Quality assessment of compounded 17-hydroxyprogesterone caproate




Objective


The purpose of this study was to evaluate the quality of compounded 17-hydroxyprogesterone caproate (17-OHPC).


Study Design


Compounded 17-OHPC that was obtained from 15 compounding pharmacies throughout the United States was analyzed for potency, impurities, sterility, and pyrogen status.


Results


Eighteen samples were supplied by 15 compounding pharmacies. The concentration of 17-OHPC in all samples was within the specification limits, and all tested samples passed sterility and pyrogen testing. Only 1 of 18 samples was out of specification limits for impurities.


Conclusion


Compounded 17-OHPC that was obtained from 15 pharmacies throughout the United States did not raise safety concerns when assessed for potency, sterility, pyrogen status, or impurities.





For Editors’ Commentary, see Contents




See related editorial, page 12



The use of 17-alpha-hydroxyprogesterone caproate (17-OHPC) reduces the risk of recurrent spontaneous preterm birth in women with singleton gestation and a previous preterm birth. Until recently this medication was available only from independent compounding pharmacies across the country. In February 2011, the Food and Drug Administration (FDA) approved the New Drug Application (NDA) of KV Pharmaceuticals to market 17-OHPC as Makena (Ther-Rx Corporation, St. Louis, MO). The company initially set the price of Makena at $1500/ injection, whereas the cost of compounded 17-OHPC before FDA approval was $10-15/ injection. The resultant public outcry led to congressional hearings and universal condemnation of the company’s pricing policies. Consequently, the FDA issued a statement indicating it would not take enforcement action against compounding pharmacies that continued to produce 17-OHPC to allow continued patient access to this medication.


A recent report by Chollet and Jozwiakowski from the Ther-Rx Corporation (markets Makena) suggested that compounded 17-OHPC poses a risk because many unspecified impurities were identified in the active pharmaceutical ingredients that were used to compound 17-OHPC and that the concentration of the compounded product was commonly not in the range of accepted potency. The FDA conducted their own investigation and could not identify any major safety problems for compounded 17-OHPC. The FDA, however, stated that it was again applying its normal enforcement policy to compounded 17-OHPC.


We undertook this study after the report of Chollet and Jozwiakowski and before the time the FDA undertook their investigation. Our purpose was to obtain compounded 17-OHPC formulations from compounding pharmacies throughout the United States and to analyze the product for potency (concentration), impurities, sterility, and pyrogen status. Sterility and pyrogen status assessments of compounded 17-OHPC were not provided in the reports of the FDA or of Chollet and Jozwiakowski. Additionally, several differences in the assessment of compounded 17-OHPC were evident in those 2 reports.


Materials and Methods


This study has been deemed to be exempt by the University of Pittsburgh institutional review board because it involves no patients or biologic materials.


Identification of compounding pharmacies for recruitment


Twenty Maternal-Fetal Medicine specialists who were practicing in high-volume clinical centers (eg, university hospital-based clinics or large group practices) were contacted to obtain information regarding the compounding pharmacies that were used to fill their patients’ prescriptions of 17-OHPC. Many of these physicians were identified based on their participation as clinical investigators in various research networks.


Recruitment of the compounding pharmacies


Compounding pharmacists, who were contacted by study investigators or by the participating Maternal-Fetal Medicine clinicians, were asked to participate in the study. A representative sample of their compounded 17-OHPC was purchased and shipped to the University of Pittsburgh for testing. The funds for purchase of the compounded 17-OHPC came from the University of Pittsburgh at times that were not predictable. This uncertainty of time of purchase lessens the possibility that the pharmacies had any opportunity to provide anything other than a “representative sample” of 17-OHPC. Each pharmacist was then asked to participate in a brief survey regarding their compounding and quality assurance practices. The pharmacies’ voluntary accreditation status with the Pharmacy Compounding Accreditation Board was assessed by reviewing the website of accredited pharmacies ( www.pcab.org/accredited-pharmacies ; accessed on June 21, 2013). Samples (n = 3) were also from a research pharmacy that was used by the Maternal-Fetal Medicine Units Network and the Obstetrical-Fetal Pharmacology Research Units Network in trials that used 17-OHPC.


Sample analysis


Compounded 17-OHPC that was obtained from these various compounding pharmacies was stored at room temperature until analysis for content uniformity, impurity analysis, microbiologic testing, and pyrogen status.


