Technical Guide Change Control
Technical Guide Change Control
A Practical Guide to
Change Control
Systems Management
. . . FDA has cited
a number of
manufacturers
for lack of
comprehensive
change control
systems.
by
Shahid T. Dara
President
Compliance Consulting Inc.
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hange is accepted as
part of everyday manufacturing operations by
current good manufacturing
practice (cGMPs) and FDA.
Pharmaceutical manufacturers
have developed excellent quality/compliance systems to minimize unplanned changes in the
manufacturing/packaging operations. However, planned changes
also require a stringent set of
controls to attain desired results.
In recent years, FDA has cited a
number of manufacturers for lack
of comprehensive change control systems. The Agency
expects industry to have quality/compliance systems in place,
which should trigger a chain of
events whenever there is change
involving a drug product or medical device intended for consumer use. The ultimate goal is
to build quality into a drug product instead of testing a sample
for conformance at the end,
thereby rigidly controlling any
changes and deviant behavior of
the systems involved.
This paper will provide quality/validation professionals with
basic concepts about change
control systems, different types
cGMP REGULATIONS
AND CHANGE CONTROL
Since the end of World War II,
the pharmaceutical industry has
experienced tremendous growth
and expansion in more than just
economic terms. Starting with
antibiotics, the drug discovery
process has introduced hundreds of new remedies along
with new and novel drug delivery
systems, transforming the art of
formulation into a pure science.
Technological advances in manufacturing equipment enabled
industry to not only increase the
speed of manufacturing, but
improve the quality of the end
product as well. All these
changes in pharmaceutical manufacturing happened in a little
over 50 years, and the process
is continuing. The new global
economic realities and market
pressures of the 1990s have
forced the entire industry to
adopt cost-effective ways of
managing every aspect of the
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business. There are fewer qualified individuals
managing multitudes of critical responsibilities
within each organization, thereby making it imperative that new techniques of managing quality and
compliance be adopted.
This constant cycle of change demands effective tools to control all such changes related to
drug products. FDA and other regulatory agencies
in the world accept the fact that change is part of
the pharmaceutical business, but expect industry
to have effective change control systems in place
to assure that the quality, strength, and efficacy of
drug products are not compromised.
Evolution of cGMPs
On the legal front, the regulatory and
quality/compliance expectations for the pharmaceutical industry have steadily increased over the
past 90 plus years, since the enactment of the
Food and Drug Act of 1906, to the point where it is
one of the most regulated industries in the world
today. Drug regulations continued to evolve over
the first half of the 20th century and culminated in
1962 with the introduction of Current Good
Manufacturing Practices (cGMPs) regulations.
Section 501(a) (2)(B) of the Food, Drug and
Cosmetic Act deems a drug to be adulterated if:
the methods used in, or the facilities or
controls used for, its manufacture, processing,
packing, or holding do not conform to or are not
operated or administered in conformity with current good manufacturing practices to assure that
such drug meets the requirements of this Act as
to safety and has the identity and strength, and
meets the quality and purity characteristics,
which it purports or is represented to possess.
The cGMP regulations were developed by the
Pharmaceutical Manufacturers Association as
guidelines for its member companies in the early
1960s and were later adopted by the FDA as part
of the Food, Drug and Cosmetic Act of 1962. From
FDAs perspective, these regulations were meant
to provide a precise, easily understood set of standards that would help both compliance and
enforcement, while encouraging the new innovations to improve the manufacturing and control
practices. Therefore, the word current in these
regulations takes on a critical meaning, as it
implies that the manufacturers will change their
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211.160:
(a) The establishment of any specifications,
standards, sampling plans, test procedures, or
other laboratory control mechanisms required by
this subpart, including any changes, in such
specifications, standards, sampling plans, test
procedures, or other laboratory control mechanisms, shall be drafted by the appropriate organizational unit and reviewed and approved by
the quality control unit. The requirements in this
subpart shall be followed and shall be documented at the time of performance. Any deviation from the written specifications, standards,
sampling plans, test procedures, or other laboratory control mechanisms shall be recorded and
justified.
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strengths and weaknesses from a quality/compliance point of view. The policy is a general statement which should spell out the quality mission of
the company along with broad guidelines on which
different quality systems will be part of the quality
program. Quality policy is usually part of the
Corporate Quality Manual, which delineates the
generic quality concepts and systems that all the
divisions of a company are supposed to develop,
depending on each units individual requirements.
Quality Culture
Corporate quality policies and quality manuals
can be useful only if the organization as a whole is
committed to its principles. Otherwise, these documents would collect dust on bookshelves, while
everyone in the company had their own interpretation of quality responsibility and accountability.
Therefore it is imperative that the organization strive
to develop a quality culture based on mutual understanding of each operational units function within
the company, with due recognition for the expertise
of different departments and individuals. Such a
working environment creates mutual respect among
peers while developing a team with a common goal:
to produce quality drug product within the cGMPs.
This means quality assurance inspectors and auditors are considered part of the team and not the
cops with a got-you attitude. Also, in such a quality
environment, efforts are directed at solving the
quality problems by addressing the systems
related issues instead of finger pointing to who did
it. In other words, the quality issues are freed from
the cult of personality conflicts.
Organizational Structure
One key aspect of the quality policy and manual
is that it should define the quality responsibility and
reporting structure of different operational units,
assuring that there is no bias when a critical quality
decision is to be made. FDA and cGMPs are vague
on the organizational and reporting structure within
a pharmaceutical manufacturing operation.
However, the Agency does expect an independent
quality function responsible for deciding all the quality-related issues which could impact a distributed
drug product or a clinical study material.
With the evolution of quality assurance practices
over the past 30 years or so, most pharmaceutical
companies now have a separate quality assurance
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master SOP also defines the general classes or
types of changes that might be encountered within a
given manufacturing operation and which changes
are considered critical, major, or minor, based on
general guidelines. The master change control system oversees the functioning of subsystems, as each
one is established for a unique type of change, for
example deviations, nonconforming materials handling, out-of-specifications data investigations, etc.
For the change control subsystems, each should
have an SOP defining a given change and how to
manage it, with its attendant corrective actions, etc.
One key element of any corrective action plan is
how it is to be implemented and whether it involves
additional training for employees. Finally, there
should be an effective audit trail to assure that the
desired changes are being implemented in a controlled environment, with full documentation of each
critical step involved and employee training and
retraining whenever necessary.
Training
Employee training in change control systems and
related procedures is essential in enforcing such a
system. The training program should be interactive,
detailing the impact of changes on the overall quality
of the drug product being manufactured and the consequences if these changes are not controlled. For
example, little deviations from an approved NDA procedure or SOP, at the time of occurrence, might
seem of no consequence, but an accumulation of
these changes can result in an adulterated drug
product, since the NDA procedure or SOP is no
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Pre-Approval Supplements
A major change to manufacturing/packaging pro-
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cess, materials, product, or procedures require
prior approval by the FDA before it can be implemented. Such a submission to FDA is referred to as
a Pre-Approval Supplement. However, there is a
minor distinction here that the change under review
can be implemented prior to FDA approval, but the
drug product so manufactured/packaged cannot be
marketed until FDAs approval of the supplement.
Internal Audits
An effective internal audit program is another
practical approach to managing change control, as
it enables the entire organization to be proactive
for planned changes while ensuring the resolution
of unplanned changes, which might have gone
unnoticed. Also, the internal audit program can be
designed to help promote a team approach to
resolving quality/compliance issues; however, it is
a huge subject in itself and, therefore, cannot be
discussed in any detail here.
Product Complaints
Product complaints should be thoroughly investigated and quantified where needed. A rash of
related complaints could be an indication of a
major change in the product, involving the components, the process, or both. Such a situation
should be handled as an emergency, and a fullscale investigation should be initiated to pin down
the change causing the quality complaints.
How to Avoid Surprises?
No one likes surprises during an FDA visit,
especially it demonstrate that the company does
not have an effective change control system. And
that could have far reaching consequences. In
recent years, FDA has cited a number of manufacturers for a lack of comprehensive change control
systems, especially in regard to incomplete failure
investigations. The best way to avoid any surprises
is to have a vibrant quality function within the organization with a quality culture that promotes selfpolicing by all departments. The change control
system should trigger a chain of events that prohibits the use or distribution of suspect quality
materials or drug products until the resolution of
change. Communication is the key to the success
of such a system, as sharing information helps
everyone understand the situation in a better way
while training individuals for future incidents.
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on industry practices grew with time. In recent years,
the change control issue has been cited as a major
cGMP deficiency by the FDA, while inspecting manufacturing facilities, both for dosage forms and active
pharmaceutical ingredients (API), but this discussion
is limited to dosage form manufacturers only. A comprehensive change control system should be able to
control the impact of any changes encountered
within a pharmaceutical company that might have a
bearing on product quality/compliance status. Also,
the master change control system should have supporting subsystems, which can adequately handle
any of the situations possible.
The following is an overview of different phases
and components involved in drug product development, the manufacturing process, and what
changes can occur in different scenarios. This
review is meant to address the possible quality
impact of the potential changes as well as how to
control them without compromising the quality of
the drug product and outlining what the procedural
considerations should be.
been that with the manufacture of the first biobatch, the entire manufacturing process should be
performed in compliance with cGMP regulations.
