Examining the Quality, Safety, Efficacy of Generic Drugs Jake J. Thiessen, Ph.D. Founding Director, School of Pharmacy, University of Waterloo Professor Emeritus, Leslie Dan Faculty of Pharmacy, University of Toronto Canadian Government Mandate (Health Canada) To ensure that the Canadian public gets medicines that are (therapeutically) safe, effective and of high quality. To ensure that manufacturers provide suitable scientific and clinical evidence - Obviously this implies safety and efficacy ….which will ultimately be demonstrated in humans…. in valid clinical trials… The Canadian government does not assess whether a drug is superior to similar therapeutic agents, nor does it determine whether the new drug is costeffective for publicly-funded formularies. The Focal Point of Today’s Talk Are Canada’s Approved Generic Drugs ‘The SAME’ as the Originator’s Drugs? ‘The SAME’ in terms of: Quality Safety Efficacy But, what is meant by ‘The Same’? How much variability can be tolerated with ‘The Same’? Are there exceptions to Canada’s common criteria? What is Different or ‘The Same’? All have ‘The Same’ purchasing power. What is Different or ‘The Same’? Permitted Product Content Variability Drugs Azithromycin Carbamazepine ER Doxorubicin Inject. Doxycycline Levetiracetam Methylphenidate ER Metoprolol ER Nifedipine ER Nifedipine Valproic Acid Verapamil ER *USP 34 NF 29 Suppl 1 (2011) Limits* 90-110 90-110 90-115 90-120 90-110 90-110 90-110 90-110 90-110 90-110 90-110 Critical Dose Drugs Content Variability TPD Drugs Cyclosporin Digoxin Flecainide Lithium Phenytoin Sirolimus Tacrolimus Theophylline Warfarin *USP 34 NF 29 Suppl 1 (2011) Limits* 90-110 90-105 90-110 95-105 95-105 NA NA 90-110 95-105 Reported Product Variability A Yacobi et al: Clin. Pharmacol. Ther. 65: 389-394 (1999) Carbamazepine data: 200 mg Taro Carbamazepine vs Tegretol Content Variability - Within and Between Products It is impossible for all capsules/tablets in a prescription to be identical and to contain the exact amount on the label. It is impossible for all batches from the same manufacturer to be identical. A quality product (originator or subsequent entry, i.e. generic) meets regulatory requirements when its variability is within an approved range (e.g. most commonly 10% of label claim). The permitted variability is really a ‘probability’ or ‘confidence limit’ that a tested sample meets the quality specification and that now all the tablets in the lot also meet that criterion. Variability as a Fundamental Issue Intra- and Inter-Product Content Variability 0.8 1 1.25 View of the Body?? Planck’s Is It Like These Constants?? View of the Body?? Is It Really Variable?? The Variable Human Illustrated Body Normal Temperature men women overall oral 35.7–37.7 °C 33.2–38.1 °C 33.2–38.2 °C rectal 36.7–37.5 °C 36.8–37.1 °C 34.4–37.8 °C typanic (ear canal) 35.5–37.5 °C 35.7–37.5 °C 35.4–37.8 °C axillary (armpit) 35.5–37.0 °C Body Normal Lab Values Parameter Serum Total T3 ‘Normal Range’ 75-220 ng/dL SGOT 11-47 IU/L Uric Acid 3-8 mg/dL Serum Albumin 3.6-5 g/dL Platelet Count 150-450 x109 /L Serum DHEA 130-1200 ng/dL Serum Uric Acid (Male) 4.0-8.5 mg/dL 13 Sources of Inter – and Intra-Human Variability Source: Goodman & Gilman's The Pharmacological Basis of Therapeutics - 11th Ed. Figure 4-1; Originally by E. S. Vesell Understanding Physiologic Realities After Administering a Drug Sources of Variability Age, gender, size, genetic traits, health status, food, etc. Absorption First-pass effect Liver – Metabolism Bile Distribution Excretion Patient Response to a Drug Blood/Int. fluid Homeostasis Drug Drug Receptor Response Cellular Barrier Biophase Variability in Therapeutic Effect TPD Critical Dose Drugs Drug Cyclosporin Digoxin Flecainide Lithium Phenytoin Sirolimus Tacrolimus Theophylline Warfarin USP Content Limits Therapeutic Window** 90-110 90-105 90-110 95-105 95-105 NA* NA* 90-110 95-105 50 - 300 ng/mL 0.8 - 2.0 ng/mL 0.2 - 1.0 mcg/mL 0.8 - 1.2 mmol/L 10 - 20 mcg/mL 5 - 15 ng/mL 5 - 20 ng/mL 10 - 20 mcg/mL 2.2 + 0.4 mcg/mL * Not Available in the USP ** Health Canada or elsewhere Evaluating Drugs Effect or response in the body is relatively insensitive for most drugs - Frequently one is unable to distinguish a difference when the dose is doubled. Even though