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Quality assessment of compounded 17-hydroxyprogesterone caproate

Published:November 06, 2013DOI:https://doi.org/10.1016/j.ajog.2013.09.039

      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.

      Key words

      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.
      • Meis P.J.
      • Klebanoff M.
      • Thom E.
      • et al.
      National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network: prevention of recurrent preterm delivery by 17 alpha- hydroxyprogesterone caproate.
      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).

      Food and Drug Administration. FDA statement on Makena, Nov. 8, 2011. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm279098.htm. Accessed Aug. 27, 2013.

      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.

      March of Dimes. Statement from the March of Dimes on 17P. Available at: http://www.marchofdimes.com/news/statement-from-the-march-of-dimes-on-17p.aspx. Accessed Aug. 27, 2013.

      Gunter J. March of Dimes response to Makena pricing reveals they are woefully out of touch. Available at: http://www.preemieprimer.com/march-of-dimes-response-to-makena-pricing-reveals-they-are-woefully-out-of-touch/. Accessed Aug. 27, 2013.

      Sherrod Brown, Senator for Ohio. Following Makena price hike controversy, Brown asks NIH director: how can we stop drug manufacturers from exploiting. Available at: http://www.brown.senate.gov/newsroom/press/release/following-makena-price-hike-controversy-brown-asks-nih-director-how-can-we-stop-drug-manufacturers-from-exploiting-taxpayer-funded-research. Accessed Aug. 28, 2013.

      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.

      Food and Drug Administration. FDA statement on Makena, March 30, 2011 Available at: http://www.fda.gov/newsEvents/Newsroom/PressAnnouncements/ucm249025.htm. Accessed Aug. 27, 2013.

      A recent report by Chollet and Jozwiakowski
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      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.

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      We undertook this study after the report of Chollet and Jozwiakowski
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      and before the time the FDA undertook their investigation.

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      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

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      or of Chollet and Jozwiakowski.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      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.
      • Caritis S.N.
      • Zhao Y.
      • Bettinger J.
      • et al.
      Qualitative and quantitative measures of various compounded formulations of 17-alpha hydroxyprogesterone caproate.
      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.

      Eagle Analytical ServicesvRapid Scan RDI–Bacteria, mold, and fungal test. Available at: http://www.eagleanalytical.com/sitecontent/589/rapid-scan-rdi-bacteria-mold-and-fungal-test/category/462/about-testing.aspx. Accessed Aug. 27, 2013.

