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Generic Drug
Product Development
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DRUGS AND THE PHARMACEUTICAL SCIENCES

A Series of Textbooks and Monographs

Executive Editor

James Swarbrick
PharmaceuTech, Inc.
Pinehurst, North Carolina

Advisory Board

Larry L. Augsburger Harry G. Brittain

University of Maryland Center for Pharmaceutical Physics
Baltimore, Maryland Milford, New Jersey

Jennifer B. Dressman Robert Gurny

University of Frankfurt Institute of Universite de Geneve
Pharmaceutical Technology Geneve, Switzerland
Frankfurt, Germany
Jeffrey A. Hughes
Anthony J. Hickey University of Florida College
University of North Carolina of Pharmacy
School of Pharmacy Gainesville, Florida
Chapel Hill, North Carolina
Vincent H. L. Lee
Ajaz Hussain US FDA Center for Drug
Sandoz Evaluation and Research
Princeton, New Jersey Los Angeles, California

Joseph W. Polli Kinam Park

GlaxoSmithKline Purdue University
Research Triangle Park West Lafayette, Indiana
North Carolina
Jerome P. Skelly
Stephen G. Schulman Alexandria, Virginia
University of Florida
Gainesville, Florida Elizabeth M. Topp
University of Kansas
Yuichi Sugiyama Lawrence, Kansas
University of Tokyo, Tokyo, Japan
Peter York
Geoffrey T. Tucker University of Bradford
University of Sheffield School of Pharmacy
Royal Hallamshire Hospital Bradford, United Kingdom
Sheffield, United Kingdom
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For information on volumes 1–160 in the Drugs and Pharmaceutical Science

Series, Please visit www.informahealthcare.com

161. Dose Optimization in Drug Development, edited by Rajesh Krishna

162. Herbal Supplements-Drug Interactions: Scientific and Regulatory Perspec-
tives, edited by Y. W. Francis Lam, Shiew-Mei Huang, and Stephen D. Hall
163. Pharmaceutical Photostability and Stabilization Technology, edited by Joseph
T. Piechocki and Karl Thoma
164. Environmental Monitoring for Cleanrooms and Controlled Environments,
edited by Anne Marie Dixon
165. Pharmaceutical Product Development: In Vitro-ln Vivo Correlation, edited
by Dakshina Murthy Chilukuri, Gangadhar Sunkara, and David Young
166. Nanoparticulate Drug Delivery Systems, edited by Deepak Thassu, Michel
Deleers, and Yashwant Pathak
167. Endotoxins: Pyrogens, LAL Testing and Depyrogenation, Third Edition,
edited by Kevin L. Williams
168. Good Laboratory Practice Regulations, Fourth Edition, edited by Anne Sandy
Weinberg
169. Good Manufacturing Practices for Pharmaceuticals, Sixth Edition, edited by
Joseph D. Nally
170. Oral-Lipid Based Formulations: Enhancing the Bioavailability of Poorly
Water-soluble Drugs, edited by David J. Hauss
171. Handbook of Bioequivalence Testing, edited by Sarfaraz K. Niazi
172. Advanced Drug Formulation Design to Optimize Therapeutic Outcomes,
edited by Robert O. Williams III, David R. Taft, and Jason T. McConville
173. Clean-in-Place for Biopharmaceutical Processes, edited by Dale A. Seiberling
174. Filtration and Purification in the Biopharmaceutical Industry, Second Edi-
tion, edited by Maik W. Jornitz and Theodore H. Meltzer
175. Protein Formulation and Delivery, Second Edition, edited by Eugene J.
McNally and Jayne E. Hastedt
176. Aqueous Polymeric Coatings for Pharmaceutical Dosage Forms, Third Edi-
tion, edited by James McGinity and Linda A. Felton
177. Dermal Absorption and Toxicity Assessment, Second Edition, edited by
Michael S. Roberts and Kenneth A. Walters
178. Preformulation Solid Dosage Form Development, edited by Moji C. Adeyeye
and Harry G. Brittain
179. Drug-Drug Interactions, Second Edition, edited by A. David Rodrigues
180. Generic Drug Product Development: Bioequivalence Issues, edited by Isadore
Kanfer and Leon Shargel
181. Pharmaceutical Pre-Approval Inspections: A Guide to Regulatory Success,
Second Edition, edited by Martin D. Hynes III
182. Pharmaceutical Project Management, Second Edition, edited by Anthony
Kennedy
183. Modified Release Drug Delivery Technology, Second Edition, Volume 1,
edited by Michael J. Rathbone, Jonathan Hadgraft, Michael S. Roberts, and Majella
E. Lane
184. Modified-Release Drug Delivery Technology, Second Edition, Volume 2,
edited by Michael J. Rathbone, Jonathan Hadgraft, Michael S. Roberts, and Majella
E. Lane
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185. The Pharmaceutical Regulatory Process, Second Edition, edited by Ira R.

Berry and Robert P. Martin
186. Handbook of Drug Metabolism, Second Edition, edited by Paul G. Pearson
and Larry C. Wienkers
187. Preclinical Drug Development, Second Edition, edited by Mark Rogge and
David R. Taft
188. Modern Pharmaceutics, Fifth Edition, Volume 1: Basic Principles and Sys-
tems, edited by Alexander T. Florence and Jürgen Siepmann
189. Modern Pharmaceutics, Fifth Edition, Volume 2: Applications and
Advances, edited by Alexander T. Florence and Jürgen Siepmann
190. New Drug Approval Process, Fifth Edition, edited by Richard A. Guarino
191. Drug Delivery Nanoparticulate Formulation and Characterization, edited by
Yashwant Pathak and Deepak Thassu
192. Polymorphism of Pharmaceutical Solids, Second Edition, edited by Harry G.
Brittain
193. Oral Drug Absorption: Prediction and Assessment, Second Edition, edited
by Jennifer J. Dressman, Hans Lennernas, and Christos Reppas
194. Biodrug Delivery Systems: Fundamentals, Applications, and Clinical
Development, edited by Mariko Morista and Kinam Park
195. Pharmaceutical Process Engineering, Second Edition, edited by Anthony J.
Hickey and David Ganderton
196. Handbook of Drug Screening, Second Edition, edited by Ramakrishna Seethala
and Litao Zhang
197. Pharmaceutical Powder Compaction Technology, Second Edition, edited by
Metin Celik
198. Handbook of Pharmaceutical Granulation Technology, Third Edition, Dilip
M. Parikh
199. Pharmaceutical Preformulation and Formulation, Second Edition: A Prac-
tical Guide from Candidate Drug Selection to Commercial Dosage Form,
edited by Mark Gibson
200. International Pharmaceutical Product Registration, Second Edition, edited
by Anthony C. Cartwright and Brian R. Matthews
201. Generic Drug Product Development: International Regulatory Require-
ments for Bioequivalence, edited by Isadore Kanfer and Leon Shargel
202. Proteins and Peptides: Pharmacokinetic, Pharmacodynamic, and Metabolic
Outcomes, edited by Randall J. Mrsny and Ann Daugherty
203. Pharmaceutical Statistics: Practical and Clinical Applications, Fifth Edition,
Sanford Bolton and Charles Bon
204. Generic Drug Product Development: Specialty Dosage Forms, edited by Leon
Shargel and Isadore Kanfer
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Generic Drug
Product Development
International Regulatory Requirements
for Bioequivalence

Edited by
Isadore Kanfer
Rhodes University
Grahamstown, South Africa

Leon Shargel
Applied Biopharmaceutics, LLC
Raleigh, North Carolina, USA
CRC Press
Taylor & Francis Group
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© 2010 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

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Version Date: 20130116

International Standard Book Number-13: 978-1-4200-2002-1 (eBook - PDF)

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strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s
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Preface

HISTORY OF THIS SERIES OF BOOKS ON GENERIC DRUG PRODUCT

DEVELOPMENT
The first book in this series, Generic Drug Product Development: Solid Oral Dosage
Forms, was published in 2005 by Marcel Dekker, Inc., New York, as part of their
series in drugs and the pharmaceutical sciences. The objective of the first book
was to describe, from concept to market approval, the development of therapeu-
tic equivalent generic drug products, including regulatory and legal challenges.
The second volume, Generic Drug Product Development: Bioequivalence Issues, was
published in 2008 by Informa Healthcare USA, Inc., New York, and focused on
problems concerning the scientific demonstration of bioequivalence (BE) of two
drug products: a test (T) and a reference (R) product.

ABOUT THIS BOOK

This book, the third in this series on Generic Drug Product Development, provides
information on the regulatory requirements for bioequivalence in several differ-
ent countries around the world.
The advent and application of bioequivalence testing has had a signif-
icant impact on the process of drug product development both for innova-
tor/brand pharmaceutical manufacturers and also for the generic drug industry.
In the former instance, innovator/brand companies’ use BE during their formu-
lation development of products prior to embarking on clinical studies on safety
and efficacy and subsequently to facilitate postapproval changes in formulation.
Generic drug manufacturers, on the other hand, are able to circumvent clinical
trials in patients by using BE to obtain market approval for their products.
Although the underlying scientific principles of BE have been well-
established and many drug regulatory agencies around the world have largely
adopted standard methodology and acceptance criteria, some differences exist
in the application of the methodology and interpretation of the outcomes among
different countries. Hence the objective of this book is to outline the specific BE
requirements of each of the included countries where such information will be
useful to prospective generic drug manufacturers intending to obtain market
approval in a specific country.

CONTENTS
The bioequivalence regulations and requirements of the following countries and
their associated regulatory agencies are included in this book:
vii
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viii Preface

r Australasia—Therapeutic Goods Administration of Australia and Medsafe, a

business unit of the New Zealand Ministry of Health
r Brazil—The National Agency for Sanitary Surveillance (Agencia Nacional
de Vigilancia Sanitaria, ANVISA), General Management of Generic Products
(Gerência Geral de Medicamentos Genéricos, GGMED)
r Canada—Health Products and Food Branch (HPFB), Therapeutic Products
Directorate (TPD), Health Canada
r European Union—European Medicines Agency (EMEA), Committee for
Medicinal Products for Human Use (CHMP)
r India—Central Drugs Standard Control Organization (CDSCO) under the
Government of India having certain powers vested in them and each State
has its own drug regulatory system having certain powers
r Japan—The Ministry of Health, Labour and Welfare (MHLW) in accordance
with the Pharmaceutical Affairs Law
r South America—In accordance with guidelines of PAHO (Pan American
Health Organization) through PANDRH (Pan American Network for Drug
Regulatory Harmonization)
r South Africa—Medicines Control Council (MCC), Department of Health
r Taiwan—The Bureau of Pharmaceutical Affairs (BPA), Department of Health
(DOH)
r Turkey—The General Directorate of Drug and Pharmacy (GDDP, Ministry of
Health (MoH)
r United States of America—Food and Drug Administration
r World Health Organization (WHO)

The chapters include background information and history of the devel-

opment of rules, regulations, and guidelines in a specific country along with
patent information and national requirements for interchangeability where such
requirements exist. This is followed by bioequivalence requirements including
the choice of reference product, bioequivalence metrics used, and acceptance cri-
teria as well as study designs for immediate-release and controlled-/modified-
release products for oral administration. Sections also include information on
the requirements for the assessment of food effects, metabolites and chiral drugs,
use of “add-on” and steady-state studies, conditions for biowaivers, bioanalyti-
cal and statistical requirements. Most of the guidelines also include recommen-
dations for the assessment of drug products not intended for absorption into
the systemic circulation such as topical products for local/regional action (e.g.,
dermatological corticosteroid products and other creams, gels, ointments, and
lotions as well as nasal sprays/aerosols and oral inhalation products). In addi-
tion, the bioequivalence requirements for postapproval formulation changes,
biowaivers for additional strengths of the same product, and the use of disso-
lution data for biowaivers are also included.
Bioequivalence has been acknowledged as a valuable tool and has been
used as a surrogate measure to assess the safety and efficacy of generic
medicines, also termed multisource products. However, as mentioned previ-
ously, in general, the methods used and the bioequivalence requirements of
most regulatory agencies have much in common, but in some countries spe-
cific issues and approaches differ. This volume provides relatively detailed infor-
mation required by the regulatory authorities of several different countries and
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Preface ix

the implications of their different requirements and approaches for the market
approval of a generic product, particularly with respect to it’s declaration of
interchangeability/switchability.
A list of definitions, abbreviations and symbols has been included where
many of the terms are commonly used in most countries.

Isadore Kanfer
Leon Shargel
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Acknowledgments

The editors wish to express their gratitude to all the authors who have given so
generously of their time and expertise to provide these texts and to the organiza-
tions, for which they work, which have graciously allowed them to do so.

x
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Disclaimer

The contents of this book represent the views of its authors. They do not nec-
essarily reflect the policies or opinions of any national authorities (regulatory
agencies), advisory or regulatory committees, pharmaceutical companies, con-
tract research organizations, consultancy companies, academic institutions, hos-
pitals, etc., with whom the authors may be associated or employed.

xi
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Annexure 1
Definitions, Abbreviations and Symbols

AM Active moiety (active)

Active moiety (active) is the term used for the therapeutically active
entity in the final formulation of a medicine, irrespective of the form
of the API. The active is alternative terminology with the same
meaning. For example, if the API is propranolol hydrochloride, the
active moiety (and the active) is propranolol.
Active pharmaceutical ingredient
A substance or compound that is intended to be used in the
manufacture of a pharmaceutical product as a therapeutically active
ingredient.
BA Bioavailability
Bioavailability refers to the rate and extent to which the API (active
pharmaceutical ingredient), or its active moiety (substance), is
absorbed from a pharmaceutical product (dosage form) and becomes
available at the site of action or biological fluids (usually plasma or
plasma) representing the site.
For drug products that are not intended to be absorbed into the
bloodstream, bioavailability may be assessed by measurements
intended to reflect the rate and extent to which the active ingredient
or active moiety becomes available at the site of action.
It may be useful to distinguish between the “absolute
bioavailability” of a given dosage form as compared with that (100%)
following intravenous administration (e.g., oral solution vs.
intravenous), and the “relative bioavailability” as compared with
another form administered by the same or another nonintravenous
route (e.g., tablets vs. oral solution).
BE Bioequivalence
Two pharmaceutical (medicinal) products are bioequivalent if they
are pharmaceutically equivalent or (pharmaceutical alternatives in
some countries) and if their bioavailabilities in terms of peak (Cmax
and Tmax ) and total exposure (AUC) after administration of the same
molar dose under the same conditions are similar to such a degree
that their effects with respect to both efficacy and safety can be
expected to be essentially the same.
The USA FDA’s definition is:
“the absence of a significant difference in the rate and extent to
which the active ingredient or active moiety in pharmaceutical
equivalents or pharmaceutical alternatives becomes available at the

xii
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Annexure 1: Definitions, Abbreviations and Symbols xiii

site of drug action when administered at the same molar dose under
similar conditions in an appropriately designed study.”
Bioequivalence focuses on the equivalence of release of the
active pharmaceutical ingredient from the pharmaceutical product
and its subsequent absorption into the systemic circulation.
Comparative studies using clinical or pharmacodynamic end
points may also be used to demonstrate bioequivalence.
FDC Fixed-dose combination
A combination of two or more active pharmaceutical ingredients in a
fixed ratio of doses. This term is used generically to mean a particular
combination of active pharmaceutical ingredients irrespective of the
formulation or brand. It may be administered as single entity
products given concurrently or as a finished pharmaceutical product.
FP Final product
A product that has undergone all stages of production, excluding
packaging.
FPP Finished pharmaceutical product
A product that has undergone all stages of production, including
packaging in its final container and labeling.
IPI Inactive pharmaceutical ingredient
A substance or compound that is used in the manufacture of a
pharmaceutical product and does not contribute to the therapeutic
effect of the product, but is intended to enhance the consistency,
appearance, integrity, stability, release characteristics, or other
features of the product.
Usually refers to excipients or other formulation
adjuvants/aids.
MSPP Multisource (generic) pharmaceutical product
Multisource pharmaceutical products are pharmaceutically
equivalent products that may or may not be therapeutically
equivalent or bioequivalent. Multisource pharmaceutical products
that are therapeutically equivalent are interchangeable.
MRDF Modified-release dosage forms
A modified-release dosage form is one for which the drug-release
characteristics of time course and/or location are chosen to
accomplish therapeutic or convenience objectives not offered by
conventional dosage forms such as solutions, ointments, or promptly
dissolving dosage forms.
Delayed-release and extended-release dosage forms are two
types of modified-release dosage forms.
r Delayed-release dosage forms: A delayed-release dosage form is one
that releases a drug(s) at a time other than promptly after admin-
istration.
r Extended-release dosage forms: An extended-release dosage form is
one that allows at least a twofold reduction in dosing frequency
or significant increase in patient compliance or therapeutic per-
formance as compared to that presented as a conventional dosage
form (e.g., as a solution or a prompt drug-releasing, conventional
solid dosage form).
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xiv Annexure 1: Definitions, Abbreviations and Symbols

The terms controlled release, prolonged action, and sustained release

are used synonymously with extended release. The term extended
release is used to describe a formulation that does not release active
drug substance immediately after oral dosing and that also allows a
reduction in dosage frequency. This nomenclature accords generally
with the USP definition of extended release but does not specify an
impact on dosing frequency. The terms controlled release and extended
release are sometimes considered interchangeable.
PA Pharmaceutical alternatives
Medicinal products are pharmaceutical alternatives if they contain
the same active moiety but differ either in chemical form (e.g., salt,
ester) of that moiety or in the dosage form or strength, administered
by the same route of administration but are otherwise not
pharmaceutically equivalent.
NB: Pharmaceutical alternatives do not necessarily imply
bioequivalence.
PDF Pharmaceutical dosage form (compare with PP)
A pharmaceutical dosage form is the form of the completed
pharmaceutical product, e.g., tablet, capsule, injection, elixir,
suppository.
PE Pharmaceutical equivalents
Pharmaceutical products are pharmaceutically equivalent if they
contain the same amount of the same API(s) in the same dosage
form, if they meet the same or comparable standards, and if they are
intended to be administered by the same route.
Pharmaceutical equivalence does not necessarily imply
bioequivalence as differences in the excipients and/or the
manufacturing process can lead to changes in dissolution and/or
absorption.
The USA FDA’s definition is:
“drug products that contain identical amounts of the identical active
drug ingredient, i.e., the same salt or ester of the same therapeutic
moiety, in identical dosage forms, but not necessarily containing
the same inactive ingredients, and that meet the identical
compendial or other applicable standard of identity, strength,
quality, and purity, including potency and, where applicable,
content uniformity disintegration times and/or dissolution rates
” (21 CFR 320.1(c)).
Products with different mechanisms of release can be
considered to be pharmaceutical equivalents or duplicates.
PP Pharmaceutical product (compare with PDF)
Any preparation for human (or animal) use, containing one or more
APIs with or without pharmaceutical excipients or additives, that is
intended to modify or explore physiological systems or pathological
states for the benefit of the recipient.
Proportionally Similar Dosage Forms/Products (South African
Guidelines)
“Pharmaceutical products are considered proportionally
similar in the following cases:
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Annexure 1: Definitions, Abbreviations and Symbols xv

r When all APIs and inactive pharmaceutical ingredients (IPIs) are

in exactly the same proportion between different strengths (e.g. a
100-mg strength tablet has all API and IPIs exactly half of a 200-mg
strength tablet and twice that of a 50-mg strength tablet).
r When the APIs and IPIs are not in exactly the same proportion but
the ratios of IPIs to the total mass of the dosage form are within the
limits defined by the Post-registration Amendment guideline.
r When the pharmaceutical products contain a low concentration of
the APIs (e.g. less than 5%) and these products are of different
strengths but are of similar mass.”
The difference in API content between strengths may be
compensated for by mass changes in one or more of the IPIs
provided that the total mass of the pharmaceutical product remains
within 10% of the mass of the pharmaceutical product on which the
bioequivalence study was performed. In addition, the same IPIs
should be used for all strengths, provided that the changes remain
within defined limits.
TE Therapeutic equivalence (equivalents)
Two pharmaceutical products are therapeutically equivalent if they
are pharmaceutically equivalent or pharmaceutical alternatives and,
after administration in the same molar dose, their effects with respect
to both efficacy and safety are essentially the same, as determined
from appropriate bioequivalence, pharmacodynamic, clinical or in
vitro studies.
According to the FDA’s Orange Book, the following is stated:
“Drug products are considered to be therapeutic equivalents only if
they are pharmaceutical equivalents and if they can be expected to
have the same clinical effect and safety profile when administered to
patients under the conditions specified in the labeling.”
FDA classifies as therapeutically equivalent those products that
meet the following general criteria: (1) they are approved as safe and
effective; (2) they are pharmaceutical equivalents in that they (a)
contain identical amounts of the same active drug ingredient in the
same dosage form and route of administration and (b) meet
compendial or other applicable standards of strength, quality, purity,
and identity; (3) they are bioequivalent in that (a) they do not present
a known or potential bioequivalence problem, and they meet an
acceptable in vitro standard, or (b) if they do present such a known or
potential problem, they are shown to meet an appropriate
bioequivalence standard; (4) they are adequately labeled; (5) they are
manufactured in compliance with Current Good Manufacturing
Practice regulations. The concept of therapeutic equivalence, as used to
develop the List, applies only to drug products containing the same active
ingredient(s) and does not encompass a comparison of different therapeutic
agents used for the same condition (e.g., propoxyphene hydrochloride vs.
pentazocine hydrochloride for the treatment of pain). Any drug product in
the List repackaged and/or distributed by other than the application
holder is considered to be therapeutically equivalent to the
application holder’s drug product even if the application holder’s
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xvi Annexure 1: Definitions, Abbreviations and Symbols

drug product is single source or coded as nonequivalent (e.g., BN).

Also, distributors or repackagers of an application holder’s drug
product are considered to have the same code as the application
holder. Therapeutic equivalence determinations are not made for
unapproved, off-label indications.
FDA considers drug products to be therapeutically equivalent
if they meet the criteria outlined above, even though they may differ
in certain other characteristics such as shape, scoring configuration,
release mechanisms, packaging, excipients (including colors, flavors,
preservatives), expiration date/time and minor aspects of labeling
(e.g., the presence of specific pharmacokinetic information), and
storage conditions. When such differences are important in the care
of a particular patient, it may be appropriate for the prescribing
physician to require that a particular brand be dispensed as a
medical necessity. With this limitation, however, FDA believes that
products classified as therapeutically equivalent can be substituted
with the full expectation that the substituted product will produce
the same clinical effect and safety profile as the prescribed product.
CV Coefficient of variation
LOD Limit of detection
LOQ Limit of quantification
LLOQ Lower limit of quantitation
SOP Standard operating procedure
QC Quality control (LQC, MQC, HQC: low, medium, high quality
control)
GCP Good clinical practice
GLP Good laboratory practice
CI Confidence interval
Cpd Concentration in a predose sample immediately following dosing in
a steady state
AUCt Area under the plasma/serum/blood concentration–time curve from
time zero to time t, where t is the last time point with measurable
concentration.
AUC∞ Area under the plasma/serum/blood concentration–time curve from
time zero to time infinity.
AUC␶ Area under the plasma drug concentration–time curve over one
dosing interval at steady state.
Cumulative urinary excretion from pharmaceutical product
administration until time t.
Ae∞ Amount of unchanged API excreted in the urine at infinite time (7–10
half-lives).
Cmax Maximum plasma concentration.
It is the maximum drug concentration achieved in systemic
circulation following drug administration.
Cmin Minimum plasma concentration
It is the minimum drug concentration achieved in systemic
circulation following multiple dosing at steady state.
Cmax (ss) Maximum plasma concentration at steady state
Cmin (ss) Minimum plasma concentration at steady state
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Annexure 1: Definitions, Abbreviations and Symbols xvii

Cav Average plasma concentration

tmax Time to Cmax
It is the time required to achieve maximum drug concentration
in systemic circulation.
Kel Apparent first-order terminal elimination rate constant calculated
from a semi-log plot of the plasma concentration versus time curve
MRT Mean residence time
t1/2 Elimination half-life
It is the time necessary to reduce the drug concentration in the
blood, plasma, or serum to one-half of the initial concentration.
%PTF (Cmax (ss) –Cmin (ss) )/Cav. 100
%Swing (Cmax (ss) –Cmin (ss) )/Cmin. 100
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Contents

Preface . . . . vii
Acknowledgments . . . . x
Disclaimer . . . . xi
Annexure 1: Definitions, Abbreviations and Symbols . . . . xii
Contributors . . . . xx

1. Introduction 1
Isadore Kanfer

2. Australasia 17
C. T. Hung, D. Ren, L. A. Folland, F. C. Lam, Noelyn Anne Hung,
and R. Smart

3. Brazil 46
Margareth R. C. Marques, Sı́lvia Storpirtis, and Márcia Martini Bueno

4. Canada 67
Iain J. McGilveray

5. The European Union 95

Roger K. Verbeeck and Joelle Warlin

6. India 114
Subhash C. Mandal and S. Ravisankar

7. Japan 164
Juichi Riku

8. South Africa 182

Isadore Kanfer, Roderick B. Walker, and Michael F. Skinner

9. South America and Pan American Health Organization 211

Silvia Susana Giarcovich and Ricardo Bolaños

10. Taiwan 232

Li-Heng Pao, Jo-Feng Chi, and Oliver Yoa-Pu Hu

xviii
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Contents xix

11. Turkey 242

Ilker Kanzik and A. Atilla Hincal

12. United States of America 254

Barbara M. Davit and Dale P. Conner

13. The World Health Organization 282

John Gordon, Henrike Potthast, Matthias Stahl, and Lembit Rägo

Index . . . . 301
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Contributors

Ricardo Bolaños Department of Pharmacology, School of Medicine,

University of Buenos Aires; Department of Projects and Plans, Direction of
Planification, National Administration of Drugs, Food and Medical Technology
(ANMAT), Ministry of Health; and Working Group of Bioequivalence, Pan
American Network of Drug Regulatory Harmonization, PAHO, Buenos Aires,
Argentina
Márcia Martini Bueno Regulatory Affairs and Pharmacovigilance, Libbs
Farmacêutica Ltda, São Paulo, Brazil
Jo-Feng Chi Bureau of Pharmaceutical Affairs, Department of Health, The
Executive Yuan, Taipei, Taiwan, Republic of China
Dale P. Conner Office of Generic Drugs, Center for Drug Evaluation and
Research, United States Food and Drug Administration, Rockville, Maryland,
U.S.A.
Barbara M. Davit Office of Generic Drugs, Center for Drug Evaluation and
Research, United States Food and Drug Administration, Rockville, Maryland,
U.S.A.
L. A. Folland Zenith Technology Ltd, Dunedin, New Zealand
Silvia Susana Giarcovich Department of Pharmacology, School of Pharmacy
and Biochemistry, University of Buenos Aires; and DIFFUCAP-EURAND
SACIFI, Buenos Aires, Argentina
John Gordon Division of Biopharmaceutics Evaluation 2, Bureau of
Pharmaceutical Sciences, Therapeutic Products Directorate, Health Canada,
Ottawa, Ontario, Canada
A. Atilla Hincal IDE Pharmaceutical Consultancy Ltd. Co., Ankara, Turkey
Oliver Yoa-Pu Hu National Defense Medical Center, Taipei, Taiwan,
Republic of China
C. T. Hung Zenith Technology Ltd, Dunedin, New Zealand
Noelyn Anne Hung Otago University Dunedin School of Medicine, Dunedin,
New Zealand
Isadore Kanfer Faculty of Pharmacy, Rhodes University, Grahamstown,
South Africa

xx
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Contributors xxi

Ilker Kanzik IDE Pharmaceutical Consultancy Ltd. Co., Istanbul, Turkey

F. C. Lam Zenith Technology Ltd, Dunedin, New Zealand
Subhash C. Mandal Directorate of Drugs Control, “NALANDA,” Fartabad,
Amtola, Kolkata, India
Margareth R. C. Marques Department of Standards Development,
U.S. Pharmacopeia, Rockville, Maryland, U.S.A.
Iain J. McGilveray McGilveray Pharmacon Inc., Ottawa, Ontario, Canada
Li-Heng Pao School of Pharmacy, National Defense Medical Center, Taipei,
Taiwan, Republic of China
Henrike Potthast Federal Institute for Drugs and Medical Devices,
Bonn, Germany
Lembit Rägo WHO Medicines Prequalification Programme, Quality
Assurance and Safety of Medicines, Essential Medicines and Pharmaceutical
Policies, World Health Organization, Geneva, Switzerland
S. Ravisankar GVK Biosciences Pvt. Ltd., Ameerpet, Hyderabad, India
D. Ren Zenith Technology Ltd, Dunedin, New Zealand
Juichi Riku Meiji Pharmaceutical University, Tokyo, Japan
Michael F. Skinner Biopharmaceutics Research Institute, Rhodes University,
Grahamstown, South Africa
R. Smart Douglas Pharmaceuticals, Auckland, New Zealand
Matthias Stahl WHO Medicines Prequalification Programme, Quality
Assurance and Safety of Medicines, Essential Medicines and Pharmaceutical
Policies, World Health Organization, Geneva, Switzerland
Sı́lvia Storpirtis College of Pharmaceutical Sciences, University of São Paulo,
São Paulo, Brazil
Roger K. Verbeeck School of Pharmacy, Catholic University of Louvain,
Brussels, Belgium; and Faculty of Pharmacy, Rhodes University, Grahamstown,
South Africa
Roderick B. Walker Faculty of Pharmacy, Rhodes University, Grahamstown,
South Africa
Joelle Warlin Federal Agency for Medicines and Health Products,
Brussels, Belgium
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1 Introduction
Isadore Kanfer
Faculty of Pharmacy, Rhodes University, Grahamstown, South Africa

INTRODUCTION
The introduction and application of bioequivalence testing as a surrogate indica-
tor of safety and efficacy has had an enormous impact on the development and
formulation of solid oral dosage forms in particular, not only for generic prod-
uct manufacturers but also for the innovator or “brand” companies. Using bioe-
quivalence as a tool to establish therapeutic equivalence between a test (generic)
and a reference product certainly forms the basis for market approval of mul-
tisource drug products, the latter being products marketed by more than one
manufacturer and containing the same active pharmaceutical ingredient (API) in
the same dosage form intended to be administered by the same route of admin-
istration. The reference product is usually the comparator product developed
and marketed by a so-called “innovator” or brand company, where their prod-
uct had been approved on the basis of clinical trials to support claims for safety
and efficacy. It is however a little-known fact that many innovator products that
eventually become available on a particular market were in fact approved on the
basis of a bioequivalence study (1) between the formulation used in the clinical
trials (as reference) and an amended formulation of the same active(s), that is, the
test product. Hence, it is apparent that using bioequivalence methodology and
sound scientifically based acceptance criteria to show therapeutic equivalence
overcomes the need to redo clinical trials that are expensive and time consum-
ing, often taking several years to produce outcomes. As mentioned previously,
it is in the area of solid oral dosage forms where the major benefits of bioequiv-
alence testing occur since plasma drug concentrations can be measured follow-
ing oral administration of a test and reference product in a cross-over fashion
in healthy human subjects. This procedure is feasible and scientifically sound
for drugs, which are intended to be absorbed into the systemic circulation since
the underlying principle is that a link exists between drug concentrations in the
blood and therapeutic effect. However, for other dosage forms, particularly those
intended for other routes of administration and more specifically those which
are not intended to be absorbed into the systemic circulation, generally no such
link exists between drug concentrations in blood and effect. Although some spe-
cific methodologies have been developed and validated, such as the human skin
blanching assay (HSBA) for topical corticosteroid products, to date relatively few
surrogate measures to assess bioequivalence of such dosage forms have been
accepted by regulatory agencies. It is thus apparent that the main objective of
bioequivalence testing is to compare the formulation performance between a test
and reference product with the premise that if bioequivalence is proven, there

1
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2 Kanfer

is unlikely to be any significant differences in clinical outcomes between such

products.
Each country has specific regulatory requirements to approve these prod-
ucts as therapeutic equivalents and therefore considered interchangeable with
the innovator/brand drug product. Regulatory approval of therapeutic equiva-
lents generally requires that the generic drug product meets certain requirements
including: (i) they are approved as safe and effective; (ii) they are pharmaceutical
equivalents in that they (a) contain identical amounts of the same active drug
ingredient in the same dosage form and route of administration and (b) meet
compendial or other applicable standards of strength, quality, purity, and iden-
tity; (iii) they are bioequivalent in that (a) they do not present a known or poten-
tial bioequivalence problem, and they meet an acceptable in vitro standard, or
(b) if they do present such a known or potential problem, they are shown to meet
an appropriate bioequivalence standard; (iv) they are adequately labeled; (v) they
are manufactured in compliance with Current Good Manufacturing Practice reg-
ulations. Therapeutically equivalent products can be substituted with the full
expectation that the substituted product will produce the same clinical effect and
safety profile as the prescribed producta . As previously mentioned, globally, reg-
ulatory approval for interchangeable multisource generic drug products is not
identical in all countries and the regulatory agency for each country may differ
in its regulatory requirements for the demonstration of bioequivalence. More-
over, there is no universal reference listed drug to be used as the comparator for
the proposed generic drug product. Each country establishes its own reference
listed drug product that is commonly available in its own domestic marketplace.
In addition, the statistical criteria for bioequivalence may vary in each country
where the brand drug product is marketed. Consequently, a generic drug prod-
uct that has established bioequivalence to the reference listed drug product in
the United States may not be bioequivalent to the reference listed drug product
in another country. The following is a summary of regulatory requirements by
the relevant countries included in this book.

