Equine Chemistry Research Legal and Ethical Veterinary Compounding Scott D. Stanley, Ph.D., Professor University of California, Davis School of Veterinary Medicine Drug Detection Determination, Identification, Confirmation Cl CH3 OH H N C CH3 H2N C C H CH3 H H Cl Clenbuterol m/z 240 100 95 90 85 80 75 70 65 60 55 50 45 40 35 1230.2482 30 25 18 20 + 15 10 5 0 1302.4410 17 + Proteomics Erythropoietin, Growth Hormone, Cobratoxin 1383.7832 16 + 1476.0369 15 + 1581.2524 14 + Serum fentanyl concentration (ng/ml) 100 1250 1300 1350 1400 1450 1500 1550 1600 1650 1700 10 1 0.1 0 1 2 3 4 5 6 Time (h) 1703.0424 13 + Pharmacokinetics T 1/2, AUC, Cl Metabolite ID Horse Industry Integrity Industry Integrity (Perception) High Profile Events Triple Crown Breeder s Cup Trainer s Livelihood Disqualification Suspension Fine Laboratory Reputation Equine Pharmaceuticals: Manufacturing/ Compounding Issues 1
Definitions Integrity means retention of potency until beyond use date Potency means active ingredient strength within ±10% of the labeled amount Quality means the absence of harmful levels of contaminants including filthy, putrid or decomposed substances and absence of active ingredients other than those noted on the label Available Pharmaceuticals FDA-Approved Pioneer Drugs For use in the horse For use in other animals For human use Generic Drugs Compounded Drugs Pioneer Pharmaceuticals FDA approval process: Dosage Efficacy Safety Withdrawal Times (food animals) Manufacturing Stability Labeling Packaging Advertising Adverse Events FDA Approved Drugs: What is Required? Drug Efficacy must be demonstrated in two well-controlled trials one of which must be in clinical cases. Drug Safety must be demonstrated in one or more studies in the target species acute toxicity study sub-acute toxicity study field safety studies 2
FDA Approved Drugs: What is Required? Manufacturing: All raw materials for drug manufacture must be obtained from an FDA approved source The manufacturing procedure must be described in detail and meet the rigorous standards of FDA s Good Manufacturing Practices (GMP) Stringent testing standards for drug potency and purity must be established FDA Approved Drugs: What is Required? Manufacturing: Stability data must be generated in order to establish the expiration dating Detailed records of each batch of drug produced must be maintained Representative samples of each batch of drugs must be retained for future testing FDA regularly inspects manufacturing facilities What is a Generic Drug? A generic drug is an exact copy of an FDA approved drug that is no longer patent protected. All generic drugs are approved by FDA Additional efficacy and safety data may be required (e.g., field safety) Generic Pharmaceuticals FDA approval process: Bioequivalence (and/or) Chemical Equivalence Manufacturing Packaging Labeling 3
What is a Generic Drug? The requirements for FDA approved raw material sources are the same for a generic drug All GMP requirements apply to generic drugs All annual reporting requirements are the same as for original drugs Compounding Pharmacies Are a necessary and beneficial component of veterinary practice Compounded drugs are not FDA-approved are not generic drugs Compounded Drugs Pharmacy compounding of veterinary drugs has exploded in the past few years Allows for DVMs to have formulated Drugs no longer commercially available Drugs not available on animal health market Reformulate drugs into suitable dosage forms Compounded Drugs No regulations on raw material sources No quality standards No stability data requisite Supposed to be a prescription for a specific need in a specific animal (VCPR) Bulk compounding is not legal 4