Bio-batch is the term used to describe that lot of
drug product used for the first clinical studies. That
is the reason that companies have a cGMP development area and a non-cGMP development area.
This practice has some benefits, but in todays
cost-conscious environment, it is much more beneficial to have one set of rules for the entire company to follow, with far less potential for any major
mishaps. If research and development and manufacturing departments are following the same basic
procedures as far as documentation practices,
change control, and employee training are concerned, then the transition from R&D to manufacturing can be much smoother. Another advantage
is that all changes and improvements made during
the development phase are properly documented
and can be a tremendous source of information for
future references.
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implementation and will be submitted to the Agency
as a supplement to an NDA/ANDA drug product
with pertinent stability and process data.
Inactive ingredients or excipients however, are
changed more frequently as the dosage form formulation is optimized. Depending on the drug substance and dosage form involved, there are always
a couple of excipients in each drug product that
are critical for its success, both for drug delivery as
well as stability of the dosage. Their percentages in
a formulation are finalized based on both scientific
knowledge and experimental data. However, any
quantitative change in a critical excipient could
have a devastating effect on the quality of the drug
product, as it can be the bulking agent in tablet, a
carrier for a lyophilized injectable, or a key preservative in a liquid. If the change in excipients is considered critical, it requires FDA pre-approval.
Excipients
Most excipients used in drug product formulation
are United States Pharmacopoeia (USP) or National
Formulary (NF) grade and therefore are well characterized chemical entities. It is common practice to
use more than one manufacturer of an excipient as
long as the raw material meets its compendial specifications. Of course, formulations using different
sources of excipients have to be evaluated for stability and overall quality of the drug product. However,
there is a potential that an unapproved source of an
excipient might find its way into a formulation, contending that it is the same official grade material.
Chemical distributors have earned a reputation for
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switching raw materials manufacturers without
notice. In most cases, such a change should be
caught at the time of receiving the material, not during the sampling/inspection process. The material
should then be put on hold for latter disposition.
Sometimes a source change is inevitable due to
natural disaster or other reasons, and that is where
the change control system should trigger the mechanisms to protect the safety, efficacy, and purity of
the dosage form. Such a change might necessitate
a reevaluation of the formulation and could even
affect the manufacturing process. In most cases, this
leads to additional stability testing of the finished
drug product, concurrent at controlled room temperature (CRT) and ambient humidity.
Equipment
The manufacturing process development starts
with lab-scale equipment and moves through midsize equipment in the pilot plant, leading to a biobatch size, which is the base for future scale-up.
Throughout this process the equipment changes
occur. Sometimes it is not just a bigger piece of
equipment, but could be of different mechanical configuration, if so dictated by the process needs. All
such changes should be documented and evaluated
for future references. During the development process, the equipment needs to evolve as the formulation characteristics are better understood. Also, batch
size and the economics of manufacturing efficiencies
also impact the selection process. Equipment
changes will be discussed in more detail later.
Process
As the manufacturing process evolves from the
development lab through the pilot plant, the process parameters begin to take shape as well.
Some of these are as follows:
Critical Process Conditions
Process conditions include mixing times, machine
speed set-ups, processing temperatures, and process time limits. Changes in these conditions should
be documented and evaluated for their impact on the
drug product. At this stage, change is part of the
development process, and it must happen. However,
even at this stage, all changes should be documented, evaluated, and kept under control.
Scale-Up Factors
Change from bio-batch to commercial-size batch
is termed scale-up, and the Agency allows a 10
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Controlled Environment
Since most drug products are temperature or
humidity sensitive, the environmental conditions
should be defined as the process is being developed, based on chemical and microbial stability of
the formulation in general and end product in particular. Again this information evolves as the process is developed, but any deviant behavior of the
manufacturing process should be documented
under adverse environmental conditions.
In-Process Controls
In-process controls and sampling/test points are
identified as the manufacturing process is evaluated in detail. For each dosage form there are
some standard in-process tests, and then there are
others which are formulation specific. These latter
tests represent the critical stages during the manufacturing process, which can potentially compromise the integrity of the drug product. The in-process specification evolution should be documented
and justified so that any future changes can be
correlated without jeopardizing the drug product.
Finished Drug Product Specifications
Finished drug product specifications are, again,
those which are dosage-form specific and then others
are formulation specific. Their development history is a
reflection of the chemical and microbiological nature of
the API(s) and their interaction with excipients during
the manufacturing process. The finished drug product
specifications include physical characteristics, chemical purity, and acceptable bio-burden for a given
dosage form. These specifications do change as the
development process progresses and more information becomes available from process evaluation and
stability studies. All such changes should be documented and explained for future reference.
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Analytical Method Development
Whether it is a compendial method or not, each
analytical method has to be qualified for a given
testing laboratory. Depending on the nature of the
formulation, the methodology always undergo
changes, which should be fully documented and
justified according to method qualification protocols.
Stability Testing
Stability testing starts at an early stage in the development process, and the only major change is usually
in the container/closure system, depending on the stability profile of the drug product. Another change can
be the storage conditions for the stability samples,
again depending on the temperature, humidity, and
sensitivity of the drug product. All changes in the container/closure system and storage conditions should be
documented, explaining the reason for every change
and its impact on the drug product involved.
Product Development Report
As the initial development process comes to a
close for a drug product, a complete development
report should be prepared, detailing the following:
Formulation: List of ingredients with quantities
per dosage unit and their quality reference,
i.e., USP, NF, etc.
List of manufacturing equipment:
Manufacturing process: Development and
scale up process with special emphasis on
bio-equivalence of bio-batch versus the commercial drug product
Packaging process: Container/closure system
and packaging conditions
Analytical methods
In-process and finished-product specifications
Stability studies protocols and data summary
Detailed discussion of process deviations and
excursions during the development and scaleup process and consequent corrective actions
Conclusion and summary
Such a report can be a ready reference for a
given product for future trouble-shooting. Also, it
can be presented to the FDA if needed instead of
bringing in stacks of paper for their review.
Facilities Changes
Facilities are usually not considered critical
when a change control system is devised.
Pest Control
21CFR Part 211, Subpart C
Buildings and Facilities
211.56 Sanitation
This section clearly states that the manufacturer
should have written procedures in place to define the
responsibility and procedures for cleaning and sanitation of facilities. It also requires that only those rodenTechnical Guide
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ticides, insecticides, and fungicides which are registered and used according to the provisions of the
Federal Insecticide, Fungicide, and Rodenticide Act
(7 U.S.C. 135) can be used in a pharmaceutical manufacturing facility. Requirements of this section apply
to both contractors and company employees. Only
approved pest control agents should be used in the
facility, and this approval is granted by quality assurance with due consultation with other departments.
Pest control is usually performed by outside contractors. Each visit should be fully supervised to
ensure that components, container/closures, or drug
products are not exposed to any of these agents. If
there will be a change in any of the agents, it should
be pre-approved by the appropriate organizational
units according to the pest control SOP. The contractor should be periodically audited to ensure that only
approved chemicals are used and in the right concentration. An unauthorized change of pest control
agents could compromise the quality and safety of
the drug products involved.
Natural Disasters
Following a natural disaster, most organizations
experience the most profound changes possible, yet
companies strive to recover as quickly as humanly
possible. A tornado or a flood can devastate manufacturing facilities, destroying inventories of both components and finished drug products. Even under such
circumstances, the change control activities should
be part of the Disaster Recovery Plan, as it will be
necessary to change the quality status of a number
of components, packaging/labeling materials, and finished drug products, from acceptable to rejected due
to natural cause. Though the investigation will be simple, the activities have to be performed to close out
inventory cards, batch records, etc.
Another aspect of the Disaster Recovery Plan
should address how to recover all the quality/compliance information related to marketed drug products. Equipment could be replaced, but critical documentation recreation is a monumental task. In
brief, companies should have a comprehensive
Disaster Recovery Plan that addresses not only the
financial data, but also scientific, technical information, and documentation, and this could be part of
the master change control system.
Utilities Changes
Although cGMPs refer only to lighting, the
HVAC system, and water supply under utilities,
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Critical Utilities
Define the critical utility systems for the operations, ones that could have an impact on drug
product quality and include:
HVAC system
Water purification system
Dust collection system
Compressed air system
Clean steam
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impact on the operation of the system. In other cases,
a critical part might have to be replaced, which could
have a major effect on the operation of the utility system and the quality of its product and service provided to the operations. In most instances, such part
changes are addressed during validation of these
systems, clearly defining which part changes could
lead to a requalification of the system. This aspect is
usually covered under the validation change control
SOP that describes the criteria for such an option and
the review and approval process. In other words,
mechanics and technicians are not allowed to change
parts without prior approval from appropriate organizational units, including quality assurance.
For each utility system there should be a maintenance SOP in place, defining the parts change control and a list of approved parts or a reference to the
utility system equipment manual. Use of unapproved
change parts should be strictly prohibited, as it
could compromise the performance of the system.