Content analysis


Content and impurity analysis were performed at the University of Pittsburgh with high-performance liquid chromatography (HPLC) with a Waters 2695 Separations Module attached to a Waters 2998 Photodiode Array Detector 9 (Waters Corporation, Milford, MA). Aliquots of the samples were removed from the container in a laminar flow hood at room temperature and were tested to evaluate, in triplicate, concentrations of 17-OHPC, benzyl alcohol (a preservative), and benzyl benzoate (used to enhance solubility of 17-OHPC in castor oil). The sample was diluted with methanol or acetonitrile to a final 17-OHPC concentration of 50 μg/mL. Twenty microliters of this final solution was injected onto the HPLC. The concentrations of 17-OHPC (wave length, 242 nm), benzyl alcohol (wave length, 206 nm), and benzyl benzoate (wave length, 229 nm) in each sample were quantified with the use of corresponding standard compounds. The calibration curves were generated by least-squares linear regression analysis of the peak areas vs concentration in the standard curve samples. The retention times of 17-OHPC, benzyl alcohol, and benzyl benzoate were 13.5, 7.0, and 7.9 minutes, respectively, under the chromatographic conditions that were used.


Impurity analysis


Impurity analysis was also performed at the University of Pittsburgh. The same sample aliquots that were used for content analysis were analyzed for impurities. Quantification of the content of caproic acid was performed at 208 nm. Quantification of 17-OHP and the unspecified components in the sample were performed at 242 nm with the same chromatographic separation conditions that were used for 17-OHPC. The content of the other unspecified components was evaluated as the ratio of the area under the corresponding peak vs the area of 17-OHPC in the same sample. The percentage of each additional unspecified component in the test solution was calculated with the following formula: percentage of component = 100 × (Ac/Ar), where Ac is peak area of the individual component and Ar is the peak area of 17-OHPC in the same test solution.


The HPLC method was validated for the determination of 17-OHPC and its related impurities of 17-OHP and caproic acid. The limit of quantification values for 17-OHPC, 17-OHP, and caproic acid were 62.5, 10, and 200 ng, respectively on-column. Accuracy (≥90%) and precision (coefficients of variation, ≤10%) were evaluated by repeated analysis (n = 6) for 17-OHPC, 17-OHP, and caproic acid. The analytic stability of 17-OHPC and 17-OHP in the HPLC autosampler was confirmed over a storage period of 72 hours at 8°C (ie, the sample compartment temperature). The test formulations of 17-OHPC showed no increase in the amount of impurities over a 72-hour period in the autosampler.


Pyrogen and sterility testing


Sterility testing was performed by Eagle Analytical Services (Houston, TX) as described in the US Pharmacopeia Convention 71 with the membrane filtration procedure with tryptic soy broth medium and fluid thioglycollate medium under 22.5 ± 2.5°C and 32.5 ± 2.5°C, respectively, at days 3, 7, and 14 to test for bacteria, mold, yeast, and fungi in each sample.


Endotoxin testing was performed by Eagle Analytical Services as described in US Pharmacopeia Convention 85 using the turbidimetric procedure, with endotoxin inhibition/enhancement tests performed on each sample. Quantities of endotoxin are expressed in endotoxin units per milliliter. The Pyros Kinetix Incubating Kinetic Tube Reader (Associates of Cape Cod Incorporated, East Falmouth, MA) was used to detect endotoxin levels to 0.001 EU/mL.




Results


Twenty Maternal-Fetal Medicine specialists were contacted within each geographic region of the country (4 in the west, 3 in the northeast, 3 in the mid-Atlantic region, 6 in the south, 4 in the mid-west). Of the 20 physicians contacted, 15 agreed to participate. With the assistance of each of these physicians, a total of 17 compounding pharmacies were contacted and invited to participate in the study. Fifteen of these compounding pharmacies participated in the study by providing samples of 17-OHPC for testing (1 pharmacy provided 2 samples, and another pharmacy provided 3 samples). Twelve of these pharmacies additionally agreed to participate in a brief survey that described their compounding practices.


