Risk-based analysis in pharmaceutical procurement and market analysis Vivienne Christ Therapeutic Goods Administration Australia Interregional Seminar for Quality Control Laboratories involved in WHO Prequalification Programme and/or participating in respective sampling and testing projects, Nairobi, Kenya, 23-25 September 2009 Outline Pharmacopoeial and other tests – General requirements – Microbiological and chemical tests – Tests for various dosage forms Risk assessment (analysis) An approach to targeted sampling and testing Example of a risk-based assessment – To assist your with hands-on exercise 2| Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Pharmacopoeial and other tests British Pharmacopoeia (BP) European Pharmacopoeia (Ph Eur) United States Pharmacopeia (USP) International Pharmacopoeia IP) Other validated methods (ISO17025, ICH Guideline) • ICH Tripartite Guideline Validation of Analytical Procedures: Text and Methodology Q2(R1) http://ich.org/LOB/media/MEDIA417.pdf 3| Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 General monograph requirements Visual examination – – – – Packaging Labelling Product appearance, particulates, integrity Storage conditions Microbiological tests – Sterile products • Test for sterility and endotoxin test for parenterals – Non-sterile products • Microbial attributes tests Chemical tests 4| Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Microbiology laboratory 5| Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Microbiological testing Sterility testing Endotoxin testing Microbial attributes – Total aerobic microbial count (TAMC) – Presence/absence testing Preservative efficacy testing Microbiological bioassay for potency – Eg. nystatin, gentamicin Disinfectant efficacy testing 6| Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Chemistry laboratory 7| Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Chemical tests Uniformity of mass, - dose, - content Disintegration and Dissolution tests pH and moisture content Presence of heavy metals Identity tests – – – – IR spectrophotometry, TLC + UV detection Colorimetry Absorption spectrum (AA) Optical rotation (useful for natural products) Assay of active(s) – HPLC, UV, AAS, GC (for volatiles) Related substances for organic chemicals – – 8| For process impurities and degradation products (HPLC, TLC) Organic volatile impurities (GC) Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Access to Chemical Reference Substances Pharmacopoeial CRS International Chemical Reference Substances (ICRS) Used to validate test methods and test results Used as primary standard to calibrate secondary standards 9| Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Dosage forms Parenteral products Ophthalmic products Oral dosage forms – Tablets, capsules, powders Rectal products – Suppositories Inhalation and nasal products Topical products – – – – 10 | Creams, gels Ointments Transdermal patches Suppositories, pessaries Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Parenteral products (SVP & LVP) Supplied as – Vials, ampoules, bottles, bags, pre-filled syringes, etc – Solutions, freeze dried powders or emulsions – Single or multidose presentations Test for Sterility – Terminal sterilization? Parametric release? – Aseptic processing? Pharmacopoeial bacterial endotoxin/pyrogen test – LAL test Pharmacopoeial microbiological bioassay for potency – eg vancomycin Pharmacopoeial preservative efficacy test for all multidose presentations – Closed shelf-life testing (developmental and at expiry) – Open-shelf life testing to support in-use life if > 24 hours 11 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Parenteral products (SVP & LVP) Chemical tests – Powders for reconstitution: • Uniformity of mass for single dose preparation • Moisture content (Karl Fischer or LOD) for antibiotics, etc • Uniformity of content – pH of solutions – Particulate matter – Preservative content assay – Identity, assay and related substances • HPLC – Extractable volume for SVP 12 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Ophthalmic (eye) products Supplied as – – – – Sterile liquid, semi-solid, or solid preparations Presented as eye drops and ointments Usually aseptic manufacturing process Quality of WFI? Test for Sterility Preservative efficacy if multidose – – Closed shelf-life testing (developmental and at expiry) Open-shelf life testing to support in-use life if > 24 hours Microbiological bioassay – eg gentamicin eye drops Particle size Chemical tests – – – – 13 | pH, Identity Assay and related substances by HPLC Composition for antibiotics by HPLC Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Inhalation products Depends on presentation – – – – Pressurised metered dose inhalers (MDI) Dry powder inhalers Products for nebulization Non-pressurised metered dose inhalers (MDI) Sterile single dose presentations preferred – Test for sterility for single dose products for nebulization Microbial attributes for all non-sterile products PET for multidose products for nebulization and non-pressurised MDIs Chemical tests – Moisture content, mean delivered dose, uniformity of delivered dose, uniformity of content (single dose), particle size distribution (twin impinger