Sometimes utility systems are underutilized and,
as the operational activities increase, the utility systems are expanded to meet the increased demand or
to supply a utility to another part of the operation. It is
a common practice to extend the water supply pipelines or to add outlets for compressed air. These are
major changes and additional piping and outlets will
necessitate extensive cleaning of the pipes, etc., to
prevent contamination of the system as a whole. This
system extension should be strictly controlled, as it
can affect the overall operation of the utility system as
well as its validation status. Also, as part of this
change control system, the as-built drawings of the
system must be changed to reflect these extensions.
Operational Parameters
Each utility system operates within a predetermined set of conditions or parameters. If these
operational parameters are changed, it could
impact the functioning of the system as a whole. It
could be the rate of feed water supply to a deionizing tank in a water purification system or the
operating temperature for a compressed air system. Such a change should be avoided at all costs,
as it can physically damage the system. But, if
such a change does occur, it should be addressed
immediately to control the damage and minimize
the impact on the quality of the drug products
involved. Every utility system is equipped with controls, alarms, and emergency shutdown mechanisms, which immediately trigger a chain of events
to control the situation. However, the operators and
Equipment Changes
Manufacturing/packaging/analytical equipment is a
major capital investment, and each piece is carefully
selected considering a companys immediate and
long-term manufacturing needs. Usually, major pieces
of equipment are not changed very frequently, as is
evident from the fact that some manufacturing operations employ equipment that is 20 30 years old.
Although cGMPs refer to current technology, there is
no regulation barring the use of old equipment if it is in
good repair and qualified to perform the job required.
Another fact is that a number of old application products were approved with the old equipment available
at the time, and many companies find it very costly to
upgrade some of that equipment, as it will require a
number of regulatory submissions. However, some old
pieces of equipment are replaced by newer equipment
because of technological innovation or capacity reasons. Such equipment change is usually very well
controlled, as it involves the qualification of new equipment, including product specific process validation.
The first few lots manufactured with the new equipment are placed on stability, either on concurrent CRT
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or under accelerated conditions, depending on the
regulatory status of the drug product and its stability
profile. If it is an NDA/ANDA drug product, FDA is notified either through a pre-approval supplement to the
application or as a changes being effective (CBE)
notice, along with process and stability data.
SUPAC (Scale-Up and Post-Approval Changes)
guidelines were developed jointly by FDA, industry,
and academia in response to the growing number of
changes that the pharmaceutical industry had experienced in manufacturing operations in recent years,
which resulted in an excessive number of submissions to FDA for application drug products. Another
factor that contributed toward this effort was a rash of
mergers and acquisitions over the past decade,
which led to a considerable consolidation of manufacturing operations and technology transfers from
one plant to another. While addressing the questions
of process scale-up and how to handle post-approval
changes in manufacturing procedures and specifications, these guidelines also provide a definition and
listings of what is considered similar equipment,
based on the same design and operating principle
for immediate release drug products. Examples of
similar equipment include replacing a ribbon blender
from one manufacturer with a ribbon blender from
another manufacturer, as it will not present any
change in design or operating principle. Switching
from a ribbon blender to a V-blender is a change
involving different equipment based on their design
and operating principle. However, applicants should
review each equipment change case on its own
merit and make a judicious decision based on sound
scientific data. Switching from a ribbon blender to a
fluidized bed dryer and mixer is a major change that
affects the manufacturing process parameters. Try
not to justify this change as part of the SUPAC
Similar Equipment Guideline. These are useful reference guides and can be of tremendous value when
replacing equipment or transferring manufacturing
from one plant to another. There are some limitations, however, which will be discussed later.
Equipment Usage
Routine usage of equipment also needs to be
managed from a change control perspective.
Possible variables, which could impact the quality
of the drug product, include:
Machine setups
Mixing speeds
Timers
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Equipment cleaning procedures should be followed religiously, and cleaned equipment should be
inspected and released for use by quality assurance. However, the biggest source of variation in
equipment cleaning sometimes is the cleaning procedure itself, as it may be vague. Another variable is
uncontrolled use of cleaning agents, as the individual procedures may not describe the dilution factors
and how to prepare a solution from concentrate. But
most of all, the manufacturing crew responsible for
cleaning might cause the biggest problem by not following the cleaning procedures, using incorrect dilutions of agents and causing drug product contamination. Thus, operator training in correctly following
the equipment cleaning procedures is as important
as knowing how to use the equipment.
If a drug product is contaminated due to inadequate cleaning of the equipment, the change control
system should immediately trigger the batch to be
placed on hold/quarantine until the investigation is
complete and a decision is made as to its disposition.
Such an investigation will focus on both the quality
failure of the product as well as failure of the cleaning
procedure itself. If the suspected drug product can be
proven to be safe and effective based on analytical
data and clinical toxicology of the potential contaminants, then it should be considered for release to distribution. Otherwise, it should be non-conformed and
processed according to the non-conforming materials SOP. The cleaning procedures involved might
require extensive revision and follow-up training of
the operators. All such activities should be documented, reviewed, and approved by quality assurance, and the revised SOPs and training records
made part of the change control investigation.
parts without prior approval from appropriate organizational units, including quality assurance.
There should be a maintenance SOP in place
for each major piece of equipment, defining the
parts change control and a list of approved parts or
a reference to the equipment manual. Use of unapproved change parts should be strictly prohibited,
as it could compromise the performance of the
equipment. All critical part changes should be
logged into the individual maintenance log for each
piece of equipment to maintain traceability. If the
equipment requires too many change parts too
often, it might be time to replace it.
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are within calibration when installed. The change
control system should address these changes, as it
is a compliance requirement to have all critical equipment and associated controls calibrated which could
have an impact on the safety, quality, purity, identity,
and strength of a drug product.
Equipment Breakdown
Equipment failure in the middle of a manufacturing or packaging run is a critical but unplanned
change that needs to be carefully controlled to protect the integrity of the drug product. The product
or in-process materials should be quarantined
immediately to assess the impact of the breakdown and how long it will take to repair the
machine. The process time limit conditions for the
given operation should also be considered to
assure that these limits are not exceeded. If this is
the case, additional sampling and testing might be
required before proceeding further with manufacturing or packaging operations. This is more critical
for liquid preparations and those with natural ingredients, as these drug products are more prone to
supporting microbial growth.
For parenteral drug products, if the equipment
breakdown exceeds the validated process time limits, then the drug product has to be discarded.
There should be an SOP addressing equipment
breakdown change control situations, detailing the
steps needed to assure the integrity of the product,
including review and approval requirements and
follow-up actions. There should be a log of equipment breakdown, recording each incident, cause,
and how long the equipment was out of commission. Also consider the extent of repair required
and its effect on the validated status of the equipment. Frequent breakdown of equipment is a sign
of age or poor maintenance practices.
Automated Equipment
Automated equipment operation, repair, and maintenance pose a different set of issues from a change
control perspective. Whenever there is a change
involving the PLC boards or software code upgrades,
it should be carefully reviewed by information technology and quality assurance personnel to assure that
the equipment will continue to perform within its validation parameters. All such changes should be documented, reviewed, and approved by quality assurance
according to the change control SOP. The equipment
should be fully tested before it is released for use.
Likewise, if there is a software code change, then all
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Component Changes
Raw Materials
Raw materials include both active pharmaceutical ingredients as well as excipients, and possible
changes could include the following:
Manufacturer Change
Alternate manufacturers are essential to maintaining the reliable supply of a drug product. A
manufacturing change is either a planned change
to qualify an alternate source or to respond to an
emergency caused by a plant shut down due to
natural disasters or quality/compliance issues. In
either case, the formulation change control procedure should be followed. The formulation has to be
re-evaluated, and the drug product has to undergo
additional stability testing to assure that the new
API has no impact on the purity, safety, efficacy,
and quality of the drug product. The stability testing
could be concurrent if the API from a new manufacturer proves to be identical to the original
source. Also, the impurity profile of the new API
and its stability characteristics must be established
to make it a viable source. Such a change requires
pre-approval by FDA prior to its implementation
and will be submitted to the Agency as a preapproval supplement to an NDA/ANDA drug product with pertinent stability and process qualification
data. In this case, the API from a new source is
proven to be identical to the original and is a com-
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pendial material. This change in formulation could
be reported to FDA as a Changes Being Effective
(CBE) supplement.
A new manufacturing process or major change in
the manufacturing process of an API can have similar consequences. Such a change would again
require pre-approval by FDA prior to its implementation and submitted to the Agency as a supplement
to an NDA/ANDA drug product with pertinent stability and process data. However, in some cases, this
can be a CBE supplement, if the change in manufacturing process is an improvement in the overall
quality of the API. Nonetheless, the drug product
manufactured with the new API has to be evaluated
for stability. This type of change has to be communicated to the drug manufacturer by the API manufacturer and requires effective communication between
the two based on a recognized quality agreement,
mandating that any change in the manufacturing
process be reviewed and approved by the dosage
form manufacturer.