All of the formulations were clear, colorless, or pale yellow and without any particulate matter at the time they were received. Each sample of 17-OHPC was tested for potency, impurities (both specified and unspecified), and microbe and pyrogen status; the results are summarized in Tables 1-4 . The label from each sample reported a final concentration of 250 mg/mL of 17-OHPC. The average 17-OHPC concentration in these samples as determined by HPLC assay that had been performed at the University of Pittsburgh was 251 mg/mL ( Table 1 ). All of the samples tested were within the acceptable specification limits for potency (90-110%) and also as stated in the Makena NDA. The average percentages of benzyl benzoate and benzyl alcohol were 47% and 2.1%, respectively ( Table 1 ). The mean concentration for benzyl benzoate was exactly as stated in the Makena NDA with very little scatter around the mean. The mean concentration of benzyl alcohol was identical to the Makena NDA; however, 2 of the samples were out of the specification limits for benzyl alcohol.



Table 1

Chemical analysis of 17-OHPC, benzyl benzoate, and benzyl alcohol from different compounding pharmacies








































































































































Sample 17-OHPC, mg/mL Percentage of labeled concentration, % Content of benzyl benzoate, % Content of benzyl alcohol, %
1 239 96 49 2.2
2 253 101 46 2.0
3 261 104 47 2.3
4 260 104 48 1.9
5 251 100 51 2.1
6 244 98 46 2.8
7 244 98 43 2.1
8 255 102 44 2.6
9 254 102 44 1.9
10 247 99 46 1.9
11 265 106 48 2.3
12 265 106 49 2.1
13 251 100 47 2.0
14 247 99 48 1.7
15 248 99 48 1.9
16 243 97 49 2.0
17 243 97 46 2.0
18 243 97 45 2.1
Mean ± SD 251 ± 8 (CV, 3) 100 ± 3 (CV, 3) 47 ± 2 (CV, 4) 2.1 ± 0.3 (CV, 1)
90% CI 248–254 99–101 46–48 2.0–2.2
Accepted criteria a 225–275 90–110 46 1.7–2.3

CI, confidence interval; CV , coefficient of variation; 17-OHPC , 17-hydroxyprogesterone caproate.

Chang. Quality assessment of compounded 17-OHPC. Am J Obstet Gynecol 2014 .

a Criteria in Makena (Ther-Rx Corporation, St. Louis, MO) New Drug Application.



Table 2

Microbiologic and endotoxin assessment of different formulations of 17-hydroxyprogesterone caproate
















































































Sample Sterility a Bacterial endotoxin (endotoxin units per milliliter) b
1 Pass NA c
2 Pass 11.22
3 Pass <1
4 Pass 0.02
5 NA c NA c
6 Pass 0.06
7 Pass <1
8 Pass <1
9 Pass 0.006
10 Pass <1
11 Pass 0.005
12 Pass <1
13 Pass 0.078
14 Pass <1
15 Pass 0.013
16 Pass <1
17 Pass <1
18 Pass <1

Chang. Quality assessment of compounded 17-OHPC. Am J Obstet Gynecol 2014 .

a Testing carried out over a 14-day time period


b <300 IU/mL


c NA , not available (testing not done because of limited sample volume; <1 mL.



Table 3

Specified impurity analysis of compounded 17-OHPC


































































































































No. Concentration of caproic acid, μg/mL a Caproic acid a /17-OHPC b ratio, % Concentration of 17-OHP, b μg/mL 17-OHP/17-OHPC b ratio, %
1 30 0.012 242 0.10
2 0 0 99.8 0.04
3 0 0 99.0 0.04
4 0 0 107 0.04
5 30 0.012 179 0.07
6 0 0 49.5 0.02
7 0 0 52.0 0.02
8 50 0.020 53.2 0.02
9 0 0 0 0
10 0 0 0 0
11 30 0.012 47.3 0.02
12 0 0 96.2 0.04
13 0 0 152 0.06
14 0 0 51.9 0.02
15 0 0 52.4 0.02
16 0 0 48.4 0.02
17 0 0 0 0
18 0 0 0 0
Mean ± SD 7.8 ± 15.6 0.003 ± 0.006 73.8 ± 65.9 0.03 ± 0.03
90% CI 1.4–14.2 0.001–0.005 46.8–101 0.02–0.04

CI , confidence interval; 17-OHP , 17 hydroxyprogesterone; 17-OHPC , 17-hydroxyprogesterone caproate.

Chang. Quality assessment of compounded 17-OHPC. Am J Obstet Gynecol 2014 .

a Measured at 208 nm


b Measured at 242 nm with the use of standard curves that were generated with corresponding standards.


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May 11, 2017 | Posted by in GYNECOLOGY | Comments Off on Quality assessment of compounded 17-hydroxyprogesterone caproate

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