In mid-November, FDA commissioner Margaret Hamburg testified before a Congressional committee that FDA recommends new legislation that distinguishes between “traditional” and “nontraditional” compounding, with FDA having enhanced authority to investigate the latter. Nontraditional compounding would include, among other things, the volume of compounded product produced, its risks for sterility (if an injectable), interstate shipping and other factors.
Most recently (at presstime), the House Energy and Commerce Committee initiated an investigation of the International Academy of Compounding Pharmacists (IACP; Missouri City, TX) over allegations that it had orchestrated resistance to FDA inspections of member facilities—a contention that the organization denies. (It’s also worth noting that NECC was not a member of IACP, which has a relationship with the Pharmacy Compounding Accreditation Board that provides voluntary accreditation.) IACP contends that FDA failed its responsibility to police NECC, while conceding that “changes may be needed in some areas to address federal and state oversight of the compounding profession.”
Meanwhile, the Massachusetts state government has issued emergency rules to require compounding pharmacies to report volumes of drugs so produced, and to report to the state when other states are investigating a pharmacy’s products. It has also set up a commission to develop a report to the governor by year-end. “The compounding industry has evolved, and in some ways, it has outgrown the current regulatory framework, not just the state but the federal regulatory framework,” said Gov. Deval Patrick, according to a Boston Globe report.
The VALID Act specifies that compounded drugs be labeled as such (and with the notation that the drug has not been approved by FDA), and clarifies, to some degree, the distinction between pharmacies compounding drugs for individual patients (which has been and will continue to be under state regulatory authority) and those who are effectively engaged in manufacturing. The Secretary of HHS is to provide a list of drugs that are not to be compounded, and to prohibit the copying of commercially available drugs. A set of waivers allowing production of compounded product without individual prescriptions, and of certain types of pharmacies (such as those at hospitals) is also specified.
It’s not clear to what extent Markey’s proposed legislation would change the existing circumstances, except perhaps that physicians and patients are better informed that a compounded product is being dispensed. But even in that case, would a patient reconsider taking a drug that a physician is recommending? FDA already has authority to regulate what it believes to be manufacturers—but that authority has been under steady attack by trade associations affiliated with compounding pharmacists. Finally, FDA itself authorized the compounding (or, to be precise, announced that it did “not intend to take enforcement action against pharmacies” involved in the activity) of hydroxyprogesterone caproate, when KV Pharmaceuticals won approval to market that compound as a branded product, Makena, in 2011. KV (which is now in bankruptcy proceedings) intended to sell the drug for roughly $1,500 per injection, while the compounded product had been available for around $20.
Several trends are going to drive this debate: the heightened focus on using generic drugs as a cost-saving measure by health systems; the twists and turns that “personalized” medicine is taking—including bringing consumer interests and preferences into drug-dispensing decisions; and the intensifying push by pharmacists’ business and professional associations to have a greater say in prescribing practices. The ongoing drug-shortage problem has also played into this growing debate, as there are indications that a backup for some drugs in short supply has been to compound the product to address immediate needs. (Markey’s bill specifies a waiver for “when necessary to protect public health.”)