Compounded Drugs Compounded Drugs It is illegal to compound a specific product when there is an approved drug form of that specific product except to make a different dosing form. However, the approved product must be used to make the compounded new dose form. It is illegal to mark up prices on compounded drugs If you use a compounded product, you assume liability for any adverse effects or efficacy failure Drug manufacturers are required to carry product liability insurance Pharmacies are not required to carry product liability insurance Compounded Drugs Veterinary Practitioners It is illegal to place expiration dating on compounded drug beyond 180 days from preparation It is illegal to have a drug compounded in order to obtain the drug at a lower price Compounded products are not generic forms of approved drug products!... are put in a position of evaluating the integrity of the compounding pharmacy as well as the quality and consistency of the pharmaceuticals they produce! 5
Concerns: Compounded Drugs Efficacy Quality Potency Purity Consistency Liability Little or no ongoing external oversight of: Consistency Quality Potency Bioavailability Sterility Mainly self-regulated Stability Safety Labeling Advertising Adverse Events Questions you may want to ask: Who is doing the compounding? Often a technician with minimal training Where were they trained? Pharmacists - little training in compounding; No training in manufacturing Do they use pharmaceutical grade chemicals? Drug companies will not supply Chemicals bought through sources like PCCA are questionable, often produced overseas (e.g., China) Comparison for Pharmaceutical Equivalence of Compounded Preparations of Perigolide Mesylate Scott D. Stanley, PhD Heather K. Knych, DVM, PhD University of California - Davis 6
Illegal Veterinary Compounding Product Potency Suspensions stated concentration for all products was 1.0 mg/ml Capsules stated concentration for all products was 1.0 mg/capsule Powders stated concentration for was 1.0 mg/scoop Liquid (Suspensions) Liquid (Suspensions) Pergolide Mesylate (Suspension) Storage at 8 C Pergolide Mesylate (Suspension) Storage at 25 C Pergolide Concentration (ng/ml) 1000 Target Conc. Minimum Conc. 800 Day 0 Day 30 600 Day 60 400 200 Pergolide Concentration (ng/ml) 1000 Target Conc. Minimum Conc. 800 Day 0 Day 30 600 Day 60 400 200 0 A B C D E F G Compounding Pharmacy 0 A B C D E F Compounding Pharmacy 7
Powder Products 1200 Pergolide Mesylate (Powders) Storage at 8 C Pergolide Concentration (ng/ml) 1000 800 600 400 200 Target Conc. Minimum Conc. Day 0 Col 3 Col 4 0 A B C D E F G H Compouning Pharmacy Capsule Products Product Preparation Pergolide Mesylate (Capsules) Storage at 8 C 1000 Target Conc. Pergolide Concentration (ng/ml) 800 600 400 200 Minimum Conc. Col 2 Col 3 Col 4 0 A B C D E F Compounding Pharmacy 8
Conclusions Many products were below labeled potency upon delivery (1.0 mg/ml, 1.0 mg/capsule, or 1 mg/scoop) Liquid formulation were unstable and degraded rapidly regardless of storage conditions. Conclusions The powder formulations were less susceptible to degradation but had erratic potency. The capsule products also degraded more slowly then suspensions but capsule to capsule variability made results of product assessment uninterpretable. Comparison for Pharmaceutical Equivalence of Commercially Available Preparations of Omeprazole Scott D. Stanley, PhD Heather K. Knych, DVM, PhD University of California Davis School of Veterinary Medicine Introduction Omeprazole Proton Pump Inhibitor Irreversibly binds - H + K + ATPase enzyme Indications: For treatment and prevention of GI Ulcers Equine Gastric Ulcers Syndrome (EGUS) 9
Introduction Omeprazole FDA approved - Formulations: GastroGard Paste UlcerGard Paste Compounded formulations: Oral Paste Oral Powders Oral Suspensions Comparison Omeprazole Formulations Nieto et al; JAVMA; 221, Oct 15, 2002 Commercial Paste Effective in promoting healing of Gastric Ulcers C max and T max 2.85 g/ml; 34 min Suspension Ineffective in promoting healing of Gastric Ulcers C max and T max 1.13 g/ml; 105 min Omeprazole Stability Practitioners Concerns: Omeprazole is a lipophilic weak base that degrades rapidly in acid aqueous solutions. The paste vehicle provides Omeprazole with some protection from intragastric degradation. Acidic suspensions will have a deleterious effect on the stability of OME Efficacy Quality Potency Stability Consistency 10