      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 Table 1, Table 2, Table 3, Table 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.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      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
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      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.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      Table 1Chemical analysis of 17-OHPC, benzyl benzoate, and benzyl alcohol from different compounding pharmacies
      Sample17-OHPC, mg/mLPercentage of labeled concentration, %Content of benzyl benzoate, %Content of benzyl alcohol, %
      123996492.2
      2253101462.0
      3261104472.3
      4260104481.9
      5251100512.1
      624498462.8
      724498432.1
      8255102442.6
      9254102441.9
      1024799461.9
      11265106482.3
      12265106492.1
      13251100472.0
      1424799481.7
      1524899481.9
      1624397492.0
      1724397462.0
      1824397452.1
      Mean ± SD251 ± 8 (CV, 3)100 ± 3 (CV, 3)47 ± 2 (CV, 4)2.1 ± 0.3 (CV, 1)
      90% CI248–25499–10146–482.0–2.2
      Accepted criteria
      Criteria in Makena (Ther-Rx Corporation, St. Louis, MO) New Drug Application.
      225–27590–110461.7–2.3
      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 2Microbiologic and endotoxin assessment of different formulations of 17-hydroxyprogesterone caproate
      SampleSterility
      Testing carried out over a 14-day time period
      Bacterial endotoxin (endotoxin units per milliliter)
      <300 IU/mL
      1PassNA
      NA, not available (testing not done because of limited sample volume; <1 mL.
      2Pass11.22
      3Pass<1
      4Pass0.02
      5NA
      NA, not available (testing not done because of limited sample volume; <1 mL.
      NA
      NA, not available (testing not done because of limited sample volume; <1 mL.
      6Pass0.06
      7Pass<1
      8Pass<1
      9Pass0.006
      10Pass<1
      11Pass0.005
      12Pass<1
      13Pass0.078
      14Pass<1
      15Pass0.013
      16Pass<1
      17Pass<1
      18Pass<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 3Specified impurity analysis of compounded 17-OHPC
      No.Concentration of caproic acid, μg/mL
      Measured at 208 nm
      Caproic acid
      Measured at 208 nm
      /17-OHPC
      Measured at 242 nm with the use of standard curves that were generated with corresponding standards.
      ratio, %
      Concentration of 17-OHP,
      Measured at 242 nm with the use of standard curves that were generated with corresponding standards.
      μg/mL
      17-OHP/17-OHPC
      Measured at 242 nm with the use of standard curves that were generated with corresponding standards.
      ratio, %
      1300.0122420.10
      20099.80.04
      30099.00.04
      4001070.04
      5300.0121790.07
      60049.50.02
      70052.00.02
      8500.02053.20.02
      90000
      100000
      11300.01247.30.02
      120096.20.04
      13001520.06
      140051.90.02
      150052.40.02
      160048.40.02
      170000
      180000
      Mean ± SD7.8 ± 15.60.003 ± 0.00673.8 ± 65.90.03 ± 0.03
      90% CI1.4–14.20.001–0.00546.8–1010.02–0.04
      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.
      Table 4Unspecified impurity analysis of compounded 17-hydroxyprogesterone caproate
      Quantification at wavelength of 242 nm
      Sample17-hydroxyprogesterone caproate
      Impurity 1,
      Retention time, 2.9 minutes
      %
      Impurity 2,
      Retention time, 3.8 minutes
      %
      Impurity 3,
      Retention time, 6.7 minutes.
      %
      Total unspecified impurities, %
      10.030.160.050.24
      20.110.140.040.29
      30.080.010.060.15
      400.0400.04
      50.010.300.040.35
      600.200.020.22
      700.0700.07
      80.040.030.010.08
      900.050.020.07
      1000.060.020.08
      110.020.200.010.23
      120.040.0300.07
      130.070.1000.17
      140.070.0800.15
      150.200.050.030.28
      160.020.1600.18
      1700.0700.07
      1800.0700.07
      Mean ± SD0.04 ± 0.050.10 ± 0.080.02 ± 0.020.16 ± 0.09
      Median0.020.010.15
      Chang. Quality assessment of compounded 17-OHPC. Am J Obstet Gynecol 2014.
      a Quantification at wavelength of 242 nm
      b Retention time, 2.9 minutes
      c Retention time, 3.8 minutes
      d Retention time, 6.7 minutes.
      Findings related to sterility and endotoxin testing are summarized in Table 2. Of the 18 formulations, 17 had adequate volume for sterility and pyrogen testing, and all passed sterility testing and demonstrated no evidence of bacteria, mold, yeast, or fungi. Of the 18 samples from 15 pharmacies, 2 samples did not have sufficient remaining volume after potency and microbial testing to allow for endotoxin testing. Of the remaining 16 formulations that were tested, 9 had undetectable pyrogen level, and 7 had low levels of pyrogen, which was below that thought to be clinically relevant (ie, these samples had pyrogen levels below the recognized threshold of 300 IU/mL).
      Specified additional components that were evaluated included caproic acid and 17-hydroxyprogesterone; these components may be identified as impurities during testing. The quantity of each of these components is listed in Table 3. Caproic acid was detected in 4 samples with a final concentration of 30-50 μg/mL; in the other 14 samples, no caproic acid was detectable. All but 4 of the samples contained 17-hydroxyprogesterone with concentrations up to 179 μg/mL. The amount of these “specified impurities,” however, was very low when compared with the amount of 17-OHPC; the highest percentage ratio was 0.003% for caproic acid and 0.03% for 17-OHP (Table 3). The NDA specification limit is <0.58% for caproic acid and <1% for 17-OHP. Other measurable impurities that were “not identified” are listed in Table 4. The NDA specifications for “unspecified impurities” call for levels of <0.2%.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      In our cohort, only 1 of 18 samples exceeded this level. The total amount of the unidentified impurities was low and, quantitatively, amounted to an average of 0.16% of the amount of 17-OHPC (Table 4). No additional quantifiable peaks were evident in the chromatograms.
      Twelve of the 15 pharmacies agreed to participate in a brief survey that described their compounding practices. All of these pharmacies described scheduled or routine quality assessments of their compounded 17-OHPC, which consistently included sterility testing and potency testing in 75% of respondents.