A change in physical characteristics of an API
can also have a critical effect on the drug product,
for example, particle size, crystal form, isomeric resolution, etc. These can impact the manufacturing
process, like mixing times for powders, dissolution
rates, drug delivery, and in-vivo bio-availability. Such
potential changes should be carefully monitored and
controlled via routine sampling and testing of the
API. A sudden change in physical characteristics is
a clear sign of a change or deviation in the manufacturing and purification process of the API. For
dosage form manufacturers, such changes can be
reported to FDA as part of an Annual Report, if the
data shows no adverse effects on the drug product.
A change in the impurity profile of the API
poses an equally serious challenge and could go
undetected if the incoming API samples are not
routinely checked for impurities. Potentially, this
could have fatal consequences for the end user
and be a major regulatory nightmare for the drug
product manufacturer. To avoid this situation, each
shipment of an API should be tested for known
impurities of consequence, and if the API fails its
specifications for impurities, it should be considered for rejection. It gets real interesting when
unknown impurities are found during testing of the
finished drug product while assaying for the API,
putting the drug product release in jeopardy. To
trace the source of an impurity is a monumental
task, and the culprit could be the API itself or the
manufacturing process, like a cleaning agent
residue. Such instances should be duly investigated, and the drug product disposition decision
should be made after considering all the relevant
facts, analytical data, regulatory consequences,
and above all, the consumers health and wellbeing.
Excipients
Most excipients used in drug product formulation
are USP or NF grade and therefore, are, well characterized chemical entities. It is common practice to
use more than one manufacturer of an excipient as
long as the raw material meets its compendial specifications. Of course, formulations using different
sources of excipients have to be evaluated for stability and overall quality of the drug product. However,
there is a potential that an unapproved source of an
excipient might find its way into a formulation, contending that it is the same official grade material.
Chemical distributors have earned a reputation for
switching raw material manufacturers without notice.
In most cases, such a change should be caught at
the time of receiving the material, and if it goes
unnoticed, during the sampling/inspection process,
the material should be rejected. Sometimes, a
source change is inevitable due to natural disaster or
other reasons and that is where the change control
system should trigger the mechanisms to protect the
safety, efficacy, and purity of the dosage form.
A change in a critical excipient would have more
impact on the quality of the drug product compared to
a minor ingredient, especially if it has any bearing on
the dissolution or bio-availability of the dosage form.
In such a case, the formulation with the new excipient
should be carefully monitored for stability profile as
well as dissolution and bio-availability behavior. If the
new excipient has impacted any of these features, a
pre-approval supplement to the application might be
required. If it can be proved that the excipient from
the new manufacturer is equivalent to the original,
then such a change could be reported as CBE or
even as part of the Annual Drug Report.
Storage Conditions
Storage conditions for raw materials are equally
critical in maintaining the quality of a drug product.
This is especially true for biological derivatives and
those raw materials that are susceptible to heat,
humidity, or microbial infestations. Warehousing
practices and overall environment monitoring of the
facilities should have built-in change control mechanisms whenever the temperature/humidity condiTechnical Guide
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tions drift from the specified ranges. Storage conditions are of critical importance for soft gel capsules
both empty and filled. If these are stored at very
high temperature or under extreme humidity conditions, the soft gels become brittle and fail to perform during the capsule filling operation.
Packaging Components
Packaging components describe the immediate
container/closure system for the drug product and
usually include the following:
Bottles
Caps
Tubes
Cans
Vials
Ampoules
Stoppers
Filler
Desiccants
Blister materials (both base and lidding)
Storage Conditions
Like raw materials, packaging components should
be stored under controlled temperature and humidity.
Exposure to excessive heat and dry conditions could
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make certain plastic bottles brittle and even develop
cracks. Such conditions can also adversely affect the
liner material on closures, especially the pressure-sensitive type. High humidity can also cause deterioration
of cotton, used as filler in packaging operations, by
making it soggy or facilitating microbial growth.
Storage conditions should be constantly monitored
with built-in alarms to trigger corrective actions if the
temperature/humidity conditions drift outside the predetermined specifications. Details of such a system
should be described in an SOP and be part of the
master change control system.
Process Changes
The manufacturing process generally consists
of a number of unit operations, e.g., tablet manufacturing involves blending, wet or dry granulation,
milling, drying, and compression as unit operations. Each unit operation has its own set of critical
parameters that determine the quality of the overall
manufacturing process. To fully understand the
complexity of a manufacturing process, all the unit
operations should be drawn up as a flow diagram.
Based on the sensitivities of the drug substance
involved and the dosage form being manufactured,
define the critical steps, which need to be monitored against any change. Mapping of the manufacturing process is usually done during the pro-
Process Parameters
Process parameters usually refer to machine
set-up, mixing speeds, mixing times, drying temperature, sequence of addition of ingredients, etc.
They all usually have a predefined range described
in the batch record that is based on the process
qualification and validation data. Most of the time
these process parameters are followed religiously,
and the manufacturing operations go on smoothly.
However, once in a while, the granulation might be
over-mixed or dried at a temperature that was out
of its range for part of the cycle. Worst of all, many
of these digressions are not caught when they
happen, and they come to surface only when the
finished batch record is being reviewed by quality
control prior to its release for distribution. Now, the
granulation that was dried under the suspect drying cycle has already been compressed, as the inprocess test for moisture content was well within
specifications and the finished product also met all
its specifications. But this is a deviation nonetheless and a change that must be reviewed by
appropriate organizational units to pin down the
cause of deviation and its impact on the quality,
safety, and efficacy of the drug product and is evaluated according to the deviation SOP. The product
disposition should be decided based on the nature
of the deviation, product quality history, and the
available data.
Process Conditions
Process conditions refer to the manufacturing
environment, and it includes both the facilities as
well as the temperature/humidity conditions. Depending on the nature of the drug product, the environmental controls can vary from simple temperature/humidity controls to extensive environment
monitoring schemes utilized for aseptic processes.
Most manufacturing operations are carried out
under controlled temperature and humidity conditions. An occasional deviation from the settings
should be considered as part of the system operation and could be caused by extremes of external
environment. However, if the drug substance or unit
operation involved is temperature or humidity sensitive, then it is a cause for investigation, and such a
change should be controlled. Again, such changes
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are usually noticed post-occurrence and, therefore,
fall under the category of unplanned deviations and
should be processed accordingly.
Reprocessing
Reprocessing is allowed under cGMP regulations; however, it is a critical change in an otherwise validated manufacturing process. It could be
a failure of an in-process material or the bulk finished drug product that could force a company to
consider a reprocessing option. There should be a
reprocessing SOP in place to address such a situation. First of all, the cause of the failure should
be investigated per quality failure investigation
SOP. The impact of reprocessing on the safety
and efficacy of the drug product involved should
be thoroughly studied. If it is an NDA/ANDA drug
product, regulatory implications of reprocessing
should also be carefully examined. Once all the
reviews are done and a decision is made to reprocess the material involved, a reprocessing procedure should be prepared, reviewed, and approved
by manufacturing and quality assurance. The
reprocessing procedure should also detail any
additional sampling and testing to be performed. It
should define if the reprocessed batch is to be
placed on concurrent stability for long-term monitoring. A detailed investigation report should also
be prepared, focusing on the corrective actions,
particularly the need for revalidation of the manufacturing process. As the batch in question is
being considered for reprocessing, it should be
placed under quarantine according to the nonconforming materials SOP, so that it is not processed
any further.
CHANGE CONTROL
MANAGEMENT TOOLS
A master change control system is composed of
a number of individual procedures and systems
that are meant to control changes in various
aspects of the operational activities within a pharmaceutical manufacturing operation. Such a system should be interactive, managed by the quality
assurance function with due representation from
other functionary disciplines to address different
changes. An integral part of any change control
system is an effective quality failure investigation
procedure. This section details some of the tools
and procedures that should be implemented to
have an effective change control system.
20
Deviations
21CFR211.100 Written Procedures; Deviations
This section mandates that there will be written
procedures for production and process control to
assure the identity, strength, quality, and purity of
the drug product. However; if there is a deviation
from written procedures it shall be documented
and justified. The following discussion is a procedural approach on how to handle any deviations.
Definitions
A deviation is any modification or temporary
change in any approved procedure, document, or
specification. The deviation request/report is a specific one-time use document that will modify documents contained within or referenced by the batch
record. It does not permanently change existing
specifications, SOPs, or other batch record documents. These documents could be revised according
to document change control procedures, if needed.
Types of Deviations
Deviations could be process or procedure
related, and the following types of deviations can
be found in a manufacturing operation.
Planned vs. Unplanned
A planned deviation is a proposed change to
any approved procedure, document, or specification prior to execution. An example is the use of
water-for-injection instead of purified water to rinse
cleaned equipment.
An unplanned/in-process deviation is an unexpected event that requires a change to any
approved procedure, document, or specification. It
is usually discovered after the fact. An example is a
sudden change in temperature/humidity in the
manufacturing area, missed sampling points, or
temperature digression during a drying cycle outside the specified range.
Temporary vs. Permanent
A deviation could be temporary or permanent,
depending upon its impact. If the deviation is a
one-time occurrence, then it should be treated as
temporary. Otherwise, if the deviation is going to
result in permanent changes in an approved procedure, document, or specification, then it is a permanent change and will require detailed follow-up
corrective actions to implement the required
changes, including employee training.