AUSTRALASIA (AUSTRALIA AND NEW ZEALAND)

The chapter on Australasia includes the Australian requirements according to the
Therapeutic Goods Administration (TGA) of Australia controlled by the Ther-
apeutic Goods Act 1989 (2) and the New Zealand requirements as set out by
Medsafe, a business unit of the New Zealand Ministry of Health, in accordance
with the Medicines Act 1981, Section 20 (3). It was initially intended that from
July 1, 2006, all medicines were to receive regulatory approval from a proposed
Trans-Tasman Joint Regulatory Authority. This Joint Agency was to have respon-
sibility for the control of medicines in both Australia and New Zealand. How-
ever establishment of the Joint Agency has been postponed and there has been
no indication if and when such an agency will come into being. Currently, the
Australian and New Zealand registration requirements are largely aligned with
the Committee of Proprietary Medicinal Products (CPMP) guidelines of the

a Approved Drug Products with Therapeutic Equivalence Evaluations,” Orange Book, (www.
fda.gov/downloads/Drugs/DevelopmentApprovalProcess/UCM071436.pdf).
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Introduction 3

European Medicines Agency (EMEA) (4). Prescription medicines for Australia

are evaluated by the Drug Safety and Evaluation Branch (DSEB) of the TGA and
generic prescription medicines in both Australia and New Zealand are required
to conform to the (European Union) EU’s Common Technical Document (CTD)
format although, unlike the EU, an abbreviated format is acceptable.

BRAZIL
In Brazil, the National Policy for Drug Products published in 1998 created the
National Agency for Sanitary Surveillance (Agencia Nacional de Vigilancia Sani-
taria, ANVISA), which is responsible for the approval of the law and the publica-
tion of the technical guidances for the registration of generic products (5–8). The
law and guidances for the registration of generic products in Brazil are based on
the regulations of countries such as Canada, United States of America, and the
EU. Brazil was the first country in South America to implement the evaluation
of pharmaceutical equivalency and bioequivalence studies for the registration of
generic products.

CANADA
Canadian regulators, under the Health Products and Food Branch (HPFB), Ther-
apeutic Products Directorate (TPD), Health Canada, were the first to apply phar-
macokinetics (PK) to safety and efficacy risk assessment of generic drug products
as a consequence of 1969 amendments to the Patent Act (9) (compulsory licens-
ing). Guidelines [Reports A, B, and C (10–12)] were only published in the 1990s
by an Expert Advisory Committee (EAC), currently referred to as the Scientific
Advisory Committee (SAC). However, Canada is governed as a Confederation
of Provinces and the regulations and guidelines for bioequivalence are federal,
leading to a Notice of Compliance (NOC) to sponsors for marketing in Canada.
Although an application may lead to a Declaration of Bioequivalence for specific
products, the various Canadian provinces and associated Provincial formulary
committees may not accept the Federal decision of bioequivalence (which also
evaluates quality) to be sufficient to list a particular product as interchangeable.
Revision of the Canadian guidelines was mentioned during presentations
at the 2008 and 2009 annual meetings of the Canadian Society of Pharmaceu-
tical Sciences (CSPS) held in Banff during May 2008 and in Toronto during
June 2009 (13).

EUROPEAN UNION
The EU has established requirements which must be met by a generic drug prod-
uct to receive marketing authorization (14). The EU offers four routes for the
registration of generic drug products (15):
1. National Procedure
2. Mutual Recognition Procedure
3. Decentralized Procedure
4. Centralized Procedure.
The national procedure (NP) is strictly limited to medicinal products that
are not authorized in more than one member state and may lead to marketing
authorization of the generic drug product in the concerned member state. The
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4 Kanfer

mutual recognition procedure (MRP) makes provision for the extension of market-
ing authorizations granted to one member state, the so-called reference member
state (RMS), to one or more member states identified by the applicant. The decen-
tralized procedure (DCP) was implemented from November 2005 where a submis-
sion can be made to each of the member states, where it is intended to obtain a
marketing authorization with a choice of one of them as the RMS. The centralized
procedure (CP) has been in use since 2004 for marketing authorization of medic-
inal products in the EU. Here a single application is introduced for evaluation
that is carried out within the Committee for Medicinal Products for Human Use
(CHMP) of the EMEA and is valid throughout the EU with the same rights and
obligations in each of the member states.
The first European bioequivalence guidelines were published in 1991 (16)
and assessment was based on the principles published in the scientific literature,
FDA guidelines, and the first European guidelines on pharmacokinetic studies
in man (17). In 2001, the EMEA’s CPMP published the current version of the
Note for Guidance on the Investigation of Bioavailability and Bioequivalence
(18). A draft version of revised bioequivalence guidelines, entitled Guideline
on the Investigation of Bioequivalence, was made publicly available in August
2008 on the EMEA Web site and a modified version is due to come into effect
in 2010 (19).

INDIA
Bioequivalence assessment for generic medicines in India was instituted by the
incorporation of Schedule Y of the Drugs and Cosmetics Act in 1988, followed
by subsequent amendments of Schedule Y in 1989 and 2005 (20).
In India, generic medicines are those medicines, which are labeled with
their generic names. There is no separate law for registering generic medicines.
Drugs and drug products are classified as either “new drugs” or drugs other than
new drugs. However, in general “generic drugs” refer to those drugs than are no
longer subject to patent protection and are being marketed by their generic name.
In fact, it’s interesting to note that India only started observing product patents
from January 1, 2005 (21,22).
India has a two tier regulatory system, the Central Drugs Standard Control
Organization (CDSCO) under the Government of India and each State has its
own drug regulatory system having certain powers.

JAPAN
In Japan, data from 2006 indicated that generic drug products accounted for as
little as 16.9% of the market by volume 5.7% by value. In the following year,
the Japanese government announced a specific program to increase the use of
generic products to more than 30% by the year 2012 and a system for generic
substitution was targeted for implementation in April 2008.
Approval to manufacture and market generic drug products in accordance
with the Pharmaceutical Affairs Law in Japan is granted by the Minister of
Health, Labour and Welfare (MHLW). An independent administrative organiza-
tion, the Pharmaceutical and Medical Devices Agency (PMDA), under the aus-
pices of the MHLW, undertakes the review and assessment of bioequivalence
data as part of the “Equivalence and Compliance Review.”
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Introduction 5

The first guideline for bioequivalence studies for generic dugs was released
in 1971, in which large animals, such as dogs and rabbits, could be used in bioe-
quivalence studies, but humans were not required. Subsequently in 1997, the
MHLW published a revised Guideline “The Guideline for Bioequivalence Stud-
ies of Generic Products 1997 (23) was introduced. Several newer guidelines and
revisions have been published such as the Guideline for Bioequivalence Studies
for Different Strengths of Oral Solid Dosage Forms 2000 (24), Guideline for Bioe-
quivalence Studies for Additional Dosage Forms of Oral Solid Dosage Forms
2001 (25), Guideline for Bioequivalence Studies of Generic Products for Topical
Dermal Application 2003 (26), Guideline for Bioequivalence Studies for Formu-
lation Changes of Oral Solid Dosage Forms 2000 (27), Draft Guideline for Bioe-
quivalence Studies for Changes in Manufacturing of Oral Solid Dosage Forms:
Conventional, Enteric Coated and Prolonged Release Products, 2003 (28), and
Revision of Guideline for Bioequivalence Studies of Generic Products, 2006 (29).
For oral drug products, in Japan, dissolution testing of these dosage forms
is required together with bioequivalence studies and plays an important role in
selecting appropriate subjects for the in vivo study. In fact, it is noteworthy that
the use of dissolution testing for BA/BE in Japan clearly marks a distinct differ-
ence between Japanese BA/BE guidelines and those of most other countries.

SOUTH AFRICA
The Medicines Control Council (MCC) in South Africa is a statutory body that
was established in terms of the Medicines and Related Substances Control Act
(MRSCA), 101 of 1965, to oversee the regulation of medicines in South Africa.
To facilitate the registration process for generic medicines, guidelines have been
prepared to serve as a recommendation to applicants wishing to submit data in
support of the registration of such medicines (30–33).
In the early 2000s, the requirements for the registration and market
approval of generic medicines were published as official guidelines. Prior to
that time, proof of safety and efficacy of generic medicines were based on
requirements described in “official” notices or circulars issued by the MCC. In
many instances, only in vitro dissolution testing was required based upon Cir-
cular 14/95 that was first issued in the early 1990s and subsequently updated
in 1995 (34).
During 2002 (35,36), legislation was introduced to make provision for
generic substitution whereby dispensers of medicines were mandated to inform
patients of the benefits of the substitution for a branded medicine by an inter-
changeable multisource medicine and to recommend accordingly. The final deci-
sion, however, has been left in the hands of the patient.

SOUTH AMERICA (EXCLUDING BRAZIL)—PAN AMERICAN

HEALTH ORGANIZATION
In South American countries (Brazil has been dealt with previously) harmoniza-
tion efforts have been carried out by different economic integration groups, such
as TLCN (Tratado de Libre Comercio de Norteamérica) in Canada, Estados Unidos,
and México; MERCOSUR in Argentina, Brazil, Paraguay, and Uruguay (Chile
and Bolivia participate without being members); SICA (Sistema de la Integración
Centroamericana) in Guatemala, El Salvador, Honduras, Nicaragua, and Costa
Rica; CAN (Comunidad Andina de Naciones) in Bolivia, Colombia, Ecuador, Perú,
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6 Kanfer

and Venezuela; CARICOM (Caribbean community) in Caribbean Islands; and by

PAHO (Pan American Health Organization) through PANDRH (Pan American
Network for Drug Regulatory Harmonization). Generally, most South Ameri-
can countries, apart from Brazil, do not have regulations for the registration of
generic products as such. However, proof of bioequivalence and an inference of
therapeutic equivalence and/or declaration of interchangeability (through either
in vitro or in vivo methodology) are required as a condition either for registration
or commercialization of generic (i.e., noninnovator) products.

TAIWAN
The Bureau of Pharmaceutical Affairs (BPA) within the Department of Health
(DOH) is responsible for the regulation of medicinal products in Taiwan. In 1984,
the BPA outsourced the drafting of BA/BE guidelines and Taiwan guidelines on
BA/BE for generic medicines were issued in 1987. Generic products are reviewed
and approved within the BPA at the DOH. The applicant needs to certify to the
DOH that the patent in question is not infringed by the generic product. Once
the BPA staff have completed the filing review of the submission and have ver-
ified that the application has met all the necessary regulatory requirements, the
application is then assigned to technical review which focuses on BE data and
chemistry and manufacture quality.

TURKEY
Marketing authorization for medicinal products for humans are issued by the
Ministry of Health (MoH) in Turkey, but the entire procedure is managed by the
General Directorate of Drug and Pharmacy (GDDP). Turkish licensing regula-
tions for all pharmaceutical products, innovator/brand and generics, came into
force on June 30, 2005 (37). This legislation brought Turkish law in line with that
of the EU and covered all aspects of the drug registration procedure and all new
Turkish regulations are intended to be, as far as possible, compatible with those
of the EU. However, bioequivalence became compulsory for a generic drug prod-
uct to receive a marketing license after the publication of a regulation on May 27,
1994 (38). In general, the design and conduct of a BE study should follow Turkish
and/or EU regulations on Good Clinical Practice (GCP).

UNITED STATES OF AMERICA

The Food and Drug Administration (FDA) in the United States of America intro-
duced the Abbreviated New Drug Application (ANDA) procedure in 1984b ,
which is used for the marketing approval of generic drug products. The ANDA
pathway for generic drug product approval was enacted due to earlier concerns
in the 1960s that there may be differences in bioavailability between two chemi-
cally equivalent products (39). In 1974, a report entitled “Drug Bioequivalence”
(40) was published and in 1977, the FDA published its Bioavailability and Bioe-
quivalence regulations that facilitated the rational development of generic drug

b The Drug Price Competition and Patent Term Restoration Act of 1984, informally known as
the ”Hatch-Waxman Act” is an amendment to the U.S. Food and Drug Law that established
the Abbreviated New Drug Application (ANDA) as a pathway for approval of generic drug
products.
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Introduction 7

products (41), which was revised in 1992 (42). The current FDA guidance for
industry was posted in 2003 and updates recommendations for documentation
of bioavailability and bioequivalence required for regulatory submissions (43).
Although this guidance indicates that it provides recommendations for orally
administered drug products, the guidance also applies to nonorally administered
drug products where reliance on systemic exposure measures is suitable to docu-
ment bioavailability/bioequivalence such as for transdermal and some rectal and
nasal products. Several separate guidances have also been published and which
relate to topical dermatologic corticosteroids (44), food effects (45), and guidance
on waivers for in vivo studies for immediate-release solid oral dosage forms on
the basis of the Biopharmaceutics Classification System (BCS) (46). On Friday,
January 16, 2009, “Final rule” on the requirements for submission of Bioequiv-
alence Data was published in the Federal Register (47). Several other guidances
that have been published are given here.
CDER Guidance for Industry: BE Recommendations for Specific Products
(48) and CDER Guidance for Industry: Individual Product Bioequivalence Rec-
ommendations (49). These latter two guidances provide information on specific
drug products relating to the design of BE studies to support ANDAs and infor-
mation on individual products. Another draft, Guidance on the Submission of
Summary Bioequivalence Data for ANDAs (50), relates to the FDA’s require-
ment that ANDA applicants submit data from all BE studies that the applicant
conducts on a drug product formulation including studies that do not demon-
strate bioequivalence of their generic product submitted for approval. This guid-
ance also provides information on the format for summary reports of BE studies
and types of formulations that the FDA considers to be the same drug product
formulation for different dosage forms, based on differences in composition.
The ANDA is submitted to the Office of Generic Drugs (OGD)c and upon
filing acceptance the application is assigned for bioequivalence review, where the
review process assesses the bioequivalence data comparing the generic product
and the reference listed drug (RLD) indicated in the Orange Book (51).

WORLD HEALTH ORGANIZATION

World Health Organization (WHO) has developed a document entitled “937,
WHO Expert Committee on Specifications for Pharmaceutical Preparations,”
40th Report (52) in which annex 7 relates to bioequivalence. WHO, which is the
directing and coordinating authority for health within the United Nations sys-
tem, is responsible for providing leadership on global health matters, shaping
the health research agenda, setting norms and standards, articulating evidence-
based policy options, providing technical support to countries, and monitor-
ing and assessing health trends. In particular, the intention is to help national
and regional authorities (in particular drug regulatory authorities), procurement
agencies, as well as major international bodies and institutions, to combat prob-
lems of substandard medicines and underpin important initiatives. Importantly,
since the overall tendency is that resource-constrained or resource-poor countries
are less likely to control the quality of products on the market, due to the absence

c New BE Review Organization: Divisions 1 and 2; http://www.fda.gov/AboutFDA/

CentersOffices/CDER/ucm119462.htm. Accessed June 8, 2009.
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of properly resourced and functioning regulatory authorities, WHO publications

and guidelines are intended to fill an important void by providing appropriate
information in the quest to ensure medicinal product quality.

ISSUES OF SEMANTICS AND DIFFERENCES IN INTERPRETATION

Several semantic issues prevail in the official documents and guidelines pub-
lished by various regulatory authorities, which appear to have resulted in confu-
sion and misinterpretation of criteria and conditions for the declaration of bioe-
quivalence and consequently establishing the interchangeability/switchability
of a generic product for and innovator/brand product.
The definition of the term “bioequivalence” itself gives rise to a degree of
misunderstanding when related to generic substitution. For example, the Orange
Book (51) provides the following definition for bioequivalence, viz:
the absence of a significant difference in the rate and extent to which the
active ingredient or active moiety in pharmaceutical equivalents or phar-
maceutical alternatives becomes available at the site of drug action when
administered at the same molar dose under similar conditions in an appro-
priately designed study.
Importantly, in this definition, provision is made for “pharmaceutical alter-
natives” to be declared bioequivalent to the listed reference product in the
Orange Book. However, pharmaceutical alternatives are not considered as ther-
apeutic equivalents and therefore are neither interchangeable nor switchable.d
According to the Orange Book (51), the following is stated:
Drug products are considered to be therapeutic equivalents only if they are
pharmaceutical equivalents and if they can be expected to have the same
clinical effect and safety profile when administered to patients under the
conditions specified in the labeling.
Consequently, in terms of the FDA’s requirements, only products classified
as therapeutically equivalent can be substituted with the full expectation that
the substituted product will produce the same clinical effect and safety profile
as the prescribed product. FDA specifically excludes a “pharmaceutical alterna-
tive” dosage form from attaining therapeutic equivalent status. In contrast, this
specific requirement for therapeutic equivalence is either overlooked or deemed
unnecessary in several countries where pharmaceutical alternatives, once shown
to be bioequivalent are considered to be interchangeable. Reference to the WHO
document (52) includes the following definitions/descriptions where the term,
pharmaceutical alternatives is mentioned. For example, a multisource (generic)
pharmaceutical product is described as pharmaceutically equivalent or pharma-
ceutically alternative products that may or may not be therapeutically equiva-
lent. This intention is unclear since what would be the basis of market approval
for a pharmaceutically equivalent or pharmaceutically alternative generic prod-
uct that has not been shown to be therapeutically equivalent?

d Pharmaceutical alternatives may be a capsule and a tablet containing the same active drug
substance in the same dose strength. However, the U.S. FDA does not allow capsule formu-
lations to be interchanged for tablet formulation of the same drug even if both products are
bioequivalent.
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Introduction 9

COMPARATOR (REFERENCE) PRODUCTS

A further confusing issue also arises from some of the requirements stated in
the bioequivalence WHO document (52). Specifically, mention is made in that
document of a “Comparator Product” under section 3 entitled Choice of Com-
parator Products. This section describes how to identify the correct Comparator
Product against which the proposed multisource pharmaceutical product (MPP
or generic) must be compared. Generally, the comparator or reference product for
use in a bioequivalence study needs to be the “nationally authorized innovator,”
usually the innovator/brand product that has been approved and available on
that domestic market. However, the WHO document makes provision for some
options of choice regarding the comparator product by including the permitted
use of an innovator product currently available on the market in a well-regulated
country. This brings into consideration the use of a foreign or nondomestic refer-
ence product. Although such a choice is permitted only when a nationally autho-
rized innovator may not be available (i.e., countries where no innovator/brand
product is available on their domestic market), this constraint appears to have
been dismissed by some countries where in spite of the availability of a nationally
authorized innovator, use of a foreign reference product is permitted. The WHO
comparator product was instituted specifically as an effort to assist national drug
regulatory authorities and pharmaceutical companies in selecting appropriate
comparator products from a list of comparator products derived from informa-
tion collected from drug regulatory authorities and the pharmaceutical industry.
The WHO document includes the following:
Note: a product that has been approved based on comparison with a non-
domestic comparator product may or may not be interchangeable with cur-
rently marketed domestic products.

Hence, it is important to be aware that should a nationally authorized inno-

vator product not be available as the comparator product, products approved on
the basis of comparison to the chosen comparator product may or may not be
interchangeable with other products currently available within that particular
market. In other words, “generic substitution” per se cannot be recommended
unconditionally.

GENERIC SUBSTITUTION (INTERCHANGEABILITY)

In some countries, where the market share of a new generic product may be rela-
tively small, sponsors tend to submit bioequivalence studies where the reference
product from another country (foreign/nondomestic) was used. Therefore, bioe-
quivalence studies that were performed in compliance with the requirements
of one country are submitted in support of approval of that generic in another
country. The intent for such practice is to reduce costs and avoid the necessity
of performing an additional bioequivalence study. However concerns have been
raised about such practice in view of the fact that different formulations of the
same product are often used in different countries and may have significant con-
sequences with respect to bioavailability.
A unique situation currently exists in South Africa. The government, a
few years ago, decided that when a generic medicine has been approved for
marketing by the national medicines regulatory authority, the MCC, prescribers
and dispensers of medicines must inform the patient that such prescribed
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10 Kanfer

medicines may be available at a lower price than the innovator/brand prod-

uct and recommend accordingly. In other words, where an approved generic
medicine exists, the generic medicine will be substituted for the innovator/brand
product unless the dispenser is prohibited to do so by the patient. The manda-
tory instruction is based on the premise that approved generic medicines have
been assessed by the MCC and deemed to be interchangeable. However, in terms
of the national guidelines, most generic medicines approved and marketed in
South Africa do not comply with the usual internationally accepted requirements
for interchangeability since most have not been assessed by comparison with
the innovator/brand product available on the South African market. The rea-
son for the “noninterchangeability” notion is that provision has been made in
the local guidelines to permit bioequivalence assessment to be conducted using
a “foreign” reference product. This means that the “foreign” reference product,
although being supplied by the same innovator/brand company, may not be the
same (identical formulation, manufacture, etc.) as the innovator/brand product
being sold on the South African market.
There are many instances where the innovator/brand products are formu-
lated differently for different markets. For example, Tegretol XR R
tablets, a pro-
longed action carbamazepine product is marketed in the United States as a non-
disintegrating dosage form using the OROS R
mechanism. The same innovator
is listed as the manufacturer of prolonged action carbamazepine dosage forms in
various other countries where those dosage forms are also tablets but which dis-
integrate in aqueous fluid and are marketed as Tegretol CR R
in South Africa. The
release mechanisms and formulation of the United States reference listed prod-
uct and the product marketed by the same innovator in South Africa are clearly
different. In some instances this is done intentionally due to patents. In other
cases, there may be unintended differences in release of the active ingredient(s),
due to various factors such as the manufacturing process. Bioavailability differ-
ences between products can be due to factors such as sources of raw material
and synthesis (nature) of the API including particle size and crystal forms (poly-
morphs, crystal shapes and degree of hydration or salvation, etc.), use of differ-
ent methods of manufacture and manufacturing equipment, amongst others. All
of these factors can have significant effects on bioavailability with consequent
implications for their bioequivalence. Hence, in the absence of specific confirma-
tory data, a nondomestic innovator/brand product used as the reference product
in a bioequivalence study involving a generic medicine intended for a particular
domestic market cannot be assumed to be bioequivalent to the domestic inno-
vator/brand product. In spite of the foregoing, the only data required by the
MCC to show that the “foreign” reference product is the “same” as the reference
product marketed in South Africa are dissolution profiles comparing f 2 values
between the foreign and domestic reference product conducted in three different
dissolution media at pH 1.5, 4.5, and 6.8. These comparisons are not constrained
to any particular class of medicine or properties such as the BCS (53) or drug
use, potency, therapeutic index (e.g., narrow) amongst others. Risk assessment
has apparently neither been done nor is required?
Whereas it should be noted that a generic product which has been shown
to be bioequivalent to a reference product purchased in a nondomestic market
will likely provide a spectrum of safety/efficacy associated with the included
active ingredient, it is important to stress that such a generic product cannot be
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Introduction 11

deemed to be equivalent to the innovator/rand product available on another

(domestic) market and vice versa, unless appropriate data have been obtained to
show bioequivalence. In other words, a generic product that has been shown
to be bioequivalent to a nondomestic reference product may well be usable
or “prescribable” but in the absence of the necessary comparative bioavailabil-
ity data showing bioequivalence between that same generic product and the
domestic reference product, that generic product cannot be considered to be
interchangeable.
From the foregoing discussion it appears that the MCC, by making pro-
vision for a foreign reference product to be used in a bioequivalence study
(i.e., using a nondomestic innovator/brand product as the reference) has inad-
vertently and naively created a two-tiered system for the approval of generic
medicines in South Africa. The top tier can therefore be considered to consist of
generic products approved on the basis of comparison with the domestic inno-
vator/brand product as the reference, whereas another (second or lower) tier
includes those generic products approved on the basis of a comparison of the
generic with a nondomestic innovator/brand as the reference in a bioequiva-
lence study. In addition, the latter tier probably also includes all other generic
medicines which have been approved on the basis of in vitro testing only, apart
from those products which incorporate an API classified as Class 1 according to
the BCS (53,54).
It also appears that a similar situation of ill-conceived interchangeability
for approved generic controlled/modified release dosage forms and also nono-
ral dosage forms such as topical products for local use, inhalation products and
various other such generic products which are not intended to be absorbed into
the systemic circulation.
In summary, it should be emphasized that only when a generic medicine
has been shown to be bioequivalent with the domestic innovator/brand product
used as reference, will substitution be acceptable and appropriate. On the basis of
“similar” bioavailability, as would the case be when the generic has been shown
to be bioequivalent to a nondomestic reference product, a clinical decision may
be justified to declare a “second tier” generic product “prescribable” for a patient
who is naı̈ve to that particular medicine, but certainly interchangeability of such
a product is highly questionable.

BIOWAIVERS
The main intentions of a biowaiver is to provide a cost-effective approach to
improve the efficiency of drug development and the review process by recom-
mending a strategy for identifying expendable clinical bioequivalence tests.e The
BCS published by Amidon et al. in 1995 (53) finally lead to consideration of
the possibility of waiving in vivo bioequivalence studies for certain immediate-
release drug products in favor of specific comparative in vitro testing to con-
clude bioequivalence without requiring an in vivo bioequivalence study. This
approach is meant to reduce unnecessary in vivo bioequivalence studies and the
use of human subjects but is, however, restricted to noncritical drug substances
in terms of solubility, permeability, and therapeutic range, and to noncritical

e http://www.fda.gov/AboutFDA/CentersOffices/CDER/ucm128219.htm.
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12 Kanfer

pharmaceutical forms. Several countries, however, such as Canada, Japan,

Taiwan, and Brazil, amongst others, do not make provision for BCS biowaivers,
even for Class 1 drugs whereas the WHO have proposed an extension of the
BCS for biowaivers for some Classes 2 and 3 drugs (52). In general, BCS-based
biowaivers appear to be relatively under-used due to uncertainties by both phar-
maceutical companies and regulatory authorities (55) although some countries
have permitted the indiscriminate use of BCS dissolution conditions for certain
biowaivers.

SUMMARY
Most countries appear to have adopted the basic tenets and approaches used by
those countries that pioneered (Canada and United States) the introduction and
application of this particular tool for the assessment of bioequivalence of differ-
ent formulations of the same drug product. Apart from its general use, both by
innovator and generic drug companies, there still appears to be a certain degree
of naivety and ignorance associated with BE testing where the notion persist that
it is specifically a tool for use only in the assessment of generic drug products.
However, some causes for concern still remain, and those relate to issues
of semantics and interpretation of the main objectives such as, for example, the
association between bioequivalence, therapeutic equivalence, and generic sub-
stitution. In particular, statements such as,“may or may not be interchangeable,”
or “may or may not be bioequivalent or therapeutically equivalent,” which appear in
some formal definitions such as the following are disconcerting.
r Note: a product that has been approved based on comparison with a nondo-
mestic comparator product may or may not be interchangeable with currently
marketed domestic products (Ref. 52, 6.5.2, p. 364).
r Multisource pharmaceutical products (52).
Pharmaceutically equivalent or pharmaceutically alternative products that
may or may not be therapeutically equivalent. MPP that are therapeutically
equivalent are interchangeable.
r Pharmaceutical alternatives (52).
Pharmaceutical alternatives deliver the same active moiety by the same route
of administration but are otherwise not pharmaceutically equivalent. They
may or may not be bioequivalent or therapeutically equivalent to the compara-
tor product.

In addition, the term “essentially similar” (56) as used in EU guidances and

documents creates confusion with respect to considerations of bioequivalence,
therapeutic equivalence, and interchangeability. The issue of pharmaceutical alter-
natives remains inconsistent between countries with respect to permission for
market approval with interchangeability status.
Finally, the issue and questionable use of an “acceptable reference prod-
uct” or comparator product for generic substitution (AB rating) differs between
countries. In the United States it is quite clear that the reference product for use
in a bioequivalence study must be a reference-listed drug (RLD) as published in
the Orange Book (51) whereas in many other countries, including the EU, a non-
domestic reference product may be used to establish bioequivalence, therapeutic
equivalence, and interchangeability of an MPP.
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Introduction 13

In spite of the foregoing, the applications of the principles of average bioe-

quivalence and its related methodologies have clearly served the international
pharmaceutical industry very well over the years since its introduction. BE test-
ing has proved to be an extremely valuable tool, expedient, efficient, and rel-
atively inexpensive in comparison with the costs to conduct clinical trials. It
serves both innovator/brand companies during their formulation development
and post-approval changes of products initially approved on the basis of clinical
safety and efficacy studies and generic manufacturers to obtain market approval
for their MPP.

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2 Australasia
C. T. Hung, D. Ren, L. A. Folland, and F. C. Lam
Zenith Technology Ltd, Dunedin, New Zealand

Noelyn Anne Hung

Otago University Dunedin School of Medicine, Dunedin, New Zealand

R. Smart
Douglas Pharmaceuticals, Auckland, New Zealand

INTRODUCTION

History
In Australia, as in many other countries, registration of medicines prior to their
sale became a legal requirement soon after the problems with thalidomide (1)
were identified. At present, the registration of medicines is controlled by the
Therapeutic Goods Act 1989 (2). Under this Act, all medicines sold across state
borders, prescription medicines and any nonprescription medicines intended for
inclusion in the Pharmaceutical Benefits Schedule (PBS), cannot be sold until
they are either registered or listed on the Australian Register of Therapeutic
Goods (ARTG) (www.tga.govt.au). Responsibility for inclusion or otherwise of
medicines on the ARTG rests with the Therapeutic Goods Administration (TGA)
based in Canberra. Prior to the Therapeutic Goods Act 1989, only prescrip-
tion medicines and nonprescription medicines intended for inclusion in the PBS
were evaluated. Nonprescription medicines not intended for inclusion in the PBS
and medicines manufactured and sold within a single state or territory did not
need to receive formal regulatory approval before being sold except in some
states such as the state of Victoria, where registration dubbed “Reg. Vic” by the
Victorian Ministry of Health was required. Hence, in most states, no controls
on the quality, safety, or efficacy of such medicines were enforced. “Reg. Vic”
requirements related to good manufacturing practices (GMP) compliance of the
finished product manufacturer along with evaluation of the quality and labeling
of the finished product. With the coming into effect of the Therapeutic Goods
Act 1989 on the January 15, 1991, these “Reg.Vic” requirements developed some
time later into the OTC compliance branch of the TGA. From July 1, 2006, it
was intended that all medicines, irrespective of scheduling, site of manufacture
or distribution receive regulatory approval from a proposed Trans-Tasman Joint
Regulatory Authority before being permitted for sale. The Joint Agency was to
have responsibility for control of medicines in both Australia and New Zealand
such that both countries were to be viewed as a single regulatory market, with-
out being a single sales market. However in July 2007, the Labor party in the
New Zealand Government at that time, failed to achieve sufficient votes to rat-
ify the legislation designed to give authority to the agency. Establishment of the

17
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18 Hung et al.

Joint Agency has, therefore been postponed and no indication is presently avail-
able as to when such an agency will come into being. Therefore until such time
as negotiations recommence, the status quo applies with the Therapeutic Goods
Act 1989 being the applicable legislative authority. Continuation of registration
or listing on the ARTG requires payment of an annual fee and no evaluation
occurs with such payment. In relation to the sale of generic medicines, substitu-
tion, at the discretion of the dispensing pharmacist or at the request of the end
user, on prescription is legal in Australia.
In New Zealand, as in Australia, government approval prior to the sale of a
medicine also became a legal requirement soon after the problems with thalido-
mide (1) were identified. New Zealand, however, does not have either a regis-
tration or licensing system. Instead, companies who wish to market medicines
in New Zealand must apply for “Consent to Distribute” (Medicines Act 1981,
Section 20) (3) and cannot begin to market the medicine until such consent is
notified in the New Zealand Gazette. Responsibility for recommending “Consent
to Distribute” rests with Medsafe, a business unit of the New Zealand Ministry
of Health based in Wellington (www.medsafe.govt.nz). Prior to the Medicines
Act 1981 coming into force in 1984, Government approval of medicines was con-
trolled by the Food and Drug Act 1969. Unlike Australia, as New Zealand is a
single country rather than a federation, all medicines irrespective of scheduling,
site of manufacture, or distribution must have “Consent to Distribute” before
sales can commence. “Consent to Distribute,” once notified, remains in force
until 5 years after either the date of the last sale of the product by the company
responsible for placing the product on the market or the date of the last regu-
latory activity such as submission and approval of a Changed Medicine Notifi-
cation, the equivalent of a variation in other regulatory systems. No annual fees
apply. In relation to the sale of generic medicines, substitution on prescription
may only occur where the doctor either writes on the prescription that substitu-
tion of another brand of the same active ingredient is allowed or the prescription
is written using the generic name only of the intended medicine.
In both Australia and New Zealand, medicines may be scheduled as either
prescription medicines, pharmacist medicines, pharmacy only medicines, or gen-
eral sale medicines. In Australia, the scheduling is performed by the Subcommit-
tee on the Uniform Scheduling of Drugs and Poisons (SUSDP), while in New
Zealand, scheduling is the responsibility of an advisory committee to the min-
ister of health known as the Medicines Classification Committee (MCC). The
SUSDP and MCC have worked together closely in the past few years to promote
harmonization of the schedules in each country.

Regulatory Format for Marketing Applications

In both Australia and New Zealand, the preferred format for submission of an
application to market a new generic medicine is the common technical document
(CTD). In line with the use of the CTD in other countries, the information in
Modules 2 to 5 is product related and identical to the information intended for
submission in other countries. Module 1 is administrative data and at present
and until such time as the Joint Agency is established, the information required
to be included in Module 1 is unique to each country.
An application for a generic prescription medicine in Australia must
be accompanied by 75% of the evaluation fee described in the fees schedule
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published on the TGA Web site (www.tga.gov.au). However, in New Zealand

the application must be accompanied by 100% of the fee described in the fees
schedule published on the Medsafe Web site (www.medsafe.govt.nz).
In Australia, the information that is required to be included in an appli-
cation for registration of a generic medicine on the ARTG is detailed in the
Australian Regulatory Guidelines for Prescription Medicines (ARGPM) June
2004 (4) and Notice to Applicants CTD-Module 1 TGA Edition September 2007
(5) (www.tga.gov.au). As stated earlier, Modules 2 to 5 are identical to Modules 2
to 5 prepared for submission elsewhere in the world. The following information
is required for Module 1.

