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Pharmacy Issues: 2004 ® Elizabeth Curry-Galvin, DVM Assistant Director, Scientific Activities AVMA-Schaumburg [email protected] Pharmacy Issues: 2004 ® Topics Compounding Ethical Products Internet Pharmacies Context Business Legal Ethical Reminder Allegations, No Names Policy vs. Not State laws and rules vary-check Colorado What’s Compounding? ® Definition Fills a niche Simply, the preparation of custom medication for a particular patient (manipulation--> unapproved drug) Pharmacists or Veterinarians No drug approved for condition Approved drug needs modification Examples Mixing two pre-anesthetics Tablets into suspension Diluting Flavoring Be Precise ® Avoid generalizing when discussing “compounding” DRUG VCPR Custom medication prescribed for one animal vs. purchases outside of a VCPR SCALE Approved drug (AMDUCA) vs. bulk drug [raw drug ingredient or chemical] (not legal) Individual animal (compounding) vs. manufacturing / wholesaling (piracy) ANIMAL Food vs. non-food animal (different risks, differences in regulatory discretion) 2 Compounding Issues ® Address Piracy Compounding from bulk drugs is not legal Need regulatory discretion from states and FDA when veterinarians compound medically necessary drugs from bulk ingredients for individual, non-food animals, within a VCPR because no drug is approved and available to adequately treat the patient. “Piracy” (manufacturing unapproved drugs) ® “Piracy” as distinct from traditional compounding Essentially wholesaling unapproved drugs Made from bulk ingredients Circumvents FDA drug approval & monitoring process Mass markets products with little quality control Mimic approved drug (knock-off) Omeprazole, enrofloxacin, praziquantal, ivermectin formulations Beware these are not generics! Why Piracy? ® Financial Drivers $$$$$ Pirating firms Veterinarians Purchase drug at lower price than approved product, pass along or keep savings Unfamiliarity Mass production with no FDA costs Lack of appreciation of differences between FDA approved and compounded drug Lack knowledge of laws and rules Mistaking compounded drugs for generic drugs Assuming provider is working in patient’s best interest Little enforcement visible in recent history..changing Approved Drug Assurances ® Safe Effective Studied under label conditions of use in target species No contaminants (chemical, biological, toxins) Studied under label conditions of use Not sub- or super-potent (active ingredient) Formulation proven successful Batch to batch consistency No surprises You get what you paid for Approved Drug Assurances ® Scientifically proven expiration dates Scientifically proven withdrawal times Proper packaging assures stability Label information derived from studies Dose, indications, precautions, contraindications Post-marketing surveillance / Label updates Adverse event tracking Laws & Rules ® Federal Oversight Different “rules” for humans vs. animals! FFDCA does not permit veterinarians to compound unapproved finished drug products from bulk drug substances (affirmed by two Federal Appeals Court decisions) AMDUCA-permits compounding from approved drugs FDA Compliance Policy Guide on Compounding “when the scope and nature of compounding raise the kinds of concerns normally associated with a drug manufacturer” State Oversight Board of Pharmacy Laws, regulations, policies, standards Why is Piracy Bad? ® Denies patient treatment with approved drug Safe, effective, pure, potent, stable, GMPs Exposes patient to unapproved drug Contaminated, sub- or super-potent, unstable Exposes parties to unnecessary liability Undermines R&D by drug companies Veterinarians will have fewer approved drugs Bulk ingredients…quality? bio-terrorism? Illegal AVMA Position on Compounding ® Decision to use compounded drug driven by veterinarian within VCPR Comply with AMDUCA and FDA Compliance Policy Guide on Compounding for Animals Food safety concerns preclude use unless information exists to assure avoidance of illegal tissue residues AVMA Position on Compounding ® Limited to: Safety and efficacy of compounded drug demonstrated in target species, Response to therapy or drug concentrations can be monitored, or Individual patients where no other drug delivery is practical. Precautions, counsel client, adverse reactions, unintended exposure 2 Compounding Issues ® Address Piracy Compounding from bulk drugs is not legal Need regulatory discretion from states and FDA when veterinarians compound medically necessary drugs from bulk ingredients for individual, non-food animals, within a VCPR because no drug is approved and available to adequately treat the patient. New CPG on Compounding ® Replaced 1996 CPG (federal) Emphasizes FDA’s concern with compounding that approximates manufacturing Did it make use of bulk drugs in compounding illegal? Written to facilitate enforcement No, compounding from bulk drugs has been not legal for years However, less text on regulatory discretion..bulk New CPG on Compounding ® Less text on regulatory discretion for medically necessary