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Lot Specific vs. Multiple Lots
A deviation is usually lot specific for a given
drug product but can also involve multiple lots.
Product Specific vs. Multiple Products
A deviation is generally product specific, but in
some cases, it can involve more than one drug
product. An example is a sudden failure of the
water system, impacting multiple drug products,
which might have used suspect-quality water for
equipment cleaning or product manufacture.
Potential Areas of Deviations
Following is a listing of potential deviation areas
and how each could influence the drug product
quality attributes.
Materials
Raw materials as well as labeling and packaging components must meet their quality specifications before their usage in manufacturing. Yet there
will be situations when an unreleased material
might end up in manufacturing, or an unapproved
labeling component might be used in the labeling/packaging operation.
In either case, the impact on the quality/compliance status of the drug product should be
reviewed in detail before deciding its disposition.
Equipment
The sudden breakdown or malfunction of equipment is an unplanned deviation that could have an
adverse impact on drug product quality. Also, if the
equipment is beyond its calibration period and is
used in manufacturing, packaging, or testing of the
drug product, it will compromise its compliance status. Such deviations may not have any apparent
effect on the quality, safety, and efficacy of the drug
product but still have compliance implications.
Another deviation could be replacing equipment by
similar or comparable equipment in the middle of a
manufacturing run. Such a change should be documented and justified at the time of occurrence and
be pre-approved by the quality assurance function.
Process
Deviations from both process parameters and
process conditions could affect the drug product.
Machine setups, mixing speeds, drying temperatures, etc., all should remain within the preset limits. Any digression would be a deviation and would
require an investigation, especially if the machine
Practices
If the written procedures are not followed
strictly, this will be a deviation as spelled out by the
regulations. For example, if sampling procedures
are not followed, the samples collected will
become suspect, and any data obtained from their
testing will not be of value to make any quality
decisions. Such a deviation requires resampling
and retesting of the materials along with other corrective actions, including retraining of employees.
Documentation practices
cGMPs require that all quality/compliance
related documents be prepared, reviewed, revised,
and approved according to written SOPs. Likewise,
such documents should be used in a consistent
manner; if not, this will be a deviation that has to be
explained. Documentation practices are a cause for
concern throughout the company, and employees
should be trained and retrained on this subject.
Test Methods
Analytical test methods are qualified relative to
a given drug product and set of instruments.
Whenever there is a deviation from an approved
analytical procedure, it requires a detailed investigation and sound scientific justification before the
data is accepted for any quality decision. Some
deviations are minor, yet these should be documented, while others could lead to a reevaluation
of the analytical method or the instrument used.
Sometimes deviation from an approved test
method is necessary because of compendial
changes, and the written procedure is yet to be
reviewed and approved by the organization.
Specifications
Specifications are based on sound scientific
data and are a direct result of drug product behavior during the development process. Raw material
and packaging component specifications are either
based on the most current USP or supplier specifications. Deviations from approved specifications
result in failure and rejection or rework of the materials involved.
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Deviation Management
Whether a deviation is planned or unplanned,
there should be a change control system in place
to handle it. Essential elements of such a system
would include the following:
SOP
There should be a written procedure in place on
deviation processing, detailing all the steps necessary in resolving a deviated scenario.
Deviation Report
A standardized deviation report form should be
part of the SOP. Such forms should be prenumbered for control and reference purposes and controlled and issued by the quality assurance function. QA should also be responsible for the appropriate closure of each deviation report. The deviation report form should detail all the steps necessary to complete the investigation and resolution of
an incident.
Probable Cause
The deviation reporter or requester should provide information as to the probable cause of the
incident, especially if it is process related.
Otherwise, the quality/compliance review committee would have to find the cause of the deviation
as part of the investigation.
Responsible Personnel
Whenever a corrective action is required, the
corrective action plan should clearly define the
responsibilities and accountabilities with quality
assurance to oversee the effort. By naming the
individuals or departments, it becomes much easier to follow up on the progress of the project.
Deviation Disposition
Once the investigation phase is completed, a
decision needs to be made to decide the disposition of the materials or drug products involved.
Consider if the deviation is an isolated incident or
involves multiple lots of the same drug product or
multiple drug products. Due consideration should
be given to the stability profile of the product, as
most process-related deviations necessitate additional stability testing for the lot under review. Also
look into the regulatory/compliance status of the
drug product; the regulatory affairs department
should agree to the proposed disposition of the
product. All deviations should be reviewed periodi-
Corrective Actions
The quality assurance function should consult
with the affected department(s) to determine if a
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cally to determine if there are any trends developing which could be indicative of systemic problems. In other words, what might appear to be an
isolated incident could prove to be an ongoing
quality issue that requires systemic changes, both
procedural and practical.
each nonconforming situation and deciding the disposition of the materials involved. This could be
part of the quality/compliance review committee.
Definitions
Nonconforming material refers to a material that
fails to meet quality acceptance criteria or its predefined specifications. A Nonconformance Material
Report (NCMR) is a specific onetime use report,
which documents the nonconformance material
and its disposition.
Material Review Board refers to a group of
individuals within an organization representing
quality assurance, quality control, regulatory
affairs, operations, production planning, and purchasing. This group is responsible for reviewing
Labeling Components
Incoming labeling components could fail to meet
specifications due to shipping damage, contamination, and, most serious of all, printing errors.
Sometimes, labeling changes are mandated by
FDA, and the existing stock of labeling components can no longer be used and, therefore,
becomes nonconforming. In such situations, the
labeling components involved should be declared a
nonconforming material according to company policies and procedures.
In-Process Materials
In-process materials require further processing to
complete the manufacturing cycle and are sampled
and tested at critical points during the process to
assure that the process is functioning within its limits. Sometimes the in-process materials fail to meet
specifications upon testing, and the material should
be declared nonconforming at this stage. It might be
resampled and retested or reprocessed depending
on the nature of the failure and its cause. But by
declaring it a nonconforming material, it is assured
that the material will not be processed further. Also
expired in-process materials should be processed
as nonconforming and be destroyed.
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Finished Drug Products
When a finished drug product fails to meet
specifications or alert limits, it should be declared
nonconforming at this stage to prevent its distribution unless the deficiency is corrected by reprocessing or repackaging. Also, expired drug products should be processed as non-conforming
materials and be destroyed.
Nonconforming Materials Management SOP
There should be a written procedure in place on
Nonconforming Materials Handling, detailing all
the steps necessary in deciding the disposition of a
nonconforming material.
Nonconformance Material Report (NCMR)
A standardized NCMR form should be part of
the SOP. Such forms should be prenumbered for
control and reference purposes and be controlled and issued by the quality assurance function. The latter should also be responsible for
appropriate closure of each NCMR form and disposition of associated materials. The NCMR
form should detail all the steps necessary to
resolve a nonconforming situation and document
the disposition decision as well as actual disposition of the materials as to when and by whom.
Probable Cause
The nonconformance reporter should provide
information as to what materials are involved and
what could be the apparent cause of this nonconformance, such as shipping damage or sampling error,
etc. The material review board or Quality/Compliance Review Committee can further investigate
the issue to define the most probable cause.
Review/Investigation (if needed)
Some nonconforming situations are self-explanatory, like material contaminated with oil or
grease, while others require more in depth investigation, especially those involving a raw material
sample test data, failure of an in-process material,
or a finished drug product. Quality assurance
should define if there is a need for further investigation in consultation with other departments. The
investigation phase could involve resampling and
testing of the materials involved in order to gather
more information. A review of the process validation
history and drug product quality profile might also
be required to determine the possible cause of failure and potential corrective actions, if possible.
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Committee. There should be a rework procedure prepared and approved by quality assurance before
reprocessing or repackaging is initiated and the
rework procedure becomes part of the batch record.
The justification for the rework decision should be
fully documented and become part of the NCMR file
for the drug product involved.
Reprocessing/repackaging is an example of a
temporary change control system that allows for a
one time deviation from the approved manufacturing or packaging procedure to correct a quality
deficiency. Here, a normally processed batch has
to be reworked or repackaged to correct the problem. Once the situation is resolved, go back to the
originally approved manufacturing/packaging procedure or batch record.
Responsible Personnel
Whether a material is to be rejected or a drug
product has to be reworked, the responsibilities
should be clearly defined with QA interaction
throughout the process to assure proper disposition of the nonconforming materials and closure of
the NCMR form. The responsible personnel should
be indicated on the NCMR form.
NCMR Disposition
Once a disposition decision is made for a nonconforming material, QA should be responsible for
assuring that the material is disposed of accordingly.
Release/Reject
If the material is to be released for use, its quality status should be changed accordingly. If the
material is rejected, it should be moved immediately to the rejected material storage area and be
marked for destruction.
Return to Vendor
If shipping damage is the cause for nonconformance or the raw material fails to meet specifications on testing, it could be returned to the vendor
for credit. For contract manufactured/packaged
drug products, a similar approach can be taken.
Inventory Adjustments
Inventory control and reconciliation of raw materials, container/closure, labeling components, as
well as in-process and finished drug products is
required by cGMP. Whenever a material is nonconformed, inventory records should be adjusted
accordingly, with full explanation for the changes.