or impactor), leak rate for pressurised MDI – Assay of quantity of drug substance 14 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Nasal products Microbial attributes – TAMC, presence/absence testing Preservative efficacy – Closed shelf-life testing (developmental and at expiry) Chemical tests – As for parenteral solutions 15 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Oral medicines - Liquids Microbial attributes – TAMC, absence/presence testing Test for Sterility – Eg sterile paediatric oral antibiotic products and some oral products for HIV/AIDS patients Preservative efficacy – Closed shelf-life testing (developmental and at expiry) – Open-shelf life testing to support in-use life if > 24 hours Bioassay – Potency of nystatin oral suspension Chemical tests – – – – 16 | pH Identity Assay and related substances Preservative content Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Oral Medicines - Tablets and capsules Hard, soft and modified release capsules Uncoated, coated and modified release tablets – Modified release – extended or delayed? • Micro-encapsulation process to modify rate of release in GI tract Microbial attributes – Gelatin used in capsule shell – Not usually necessary as tablets have low Aw – TAMC, absence/presence testing 17 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Oral Medicines - Tablets and capsules Chemical tests – – – – Uniformity of mass if active >5% of mass per IP Uniformity of content if active is <5% of total formulation per IP Disintegration test – not required if dissolution test is required Dissolution test • Enteric coated delayed release: dissolution testing at low gastric pH 2 and higher intestinal pH 6.8 • Modified release: dissolution test over intended period (eg 24 hours) – Identity tests – Related substances test – Assay if uniformity of content does not apply 18 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Rectal preparations Suppositories – Uniformity of mass for single-dose preparations – Uniformity of content if active <2% of total mass (IP) – Microbial attributes • TAMC, presence/absence tests – Chemical tests • Disintegration • Identification • Assay and related substances 19 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Topical medicines – Creams & gels Hydrophobic or hydrophilic preparations applied to skin or mucous membranes Sterile or non-sterile Test for sterility – Microbial attributes – Closed shelf-life testing (developmental and at expiry) Open-shelf life testing to support in-use life if > 24 hours Chemical tests – – – – – 20 | nystatin Preservative efficacy – – TAMC, presence/absence tests Microbial Bioassay – Sterile creams used on burns and open wounds pH Identity Assay and related substances Preservative content Composition (including homogeneity) by HPLC Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Topical medicines – Transdermal patches Microbial attributes – TAMC, presence/absence (patch and backing material) Chemical tests – Release tested with a suitable dissolution test – Active released per surface area per time unit • Method: disc assembly, cell or rotating cylinder (drum) depending on composition, dimensions and shape • Ph Eur “Dissolution test for transdermal patches” – Uniformity of content – Identity – Assay and related substances 21 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Topical medicines - Ointments Low Aw Bioassay – Eg nystatin Preservative efficacy not required due to low Aw Chemical tests – As for creams and gels – Need to extract active by heating 22 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk Management Overview 23 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk-management? AS/NZS 4360:2004 – Risk management standard & HB 436 – Available from www.standards.com.au – ISO/FDIS 31000:2009 – 1st draft based on AS/NZS 4360:2004 – ISO/IEC Guide 73 Risk Management – Vocabulary – Guidelines for use in standards “Although the concept of risk is often interpreted in terms of hazards or negative impacts, this Standard is concerned with risk as exposure to the consequences of uncertainty, or potential deviations from what is planned or expected. The process described here applies to the management of both potential gains and potential losses.” “Organizations that manage risk effectively and efficiently are more likely to achieve their objectives and do so at lower overall cost.” “Risk management is aiming to make optimal decisions in the face of uncertainty” 24 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 What do we mean by risk? Risk can be defined as the combination of the probability of an event and its consequence Risk assessment is the overall process of risk analysis and risk evaluation In the health safety field consequences are generally only negative and the management of safety risk is focused on prevention and mitigation of harm 27 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk Management Process – Overview Analyse Risks Evaluate Risks Monitor and Review Identify Risks Risk Assessment Communicate and Consult Establish the Context Treat Risks Adapted from AS/NZS 4360 2004 28 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk Management Process – Overview Analyse