bulk drugs Includes an Appendix Bulk drugs for which the FDA would not ordinarily object if compounded Certain large animal antidotes No listing of bulk drugs that are important companion animal therapeutics, e.g. potassium bromide Makes one worried if needed drug is “not on the list” Renewed visibility of thorny issue Business as usual? Should CPG be withdrawn? ® IACP (pharmacists) lobbying veterinarians COBTA says “no” Pro-enforcement against mfg. of unapproved drugs Seeking ways to specify regulatory discretion Medically necessary drugs compounded from bulk ingredients for individual non-food animals when no such approved drug exists COBTA meets March 26-27 In-Office Use ® “In-Office Use” generally recognized by state Pharmacy Boards Upon prescription, pharmacist prepares small quantity for veterinarian’s “in-office” use (administration) Facilitates timely administration of medication since compounded drug often mailed Product labeled “In-Office Use” in place of patient name Stability not definitively known…watch shelf life Not to be used as stock from which to dispense Makes pharmacist a “wholesaler” “Resale” of Compounded Products ® FDA Compliance Policy Guide Concern with “compounding drugs for third parties who resell to individual patients, or offering compounded drugs at wholesale to other state licensed persons or commercial entities for resale.” Possible state Board of Pharmacy rules Makes pharmacist a wholesaler Don’t buy pirated drugs wholesale for resale Don’t receive a drug compounded by a pharmacist for a particular patient, change the label & dispense “Resale” of Compounded Products ® Question whether you can dispense “In-Office Use” compounded drug to provide timely treatment and bridge the time needed for the mail order drug to arrive (needed regulatory discretion) Question whether you can prescribe, pay for, and receive a drug compounded by a pharmacist for a particular patient, then sell it (unaltered) to the client with a mark-up (?) Reminders ® A drug is a formulation, not just an active ingredient Changes in formulation affect bioavailability Adsorption, Distribution, Metabolism, Excretion transdermals Alterations in bioavailability affect treatment outcome Reminders ® Compounded drugs are NOT generics Generics have been approved by FDA to ensure safety, efficacy, quality, stability, package, label Flavored preparations can be legally compounded when APPROVED drugs are flavored Flavoring can be an non-legal profit center for those who flavor bulk drugs without purchaser’s knowledge State Compounding Issues ® Arkansas Board of Pharmacy Regulation 0702-0002 Section (m)(5) “Compounding for office stock for veterinarians is prohibited, except for compounds to be used in life-threatening situations where lack of immediate availability of the product could result in patient harm and no FDA-approved product is commercially available.” ArVMA opposes, under discussion State Compounding Issues ® Texas Board of Pharmacy Proposal “The quantity of all compounded pharmaceuticals distributed to all practitioners during the previous 12 months pursuant to this exception does not exceed 5% of all prescriptions compounded and dispensed during the previous 12 months. For the purposes of the exception, distributions to practitioners shall not be included in the 5% if the pharmacy receives and documents within 30 days of distribution, the name of the patient to whom the compounded pharmaceutical was administered.” “Ethical” Products ® AVMA defines ethical product: Mfg. voluntarily limits sale to veterinarians Often different name/packaging than direct to consumer products Sold only to veterinarians as a condition of sale that is specified in a sales agreement or on the product label. “Ethical” Products ® AVMA Principles of Vet. Med. Ethics state “it is unethical for veterinarians to use or permit the use of their names, signatures, or professional status in connection with the resale of ethical products in a manner which violates those directions or conditions specified by the manufacturer to ensure the safe and efficacious use of the product.” “Ethical” Product Diversion ® Distribution channel is manufacturer’s policy Not government restricted distribution, e.g. Rx Manufacturer’s responsibility to enforce its policy—contact manufacturer with concerns Legally not appropriate for associations to seek to influence those policies Manufacturer may deny future purchases? Registered as distributor? Tax laws? Flea and Tick ® 40% of practices only sell flea and tick products to clients who have visited with the pet in the last year. 43% practices sell to anyone Source: VetMedTeam.com in Veterinary Economics, October 2003 Internet Pharmacies ® Internet pharmacies are here to stay! Honor client requests for prescriptions Know your rights Know your responsibilities Answers & enforcement frequently found at state level Do your part right; Can’t police everything Offer clients value and convenience Speak factually Report complaints; Complete documentation AVMA Position on Internet Pharmacies ® Drug therapy