Study Objectives: Determine initial product potency (upon receipt) for several formulations of Omeprazole obtained from various veterinary compounding pharmacies Establish the stability each compounded formulations for Omeprazole at several predetermined time points (30, 60 and 90 days). Variable Product Potency Paste Ten products (2) Labeled concentration = 2.0 g per tube (3) Labeled concentration = 2.28 g per tube (1) Labeled concentration = 3.08 g per tube (1) Labeled concentration = 4.0 g per tube (1) Labeled concentration = 4.4 g per tube (1) Labeled concentration = 6.6 g per tube (1) Labeled concentration = 8.0 g per tube Omeprazole (Paste) Product Stability 100 Target Conc Minimum Conc. % Product Potency 80 60 40 Day 0 Day 30 Day 60 Day 90 20 0 1 2 3 4 5 6 7 8 9 10 Compounding Pharmacy 11
Variable Product Potency Omeprazole Suspensions Suspensions Six products (2) Labeled concentration = 150 mg/ml (2) Labeled concentration = 100 mg/ml (1) Labeled concentration = 73.5 mg/ml (1) Labeled concentration = 50 mg/ml Omeprazole suspensions analysis determined concentration was only 71% of the label claimed potency! Solution ph was 5.0. 140 Omeprazole (Suspensions) Product Stability Variable Product Potency % Percent Potency 120 100 80 60 40 20 Target Conc. Minimum Conc. Day 0 Day 30 Day 60 Day 90 Powders Seven products (1) Labeled concentration = 1.4 g per scoop (1) Labeled concentration = 2.0 g per scoop (2) Labeled concentration = 2.2 g per scoop (3) Labeled concentration = 2.28 g per scoop 0 1 2 3 4 5 6 Compounding Pharmacy 12
Omeprazole (Powder) Product Stability Powder Preparation 140 % Percent Potency 120 100 80 60 40 20 0 Compounding Pharmacy Target Conc. Minimum Conc. Day 0 Day 30 Day 60 Day 90 Omeprazole powder analysis determined concentration was only 78% of the label claimed potency! Product Preparation 13
Economic Appraisal Cost Estimation: Chemical Grade Omeprazole China, India, unknown $ 1.00 per kilogram Raw Material Cost >$ 0.01 per dose Compounded paste products cost $ 8.90 - $23.00 per dose Conclusions Conclusions Most of the compounded omeprazole products were below the labeled potency at the original analysis. 2 30 grams per tube 50 150 mg per ml 1.8 2.28 grams per scoop Liquid suspensions were the most unstable and degraded rapidly regardless of vendor. The paste products degraded more slowly then aqueous suspensions. The powder products degraded the slowest but had erratic potency with scoop-to-scoop variability making the product evaluated unacceptable. 14
Take Home Message Questions? Results from this study demonstrated significant differences in product potency and stability for Omeprazole in the various preparations obtained from veterinary compounding pharmacies. This could have major consequences both from an efficacy and toxicity standpoint. Medical Therapies for Equine Joint Disease Medical Therapy for Equine Joint Disease: Understanding your Choices? FDA Approved Animal Drugs FDA Approved Generic Drugs Compounded Products Off-Label Use of Medical Devices as Drugs 15
NSAIDs FDA Approved Drugs For Equine Joint Disease Phenylbutazone, flunixin, ketoprofen, diclofenac Corticosteroids Methylprednisolone acetate, triamcinolone acetonide, dexamethasone Hyaluronic acid Hylartin-V, Hyvisc, Hylovet, Legend PSGAG (Adequan) Generic Drugs for Equine Joint Disease: Phenybutazone Flunixin Methylprednisolone acetate Dexamethasone SP What is not a Generic Drug Compounded Products HA solutions Glucosamine Injection Pentosan Polysulfate Cocktails (HA, Glucosamine, Chondroitin) Medical devices used off label as drugs MAP-5 and Chondroprotec Well Controlled Study Blinded: The person making observations is not aware of treatment group assignment Randomized: The subjects are randomly assigned to treatment group Standardized: All subjects are treated exactly the same (exercise, feeding, other drugs, etc). The only difference between groups is test drug(s) 16