Risks Evaluate Risks Monitor and Review Identify Risks Risk Assessment Communicate and Consult Establish the Context Treat Risks Adapted from AS/NZS 4360 2004 29 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk Management Process – Detail Communicate and Consult Identify Risks Analyse Risk Evaluate Risks Internal Context What can happen? Identify existing controls Compare against criteria External Context When and where? Risk Management Context How and why? Establish the Context Treat Risks Identify options Assess options Determine Consequences Determine Likelihood Set priorities Prepare and implement treatment plans Develop the Criteria Define the Structure Determine levels of risk Treat Risks YES Analyse and evaluate residual risk NO Monitor and Review Adapted from AS/NZS 4360 2004 30 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Establish the context Communication and consultation – Consultation is a process not an outcome • impacts on a decision through influence • about inputs to decision-making With whom do you need to consult and communicate? – List external organisations and individuals – List internal individuals Formalise this process – Document it! 31 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Medicine testing - Risk assessment team Clinical experts Pre-market assessors/evaluators GMP experts Adverse event reporting for the product Complaint and recall histories for the product Supply chain advisors Surveillance and counterfeit advisors Laboratory technical experts Consumers and community groups 32 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk assessment - Identify risks If something happens, then it might lead to an outcome, which might have an impact on public health due to the quality, safety or efficacy of a medicine Questions – – – – – What can happen? Where can it happen? When can it happen? Why it can happen? How can it happen? Tools and techniques depend upon the purpose of the risk management study and include: – – – – – – 33 | Checklists Judgements based on experience and records Flow charts Brainstorming Systems analysis Scenario analysis and systems engineering techniques (eg fault analysis) Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Identify risks A source of risk or hazard An event or incident A consequence, outcome or impact A cause (what and why) When and where could the risk occur Controls and effectiveness 34 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Analyse risks Develop and understand the risk Consider the source of risk Consider both positive and negative consequences Consider the likelihood that consequences might occur Identify factors that affect consequences and likelihood Analyse risk by combining consequences and likelihood Take into account existing controls 35 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Evaluate risks Compare against your defined criteria Consider balance between potential benefits and adverse outcomes Set priorities – In terms of the extent and nature of treatments required – What tests can your laboratory target to increase the likelihood of detecting a substandard medicine in order to prevent an adverse event occurring? Performing a risk assessment is an iterative process 36 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Types of risk analysis Qualitative analysis – Words describes the magnitude of potential consequences and the likelihood that they will occur – eg high, medium, low risk – Informed by factual information and data where available Semi-quantitative analysis – Descriptive words are given values (1= low, 10 = high) Quantitative analysis – Numerical values “Particular care must be taken with quantitative analysis when examining consequences that are intangible or difficult to quantify such as environmental or safety effects or reputation” (AS/NZS 4360:2004) Check sensitivity of the method 37 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Treat risks Identify options Assess options Prepare and implement treatment plans Analyse and evaluate residual risk 38 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Monitor and review Monitor effectiveness of risk management process Ensure priorities have not changed 39 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 TGA 40 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 TGA’s targeted testing approach Service Level Agreements (SLA) define annual lab testing program – Prescription Medicines Regulator • Includes drugs, plasma products, vaccines, biologicals, blood and tissues – Over-the-Counter (OTC) Medicines Regulator – Complementary Medicines Regulator – Medical Devices Regulator Non-discretionary sample testing (urgent or priority) – Usually unplanned from an operational viewpoint Discretionary sample testing (routine) – Amenable to operational planning – Based on an agreed risked-based sampling program 41 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 TGA’s testing priorities Non-discretionary testing – – – – – – – Problem and complaint investigations Adverse reactions GMP alert samples International alerts Referral as a result of surveillance seizures Suspect counterfeits Urgent or high priority according to set performance timeframes