1. Letter of application
2. Comprehensive table of contents
3. Application form: The template for this form can be downloaded from the
TGA Web site.
4. Australian labeling and packaging
5. Information about the experts
6. Specific requirements for different types of application
7. Drug and Plasma Master Files and Certificates of Suitability of Monographs
of the European Pharmacopoeia: Where products involve manipulation
of blood at some stage, applications must be accompanied by a file, the
“Plasma Master File,” describing that manipulation and the controls
applied. For medicines, the Master file in Module 3.2.S of the application
should include either a full description of the synthesis and controls applied
in manufacturing the active pharmaceutical ingredient (API) as is usual
for applications for new chemical entities (NCEs) or for generics, either
a current Certificate of Suitability issued by the European Directorate for
the Quality of Medicines (www.edqm.eu) or a Drug Master File describing
the synthesis and controls applied in the manufacture of the API. The
information must be accompanied by a specific authorization to allow the
TGA to access the information provided by the API manufacturer on behalf
of the applicant.
8. Good Manufacturing Practice: The TGA requires both the API and finished
product manufacturers located outside Australia to comply with the same
GMP standards as manufacturers resident in Australia. The evidence of
such compliance that is accepted by the TGA is detailed in the 16th edi-
tion of the Guidance on the GMP Clearance of Overseas Manufacturers (6)
available on the TGA Web site.
9. Meetings: A meeting can be arranged between the TGA and an applicant to
discuss and resolve possible issues that are important for a marketing appli-
cation or that may arise during evaluation of an application. The intention
is to reduce barriers to approval of an application
10. Individual patient data: In Australia, individual patient data are not
required to be included as part of a product application except for
the plasma/blood/serum or urine concentrations and derived data from
bioavailability studies. Such data should however, be held by the applicant
in a form suitable for submission in the European Union (EU) or the United
States and be able to be submitted to the TGA on request.
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20 Hung et al.

11. Overseas regulatory status: The TGA requires applicants to provide a list
of overseas countries where the product has been submitted, the product
information for those countries, any differences between the applications
submitted in those countries and a statement about the regulatory status in
Canada or the United States.
12. Summary of biopharmaceutical studies (defined as bioequivalence and/or
bioavailability studies): Where an application contains biopharmaceutical
studies, the application should include a summary of the study. The appro-
priate template for the summary can be downloaded from the TGA Web site
and covers details such as study design, analytical validation, and pharma-
cokinetic results obtained. If no biopharmaceutical study is included in the
application, justification for not providing such data is required. The infor-
mation to be included can be found in Appendix 15 of the ARGPM.
13. Pediatric development program
Besides the above information there are three additional annexures to be
completed:
1. Environmental risk for non-GMOs (genetically modified organisms) contain-
ing medicines.
2. Antibiotic Resistance Data.
3. Overseas Evaluation Reports.
An application in Australia for a generic product may be classified as either
a Category 1 or a Category 2 application. A Category 1 application is an applica-
tion for a generic product that is not supported by copies of evaluation reports
from two or more overseas regulatory authorities. The Therapeutic Goods Act
1989 requires that the TGA complete the evaluation of a Category 1 application
within 255 working days otherwise the remaining 25% of the evaluation fee is
not paid to the TGA. Where an application for a generic product is supported by
two or more independent evaluation reports of Module 3 data from overseas reg-
ulatory authorities, the application is a Category 2 application, and must be eval-
uated within 120 working days. The TGA currently accepts evaluation reports
from Canada, Sweden, the Netherlands, the United Kingdom, and the United
States. The evaluation reports should be included in Annex 3 to Module 1.
In New Zealand, there is no formal listing of the requirements for inclusion
in Module 1. In general however, the following information should be included.
1. Application form: The same form is used irrespective of whether or not the
medicine is a generic or NCE. Appendices to this form include evidence of
compliance with GMP for the active ingredient manufacturer, finished prod-
uct manufacturer and finished product packer.
2. Generic medicine check list: This is a unique form that must be completed
by an applicant requesting approval of a generic medicine, but not by an
applicant requesting approval of a NCE.
3. Comprehensive table of contents for the whole application.
4. Data sheet: New Zealand has a specific format for presentation of qual-
ity, safety, and efficacy information to health professionals; however, New
Zealand will also accept such information in the form of an SPC (summary of
product characteristics) or Australian Product Information. If a New Zealand
specific data sheet is prepared, it must be accompanied by a completed data
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sheet checklist and declaration. The format of the data sheet, checklist, and
declaration may be found in the New Zealand Regulatory Guidelines for
Medicines (NZRGM) (7) (www.medsafe.govt.nz).
5. Proposed labeling: The requirement is that it should be in the form of either
finished label(s) or finished artwork ready for printing the label(s) or as draft
artwork showing design, color, and wording proposed to be used on the label
for each dose form, strength and pack size. It is emphasized that in New
Zealand, the term “label” refers to the words and designs that are attached to
or part of the container in which the medicine is packed. It does not include
the data sheet or consumer medicine information (CMI).
6. Consumer Medicine Information: The provision of CMI is not a mandatory
requirement; however, it is recommended and if prepared it must be accom-
panied by a declaration of content. The proposed format for CMI and the
declaration to be completed may be found in the New Zealand Guide to the
Registration of Medicines.

In Australia, generic medicines that are scheduled as prescription

medicines are evaluated by the Drug Safety and Evaluation Branch (DSEB) of
the TGA. The information required to be included in an application is detailed
in the Australian Guide to the Registration of Drugs (AGRD) Volume 1 (www.
tga.gov.au) Generic medicines that are scheduled as pharmacist medicines, phar-
macy only medicines, or general sale medicines are evaluated by the over-the-
counter (OTC) branch of the TGA. The information required to be included in an
application for a pharmacist medicine, pharmacy only medicine, or general sale
medicine is detailed in the Australian Regulatory Guidelines for OTC medicines
(8) (www.tga.gov.au).
In New Zealand, there is no distinction made between the four medicine
schedules as to which regulatory agency will evaluate an application.
As already indicated, applications for Generic Prescription Medicines in
both Australia and New Zealand should be in CTD format as is required for
submission of an application in the EU. However, unlike the EU, an abbrevi-
ated format is acceptable. The abbreviated format consists of Module 1, Module
2.3, Module 3 (3.2.S and 3.2.P), and Module 5.3.2 (bioequivalence). In Australia,
applications for pharmacist medicines, pharmacy only medicines, or general sale
medicines may also be in an abbreviated CTD format that comprises: Module 1,
Module 3.2.P, and Module 5.3.2 for specified medicines. Applications for phar-
macist medicines, pharmacy only medicines, or general sale medicines in New
Zealand require Module 1, Module 3 (3.2.S and 3.2.P), and Module 5.3.2 for spec-
ified medicines.
An application for a generic prescription medicine submitted to Medsafe in
New Zealand or to the TGA in Australia, should preferably contain a bioequiva-
lence study that has been performed using either the New Zealand or Australian
innovator product as the reference product, respectively. However, where jus-
tified by appropriate additional in vitro comparative studies, both agencies will
accept bioequivalence studies where the innovator product used as reference was
sourced from outside their respective countries. The in vitro studies required are
detailed in either Section 14.2 of the NZRGM or Appendix 15 (Section 7) of the
ARGPM.
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22 Hung et al.

BIOEQUIVALENCE REQUIREMENTS

Ethical Review and Approval Processes

Ethical review of research involving humans has been a requirement of the
Australian and New Zealand health research system since the 1950s. The ethi-
cal principals outlined in the Nuremberg Code (9) and Declaration of Helsinki (10)
formed the basis of the development of the ethical review process in both coun-
tries. These historic documents (along with their subsequent amendments) were
fundamental in guiding the ethics for human research practice.

New Zealand
In New Zealand the current system was developed largely in response to the
Cartwright Inquiry, which was concluded in 1988 (11). This inquiry formed the
basis of an independent ethical review process. Further refinements occurred as
a result of the Gisborne Cervical Screening Inquiry in 2001 (12), which recom-
mended that the current process for ethical review be re-evaluated.
The primary role of all ethics committees is the protection of the rights,
health, and well-being of consumers and research participants. Ethics commit-
tee approval is required for all research involving human participants (whether
health or disability support services consumers, healthy volunteers, or members
of the community at large) and where the research falls under one of the spec-
ified categories for matters requiring ethical review. Ethics committees consider
whether the research meets ethical guidelines and considers such matters as to
how participants are selected for the trial and whether they are provided with
enough information to enable them to make an informed decision about partici-
pating. An ethics review is required for each study.
For human ethics, the following committees have been established in
statute, under the New Zealand Public Health and Disability Act 2000:
r The Health Research Council Ethics Committee
r The National Advisory Committee on Health and Disability Support Services
Ethics
r The Ethics Committee on Assisted Reproductive Technology
r Six Regional Health and Disability Ethics Committees and the Multiregion
Ethics Committee
The regional ethics committees consider applications for research that is
to be carried out entirely within just one of New Zealand’s four ethics commit-
tee regions. The multiregion ethics committee considers applications for research
that is carried out in more than one of the ethics committee regions.
Ethics committees are also formed by other organizations and gain accred-
itation through the Health Research Council Ethics Committee (HRCEC). These
include institutional ethics committees (e.g., Universities) and private sector
ethics committees (e.g., Zenith Biomedical Ethics Committee). These committees
may have restrictions upon them as to what type of research they can review
(e.g., healthy volunteer studies only). Any research, however, that involves the
use of patients in the health sector has to be reviewed and approved by a health
and disability ethics committee (or the Multiregion ethics committee if the pro-
posal covers more than one region).
The accreditation of ethics committees by the HRCEC is a formal process.
Every accredited ethics committee is required to provide an annual report plus
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other relevant information as required in the HRC Guidelines for Ethics Committee
Accreditation (13). All accredited ethics committees are required to provide inde-
pendent, competent and timely review of research studies. All members of the
ethics committee are required to be independent, having no connection with any
research proposals that are reviewed, which may cause a conflict of interest.
Ethics committees generally operate in accordance with the ministry of
health’s Operational Standard for Ethics Committees but can also have their own
operational procedures. There is generally a turnaround time of 1 to 2 months
from the ethics committee submission date to obtain full approval.
All applications for research proposals to accredited ethics committees are
completed by way of a formal application process although the exact require-
ments can vary between committees. A requirement of all applications however
is the submission of the study using the National Ethics Application Form.
It is the ethics committee’s responsibility to ensure that adequate compen-
sation provisions are in place for injuries suffered by participants in a clinical
trial. Trials that are sponsored by a pharmaceutical company principally for the
benefit of the manufacturer or distributor are not covered by the Accident Com-
pensation Corporation (ACC). Compensation is provided by the pharmaceuti-
cal company to the extent described in the Researched Medicines Industry Guide-
line (RMI) (14). The “no-fault” principle forms the basis of these guidelines and
the sponsor company should pay compensation to participants suffering bodily
injury in accordance with these guidelines.
A separate approval process is required for clinical trials involving new and
unregistered medicine formulations. The Ministry of Health’s Standing Commit-
tee on Therapeutic Trials (SCOTT) reviews this research in parallel with an ethics
committee application. SCOTT will initially issue a “recommended for approval”
letter, which means it will give final approval once the ethics committee approval
has been obtained. The SCOTT approval process takes a maximum of 45 days
but is generally less. Final approval only takes a few days once ethics committee
approval has been given.
The cost for each SCOTT application is approximately NZ $10,000.

Australia
In Australia, clinical trials of medicines and devices are subject to government
regulations that are administered by the (TGA). Approval for a clinical trial is
gained through a Human Research Ethics Committee (HREC). Only ethics com-
mittees that are constituted and operate in accordance with the National Health
and Medical Research Council’s (NHMRC) National Statement on Ethical Conduct
in Research Involving Humans can approve a clinical trial. HRECs must follow
the guidelines outlined in the National Statement regarding their composition,
appointment of members and various aspects of their operational procedures.
The terms of reference and working procedures of each ethics committee must
be documented. All HRECs must also report annually to the NHMRC through
its principal committee, the Australian Health Ethics Committee. Clinical trials
must be approved by an institutional HREC with jurisdiction at the site where
the study is to be conducted (e.g., hospital, medical center, etc.). In addition,
there is a private ethics committee registered with the NHMRC that can be used
for some sites.
There are two schemes under which clinical trials involving therapeutic
goods may be conducted, the Clinical Trial Notification Scheme (CTN) and the
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24 Hung et al.

Clinical Trial Exemption (CTX) Scheme. The CTN scheme is a notification scheme
whilst the CTX scheme is an approval process. The vast majority of clinical trials
that are conducted in Australia are approved through the CTN process.
The CTN scheme involves the protocol being submitted directly to the
HREC who is then responsible for assessing the scientific validity and safety of
the project. The TGA does not undertake any review of the study but the sponsor
company is required to submit the CTN form to the TGA along with the appro-
priate fee (presently AU $240) once ethical approval has been granted.
The CTX scheme is intended to assist HRECs when technical, scientific, or
medical data are lacking or where further advice is required. Under this scheme
the sponsor company submits data to the TGA for evaluation and comment. The
CTX application can be made under a 50- or 30-day review and has associated
costs that are substantially higher than a CTN review. Under the CTX scheme,
the TGA will focus primarily on the study in relation to safety issues. An HREC
must also approve the study and the sponsor must wait for written approval
from the TGA before they are permitted to commence their research. All CTN
and CTX trials must have an Australian sponsor.
Compensation for participants for person injury must be provided by the
sponsor company in a form no less favorable than the current version titled
Medicines Australia Form of Indemnity for Clinical Trials (15).
Although clinical trials conducted in New Zealand and Australia are not
required to be registered, registration is recommended. In May 2006, the World
Health Organization (WHO) recommended that all international clinical trials
should be registered. Registration can be completed through the Australian New
Zealand Clinical Trials Registry (www.anzctr.org.au).
There is an intention to establish a Joint Agency that will replace the TGA
and the New Zealand Medicines and Medical Devices Safety Authority (Med-
safe) and be accountable to the Australian and New Zealand Governments.

Participant Selection
Studies should normally be performed using healthy volunteers with the
inclusion/exclusion criteria clearly outlined in the study protocol. Participants
may belong to either sex, with any risk to woman of childbearing potential
considered on an individual basis.
Generally participants should be aged 18 to 55 years and have a weight
within the normal range according to body mass index (BMI) or other appro-
priate accepted weight range indicators (e.g., Metropolitan Life Tables). In New
Zealand and Australia, where the population is multicultural, no restrictions are
placed on the selection of race when conducting studies.

Genetic Phenotyping
Although to date, phenotyping of participants has, to the best of our knowledge,
not been requested by either Medsafe or the TGA, it is worth considering
specifically for parallel design studies where the medicine is known to be
subject to major genetic polymorphism. Phenotyping would allow fast and
slow metabolizers to be evenly distributed in the two groups of participants.
Genetic phenotyping may also be considered for multiple dosing to steady state,
where slow metabolizers are known to present a significantly longer t1/2 of the
active compound. Under these circumstances slow metabolizers should not be
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Australasia 25

included in the study since the dosing period would have to be prolonged to
accommodate their inclusion.

Informed Consent
In obtaining and documenting informed consent, investigators should adhere
to GCP (good clinical practice) and the Declaration of Helsinki. Prior to com-
mencement of any study, written approval of (i) information for participants and
(ii) consent to participate documentation should be obtained from an indepen-
dent ethics committee (IEC). Any amendments to this documentation, which
are relevant to participant consent, should be approved by the IEC and revised
copies provided to the participants. The language used in this documentation
should be in lay terms, both practical and understandable to participants.
Participants must give their consent willingly and without coercion or
undue influence from the investigator or study staff. Prior to obtaining con-
sent from any participant the investigator must ensure that each participant is
made aware of the procedures to be carried out during the study. Participants
are required to attend a meeting at which the information for participants form
is read aloud. Participants are encouraged to ask questions relating to the study
medicine, possible side effects, and study procedures.
Prior to informed consent being obtained, subjects are given time to inquire
about details of the study and to decide whether or not to participate. A trial
physician, listed in the study protocol, must be present at each meeting to answer
any medical questions that participants may have and to witness that informed
consent was given freely by each participant. Written informed consent should
be signed and personally dated by the participant and trial physician as well as
an independent witness.
Informed consent should be filed as part of each individual participant
study record.

Participant Screening
The screening and consent of volunteers involves many challenges. In the case of
healthy volunteers, it involves both medical and psychological aspects. Most par-
ticipants with a health science background will request or appreciate knowing
their laboratory results. The most frequently requested result in our experience
is blood type, but obviously this is not a routinely performed test for studies.

Social History and Exclusion Criteria

A questionnaire detailing social history will usually identify issues regarding
substance abuse, high-risk travel, or high-risk behaviors for infectious disease
such as HIV infection.
Tobacco smoking is not permitted currently or within the previous
6 months for most studies. Beverages containing high levels of caffeine are also
frequently used especially in young adults, and may require a withdrawal period
for some participants who use these daily.
Blood donations should not have been made within the previous 60 days of
participating in the study, or within a certain period after the study depending on
test drug half-life, test drug metabolites, or possibly lowered hemoglobin levels.
Recognition of cultural values is also essential in some instances. In New
Zealand, for example, Maori have certain requirements concerning the body and
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26 Hung et al.

examination thereof, which must be respected. Food restrictions are required for
participants from Hindu, Jewish, or Islamic faith, for example.

Medical History
A full medical history is essential and a list of medical conditions forms the basis
of screening. It acts as an aide-memoir for the healthy volunteer who may ignore
or minimize previous illnesses, and can be completed in a relaxed environment
before meeting the examining physician.
Asthma is a commonly experienced condition in childhood, which may
extend into young adulthood, and which a participant will often deny or regard
as a “nonillness,” especially if it is controlled by intermittent inhaler use and
avoidance of precipitating factors. At least a 5-year period free of inhaler use
or symptoms to confirm the participant is suitable for inclusion in a study is
required for study participation.
The medical history should include previous hospital admissions, allergies,
adverse reactions, drug reactions, and complications with anesthesia, in addi-
tion to family medical history. The examining physician also has the opportunity
to assess the participants understanding of the Protocol and procedures, under-
standing of English, and answer any further questions about the study. A mul-
tilingual staff and access to independent interpreters are essential in some cases
to ensure informed consent, understanding of the procedures, and cooperation
with the study requirements.

Provocation Screening
In some instances, especially antibiotics, where the risk of anaphylaxis is higher
than with other drugs, skin testing is performed. The test drug is placed on bro-
ken skin and the response observed and recorded immediately and over the
ensuing days. A full medical response must be in place to treat anaphylaxis. Usu-
ally, any rash is mild and resolves without need for treatment.

Physical Examination
Blood pressure (supine and sitting), height, and weight are recorded. A rise in
systolic blood pressure to about 140 mm Hg is typical for some participants, who
promptly return to a lower pressure when relaxed. Occasionally, a high blood
pressure is found, particularly in older participants (>50 years), females on the
oral contraceptive, and overweight male participants who are then referred to
their family practitioner. Frequently, in the young adult, blood pressure is less
than 100 mm Hg systolic, and this becomes a concern for studies involving blood
pressure lowering drugs. A systolic pressure around 90 mm Hg should exclude
participants from blood pressure lowering studies.
The routine physical examination involves the visual assessment of skin
features (scars, wounds, body fat, peripheral edema) respiratory and cardiac aus-
cultation, abdominal examination, and lymph node examination.
The exclusion of cardiac valve abnormalities is particularly important as
the skin barrier is breached multiple times for venipuncture and intravenous (IV)
line access. An enlarged spleen may be asymptomatic, as may be a cirrhotic liver
or enlarged lymph node.
The forearm skin should be checked for scarring, especially from burns,
which might preclude suitable IV line access. Long forgotten abdominal scars
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Australasia 27

may also indicate previous cholecystectomy (perhaps high lipid levels) or the
recent onset of numerous seborrheic keratoses (Leser–Trélat sign of internal
malignancy).

Electrocardiograph
A 12-lead electrocardiograph (ECG) is useful for determining the risk of sudden
cardiac death from prolonged QT interval, short PR interval, or cardiac arrhyth-
mias, for which a participant will be excluded from a study. A copy of the ECG
will be given to the participant along with a referral letter to the family medical
practitioner for further counseling.
In some instances the “stress” of the screening process will be associated
with supraventricular ectopic events, for which a repeat ECG the following day
is recommended.

Laboratory Tests
Medical screening that includes basic hematology, biochemistry, pregnancy tests,
and, drugs of abuse, is designed not only to identify potential medical problems
but also to provide a baseline for possible adverse events.
A hematology screen including full blood count, red cell indices, and ESR
is extremely useful. For example, the young iron deficient vegetarian female par-
ticipant, with a mild anemia may not demonstrate any of the more obvious clin-
ical features of anemia such as pallor, glossitis, stomatitis, or heart failure, but
on prompting will often admit to nonspecific lethargy and weakness. In the pro-
cess of venipuncture during intensive sampling over a short study period, the
hemoglobin may decrease by 10 to 15 g/dL. This can be rapid enough to produce
nonspecific symptoms such as lethargy. Iron replacement therapy may be pre-
scribed or dietary advice given. Also, participants should be within the recom-
mended hemoglobin range to avoid anemia from borderline iron stores (assessed
with a ferritin measurement).
A platelet count is useful to identify idiopathic thrombocytopenic purpura
in the undiagnosed participant. As this is a relatively common disorder in young
or middle-aged adults, medical screening is likely to identify such problems.
Although the ESR is a nonspecific test it has some value if a particularly
high value is obtained (e.g., >100 mm/hr). In the early nonspecific phases of
collagen vascular disorders and malignancy (especially mediastinal Hodgkin’s
lymphoma and multiple myeloma), it may provide an early indicator. While not
diagnostic, it invites referral to the family medical practitioner and further test-
ing, and exclusion from the study.
Biochemistry including plasma sodium and potassium levels provides a
nonspecific overview of homeostatic mechanisms that include renal and nonre-
nal causes of potential abnormalities. Most commonly a raised potassium result
reflects delayed processing or refrigeration of the specimen. Many drugs likely
to be studied (e.g., angiotensin-converting enzyme inhibitors) also run the risk
of hyperkalemia, and normal baseline levels are useful in those instances. In
rare instances the bulimic anorexic participant will present with hypokalemia,
in addition to other factors such as BMI should be helpful.
A screen of liver enzymes can produce small elevations in aspar-
tate aminotransferase (AST), alanine aminotransferase (ALT), or gamma-
glutamyltransferase (gGTP), which can rapidly disappear on repeat testing
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28 Hung et al.

within days of the initial test. If ALT and/or gGTP are raised, in our experience a
history of alcohol intake 1 or 2 days previously is commonly elicited. Very occa-
sionally the mean red cell hemoglobin is also raised implicating more chronic
use (or abuse) of alcohol. A raised AST level may reflect skeletal muscle derived
enzyme following exercise and this is readily resolved by creatine kinase mea-
surements and history of exercise. The AST can also be falsely elevated by delay
in plasma separation, and release of AST from red cells.
In some instances the residual effects of glandular fever remain, or, the par-
ticipant has a high BMI and fatty liver. In either case the participant would not
be entered into the study.
Alkaline phosphatase is occasionally mildly elevated in the late, male
teenagers, reflecting possible bone injury in extreme sports or a late growth
spurt.
An unconjugated hyperbilirubinemia between 20 and 40 ␮mol/L, and
occasionally up to 60 or 80 ␮mol/L is a relatively common finding (up to 10%) in
the general population, and, in the absence of hemolysis and other hepatic disor-
ders, reflects Gilbert’s syndrome. Gilbert’s syndrome may become evident at any
age but is often seen in young adulthood associated with menstruation, fasting,
intercurrent illness, or dehydration. Fluctuating plasma bilirubin levels are typ-
ical, and the syndrome should not be interpreted as “disease.” Dubin–Johnson
and Rotor syndromes are likewise benign conditions that produce a conjugated
hyperbilirubinemia due to the failure of excretion of conjugated bilirubin.
An important adjunct to hepatic laboratory testing is, of course, the clinical
examination and history, as early cirrhosis may produce near normal or even
normal results for the above-mentioned tests.
Serological testing for hepatitis A, B, and C exclude participants with liver
damage from hepatitis B and C. Hepatitis A is diagnosed by the detection of IgM
anti-HAV (hepatitis A virus) during the acute illness, while IgG anti-HAV may
reflect a previous resolved episode of hepatitis A or vaccination.
A panel of antibody and antigen tests for hepatitis B and C will determine
the hepatitis status adequately in most instances, even in the early stages of dis-
ease. A note of caution is added, however, in participants who may have been
recently vaccinated, as we have found that vaccine antigens can be detected by
sensitive newer tests.
HIV testing must be performed with the knowledge that professional HIV
counseling is available should an unexpected positive test result occur, even
though HIV positive cases do not participate in a study. Counseling may also
be required for inconclusive first-line testing for other tests such as hepatitis B
and C, before confirmatory testing is available.
Renal function testing is an important part of screening to rule out renal
impairment that may affect drug excretion or drug handling by the body. Athletic
or body-building participants are particularly prone to the use of dietary supple-
ments such as proteins and creatinine, with consequent increases in plasma urea
and creatinine values. Conversely, significant renal impairment is possible while
plasma creatinine values remain within the reference range.
Adhering to conditions of testing is important. Glucose and cholesterol lev-
els need to be performed in the fasting state for reliable results. Furthermore, a
regular blood taking time, such as 8 AM, helps to negate circadian rhythm and
diurnal variation for some tests.
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Interpretation of Laboratory Results

Minor deviations from the reference ranges can cause considerable consterna-
tion, especially for participants who may be health science students early in their
education, or the non–health science educated participant. Frequent use of the
internet by participants for information concerning the results, and to check and
countercheck protocol information, is a common occurrence, and minor varia-
tions outside reference ranges need to be put into perspective by the trial physi-
cian. These need to be explained clearly and precisely to alleviate concerns of ill
health. Screening results of any type should not, unnecessarily, create a “patient”
out of a healthy volunteer.
By convention, reference ranges include 95% of the population or about 2
standard deviations from the mean, and are usually determined by individual
laboratories having investigated their own local healthy population with their
own analytical instruments. About 2.5% of the results at either extreme of a
normally distributed Gaussian distribution will be outside the reference range.
Reference ranges will vary between laboratories even within the same locality,
as different laboratories use different assay temperatures, substrates, pH condi-
tions, assays, and instruments. Hence a result outside of the reference range is
not necessarily abnormal, and reference ranges are not always the same at the
same laboratory or between laboratories. Local laboratories can also influence
reference ranges by using a preponderance of hospitalized patients compared
to ambulant community-based patients. Protein fractions in particular are influ-
enced by whether the blood was drawn from a recumbent hospital patient with
a minor illness in the early hours of the day or an ambulant participant. The
ambulant participant, or participant who is somewhat dehydrated by the end of
a busy workday, is likely to have a higher protein fraction, that may even exceed
the stated reference ranges.
Further variation of laboratory results can also occur between participants
on the basis of age, sex, and ethnicity. High-density lipoprotein cholesterol, for
example, is higher in premenopausal women than in men. Plasma creatine kinase
may also be higher in those of African descent compared with those of Caucasian
descent.

Repeat Examinations
While it is incumbent upon the clinical investigator to minimize participant dis-
comfort and time use, some tests and procedures need to be repeated to fully
determine their significance. These tests must be carefully followed and reported
to the participants (and/or family medical practitioner), especially if they have
been excluded from the study because of the initial abnormality.

Poststudy Testing
Laboratory tests are repeated at the end of the study. If abnormalities are detected
the test is usually repeated until it returns to normal (or nonsignificant) levels, or,
referred to the family medical practitioner for follow-up.

A Team Approach
Staff cognizant of the need for confidentiality initially greet and enroll partici-
pants and perform the social histories, ECG, blood pressure, height, and weight
recordings.
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30 Hung et al.

The participant will meet several physicians during the reading, consent,
examination stages, and study periods. This provides the participant with a vari-
ety of opportunities for discussion, in both group and individual situations, and
with both physicians and nonphysician staff. In cases where doubt is cast on a
participant’s ability to understand the protocol or be willing to adhere to the
conditions of the study, a consensus of opinion is useful.

Study Design
Generally, if only two products are to be compared, a two-period, two-sequence
cross-over study design should be used. However, alternate, well-established
designs could also be considered such as a parallel design for substances with
a very long half-life (>100 hours).
For highly variable medicines (refer to Highly Variable Drugs and Drug
Product section), a replicate cross-over design should be considered. For exam-
ple, the following four-period, four-sequence cross-over design has been success-
fully employed for TGA registration of alendronate. In this study, the urine con-
centration of alendronate was measured and the bioavailability of alendronate,
as summarized by the accumulated excreted amount, was compared between
the two formulations.
Four-Period, Four-Sequence Cross-Over Design
Sequence Period 1 Period 2 Period 3 Period 4
1 A B B A
2 B A A B
3 A A B B
4 B B A A

Treatment A represents the test formulation while treatment B is the ref-

erence formulation. Many different designs can be constructed for two formu-
lations with four periods and four sequences; see Jones and Kenward (16) for
some examples. However, the above replicated cross-over design has the small-
est error variance among all four sequences, four periods, and two formula-
tions cross-over design (17). The intrasubject variation for testing the formulation
effect is only a quarter of that of a standard two-formulation, two-period, two-
sequence cross-over design. Recently a three-period, reference-replicated cross-
over design, with sequences of TRR, RTR and RRT has been proposed by the US
FDA. A simulation study on this design has been performed but the results are
yet to be published.

Steady-State Studies
For most formulations, single-dose studies should generally suffice. However
there are instances where a steady-state design will be (i) required by the TGA
and Medsafe, for example, dose- or time-dependent pharmacokinetics and mod-
ified release products or (ii) considered, for example, where single dose admin-
istration does not allow adequate sensitivity for precise plasma concentration
determination or where it is intended to reduce intraindividual variability by
using a steady-state design. However, in some countries, steady-state studies are
no longer “considered” for the very reason that it dampens “true” variability
of a product as well as the ethical implications of multiple dosing to healthy
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participants. Consideration of a steady-state design should also be given when

the study population is patients. For example, with some pharmaceutical ingre-
dients, the effects of a normal dose in healthy volunteers could be intolerable or
toxic, hence in such a case either a lower dose should be used or if the active
compound is not dose proportional, a steady-state design in patients should be
considered. An example of this would be the antipsychotic medicine clozapine,
which can be given to healthy volunteers in a low dose (12.5 mg or less). How-
ever, such compounds can also be studied in the appropriate patient popula-
tion by using a steady-state design with no washout period, if recommended for
submission by the regulatory body, for example, clozapine for US registration,
cytotoxic compounds for TGA, and Medsafe or any compound that can poten-
tially cause severe untoward side effects to healthy volunteers. In addition, for
the measurement of compounds in healthy volunteers where there is an inherent
plasma concentration, such as calcitriol, the use of a steady-state design for the
determination of bioequivalence, in our experience, may be acceptable for TGA
and Medsafe registration.

Fasted and Fed Studies

The use of fasted and fed study designs in bioequivalence determinations is
dependent on two factors: (i) whether the formulation is immediate release or
modified release and (ii) formulations that are indicated for administration with
food.
Studies on immediate release formulations are generally conducted using a
fasted state design, unless the product is known to cause severe gastrointestinal
disturbance or is indicated for administration with food. Under these circum-
stances a fed state design would be used without a fasting study. A high-fat con-
tent, standardized meal consisting of, for example, two pieces bacon, one hash
brown, one english muffin, 20 g cheese, 20 g butter, 240 mL milk, 240 mL water
should be consumed over a 30-minute period immediately prior to dosing. The
dose should be administered no more than 5 minutes after completing the meal.
Studies on modified release formulations include fasted, fed, and steady-
state studies typically at the highest marketed strength. However, in formula-
tions where the highest strength is known to cause intolerable adverse events
and relevant proof of dose proportion between strengths can be provided, that
is, the active compound and metabolite exhibit linear pharmacokinetics, a lower
dose could be administered.
As an alternative to conducting two single-dose studies, a four-way, four-
sequence, cross-over design could also be employed. The design allows for the
conduct of both the fed and fasted studies by using a single group of subjects,
typically with a 32 to 48 subject sample size. Each subject is randomly assigned a
sequence as follows:

Four-Way, Four-Sequence, Cross-Over Design

Sequence Period 1 Period 2 Period 3 Period 4
1 A D B C
2 C B D A
3 B A C D
4 D C A B
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32 Hung et al.

Treatments A, B, C, and D can be either test (modified release) fed, test

(modified release) fasting reference modified release fed or reference modified
release fasting.
The advantage of adopting a four-way design is the ability to compare, for
example, any food effect on the pharmacokinetic parameters of the test formula-
tion with that of the results from the reference formulation

Sample Size
The number of subjects should be determined statistically, however, generally
the minimum number of subjects starting the study should not be less than
12. The minimum number of completing subjects should be determined and
outlined clearly in the study protocol. In a cross-over design, the total variation
consists of sequence variation, subject (sequence) variation, period variation, for-
mulation variation, and error variation. For testing the formulation effect, the
error variation or intrasubject variation (18) is used. Therefore the sample size
required for a bioequivalence study should be estimated using the intrasubject
variation. In particular, since the logarithmic transformed AUC and Cmax val-
ues are used in constructing the 90% confidence intervals (CIs), the intrasubject
variation based on the lognormal distribution (19) must be used. However, this
intrasubject variation (or coefficient of variation, CV) can only be estimated if the
data of a previous bioequivalence study on the same formulation is available. In
most cases sample size is estimated from literature data. This typically consists of
only summary statistics such as average and standard deviation for the untrans-
formed AUC and Cmax values. Sample size estimation is highly dependent on the
standard deviation of the above pharmacokinetic parameters and the standard
deviation data provided in the literature do not usually provide information on
the intrasubject variation. In general, the CV calculated from published data on
standard deviation would be much larger than the intrasubject CV based on the
logarithmic transformed values. Therefore the sample size estimated from these
summary statistics is generally extremely conservative.
Data obtained from one of our studies on tramadol is used here to illus-
trate this discrepancy. In this study, the mean and standard deviation for AUC0–∞
(ng hr/mL) of the reference formulation were 2997.8 and 1259.2 respectively. The
CV estimated using only this information is 42%. With a CV of 42%, at a 5%
level of significance and 80% power, a minimum sample of 76 subjects would
be required even if the reference and the test formulation means were the same,
and a sample size of 94 would be required when the two means differed by 5%
(18). However, the mean squares error, obtained from the ANOVA table for the
logarithmic transformed AUC0–∞ values, was 0.03997637. By using the lognor-
mal distribution, the intrasubject CV was estimated to be 20% and a sample size
of 20 was large enough for a 5% difference in the two means (19). Twenty-four
subjects were included in this study and the resulting 90% CI for logarithmic
transformed AUC0–∞ was (0.975, 1.074). It is therefore obvious that a sample size
of 94 is excessive.