Definition
Hold is a questionable quality status of a drug
product or its components, or for any other reason, which prevents further processing until it can
be determined whether to quarantine, release, or
reject the drug product or its component. In all
cases, the Hold status should prevent distribution
of drug products for marketing. Materials placed
on hold typically require further investigation or
testing and may result in return to vendor or
destruction.
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Types of Hold
Hold status could be invoked because of a
materials failure to meet specifications or for regulatory/compliance reasons. Most questionable
quality status situations fall into one of the following categories:
Planned vs. Unplanned
A planned hold status is when the reason for
questionable quality status is known and related to
a change in formulation, manufacturing process, or
container closure system for the drug product.
Such changes require additional process validation
and stability testing of the drug product to determine the effect of the change(s) on the safety,
quality, and purity of the drug product. Until these
studies are completed, the drug product cannot be
released for distribution.
An unplanned hold status is an unexpected
event resulting from a sudden failure of the material to meet its specifications. This could happen to
an already released drug product or raw material,
e.g., a drug product complaint might force the
organization to put on hold its existing released
stock of particular drug product until the complaint
is investigated and resolved.
Temporary vs. Permanent
Hold status is usually a temporary situation,
and the material or drug product involved is
either released or rejected. However, under certain regulatory/compliance circumstances, a
company might be forced to put its drug product(s) on permanent hold leading to rejection and
destruction. This could happen when FDA finds a
lack of cGMP compliance or other serious violations of the Act.
Lot Specific vs. Multiple Lots
Hold status could involve only one lot of drug
product or multiple lots.
Product Specific
Hold status should always be product specific
and, if more than one drug product is involved,
each should be placed on hold separately, and
documentation should reflect this.
Reason for Hold
Hold status is a result of a questionable quality
status and could be caused by one or more of the
following reasons:
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Equipment Change
Major equipment change necessitates a revalidation of the manufacturing process, unless it
could be proven that the change falls under similar
equipment criteria based on SUPAC guidelines.
The drug product manufactured with new equipment, however, should be placed on hold until the
issue is resolved.
Process Change
A critical change in the manufacturing process
also requires a revalidation of the process and
additional stability testing for the drug product produced.
Again, the drug product has to be placed on
hold until these issues are resolved and the drug
product safety, purity, and quality can be proven.
Stability Data
On-going stability studies might reveal a sudden
negative trend in drug product potency, making the
expiration dating assigned to the drug product
questionable. In this case, the current stock of the
drug product should be put on hold and distribution
temporarily halted until this stability issue is
resolved.
Validation
Validation batches are completed much before a
validation study is completed, i.e., all the documentation is signed off and a summary report is prepared and approved by quality assurance. The validation batches should be placed on hold until the
validation is complete and successful. Other valida-
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tion-related issues, which would necessitate the
use of this procedure, could include the following:
Change in process
Cleaning validation
Test method
Packaging configuration
Facility/utility changes
Quality issues
Regulatory Issues
Regulatory/compliance reasons could also
dictate that a drug product should be placed on
hold until resolution of these concerns. A change
in an API requires a pre-approval supplement to
the FDA, and until that is approved, the drug
product lots involved cannot be released for marketing.
Hold for Release Management
Whether a hold status is planned or unplanned,
there should be a change control system in place
to deal with questionable quality status of raw
materials, containers/closures, or drug products.
Essential elements of such a system include:
SOP
There should be a written procedure in place on
Hold for Release issues, detailing all the necessary
steps in controlling and resolving the situation.
Hold for Release Report (HFR) Form
A standardized Hold for Release report form
should be part of the SOP. These forms should be
prenumbered for control and reference purposes
and be controlled and issued by the QA function.
The latter should also be responsible for appropriate closure of each HFR form. The HFR form
should detail all the steps necessary to complete
the investigation and resolution of a questionable
quality status. It should also refer other change
control documents involved, like a deviation report
or an NCMR form.
Responsible Personnel
Whenever a corrective action is required, the
plan should clearly define the responsibilities and
accountabilities with QA to oversee the effort.
If it is a multidisciplinary effort, then it is even
more important to define all the participants roles
in carrying out the project.
Hold for Release Disposition
Based on analytical data or regulatory approval
of a supplement, the material or drug product
involved can be released for use or distribution;
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otherwise, the material might have to be rejected.
Care should be taken that all necessary validation
or stability testing is completed, and a final report
is written up before the drug product is released.
Out-of-Specifications Investigations
Out-of-specification (OOS) data investigation is at
the top of the current list of issues facing industry and
FDA. Not that it is a new subject, as it has always
been part of the cGMP regulations, 21 CFR 211.194,
but the issue has assumed a new significance since
the infamous Barr Decision. The old school of testing
a product till it passed was supposed to be gone with
the introduction of cGMP regulations. However, this
monster still lives on in some pharmaceutical manufacturers. Like any other compliance issue, OOS is
part of analytical reality in any organization, and how
to investigate and resolve a situation involving OOS
data should not be the subject of deep philosophy
and considered right up there with universal metaphysical forces in action. The simple truth is that
every drug manufacturer is responsible for investigating OOS data according to a written procedure, with
due review and an approval process in place. The following discussion is a procedural approach on how to
handle any OOS investigation.
Definitions
GMP data means data upon which a quality
or GMP decision is made and includes data collected in determining the disposition (release or
rejection) of a raw material, intermediate or inprocess material, or drug product, as well as data
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Barr Decision
In 1992, Judge Wolin made a landmark decision in
U.S. vs. Barr Laboratories, clarifying the issues of
OOS data and the practice of retesting the drug product until it passes. cGMP regulations imply that the
drug manufacturer should conduct a failure investigation when a drug product fails to meet test specifications. The Barr decision made it clear that it is a legal
requirement for every manufacturer to address the
OOS data investigation in a systemic way, and written
procedures should be in place to define the course of
action. It also emphasized the fact that quality cannot
be tested into a drug product, rejecting the practice of
testing till it passes. The OOS data should not be
summarily dismissed, and it should be part of the
analytical results along with the retest data and justification for the retesting of the original sample or
resampling and retesting of this sample.
The Barr decision had a far-reaching impact on
the pharmaceutical industry, as Judge Wolins
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opinion was the first established detailed explanation of how an OOS situation should be handled.
FDA has incorporated this explanation into its
inspection guidelines and expects industry to follow it.
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Investigation Team
Members of the investigation team should
include the analyst, his/her supervisor, representatives from regulatory affairs, production, and QA.
A quality/compliance review committee might be
entrusted to make a final decision based on the
recommendations of the investigation team.
determine, with reasonable assurance, if the incident is an isolated event or a systemic problem. If
the OOS data is a result of the quality systems
deficiencies, like lack of proper process validation,
then the investigation scope takes on a whole new
meaning, and the QA function should act accordingly to correct the problems.
Review/Investigation
The investigation should focus on the following:
Conclusion
Once the investigation is completed, a decision
has to be made as to the disposition of the materials involved. The material could be released or
rejected, and that should close the investigation
for the particular OOS incident. However, sometimes the original and retest data are submitted to
experts within the company, along with key members of management, to make a decision. The
assistance of outside experts might also be
sought. All these activities must be documented
to maintain a level of control desired by cGMPs.
Define Cause
The investigation should result in narrowing down
the cause for OOS data, and a brief summary of the
reasoning behind this decision should be prepared.
Probable causes of OOS data could include:
Laboratory error
Inconclusive laboratory error
Nonprocess related error
Process related error
Stability degradation
Corrective Actions
The corrective action plan should be defined to
address the following:
Retest plan
Retest of original sample
Resample of material for analysis
Predetermined testing procedure to define the
source of retest sample and the number of
samples to be retested for statistical significance of data
A second analyst to perform the analysis, when
necessary, to verify the ruggedness of method
Evaluation of retest data
Related Batches/Drug Products
Related batches of the same raw material or
drug product or related drug products should be
evaluated to establish an analytical history of the
material involved. This review is necessary to
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transfer from one plant to another, creating more
challenges for the change control systems.
Validation change control applies to all validated
systems and processes, including facilities, utilities,
equipment, and manufacturing/packaging processes. However, routine preventive maintenance
should not be confused with a change in the validated status of a system. This discussion is meant
to provide an overview of validation change control
and how to manage it in day-to-day operations.
Definition
Validation change control can be defined as the
process by which each critical or major change in
a validated system or process is evaluated to
determine if the proposed change impacts the validated status of the system or process involved.
Due consideration should be given to the possibility of the revalidation of the system or process.
These potential changes include equipment
upgrade, change of critical parts of a utility system,
major changes in manufacturing process, etc.
Types of Validation Changes
Planned vs. Unplanned
Planned changes in a validated system are
meant to improve operation. Such changes usually
have been thoroughly studied and agreed upon by
different organizational units. However, distinction
should be made for planned routine maintenance
activities, as these are extensions of the original
validation of the equipment or system.
Unplanned changes, on the other hand, are a
result of an emergency and have to be made to
keep operations going. Many times the review process starts after the fact, and the drug product
manufactured has to be evaluated for compliance
with all its regulatory and quality specifications.