Discretionary testing – – – – – 42 | Compliance monitoring of products on the market Selection of marketed products according to risk assessment Usually includes a random selection of a small percentage of products Product surveys conducted to maximise resources Routine testing according to a monitored performance timeframe Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Targeted testing Level of risk associated with medicine itself – Intrinsic toxicity of the medicine – Likelihood of treatment failure if the medicine is ineffective – Medicine failure due to likelihood of deficiencies in quality • eg if product is difficult to make, or often poorly made Other concerns about quality, safety, efficacy – – – – 43 | Surveillance activity Reports of adverse consumer reactions Quality problems identified during manufacturer audits Literature reports and international concerns Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Factors that might affect the level of risk – The quality of the manufacturing process – The history of the manufacturer or sponsor – The potential for product to be contaminated with adventitious agents such as viruses and prions – Whether the product is intended to be sterile – Whether the product is an antibiotic, where potency may give rise to antibiotic-resistant strains – The natural propensity of the active constituent to instability, both molecular structure and pharmaceutic form (formulation) – The degree of exposure of the population to the product – The availability of counterfeit products in the market place, and – The outcome of other post-market activities 44 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Formulating a risk-based testing plan Consult Regulators, adverse reactions, surveillance, recalls, and GMP areas Products prioritised for testing after determining risk level Example outcomes – High end of risk spectrum • Every batch of product tested • Comprehensive selection of tests applied to each batch – Medium risk range • Might be subjected to physical testing periodically • Narrower range of relevant tests applied – Lower end of risk spectrum • Might undergo review of every batch documentation without physical testing • Periodic review of batch documentation only 45 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 The risk assessment (Introduction to hands-on exercise) 46 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Product: (Proprietary name, generic name) Presentation Dosage Forms Registration numbers (1) Event Consequence Table (1=insignificant, 2=minor, 3=moderate, 4=major, 5=catastrophic) Rank Adverse Reactions Clinical Issues Parameter Manufacturing Recalls Aspects Score Testing/other Total Rank (2) Event Likelihood: Event Likelhood Outcome Risk Rating Risk Action Comments: Assessed by: Date Approved: (eg rare, unlikely, moderate, likely, almost certain) Event consequence Table 1 (example) Rank Description 1 Insignificant 2 Minor Parameter Adverse Reactions Clinical Issues Manufacturing aspects Recalls Testing/other No or few reports of adverse events associated with product Quality failures not of clinical significance Current GMP licence with A1 rating. No reported problems. No evaluation issues. Product never recalled No substantiated complaint. No counterfeiting or illegal supply known. No testing failures. Product of minor concern to ADRU with few serious reactions Quality failures of low clinical significance A2 rating for last GMP audit. Medium risk manufacturer. Class II or III Wholesale. Counterfeiting or illegal supply of low concern. Failed low concern quality issues (eg label) Class III Hospital or Retail level 3 Moderate Product of moderate concern to ADRU with a number of serious reactions Quality failures of moderate clinical significance A3 rating for last GMP audit. High risk manufacturer Class I Wholesale Class II Hospital Class III Consumer 4 Major 5 Catastrophic 48 | Product of major concern to ADRU and has been associated with a relatively small number of patient deaths or a significant number of adverse reactions ADRU has recommended regulatory action because of significant number of deaths or a large number of serious adverse reactions. Quality failures of severe clinical significance Unacceptable risk assigned by GMP auditors Class I Hospital or Retail Class II Retail or Consumer Manufacturer’s licence revoked or suspended due to critical deficiencies Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Class 1 Retail or Consumer Class 1 Hospital for Highly Specialised Drugs Counterfeiting or illegal supply of mod. concern. Failed mod. quality parameters (eg borderline potency) High frequency counterfeiting, including overseas. Failed critical quality issues (eg dissolution) Product failed critical quality parameters (eg sterility, wrong active) Applied example for Capsule Product X from Table 1 Capsule Product X: Rank Total Parameter Score ? 