Washout Periods
Treatment periods should be separated by an adequate washout period. The
interval between study days should be long enough to ensure elimination of
the previous dose. The interval should be no less than five terminal elimination
half-lives of the active compound or metabolite. The interval between treatments
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should not exceed 3 to 4 weeks. If a longer washout period is indicated a parallel

design should be considered.

Sampling Schedules
The sampling schedule should provide an adequate estimation of Cmax and cover
the plasma concentration versus time curve long enough to provide a reliable
estimate of the extent of absorption. The Medsafe and TGA adopted guidance
indicates this is achieved if AUC0–t is at least 80% of AUC0–∞ . However, typically,
AUC0–t is at least 90% of AUC0–∞.

Long Half-Life Compounds

For medicines with a long half-life, relative bioavailability can be adequately
estimated using truncated AUC. In this instance the sample collection period
should be adequate to ensure comparison of the absorption process. Although
this is specified by MedSafe and the TGA (20), such an approach, to our knowl-
edge, has never been requested by either a sponsor company or the regulatory
authorities, for compounds with long half-lives (>100 hours). Furthermore, with
the continuing advances in LC-MS/MS (liquid chromatography mass spectrom-
etry) technology providing greater sensitivity and lower detection limits for most
compounds, the necessity for truncated AUC to overcome assay sensitivity issue
is questionable. It is our opinion that the either AUC0–∞ or AUC0–t should be
used as the primary parameter for the determination of bioequivalence. The con-
ditions under which a study is conducted should be standardized as far as pos-
sible to reduce the variability of factors external to the formulations/products
being tested.

Test and Reference Products and Foreign Data

Test products are generally compared with the corresponding dosage form of an
innovator product (reference product). Both Medsafe and TGA prefer an applica-
tion for registration of a generic product to include a bioequivalence study versus
a leading brand purchased from within their own country. However, in certain
circumstances where extensive in vitro testing of innovator products has been
performed and comparative excipient analysis, the similarity should be justified
by dissolution profiles using buffers at three different pHs. The similarity factor,
f 2 , is evaluated and an application containing foreign bioequivalence data may
be accepted by both Australian and New Zealand authorities provided that the
following conditions have been met:
1. A minimum of three time points excluding zero.
2. The time points should be the same for the two formulations.
3. Twelve individual values for every time point for each formulation.
4. Not more than one mean value of >85% dissolved for any of the formula-
tions.
5. The relative standard deviation of coefficient of variation of any product
should be less than 20% for the first point and less than 10% from second
to last time point. Test products must be prepared according to the GMP-
regulations. Oral solid forms for systemic action should usually originate
from a batch of at least 10% of an intended full production batch or 100,000
units, whichever is greater. Other dosage forms of test products, such as sus-
pensions, should originate from a batch of at least 10% of a production batch.
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34 Hung et al.

Highly Variable Drugs and Drug Product

Highly variable drugs (HVDs) have been defined as active pharmaceutical
ingredients associated with a within-subject variability of ≥30% in terms of
the ANOVA-CV (21). Therefore, proving bioequivalence of products containing
HVDs is problematic because the higher the ANOVA-CV the wider the 90% CI.
Consequently the sample size required to achieve adequate statistical power in
these compounds is typically large. There are several approaches currently being
applied to this problem (22). Medsafe and the TGA indicate that in rare cases
a wider 90% CI may be acceptable for AUC if it is based on sound clinical jus-
tification and that the Cmax interval may be widened if it is predefined in the
protocol, for example, from 0.75 to 1.33 and justified with respect to safety and
efficacy concerns of patients switching between formulations. In our experience,
however, it is unlikely that an AUC falling outside the general acceptance crite-
ria of 0.8 to 1.25 would be accepted by either authority. It is also our experience
that by using a replicated cross-over design, as indicated in the previous section
(Study Design), bioequivalence of HVD products can be demonstrated without
widening the generally acceptable 90% CI.

Combination Products
Combination generic products should be compared with an equivalent innovator
combination product. However, in cases where there is no marketed innovator
product, separate products administered alone can be used for comparison. The
sample schedule should adequately provide for the determination of the phar-
macokinetic parameters of all active analytes and statistical analyses should be
conducted for all active analytes using the 90% CIs for all the active components
to fall within the usual acceptance ranges. However, in such cases, the combina-
tion product will be considered under a new medicine application (i.e., a new
formulation).

Over-the-Counter Products
The bioequivalence requirements for oral OTC products are the same as for pre-
scription only products However, both the TGA and Medsafe will consider a
bioequivalence study where the reference product is not sourced from Australia
or New Zealand provided that comparative dissolution testing and comparative
excipient analysis demonstrates that the reference products are essentially simi-
lar (refer to Test and Reference Products and Foreign Data section).

Add-On Studies, Outliers, and Dropouts

The method of statistical analysis should be clearly defined in the protocol. The
protocol should include provisions for subject withdrawal (dropouts) and for
biologically spurious data (single-point outliers), for example, the sample shows
no peak where a peak is expected; the sample shows a peak where not expected;
unexpected low concentration around the Cmax region; unexpected high con-
centration in the elimination phase or data that produces a peculiar concentra-
tion/time curve. The most effective method of dealing with subject dropouts
is to include an additional 5 to 10% of subjects above the number required for
completion (e.g., 26 subjects with 24 completing). A definitive statement regard-
ing replacement subjects should also be included in the protocol. As a general
guideline, subjects should only be replaced when the number of completing
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subjects falls below the minimum. All subject samples should be analyzed, and
only those completing all phases of the study should be included in the final
pharmacokinetic and statistical analyses. Exclusion of entire subject data (out-
liers) is not generally accepted, except when a biological justification can be
proved, such as vomiting within twice the Tmax after dosing (23). Add-on stud-
ies as a rule are not permitted unless included in the original protocol. However,
revised analysis is allowed if the original statistical plan (e.g., AUC0–∞ ) proves to
be invalid. For example, if the results obtained in the study are markedly differ-
ent from the results referenced in published data or from previous studies, that is,
the sampling profile used in the study is not long enough to allow estimation of
AUC0–∞ or the accurate estimation of AUC0–∞ is difficult due to an erratic elimi-
nation phase and consequent difficulty in determining t1/2 , most likely the result
of endohepatic recycling. The original and revised results should be presented in
the final report (20).

Sample Analysis
All analytical methods used to determine the concentrations of the analyte(s)
and/or metabolites in the biological matrix must be fully validated and the
results documented (validation report). Validation procedures, methods, and
acceptance criteria must be specified in relevant standard operating procedures
(SOPs). A calibration curve should be constructed for each analyte in each ana-
lytical run and should be used to calculate the concentration of the analyte(s) in
the unknown (subject) samples. The calibration curve should consist of a blank
sample (drug-free plasma sample processed without internal standard), a zero
sample (drug-free plasma sample processed with internal standard), and an
appropriate number of nonzero plasma samples, including LLOQ (lower limit
of quantification) to cover the expected range of concentrations from the sub-
ject samples. Quality control samples [at three concentrations over the range of
the calibration curve, that is, one within 3 × LLOQ (low QC sample), one at the
geometric or arithmetic mean of the low and high QC sample (QC sample), and
one close to the upper boundary of the standard curve, that is, 80% of ULOQ,
(high QC sample)] should be included in the run in duplicate (six samples per
run). All the samples for each individual subject (all periods) should preferably
be medium analyzed in the same analytical run.

Analytes to be Measured
Parent Compound Versus Metabolite(s)
The analyte to be measured (23) in biological fluids collected in bioequivalence
studies is either the parent compound or when appropriate, its active metabo-
lite(s) (24). Measurement of only the parent compound rather than the metabo-
lite is generally recommended. The rationale for this recommendation is that the
concentration-time profile of the parent is more sensitive to changes in formula-
tion performance than a metabolite, which is more reflective of metabolite for-
mation, distribution, and elimination. However, the following are exceptions to
this general approach. Measurement of a metabolite may be preferred when the
concentrations of the parent compound are too low to allow reliable analytical
measurement in blood, plasma, or serum
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36 Hung et al.

If there is a clinical concern related to efficacy or safety of the parent com-

pound, it is also recommended that sponsors and/or applicants contact the
appropriate regulatory review division to determine whether the parent com-
pound should be measured and analyzed statistically. For example, following
administration of simvastatin (an inactive lactone), the drug is hydrolyzed to
simvastatin acid. Simvastatin acid is the principal metabolite, which acts to
lower cholesterol levels (25). If the metabolite contributes meaningfully to safety
and/or efficacy, it is recommended that the metabolite as well as the parent com-
pound be measured. Accordingly, the metabolite data should therefore also be
subjected to the usual statistical analysis and meet the usual acceptance criteria
for bioequivalence.
Chiral Compounds
For bioequivalence studies, the guidance recommends measurement of the race-
mate using an achiral assay. Measurement of individual enantiomers in bioequiv-
alence studies is recommended only when all of the following conditions are
met: (i) the enantiomers exhibit different pharmacodynamic characteristics, (ii)
the enantiomers exhibit different pharmacokinetic characteristics, (iii) primary
efficacy and safety activity resides with the minor enantiomer, and (iv) nonlinear
absorption is present (as expressed by a change in the enantiomer concentration
ratio with change in the input rate of the medicine) for at least one of the enan-
tiomers. In such cases, it is recommended that bioequivalence factors be applied
to the enantiomers separately. For example, bicalutamide, a racemate with activ-
ity being almost exclusively in the R-enantiomer. Bicalutamide undergoes stere-
ospecific metabolism, with the S-enantiomer cleared rapidly relative to the R-
enantiomer (26). In this case, the enantiomers should be analyzed separately and
determination for bioequivalence based primarily on the R-bicalutamide with
S-bicalutamide treated as a secondary parameter since R-bicalutamide is active
while S-bicalutamide is inactive.
Prodrugs
There is no recommendation from the regulatory authorities about measurement
of prodrugs and their metabolites in bioequivalence studies. On the basis of our
experience, we recommend measuring the metabolite(s) rather than the prodrug
if the following conditions are met: the prodrug is well absorbed and rapidly and
almost completely converted to its active metabolite(s), peak plasma concentra-
tions of prodrug are less than 10% and occur in a very short time (e.g., less than
30 minutes), and are at or below the limit of quantification within a short time
(e.g., 2 hours) after dosing. In the absence of specific guidance information per-
taining to the study design for the determination of bioequivalence, the sponsor
should consult the applicable regulatory body.
Urine Data
Assessment of bioequivalence in urine can be used in compounds where there is
very little systemic absorption (<5%) and the dose absorbed is exclusively elim-
inated in urine, for example, alendronate. When urine samples are utilized to
determine bioequivalence, cumulative urinary recovery (Ae), and maximum uri-
nary excretion rate (Rmax ) are employed in the statistical analysis instead of AUC
and Cmax . A replicate cross-over design, as indicated in section (Study Design),
is recommended for low systemic absorption medicines based on urinary data.
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Australasia 37

Data Analysis
All pharmacokinetic analyses should be performed using validated com-
puter programs. Individual concentrations, AUC, Cmax , Tmax , and t1/2 calcu-
lations should be presented along with individual and mean plasma drug
concentration–time curves on both linear/linear and log/linear scales for each
completing subject. In addition, calculations for mean, geometric mean, standard
deviation, coefficient of variation, and ranges must also be presented. Spread-
sheets for each individual subjects’ raw data should be submitted. These should
include the following information: chromatogram identification, method file,
date and time of collection, retention times for the active compound(s) and inter-
nal standard(s), peak areas (heights) for the active(s) and internal standard(s);
calibration data, regression data and actual calculated drug concentrations. The
analytical report should also present a summary of data for each individual sub-
ject run, that is, mean and standard deviation of peak retention times, regres-
sion data, and “spiked” sample concentrations. Samples that require re-analysis,
according to a prespecified protocol, should be clearly identified and reasons
for re-analysis must be provided. The analytical report should also contain the
validation data. The method used to determine the active compound and/or
metabolites in a suitable matrix should be characterized, fully validated and doc-
umented (20). The main objective of the validation is to demonstrate the accept-
ability and reliability of the analytical results from the study and should include
the following information: (i) stability of stock solutions and of the analyte(s)
in the biological matrix under processing conditions and during the entire stor-
age period, (ii) specificity, (iii) accuracy, (iv) precision, (v) limit of quantification,
(vi) matrix effect when relevant, and (vii) dilution effect. The validation report
should include certificates of analysis for the analyte(s) and internal standard(s)
and representative chromatograms.

Calibration Curves
Calibration curves must be generated for each analyte in each analytical run and
used to calculate the concentration of the analyte in all subject samples. The stan-
dard curve fitting is determined by applying the simplest model that adequately
describes the concentration-response relationship by using appropriate weight-
ing and statistical tests for goodness of fit. Both x12 weighting and y12 weighting
are commonly used in regression calculations. Pateman (27) recommends a
weighting of x12 by assuming that “the SD of response tends to be proportional
to the concentration (x).” However, if no assumption is made on the SD except
that the CV is constant over the majority of the calibration range then the appro-
priate weight will be (␣+␤x)1
2 and the regression model is y = ␣ + ␤x + ε . The
random error, ε , is unknown but the mean of the random error, E(ε) = 0 so it is
reasonable to replace ε by 0. This results in a weight of y12 , which is also called
the “empirical weight” (28). To compare the difference between the unweighted,
1
x2
weighting and y12 weighting a simple simulation can be performed by adding
10% to a single point in an ideal linear standard curve. This process is repeated
at each concentration and the absolute percentage deviation from the ideal con-
centration of the entire calibration curve standards is calculated. The results of
this simulation are presented in the table on page 38.
 IHBK055-02
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SPH
38

IHBK055-Kanfer
Standarda Unweightedb sum Abs.% deviation of 1/y 2 sum of abs.% Abs.% deviation of 1/x 2 sum of abs.% Abs.% deviation of
concentration of abs.% deviation the lowest and the deviation of all the lowest and the deviation of all the lowest and the

January 6, 2010
(␮g/mL) 10% added of all standards top standards c standards top standards c standards top standards c
1 9.97 (8.596,0.001) 11.04 (2.545,0.586) 11.08 (2.201,0.612)
2 12.75 (−2.802,0.002) 15.17 (-−3.066, −0.272) 16.04 (−3.582, −0.318)
4 18.27 (−5.575,0.004) 16.69 (−1.239, −0.653) 17.95 (−1.473, −0.777)
8 29.13 (−11.033,0.006) 16.68 (−0.358, −0.845) 17.93 (−0.425, −1.004)
16 50.16 (−21.598,0.010) 16.65 (0.082, −0.943) 17.88 (0.097, −1.118)
32 89.45 (−41.316,0.010) 16.94 (0.302, −0.992) 18.22 (0.357, −1.174)

18:19
64 156.94 (−75.070, −0.021) 17.08 (0.412, −1.017) 18.37 (0.488, −1.203)
128 247.30 (−119.658, −0.209) 17.15 (0.467, −1.029) 18.45 (0.552, −1.217)
256 248.90 (−116.960, −1.077) 17.18 (0.495, −1.036) 18.48 (0.585, −1.224)

Char Count=
460.8 260.77 (131.533, −3.722) 17.19 (0.507, −1.039) 18.50 (0.560, −1.227)
512 463.45 (236.620,4.898) 17.19 (0.509,8.857) 18.50 (0.601,8.649)
Mean 144.28 16.27 17.40
S.D 146.12 1.83 2.21
CV% 101.27 11.24 12.71
a Ten percent increase in the ideal peak area (height) ratios (PAR, range between 0.01 and 5.12 in this simulation) at one concentration each time while the ideal PARs of the
remaining concentrations are unchanged.
b Sum of the absolute% deviation from the estimated concentrations to the stated concentrations for all standards.
c Absolute% deviation of the lowest and highest standards.

Hung et al.
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Australasia 39

By examining the percentage deviation it is obvious that the unweighted

regression should not be used. A 10% variation at the lowest standard will cause
only 0.001% variation of the highest standard, whilst an increase of 10% in the
highest standard will cause over 200% variation of the LLOQ. Although the
sum of the absolute% deviation for the x12 and y12 weighting are very similar, y12
weighting fit is always smaller than that obtained from the x12 weighting fit, indi-
cating that, the y12 weighting provides a better fit to the data. This is not surpris-
1
ing as using the y2
weighting, the weighted least squares method minimizes the
quantity,

  yi − ŷi 2
,
yi

that is, it minimizes the relative errors.

Statistical Analysis
Pharmacokinetic parameters derived from the measures of concentration, for
example, AUC and Cmax should be analyzed using ANOVA. The data should
be transformed prior to the analysis by using a logarithmic transformation. The
statistical model includes the factors, sequence, subject (sequence) (i.e., subjects
nested within sequences), period, and formulation. The sequence effect should
be tested using the subject (sequence) mean square as the error term while the
other main effects should be compared to the mean square error obtained from
the ANOVA. Ninety percent CIs should be constructed for the ratio between
the test and reference formulation averages based on the logarithmic trans-
formed AUC and Cmax values using the Schuirmann’s two one-sided tests
procedure (29).
The pharmacokinetic parameters to be tested, the procedure for testing and
the acceptance criteria for each parameter should be outlined in the protocol. The
acceptance intervals for the primary pharmacokinetic parameters are as follows:
AUC (AUC0–t , AUC0–∞ , or AUC␶ for steady-state designs)—the 90% CI
should lie within an acceptance interval of 0.80 to 1.25.
Cmax —the 90% CI should lie within an acceptance interval of 0.80 to 1.25.
As previously discussed, in certain cases a wider interval may be acceptable, but
must be justified and predefined in the protocol.
Tmax , t1/2 , and DF (Cmax −Cmin )/(AUC0–t/t ) for a steady-state design] are
considered to be secondary parameters and hence would not be used for evalu-
ating bioequivalence. However, 90% CI, based on nonparametric technique, for
untransformed data of Tmax and 90% CIs for the untransformed data of the other
secondary parameters are also presented for completeness.

Biowaivers
As previously indicated, an application for registration of a generic product
in either New Zealand or Australia should generally include a bioequivalence
study versus a leading brand (market leader) obtained from within the relevant
country. However, in certain well-defined circumstances, both authorities may
accept submission of foreign bioequivalence data, provided it can be shown that
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40 Hung et al.

the local product and foreign product are identical, that is, supported by exten-
sive comparative dissolution testing and comparative excipient testing.
If an application pertains to several strengths of an active ingredient, a bioe-
quivalence study using only the highest strength may be acceptable. In this case
Medsafe and the TGA may grant a biowaver for the other strengths provided the
strength chosen for investigation has been justified and the following conditions
have been met:

1. The products are manufactured by the same manufacturer and using the
same process.
2. The active ingredient has demonstrated linear kinetics over the therapeutic
dose range.
3. The qualitative compositions of the different strengths are the same.
4. The ratio of the amounts of active ingredient and excipients is the same, or
where the concentration of the active ingredient is low (less than 5%), the
ratio of the amounts of excipients is similar.
5. The similarity should be justified by dissolution profiles covering at least
three time points, in three different buffers covering the physiological range,
that is, normally pH 1 to 6.8 (e.g., 1.0, 4.5, and 6.8), where the f 2 similarity
factor is >50 for the additional strengths and the strength of the batch used
in the bioequivalence study.

Lifespan of Bioequivalence Data

In general, bioequivalence data and study reports do not have a “use by date.”
In our experience, bioequivalence reports produced and submitted for local reg-
istration in a particular country can be re-submitted to other countries, for exam-
ple, a study undertaken for Australian registration can subsequently be submit-
ted, for example, in South America or Asia. As the submission process varies
for each country, this may occur anywhere from 1 to 10 years after the study
report has been finalized and released. The local regulatory body will assess the
bioequivalence data according to the relevant guidance available at the time of
submission. In this case, given the ever improving and evolving nature of tests
and testing methods, the sponsor/CRO may be asked to clarify results or present
additional information depending on the requirements of the reviewing regula-
tory body.

Topical Dosage Forms

Topical Corticosteroid products
Apart from topical corticosteroid products, currently Medsafe and the TGA pre-
fer that topical generic dosage forms be compared using a clinical end point
study design. We understand that sponsor companies have submitted bioequiv-
alence applications by using the human skin blanching assay (HSBA) to both
authorities on the basis of chromometer studies for topical corticosteroids accord-
ing to the FDA guidance (30). Use of the HSBA requires a pilot study which deter-
mines the dose duration–response relationship of a marketed reference product
followed by a pivotal equivalence study. In the FDA guidance only the marketed
reference product is employed in the pilot study. In our experience, the pilot
study should also include the test formulation as it can provide the sponsor an
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Australasia 41

estimate of the likelihood that the test product will be bioequivalent in the pivotal
equivalence study.

Safety Studies
When comparing topical corticosteroid formulations using a clinical end point
study, the safety of the product following application must be considered. For
example, one of the most obvious side effects of prolonged use of steroids is
hypothalamic–pituitary–adrenal (HPA) axis suppression. Typically this can be
addressed by using a parallel study design that monitors the plasma cortisol lev-
els before and after prolonged application (e.g., 4 weeks) of the test and reference
topical formulations. The area under the plasma cortisol concentration versus
time curve (AUC0–24 ) on Day 1 should be compared with the cortisol AUC0–24
on Day 29 to determine any significant difference between each treatment. The
test formulation will be deemed safe if the 90% CI is below the limit of 125%,
when compared to the reference formulation. If a toxicity study is required a ran-
domized, single topical application, irritancy study using synchronized applica-
tion and synchronized removal may be adopted. This design can be adopted to
show that there is no irritancy effect following the administration of a topical
formulation.

Sample Size Determination for Human Skin Blanching Studies

An analysis of variance for parallel group design is performed with only the data
on the “detectors” that was obtained in the pilot study. The mean square error in
the ANOVA and the mean AUEC for the reference formulation should be used to
calculate the CV. The sample size required for a parallel group study, np , should
be computed using the method specified by Hauschke et al. (31).
However, a randomized block design should be used for the pivotal in vivo
bioequivalence study. It can be shown that the relative efficiency between the
randomized block design and the parallel group design is 100/(1 − ␳ ), where
␳ is the correlation coefficient between the AUEC (reference) and AUEC (test)
from the same subject (32). Therefore the sample size for the randomized block
design,nB , is equal to the sample size for the parallel group design × (1 − ␳ ), that
is, nB = np × (1 − ␳ ). Since ␳ is expected to be positive, nB is typically smaller
than np .
Finally, the sample size obtained for the randomized block design will
be adjusted upward by the percentage of “detectors,” pd , observed in the pilot
study. Therefore the required sample size for the pivotal in vivo bioequivalence
study will be n = nB / pd .

Nasal Sprays and Inhalers

At present Medsafe and the TGA require data to confirm bioequivalence of nasal
sprays and inhalers using clinical studies.

Nasal Sprays
At present, there is no guidance from the Authorities in either New Zealand or
Australia for demonstrating bioequivalence between nasal sprays for locally act-
ing products. However, protocols have been proposed by Sponsors to address
the efficacy and safety issues of nasal sprays for allergic rhinitis. The efficacy
study design is based on the draft guidance proposed by the FDA (33), which
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42 Hung et al.

is a sequential, randomized, double-blind, double-dummy (one active test, one

inactive reference cross-over to one inactive test, one active reference), placebo-
controlled, parallel group study of 14 days duration (each for test and reference)
preceded by a 7-day placebo run-in period. Volunteers with seasonal allergic
rhinitis are required to be administered doses from the nasal spray product,
either the test or reference formulation, according to the dosing schedule. The
lowest labeled adult recommended dose should be employed in the study to
increase the sensitivity of detecting potential differences between products. A
scoring system based on the common nasal symptoms of allergic rhinitis is used
to assess and compare the study results. A total nasal symptom score (TNSS) is
used, that includes a 4-point scale with signs and symptoms ordered in severity
from 0 (no symptoms) to 3 (severe symptoms). About 20% of the volunteers will
be identified as placebo responders or who will not meet the minimum qual-
ifying criteria during the 7-day placebo period. For the equivalence and effi-
cacy analyses, the primary endpoint involves reflective scores for the 12-hour
pooled TNSS over the 2-week randomized portion of the study. The suppres-
sion of eosinophil count (34) in the nasal lavage has also been used as a more
objective endpoint in addition to the TNSS in the final analyses.
The safety issue, for example, HPA axis suppression resulting from nasal
spray administration can be determined by measuring serum cortisol levels in
healthy volunteers as indicated for the topical corticosteroid studies (35).

Inhalers
Both Medsafe and the TGA have developed guidance documents to demon-
strate bioequivalence of inhaled medications, Medsafe in Section 16 and TGA
in Appendix 19 of their respective guidelines. In general, the following protocols
address the requirements for exhibiting the bronchodilation and bronchoprotec-
tion effects of inhalers.

Bronchodilator Inhalers
Typically, therapeutic equivalence of bronchodilators, such as short-acting and
long-acting ␤2 -agonists, should be compared by their bronchodilatation potency
and efficacy to protect against bronchoconstriction caused by stimuli such
as methacholine (36), histamine (37), hypertonic saline (38), or exercise (39).
A double-blind, double-dummy, placebo-controlled, six-period, four-sequence
cross-over study, similar to that employed by Lavorini et al. (40) has been pro-
posed for the assessment of bioequivalence of salbutamol inhalers. Bioequiva-
lence is assessed by calculating the relative potency of two salbutamol formula-
tions by using either Finney’s 2 × 2 parallel regression analysis or the Emax model
(AUC0–60 of FEV1 vs. time). The relative potency is calculated and expressed as
the ratio of the estimated doses of salbutamol delivered by the two formulations
to achieve similar AUC0–60 values with Finney’s regression. If the Emax model
is used then the relative potency is estimated by the ratio of the ED50 values
obtained from the models. Two formulations are considered bioequivalent if the
90% CI of the relative potency is between 0.67 and 1.5. Whether this protocol can
be applied to long-acting ␤2− agonists, for example, salmeterol is not known. It
is our experience that the FEV1 is relatively insensitive to dose differences and
there is evidence that the commonly used doses of salmeterol may be higher
than required to produce a maximal effect. Other parameters such as PEFR (peak
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Australasia 43

expiratory flow rate) heart rate, QTc interval, plasma potassium concentration
and tremor in addition to bronchial reactivity can be measured to provide
unequivocal clinical effectiveness of the medicinal product (41).

Steroid Aerosols
The following protocols have been proposed for the evaluation of the bioequiva-
lence of inhaled steroids.

Cross-Over Designs
A randomized, double-blind, double-dummy, cross-over design with a 2- to 3-
week run-in period followed by a 4-week treatment period has been used. Each
treatment consists of either the test product and placebo as reference, or the ref-
erence product and the placebo as test. PD20 (36), after methacholine challenge
testing, is measured at the start and at the end of each treatment period.
1. Start of treatment period 1 (PD20 S1)
2. End of treatment period 1 (PD20 E1)
3. Start of treatment period 2 (PD20 S2)
4. End of treatment period 2 (PD20 E2)
For each subject, the difference of PD20 within each treatment is calculated:
D1 = PD20 E1 − PD20 S1 and D2 = PD20 E2 − PD20 S2
An ANOVA is performed on the logarithmic (base 2) transformed differ-
ences log2 (D) and a 95% CI is calculated on the log2 -scale. The formulations are
considered to be bioequivalent if the 95% CI is within the range (−1, 1).

Parallel Design
A randomized, double-blind, double-dummy, parallel group design with a 2-
week run-in period followed by a 6-week treatment period can be performed.
PD20 after methacholine challenge testing is measured at the start and at:
1. Start of run-in period (PD20 R)
2. End of run-in period (i.e., Start of treatment) (PD20 S)
3. After 3 weeks of treatment (PD20 M)
4. End of treatment period (PD20 E)
For each subject, the following difference will be calculated:
D = PD20 M − PD20 S or D = PD20 E − PD20 S
Analysis of covariance (with PD20 S as the covariate) is performed on the
untransformed differences D and a 90% CI is calculated on the untransformed
scale. The formulations are considered bioequivalent if both values of the 90% CI
are 0.8 or above (i.e., noninferior).
Side effects such as HPA axis suppression by inhalers can be determined
by measuring serum cortisol levels in healthy volunteers as described for topical
studies (35).

Combined (Steroid Plus ␤2− Agonists) Aerosols

A combination of the above-mentioned study protocols may be useful for bioe-
quivalence evaluation of these products.
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44 Hung et al.

Antiallergic Aerosols
Antiallergic aerosols such as sodium cromoglycate and nedocromil sodium are
generally less potent bronchodilators than ␤2− agonists and less potent bron-
choprotectors than steroids. Common side effects are limited to throat irrita-
tion on inhalation and unpleasant taste. A combination of the above-mentioned
study protocols may be useful for bioequivalence evaluation of the antiallergic
aerosols. However, these medicines are not effective in every subject and so the
demonstration of their effectiveness, on the provoked response, is a prerequisite
for entry into such studies (42).

REFERENCES
1. McBride WG. Thalidomide and congenital abnormalities. Lancet 1961; 2:1358.
2. Therapeutic Goods Act 1989—Australian Government Publishing Service, Canberra.
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5. Module 1—Administrative Information and Prescribing Information for Australia.
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6. Guidance on the GMP Clearance of overseas medicines manufacturers, 16th ed.
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Washington, D.C.: U.S. G.P.O, 1949–1953.
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Research involving Human Subjects 1964 (current version 2000).
11. Cartwright Inquiry. 2008. http://www.womens-health.org.nz/cartwright/cartwright
.htm.
12. Gisborne Cervical Screening Inquiry. 2008. http://www.csi.org.nz.
13. The Health Research Council of New Zealand, HRC Guidelines for Ethics Committee
Accreditation, June 2008.
14. New Zealand Researched Medicines Industry Guidelines on Clinical Trials Compen-
sation for Injury Resulting From Participation in an Industry Sponsored Clinical Trial.
2008. http://www.rmianz.co.nz.
15. Medicines Australia Form of Indemnity for Clinical Trials. 2008. http://www.
medicinesaustralia.com.au.
16. Jones B, Kenward MG. Design and Analysis of Cross-Over Trials. London: Chapman
and Hall, 1989.
17. Haider SH, Davit B, Chen ML, et al. Bioequivalence approaches for highly variable
drugs and drug products. Pharm Res 2008; 25:237–241.
18. Chow SC, Liu JP. Design and Analysis of Bioavailability and Bioequivalence studies,
2nd ed. New York: Marcel Dekker, 2000.
19. Hauschke D, Steinijans VW, Diletti E, et al. Sample size determination for bioequiv-
alence assessment using a multiplicative model. J Pharmacokin Biopharm 1992; 20:
557–561.
20. Note for Guidance on the investigation of bioavailability and bioequivalence
(CPMP/EWP/QWP/1401/98). CPMP Guidance-As adopted by the TGA-with
amendment. 10 April 2002. http://www.tga.gov.
21. Blume HH, Midha KK. Bio-International 92, Conference on bioavailability, bioequiv-
alence and pharmacokinetic studies. J Pharm Sci 1993; 2:1186–1189.
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22. Guidelines on registration requirements to establish interchangeability, Multisource

(Generic) Pharmaceutical Products: WHO, Draft Revision, QAS/04.093/Rev.4.
23. Guidance for Industry, bioavailability and bioequivalence studies for orally adminis-
tered drug products — general considerations, CDER, U.S Dept of Health and Human
Services, FDA, March 2003 (Revision 1).
24. Title 21—Food and Drugs. Code of Federal Regulations. Part—Section 320.24 (b)(1)(i).
25. Simvastatin Prescribing Information. eMIMS MIMS, April 2008.
26. Bicalutamide Prescribing Information. eMIMs MIMS, April 2008.
27. Pateman, J. Bio-International 92. In: Blume HH, Midha KK, eds. Bioavailability, Bioe-
quivalence and Pharmacokinetic Studies, Stuttgart: Medpharm Scientific, 1995:399–
403.
28. Miller RG. Beyond ANOVA: Basics of Applied Statistics. New York: Wiley, 1986.
29. Schuirmann DJ. A comparison of the two one-sided tests procedure and the power
approach for assessing the equivalence of average bioavailability. J Pharmacokin Bio-
pharm 1987; 15:657–680.
30. Guidance for Industry, Topical Dermatologic Corticosteroids: In Vivo Bioequivalence,
CDER, U.S Dept of Health and Human Services. FDA, 2 June 1995.
31. Hauschke D, Kieser M, Diletti E, et al. Sample size determination for proving equiv-
alence based on the ratio of two means for normally distributed data. Stat Med 1999;
18:93–105.
32. Fleiss JL. The Design and Analysis of Clinical Experiments. New York: Wiley, 1986.
33. Guidance for Industry, Bioavailability and Bioequivalence Studies for Nasal Aerosols
and Nasal Sprays for Local Action. FDA, 2003.
34. Beclomethasone 50 ␮g/dose nasal spray—Clinical Equivalence Study. C93–586-LBB,
April 1994, Zenith Technology Corporation Ltd. Study Archive.
35. A Parallel, 4 arm, Safety Study to evaluate cortisol levels following continuous appli-
cation of topical corticosteroids in healthy subjects. Zenith Technology Corporation
Ltd. Study Archive.
36. Creticos PS, Adams WP, Petty BG, et al. A methacholine challenge dose-response
study for development of a pharmacodynamic bioequivalence methodology for
albuterol metered-dose inhalers. J Allergy Clin Immunol 2002; 110:713–720.
37. Ahrens RC, Harris JB, Milavetz G, et al. Use of bronchial provocation with his-
tamine to compare the pharmacodynamics of inhaled albuterol and metaproterenol
in patients with asthma. J Allergy Clin Immunol 1987; 79:876–882.
38. Delvaux M, Henket M, Lau L, et al. Nebulised salbutamol administered during spu-
tum induction improves bronchoprotection in patients with athma. Thorax 2004;
59:111–115.
39. Anderson SD, Lambert S, Brannan JD, et al. Laboratory protocol for exercise asthma
to evaluate salbutamol given by two devices. Med Sci Sports Exerc 2001; 33:893–900.
40. Lavorini F, Geri P, Camiciottoli G, et al. Agreement between two methods for access-
ing bioequivalence of inhaled salbutamol. Pulm Pharmacol Ther 2008; 21:380–384.
41. Wong CS, Williams J, Britton JR, et al. Bronchodilator, cardiovascular, and
hypokalaemic effects of fenoterol, salbutamol, and terbutaline in asthma. Lancet 1990;
336:1396–1399.
42. Wong BJO, Hargreave FE. Bioequivalence of metered-dose inhaled medications.
J Allergy Clin Immunol 1993; 92:373–379.
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3 Brazil
Margareth R. C. Marques
Department of Standards Development, U.S. Pharmacopeia, Rockville,
Maryland, U.S.A.