initiated by DVM within VCPR Veterinarians should honor client requests to prescribe rather than dispense a drug Client has option of filling at any pharmacy Might advise clients of VIPPS pharmacies Veterinarians asked by pharmacies to approve prescriptions they have not initiated should do so only if the prescription is appropriate and VCPR exists AVMA Position on Internet Pharmacies ® Veterinarian’s purview to determine medical criteria whereby drug is indicated, not pharmacist Maintain written record of prescription Communicate proper use, risks regardless of drug source Use of drugs of foreign origin that lack FDA approval generally is not permitted Current Commonly Asked DVM Questions ® Can I charge for a prescription? Do I have to provide a prescription? Can I write a prescription to be used at a Canadian pharmacy? Generic substitution? Can I ignore the fax, but work with client, and offer a written Rx? Hospital policy? What can I say about the pharmacy? Can I insist the client come in for a written Rx? Where do I report….? Other Contacts ® Consumer calls Is it legal for my vet to… Agency Calls: MO, MI, TN, DE responding to consumers allegations (Per FTC: It would be within its jurisdiction to create a regulation if consumer complaints indicate consumers need greater protection) Jurisdictional Challenges: agencies may not see total picture Internet (human) pharmacy is exploring animal drugs Environmental ScanningFTC ® 1978 FTC regulations require prescribers to provide eyeglass prescriptions; upheld by courts Dec. 6, 2003 President Bush signed Fairness to Contact Lens Consumers Act; FTC jurisdiction Congressman’s wife’s experience (10 years), “long overdue, important consumer’s rights issue” Requires prescriber to provide copy of prescription Prescriber may not charge for prescription Requires prescriber to verify electronic prescription requests w/in 8 business hours or request is considered authorized Consumers Union an early supporter Environmental Scanning ® Reader’s Digest from Consumer Reports (a publication of Consumer’s Union) “…the veterinary care industry languishes in the Stone Age of consumer-protection law…” “…dispute a bill…Fluffy may be held hostage under state lien laws…” “…vets dispense medicine, but few states require basic price disclosure and some don’t even mandate written prescriptions for those keen on bargain hunting…” Environmental Scanning ® VIPPS program for “veterinary pharmacies” To my knowledge, there are no animal-related: Pharmacy school classes required for graduation Licensure requirements CE requirements American College of Veterinary Pharmacists Offering certification to pharmacists who complete educational program on animal drugs and their regulation Society of Veterinary Hospital Pharmacists Revenue Impact of I.P. in Well-Managed Practices ® Medicine dispensed: 15% total revenue 50% say volume of meds dispensed declining Drop in pharmacy revenue? 11% drop say 1 percent of respondents 6-10% drop say 6 percent <5% drop say 38 percent No change in revenue say 55% Source: The 2003 Well-Managed Practice Study according to Veterinary Economics, October 2003 Environmental Scanning ® Prepare for change-United Kingdom Address current medicine margins Identify contribution to practice income & profits Assess true costs of supplying medicines Premises, heating, lighting Staff time for ordering, unpacking orders, stock control, auditing stock and labeling, dispensing. Consider difference between all medicine sales being lost vs.losing half…retain most of cost base Source: Peter Gripper, Anval, “In Practice” publication of British Veterinary Assoc. Environmental Scanning ® Pharmacy and flea and tick products provide an average of just 3-4% of gross profit and Pharmaceuticals have even less of an impact on the bottom line after accounting for operating expenses Source: Cynthia Wutchiett, Wutchiett, Tumblin and Assoc. in Veterinary Economics, September 2003 “By overcharging for medications or refusing to volunteer written prescriptions, the profession invites both regulation and loss of respect.” Source: Linda Walker, Amboy Assoc., Veterinary Economics, Sept 2003 Enviromental Scanning ® “Charge for your time both on the farm and in the exam room” and “Those fighting the Internet are modern day Don Quixotes.” Source: David M. Lane, DVM Newsmagazine, Jan 2004 Wake up call: “Change emphasis from selling products to providing services-and charging appropriately for services” and Sell at competitive prices to avoid client perception that everything else is overpriced Source: Ronald Whitford, Veterinary Forum, Sept 2003 Impact of pet insurance? Taxation of Internet? Need for Information Exchange ® Know your state rules and tell others! Understand application of jurisdiction Groom relationships between Bd. Of Vet Med and Bd of Pharm Groom relationships between state VMA and state Boards Recycling Label of dispensed products Boards know the rules VMAs have constant interaction with profession Report trouble! And document! Are laws/rules adequate? Envision a preferred future