      Comment

      The present study evaluates compounded 17-OHPC formulations that were obtained from compounding pharmacies that are used by Maternal-Fetal Medicine specialists in several high-volume clinical practices throughout the United States. The 17-OHPC compounded for the Maternal-Fetal Medicine Units trial reported by Meis et al
      • Meis P.J.
      • Klebanoff M.
      • Thom E.
      • et al.
      National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network: prevention of recurrent preterm delivery by 17 alpha- hydroxyprogesterone caproate.
      and the product approved by the FDA (Makena)

      Food and Drug Administration. 17 alpha hydroxyprogesterone caproate injection, NDA 21-9435. Adeza Biomedical Advisory Committee Meeting, Aug. 9, 2006. Available at: www.fda.gov/ohrms/dockets/ac/06/slides/2006-4227S1-01-01-Adeza.pdf. Accessed Aug. 27, 2013.

      have identical ingredients that include 250 mg/mL 17-OHPC dissolved in castor oil with 46% benzyl benzoate to help dissolution and 2% benzyl alcohol as a preservative. Recently, Chollet and Jozwiakowski
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      (whose research was supported by Ther-Rx Corporation, which distributes the FDA-approved 17-OHPC product from KV Pharmaceuticals, St. Louis, MO) examined various compounded formulations of 17-OHPC. The FDA performed a similar analysis of compounded 17-OHPC using the samples of Chollet and Jozwiakowski and additional samples that were obtained independently from other compounding pharmacies.

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      Our assessment of the compounded products differed in some key respects from the reports of the FDA and Chollet and Jozwiakowski (Table 5). We sampled only the final product from various compounding pharmacies and did not obtain the individual components that were used in preparing the 17-OHPC directly from the suppliers. We did not test the Makena product but relied on the FDA-approved standards for the compounded product. Our interest was focused on the product that patients received from the pharmacies that were used by the prescribing physicians. Our study also differed from the other 2 studies in that we performed microbiologic and endotoxin testing, whereas the other reports did not provide data on these parameters. Finally, we explored both specified (caproic acid and 17-OHP) and unspecified impurities and total impurities, whereas the other 2 reports commented primarily on unspecified and total impurities. Although our sample size was small, it was comparable to the size reported by the FDA

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      and by Chollet and Jozwiakowski.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      Table 5Comparison of studies that evaluated the quality of compounded 17-OHPC
      Chollet and Jozwiakowski (October 2011)FDA report (June 2012)Current study
      Active pharmaceutical ingredient (hydroxyprogesterone caproate powder)
       10 samples evaluated16 samples evaluatedNot done
       1/10 samples were OOSL for content (high-performance liquid chromatography)0/16 samples were OOSL for potencyNot done
       8/9 samples were OOSL for unspecified impurities0/16 samples were OOSL for total purity; 16/16 samples were OOSL for unidentified impurities; 4 impurities identifiedNot done
      Compounded formulations of 17-OHPC
       30 samples from 30 compounding pharmacies26 retained samples from Chollet and Jozwiakowski tests and 13 FDA samples from 8 compounding pharmacies18 samples from 15 compounding pharmacies
       5/30 samples were OOSL for content (high-performance liquid chromatography)3/26 samples of Chollet and Jozwiakowski were OOSL for potency0/18 samples were OOSL for content
       17/30 samples were OOSL for unspecified impurities7/26 samples of Chollet and Jozwiakowski were OOSL for impurities1/18 samples were OOSL for impurities
      1/13 FDA–acquired samples were OOSL for potency
      0/13 FDA–acquired samples were OOSL for total impurities, but 2/13 samples were OOSL for unidentified impurities
      Sterility and endotoxin testing of compounded formulations
       Sterility testing not reportedSterility testing not reported17/17 samples passed sterility testing
       Pyrogen testing not reportedPyrogen testing not reported16/16 samples passed pyrogen testing
      FDA, Food and Drug Administration; OOSL, out of specification limit; 17-OHPC, 17-hydroxyprogesterone caproate.
      Chang. Quality assessment of compounded 17-OHPC. Am J Obstet Gynecol 2014.
      We report that the compounded product from the selected pharmacies is consistent in potency with the product that was prepared for the Maternal-Fetal Medicine Unit study reported by Meis et al
      • Meis P.J.
      • Klebanoff M.
      • Thom E.
      • et al.
      National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network: prevention of recurrent preterm delivery by 17 alpha- hydroxyprogesterone caproate.
      and the product that was approved by the FDA (Makena). We found very little variation among the compounding pharmacies in the drug concentration (potency; mean value, 251 mg/mL). All samples in our cohort were within the acceptable range (90–110%) of declared potency on the label. In the FDA report, 1 of 13 samples (7.7%) from 8 different pharmacies was subpotent (potency, 80%). On the other hand in the report of Chollet and Jozwiakowski,
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      17% of samples were out of the acceptable potency range. The FDA reanalyzed the samples that initially were analyzed by Chollet and Jozwiakowski and found that only 11% of samples (3/26) were out of the acceptable potency range and that all of those samples were in the 115% range, which meant that the concentrations were 115% higher than the 250 mg/mL target.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      Thus, dramatic differences were seen in the results of the drug assays that were performed on the same samples by the FDA