Sı́lvia Storpirtis
College of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil

Márcia Martini Bueno

Regulatory Affairs and Pharmacovigilance, Libbs Farmacêutica Ltda,
São Paulo, Brazil

INTRODUCTION
The publication of the National Policy for Drug Products in 1998, the creation of
the National Agency for Sanitary Surveillance or Agencia Nacional de Vigilancia
Sanitaria (ANVISA), the approval of the law, and the publication of the tech-
nical guidances for the registration of generic products dramatically changed
the pharmaceutical market in Brazil. New concepts such as pharmaceutical
equivalency, therapeutic equivalency, bioavailability, and bioequivalence were
introduced (1–4).
The law and guidances for the registration of generic products in Brazil
were developed based on the regulations from countries or regions, such as
Canada, United States of America and the European Union, with a great deal
of experience with these type of products.
Brazil was the first country in South America to implement the evaluation
of pharmaceutical equivalency and bioequivalence studies for the registration of
generic products and nowadays is considered a model for the other countries in
the region.
A “similar” drug product is a product that contains the same drug(s) in the
same concentration, dosage form, route of administration, strength, and thera-
peutic indication as the reference drug product registered at the federal agency
in charge of sanitary surveillance, being allowed to differ only in characteristics
related to size and shape of the dosage form, expiry date, packaging, labeling,
excipients, and vehicles. It is always identified by its trade (branded) name and
not by the generic name.
Using the regulations for generic products (3,4) as a model, in 2003 new reg-
ulations and guidances were published for the registration of new similar prod-
ucts and for similar products already in the market. These regulations included
the evaluation of pharmaceutical equivalency, relative bioavailability, and good
manufacturing practices (GMP).
Similar products registered from May 2003 up to date must be in accor-
dance with the same regulations as generic products with the following
exceptions:
46
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Brazil 47

Characteristics Generic Similar

Interchangeability with the Yes No
reference producta
Use of a trade name No, only generic designation Brand name is mandatory
together with the generic
designation
Number of approved Not more than three No limits
suppliers for active suppliers per API
pharmaceutical ingredient
(API)b
a Interchangeability between similar products and the reference product is not allowed by the Brazilian reg-
ulations because of the similar products registered before 2003. The deadline for similar products to meet
the registration criteria according to the current regulations is 2014. If similar products registered before 2003
comply with current requirements for the registration of generic products, ANVISA may approve the inter-
changeability between similar and reference products. In this case, the product is designated as a branded
generic.
b All API suppliers must be GMP certified by ANVISA. The company must submit stability studies for each
API from different suppliers. In the case of dosage forms, the company must demonstrate that the dissolution
profiles of products manufactured with API from different suppliers are equivalent. The dissolution profile
comparison must include the reference product approved by ANVISA.

GENERIC PRODUCTS IN BRAZIL

Definitions and History

According to the Brazilian regulations, a generic drug product contains the same
active substance(s), it has the same strength(s), same pharmaceutical dosage
form, same route of administration, dosing, and therapeutic indications as the
reference product. The differences could be size and shape of the product, its
expiry date, packaging material, and excipients. It is intended to be interchange-
able with a reference product and can be manufactured after the patent expi-
ration or after transfer of the patent rights to the appropriate organizations. In
other words, a generic product as opposed to a similar product is intended to
be interchangeable—it cannot use a branded name but must state the drug sub-
stance name. It must be efficacious, safe, and manufactured under current GMP.
Its name should be in accordance with the Brazilian Common Nomenclature
(Denominação Comum Brasileira, DCB) or with the International Drug Name (3).
The reference product must be registered at ANVISA, supported by doc-
umentation related to its efficacy, safety, and quality, and it must be sold in the
Brazilian market (3).

Brazilian Regulations
The use of the generic name of the drug substance(s), according to the Brazilian
Common Nomenclature, together with the brand name on the packaging mate-
rial of products marketed in Brazil has been mandatory since 1980 (5,6).
The Law 793/93, published on April 5, 1993, defines the information on
the packaging materials of generic products. The generic name should be writ-
ten using a font with a size three times bigger than the brand name. The main
objective of this law was to stimulate competition on the drug product market
with subsequent reduction of product price. Unfortunately, the text of the law
was not very clear, with the main problem being the lack of demonstration of
therapeutic equivalency between generic and reference products (7).
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48 Marques et al.

On May 14, 1996, Law 9279 establishing the regulations regarding intellec-
tual property was approved. This law was a significant step for the introduction
of new pharmaceutical dosage forms in the Brazilian market because there were
no regulations in Brazil for intellectual property rights for medicines and drug
products, allowing the registration of drug products, based only on its similar-
ity. This law was the first step toward regulations for the registration of generic
products similar to other countries with established and more modern regulatory
systems (8).
The regulations for generic drug products are part of the National Policy of
Drug Products, with the registration of this type of product being made accord-
ing to the following:
r Definition of criteria to demonstrate therapeutic equivalency, mainly regard-
ing bioavailability.
r Training and infrastructure of local laboratories to perform bioequivalence
studies.
r Incentive to produce generic drug products, laws and guidances for the
marketing, prescription and dispensing of generic products in the Brazilian
market (1).
On February 10, 1999, a new approved Law, 9787 (3), defined the con-
cept of a generic drug product and established the conditions for the use of the
generic drug name for all products. According to this law, the responsibilities of
ANVISA are
r to establish criteria and conditions for the registration and quality assurance
of generic products,
r to establish criteria for bioavailability studies of any drug product,
r to establish criteria for the verification of therapeutic equivalency through
bioequivalence studies to allow their interchangeability,
r to establish criteria for the dispensing of generic products. The decision to
replace the reference or branded product with a generic version is at the dis-
cretion of the practitioner (9). Items 3 and 5 of this law promote the prescrip-
tion and acquisition of generic drug products by all clinics and dispensaries
in the network maintained by the federal government, government actions
to facilitate the registration, sales and marketing of these products and facil-
itation of the information and education of the public and funding of special
programs to improve the quality of drug products. As a consequence of Law
9787/99 (3), a group of Brazilian experts in the areas of quality control, phar-
macology, and pharmaceutics was created to write the technical guidances for
the registration of generic products in Brazil. All the texts were revised by a
consultant with a great deal of experience on bioequivalence studies from the
University of Texas. As a result of the work of this team, on August 9, 1999,
Resolution RDC 391 (4) was approved. This document defined the technical
parameters for the registration of generic drug products and had the follow-
ing six annexures:
1) Guidance for stability studies.
2) Guidance for protocol and technical reports, bioequivalence, or bioavail-
ability studies.
3) Guidance for the validation of analytical methods.
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Brazil 49

4) Guidance for templates for pharmaceutical equivalency studies.

5) Guidance for biowaivers.
6) First list of reference products.

To implement all these new guidances and regulations and to review the
new dossiers submitted for the registration of this new category of products,
a new department within ANVISA, the General Management of Generic Prod-
ucts (Gerência Geral de Medicamentos Genéricos, GGMED) was created in
September 2000. The major actions undertaken by this new department were the
following:

1. Elimination of similar products without brand name or similar products with

generic names to avoid the confusion created by some pharmaceutical com-
panies that were promoting similar products as if they were generic products;
2. Inclusion of a yellow strip containing the letter G in blue and the term
“Medicamento Genérico” (generic product) on the packaging materials of
generic products;
3. Use of billboards in public areas and broadcasting of special advertisement
on TV to explain and promote the use of generic products together with spe-
cial leaflets distributed to clinics and dispensaries;
4. Training of practitioners on the prescription of generic drug products;
5. Introduction of a nation-wide program to monitor the quality of generic
products on the market. This activity is under the coordination of the
National Institute of Quality Control in Health Products and Services (Insti-
tuto Nacional de Controle de Qualidade em Saúde, INCQS).
6. Special funding for manufacturers of generic products by the Banco Nacional
de Desenvolvimento Econômico e Social (BNDES).
7. Publication of a new law, Decreto 3675, on November 28, 2000 (10) [reprinted
with modifications as Decreto 3841 (11) on May 11, 2001]. This law established
the process of registration of generic products already approved as generics
in the United States, Canada, and some European countries with similar reg-
ulations for generic products. This registration would be valid for one year
and, during this period of time, the company should present a bioequivalence
study done in accordance to the Brazilian regulations. After 8 months follow-
ing registration approval, the pharmaceutical company should provide their
indication of intent to undertake manufacture of the product in Brazil.

Besides all these activities, ANVISA promoted and funded the installation
of Pharmaceutical Equivalency Centers and Bioequivalence Centers in the coun-
try. The former were accredited by ANVISA
In 2000, ANVISA introduced the Chamber of Regulations for Medicines
Market (Câmara de Regulação do Mercado de Medicamentos, CMED) to be
responsible for the management of the prices of generic drug products, main-
taining them at least 35% below the price of the reference product (12).
Since the introduction of generic products in Brazil, their sales have been
increasing at a very fast pace, and currently they represent about 16% of
medicines sold in Brazil (13).
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50 Marques et al.

Bioavailability
ANVISA defines bioavailability as the rate and the extension of absorption of
a drug product in a dosage form, based on its concentration/time curve in the
systemic circulation or its excretion in urine (14).

Relative Bioavailability and Bioequivalence

The first official definition of bioequivalence in Brazil was the one included in
Law 9787 (February 10, 1999) (3), which introduced the concept of a generic drug
product. According to this law, bioequivalence is the demonstration of pharma-
ceutical equivalency between two products in the same pharmaceutical dosage
form, with identical qualitative and quantitative amount of active substance(s),
and that show comparable bioavailability when evaluated using the same study
design.
The Resolution RDC 16 (March 2, 2007), guidance for the registration of
generic products, defines two drug products as bioequivalent when they are
pharmaceutical equivalents and when administered at the same molar dose,
under the same experimental conditions and do not show statistically signifi-
cantly differences in bioavailability (15).
According to the ANVISA definition, bioequivalent drug products are
pharmaceutical equivalents that, upon administration of the same molar dose
in the same experimental conditions do not present significant statistical differ-
ences concerning bioavailability.
Resolution RDC 17 (March 2, 2007), guidance for the registration of similar
products, defines relative bioavailability as the rate and extent of absorption of an
active ingredient that reaches systemic circulation as a result of the extravascular
administration of a preparation compared to those of a reference product that
contains the same active ingredient (16).
Due to the innovative character of these activities, it became evident dur-
ing the assessment of the bioequivalence centers by ANVISA that more train-
ing and discussion on validation of the analytical methods, statistical evaluation,
handling and storage of biological samples, and so on was needed. As a con-
sequence, ANVISA organized discussion groups including representatives from
academia, industry, regulatory bodies, and so on to prepare a manual on good
practices on relative bioavailability and bioequivalence and a check list for the
inspections of those centers (17). The final version of the Manual on Good Prac-
tices in Bioavailability and Bioequivalence was published in 2002, and on May 2003,
Resolution RDC 103 became official. This resolution defines the activities of the
bioequivalence centers and contains a check list for the inspection carried out
during the certification of the national and international bioequivalence centers.
Three months later, only certified centers were authorized to carry out bioavail-
ability/bioequivalence studies for the registration of drug products in Brazil.

Pharmaceutical Equivalency
According to ANVISA, pharmaceutical equivalents are drug products that con-
tain the same drug substance, in the same salt form or free base, in the same
amount, in the same type of dosage form, with or without the same excipi-
ents. These products should comply with the corresponding monograph in the
Brazilian Pharmacopeia. In the absence of a specific monograph in the Brazilian
Pharmacopeia, they should comply with the monograph in any other compendia
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accepted by the Brazilian health authorities, or with any other applicable qual-
ity standard. These quality standards include identity, strength, purity, potency,
uniformity, disintegration, and dissolution, when applicable. In Brazil, the eval-
uation of pharmaceutical equivalency should be done by a center qualified by
ANVISA (18). In June 2001, ANVISA implemented its quality system and posted
all standard operating procedures (SOPs) and criteria for the certification of phar-
maceutical equivalency centers on the agency website (www.anvisa.gov.br).

Good Manufacturing Practices

GMP was adopted in Brazil in 1995 through the Portaria 16 from March 6, 1995.
This law established the technical regulations and the check list for the verifi-
cation of compliance to GMP (19). This regulation was updated in 2003 by the
Resolução RDC 210 (August 4, 2003), based on the guidances from the World
Health Organization and on the experience acquired during inspections carried
out in Brazil. The new law provides more details regarding validation of pro-
cesses and methods, qualification of suppliers, and manufacturing process of
products that need segregation such as antibiotics, hormones, etc. (19). Among
the objectives of the GMP inspection is to certify that the pharmaceutical com-
pany complies with current GMP guidances. This certification is included in
Resolução RDC 210 from 2003. This activity is sponsored by some fees paid by
the company requesting this certification. A GMP certificate is given for each
line/dosage form at each pharmaceutical plant, and it is valid for one year (20).

Evolution of the Technical Regulations

The major aspects of the first regulation for generic drug products in Brazil are
summarized in Table 1.

TABLE 1 Major Characteristics of the First Regulation for Generic Drugs Products in Brazil
Law Characteristics
√
√ Mandatory presubmission
RDC 391 √ Production and Quality Control Technical Report
(Aug 9, 1999) √ Manufacturing report for three pilot batches
Technical √ Validation of the manufacturing process
Guidance for the √ Name(s) of the supplier of the drug substance (not more than three)
Registration of √ Description of the synthesis route, including isomers and polymorphs
Generic √ Specifications and validated analytical methods
Products in √ Pharmaceutical equivalency
Brazil √ Certificate of GMPs and QC
√ Stability studies according to Zone 4
Bioequivalence—Quantification of the drug substance or metabolite
- Washout period of minimum of five t 1/2
- Number of healthy volunteers (in general 24)
- Weight variance ± 10% of the normal value
-√ Use of the Brazilian or international reference product.
Prescription: In the network by Brazilian Common Nomenclature
√ (DCB)—In private practice: brand name or DCB
Dispensing: Possibility of the pharmacist replacing the brand name
product by the generic version, if there are no restrictions by the
private practitioner
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The experience acquired during the first years of implementation of the

regulations for generic products and the need for compliance to international
standards were the major reasons for the several updates made in the regula-
tions. This process is summarized below:

Law Major Characteristics

√
First revision √ Presubmission not mandatory
RDC 391/99 √ Guidance for imported generic products
⇓ The list of reference products began to be published and
√ updated by ANVISA on the Web site
RDC 10/01 √ Biowaivers; in vitro studies
√ New guidances
Second revision √ Annexes—Guidances changed to Resolutions (RE)
RDC 10/01 New Guidances: Manufacturing of pilot batches, scale-up,
⇓ and postapproval changes—Experimental design for
√ bioequivalence studies
RDC 84/02 Authorization for bioequivalence studies using truncated area
√ under the curve (AUC) for drug substances with long half-life
Third revision √ Notification for the production of a pilot batch
Dissolution profile comparison between the biobatch and the
RDC 84/02 batch manufactured with the drug substance from a new
⇓ √ supplier
Explanation for the need for the quantification
RDC135/03 √ of metabolite(s)
√ Possibility of employing a parallel experiment design
Reduction in the number of healthy volunteers to 12
√ supported by a test power of not less than 80%
√ Truncated AUC (72 hr) for drug substances with long half-life
√ Special cases with multiple dosing
For modified release dosage forms, bioequivalence must be
demonstrated in both fed and fasted states. In the case of
immediate release dosage forms fasted studies are
necessary only in cases where the presence of food can
influence its absorption. This information must be included
in the Instructions for Patients in the insert included in
√ the product packaging material of the reference product.
√ Explanation for pharmacodynamic studies
√ Criteria for the transportation of samples
Fourth revision √ More details in the listing of formulation components
Protocol for bioequivalence studies prepared by an
RDC 135/03 evaluation center certified by ANVISA for oral
⇓ contraceptives, endogenous hormones, and
RDC 16/07 √ immunosuppressants
Approval for the simultaneous manufacture of a generic
√ product in more than one manufacturing site
Six months report on adverse effects and nontherapeutic
action for contraceptives, endogenous hormones, and
√ immunosuppressants
Report on adverse effects and nontherapeutic action for all
√ other therapeutic products in the renewal of the registration
Permit for registration of oral contraceptives and endogenous
hormones
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Law Major Characteristics

√
Guidances for Portions of resolution RE 901 are converted into
Pharmaceutical recommendations for carrying out dissolution tests of
Equivalency and √ immediate release oral pharmaceutical dosage forms
Dissolution Profiles Comparison of dissolution profiles must use the same
dissolution method as used in the pharmaceutical
RE 900 e 901/03 equivalency study. If the dissolution method is not a
compendial one, the dissolution profiles must be obtained
⇓ using at least three different media within the physiological
√ pH range.
RE 310/04 Inclusion of the dissolution profile comparison between the
reference product and the generic product. It is not
√ mandatory to meet the f2 acceptance criteria.
Inclusion of the certificates of pharmaceutical equivalency
and dissolution profiles study according to the form
available at http:www.ANVISA.gov.br/REBLAS/
√ certificados/index.htm
Calculation and acceptance criteria for dissolution profiles
comparison using independent model approach,
calculating the difference factor (f 1 ) and similarity
√ factor (f 2 )
Relative bioavailability Quantification of metabolites only if it is not possible to
and bioequivalence determine the drug substance by itself or in special cases,
RE 896/03 with preapproval by ANVISA. Definition of the analyte
⇓ √ quantified in the bioequivalence studies.
RE 397/04 Minimum of 12 volunteers, if the statistical power is more
than 80%. In cases where it is not possible to determine
the number of volunteers, a minimum of 24 volunteers
√ can be used.
Description of the cases where a fed state study should be
done. Posting of Table 1 – Administration route on the
ANVISA Web site. This list is only for immediate release
and delayed-release (gastro-resistant) dosage forms. For
extended-release dosage forms, fed studies are
√ mandatory. This list is inteded to be updated regularly.
Detailed explanation on the pharmacokinetic parameter
AUC0–t , where t is the time corresponding to the last
concentration of the drug substance determined
√ experimentally (above the quantitation limit).
√ New text format for conclusions in bioequivalence studies.
Alteration of the confidence interval requirement from 95% to
90% of the ratio of the geometric averages (AUC0–t test/
AUC0–t reference and C max test/C max reference) for the
evaluation of bioequivalence of drug products containing
narrow therapeutic index drugs such as carbamazepine,
√ valproic acid, clindamycin, etc.
Relative bioavailability Definition of the analyte used to establish bioequivalence.
and bioequivalence Listing 2—Analyte used to establish relative bioavailability/
RE 397/04 √ bioequivalence
⇓ The sampling schedule should allow the appropriate
RE 1170/06 characterization of the plasma profile of the drug or its
metabolite (concentration x time) considering a time equal
or higher than 3 to 5 times the elimination half-life of the
compounds.
(Continued )
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54 Marques et al.

Law Major Characteristics

√
Inclusion of transdermal products and depot dosage forms
√ with information regarding the sampling frequency.
Exclusion of the age limit of the participants in the studies,
√ maintaining the age limit of not less than 18 years.
Restrictions regarding age and gender of the volunteers. In
the cases of products used by specific populations, the
study should be carried out with volunteers representing
these specific populations. In the case of contraceptives,
√ the studies should be run with women of child-bearing age.
Inclusion of the control of body weight variability (maximum
√ 10%) among volunteers for oral contraceptives
√ Inclusion of transdermal patches
Inclusion of more information regarding endogenous
compounds, taking into account the basal levels.

The new regulations published in 2003 for fixed combination products

(FDCs), required the comparison of the bioavailability of the drug substance(s)
alone and in combination, demonstrating that the combination product does not
modify the bioavailability of the individual drugs. For the registration of new
strengths, new dosage forms, and/or new routes of administration, within the
therapeutic range, relative bioavailability studies may replace phase 2 and phase
3 studies (21,22).
At the beginning of the implementation of the new regulations for
the registration of generic products in Brazil, bioequivalence studies were
permitted to use an international reference product (reference products from
countries/regions such as United States, Canada, or United Kingdom). This
facilitated the registration of products in a more expedient way. The review of
international bioequivalence dossiers was a learning experience for reviewers at
ANVISA. The knowledge obtained helped them to update and modify the reg-
ulations and guidances in Brazil. On May 14, 2003, Law 10669 was published,
defining the deadline of June 30, 2003, for submission of studies carried out with
an international reference product.

Biopharmaceutical Classification System

Currently, the Biopharmaceutical Classification System (BCS) is not accepted by
ANVISA for biowaivers because of the lack of sufficient information regarding
mainly the permeability of drug substances, the high cost of permeability deter-
mination, and incomplete validation of the methodology.

DESIGN AND CONDUCT OF BIOEQUIVALENCE STUDIES FOR ORALLY

ADMINISTERED DRUG PRODUCTS
Bioequivalence studies in Brazil are regulated by the Guidance for Bioavailabil-
ity/Bioequivalence Studies Resolution 1170 from 2006 (23).

Study Design
An open, cross-over, randomized design is required where the volunteers receive
test and reference drugs on separate occasions (periods), in a single- or multiple-
dose regimen. If necessary, a parallel design can be used, for long terminal half-
life drugs (longer than 24 hours).
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Subjects
Number of Subjects
The number of subjects included must provide adequate statistical power for
bioequivalence demonstration. Numbers of participants can be calculated from
the coefficient of variation (intraindividual) and statistical power, and no less
than 12 volunteers may be used. If no literature data are available the investigator
can opt for the inclusion of at least 24 volunteers. The guidance for planning the
statistical issues of bioavailability/bioequivalence studies [Resolution 898 from
2003 (24)] describes a method to calculate the number of volunteers based on the
procedure described by Chow and Liu (25).

Selection of Subjects
Sex/Age
Subjects must be 18 years of age or older and capable of giving informed consent.
They may be of either/both sexes but if males and females are included, there
must be an equal distribution among the study sequences. If the drug product
is to be used in a specific population (age and gender) the investigator must
include volunteers of this population. As an example, bioequivalence studies of
oral contraceptives must include women of child-bearing age.

Mass
The weight of the subjects should be within 15% of the normal range for males
and females, taking into account their height and physical type. It also recom-
mends the inclusion of woman within 10% of the normal range in bioequivalence
studies for oral contraceptives.

Informed Consent
Informed consent must be approved by an ethics committee that has to be sub-
mitted for ANVISA evaluation together with the bioequivalence study report.
The informed consent form must contain the drug name, the dose by unit, the
pharmaceutical form, and the name of the manufacturer(s). Detailed information
about the informed consent content is presented in Resolution 196 from 1996 (26).

Medical Screening
The Guidance for bioavailability/bioequivalence studies [Resolution 1170 from
2006 (23)] does not state any information regarding medical screening but the
Guidance for protocol of bioavailability/bioequivalence studies [Resolution 894
from 2003 (27)] states that the protocol must contain the clinical evaluation of the
volunteers, a list of the laboratory tests (blood, biochemistry, hepatitis B and C,
HIV, beta-HCG for women, type I urine tests, and electrocardiogram).

Smoking/Drug and Alcohol Abuse

Smokers and individuals with drug abuse history should be avoided. If smokers
are included, they must be identified.

Inclusion of Patients Instead of Healthy Subjects

For cytotoxic drugs, the study must include patients whose disease process is
stable and who are being treated with cytotoxic medicines.
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Phenotyping/Genotyping
The Brazilian regulations for bioavailability/bioequivalence studies do not dis-
cuss this topic.

Standardization of Study Conditions

Dosing Times
Multiple-dose studies should be avoided, since single-dose studies are usually
more sensitive to show differences in formulations. Multiple-dose studies can be
performed when it is shown that this approach can reduce the intraindividual
variability of drug absorption in cases such as high variability drugs.

Food and Fluid Intake

The products should be administered with a standard liquid volume (usually
200 mL of water). For modified-release products, two bioequivalence studies
must be performed, one in the fasted state and the other in the fed state. For
immediate and delayed release formulations only a fasted study is requested for
the majority of the drugs. There is a list on the ANVISA Web site (List 1, available
at http://www.anvisa.gov.br/medicamentos/listas/lista1.htm) that establishes
whether the study should be conducted in a fasted or fed state. A fed study
is requested only if the drug has a significant change in bioavailability when
administered with food and the reference product indicates that the drug has to
be taken with food.

Concomitant Medication, Posture, and Physical Activity

Brazilian regulations for bioavailability/bioequivalence studies do not discuss
this topic.

Blood/Urine Sample Collection and Times

The study can be performed by measuring drug or its metabolite concentration
in the circulation (blood, plasma, or serum) or in urine if there is a justifica-
tion for this choice. It is preferable to have bioequivalence studies that quantify
the nonmodified drug substance. The quantification of any other entity will be
accepted only when there are analytical limitations or the drug substance under-
goes very fast biotransformation, with proper justification. A possible scenario is
when the metabolite is active (has the same potency as the original drug or has
greater activity/potency than the original drug), it is biotransformed by presys-
temic metabolism and it is important for the efficacy and safety of the product. In
all cases, the study protocol must be approved by ANVISA. The protocol must
specify the metabolite that will be quantified during the bioequivalence studies
according to List 2—Analyte for Relative Bioavailability/Bioequivalence (avail-
able on the ANVISA website), and must meet the criteria established by the reg-
ulatory agency.

Duration and Frequency of Sampling

Frequency and number of samples collected have to guarantee an adequate
characterization of the pharmacokinetic profile (plasma concentration vs. time).
It must cover at least three times the elimination half-life of the drug and it
should be sufficient to account for at least 80% of the known area under the
drug concentration versus time curve (AUC). For transdermal delivery systems
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and depot dosage forms, the duration and the frequency of sampling should
be sufficient to characterize the absorption, distribution, and elimination of the
drug. For long terminal half-life drugs (longer than 24 hours), an alternative
collection time, for at least 72 hours, or a parallel design may be used.

Number of Samples
The Brazilian regulations for bioavailability/bioequivalence studies do not dis-
cuss this topic.

Characteristics to Be Investigated
Blood/Plasma/Serum Concentration Versus Time Profiles
The pharmacokinetic parameters should be calculated based on plasma drug
concentration versus time profile. When dealing with endogenous compounds,
the baseline level should be measured and the analysis must be done with and
without basal correction. The following pharmacokinetic parameters should be
presented: AUC0–t , AUC0–∞ , Cmax , tmax , and the half-life, t1 . For multiple-dose
/2
studies, the parameters should be AUC0–␶ , Cmax , tmax , Cmin , C avg , and the fluctu-
ation index where
AUC0–t —Area under the plasma/serum/blood concentration–time curve from
time zero to time t, where t is the last time point with measurable concen-
tration for individual formulation;
AUC0–∞ —Area under the plasma/serum/blood concentration–time curve from
time zero to time infinity.
tmax —Time to maximum plasma concentration.
Cmax —The maximum observed plasma concentration after dose administration.

Urinary Excretion Profiles

The Brazilian regulations for bioavailability/bioequivalence studies do not pro-
vide the pharmacokinetic parameters required for urine studies.

Pharmacodynamic Studies
Pharmacodynamic studies are indicated when it is not possible to measure the
drug in plasma or in urine in an accurate way, for example, ophthalmic suspen-
sions and local acting inhalers.

Bioanalysis
Details about performing and validating bioassays are stated in the Guidance for
bioanalytical method validation [Resolution 899 from 2003 (28)].

Stock Solutions Stability

The stability of stock solutions of the drug and the internal standard should be
evaluated at room temperature for at least six hours and, if the stock solutions
are refrigerated or frozen for a relevant period, stability should be done in this
condition as well.

Stability of Analyte in Biological Matrix:

Freeze and thaw stability: the analyte stability should be determined after three
freeze and thaw cycles.
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58 Marques et al.

Short-term stability: the aliquots of low and high concentrations should be

thawed at room temperature and kept at this temperature from 4 to
24 hours.
Long-term stability: the storage time evaluation should exceed the time between
the date of first sample collection and the date of last sample analysis.
Processed sample stability: the stability of processed samples, including the res-
ident time in the autosampler, should be determined.

Validation
Specificity
Analyses of blank samples of the appropriate biological matrix (blood, plasma,
serum, urine, or other matrix) should be obtained from at least six sources (four
normal, one lipemic, and one hemolyzed). Each blank sample should be tested
for interference, and selectivity should be ensured at the lower limit of quantifi-
cation (LLOQ).
Precision and Accuracy
Precision should be measured using a minimum of five determinations per con-
centration (high, middle, and low). The precision determined at each concentra-
tion level should not exceed 15% of the coefficient of variation (CV) except for
the LLOQ, where it should not exceed 20% of the CV. Accuracy is determined by
replicate analysis of samples containing known amounts of the analyte. Accuracy
should be measured using a minimum of five determinations per concentration
(high, medium, and low). The mean value should be within 15% of the actual
value except at LLOQ, where it should not deviate by more than 20%.
Lower Limit of Quantification
The limit of quantification should be at least five times the response compared
to blank response or analyte peak (response) should be identifiable, discrete, and
reproducible with a precision of 20% and accuracy of 80% to 120%.
Limit of Detection
The limit of detection (LOD) should be at least two or three times the response
compared to blank response.
Recovery
The recovery of the analyte does not need to be 100%, but the extent of recovery
of an analyte and of the internal standard should be consistent, precise, and exact.
Recovery experiments should be performed by comparing the analytical results
for extracted samples with unextracted standards that represent 100% recovery.
Response Function
The simplest model that adequately describes the concentration–response rela-
tionship should be used. Selection of weighting and use of a complex regression
equation should be justified.
Robustness
This parameter should be considered during the method development phase. If
measurements are susceptible to variations in analytical conditions, the analyti-
cal conditions should be suitably controlled or a precautionary statement should
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be included in the procedure. Examples of typical variations are stability of ana-

lytical solutions and extraction time. In the case of liquid chromatography, exam-
ples of typical variations are
influence of variations of pH in a mobile phase,
influence of variations in mobile phase composition,
different columns (different lots and/or suppliers),
temperature, and
flow rate.
In the case of gas chromatography, examples of typical variations are
different columns (different lots and/or suppliers),
temperature, and
flow rate.

Calibration Curves
A calibration curve should be generated for each analyte in the sample. A suf-
ficient number of standards should be used to adequately define the relation-
ship between concentration and response. Concentrations of standards should
be chosen on the basis of the concentration range expected in a particular study.
A calibration curve should consist of a blank sample (matrix sample processed
without internal standard), a zero sample (matrix sample processed with internal
standard), and six to eight nonzero samples covering the expected range, includ-
ing LLOQ. The following conditions should be met in developing a calibration
curve: 20% deviation of the LLOQ from nominal concentration and 15% devi-
ation of standards other than LLOQ from nominal concentration. At least four
out of six nonzero standards should meet the above criteria, including the LLOQ
and the calibration standard at the highest concentration. The exclusion of any
standards should not change the model used.

Quality Controls Sample

Quality Control (QC) samples at three concentrations [one near the LLOQ (i.e.,
smaller or equal than 3 × LLOQ), one in midrange, and one close to the high
end of the range (between 75% and 90% of the higher concentration)] should be
incorporated in each assay run. The number of QCs should not be less than 5%
of the total number of samples in an analytical run, and in the case that the run
has less than 120 samples, a minimum of six QCs. The results of the QC samples
provide the basis of accepting or rejecting the run. At least four of every six QC
samples should be within 15% (or 20% to LLOQ) of their respective nominal
value. Two of the six QC samples may be outside the 15% (or 20% to LLOQ) of
their respective nominal value, but not both at the same concentration.

Standard Operating Procedures

The following SOPs should be presented in the final report:
Bioanalytical method
Preparation, storage, and criteria of acceptance of the stock solutions, calibration
standards, QCs, dilution standards, and reference solutions
Validation of bioanalytical method
Acceptance of analytical runs
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Reassay
Chromatographic analyses
Reintegration
Others.

Choice of Reference Product

The Brazilian reference products are listed on the ANVISA Web site
(www.anvisa.gov.br).

Study Products and batch size

Before starting a bioequivalence study, the recommendation is to perform all in
vitro tests comparing test and reference products. These tests have to be per-
formed at a certified laboratory in Brazil. Both test and reference products have
to comply with the drug monograph and the potency difference between test
and reference drug content cannot be higher than 5%. The same batch product
should be used for the in vitro and in vivo (bioequivalence) tests.

