivalent in terms of C_max and AUC_0–72 (0.8–1.25 bioequivalence limit). The drug in both formulations was safe and well tolerated. The approval of the generic oral suspension provides a beneficial lower cost alternative to the marketed Fycompa^® for patients requiring a non-tablet oral formulation.

Funding

This work was supported by Global Napi Pharmaceuticals for Global Advanced Pharmaceuticals, Egypt.

Declarations

Conflict of interest

Aya M. AbdelMagid, Kamal A. Badr, and Mamdouh R. Rezk have no conflicts of interest that are directly relevant to the content of this article. Aya M. AbdelMagid is an Editorial Board member of Drugs in R&D. Aya M. AbdelMagid was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions.

Ethics approval

The study protocol was approved by the Independent Ethics Committee of ARC. The ClinicalTrials.gov registration number is NCT06969963, retrospectively registered on 13 May, 2025. All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional committee, the Guidelines for Good Clinical Practice of the International Conference on Harmonisation, and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent to participate

Prior to the initiation of study procedures, written informed consent was obtained from all participants. The form was explained to all subjects before signing it so that the nature, purpose, benefits, and potential risks of the study were understood.

Consent for publication

Not applicable.

Data availability

Not applicable.

Code availability

Not applicable.

Authors’ contributions

All authors read and approved of the final version of the manuscript. They have made contributions to the conception and design of the study, data analysis, interpretation of the results, drafting the article, revising it critically for important intellectual content, and final approval of the version to be submitted. The authors confirm that no paper mill and artificial intelligence was used.

Dedication

This paper is dedicated to the soul of the late Prof. Dr. Emad B. Basalious (1974–2024), late Professor of Pharmaceutics and Industrial Pharmacy Department, Faculty of Pharmacy, Cairo University.