49 | 8 Adverse Reactions Clinical Issues Manufacturing aspects Recalls Testing/other Product of minor concern to TGA’s Office of Medicines Safety Monitoring (OMSM) with few serious adverse reactions Quality failures of low clinical significance A1 rating for last GMP audit. Current licence. No previous reported problems or pre-market evaluation issues identified. Product has never been recalled. Counterfeiting or illegal supply is of low concern. Failed low concern quality issues (eg minor label issues) 2 (Minor) 2 (Minor) 1 (Insignificant) 1 (Insignificant) 2 (Minor) Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Table 1(a) Risk category rank Use score from Table 1 50 | Risk consequence score Risk Category Rank 5-10 Insignificant 11-15 Minor 15-19 Moderate 20-23 Major 23-25 Catastrophic Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Event likelihood Table 2 (example) Rank Description I Rare Event Likelihood (examples only) Product not distributed in your country. No previous testing failures. Product has never been recalled No recent changed to manufacturing process, specifications or test procedures. Recent self-assessable change by manufacturer. Current manufacturing licence. No previous reported problems. No issues identified during premarket evaluation stage. II Unlikely Product used infrequently (eg vaccines used by travellers, antivenoms). Testing failures more than 5 years ago. Product has been subjected to a Level 1 Recall more than 3 years ago. Product subjected to a Level 3 Recall only in the last 5 years. Recent minor change to manufacturing process, specifications, test procedures. Recent change of manufacturing site for excipients. Manufacturing problems more than 3 years ago. III Moderate Product failed significant quality parameters in the last 2-5 years. (eg potency, impurities). Failed moderate quality parameters within last 2 years. Recent moderate change to manufacturing process. Specifications, test procedures. Recent change of manufacturing site for API. Manufacturing problems in last 3 years. IV Likely Product failed significant quality parameters in last 2 years (potency, impurities, incorrect active present). Subject to a Level 1 or 2 Recall in the last 3 years. Recent moderate change to manufacturing process, specifications, test procedures. Recent change of manufacturing site for API. V (Almost) Certain 51 | Product administered to large proportion of population (eg National Childhood Immunization Program). Product subject of a Level 1 or 2 Recall in past 12 months. Significant adverse events reported in last 3 years. Stability studies indicate low thermal stability. Recent major change to manufacturing process, specifications, test procedures. Recent change of manufacturing site for API and previous problems notes with manufacturing process. Manufacturing audit is overdue or license has expired. Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk ranking Table 3 Use the risk consequence score from Table 1(a) and the likelihood from Table 2 Remember the score from Consequence Table 1(a) is ‘Insignificant’ Remember the score from Likelihood Table 2 is ‘V (Almost certain)’ Risk Category (from Table 1(a)) 52 | Likelihood (From Table 2) Insignificant Minor Moderate Major Catastrophic I (Rare) 1 3 6 10 15 II (Unlikely) 2 5 9 14 19 III (Moderate) 4 8 13 18 22 IV (Likely) 7 12 17 21 24 V (Almost certain) 11 16 20 23 25 Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Risk action Table 4 (example) Example of level of Post-market compliance testing required. Remember score from Risk ranking Table 3 is ’11’ Risk Ranking Risk Rating Action Required (TGA’s test groupings) Over 23 Severe 17 to 22 High Product(s) placed in Test Group 3: products requiring the highest level of postmarket assessment. (Batch release protocols examined for every batch and samples of every batch required, but not every batch is tested). 11 to 16 Moderate Product(s) placed in Test Group 4: products requiring a moderate level of postmarket assessment. (Batch release protocols examined for every batch and samples requested periodically for testing). New products placed in Test Group 2 until acceptable consistency established. (Protocols and samples required for first 5 batches. 3/5 batches tested and if results satisfactory, then move to Test group 4). 0 to 10 Low Urgent laboratory testing/ investigation Product(s) placed in Test Group 5: products requiring a lower level of postmarket assessment. (Protocols and samples might be requested occasionally. Annual requirement for a report of batches manufactured. Status reviewed ever 5 years). Note: Test Group 1 - Pre-Registration testing to facilitate method development and validation in quality control testing laboratory. 53 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Product X Capsule Oral 2009001234 2 2 1 1 2 8 Insignificant V (almost certain) 11 Moderate. Samples of first five batches tested (Group 2), then tested periodically (Group 4) Target tests: visual, LOD, degradation products (related substances) by HPLC or TLC, and dissolution profile. V. Christ 1/0/2009 Summary Pharmacopoeial tests – General, microbiological and chemical tests – Tests for various dosage forms Risk assessment (analysis) TGA’s approach to targeted sample testing Worked example of a risk-based analysis to target samples and testing to assist with the hands-on exercise 55 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009 Questions??? 56 | Sampling and testing for Quality Control Laboratories, Nairobi, September 2009