Data Analysis
The statistical evaluation should be done according to the Guidance for planning
and accomplishment of the statistical phase of bioavailability/bioequivalence
studies [Resolution 898 from 2003 (24)].

Statistical Analysis
Pharmaceutical parameters shall be obtained from the blood concentration
curves of the drug versus the time, and statistically analyzed to determine the
bioequivalence; in case of endogenous substances, statistical analysis should
be conducted using quantified plasma concentrations with and without base-
line level correction, while the decision on bioequivalence should be based on
the corrected values.
The following pharmacokinetic parameters should be determined:
r AUC0–t , AUC0–∞ , Cmax of the drug and/or metabolite, and the time to reach
this peak (Tmax ) should be directly obtained, without data interpolation; elim-
ination half-life (t1/2 ) of the drug and/or metabolite should also be deter-
mined, although there is no need for statistical treatment.
r For evaluation of bioequivalence, the parameters AUC0–t , Cmax , and Tmax
should be used and in the case of multiple-dose studies, steady state after
administration of the test and reference drugs must be confirmed.
r The exclusion of more than 5% of volunteers that participated in the study is
not permitted until the conclusion or absence of over 10% of the blood concen-
tration values of the drug from the administration of each drug per volunteer.

Data Presentation
a) Present a table containing individual values, averages (arithmetical and geo-
metrical), standard deviation, and variation coefficient of all pharmacokinetic
parameters related to the administration of test and reference drugs.
b) It is recommended that the AUC0–t and Cmax parameters be transformed into
natural logarithms.
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c) Conduct variance analysis (ANOVA) of pharmacokinetic parameters AUC0–t

and Cmax transformed to evaluate sequence effects, of volunteer within the
sequence, period, and treatment. In addition, present ANOVA table contain-
ing source, release level, sum of squares, mean square, F statistics, p values,
and the intra- and interindividual coefficient values.
d) Build a reliability interval (RI) of 90% for the differences measured from the
transformed data of the test and reference drugs, for AUC0–t and Cmax param-
eters. The RI antilogarithm obtained constitutes the RI of 90% for the amount
of geometric means of the parameters.
The construction of this IC should be based on the mean residual square of
the ANOVA obtained according to (c) above.
e) Tmax shall be analyzed as individual difference ( = test – reference), building
the RI of 90%, using a nonparametric test.
f) This method based on RI is equivalent to the procedure of two correspond-
ing unicaudal tests with the null possibility of bioinequivalence, with level
significance level of 5% (␣ = 0.05).
g) Validated statistical programs should be used.
h) When necessary, suitable statistical models, depending on the type of study
(for instance, of multiple doses) should be adopted.
i) In case of volunteers presenting discrepant behavior in the pharmacokinetic
parameters in relation to the others, their exclusion from the study should be
justified. Present study results with and without the inclusion of their data.
j) Information on the software used for statistical data analysis to be included.

Acceptance Range for Pharmacokinetic Parameters

Two drugs shall be considered bioequivalent if the extreme values of the RI
of 90% of the ratios of the geometric means (AUC0–t test/AUC0–t reference and
Cmax test/Cmax reference) are greater than 0.8 and less than 1.25. Other RI of 90%
limits for Cmax previously established in protocol can be accepted upon scientific
justification. When clinically relevant, Tmax shall also be considered.

Single-Dose Studies
The following pharmacokinetic parameters have to be presented in the report:
Cmax , tmax , AUC0–t , AUC0-∞ , and t1 . The 90% CI for Cmax and AUC0–t has to be
/2
between 80% and 125%.

Steady-State Studies (Immediate Release Dosage Forms,

Controlled/Modified Release Dosage Forms)
The following pharmacokinetic parameters have to be presented for a multiple-
dose study: Cmax , tmax , AUC0–␶ , average concentration at steady-state and the
fluctuation index. It has to be proven that steady state was reached. The 90% CI
for Cmax and AUC0–␶ (AUC during a dosage interval) has to be between 80% and
125%. No special request is made for modified release dosage forms.

Reporting of Results
The Resolution 895 from 2003 (29) describes all the information that should be
presented in the bioequivalence report, which includes the test and reference
data, administrative information, responsible personnel and sites, study proto-
col, ethics committee approval, and the specific information about each phase.
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62 Marques et al.

Clinical Report
The documents should include study design, randomization list, drug informa-
tion, drug accountability, and all the information of the study population (demo-
graphic, laboratory tests), inclusion and exclusion criteria, time of drug adminis-
tration and blood collections, fasted and fed times, dose washout period, adverse
effects, and protocol deviations.

Analytical Report
Should contain bioanalytical method description and validation, reference stan-
dards, method to calculate drug concentrations, complete information about the
analytical runs (date, initial and final time, volunteers analyzed, calibration stan-
dard and bias, quality controls, and bias), reanalysis (initial and reanalysis val-
ues, cause for reanalysis, criteria for choosing the value), and complete series of
chromatograms from 20% of the volunteers.

Pharmacokinetic and Statistical Report

It should contain the calculation of sample size, ANOVA table for the pharma-
cokinetic parameters, CI for Cmax and AUC, statistical program outputs, and the
study conclusion. The individual plasma concentrations and individual phar-
macokinetic parameters should be tabulated. These data can be presented in a
spreadsheet and can be submitted in electronic format.

Quality Assurance
The Resolution does not say anything about quality assurance, but the study can
be performed only in contract research organizations (CROs) previously certified
by ANVISA.

BIOAVAILABILITY AND BIOEQUIVALENCE REQUIREMENTS

Orally Administered Drug Products Intended for Systemic Action

Solutions
For oral solutions, a bioequivalence study can be waived according to item 1.2 of
the Guidance for waiver [Resolution 897 from 2003 (30)]. However, if the solution
contains an excipient that can change the intestinal motility, a bioequivalence
study is required.

Suspensions
A bioequivalence study is always required.

Immediate Release Products—Tablets and Capsules

For immediate release products a bioequivalence study is always required.

Other Oral Dosage Forms

If the drug is absorbed, a bioequivalence study is required.

Orally Administered Drug Products Intended for Local Action

For orally administered drug products intended for local action that are not
absorbed, a bioequivalence study can be waived according to item 1.8 of the
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Brazil 63

Guidance for waiver and substitution of bioequivalence studies [Resolution 897

from 2003—oral products in which the drug substance is not absorbed by the
gastrointestinal system (30)].

Parenteral Solutions and Suspensions/Emulsions

For aqueous parenteral solutions, which have the same drug, at the same con-
centration and excipients with the same function, a bioequivalence study can
be waived according to item 1.1 of the Guidance for waiver and substitution of
bioequivalence studies [Resolution 897 from 2003 (30)]. A bioequivalence study
is required for parenteral suspensions whereas Brazilian regulations do not give
any information about emulsions for parenteral use.

Topically Administered Drug Products

If intended for systemic action, bioequivalence study is required, including trans-
dermal dosage forms.

Topical Products for Local Action

For topically administered drug products intended for local action, that have the
same drug, at the same concentration and excipients with the same function, a
bioequivalence study can be waived according to the Guidance for waiver and
substitution of bioequivalence studies [Resolution 897 from 2003 (30)].

Topical Products Containing Corticosteroids

For nasal and oral inhalation products containing corticosteroids, which have
the same drug, at the same concentration and excipients with the same func-
tion, a bioequivalence study can be waived only for solutions. For other phar-
maceutical forms, a bioequivalence study is required. The type of study to be
performed, bioavailability or bioequivalence or clinical study, must be discussed
with ANVISA before undertaking a study.

Topical Products Other Than Those Containing Corticosteroids

and Which are Not Simple Solutions
If intended for systemic action a bioequivalence study is required. For any topical
product, such as cream, lotions, ointments, etc., with no systemic action, only in
vitro studies are required.

Products Intended for Other Routes of Administration

For oral products for local use, dermal, rectal, vaginal, etc. intended to act with-
out systemic absorption, bioequivalence studies can be waived according to item
1.6 of the Guidance for waiver and substitution of bioequivalence studies (Res-
olution 897 from 2003 (30). Bioequivalence studies for nasal products other than
solutions are required and the guidance for nasal products and products for
inhalation (Public Consult no. 22/2008) are under discussion by ANVISA.

Variations or Postregistration Amendment Requirements

In the case of postregistration, the Guidance for alterations, inclusions and noti-
fications of postregistration [Resolution RE no 893 from 2003 (31)] should be
followed. A bioequivalence study is required only when there is a significant
change in the formulation that can result in different bioavailability.
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64 Marques et al.

WAIVERS OF IN VIVO BIOEQUIVALENCE STUDIES

Immediate Release Drug Products

Bioequivalence assessment of drug products that contain acetyl salicylic acid, or
acetaminophen, or dipyrone or ibuprofen, in the solid form, are not required.

Different Strength Dosage Forms

For immediate release products with different doses, in the same pharmaceuti-
cal dosage form and with proportional formulations, manufactured by the same
producer, at the same locale, a bioequivalence study should be performed with
the higher dosage strength and the other strengths can be waived if the dissolu-
tion profiles are comparable according to the Guidance for assay dissolution for
solid oral pharmaceutical forms of immediate liberation [Resolution 310 from
2004 (32)]. It also states that the waiver is acceptable if there is linearity in the
drug’s pharmacokinetics.

BCS Class Exemptions

Brazilian regulations for bioavailability/bioequivalence studies do not discuss
this issue.

Controlled/Modified Release Dosage Forms

Capsules Containing Beads—Lower Strengths
Brazilian regulations for bioavailability/bioequivalence studies do not discuss
this type of dosage form.

Tablets—Lower Strength
Tablets with different strengths/doses, in the same pharmaceutical dosage form
and with proportional formulations, same release mechanism, manufactured
by the same producer, at the same site, a bioequivalence study should be per-
formed with the higher dosage strength and a bioequivalence study for the other
strengths can be waived if the dissolution profiles are comparable among all
strengths according to the Guidance for assay dissolution for solid oral phar-
maceutical forms [Resolution 310 from 2004 (32)]. For modified release dosage
forms, a comparative dissolution study using three different dissolution media
(such as pH 1.2; pH 4.5, and pH 6.8 media) should be performed. In addition, the
dissolution profile should be comparable among test and reference dosage forms
for all dosage strengths.

REFERENCES
1. Brazil. Health Minister. National Health Surveillance Agency. MS/GM Ordinace no.
3916 of October 30, 1998. Approves the National Drug Policy. Brası́lia, DF; 1998.
http://e-legis.bvs/leisref/public/showAct.php?id=751. Accessed June 16, 2009.
2. Brazil. Law no. 9782 of January 26, 1999. Defines the National Health Surveillance
System, establishing the National Health Surveillance Agency, among other pro-
visions. Brası́lia, DF; 1999. http://e-legis.bvs/leisref/public/showAct.php?id=182.
Accessed June 16, 2009.
3. Brazil. Law no. 9787 of February 10, 1999. Amending the Act no 6360, to Septem-
ber 23, 1976, which deals with health surveillance, provides the generic product,
provides for the use of generic names in pharmaceutical and other provisions.
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Brazil 65

Brası́lia, DF; 1999. http://e-legis.bvs/leisref/public/showAct.php?id=245. Accessed

June 16, 2009.
4. Brazil. Health Minister. National Health Surveillance Agency. Resolution no. 391 of
August 9, 1999. Technical regulation for generic drugs. Brası́lia, DF; 1999. http://
e-legis.bvs/leisref/public/showAct.php?id=251. Accessed June 16, 2009.
5. Storpirtis S, Oliveira PG, Rodrigues D,et al. Biopharmaceutical considerations in the
manufacturing of generic products: factors affecting dissolution and absorption of
drugs. Rev Bras Cienc Farm 1999; 35(1):1–16.
6. Vernengo M. Technical elements of a generic drug policy: an agenda of essential
medicines and technology for health care. Geneve, Switzerland: PAHO/WHO, 1993.
7. Brazil. Decree no. 793 of April 5, 1993. Amendment to the Decree No. 74,170s of 10
June 1974 and 79094 of January 5, 1977, which govern, respectively, Laws paragraphs
5991 of January 17, 1973 and 6360, from September 23 1976, among other provisions.
Brası́lia, DF; 1993. http://e-legis.bvs/leisref/public/showAct.php?id=513&word.
Accessed June 16, 2009.
8. Brazil. Law no. 9279 of May 14, 1996. Regulates rights and obligations relat-
ing to industrial property. Brası́lia, DF; 1996. http://e-legis.bvs/leisref/public/
showAct.php?id=5565&word. Accessed June 16, 2009.
9. Dias HP. Flagrant judicial system of health. Brası́lia: ANVISA, 2004.
10. Brazil. Decree no. 3675 of November 28, 2000. Provides for special measures
relating to the registration of generic drugs, as mentioned in art. 4 of Law no
9787 of 10 February 1999. Brası́lia, DF; 2000. http://e-legis.bvs/leisref/public/
showAct.php?id=236. Accessed June 16, 2009.
11. Brazil. Decree no. 3841 of June 11, 2001. Gives new wording to devices of Decree
no. 3675 of 28 November 2000, which provides for special measures relating to the
registration of generic drugs, as mentioned in art. 4 of Law no 9787 of 10 Febru-
ary 1999. Brası́lia, DF; 2001. http://e-legis.bvs/leisref/public/showAct.php?id=
513&word. Accessed June 16, 2009.
12. Brazil. Health Minister. National Health Surveillance Agency. Market survey on
the price of medicines.(Monitoramento de mercado reverte aumento dos preços
de medicamentos). Boletim Informativo da Anvisa, Brası́lia, 2002; (16):4–5. http://
www.anvisa.gov.br/divulga/public/boletim/16 02.pdf. Accessed June 16, 2009.
13. Pró Genéricos—Brazilian Association of Industries of Generic Drugs. World market
for generic. Sao Paulo: Pró Genéricos; 2008. Available at: http://www.progenericos
.org.br/mercado.shtml. Accessed June 16, 2009.
14. Brazil. Health Minister. National Health Surveillance Agency. RDC Resolution no.
135 of May 29, 2003. Approves Technical Regulation for Generic Drugs. Brası́lia, DF;
2003. http://www.anvisa.gov.br/eng/legis/resol/135 03 rdc e.htm. Accessed June
16, 2009.
15. Brazil. Health Minister. National Health Surveillance Agency. RDC Resolution no. 16
of March 2, 2007. Approves the technical regulation for generic drugs, annex I. Accom-
panying this regulation to annex II, entitled “face sheet of the registration process and
post-registration of generic drugs. Brası́lia, DF; 2007. http://e-legis.anvisa.gov.br/
leisref/public/showAct.php?id = 25960&word = Accessed June 16, 2009.
16. Brazil. Health Minister. National Health Surveillance Agency. RDC Resolution no.
17 of March 2, 2007. Approves the technical regulation for registration of similar
drug. Brası́lia, DF; 2007. http://e-legis.anvisa.gov.br/leisref/public/showAct.php?id
= 26132&word = Accessed June 16, 2009.
17. National Health Surveillance Agency. Manual of good practices in bioavailability and
bioequivalence. Brası́lia: ANVISA, 2002.
18. Brazil. Health Minister. National Health Surveillance Agency. Resolution no. 41 of
April 28, 2000. ANVISA (National Health Surveillance Agency) sets the minimum
criteria for acceptance of units that perform testing of pharmaceutical equivalence,
bioavailability and bioequivalence of drugs. Brası́lia, DF; 2000. http://e-legis.bvs/
leisref/public/showAct.php?id=2114. Accessed June 16, 2009.
19. Brazil. Health Minister. National Agency for Sanitary Surveillance. SVS/MS Ordi-
nance no. 16 of March 6, 1995. Approves the regulation on appropriate practices
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for the manufacture and quality inspection of drugs. Brası́lia, DF; 1995. http://
e-legis.bvs/leisref/public/showAct.php?id=5355. Accessed June 16, 2009.
20. Brazil. Health Minister. National Health Surveillance Agency. RDC Resolution no.
210 of August 4, 2003. Determines all establishments manufacturers of drugs, com-
pliance with the guidelines established in the technical regulation of the prac-
tice for the manufacture of drugs. Brası́lia, DF; 2003. http://e-legis.anvisa.gov.br/
leisref/public/showAct.php?id = 22321&word = Accessed June 16, 2009.
21. Brazil. Health Minister. National Health Surveillance Agency. RDC Resolution no.
134 of May 29, 2003. Available on the suitability of drugs already registered Brası́lia,
DF; 2003. http://e-legis.bvs/leisref/public/showAct.php?id=7904. Accessed June
16, 2009.
22. Brazil. Health Minister. National Health Surveillance Agency. RDC Resolution no. 136
of May 29, 2003. Provides for the registration of new drug. Brası́lia, DF; 2003. http://e-
legis.bvs/leisref/public/showAct.php?id=7914. Accessed June 16, 2009.
23. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no.
1170 of April 19, 2006. Determines the publication of guidelines for evidence
on bioavailability/bioequivalence of drugs. Brası́lia, DF; 2006. http://e-legis.bvs/
leisref/public/showAct.php?id=21746&word. Accessed June 16, 2009.
24. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no. 898
of May 29, 2003. Guide to planning and performing the step of statistical studies on
the bioavailability/bioequivalence. Brası́lia, DF; 2003. http://e-legis.anvisa.gov.br/
leisref/public/showAct.php?id = 2489&word = Accessed June 16, 2009.
25. Chow SC, Liu, JP. Design and Analysis of Bioavailability and Bioequivalence Studies.
New York: Marcel Dekker, 2000.
26. Health Minister. National Health Surveillance Agency CNS Resolution no. 196
of 10 October 10, 1996. Requirements for conduct of clinical research using
health products for humans. Brası́lia, DF; 1996. http://e-legis.anvisa.gov.br/leisref/
public/showAct.php. Accessed June 16, 2009.
27. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no.
894 of May 29, 2003. Determines the protocol for publication of the guide and
technical report of the bioequivalence study. Brası́lia, DF; 2003. http://e-legis.bvs/
leisref/public/showAct.php?id=1914. Accessed June 16, 2009.
28. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no.
899 of May 29, 2003. Determines the publication of guidelines for validation of
analytical and bioanalytical methods, is repealed RE Resolution no 475 of March
19, 2002. Brası́lia, DF; 2003. http://e-legis.bvs/leisref/public/showAct.php?id=5745.
Accessed June 16, 2009.
29. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no.
895 of May 29, 2003. Determines the publication of “Guidelines for preparation of
technical report on the study of bioavailability/bioequivalence”. Brası́lia, DF; 2003.
Accessed June 16, 2009.
30. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no. 897
of May 29, 2003. Determines the publication of guidelines for relief and replace-
ment of bioequivalence studies. Brası́lia, DF; 2003. http://e-legis.bvs/leisref/public/
showAct.php?id=1775. Accessed June 16, 2009.
31. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no. 893
of May 29, 2003. Determines the publication of the guide to make changes, addi-
tions and reporting post-registration of drugs. Brası́lia, DF; 2003. http://e-legis.bvs/
leisref/public/showAct.php?id=1909. Accessed June 16, 2009.
32. Brazil. Health Minister. National Health Surveillance Agency. RE Resolution no. 310
of September 1, 2004. Determines the publication of the guide for the study and
reporting of pharmaceutical equivalence and profile of dissolution. Brası́lia, DF; 2004.
http://e-legis.bvs/leisref/public/showAct.php?id=12431. Accessed June 16, 2009.
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4 Canada
Iain J. McGilveray
McGilveray Pharmacon Inc., Ottawa, Ontario, Canada

INTRODUCTION
As a result of 1969 amendments to the Patent Act (1) (compulsory licensing),
Canadian regulators were the first to apply pharmacokinetics (PKs) to safety and
efficacy risk assessment of generic drug products. However, formal guidelines
developed by an Expert Advisory Committee (EAC), currently referred to as the
Scientific Advisory Committee (SAC), were not published until the 1990s. Cur-
rently, guidelines are being updated and new SAC initiatives such as Guidances
for nonproportional PK drugs and for drug products requiring fed studies have
been published in draft form for stakeholder comments and consultation while
others, such as guidance for critical dose drugs, have been finalized.
The Canadian Food and Drugs Act and consolidated Regulations in Divi-
sion 8 (2) require that for new drugs (which also means drug products), the man-
ufacturer must file a New Drug Submission (NDS) that must provide evidence of
safety, efficacy, and consistency of quality. (This requirement includes all drugs
submitted after 1962, but for some older drugs, it may be applied if presented for
new claims or in a new dosage form or strength.) However, for second and sub-
sequent entry new drugs (generic drug products), an abbreviated NDS (ANDS),
the regulation was revised in 1995 as C.08.002.1., noting that a manufacturer may
file an abbreviated new drug submission (ANDS) for the generic product (i.e.,
“the new drug”), where, in comparison with a Canadian reference product,
a. the new drug is the pharmaceutical equivalent of the Canadian reference
product;
b. the new drug is bioequivalent with the Canadian reference product, based on
the pharmaceutical and, where the Minister considers it necessary, bioavail-
ability characteristics;
c. the route of administration of the new drug is the same as that of the
Canadian reference product;
d. the conditions of use for the new drug fall within the conditions of use for
the Canadian reference product.
In this regulation “pharmaceutical equivalent” means a drug product that,
in comparison with another drug product, contains identical amounts of the
identical medicinal ingredients, in comparable dosage forms, but does not nec-
essarily contain the same nonmedicinal ingredients; and “Canadian Reference
Product C.08.001.1.” (http://www.canlii.org/ca/regu/crc870/secc.08.001.1.html)
means:
a. a drug in respect of which a notice of compliance is issued pursuant to Section
C.08.004 and which is marketed in Canada by the innovator of the drug,

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68 McGilveray

b. a drug, acceptable to the minister, that can be used for the purpose of demon-
strating bioequivalence on the basis of pharmaceutical and, where applica-
ble, bioavailability characteristics, where a drug in respect of which a notice
of compliance has been issued pursuant to Section C.08.004 cannot be used
for that purpose because it is no longer marketed in Canada, or
c. a drug, acceptable to the minister, which can be used for the purpose of
demonstrating bioequivalence on the basis of pharmaceutical and, where
applicable, bioavailability characteristics, in comparison to a drug referred
to in paragraph a

In general, this means an innovator product, but there is a policy (3) for
exceptions when the innovator has withdrawn from the Canadian market. This
regulation was developed after application of internal policies and decisions by
reviewers of applications over about 30 years. These ad hoc policies resulted after
amendments to the Canadian Patent Act in June 1969 (1), which made provision
for compulsory licensing and facilitated registration of generic drug products in
Canada. [“In a compulsory license, a government forces the holder of a patent,
copyright or other exclusive right to grant use to the state or others. Usually, the
holder does receive some royalties, either set by law or determined through some
form of arbitration” (4). In Canada, this royalty was set at 4%.]
The Patent Act amendment in Canada, facilitated growth of a substantial
generic market (the first in a developed country), although the amendment was
attenuated in 1988 when the patent life was extended to international norms. Fol-
lowing the legal changes, introduction of generic products led to a need for assur-
ing the safety and efficacy of such products and a research program into compar-
ative bioavailability was undertaken in the 1970s. In fact, Health Canada was
the first jurisdiction to apply bioequivalence (BE) to safety and efficacy review of
new drug products (5).
Many of the internal decisions for generic product approval involved an
Expert Advisory Committee on Bioavailability first formed in 1971, which was
at that time largely a review committee for early BE studies carried out in Health
Canada laboratories. However, the EAC not only provided decisions from review
of study results for generic studies, but also was the first to define bioequiv-
alence from comparative bioavailability and to provide an early standard that
such products should have a bioavailability of at least 80% relative to a “refer-
ence formulation” according to a statistically sound design (6).
The major work of the EAC toward the end of the 1980s was the produc-
tion of three reports A, B, and C that were the basis of two guidelines (7,8) and
several policies that provide the foundation of most of this chapter. There is
also draft guidance, “Preparation of Comparative Bioavailability Information for
Drug Submissions in the CTD Format” (9), which provides a list of the require-
ments to be met and integrates unique Canadian bioequivalence requirements
with the ICH harmonized approach (Common Technical document, CTD) for
drug product registration, to which Canada is a signatory.
However, it must be understood that Canada is governed as a Confedera-
tion of Provinces. Thus, the regulations and guidelines for BE are federal, lead-
ing to a Notice of Compliance (NOC) to sponsors for marketing in Canada and
while their application leads to a Declaration of Bioequivalence for specific prod-
ucts, the Provinces in the Canadian Confederation have the responsibility for
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Canada 69

health care and the licensing of health professions. Thus, provincial formulary
committees consider interchangeability of products and may not accept the fed-
eral decision of BE (which also evaluates quality) to be sufficient to list a particu-
lar product. Also, each province has different formulary rules, usually permitting
product substitution of prescribed brand name by pharmacists and also govern-
ing prices. Of course, before being approved federally with a Notice of Com-
pliance, the generic product must comply with the patent laws. This has been
problematic in some cases, as slight changes in innovator products have gained
extensions and often delayed introduction of generic products into the market.
Most of the Canadian requirements for bioavailability and particularly BE
are, as previously mentioned, provided in two guidances, Part A for immediate-
release or conventional oral products (7) and Part B for modified-release (MR)
products (8). Both the guidances, Part A and B, state that “this guidance docu-
ment deals with drugs that have uncomplicated Characteristics.”
Part A provides examples of drugs that may require methodology and stan-
dards to be modified for certain drugs (products)—for example, those with one
or more of the following characteristics:
a. MR dosage forms.
b. Complicated or variable PKs, for example,
r nonlinear kinetics;
r substantial first-pass effect (greater than 40%);
r variable kinetics owing to different genetic phenotypes;
r stereochemical effects such as in vivo inversion of configuration;
r an effective half-life of more than 24 hours.
c. (An important) time of onset of effect or rate of absorption.
d. High toxicity or a narrow therapeutic range.
e. Little or no absorption with activity exerted locally in the gastrointestinal
tract.
f. A drug measurement methodology insufficiently sensitive or reliable to
determine blood concentrations to at least three terminal half-lives.
g. Combination products.
h. Biologicals.
Guidances for these types of drugs were never finalized, but report C of
the EAC (10) suggested modifications for some of the above and, more recently,
some specific guidances or policies have been developed for these exceptions, as
will be discussed later in this chapter.

DESIGN AND CONDUCT OF BIOEQUIVALENCE STUDIES

FOR ORALLY ADMINISTERED DRUG PRODUCTS
Part A (7) is akin to the FDA general guidance and lays out the scope and con-
ditions for both bioavailability and bioequivalence (comparative bioavailability)
studies.

Study Design
This is described under Section 4 of the guidance, “Study Design and Environ-
ment,” which is introduced with the statement “The design of a bioavailability
study should minimize variability that is not attributable to the drug per se and
should eliminate bias as much as possible. The guidances in this section serve for
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70 McGilveray

the usual case. Other designs may be permissible after consultation with Health Canada
(HC) before the study is initiated.”
Section 4.3 states that “The basic design to be used is a two-period cross-
over, in which each subject is given the test and reference formulations at differ-
ent times in a blinded manner). In cases where more than two formulations are
under study, or are studied under different conditions, each volunteer should
receive all treatments in a restricted randomized design. However, when the
number of treatments results in a study that is longer than a month, a balanced
incomplete block design may be considered.” The latter type of design is rarely
used.

Number and Selection of Subjects or Patients

and Phenotyping/Genotyping
Section 3 of the guidance deals with the selection of subjects for a study.
There is considerable advice given in Part A, Section 3.3, on the calculation
of study size.
“The number of subjects to be used in the cross-over study should be esti-
mated by considering the standards that must be passed (discussed later) and the
drug products being compared. The probability that a study of a given size will
pass the standards depends on the expected mean difference between the test
and reference formulations of both AUCT (or last) and Cmax , and the anticipated
intrasubject coefficient of variation (CV) of both AUCT and Cmax . For drugs with
uncomplicated characteristics, the intrasubject CV is generally less than 20%;
however, as a result of sampling, or if the study is poorly run, the intra-subject
CV can be higher.”
“The minimum number of subjects is 12, but a larger number is often required.”
Probability diagrams are included and calculations are suggested to estimate the
appropriate number of subjects.
Section 3.2 notes that drugs with uncomplicated characteristics can usually
be tested in normal, healthy volunteers. Subjects of both genders are acceptable
and investigators should ensure that female volunteers are not pregnant or likely
to become pregnant during the study. Confirmation should be obtained by urine
tests just before the first and last doses of the study.
“In some instances, studies may be required to ascertain bioavailability in
patients or subjects with special characteristics—for example, for drugs to be
used in the treatment of conditions accompanied by altered absorption or dis-
tribution, or for drugs to be used in special age groups such as children or the
elderly.” This is relatively rare for BE, except for some critical dose drugs dis-
cussed later. However, women subjects would be preferred for testing oral con-
traceptives and products for treatment of menopause.
It is also noted that an important objective in the selection of subjects is
to reduce the intrasubject variability in PKs that may be attributable to certain
characteristics of the subject. “Subjects should be assigned in such a way that the
study design is balanced for any factors that are suspected to contribute to variability.”
A range of subject age from 18 to 55 years of age is specified. As this is an older
guidance, the height/weight ratio suggested is based on insurance tables and
“should be within 15% of the normal range.” However common body mass index
(BMI) limitations are accepted.
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Section 3.2.c deals with health checks and since adoption of the ICH good
clinical practice (GCP) guidance (11) the Health Canada guidance has been
superseded, although in general the statement “The health of the volunteers
must be determined by the supervising physician through a medical examina-
tion and review of results of routine tests of liver, kidney, and hematological
functions” covers many of the GCP expectations. Psychological evaluation of
candidate subjects is also required to exclude patients unlikely to comply with
study restrictions or unlikely to complete the study. Also, when the drug has a
cardiac effect, an electrocardiogram should be included in the study documen-
tation. Of course, as in the GCP guidance (11), full documentation of aberrant
laboratory values should be rechecked and a summary must be presented along
with the physician’s opinion. While there is no actual direct mention of informed
consent from volunteers, the requirement for ethical review board approval (now
according to clinical trial certification (12) with advice for BE applications (13)
and citation of good clinical practice guidelines (now ICH) are very clear on doc-
umentation of consent, as well as responsibilities of investigators and suitability
of clinical, laboratory and analytical facilities involved in the study. For details
see also “CTD preparation” document (13).
Nonsmoking subjects are preferred, but if smokers are included they must
be identified, with discussion on any likely effect on the study included in the
study report. Volunteers should not take any other drug, including alcoholic bev-
erages and over-the-counter (OTC) drugs, for an appropriate interval before, as
well as during, the study (Section 4.1). In the event of emergency, the use of any
drug must be reported (dose and time of administration). It is expected that alco-
hol and other recreational drug abuse would be detected during health checks.
There is no direct mention of genotyping or phenotyping in the older guidance.
However for subject safety, GCP requires that poor metabolizers be protected
from adverse effects.

Standardization of Study Conditions

Section 4.1 in Part A states, “Every effort should be made to standardize the study
conditions in every phase of the study—for example; exercise, diet, smoking, and
alcohol use.” Section 4.4 details the expectations in standardizing administration
of food and fluids, viz:
The administration of food and fluid should be controlled carefully. Nor-
mally, subjects should fast for 10 hours before drug administration. A fast
means that no food or solids are to be consumed, although alcohol-free
and xanthine-free clear fluids are permissible the night prior to the study.
On the morning of the study, up to 250 mL of water may be permitted up
to two hours before drug administration. The dose should be taken with
water of a standard volume (e.g., 150 mL) and at a standard temperature.
Two hours after drug administration, 250 mL of xanthine-free fluids are
permitted. Four hours after drug administration, a standard meal may be
taken. All meals should be standardized and repeated on each study day.
“Some drugs are given with food to reduce gastrointestinal side effects.
Studies of such drugs should include studies with standard meals” refer to
“Guidance for industry. Bioequivalence Requirements: Comparative Bioavail-
ability Studies Conducted in the Fed State” (14). This suggests that for uncom-
plicated drugs, as defined in Part A, BE should be demonstrated in a single-dose
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study under fasting conditions. The exception would be if there is a documented

serious safety risk to subjects from single-dose administration of the drug or drug
product in the absence of food.
For complicated drugs contained in immediate-release dosage forms (crit-
ical dose drugs and nonlinear drugs) and for drugs in MR dosage forms, BE
should generally be demonstrated under both fasted and fed conditions. While
there an example of a test meal is provided, sponsors must be able to justify the
choice of meal in a fed BE study and relate the specific components and timing
of food administration.
Section 4.5 discusses posture and physical activity during the study. “For
most drugs, subjects should not be allowed to recline until at least two hours after
drug ingestion. Physical activity and posture should be standardized as much as
possible to limit effects on gastrointestinal blood flow and motility. The same
pattern of posture and activity should be maintained for each study day.”
Section 4.6 considers the interval between doses. “The interval between
study days should be long enough to permit elimination of essentially the entire
previous dose from the body. The interval should be the same for all subjects and,
to account for variability in elimination rate between subjects, normally should
be not less than 10 times the mean terminal half-life of the drug. Normally, the
interval between study days should not exceed three to four weeks. Furthermore,
the drugs must be administered at approximately the same time on each study
day and, where possible, the same day of the week.” Long half-life drugs are
considered in Report C (10) and in a separate guidance discussed later in the
chapter.