Potential Areas of Validation Change
Pharmaceutical manufacturing is conducted in a
controlled environment, and, anything that could
have an impact on the safety, identity, quality,
purity, and strength of a drug product should be
validated. This validated status must be maintained
throughout the life of the system involved. Any critical or major changes in any of the following systems must be carefully reviewed and evaluated for
its impact on the system individually and as part of
the manufacturing cycle for the drug products
involved.
Facilities
Procedural changes
Utilities modifications
Equipment calibration
New equipment/replacement of equipment
Maintenance frequency
Engineering study for process improvement
Change in API/major excipient source
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Production/packaging process changes
Deviations
Nonconformance reports
Pre-Approval
The validation change request should be preapproved by validation and quality assurance,
authorizing that the proposed change can be made.
Validation Change Execution
Once it is decided that the change has to be
made and the system/process needs revalidation,
the following activities should occur in succession:
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Follow-up Actions
Validation is not an event but an on-going cycle
that ends only when a system is retired or the drug
product is removed from the market. An astute validation professional understands that the systems
and processes qualified at one point in their life have
to be monitored periodically to assure that they are
still operating within the same validated parameters.
QUALITY FAILURE/INCIDENT
INVESTIGATIONS
Quality systems and procedures are implemented to minimize quality defects, with the aim to
create a zero-defect manufacturing environment. In
reality, there is no such thing as a perfect system.
Quality defects and failures are part of any
manufacturing operation, and pharmaceutical manufacturing is no exception. cGMPs require that all
quality failures/incidents be investigated, documented, and corrective actions implemented to
prevent recurrence. Most pharmaceutical manufacturers have established detailed procedures on
how to investigate out-of-specification data originating in the analytical laboratory following the Barr
Decision. However, there is a need to have separate procedures to address other operational quality issues, i.e., quality failure/incidents. The quality
failure/incident investigation procedures offer a
number of benefits, such as:
Quality Failure/Incident
Investigation Procedure
What is a Quality Failure/Incident?
Quality failure refers to a situation where a finished drug product, process, or service does not
meet its expected attributes or specifications. A
quality incident, on the other hand, is a failure of
the quality system practices which may or may not
Figure 1
Failure/Incident Investigation
Procedure
Elements of Quality Failure/Incident
Investigation Procedure
Define quality failure/incident
Define quality significance of the failure/incident
Define the cause of the quality failure/incident
Facilities
Utilities
Components
Equipment
Process
Drug Product
Analytical
Personnel
Quality failure/incident investigation
Facilities
Utilities
Components
Equipment
Process
Drug Product
Personnel
Procedures and documentation practices
Corrective action plan
Summary, conclusion, and sign off
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Define the Cause of Quality Failure
A quality failure/incident could be caused by
one or more of the following; however, use the process of elimination to narrow down this list as
much as possible;
Facilities
An example of facilities as a possible cause of
quality incident/failure could be improper
cleaning/sanitization of manufacturing areas leading to increased bioburden in the environment with
the potential for drug product contamination.
Utilities
A malfunction of any of the following utility systems can cause a quality failure/incident leading to
a drug product failure. They include:
HVAC system
Water purification system
Compressed air system
Dust collection system
Components
Both chemical raw materials and
packaging/labeling components can cause a quality failure/incident.
Equipment
Equipment breakdown as well as improper
cleaning can lead to a quality failure/incident.
Process
The manufacturing process as well as process
conditions can contribute to a quality failure/incident.
Drug Product
Failure to meet drug product specifications is
the ultimate quality failure/incident.
Analytical
Most analytical laboratory quality issues are
related to analytical data and are usually investigated according to an out-of-specification data
investigation SOP. An OOS investigation will likely
involve some of the aspects discussed here.
Personnel
Personnel expertise and level of training can
also significantly contribute to quality failures.
This list should not be considered all inclusive,
and there could be other factors involved. Review
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Components
Always review the sampling/inspection and
release processes if a component is a potential
cause for a quality failure/incident. Sample manipulation can have a potential negative impact on the
quality of the material being sampled. Both active
and inactive raw materials can have a direct bearing on the drug product quality if these are not of
desired quality or their quality is compromised
either during sampling process or due to improper
storage conditions.
Packaging/labeling component quality defects
can cause potential stability concerns as well as
mislabeling situations. Almost one-third of all drug
product recalls in recent years were due to mislabeling of drug products, per FDA enforcement
reports.
Equipment
If manufacturing/packaging equipment is a
potential cause for a quality failure/incident, review
the following:
Process
Review the manufacturing process in detail to
see if there were any deviations or anomalies.
Also, review the process conditions, like temperature, humidity, machine speed setups, order of
addition of ingredients, process time limits, etc. A
review of process validation records might also be
in order, if considered necessary.
Drug Product
Review other batches of the same drug product to see if this is a product-specific quality issue
or an isolated incident. Review batches of related
drug products manufactured under similar sets of
conditions. This will help determine if other drug
products are also involved.
This part of the investigation demands
extreme diligence on the part of the quality management team, as it can have far-reaching implications. In recent years, FDA has repeatedly
cited pharmaceutical manufacturers for failure to
perform an in-depth investigation of quality failure/incidents.
Personnel
This is a subjective issue that is difficult to measure as it tends to indirectly validate the effectiveness of the employee training program. Ensure that
the individuals involved in all phases of a given
quality failure/incident have the knowledge, expertise, and training to carry out their assignments,
and there is documented evidence to support this
claim. If not, an isolated quality failure incident
could be an indication of a major systemic quality
problem within the organization.
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erenced or attached to the investigation report, like
employee training records, copies of the purchase
order, copy of the approved change control, etc.
The report should be reviewed and approved by
the appropriate departments within the organization. QA and other pertinent departments should
sign off on the report, and sign off responsibilities
should be delineated in an SOP. The summary
report should be used to inform upper management of any critical quality issues, especially those
which would involve capital investments as part of
their corrective action plan.
Figure 2
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Purification system malfunction
Chemical
Microbiological
In most instances, it is the failure of a water sample for chemical or microbiological specifications
which triggers an investigation. Since purified water
is constantly being used in production, there is
always a chance that the suspect quality water might
have been used in equipment cleaning or manufacture of a drug product, thereby putting it at risk.
Source Water
The quality of source water as supplied by local
water authorities changes with the time of the year
and geographic location of the plant. Microbial quality and the total dissolved solids in source water
play a vital role in determining the capability of a
given water purification system. Source water test
data should be part of the validation file for a given
water purification system. Sudden changes in
source water quality can cause purified water failure, especially after natural disasters, like floods.
Source water test data from the local water
authority and in-house periodic source water test
results should be reviewed to determine any sudden change in source water quality. This review
should also indicate any trends that might be
developing over recent weeks, especially after
heavy rains or floods in the area, as they can affect
the composition of natural water reservoirs.
Pretreatment
Source water is pretreated to minimize the level
of both organic and inorganic impurities before
water is actually processed through the final purification step. If pretreatment steps are not precisely
controlled and routinely monitored for performance
within preset limits, these could cause quality failure of the water produced.
Chlorination
Chlorine is added to the source water to
decrease its bio-burden. It also helps to minimize
microbial growth in pipes and storage equipment.
Local water authorities usually add a chlorine gas
generating chemical to wate like sodium hypochlorite to produce one to two PPM of chlorine gas.
However, there is a downside to the presence of
chlorine in water, as it tends to corrode stainless
steel surfaces and will deteriorate reverse osmosis
membranes. Therefore, it is important that chlorine
be removed from water before it actually reaches
the purification and storage stage.
However, if there is insufficient or no chlorine in
the source water, the purification system downstream may not be able to remove all the microbial
contaminants, thereby causing a quality failure of
the water produced.
Depth Filters
Source water is passed through a series of
coarse filters to remove suspended solids. The filtration media could be different grades of sand.
However, such filters tend to harbor microbes and
should be periodically back-washed to remove all
trapped waste. If left unsanitized, these filters could
contaminate the water with microbes, causing failure of the water produced after purification.
Water Softeners or Deionizers
Water softeners or deionizers are used to
remove heavy metal ions from source water to
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avoid scaling downstream during the purification
process. Deionizing resins need to be regenerated
periodically, and the regeneration process should
be controlled to ensure that a deionizer tank does
not sit idle for long periods of time after regeneration, as it could promote microbial growth. If such a
tank is used in water purification, it might overburden the system, and the water produced could fail.
Carbon Filter
Activated carbon filters are used to remove dissolved chlorine and other gases from source water,
along with organic materials, before water is subjected to the final purification process. However, carbon filters can promote microbial growth and, therefore, foul the downstream components. Frequent
monitoring and sanitization of carbon filters should
be carried out to prevent this situation. Nonetheless,
carbon filters can be a cause of water quality failure.
Purification System
Deionization
Deionization is not considered by FDA to be an
acceptable water purification process to produce
Water-for-Injection (WFI); however, it is used to
produce purified water. Cation, anion, and mixed
bed resins are used to remove ionic impurities
from source water. The quality of these resin beds
can be monitored by determining the conductivity
of effluent water. A sudden increase in effluent
water conductivity indicates that a resin bed needs
to be regenerated. Ion exchange resin tank regeneration should be controlled, and regenerated
tanks should not sit idle, as this can promote
microbial growth. Also, if there is leakage of
sodium ions from a cation exchange resin, the
water produced will have a higher pH greater
than 7.0.