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      and by Chollet and Jozwiakowski.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      Our results are more consistent with those of the FDA.
      In our cohort, unlike in the reports of Chollet and Jozwiakowski
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      and the FDA,

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      we performed microbiologic and pyrogen testing and found that all compounded samples were free from microbial contamination and without significant levels of pyrogen. There exist many potential sources of pyrogen including water, equipment used in the product preparation, and microbes. The assessment for pyrogens and microbes is highly relevant, given the recent calamity attributed to the New England Compounding Center where contaminated products, apparently resulting from improper preparation, are alleged to have led to death and serious morbidity in many patients.

      American College of Obstetricians and Gynecologists. ACOG/SMFM update on New England compounding center. Available at: http://www.acog.org/About_ACOG/Announcements/ACOG-SMFM_Update_on_New_England_Compounding_Center. Accessed Aug. 27, 2013.

      Sterilization of compounded 17-OHPC generally is performed by membrane filtration or by dry heat. Sterilization is more difficult with an oil-based viscous compound compared with a water-soluble compound. Although other methods of sterilization may prove effective, the current method that is used most often in the preparation of 17-OHPC for injection is filtration. This approach appears to be effective, based on the findings that we have reported here. As noted in the responses that we received from some of the compounding pharmacies in our cohort, isolation or quarantine of the compounded product for some period of time provides an additional safeguard against dispensing a contaminated product that may appear cloudy or may contain particulate matter that is visible in the solution.
      In both the FDA report

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      and the report of Chollet and Jozwiakowski,
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      the compounded products that were obtained from compounding pharmacies in the United States were tested for impurities. These impurities are detected in the assay method as “unspecified” peaks in the HPLC output. These peaks cannot be identified easily, unless the nature of the compound is known; therefore, these peaks are referred to as unspecified. A summation of these peaks or individual peaks generally are compared with all peaks or to the primary product and expressed as a percentage. A level of <0.20% was defined by KV Pharmaceuticals as an acceptable range for the FDA-approved 17-OHPC product (Makena).
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      Chollet and Jozwiakowski reported that 17 of 30 samples (57%) of 17-OHPC compounded by US pharmacies in their cohort contained at least 1 impurity of >0.2%.
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      In the FDA report, only 7 of 26 of the Chollet-retained samples (27%) contained unspecified impurities of >0.2%, and 2 of 13 of the samples (15%) that were obtained by the FDA from compounding pharmacies demonstrated unspecified impurities of >0.2%.

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      The FDA report concluded that the level and character of the unspecified impurities did not pose a risk. In our cohort, only 1 of 18 samples had unspecified impurities of >0.2%.

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      Unlike in the reports of the FDA

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      and Chollet and Jozwiakowski,
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      we reported results of our analysis of 2 components, caproic acid and 17-OHP, which are not unexpected in a formulation of 17-OHPC and are not expected to cause harm or alter the effectiveness of the active ingredient. These substances were present, albeit in low concentrations relative to the concentration of 17-OHPC. In the report of Chollet and Jozwiakowski,
      • Chollet J.L.
      • Jozwiakowski M.J.
      Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
      up to 6 unspecified impurities were seen in multiple formulations (typically 1 or 2 in each). Because they did not report specific impurity analysis, it is unclear if some of their unspecified impurities were indeed caproic acid or 17-hydroxyprogesterone. In the FDA analysis,

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      4 impurities were identified, but they likewise did not assess the samples for specified impurities such as caproic acid and 17-hydroxyprogesterone.
      In summary, we have analyzed formulations of 17-OHPC that were compounded by several pharmacies throughout the United States. We found that these compounded products provided the labeled amount of the medication (250 mg/mL) that was free of microbial contamination and contained no or clinically insignificant levels of pyrogen. The amount of unspecified impurities was well within acceptable limits; caproic acid and 17-OHP were the most common components. Thus, the compounded products that were provided by these pharmacies fulfilled the US Pharmacopeia Convention and Makena NDA criteria that are required for formulations of 17-OHPC. It is notable that most of these participating pharmacies endorse regular quality testing of their compounded17-OHPC formulations. In their report of June 2012, the FDA stated that it was applying its normal enforcement policies for compounded 17-OHPC and reiterated the general caution that the compounding of any medication should not exceed the scope of traditional pharmacy compounding if a compounding pharmacy is used for the preparation of 17-OHPC.

      Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

      A discussion with the pharmacy that prepares the product is prudent with a focus on the policies and procedures that are used by the pharmacy to ensure the production of a high-quality product.

      Acknowledgments

      Drs Chang and Y. Zhao contributed equally to the work. We thank the following individuals for their valuable assistance in identifying and/or recruiting pharmacies: Brenna Anderson, MD (Brown University); Leo Brancazio, MD (Duke University), Francesca Facco, MD (University of Pittsburgh); William Grobman, MD (Northwestern University); David Haas, MD (Indiana University); David Hackney, MD (Case Western Reserve University); Jay Iams, MD (the Ohio State University); Vanita D. Jain, MD (Delaware Center for Maternal Fetal Medicine, Christiana Care Hospital Services); Carol Lin, MD (Kaiser Permanente); Clifton Moore, MD (Ochsner Medical Center); Chris Robinson, MD (Medical University of South Carolina); Robert Silver, MD (University of Utah); David Stamilio, MD (Washington University); John Thorp, MD (University of North Carolina); Doug Woelkers, MD (University of California, San Diego).

      References

        • Meis P.J.
        • Klebanoff M.
        • Thom E.
        • et al.
        National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network: prevention of recurrent preterm delivery by 17 alpha- hydroxyprogesterone caproate.
        N Engl J Med. 2003; 348: 2379-2385
      1. Food and Drug Administration. FDA statement on Makena, Nov. 8, 2011. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm279098.htm. Accessed Aug. 27, 2013.

      2. March of Dimes. Statement from the March of Dimes on 17P. Available at: http://www.marchofdimes.com/news/statement-from-the-march-of-dimes-on-17p.aspx. Accessed Aug. 27, 2013.

      3. Gunter J. March of Dimes response to Makena pricing reveals they are woefully out of touch. Available at: http://www.preemieprimer.com/march-of-dimes-response-to-makena-pricing-reveals-they-are-woefully-out-of-touch/. Accessed Aug. 27, 2013.

      4. Sherrod Brown, Senator for Ohio. Following Makena price hike controversy, Brown asks NIH director: how can we stop drug manufacturers from exploiting. Available at: http://www.brown.senate.gov/newsroom/press/release/following-makena-price-hike-controversy-brown-asks-nih-director-how-can-we-stop-drug-manufacturers-from-exploiting-taxpayer-funded-research. Accessed Aug. 28, 2013.

      5. Food and Drug Administration. FDA statement on Makena, March 30, 2011 Available at: http://www.fda.gov/newsEvents/Newsroom/PressAnnouncements/ucm249025.htm. Accessed Aug. 27, 2013.

        • Chollet J.L.
        • Jozwiakowski M.J.
        Quality investigation of hydroxyprogesterone caproate active pharmaceutical ingredient and injection.
        Drug Dev Ind Pharm. 2012; 38: 540-549
      6. Food and Drug Administration. Updated FDA statement on compounded versions of hydroxyprogesterone caproate (the active ingredient in Makena) Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm308546.htm. Accessed Aug. 27, 2013.

        • Caritis S.N.
        • Zhao Y.
        • Bettinger J.
        • et al.
        Qualitative and quantitative measures of various compounded formulations of 17-alpha hydroxyprogesterone caproate.
        Am J Obstet Gynecol. 2013; 208 (74-80): 470.e1-470.e5
      7. Eagle Analytical ServicesvRapid Scan RDI–Bacteria, mold, and fungal test. Available at: http://www.eagleanalytical.com/sitecontent/589/rapid-scan-rdi-bacteria-mold-and-fungal-test/category/462/about-testing.aspx. Accessed Aug. 27, 2013.

      8. Eagle Analytical Services. Endotoxins. http://www.eagleanalytical.com/sitecontent/588/endotoxins/category/462/about-testing.aspx. Accessed August 27, 2013.

      9. Food and Drug Administration. 17 alpha hydroxyprogesterone caproate injection, NDA 21-9435. Adeza Biomedical Advisory Committee Meeting, Aug. 9, 2006. Available at: www.fda.gov/ohrms/dockets/ac/06/slides/2006-4227S1-01-01-Adeza.pdf. Accessed Aug. 27, 2013.

      10. American College of Obstetricians and Gynecologists. ACOG/SMFM update on New England compounding center. Available at: http://www.acog.org/About_ACOG/Announcements/ACOG-SMFM_Update_on_New_England_Compounding_Center. Accessed Aug. 27, 2013.