Blood/Urine Sample Collection and Times

Section 4.7 of Part A discusses sampling times of blood and urine, “The dura-
tion of blood or urine sampling in a study should be sufficient to account for at
least 80% of the known AUC to infinite time (AUCI). This period is usually at
least three times the terminal half-life of the drug. To permit calculation of the
relevant pharmacokinetic parameters, from 12 to 18 samples should be collected
per subject per dose. An account of inter-subject variability should be used in
the placement and number of samples. The exact times at which the samples are
taken must be recorded and spaced such that the following information can be
estimated accurately:
a) Peak concentration of the drug in the blood (Cmax )
b) The area under the concentration time curve (AUC) is at least 80 percent of
the known AUCI, and
c) The terminal disposition rate constant of the drug.
There may be considerable inaccuracies in the estimates of the terminal
disposition rate constant if the constant is estimated from linear regression using
only a few points. To reduce these inaccuracies it is preferable that four or more
points be determined during the terminal log-linear phase of the curve.”
Long half-life drugs are considered in Report C (10) and in a separate guid-
ance discussed later, but blood in these cases need only be collected to 72 hour.
If urine is used as the biological sampling fluid (see below), then sufficient
samples must be obtained to permit an estimate of the rate and extent of
renal excretion.
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Characteristics To Be Investigated
Blood/Plasma/Serum Drug Concentration Versus Time Profiles
Section 4.8 of the guidance A discusses sampling of blood or urine. “Under nor-
mal circumstances, blood should be the biological fluid sampled to measure the
concentrations of the drug. In most cases the drug may be measured in serum or
plasma; however, in some cases, whole blood may be more appropriate for anal-
ysis. If the concentrations in blood are too minute to be detected and a substantial
amount (>40 percent) of the drug is eliminated unchanged in the urine, then the
urine may serve as the biological fluid to be sampled. When urine is collected,
the volume of each sample must be measured immediately after collection and
included in the report. Urine should be collected over no less than three times
the terminal elimination half-life. For a 24-hour study, sampling times of 0 to 2,
2 to 4, 4 to 8, 8 to 12, and 12 to 24 hours are usually appropriate. Quantitative
creatinine determinations on each urine sample are also required. Sometimes the
concentration of drug in a fluid other than blood or urine may correlate better
with effect. Nevertheless, the drug must first be absorbed prior to distribution to
the other fluids such as the cerebrospinal fluid, bronchial secretions, and so on.
Thus, for bioavailability estimations, blood is still to be sampled and assayed.”
Examples of drugs for which urinary excretion profiles may be used for
BE are potassium chloride and biphosphonates. Pharmacodynamic studies are
rarely used for BE, but report C has a section on this (10). It is a very general
advice. Of interest is the suggestion on appropriate standards:
The requirements of a pharmacodynamic study should be comparable to
those of standard bioavailability or bioequivalence studies, including mea-
sures of the magnitude, onset and duration of response. For approval under
such circumstances, criteria similar to those defined for bioavailability and
bioequivalence studies that use drug concentration measurements must
be derived; e.g., AUC of measured pharmacodynamic response and maxi-
mum response. In addition, similar standards should be met in these crite-
ria to establish bioavailability and bioequivalence.

In fact such studies are drug specific and usually wider standards are nec-
essary. The human skin blanching assay (HSBA) for topical corticosteroid prod-
ucts and the change in pulmonary function tests with albuterol are the known
applications and are noted later.

Bioanalysis
Section 6 of the guideline, Part A, entitled “Measurement Methodology”
describes the attributes of such methods for parent drug, and when appropriate,
metabolites in the matrix and the validation procedures required in reports to
establish and maintain selectivity, range, precision, and accuracy. There is a draft
guidance on metabolites (15), which essentially notes that parent drug should be
measured for BE, even for prodrugs, except if the sensitivity does not permit the
performance standards to be met to obtain an adequate profile. The 1992 guid-
ance refers to the report (16) of a bioanalytical methods validation workshop
(the first of its kind), which laid out internationally accepted practices for this
area but has been superseded by the report of a subsequent (second) conference
(17). The report describes the requirements for method development validation
and then partial validations required for changes in processes, methodology, or
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analytical equipment, for example, different mass spectrometers with the final
validation being the application to the study samples. Documentation requires
listing of standard operation procedures (SOPs) for sample storage, processing,
standard and quality control sample preparation, and evaluation of stability (for
analyte and internal standard) under various conditions, such as benchtop as
well as long-term frozen samples. A Canadian difference compared to interna-
tional practice requirements, given in the Part A guidance, was that there was to
be reanalysis of 15% randomized replicate (or incurred) samples for each study,
but this was revoked in 2005 (18). However, the during the May 2006 third bioan-
alytical methods validation conference discussed the need for validating meth-
ods by using incurred as well as the spiked samples normally evaluated for pre-
cision and accuracy. The “15% randomized replicate” request was an attempt
to demonstrate reproducibility in practice. However, it was difficult to apply as
other jurisdictions did not require incurred sample stability in that era. In fact
determination of the need (or not) for incurred sample investigation may be
expected in the original bioanalytical method validation report rather than the
report for each study (Eric Ormsby, TPD, personal communication, May 2008).

Choice of Reference Product—C.08.001.1.

“Canadian Reference Product” (http://www.canlii.org/ca/regu/crc870/secc.
08.001.1.html) has previously been defined
An associated policy (3) (1995) expands on the paragraph c intent. While
this recognizes that globalization of the industry leads to innovators marketing
the same formulation in many countries and even having one plant manufac-
ture a product for the entire world, the interpretation is very narrow. As well as
requiring considerable documentation of the provenance of the reference prod-
uct from another country, the following criteria are to be met by the medicinal
ingredient and the drug product.
The medicinal ingredient exhibits an aqueous solubility of more than 1%
and is “uncomplicated” as defined in the Drugs Directorate Guideline, Part A
(as noted earlier).
In addition, the drug product contains a single medicinal ingredient in
the same quantity as the innovator product marketed in Canada and is the
same as the drug product marketed in Canada with respect to color, shape, size,
weight, type of coating (e.g., uncoated, film-coated, or sugar-coated), and must
demonstrate individual and mean values of the dissolution profiles compara-
ble to the product marketed in Canada. (Usually this means meeting the FDA
f 2 dissolution criteria.) The dissolution profiles should be determined in at least
three media within the physiological range (pH 1–7.5), for example, water, 0.1 N
HCl, and pharmacopoeial buffer media at pH 4.5, 6.5, and 7.5. One dissolution
medium should be that described in the USP or BP monograph, if one exists. The
percentage of drug content released should be measured at a number of suit-
ably spaced time points, for example, at 10, 20, and 30 minutes, and continued to
achieve virtually complete dissolution.
If any of the above conditions are not met, the manufacturer must demon-
strate the equivalence of the second-entry product to the innovator’s product
marketed in Canada by the appropriate BE study or studies.
The result of these requirements and criteria is that non-Canadian refer-
ences for BE studies for generic products are rarely accepted. For changes in
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innovator products requiring proof of BE between an older and revised

(changed) product, much of the information is available from the company’s
files.

Study Products and Batch Size

The Part A document (Section 5.2) calls for “the bioequivalence batch to be rep-
resentative of proposed production batches, comparable in size and produced
using the same type of equipment and procedures proposed for the formulation
to be marketed.”
Since the time that the guidance was written, commonly, lots used in sta-
bility studies according to ICH (19) are tested and these are primary batches that
should be of the same formulation and packaged in the same container closure
system as proposed for marketing and are at least pilot scale batches.

Data Analysis
Section 7 of guideline, Part A details the PK and statistical analysis expected.

Statistical Analysis
The requirements for “analysis of data” are described in Section 7.0 of the guid-
ance. The analysis of variance (ANOVA) tables submitted with the study doc-
umentation (report) should include the appropriate statistical tests of all effects
in the model. The output from ANOVAs appropriate to the study design and
execution must be expressed with enough significant figures to permit further
calculations.
The analyses should include all data for all subjects on measured data. Supple-
mentary analyses may also be carried out with selected points or subjects initially
excluded from the analyses. Such exclusions must be justified. It is rarely accept-
able to exclude more than 5 percent of the subjects or more than 10 percent of the
data for a single subject-formulation combination.
In fact, rejection of outliers is rarely accepted and remains an issue to be resolved,
despite several advisory committee discussions. In the impending revision of
Canadian guidelines it will be proposed (20) that values from subjects identified
as extreme with an acceptable outlier test can be rejected, if after retesting the
subjects with both formulations, the retested values are found to be within the
normally expected range.
An ANOVA should be carried out on the time to peak concentration, tmax
and terminal slope (␭) data, and on the logarithmically transformed AUCT ,
AUCI , and Cmax data. The analysis and results for each parameter should be
reported on a separate page as detailed in the guidance (see Section 8, “Sample
Analysis for a Comparative Bioavailability Study”). The reported results must
include
a. means and CVs (across subjects) for each product;
b. the ANOVA, containing source, degrees of freedom, sum of squares, mean
square, F and p values and the derived intra- and intersubject CVs;
c. AUCT and Cmax ratios for test versus reference products;
d. the 90% confidence interval (CI) about the mean AUCT ;
e. estimates of measured content for each formulation being compared, and a
separate table showing points c and d above, corrected for measured content.
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Appropriate tabulation of PK parameters is required, as well as individ-

ual and mean plasma (or urinary excretion) profiles graphed both in linear and
semilogarithmic scales.
The Canadian guideline requires BE results to be calculated (and standards
should be met) with and without correction for drug content, although this is
under consideration (observed data may be accepted without the correction if
test and reference assays for labeled content are within 5% of each other) (20).

Add-On Studies
There is an allowance for add-on studies. The latter thus permits two or more
studies to be pooled if certain requirements are met, viz

a. the same protocol must be used for all studies. Specifically, this means that
the same analytical method is to be used, the blood samples drawn at the
same time, and the same lots of the same formulations used.
b. two consistency tests must be done on the studies to ensure that pooling is
meaningful. The first test is the test of equality of the residual mean squares
and the second test is the formulation by study interaction.

Add-on and sequential designs are currently under consideration for a

revised guidance (20). Consistency tests would not be mandatory, but an adjust-
ment (Bonferroni correction—see footnote d) will be required to keep the error
rate at 5% to protect the ␣. Sequential designs should be considered when vari-
ation and expected mean differences are uncertain, but use of this approach
should be stated a priori in the clinical study protocol.

Acceptance Ranges for Pharmacokinetic Parameters

Single-Dose Studies
Health Canada requires two PK metrics to be measured for uncomplicated drugs
[see Guidance Part A (8), Section 7.1]: the area under the drug (or metabolite)
concentration in plasma (or serum, or whole blood) versus time curve from zero
(time of dose) to the time of last quantifiable concentration. (AUCT ), often known
as AUClast , and Cmax , the observed maximum or peak concentration of drug (or
metabolite) in plasma (or serum, or whole blood). As already discussed these
concentrations are usually for parent drug. The area under the drug concentra-
tion versus time curve from zero (time of dose) extrapolated to infinity (AUCI )
should also be estimated and one of the acceptance criteria is that the AUCT is
at least 80% of the known AUCI , but otherwise AUCI is not usually applied as a
standard by the TPD.
Also, for a drug with a terminal elimination half-life greater than 24 hours,
BE standards in comparative bioavailability studies will be applied to AUC0–72
hours rather than to AUCT and an estimate of AUCI is not required (21). Alter-
nate designs such as parallel studies could be considered for long half-life drugs.
Part A has no description for urinary standards, but the cumulative uri-
nary excretion (Ae ) and the maximum rate of urinary excretion are reflective of
the plasma AUCT and Cmax , respectively and the identical acceptance limits for
plasma and urine metrics are invoked.
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Part A, Section 7.1 states the Standards for Bioequivalence:

For drugs with uncomplicated characteristics, the following standards,
obtained in single dose cross-over comparative bioavailability studies, determine
BE as follows:
a. The 90% CI of the relative mean AUCT of the test to reference product should
be within 80% to 125%.
b. The relative mean measured Cmax of the test to reference product should be
between 80 and 125%.
These standards must be met on log-transformed parameters calculated
from the measured data, and data corrected for measured drug content [percent
potency of label claim, but, as noted above, this is under consideration (20)].
Thus, unlike FDA and European requirements, only the geometric mean ratio
(point estimate) is required for Cmax , but the AUCT acceptance ranges are identi-
cal [currently for both measured and corrected for drug content data, but under
consideration for application to measured data only (20)].
There is a guidance for critical dose drugs (22), which includes drugs
that commonly exhibit adverse effects and limit the therapeutic use to doses
close to those required for the therapeutic effect (e.g., “narrow therapeutic
range drugs”) or drugs for which the therapeutic use may result in dose- or
concentration-dependent adverse effects, which are persistent, irreversible, or
slowly-reversible, or life threatening (e.g., “highly toxic drugs”). The guidance
provides the following acceptance ranges:
The 90% CI of the relative mean AUCT of the test to reference formulation
should be within 90.0% to 112.0%; the relevant AUC or appropriate AUC (as
described in Guidelines A and B) are to be determined.
1. The 90% CI of the relative mean measured Cmax of the test to reference for-
mulation should be between 80.0% and 125.0%.
2. These requirements are to be met in both the fasted and fed states.
3. These standards should be met on log transformed parameters calculated
from the measured data and from data corrected for measured drug content
(percent potency of label claim).The latter is also currently under considera-
tion for amendment (20).
The list of critical dose drugs is described in an appendix and includes
cyclosporine, digoxin, flecainide, lithium, phenytoin, sirolimus, tacrolimus, theo-
phylline, and warfarin.
There is also a Guidance for Bioequivalence Requirements for Drugs for
Which an Early Time of Onset or Rapid Rate of Absorption is Important (rapid
onset drugs) (23). These are defined as drugs for which the time of onset of effect
is important because of therapeutic or toxic effects; for example, an analgesic for
rapid relief of pain. In addition to the 90% CI criterion for AUCT , from Part A
above, the following standards are recommended for this group.
1. The 90% CI of the relative mean measured Cmax of the test to reference for-
mulation should be between 80% and 125%.
2. The relative mean AUCReftmax of the test to reference formulation should
be within 80% to 125%, where AUCReftmax for a test product is defined as
the area under the curve to the time of the maximum concentration of the
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reference product, calculated for each study subject. To date this standard
has only been applied to two drugs, oral gel formulations of ibuprofen, and
tablet formulations of sumatriptan.
Another update of report C was the Notice to Industry: Bioequivalence
Requirements for Combination Drug Products (24). The purpose is to state
BE requirements specific to combination drug products. Further work is being
done on requirements for fixed dose combinations, particularly in New Drug
Submissions.
For studies of combinations, the PK parameters to be reported and assessed
according to acceptance criteria, are those which would normally be required of
each drug if it were in a formulation as a single entity, as described in current
TPD guidelines (Parts A and B) and policy statements (which are given earlier).
There is a draft policy on Bioequivalence Requirements: Drugs Exhibiting
Non-Linear Pharmacokinetics (25), which states that a drug will be considered to
exhibit nonlinear PK if this is indicated in the peer-reviewed scientific literature
or the approved labeling for the drug. However, the drug may be treated in the
same way as those exhibiting linear PKs, if evidence is provided to show that
dose-normalized AUC deviate (increase or decrease) by less than 25% over the
labeled dose range for the proposed indication.
Drugs that exhibit nonlinear PK characteristics with single or multiple
doses of approved strengths should meet standards for BE as outlined in the TPD
Guideline on the Conduct and Analysis of Bioavailability and Bioequivalence Studies:
Part A or Part B, as applicable.
These requirements should be met in single-dose studies in both the fasted
and fed states for all nonlinear drugs, with the following exceptions:
a. If nonlinearity occurs after the drug enters the systemic circulation unless
there is evidence that a product exhibits a food effect;
b. If a condition (fasted or fed) for product ingestion is contraindicated, that
condition may be waived in a BE trial.
This draft policy is also under consideration (20) and it is proposed that
if the product monograph for the reference clearly states the type of nonlinear-
ity, then the drug is considered to be nonlinear (non–dose-proportional) and the
appropriate dose should be used in the study or studies. A fed study would not
be required.

Steady-State Studies
The major group of drugs with different criteria are MR products as described
in the guideline, Part B (9). This guidance defines the general acceptance crite-
ria for the required multiple-dose, steady-state studies, which are also applica-
ble to multiple-dose studies that may be required for some nonlinear drugs and
with the narrower limits previously described, for critical dose drugs. However,
the application of steady-state studies to extended-release products is also being
reconsidered (20) in harmony with the FDA general guidance. Steady-state stud-
ies do not seem to provide any better comparison of the two formulations. The
general acceptance criteria for BE from steady-state studies are described in Sec-
tion 4.3 of the guideline, Part B, and are based on the geometric mean ratio of
test to reference and the standards described below must be met for parameters
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calculated from the observed concentrations, as well as those corrected for mea-
sured drug content.
AUC: The 90% CI of the relative mean AUC␶ (generally known as AUCss : AUC
at steady state for the dosage interval) of the test to reference formulation
should be within 80% to 125%.
Cmax : The relative mean measured Cmax at steady state of the test to reference
formulation should be within 80% to 125%.
Cmin : The relative mean measured Cmin at steady state of the test to reference
formulation should not be less than 80%.

Reporting of Results
As Health Canada applies the ICH guidances and the CTD to submission review,
submissions are required to follow the subsections of this document. There is an
additional advice in the draft guidance for industry “Preparation of Comparative
Bioavailability Information for Drug Submissions” in the CTD Format, Health
Canada, May 2004 (9). Thus the clinical report, analytical report, and PK and
statistical reports would be included in CTD Module 5 Section 5.3.1, Biopharma-
ceutic studies, with reports according to the ICH good clinical practice guideline,
including “adverse events.” In addition, the Part A and other TPD guidance stan-
dards and tabulations would be expected. Quality information must be included
in the quality overall summary and details in CTD Module 2, Quality.

BIOAVAILABILITY AND BIOEQUIVALENCE REQUIREMENTS

Possible changes to Canadian guidances are under consideration (20) but the
formal consultation process has just begun and final changes may take some time
to be promulgated.

Orally Administered Drug Products Intended for Systemic Action

The Part A (7) and Part B (8) (MR) guidances include bioavailability and bioe-
quivalence requirements, but Part A in particular has little information on
bioavailability studies which are expected for the characterization of new drugs.
Absolute bioavailability is described as “Comparison of the AUC values follow-
ing oral versus intravenous administration of an equivalent dose of the same
active ingredient provides an estimate of absolute bioavailability for most drugs.”
As noted earlier, Report C (10) and the draft policy on Bioequivalence Require-
ments: Drugs Exhibiting Non-Linear Pharmacokinetics (25) comment on testing
for dose proportionality, with the latter recommending a limit of ±25% of dose-
normalized AUC deviation as the definition of linearity. However, there is no
information on the statistics or model to be applied in this calculation. As noted
previously, this guidance is under review (20). Other jurisdictions, such as FDA
and EMEA also mention nonlinear kinetics, but with few details on the determi-
nation thereof.

Solutions
There is no specific guidance for PK studies of solutions, including bioavailabil-
ity of solutions of new drugs. However, during development, basic PK studies
in support of general safety and efficacy would be expected. To integrate with
ICH guidelines, there is a relatively new guidance on Pharmaceutical Quality
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of Aqueous Solutions (26), which replaced a previous policy on Waiver of Com-

parative Bioavailability Studies for Oral Solutions. While the guidance mainly states
the expectations concerning testing parameters that should be considered during
the pharmaceutical development of these new drug products (NDS), it is also
intended to provide guidance on the quality of aqueous solutions for generic
products and certain changes to drug products contained in NDS and ANDSs.
To support the request for a waiver of the requirement to demonstrate in vivo BE
for solutions other than parenteral generic aqueous solutions (e.g., oral, dermato-
logical, ophthalmic, otic), the nonmedicinal ingredients in the formulation of the
test product, when compared to the reference product, should be qualitatively
the same and quantitatively essentially the same. For the purposes of this docu-
ment, essentially the same would be interpreted as the amount (or concentration)
of each excipient in the test product to be within ±10% of the amount (or concen-
tration) of each excipient in the reference product. Differences beyond these cri-
teria should be scientifically justified and the potential impact on the safety and
efficacy of the drug product should be discussed. However, those excipients that
could potentially modify the absorption of the drug substance should be quali-
tatively the same and quantitatively essentially the same (as defined earlier). These
would include those excipients that could enhance absorption (e.g., polysorbate
80, polyethylene glycol, ethanol) and those that could inhibit absorption (e.g.,
sorbitol, manitol).
In addition, to support the request for a BE waiver for aqueous solutions,
the results of a study comparing the physicochemical properties of the test prod-
uct against the reference product should be provided, showing their essential
similarity.

Suspensions
Bioequivalence studies are expected for oral suspensions for systemic effects
according to the 1995 Drugs Directorate Guidelines, Preparation of drug identi-
fication number submissions (27). Demonstration of bioequivalence is generally
required and oral suspensions, powders/granules for oral suspension, intended
for systemic effect containing prescription drugs are affected. The standards for
AUCT and Cmax given in the guideline, Part A (7), are identical to those listed
below for immediate-release conventional formulations of uncomplicated drugs.
For complicated drugs, such as critical dose drugs, the acceptance ranges are as
described in “Data Analysis” section of this chapter.

Immediate-Release Products—Tablets and Capsules

For immediate-release products (conventional formulations) for systemic effects,
BE standards are given in “Acceptance Ranges for Pharmacokinetic Parameters”
section of this chapter. In the guideline Part A, the general standard for uncom-
plicated drugs is given, with an example calculation.
AUC: The 90% CI of the geometric mean ratio of AUCT of the test to reference
product should be within 80% to 125%.
Cmax : The geometric mean ratio of Cmax of the test to reference product should
be between 80% and 125%.
As previously mentioned, this standard differs from most other countries,
but acknowledges that the Cmax metric is more variable than AUC and for
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uncomplicated drugs, this part measure of rate is not particularly robust. As

noted earlier in “Acceptance Ranges for Pharmacokinetic Parameters” section,
tighter standards are invoked for some complicated drugs, such as critical dose
drugs.

Other Oral Dosage Forms

MR Dosage Forms (Previously Defined as MR—Page 13, 2.9.2.1)
Guideline, Part B (8) for MR dosage forms notes that a separate guidance and
standards are required for each of the circumstances in which an MR formulation
might be developed. These circumstances fall into three groups:
r Group I—This group includes original MR dosage forms when the drug is
not marketed in either a conventional-release or MR dosage form.
r Group II—This group includes first market-entry MR dosage forms that are
developed after a conventional-release or a different kind of MR formulation
is marketed.
r Group III—This group includes second and subsequent market-entry (SME)
MR dosage forms that are developed to be bioequivalent to marketed MR
dosage forms.
This guidance mainly addresses Groups II and III. If the MR formulation
is the original market entry of the chemical substance (i.e., group I), selected PK
parameters must be determined as part of demonstrating the product’s efficacy
and safety.
For the assessment of first market-entry MR formulations (group I), stud-
ies must be performed using single-dose administration, both in subjects who
have fasted and in subjects who have eaten a meal standardized to challenge the
formulation. The following PK parameters should be calculated from the con-
centrations in plasma (or blood or serum): AUCX (dose interval), AUCT , AUCI ,
Cmax , Tmax , and ␭, the terminal slope.
For formulations that are likely to accumulate (i.e., AUCX /AUCI < 0.8),
demonstration of safety requires that steady-state studies be performed in addi-
tion to single-dose studies. The following PK parameters should be calculated
from the concentrations in plasma (or blood or serum):
r AUC␶ (steady-state dosage interval)
r Cmax
r Tmax
r Cpd (predose observed concentration)—The concentration observed immedi-
ately before administering a dose at or near steady state. This is not always
the same as Cmin
r Cmin
r Fluctuation (The range of steady-state concentrations divided by the average
concentration in percentage) (Cmax − Cmin )/(AUC␶ /␶ ) × 100
Where the AUCX /AUCI ratio cannot be reliably determined, accumulation
must be assumed to occur.
For group I products no standards are provided since the objectives are to
define the PK characteristics of the drug as background to the demonstration of
safety and efficacy for the NDS.
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For group II, first market-entry MR dosage forms, the same single- and
multiple-dose PK studies as already described for group I products are required.
The studies should be generally pursued in the context of demonstrating the
efficacy and safety of the recently developed drug product, and comparable
bioavailability should be demonstrated against an appropriate reference formu-
lation. The single-dose study should be a comparison between a single dose of
the first market-entry MR formulation and the doses of the innovator’s conven-
tional formulation that the MR formulation is intended to replace. (The doses
of the conventional formulation are administered according to the conventional
dosing regimen.) When identical doses of conventional and MR formulations
cannot be administered, a proportionality correction must be made for the cal-
culation of relevant parameters. Unless there are subject safety concerns, both
fasted and fed studies should be completed. In addition for group II products,
steady-state studies are required for formulations used at a dose interval likely to
lead to accumulation (AUCX /AUCI < 0.8 for the MR product). The comparison
should be made between the first market-entry MR formulation and equivalent
doses of the conventional formulation over the dosing interval (claimed for the
MR product) at steady state. Generally, steady-state studies should be performed
under fasting conditions unless subject safety might be compromised, in which
situation a fed study may be applied. In this case, manufacturers should consult
with Health Canada before undertaking a study.
The bioavailability standards below are suggested for group II products. It
should be noted that usually these types of products are supported by extensive
clinical trials and such information can justify results of comparative bioavail-
ability versus immediate-release reference that do not meet these standards (usu-
ally lower). The fed study is both an attempt to check for dose-dumping and to
provide labeling information.
Acceptance criteria suggested for group II products:
r AUC—The geometric mean ratio AUC of the MR formulation to the conven-
tional formulation should be between 80% and 125% in the fasting state.
The AUC may be evaluated by determining AUCT , provided that AUCT
obtained by the linear trapezoidal rule is at least 80% of the extrapolated AUCI
(i.e., AUCT /AUCI ≥ 0.80).
r Cmax —The geometric mean ratio of Cmax of a single dose of the MR formu-
lation to the conventional formulation should not exceed 125% in the fasting
state.
In some cases, the intended use of the MR formulation may call for a mod-
ification of the stated Cmax criterion. In such cases, before undertaking the
study, manufacturers should consult with Health Canada.

Suggested criteria for steady-state studies:

r AUC␶ —The relative mean AUC␶ (geometric mean ratio) at steady state of the
MR formulation to the conventional formulation should be between 80% and
125%.
r Cmax —The relative mean measured Cmax (geometric mean ratio) at steady
state of the MR formulation to the largest peak concentration of the conven-
tional formulation should not exceed 125%.
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If the MR formulation is a second or SME product (group III), developed

while marketed MR product(s) are already available, then BE studies must be
performed in healthy subjects, using an appropriate Canadian reference product.
Single-dose comparative studies, both in the fasted and in the fed state should be
completed and if there is accumulation (AUCX /AUCI < 0.8 for the MR product)
then steady-state comparative studies are required, usually only in the fasting
state.
The BE criteria for group III MR products are given below for single-dose
studies. The standards described later must be met for parameters calculated
from the observed concentrations, as well as those corrected for measured drug
content. [The latter is currently under consideration (20).]
r AUC—The 90% CI of the geometric mean ratio AUCa of the test to reference
formulation should be within 80% to 125% in the fasting state and after the
administration of an appropriate meal at a specified time before taking the
drug.
r Cmax —The geometric mean ratio Cmax of the test to reference formulation
should be between 80% and 125% in the fasting state and after the admin-
istration of a standardized meal to challenge the formulation.
For steady-state studies, the BE standards for group III MR products are as
follows:
AUC␶ —The 90% CI of the geometric mean ratio AUC␶ at steady state of the test
to reference formulation should be within 80% to 125%.
Cmax —The geometric mean ratio Cmax at steady state of the test to reference for-
mulation should be within 80% to 125%.
Cmin —The geometric mean ratio Cmin at steady state of the test to reference for-
mulation should not be less than 80%.

Modified-Release, Delayed-Release, or Enteric-Coated

For the special MR case of delayed release, the guideline, Part B, states that com-
parative bioavailability can usually be demonstrated using the AUC and Cmax
requirements for uncomplicated drug formulations, provided that the only dif-
ference between the enteric-coated formulation and the corresponding immedi-
ate release product is a time shift in the concentration–time curve (i.e., no other
modification of release occurs). Studies must be carried out using both subjects
that have fasted and those that have eaten an appropriate meal at a specified
time before taking the drug. The reference product for group III is to be the
innovator’s enteric-coated product (or the market leader’s enteric-coated prod-
uct if there is no recognized innovator). The general AUC and Cmax standards
above for immediate-release products are applied to both fasted and fed stud-
ies, with both the observed and drug-content corrected results [the latter under
consideration (20)]. For complicated drugs, the appropriate acceptance ranges, as
described in “Acceptance Ranges for Pharmacokinetic Parameters” section, will
be applied.

a AUC may be evaluated by determining AUCT , provided that AUCT obtained by the linear
trapezoidal rule is at least 80% of the extrapolated AUCI (i.e., AUCT /AUCI ≥ 0.80).
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Orally Administered Drug Products Intended for Local Action

The TPD does not have a class guidance for this type of product. Each drug
would be dealt with on a case by case basis. In most cases, unless there was
a pharmacodynamic surrogate, some type of comparative clinical trial would be
required.
Parenteral Solutions and Suspensions/Emulsions
There is a 1990 policy “submissions for generic parenteral drugs” (28), which lists
requirements for the four defined categories of parenteral products;
Category I products:
a. Water-soluble powders for reconstitution with no nonmedicinal ingredients.
b. Aqueous solutions, no nonmedicinal ingredients other than the vehicle; non-
aqueous single solvent solutions, other than oil preparations, no nonmedici-
nal ingredients other than the vehicle.
Category II: Products that include lyophilized powders, buffered powders, aque-
ous solutions, with nonmedicinal ingredients, nonaqueous solutions, other
than oil preparations, with nonmedicinal ingredients.
Category III products: Products include oil soluble preparations involving single
oil.
Category IV: Products include special products, such as suspensions, emulsions,
preparations involving cosolvent systems, MR preparations, special classes
of drugs and biological products.
Essentially, except for category I products, for which a biowaiver may be
given as described by the ICH guideline (based on pharmaceutical equivalence;
see “Solutions” section earlier in the chapter), comparative bioavailability studies
would be expected and the standards would be those of Part A guidance.
Topically Administered Drug Products
Topical Products for Local Action
There is a policy on “submissions for generic topical drugs” (29) dealing partic-
ularly with dermal–topical drug products, that is, those applied on the skin for
the purposes of achieving localized effects, for example, antiacne preparations.
Two categories for such products are defined here:
r Category I products of simple formulation, such as solutions containing the
drug substance in which the solvent does not include nonmedicinal ingredi-
ents that may affect the penetration/absorption of the drug through the skin
and Category II products of complex formulation, such as emulsions, suspen-
sions, ointments, pastes, foams, gels, sprays, and medical adhesive systems.
Category I products may not require clinical trials. In place of these trials,
extensive testing of physicochemical parameters in comparison to the innova-
tor’s product may be accepted as providing sufficient evidence of the safety
and efficacy of the generic product.
r Category II are products of complex formulation, such as emulsions, suspen-
sions, ointments, pastes, foams, gels, sprays, and medical adhesive systems.
Because of the complexity of Category II product formulation, extensive test-
ing of physicochemical parameters will not suffice to demonstrate safety and
efficacy. Direct evidence of safety and efficacy through clinical trials or via
surrogate models must be provided for these products.
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In view of the considerations that may apply to these products, a writ-

ten opinion on special requirements for individual products will be provided on
request, upon submission of chemistry and manufacturing data, and proposed
labeling. In general, well-controlled clinical trials are required to establish safety
and efficacy of the generic preparation.
The third category mentioned in this guidance are transdermal drug prod-
ucts discussed later in the chapter.

Topical Products Containing Topical Corticosteroids.

The policy quoted above (29) states that “the Vasoconstrictor assay which was
developed by McKenzie and Stoughton, has proved to be the most useful method
to compare topical corticosteroid products” and it seems to be accepted in
lieu of clinical trials for this type of product. (This is now more appropriately
called the HSBA.) There is a caveat remarked in the policy, “However, problems
may be faced in applying this method for BE testing since there is great vari-
ation in subject response and it is critical that it be carried out by experienced
investigators.”

Topical Products Other Than Those Containing Topical Corticosteroids

and Which are Not Simple Solutions
As noted in “Topical Products for Local Action” section, usually clinical trials
for equivalence would be required, but a written opinion can be obtained for an
individual product upon request.