Uncontrolled Studies Compounded Drugs Testimonials and uncontrolled studies are especially poor indicators for efficacy Rest and concurrent therapy are usually not controlled The use of other physical and medical therapies are often confounding factors Judgement of efficacy is biased Common products compounded for equine joint disease betamethasone suspension acetyl-d-glucosamine injection HA injection Pentosan Polysulfate cocktail injections containing glucosamine, HA and chondroitin Medical Devices Medical Devices There are medical devices for the veterinary field that are being sold and promoted illegally for off-label use to treat equine DJD MAP-5 is an HA solution labeled as a cryopreservative for semen Chondroprotec is a solution of chondroitin sulfate labeled as a topical for wound healing MAP-5 is not a generic form of Legend! Chondroprotec is not a generic form of Adequan! The AAEP has taken the position that it is unethical for a DVM to tell a client that one of these medical devices or a compounded drug is a generic form of an FDA approved drug 17
Pentosan Polysulfate Pinker Pinker No FDA approved form of PPS is available in the US The only reports of its use in the horse were anecdotal A POST-mortem revealed that Cox Plate winner Pinker Pinker died after having an reaction to an injection of joint maintenance medication, Pentosan Gold. Herald Sun Legal Implications Veterinarians are Liable! A legal expert at the AAEP Convention in New Orleans in 2003 warned: A client cannot consent to substandard practice The fact that the use of compounded drug or the off label use of medical devices is common practice will not constitute a viable defense in a malpractice suit No Malpractice Coverage There would be an exclusion in a veterinarian s malpractice insurance nullifying coverage if the practitioner were engaged in an illegal act, such as the use of a compounded pharmaceuticals from bulk drugs. AVMA 18
Palm Beach Polo Ponies Biodyl (Merial) Each 100 ml contains: Cyanocobalamin (Vitamin B12) 0.05 g Sodium Selenite 100 mg Potassium aspartate semihydrate 1,000 g Magnesium aspartate tetrahydrate 1,500 g Excipient q.s. 100 ml 19
Compounded Formulation Selenium Toxicity Each 100 ml contains: Cyanocobalamin (Vitamin B12) 0.05 g Sodium Selenite????? mg Potassium aspartate semihydrate 1,000 g Magnesium aspartate tetrahydrate 1,500 g Excipient q.s. 100 ml 20
Just like Ventipulmin but cheaper 21
FDA Warning Letters FDA Warning Letters 22
Illegal Veterinary Compounding Illegal Veterinary Compounding The compounding pharmacy advised that Mixture #1 was proprietary formulation. The compounding pharmacy advised that Mixture #5 was the same as Mixture #1 with an additional active ingredient. (Salmeterol) Unknown Compounds Ketoprofen Gel 23
Ketoprofen Paste Clenbuterol Solution Anabolic Steroids Glycine-Proline-Glutamate GPE is the N-terminal tripeptide of insulinlike growth factor-1 and has been shown to be neuroprotective following ischemia-induced brain injury. 24
Flunixin Injection Phenylbutazone Powder Flunixin analysis determined concentration was only 68% of the label claimed potency! Phenylbutazone powder analysis determined concentration was only 72% of the label claimed potency! Illegal Veterinary Compounding Industry Concerns: Modafinil is used treatment of narcolepsy. Modafinil has received some publicity in the past when several athletes were discovered allegedly using it as a performance-enhancing doping agent. Modafinil was added to the World Anti-Doping Agency "Prohibited List" in 2004 as a prohibited stimulant. Major source of new medications for veterinary medicine are diminishing Drug discovery is very expensive Most veterinary drugs have come via parent company human research initiatives More pharmaceutical companies have consolidated and their animal health divisions could be sold or eliminated if they are profitable 25
Recommendations: Recommendations: Use FDA approved products when available Use a compounding pharmacist that follows FDA Guidelines for Good Compounding Practices and has product liability insurance Avoid off label use of devices as drugs Do not tell a your clients that a device or a compounded drug is a generic form of an approved FDA product! Use compounded products only for individual animals Acknowledgements Questions! University of California Abel Bermudez Dan McKemie Rebecca Shepard Valerie Wiebe Nicola Pusterla Jorge Nieto EACL staff UNC Chapel Hill Ben Moeller 26