Reverse Osmosis
Reverse osmosis membranes are an efficient
water purifier when used in series. However, these
can harbor microbial growth, as they are chlorine
sensitive and, therefore, can produce water of suspect quality. Also, if the membranes are not periodically backwashed, they become overloaded and
enable organic and inorganic impurities to pass
through.
Distillation
Distillation is the method of choice for producing
WFI, assuming it is a continuous process. If, for
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areas believed to have contributed most to a given
quality failure incident.
Source water
Source water test data from the local water
authority and in-house periodic source water test
results should be reviewed to determine any sudden changes in source water quality. This review
should also indicate any trends that might be
developing over recent weeks, especially after
heavy rains or floods in the area, as they can affect
the composition of natural water reservoirs.
Pretreatment
Review all the pretreatment steps to see if the
quality of source water was compromised at any
stage. Also check for leaks or malfunction of any
alarms, controls, or autoregeneration of deionizing
tanks, etc.
Chlorination
Review the source water data to see if there
was sufficient chlorine in the water. Also, review
the residual chlorine level of pretreated water processed downstream, especially in case of a
reverse osmosis water purification system.
Depth Filters
Check the backwash records to see if the depth
filters were backwashed and sanitized per requirements, as these can cause both microbial and
chemical contamination of the water being purified.
Water Softeners or Deionizers
Review the regeneration procedure and schedule for water softener and deionizing tanks to
detect any deviation, especially if the tanks were
sitting idle for a long period of time after regeneration, promoting microbial growth, thereby causing
contamination of water.
Carbon Filter
Review the monitoring data for the post-carbon
bed to determine if there was any proliferation of
microbes which could have contaminated the system downstream.
Purification System
Deionization
Review the regeneration procedure and schedule for cation, anion, and mixed bed resin tanks to
detect any deviation, especially if the tanks were
sitting idle for a long period of time after regeneration, thereby causing microbial contamination of
water. Also, the conductivity data for effluent water
should be reviewed to determine if the tanks were
changed as per schedule and are not totally
exhausted before replacement.
Reverse Osmosis
The reverse osmosis membranes should be
checked for integrity if these were exposed to high
chlorine source water. Also, the membrane backflushing procedure should be reviewed to determine if it is effective in removing all the build-up.
The reverse osmosis system sanitization procedure and frequency should be checked to determine if they need any revisions, both in procedure
and frequency.
Distillation
Ensure that the system was in operation per
approved specifications. If there was a shutdown,
was the system sanitized before start up? Check to
determine if all alarms and controls are functioning
and are within calibration. Look for any dead legs
in the system as potential breeding grounds for
microbes.
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Sanitization Process
Review the water purification system sanitization procedure and frequency to determine if they
could be contributing factors in water quality failure, especially when residual chemicals or high/low
pH values are detected.
Sampling
Multiple water samples are drawn on a daily
basis during validation and routine monitoring of a
water purification system. The sampling procedure
and the individual samplers technique are key to
obtaining uncompromised water samples. While
investigating a water quality failure/incident, the
sampling process should be scrutinized in detail.
Review the following to determine if there is any
chance to compromise the integrity of the sample.
Sampling Procedure
The sampling procedure should be reviewed to
determine the level of detail and clarity of statement for a nontechnical person to understand it.
Also, review the training requirements spelled out
in the SOP and audit training records.
Sampling Technique
If sampling is a potential cause for water quality
failure, QA should review the sampling technique
and perhaps have a microbiologist watch the individual sampler do the actual sampling under real
time conditions. This provides a wealth of information as to the effectiveness of the sampling technique as described in the sampling procedure and
how people are trained. The sampling procedure
should simulate actual practice when the system is
used to draw water for manufacturing or cleaning
activities, i.e., flush the system for 10 seconds
before withdrawing water, etc.
Sample Container Preparation
Water sample containers are specially prepared. Microbiological samples are taken in sterile containers, while chemical samples are taken
in containers which have been specially cleaned
and rinsed with WFI to minimize contamination.
While investigating a water quality failure/incident,
also review the sample container prep practices.
This could involve reviewing cleaning procedures
and any studies done on these containers after
cleaning to determine the effectiveness of the
cleaning procedure. If presterilized containers are
obtained from an outside vendor, have access to
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the vendors sterilization procedure and supporting validation documents. Nonsterile sample containers have been blamed for false failures of
water samples.
Analytical Issues
Chemical and microbiological tests are usually
performed by the quality control laboratory, and this
phase of the investigation is best accomplished if a
chemist and a microbiologist are asked to review
different aspects of the analytical work. In particular,
the following should be closely examined:
Analytical Instruments
Review analytical instruments to determine if
they are within calibration and performance limits.
Also, check for any unusual repair or maintenance
activity that might have affected the performance of
the instrument.
Analytical Procedures
Analytical procedures should be reviewed for
both chemical and microbiological testing to determine if there are any issues and if the procedures
adequately guide the analyst in a step-by-step process to execute the test.
Analyst Training
Review training records for the analyst to make
sure they were qualified to perform the test under
review.
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Media Preparation and Storage
For microbiological testing, media preparation,
storage, and expiration dating issues are critical in
defining the success or failure of a test. Review
media preparation procedures as well as the expiration date assigned to a given lot of in-house prepared media to assure that media is used within its
expiration date. Other issues to be considered when
reviewing microbiological testing should include:
Incubation conditions
Qualification status of incubator
Use of positive/negative controls
Isolation and speciation of the microbial
contaminants
Personnel
This part of the investigation should define if
there are any deficiencies in the training program
and also, if the people are qualified to perform their
assignments.
Procedures and Documentation Practices
All the procedures and documentation involved
should be reviewed to determine if there is a need
for revisions or if new procedures should be prepared to supplement ones already in existence.
Also, a determination should be made to assess
whether all critical data is being reviewed by the
appropriate people to make critical decisions (if
needed).
Corrective Action Plan
Once all the facts are known, QA should
develop a corrective action plan in consultation
with other departments, as appropriate. The corrective action plan could involve one or more of the
Last Word
The management of change is an on-going battle and, like perpetual motion, we have yet to develop a perfect change control system that foresees
all possible changes. There will always be unforeseen circumstances that will force one to rethink
their approach to maintaining a level of control.
Document change control and contract manufacturer/packager-related change control issues have
been deliberately omitted from this discussion
because of the enormity of the two subjects.
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facturing, quality assurance, and validation. He has
held senior management positions with leading
pharmaceutical manufacturing companies. His special interests are the development and implementation of quality systems and management of validation projects. He holds MS degrees in Medicinal
Chemistry and Industrial Pharmacy. He can be
reached by phone at 972-423-6788 or by
e-mail at [email protected].
Suggested Reading
1. Food & Drug Administration, 21CFR Part 210 and
211, Current Good Manufacturing Practice for Finished
Pharmaceuticals, 1995, Rockville, Maryland.
2. Food & Drug Administration, 21CFR Part 210 and
211, Proposed Current Good Manufacturing Practice
Regulations for Finished Pharmaceuticals, Federal
Register, May 03, 1996, Rockville, Maryland.
3. Food & Drug Administration, 21CFR Part 820, Current
Good Manufacturing Practice for Medical Device
Quality System Regulations, October 06, 1996,
Rockville, Maryland.
4. Food & Drug Administration, Guidance for Industry,
Manufacturing Equipment Addendum to the Guidance
for Industry for Scale-Up and Post Approval Changes:
Immediate Release Products (SUPAC IR), Draft
Guidance, February 1997, Rockville, Maryland.
5. Food & Drug Administration, Guide to Inspection of
Pharmaceutical Quality Control Laboratories, July
1993, Rockville, Maryland.
6. Food & Drug Administration, Guide to Inspection of
Dosage Form Drug Manufacturers cGMPs, October
1993, Rockville, Maryland.
7. U.S. vs. Barr Laboratories, USDC, D. NJ, Civil Action
No. 92-1744, February, 1993.
8. D. M. Stephon, Considerations in Effectively Managing
Change Control Issues, Journal of cGMP Compliance,
Vol. 2, No. 4, July 1998.
9. J. Stromp, The Management of Change Control
Journal of cGMP Compliance, Vol. 2, No. 1, October
1997.
10. D. E. Jones, The Training Side of Change Control,
Journal of cGMP Compliance, Vol. 2, No. 4, July 1998.
11. J. L. Morgan, cGMPs in Early Clinical Development,
Journal of cGMP Compliance, Vol. 1, No. 1, October
1996.
12. D. R. Dills Handling Out-of-Specification Conditions
with Finesse, Journal of cGMP Compliance, Vol. 2,
No. 3, April 1998.
13. N. Hakim A Practical Approach to Investigating Outof-Specification Results, Journal of cGMP Compliance,
Vol. 3, No. 1, October 1998.
14. G. Amer, Validation and Change Control, Journal of
Validation Technology, Vol. 5, No. 4, August 1999.