Setting the scene: Pharma manufacturers and the FDA (part 2 of the Recall of -sartans series)

Since my previous post on the recall of -sartans, Torrent Pharmaceuticals recalled 36 additional lots of losartan potassium and losartan potassium/hydrochlorothiazide. Over the next few weeks, I will be covering various aspects of the global drug production industry as most of us, at some point or the other, would have had utilised its outputs. And we would have done so under the impression that the product we paid for (or were administered) should work, with as little side effects as possible. For the product to work, it should comprise of a precise amount of active ingredient(s), having either no contaminants or below maximum permitted limits. Tweak this formula a bit and we are looking not only at a potential placebo, but one with side effects (some of which can be dangerous). In the recent recall of -sartans, the tweaking is mainly associated with generics.


Brand-names & generics
What are generics? Drug development and manufacturing is an extensive and expensive process, requiring capital, time, and resources. This also entails extensive research and testing of a potential drug to check its efficacy, quality, and safety. Thus, very often, this is carried out by big pharmaceutical companies (e.g. Novartis, Roche), with the outputs being patented and the patent being protected for a certain duration. Given the costs involved in this process (from formulating an idea to the product being stocked in pharmacies), drugs or active ingredients manufactured by the big pharmaceutical companies (a.k.a. brand-name drugs) tend to be priced high. When the patent protection runs out after some years, other pharmaceutical companies can avail of the patent and replicate the brand-name drugs/active ingredients - these are the generics. These are significantly cheaper than the brand-name drugs for mainly three reasons:
  • Firstly, the unprotected patents can be used by anyone, leading to multiple manufacturers of generics. As there is more competition, the price of the drug decreases.
  • Secondly, these new manufacturers need not spend substantial capital, time, and resources (as essentially most of the work has been done by the big pharma), apart from proving that their generic works as a good copy of the original (e.g. Novartis's brand-name Diovan and the respective generic Valsartan). 
  • Thirdly, most manufacturers of the generics (drugs or active ingredients) are located in countries where the production costs are lower (e.g. China and India). 

The result is that generics are widely used.

Recalls & the US FDA
The recalls of -sartans led to more than a ripple in the global pharmaceutical industry as this was highlighted by the US Food & Drug Administration (FDA). One of the stated aims of the FDA is to ensure that drugs/active ingredients sold in the US comply with their standards for quality, safety, and efficacy. Obtaining FDA's approval involves several components, often including visits by FDA's inspectors and evaluation of data maintained by the manufacturer:

  • verification that the production process/factory follows good manufacturing practices (GMP)
  • verification of the properties relating to the active ingredient
  • verification of the presence/absence of any contaminants

The past years have witnessed a high approval of generics in the US, with around 80% of active ingredients being sourced from non-US facilities. This high rate was for meeting the promise of Trump administration on lowering the costs for medicines.

Whilst the election promise and the FDA inspection are aimed at the ensuring the US population have access to affordable and safe drugs, my blog post next week will list the problems associated with the verification process.

Image by Remaztered Studio from Pixabay 

The recall of -sartans (part 1)

The past few months witnessed the recall of several medicines (notably in the US) as these contained amounts of nitrosamines (specifically, N-Nitrosodimethylamine (NDMA), N-Nitroso-N-methyl-4-aminobutyric acid (NMBA), N-Nitrosodiethylamine (NDEA)), all suspected of being carcinogens according to International Agency for Research on Cancer (IARC). These nitrosamines were detected in certain angiotensin II receptor blockers (ARBs; prescribed for multiple conditions such as hypertension and heart failure) having the "-sartan" active ingredient, viz., irbesartan, losartan, and valsartan. The contamination had occurred during the production processes (the first was seen in products from Zhejiang Huahai Pharmaceutical Co. Ltd) (this will be elaborated in my post next week). The presence of the nitrosamines led to the recall of the -sartans and patients resorted to replacements... until last week.

Last Thursday, the US Food and Drug Administration (FDA), via FDA Commissioner Scott Gottlieb and Janet Woodcock (Center for Drug Evaluation and Research), identified 40 generics that are free of nitrosamines and, thus, safe for ingestion. At the same time, they also urged patients to take the impure batches of losartan. Their reasoning is as follows:
1. The recall of impure medicines led to the shortage of pure medicines as the manufacturers struggled to keep up with the demand
2. For a patient having no access to the pure medicines and not taking any medicine for their condition, the risk from other health complications (such as stroke or heart failures) cannot be ignored
3. The impure batches of losartan have negligible amounts of nitrosamines that may not increase the risk for cancer if taken for a short time

Therefore, in their opinion, it is in the best interests of patients to take the impure losartans until the shortage is resolved in approximately six months. The pros (regulating blood pressure and decreasing the probabilities of heart failures or strokes) outweigh the cons (cancer risk).

FDA's list of pure generics and their recommendation to take impure losartan are not without flaws. Regarding the list, the onus is in on the doctors and pharmacies to ensure that the prescribed (and dispensed) medicine is one of those. At the same time, it would be in the best interests of the patients (or their families) to check the prescription against the list. Regarding the temporary use of impure losartan, whilst this would make sense given the cons, what would be the outcome in vulnerable patients? Furthermore, what would be the outcome if the patient has been taking impure -sartans for several years? For a patient recently prescribed -sartans, the carcinogenic risk might be low; this would not hold for someone having taken the impure -sartans for years. These are arguments that both doctors and the FDA ought to consider.

Nonetheless, for any patients taking a -sartan based medicine, the first port of call ought to be their doctor and asking for a replacement. And, regardless of what the doctor prescribes and what the pharmacy delivers, it is imperative to check against FDA's acceptable list of nitrosamine-free ARBs.