blood concentrations change by 50%, as usually occurs between doses, one usually cannot tell the difference in effect. Blood concentrations are a much more sensitive way of evaluating the entry or presence of drugs in the body. Variability as a Fundamental Issue Indistinguishable Response Intra- and Inter-Product Content Variability 0.8 1 1.25 The Science of Comparing Two Products A AUC A AUC B Cmax A Cmax B Tmax A Tmax B B AUC Area under the concentration- time curve Cmax Maximum concentration Tmax Time to maximum concentration Bioequivalence Testing: The Complicating Problem of Variability Propafenone 300 mg IR; fasting study H.H. Blume et al: Application of single dose vs. multipledose studies. Biointernational 2002 Variability Encountered With a Dose Famotidine-Formulation A 250 250 200 200 Conc (mcg/ml) Conc (mcg/ml) Famotidine-Formulation B 150 100 50 150 100 50 0 0 0 5 10 Time (Hours) 15 20 0 5 10 Time (Hr) Intra- and Inter-Individual Variability!! 15 20 Variability With the Same Product 90 Plasma Level (ng/mL) 80 Nifedipine - Adalat 70 Sub1A 60 Sub1B 50 Sub2A 40 Sub2B 30 Sub3A 20 Sub3B 10 0 0 2 4 6 8 10 12 14 16 18 20 22 24 Time (hours) M. Spino “Non-Linear Drugs: A Pragmatic Perspective”; TPD Workshop, 2002 People/Products are Not Constant!! Intra-Product Variability (0.25 mg Lanoxin) People/Products are Not Constant!! A Yacobi et al: J. Clin. Pharmacol. Ther. 21: 301-31 (1981) Lanoxin vs Generic Digoxin: n=12 4-way crossover trial Intra-Product Variability (5 mg Coumadin) People/Products are Not Constant!! A Yacobi et al: J. Clin. Pharmacol. Ther. 40: 1-10 (2000) Coumadin vs Taro-warfarin: n=26(23completed) 4-way crossover trial Intra-subject CV ~ 20% Quantifying Comparative Study Results A AUC A AUC AUC A B AUC B Cmax A Cmax A Cmax Cmax B B Tmax Tmax A A Tmax Tmax B B B Variability as a Fundamental Issue Inter-Subject Variability Intra-Subject Variability Indistinguishable Response Intra- and Inter-Product Content Variability 0.8 1 1.25 Variability as a Fundamental Issue Bioequivalence Limits Inter-Subject Variability Intra-Subject Variability Indistinguishable Response Intra- and Inter-Product Content Variability 0.8 1 1.25 So, what do we mean when we say a product meets the criterion of 80125%?? What is this ‘confidence interval’ criterion all about? Bioequivalence Confidence Intervals It is a reasoned measure of product comparison It is quantitative limit of the in vivo performance of a test product relative to a reference product (ie in a controlled clinical test) The estimate is a “probability” [eg 90%]: Based on the results of a completed study Applies mostly to AUC, which defines the comparative fraction of the dose absorbed A forecast or projection of what the average (eg AUCtest/AUCref) would be if literally millions of people/patients were enrolled in a similar bioequivalence trial For most products this range is 80-125% Bioequivalence: Mean Ratios and Confidence Intervals (CI) . % Mean Ratio 125 100 80 This case ‘passes’: ratio and CI is within 80125% [Bioequivalent] This case ‘fails’: acceptable mean ratio but not within 80-125% This case ‘fails’: unacceptable 90% CI Health Canada’s Criteria: Apply to generic and innovator companies Apply to all products, with a few exceptions AUC must meet the 90% confidence limits of Cmax average must be between 80-125% 80-125% Exceptions: Critical dose drugs (cyclosporin, digoxin, flecainide, lithium, phenytoin, sirolimus, tacrolimus, theophylline, warfarin) AUC must meet the 90% confidence limits of 90-112% Cmax must meet the 90% confidence limits of 80-125% Fasting and Fed studies Rapid onset of action drugs Common requirements, plus The relative mean AUCReftmax of the test to reference formulation should be within 80 to 125% Concluding Comments Bioequivalence requirements are a robust international standard for designating products as ‘The Same’. They are the primary basis for decisions about interchangeability. The requirements apply to both the originator and generic companies. Originators who make changes in formulations, sites of manufacture, etc. Generics who seek to create competitive products. Interchangeability means that products can be switched with no change in therapeutic response. The public is well-served by the bioequivalence requirements.