Risks Associated with Veterinary Compounding Pharmacy Choices (AAEP 2010)
More than 12,000 compounding pharmacies operate in the United States, and each year compounded product sales reach $300 million–25% of that is spent in the animal pharmaceutical industry alone. The Food & Drug Administration (FDA) has developed regulations to provide assurances for safety and efficacy of drugs and devices, to ensure food supply safety, and to regulate food chain supplies and animal foods; so how do these apply to compounding? At the 2010 American Association of Equine Practitioners (AAEP) Convention, held Dec. 4-8 in Baltimore, Md., Scott Stanley, PhD, professor of Equine Analytical Chemistry at the University of California, Davis, discussed FDA’s ongoing attempts to ensure safety of drugs produced by compounding pharmacies (that provide individualized medications ordered by prescribers which are unavailable through normal means).
He described a study conducted by the FDA in which scientists analyzed 29 samples from 12 compounders. Stanley noted that 10 of the samples failed to meet the FDA standard for quality testing (which for potency is ±10% of the labeled concentration), yielding a 34% failure rate as compared to the typical 2% failure rate seen among the entire pharmaceutical industry in general. More than half of the failed samples contained less than 70% of the labeled potency.
Equine practitioners must evaluate the integrity of compounding pharmacies as well as the quality and consistency of drugs produced. Stanley remarked than many practitioners express concerns about efficacy of products that different compounding pharmacies compound, noting that just because a pharmacy prepares a product doesn’t mean that it’s efficacious–what an owner might perceive as a legitimate, reliable source of medication might not always be. In addition, veterinarians must consider the quality (potency, purity, and stability) and consistency of drugs as well as their liabilities for using that particular product.
Stanley explained that the FDA does not permit compounding, but rather uses “enforcement discretion,” meaning that if a product cannot be obtained to control a life-threatening disease process or to control suffering, then use of a compounded product is permitted.
The Animal Medicinal Drug Use Clarification Act (AMDUCA) allows manufacturing, preparation, propagation, processing, and compounding of drugs as long as a product is not already commercially available. In addition, there must be a valid veterinarian-client-patient relationship to dispense these drugs. Three categories of drugs are available for use:
FDA-approved “pioneer” drugs: These are studied through clinical trials that show efficacy, safety, and quality; it often costs $30 million to get a drug through the FDA-approval process;
Generic drugs: These are subjected to an abbreviated process for verifying efficacy–companies must demonstrate that generics are the biologic and/or chemical equivalent of a drug and must meet label claims for that product; and
Compounded drugs.
Compounding a drug is a form of adulteration, according to Stanley, since it is any manipulation of a drug formulation to produce a dosing form different from label requirements. He said that pharmacies should not provide drugs that are commercially available or those slightly altered by flavoring or by small changes in drug strength.
There is little external oversight; compounding pharmacies are mostly self-regulated. A compounded product cannot be called a generic equivalent and cannot be substituted for an available FDA-approved product. A compounder may reformulate an approved animal or human drug to change its delivery, as for example turning powder into paste, or if a formerly FDA-approved drug is no longer available. In addition, only a 72-hour supply should be kept on-hand at the pharmacy for dispensing. In every compounding case there must be a valid veterinarian-client-patient relationship. Label instructions include specific details on how it is to be used.
Before choosing a compounding pharmacy, Stanley recommends researching information about the pharmacy, asking if it is accredited by the Pharmacy Compounding Accreditation Board (PAB), if the pharmacist has obtained appropriate training, and if the pharmacy has liability insurance. He also recommends finding out if the product you’re seeking is prepared using pharmaceutical or chemical (bulk) grade materials and where these were obtained.
He noted red flags that are causes for concern, such as an overly long expiration date–by law the longest expiration date on a compounded product can only be six months. Other red flags include statements of sterility, marketing materials presenting the product as cheaper than an available FDA-approved product, or AVMA or pharmaceutical complaints that have been filed. Clients should be concerned about websites that advertise compounded drugs, particularly when medications are available without necessary prescriptions.
Stanley described omeprazole as an example of compounding issues that arise. Two FDA-approved products (Gastrogard and Ulcergard) with demonstrated efficacy and stability are available. Any compounded formulation with omeprazole is currently considered pirated since Merial still owns the use patent. The pH of omeprazole is very sensitive–pH less than 7.8 results in rapid deterioration. Compounded pirated omeprazole products showed low pH values as well as dosing inconsistencies–only one of six products met FDA potency requirements upon arrival at the test lab. Similar findings occurred with non-steroidal anti-inflammatory medications: Levels were only 68% of label-claimed potency in injectable flunixin meglumine (Banamine) and 72% potency in powdered phenylbutazone (Bute).
FDA regulations on medical devices are stringent–a medical device is defined as an external device that does not result in a chemical reaction within or on the body. There are several products FDA-approved as medical devices but used as drugs for intra-articular therapies; therefore, Stanley remarked that any injectable medical “device” is considered a drug. Should a practitioner choose to use a device as a pharmaceutical, he or she should be aware that these products have not been evaluated to determine their suitability for that usage by any regulatory agency.
Stanley also stressed that a client cannot consent to substandard care (per legal standards for medical malpractice). Clients might not understand that just because a product is formulated and prepared for resale doesn’t mean it is therapeutic to achieve desired results. Stanley also emphasized the importance of client education, including counseling the client regarding potential adverse reactions and possible efficacy failure.
He summed up the possibilities of what can go wrong in compounding:
Inadequate oversight of quality assurance and control, resulting in formulation error or drug used in an improper application;
Inadequate storage– If the potency is low (deteriorated) then the drug might not work (therapeutic failure). If the drug degrades into a toxic intermediate, the patient can become sick or die from it;
Lack of product testing;
Lack of recall procedures (if a product were to test as unsafe, sufficient structure might not exist to be able to recall the products, as there would be with an FDA-approved product);
Inadequate processing facilities regarding cleanliness (resulting in a potentially contaminated product).Improper operation and maintenance of equipment; and
Oversight by FDA and state pharmacy boards can be difficult/limited due to economic cutbacks.
AAEP has now required PCAB accreditation of compounding pharmacies with exhibits at their annual convention trade show to meet a minimum standard.
Bid to end duplicate drug research
A radical plan to end the “madness” of wasteful and pointless research by rival drug companies has been outlined.
The new initiative will promote freer and faster early stage drug development through collaboration rather than competition.
Central to the idea is banishing the secrecy tied to intellectual property that causes the same work to be duplicated even after it has led nowhere.
On Wednesday around 30 academics, research funders and pharmaceutical industry representatives from around the world meet in Toronto, Canada, to hammer out plans for the new model.
The objective is to launch a prototype scheme by the end of the year at an estimated annual cost of around £124 million.
Neuroscientist Dr Chas Bountra, head of the Structural Genomics Consortium at Oxford University, who is organising the conference, believes the pharmaceutical industry is in crisis and branded wasteful research as “madness”.
Speaking in London, he pointed out that under the present system different organisations can spend many years and enormous amounts of money chasing the same therapeutic targets.
The work can continue even after results that are never shared show that it is futile and will never provide a useful outcome. More than 90% of the molecules investigated by drug companies fail at the Phase II trial stage, when their effectiveness is tested on patients, said Dr Bountra.
The scheme, currently known as POC (Public/private partnership, Open innovation, Clinical consortium), would ensure that all pre-Phase II research results are publicly accessible.
“What we will do is publish that data immediately and hopefully we’ll stop other organisations doing the same and repeating these studies with their own assets,” said Dr Bountra. “This will save resources and, importantly, prevent exposing patients to medicines that will fail.”
Success rates for experimental drugs falls: study
The success rate in bringing new medicines to market in recent years is only about half of what it had been previously, but biotech drugs are twice as likely to gain U.S. approval than more traditional chemical drugs, according to a new study released on Monday.
And while oncology has been one of the hottest and most active therapeutic areas for drug development, drugmakers may want to take note of a finding that new cancer drugs have proven far more difficult to gain approval than medicines for infectious and autoimmune diseases.
Drugmakers have been complaining about the difficulty of bringing new products to market in a regulatory climate that has become increasingly unpredictable and more likely to err on the side of safety in deciding risk/benefit ratios of experimental medicines.
Data from this new study appears to bear that out.
“It ain’t getting any easier to develop new therapies.” said Alan Eisenberg, head of emerging companies and business development for the biotech trade group Biotechnology Industry Organization (BIO), putting the findings succinctly.
“Knowing more about the magnitude of risk can lead to smarter drug development as well as smarter investing,” he said.
The study, covering 2004 through 2010, found the overall success rate for drugs moving from early stage Phase I clinical trials to FDA approval is about one in 10, down from one in five to one in six seen in reports involving earlier years.
The study, conducted by BIO and BioMedTracker, which collects data on drugs in development, reviewed more than 4,000 drugs from companies large and small and both publicly traded and private. It was released in conjunction with the annual BioCEO and Investor conference in New York.
Adding weight to the desire by major pharmaceutical companies to become increasingly involved in biotechnology was a finding that biologics had a 15 percent chance of going from Phase I through to FDA approval, compared with a 7 percent success rate for traditional small molecule chemical drugs.
When broken down by therapeutic categories, the highest overall success rate from Phase 1 through likelihood of approval was infectious diseases, such as hepatitis and HIV drugs, at 12 percent, followed by endocrine system drugs, featuring diabetes treatments, at 10.4 percent, and autoimmune diseases, such as rheumatoid arthritis, at 9.4 percent, the study found.
John Craighead, BIO’s managing director for investor relations, said clinical trial goals and the approval pathways for infectious diseases and diabetes drugs are clear and very well-established.
“The Phase II results are very predictive of the Phase III outcomes and very predictive of approval,” he said.
“The overall success rate in oncology was the lowest of the therapeutic areas that we looked at,” he said, noting that cancer studies vary dramatically in design and extending survival sets a high bar for approval.
The cancer drug success rate was a mere 4.7 percent, with cardiovascular drugs second-worst at 5.7 percent, as regulators are increasingly demanding proof that heart drugs reduce heart attacks and strokes rather than just lower a risk factor, such as cholesterol levels.
The largest dropout rate along the clinical pathway came in advancing drugs from mid-stage Phase II studies to late-stage Phase III testing.
Some 63 percent of drugs in Phase I testing advanced to Phase II, but only 33 percent of Phase II drugs made it to Phase III, which requires a commitment to larger and much more expensive clinical trials. Phase III is typically the final stage of human testing before a new drug is submitted to regulators for an approval decision.
Not surprisingly, the numbers increase after that as the drugs had already shown success in the clinic.
Approval applications were filed for 55 percent of the drugs that made it to Phase III testing, and 80 percent of those gained eventual approval, although only about half were approved on their initial FDA review.
The 80 percent approval rate, while seemingly high, is down from 93 percent seen in studies of earlier years.