Topical Products for Systemic Action

The policy for submissions for generic topical drugs (25) defines three types of
product, but only deals with the first of these. For BE of transdermal systems
(patches) for which the active is absorbed through the skin and is transported
by blood to sites of action, comparison of plasma levels is possible. BE of these
products is assessed by single-and multiple-dose studies against the Canadian
reference transdermal patch and the standards for group III MR (ER) products
described in “Topical Products for Local Action” section are applied.
There is a special policy on submissions for topical nonsteroidal anti-
inflammatory drugs (topical NSAIDs) (30), which have not been approved for
marketing in Canada, due to concern about drug sensitization. The policy out-
lined in this document was developed because TPD identified a risk of potential
sensitization to these products. The policy concentrates on handling this concern
and gives some guidance in the conduct of clinical studies (mainly by skin-patch
sensitivity tests) to help ultimately in assessing the risks versus benefits of each
product on its own merits. However the one topical NSAID (diclofenac), which
was accepted for marketing in Canada was on the basis of an approved review
of a full NDS.
In the consultation with stakeholders, the following response is of
interest

While the policy is intended for topical NSAIDs, the principles outlined
therein with respect to the safety issue of sensitization could be applied
to any topically administered product that has shown potential for
sensitization.
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Products Intended for Other Routes of Administration

These include oral products for local use, nasal, inhalation, dermal, rectal,
vaginal, etc. intended to act without systemic absorption where bioavailability
measurement of the active in a biological fluid is not applicable. Submission
guidelines indicate that clinical trials would be required for equivalence to be
determined between a Canadian reference and a generic product in this category
with the exception of short-acting ␤2 -agonists (albuterol) and corticosteroids, for
which there are specific guidances that are as follows:
Guidance to establish “Equivalence or Relative Potency of Safety and
Efficacy of a Second Entry Short-Acting Beta2 -Agonist Metered Dose Inhaler
(MDI)” (31) and Draft Guidance Document: Submission Requirements for Sub-
sequent Market Entry Inhaled Corticosteroid Products for Use in the Treatment
of Asthma (32)
The ␤2 -agonist metered dose inhaler (MDI) guidance (31) requires a safety
study and two pharmacodynamic studies in patients. Details of study design
for both the bronchodilator and bronchoprotection study are given. The bron-
chodilator study endpoint of test versus reference is measured by the magni-
tude and duration of increase in FEV1 (forced expiratory volume in one sec-
ond) and the acceptance standard set is that the 90% CIs for relative potency for
maximum FEV1 and the area under the FEV1 curve (AUFC) must be contained
entirely within 80% to 125%. Cardiovascular and other adverse effects with the
test product must not be significantly greater than that seen with the reference
product.
For the bronchoprotection study the relative potency is measured by the
magnitude of protection against methacholine airway constriction [PC20 metha-
choline (provocation concentration of a bronchoconstrictor agonist causing a 20%
fall in FEV1 )] for the test to reference product. The acceptance standard is that the
90% CI for the relative potency for test to reference PC20 methacholine must be
contained entirely within 80% to 125%. Also, cardiovascular and other adverse
effects with the test product must not be significantly greater than that seen with
the reference product.
For inhaled corticosteroids, there is a draft guidance (32) and again phar-
macodynamic and PK tests are recommended. For the therapeutic equivalence
study an adequately designed, well controlled, double-blinded, randomized
study is recommended in which asthmatic patients are randomized into three
parallel arms: Canadian reference product (R), SME product (T), and placebo
(formulation placebo). This will use sputum eosinophils as inflammatory mark-
err to see inflammatory and clinically significant improvement and/or to allow
time for the endpoints to plateau. Prebronchodilator FEV1 also should be esti-
mated. Very recently (June 2009, Ormsby CSPS presentation (20), it was noted
that the eosinophil measure would be the primary endpoint and FEV1 , as well as
blood nitric oxide would be supportive. The 80% to 125% standard would only
apply to the primary metric, but the FEV1 , as well as blood nitric oxide results
should go in the same direction (see footnote c). In both of the above guidances
(31,32), if the drug is detectable in blood plasma after dosing, systemic expo-
sure must be shown to be comparable between the test (T) and the reference (R)
products. This will be with the usual type of PK exposure data measured in BE
studies, following a single-dose study at the upper limit of the dosing range. The
BE standards for AUCT and Cmax are identical to those in the guideline, Part A
(see “Immediate-Release Products—Tablets and Capsules” section).
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There is also a Draft Guidance Document: Submission Requirements for

Subsequent Market Entry Steroid Nasal Products for Use in the Treatment of
Allergic Rhinitis (33)
It is noted that drug sponsors may be exempt from the requirement to
conduct comparative bioavailability, pharmacodynamic, and/or clinical studies
for SME drug products formulated as simple solutions, since in vitro studies
may provide sufficient information to support a proposal of equivalence to the
Canadian reference product. However, if the biowaiver justification for simple
solutions is not accepted as well as for more complex formulations, such as
suspensions and emulsions, determination of therapeutic equivalence with the
Canadian reference product will be required. This requires direct evidence of
comparative safety and efficacy, through well designed comparative clinical tri-
als with appropriate outcome measures, which must be provided to demonstrate
equivalence with the Canadian reference product. For most products, this would
require using the same clinical endpoint(s) with which the Canadian reference
product was granted a NOC. However, in certain instances alternate clinical
endpoints may be acceptable where advances in clinical medicine support that
these are commonly used and accepted for the therapeutic indication(s) of
interest at the time of application.
The clinical studies required to support equivalence of the SME product
with the Canadian reference product should also include a PK study for expo-
sure. The latter may be waived should blood or plasma levels be too low to
allow reliable analytical measurements. In such cases of lack of concentration
measurement, the equivalence for systemic exposure may be carried out by
measuring the steroid side effects on the hypothalamic–pituitary–adrenal axis
(HPA).
The following clinical study is required when using patients with seasonal
allergic rhinitis:
An adequately designed, well-controlled, double-blinded, randomized
study in which patients with seasonal allergic rhinitis (SAR) are randomized
into three parallel arms: Canadian reference product (R), SME product (T), and
placebo (formulation placebo).
An appropriate primary efficacy endpoint is the change from baseline in
the Total Nasal Symptom Score (TNSS) for the entire double-blind treatment
period (2–3 weeks). For therapeutic equivalence the criteria are the following
An absolute difference in TNSS mean change from baseline of at least one
unit on a 12-point scale should be demonstrated between test and placebo, using
all available data points. A change of less than one unit would be considered
insignificant on the 12-point TNSS scale. A percentage difference would be too
variable, dependent on both the baseline value and allergy season. The weighted
average of all scores’ (e.g., days 1–21) change from baseline for the SME product
(T) and CR product (R) must be significantly different from the placebo. Test and
reference should not be significantly different from one another. Test values can
be better but not worse than those of the reference product. To demonstrate the
BE of the test product compared with the reference product, the 90% CI of the
T/R ratio mean change of the TNSS from baseline (based on log transformed
data) must be within 80% to 125%.
If a PK exposure study (single-dose cross-over) is possible, the BE stan-
dards for AUCT and Cmax are identical to those in guideline Part A (see
“Immediate-Release Products—Tablets and Capsules” section).
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Variations or Postregistration Amendment Requirements

There is a Health Canada policy on changes to marketed new drug products (34),
which defines four levels of change and the required documentation.
Level 1, documented by a supplemental new drug submission (S/NDS),
includes changes in the dosage form or strength of the drug product, (and/or)
formulation, (and or) method of manufacture, (and/or) equipment, (and/or)
process control of the drug product that would usually require supporting clini-
cal or BE data.
Level 2, documented by notifiable change (Notice of Intention to Change)
may be a change of site, (and/or) method of manufacture or formulation and
would probably require BE to be demonstrated, except for cases of a waiver
noted elsewhere in the document.
Level 3, documented by notice of change, includes changes in packaging
materials, specifications and analytical methods and would not require BE stud-
ies. Level 4 are any other changes not listed in Levels 1 to 3 and which may be
made without notification, but manufacturers are expected to maintain a list of
Level 4 changes.
There is a Draft Guidance Document, Post-Notice of Compliance Changes:
Quality Document, issued in February, 2007 (35). It provides an Appendix 1 that
has examples intended to assist with the classification of changes made to the
quality information. The information summarized in the tables provides recom-
mendations for

a. the conditions to be fulfilled for a given change to be classified as a either a

Level, 1, 2, 3, or 4 change (above).
b. the supporting data for a given change, either to be submitted to Health
Canada and/or maintained by the sponsor. Where applicable, the corre-
sponding modules of the ICH CTD for the supporting data have been identi-
fied in brackets.
c. the reporting category (e.g., supplement, notifiable change, or annual notifi-
cation).

Examples of changes in drug products that may require supporting clinical

or comparative bioavailability data or a request for a waiver of in vivo studies
include the following:
r Addition of a dosage form or strength.
r Change in the composition of a solution dosage form.
r Change in the composition of an immediate release solid oral dosage form
containing a single drug substance.
r Change in the composition (qualitative or quantitative) in the release control-
ling agent of a MR solid oral dosage form.

WAIVERS OF IN VIVO BIOEQUIVALENCE STUDIES

Immediate Release Drug Products

Different Strength Dosage Forms
There is a policy (C.08.001.1.) on BE of proportional solid oral dosage formu-
lations (33) which states; “With some exceptions, it is generally accepted that
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when a product is marketed in more than one strength, if the formulation of each
strength contains the same ingredients in the same proportion (i.e. the formula-
tions are proportional), the results of a single comparative bioavailability study
can be extrapolated to all strengths in the series. Extrapolation becomes more dif-
ficult, however, when the proportion of ingredients changes among the strengths
or when there are pre- or post-marketing formulation changes. In general if dif-
ferent strengths are proportional in formulation, or have only ‘minor’ differences
in the proportion of ingredients, a comparative bioavailability study is required
for only one strength (preferably the highest).” Differences in proportion are con-
sidered to be “minor” when no strength within a range differs from a studied
strength, by more than the percentages listed in the policy for various classes
of excipients (e.g., <5% for filler, <0.25 for magnesium stearate as lubricant).
The total additive effect of all excipient changes should not be more than 5%.
Changes in coatings that are not designed to play a role in the drug release mech-
anism are also generally concluded to be “minor.” In all instances, if compara-
tive bioavailability data are not provided for each formulation, the sponsor must
provide scientific justification for a waiver of this requirement. This justification
will include dissolution using a validated QC method. In this regard, a validated
method is one that has been demonstrated to be sensitive to changes in formula-
tion and manufacturing, including the physicochemical attributes of formulation
ingredients, as documented in method development studies. In the absence of a
validated method, the comparative dissolution profiles should be determined in
three media, as described in “Choice of Reference Product—C.08.001.1.” section.
Media should be selected to emphasize possible differences between the prod-
ucts, for example, a medium in which the dissolution rate is relatively slow (e.g.,
pH of the medium close to the pKa value of the drug) may offer some advan-
tages. The percentage of drug content released should be measured at a number
of suitably spaced time points, for example, at 10, 20, and 30 minutes, and con-
tinued to achieve virtually complete dissolution. At least six dosage units of each
should be tested.
The policy applies only to drugs with uncomplicated characteristics as
defined in the guideline, Part A. Comparative bioavailability studies would
likely be required for all strengths of critical dose drugs for generic (or formula-
tion change) approval [see, Guideline Part A, Section 5.1 and may be considered
on a case-by-case basis, Ref. (36).]

Biopharmaceutics Classification System (BCS)

Health Canada has no formal guideline accepting the BCS, however sponsors can
argue for waivers for different strengths and minor changes, on a scientific basis,
including BCS principles. Use of BCS is implied in the Draft Guidance Document
Post-Notice of Compliance Changes: Quality Document (35).

Controlled/Modified-Release Dosage Forms

The policy on BE of proportional solid oral dosage formulations (36) also applies
to (possible waiver) MR dosage forms, as defined in the guideline, Part B, except
for ingredients that affect the release of drug from the formulation. Where differ-
ences exist in the proportion of ingredients that may affect the release, compar-
ative bioavailability studies are required for each different formulation. In par-
ticular, this possibility of a BE waiver would apply to capsules containing beads,
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with the BE study of higher strength allowing a waiver of an in vivo study for
lower strengths, if the appropriate quality attributes, including dissolution pro-
files are documented and appropriate.

CONCLUSIONS
While the general Canadian guidelines for BE have many similarities to the FDA
and European guidances, there remain differences that can cause difficulties in
submitting second entry products (generics) to TPD. The Canadian reference or
comparator situation in general still requires studies to be repeated if a foreign
reference has been used in an ANDS (3). This is in distinction to an NDS when
the company can provide full details of global strategy. The nonlinear draft guid-
ance (25) is different from other jurisdictions and often results in an additional
fed study being required for Canadian approval. The correction for potency is
still required (but note below). As yet, for biowaivers, the Canadian regulators
have not embraced the BCS, or at least made clear the tolerances for acceptance
using the approach. Clearly for oral dosage forms for systemic use, the guide-
lines are clear and comprehensive. Nonoral, locally acting drugs (such as dermal
or inhaled routes), with few exceptions require clinical trials. The exceptions are
when some relevant pharmacodynamic measures can be applied, such as with
corticosteroids [dermal (30) and inhaled (32)].
As has been noted, within the Health Canada, Therapeutic Products
Directorate, changes to the general guideline Ab are under consideration (20),
although, the draft for consideration has not been released at the time of writing
this chapter ( June 2009). The objective is a revision of the guideline Part A (7)
to remove ambiguities. It will also include Guideline Part B (8) for MR products
and attempt to integrate report C classes (10) as well as modifications of other
special guidancesc or policies on BE.
With the caveat that these are not yet final, the main points for change are
provided below:

r As noted in several sections of this chapter , the potency correction require-

ment will be removed, provided the certificates of analysis of test and refer-
ence products demonstrate that the drug content assay results are within 5%
of each other.

b Guidance 1 will combine current “Conduct and analysis” guidelines Parts A (1992) and B
(1996)—clarifies some positions and adds some new approaches. Guidance 2—defines classes
of drugs and their required studies and standards (Report C drugs, 1994).
c Guidance 3—data requirements and standards for inhaled corticosteroid products used in
the treatment of asthma. Use of steroid-naive patients with mild to moderate asthma, and
3% eosinophil count and FEV1>60%. Three-treatment (reference, test, and placebo) parallel
study design for three weeks by using the lowest dose of the Canadian Reference Product and
eosinophil recommended as primary outcome measure (also FeNO, FEV1). Secondary mea-
surements (FEV1, asthma symptoms) where both test and reference must be 50% over placebo
(% change from baseline). Test versus Reference 90% CI between 80% and 125% and systemic
absorption test to reference must meet usual BE standards. Guidance 4—data requirements
and standards for nasal steroid products.
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r Add-on studies will continue to be allowed (with a 12 subject minimum) but

the requirement for consistency tests will be removed and there will be an
adjustment to keep the error rate at 5%.d
r Sequential designs can be accepted when the variation and expected mean
differences are uncertain.e , f Clearly, the design would be a priori and appro-
priate statistical aspects would need to be included.
r Despite the existence of a draft guidance on the use of metabolite data (15),
it is still unclear when metabolite data can be used to determine BE. How-
ever, whenever possible the drug administered should be measured and used
for BE decisions. If this is not possible, then measurements of a metabolite
(preferably primary) could be applied to BE decisions. The use of metabolite
must be justified and stated in the study protocol. Metabolite results can be
applied as a covariate.
r The draft policy on nonlinear PK drugs (25) was never finalized, it states that
nonlinearity could be determined from the literature and that for nonlinear
products, fed, as well as fasted BE studies must be run. The proposal is that
if the reference (innovator) product monograph states clearly the type of non-
linearity, the appropriate dose should be used for BE comparison and a fed
study will not be required.
r Although there is guidance on food studies (14) it is not entirely clear. Fed
(and fasted) studies will continue to be required for MR products. However,
the reference (innovator) product monograph information on food effect (or
lack thereof) will be used to decide when a fed study will be required (instead
of or in addition to the fasted study).
r The requirement for steady-state studies for extended-release product BE
comparisons will be removed.
r Currently the statistical analysis (7,8) recommends least squares analysis
using ANOVA with fixed effects (e.g., PROC GLM); the proposal is to apply
mixed-effects methodology (e.g., PROC MIXED). The mixed-effects model
analyses all types of cross-over designs and handles missing values, such as
when a subject misses one period.g
r There is consideration for dealing with extreme values indicated as “subjects
which give statistically significantly larger differences that other subjects but

d For “add-ons”—consideration being given to use a Bonferroni adjustment to keep error rate
at 5% and remove consistency tests.
e Sequential design being considered when variation and expected mean differences are uncer-
tain, viz, expected CV and mean difference to be stated, total N determined from table, decla-
ration of n < N where interim analysis will be performed; 93% CI to be applied as penalty for
stopping early and BE accepted. N.B. All Must Be Defined in Study Protocol.
f Adaptive designs, similar to sequential design being considered to allow re-estimation of sam-
ple size based on observed CV of the new study, viz, estimation of expected CV and mean
difference and determination of sample size N; n < N to be defined where interim analysis
will be performed; reestimation of sample size required based on observed CV. N.B. Must Be
All Defined in Study Protocol.
g More flexibility to be provided in analysis using mixed effects methodology (e.g., Proc mixed
in SAS) since mixed effects models analyze all types of cross-over designs (replicate) and han-
dles missing values, that is, when subject misses one period; per-protocol analysis not intent-
to-treat analysis being considered.
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92 McGilveray

still give well-characterised profiles i.e., not caused by poor placement of sam-
pling times.” Currently (7) (but very rarely) 5% of subjects can be removed
with justification. The proposals include application of nonparametric 90%
CIs or allowing removal of identified extreme values from an acceptable out-
lier test after retesting the subject(s) identified with both test and reference
formulations. The reanalysis with new values would indicate if the outliers
can be removed. If the subject continues to show up as an outlier, there is a
problem.h
r Incurred sample analysis will not be required for BE studies, but in bioanalyt-
ical method development the “reproducibility of samples must be shown to
be adequate for the intended purpose.”
Some other areas to be considered are the following:
r Highly variable drugs and drug products (HVDP)i
r Definition of an “acceptable plasma profile”
r Dealing with endogenous substances, for example, adjusting for baseline
r How best to analyze urinary excretion data when concentrations in blood or
its components are too low to be quantified for BE assessment.

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h Consideration being given to define an outlier as a value which is 3 standard deviations away
from mean; does not overlap with other observations; has a studentized residual greater than
at the 0.02 level. Two approaches to deal with outlier, viz, construction of a nonparametric
90% CI or two allowance of removal of identified subjects’ data after retesting subjects with
both formulations and new results not identified as outliers using same approach. These con-
siderations are based on the premise that cause of extreme values unlikely to be formulation
related.
i HVDPs defined as drugs where intrasubject CV of AUC and/or Cmax greater than 30%. Rec-
ommendations being considered, viz: outlier analysis to be done; adjustment of bioequiva-
lence interval (BI) as a function of the intrasubject CV in a stepwise manner as CV increases,
for example, if observed CV from study is between 30% and 39% BI will be 77% to 130% and
likewise if observed CV from study is between 60% and 69% BI will be 61 to 160%, which will
allow sample sizes to be significantly reduced while retaining 80% power and means at 100%.
Intention to provide consistent decision-making for same Canadian Reference Product from
different sponsors.
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7. Guidance for Industry. Conduct and Analysis of Bioavailability and Bioequivalence

Studies—Part A: Oral Dosage Formulations Used for Systemic Effects. Health
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8. Guidance for Industry. Conduct and Analysis of Bioavailability and Bioequiva-
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bio-b-eng.php. Accessed September 2008.
9. Draft guidance for industry Preparation of Comparative Bioavailability Infor-
mation for Drug Submissions in the CTD Format. Health Canada, May 2004.
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istration of pharmaceuticals for human use ICH harmonised tripartite guideline for
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12. Guidance for clinical trial sponsors: Clinical Trial Applications Health Canada, June
2003. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/
clini/ctdcta ctddec-eng.php. Accessed September 2008.
13. Draft guidance CTAs for Comparative Bioavailability Studies. Health Canada, 2001.
http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/bio/
ctabio decbio-eng.php. Accessed September 2008.
14. Guidance for industry. Bioequivalence Requirements: Comparative Bioavailability
Studies Conducted in the Fed State, Health Canada, June 2005. http://www.
hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/bio/fedstate
sujetsjeun-eng.php. Accessed September 2008.
15. Draft guidance for industry Use of Metabolite Data in Comparative Bioavail-
ability Studies, Health Canada, May 2004. http://www.hc-sc.gc.ca/dhp-mps/
prodpharma/applic-demande/guide-ld/bio/draft ebauche metabolites-eng.php.
Accessed September 2008.
16. Shah VP, Midha KK, Dighe SV, et al. Analytical methods validation: Bioavailability,
bioequivalence and pharmacokinetic studies (Conference report), Pharm Res 1992:
9(4):588–592.
17. Shah VP, Midha KK, Findlay JWA, et al Workshop/Conference Report, bioanalytical
method validation—a revisit with a decade of progress. Pharm Res 2000; 17:1551–
1557.
18. Notice to industry: Removal of Requirement for 15% Random Replicate Sam-
ples, Health Canada, 2003. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-
demande/guide-ld/bio/15rep e.html. Accessed September 2008.
19. Guidance for Industry. Stability Testing of New Drug Substances and Products ICH
Topic Q1A(R2), Health Canada. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/
applic-demande/guide-ld/ich/qual/q1a(r2)-eng.php. Accessed September 2008.
20. (i)Presentation by Eric Ormsby (Health Canada) to the Canadian Society of Pharma-
ceutical Scientists Annual Meeting, Banff, Alberta, May 24, 2008. (ii) Presentation by
Eric Ormsby (Health Canada) to the Canadian Society of Pharmaceutical Scientists
Annual Meeting, Toronto, Ontario, June 6, 2009.
21. Notice to industry: Bioequivalence Requirements for Long Half-life Drugs.
Health Canada, June 2005. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-
demande/guide-ld/bio/notice longhalflife avis longuedemivie-eng.php. Accessed
September 2008.
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22. Guidance for industry, Bioequivalence Requirements: Critical Dose Drugs, Health
Canada, May 2006. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-
demande/guide-ld/bio/critical dose critique-eng.php. Accessed September 2008.
23. Notice to industry. Bioequivalence Requirements for Drugs for Which an Early
Time of Onset or Rapid Rate of Absorption Is Important (rapid onset drugs).
Health Canada, June 2005. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-
demande/guide-ld/bio/notice rapidonset avis apparitionrapide-eng.php. Accessed
September 2008.
24. Notice to industry: Bioequivalence Requirements for Combination Drug Products,
Health Canada, June 2005. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-
demande/guide-ld/bio/notice avis comb-eng.php. Accessed September 2008.
25. Draft policy on Bioequivalence Requirements: Drugs Exhibiting Non-Linear
Pharmacokinetics, Health Canada, July 2003. http://www.hc-sc.gc.ca/dhp-mps/
prodpharma/applic-demande/pol/nonlin pol-eng.php. Accessed September 2008.
26. Guidance for industry, Pharmaceutical Quality of Aqueous Solutions. Health
Canada, February 2005. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-
demande/guide-ld/chem/aqueous aqueuses-eng.php. Accessed September 2008.
27. Drugs Directorate Guidelines, Preparation of drug identification number sub-
missions, Health Canada, 1995. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/
applic-demande/guide-ld/din/pre din ind-eng.php. Accessed September 2008.
28. Policy issue “Submissions for generic parenteral drugs”, Health Canada, 1990.
http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/pol/gen subm
pres pol-eng.php. Accessed September 2008.
29. Policy issue Submissions for generic topical drugs, Health Canada, 1990. http://
www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/pol/gener pol-eng.php.
Accessed September 2008.
30. Policy on Submissions for Topical Non-Steroidal Anti-inflammatory Drugs (Top-
ical NSAID’s). http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/
pol/topnsaids ainstop pol-eng.php. Accessed September 2008.
31. Guidance to establish Equivalence or Relative Potency of Safety and Efficacy
of a Second Entry Short-Acting Beta2-Agonist Metered Dose Inhaler (MDI).
http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/inhal-
aerosol/mdi bad-eng.php. Accessed September 2008.
32. Draft Guidance Document: Submission Requirements for Subsequent Market
Entry Inhaled Corticosteroid Products for Use in the Treatment of Asthma, May
2007. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/
inhal corticost-eng.php. Accessed September 2008.
33. Draft guidance document Submission Requirements for Subsequent Market Entry
Steroid Nasal Products for Use in the Treatment of AllergicRhinitis. http://www.hc-
sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/nas rhin-eng.php. Ac-
cessed September 2008.
34. Health Canada Policy Issues From the Drugs Directorate Changes to marketed new
drug products, April 1994. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-
demande/pol/changmar nd dn pol-eng.php. Accessed September 2008.
35. 5 Post-Notice of Compliance Changes: Quality Document, July 2006. http://www.
hc-sc.gc.ca/dhp-mps/prodpharma/activit/proj/post-noc-apres-ac/noc postnotice
ac apreavis-eng.php. Accessed September 2008.
36. Health Canada Policy issue from the drugs directorate Bioequivalence of Propor-
tional Formulations: Solid Oral Dosage Forms, March 1996. http://www.hc-sc.gc.ca/
dhp-mps/prodpharma/applic-demande/pol/bioprop pol-eng.php. Accessed Sep-
tember 2008.
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5 The European Union

Roger K. Verbeeck
School of Pharmacy, Catholic University of Louvain, Brussels, Belgium; and Faculty
of Pharmacy, Rhodes University, Grahamstown, South Africa

Joelle Warlin
Federal Agency for Medicines and Health Products, Brussels, Belgium

INTRODUCTION
The generic drug product market is projected to grow from US $15 billion in
2004 to US $27 billion in 2009 in the United States, and from US $9 billion to
US $14 billion in Western Europe (1). Moreover, the growth opportunities for
generic drug products in the near future are significant with an estimated US
$100 billion worth of branded pharmaceutical products to go off patent by 2010
(1). The substantial growth of the world generics drug market has been driven
by a number of factors, but in particular the need to contain public health care
spending, including the expenditure on drug products. In response to the impor-
tant growth of the generic pharmaceutical industry during the last 10 to 15 years,
regulatory agencies in countries all over the world, such as the Food and Drug
Administration (FDA) in the United States, Canada’s Health Products and Food
Branch (HPFB), and the European Medicines Agency (EMEA) in the European
Union (EU), have established requirements which must be met by a generic drug
product to receive marketing authorization (2,3).
The EU offers four routes for the registration of generic drug products: (i)
a national procedure, (ii) a mutual recognition procedure (MRP), (iii) a decen-
tralized procedure (DCP), and (iv) a centralized procedure (CP) (4). The national
procedure may lead to marketing authorization of the generic drug product in
the concerned member state. This national procedure is still being used, but
is strictly limited to medicinal products that are not authorized in more than
one member state. The MRP is based on the principle of mutual recognition of
national authorizations and, therefore, provides for the extension of marketing
authorizations granted to one member state, the so-called reference member state
(RMS), to one or more member states identified by the applicant. Since Novem-
ber 2005, the applicant may make use of the DCP and submit an application to
each of the member states where it is intended to obtain a marketing authoriza-
tion and choose one of them as the RMS. The RMS prepares a draft assessment
report and collects all comments received from the concerned member states that
are forwarded to the applicant. Further steps are managed by the RMS to reach
a consensus and to finalize the procedure.
Since 2004, it is possible to apply for marketing authorization of medici-
nal products in the EU by using the CP. According to this procedure, a single

95
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96 Verbeeck and Warlin

application is introduced by the applicant and is subject to a single evaluation.

The scientific evaluation of this latter type of application is carried out within the
Committee for Medicinal Products for Human Use (CHMP) of the EMEA and is
valid throughout the EU and confers the same rights and obligations in each of
the member states.a
Although the requirements for the approval of generic drug products may
still differ among countries, one or more comparative bioavailability studies
showing bioequivalence (BE) between the generic drug product and a reference
product usually constitute an important part of the information requested by the
regulatory agencies of most countries for marketing authorization. In addition,
as for all medicinal products, the applicant must demonstrate that the manufac-
turing process leads to a generic product of sufficient and reproducible quality
which will be maintained for the entire duration of its shelf-life.
The concept of BE and the methodology to assess BE have evolved over
the past several decades. The first “European” BE guidelines were published in
1991 by the Commission of the European Communities in an attempt to harmo-
nize the registration of generic drug products in the various member states of the
European Community (EC), which has been called the EU following the Treaty
of Maastricht in 1993 (5). Until the publication of this first Note for Guidance
related to BE assessment, generic drug products were registered by the national
authorities of the member states. In those days, the registration dossiers were not
comprehensive and the assessment was based according to principles published
in the scientific literature, FDA guidelines, and the first European guidelines on
pharmacokinetic studies in man (6). In 1995 the EMEA, a decentralized body of
the EU with headquarters in London, was established. Its main responsibility is
the protection and promotion of public and animal health through the evalua-
tion and supervision of medicines for human and veterinary use. In 2001, the
EMEA Committee of Proprietary Medicinal Products (CPMP) published the cur-
rent version of the Note for Guidance on the Investigation of Bioavailability and
Bioequivalence (7).
This chapter provides a short overview of the EMEA Guidelines on
Bioavailability and Bioequivalence studies for generic drug products and
includes comments on a few of the controversial issues regarding these guide-
lines. Two main Notes for Guidance, prepared by the CHMP of the EMEA, are
currently operational: (i) the Note for Guidance on the Investigation of Bioavail-
ability and Bioequivalence that came into effect in January 2002, and (ii) the
Note for Guidance on Modified Release Oral and Transdermal Dosage Forms:
Section II (Pharmacokinetic and Clinical Evaluation), which came into operation
in January 2000 (7,8). The complete text of these guidelines can be consulted
and downloaded from the EMEA website (http://www.emea.europa.eu). The
objective of these guidelines is to define, for medicinal products with a systemic
effect, when in vivo BE studies are necessary and to formulate requirements for
their design, conduct, and evaluation. After the current Note for Guidance on

a Norway, Iceland and Liechtenstein form the European Economic Area (EEA) with the 25 mem-
ber states of the EU. These countries have, through the EEA agreement, adopted the complete
EU acquis on medicinal products and are consequently parties to the EU procedures. Where in
this text reference is made to member states of the EU this should be read to include Norway,
Iceland and Liechtenstein.
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The European Union 97

the Investigation of Bioavailability and Bioequivalence came into effect (January

2002), it appeared that some harmonization regarding the interpretation of
critical parts of the guideline was needed. As a result, a Questions & Answers
document was published in 2006 by the CHMP Efficacy Working Party (EWP),
which clarifies some of the critical parts of this EMEA guidance (9). A revised
version of the current BE guidelines for oral, immediate release drug products
with systemic action has been in preparation for some time by the CPMP efficacy
working party on pharmacokinetics (EWP-PK) of the EMEA. The draft version
of this revision of the BE guidelines, entitled Guideline on the Investigation
of Bioequivalence, was made publicly available in August 2008 on the EMEA
website and a modified version will probably come into effect in 2010 (10).
The application for marketing authorization of a generic drug product, the
so-called “generic” application, is an abridged application because the applicant
is neither required to provide the results of pharmacological or toxicological tests
nor the results of clinical trials if it can be demonstrated that the medicinal prod-
uct is essentially similar to a product that has been authorized within the commu-
nity (i.e., the member states of the EU plus Norway, Iceland, and Liechtenstein)
for not less than 6 to 10 years and is marketed in the member state for which
the application is made (4). According to the EMEA Note for Guidance on the
Investigation of Bioavailability and Bioequivalence (7):
A medicinal product is essentially similar to an original product where it
satisfies the criteria of having the same qualitative and quantitative com-
position in terms of active substances, of having the same pharmaceutical
form, and of being bioequivalent unless it is apparent in the light of scien-
tific knowledge that it differs from the original product as regards safety
and efficacy.

The Note for Guidance further explains (7)

By extension, it is generally considered that for immediate release prod-
ucts the concept of essential similarity also applies to different oral forms
(tablets and capsules) with the same active substance.

As pointed out in the EMEA Note for Guidance on the Investigation

of Bioavailability and Bioequivalence, demonstration of BE is generally the
most appropriate method of substantiating therapeutic equivalence between
medicinal products, but for pharmaceutical alternatives containing a different
salt or ester of the active substance, additional safety data may be needed in
some cases (7,11).

ORAL IMMEDIATE RELEASE DOSAGE FORMS WITH SYSTEMIC ACTION

BE studies are clinical studies involving human subjects and, therefore, must fol-
low regulations on good clinical practice (GCP). The design, conduct, and evalu-
ation of BE studies for oral immediate release dosage forms intended to act, fol-
lowing absorption of the active moiety into the systemic circulation are described
in the Note for Guidance on the Investigation of Bioavailability and Bioequiv-
alence (7). In what follows, a brief description of the important aspects of BE
studies for oral immediate release dosage forms as laid out in this guidance will
be presented together with some critical comments and comparisons with the
BE guidelines of other countries such as Canada and the United States. Where
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98 Verbeeck and Warlin

necessary, reference will be made to the new revised EMEA Guideline on the
Investigation of Bioequivalence but it should be kept in mind that, at this stage,
it is only a draft version (10).

Study Design
For many drugs a large intersubject variability in pharmacokinetic parameters,
such as the extent of absorption (F), the apparent volume of distribution (V),
and plasma clearance (CL), is generally observed. The intrasubject variability
usually is substantially smaller than the between-subject or intersubject variabil-
ity and, therefore, a cross-over design is generally recommended for BE stud-
ies (12,13). The EMEA Note for Guidance on the Investigation of Bioequiva-
lence and Bioavailability is clear in this regard and recommends a two-period,
two-sequence cross-over design, with random allocation of the subjects to each
sequence, when comparing the bioavailability of two medicinal products (7).
Other study designs may be acceptable, such as a parallel study design for
long half-life substances and replicate designs for substances with highly vari-
able pharmacokinetics (14). In the case of a cross-over design, treatments should
be separated by a sufficiently long washout period (usually at least five times the
terminal plasma half-life of the active drug substance or its metabolites) to ensure
that all of the drug and/or its metabolite(s) has been cleared from the body prior
to the time of the subsequent administration.
The number of subjects required for a BE study should ideally be estimated
at the design stage and is determined by (i) the error variance (␴ 2 ) of the primary
BE metrics to be studied, (ii) the significance level (␣), (iii) the expected deviation,
with respect to the primary BE metrics, between the two formulations which is
considered compatible with BE (e.g., ± 20% for AUC), and (iv) the required sta-
tistical power (15,16). An estimate of the error variance can be obtained from
the published literature, a previous BE study, or by undertaking a pilot study.
Nomograms of the number of subjects required for various ratios of the expected
means for test and reference products and various intrasubject coefficients of
variation have been published by Diletti et al. (15,17). The guidance document of
Canada’s HPFB allows an add-on study (stated a priori in the protocol) when the
results from the first study fail to reach the required power, under the condition
that appropriate statistical tests validate the analysis of the combined data (18).
The draft version of the revised EMEA Guideline on the Investigation of Bioe-
quivalence includes a recommendation regarding under which circumstances a
sequential design (a so-called two-stage approach) may be used (10).
For oral immediate release dosage forms the EMEA guidance favors a
study where a single dose is taken on an empty stomach, that is, following
an overnight fast, with a fixed volume of fluid (at least 150 mL). However, if
it is recommended in the summary of product characteristics (SPC) that the
reference medicinal product should be taken with a meal, the BE study should be
carried out under fed conditions if the recommendation of food intake has any
pharmacokinetic implications such as a higher bioavailability (9). All subsequent
meals and drinks as well as other test conditions (e.g., posture during the first
few hours following intake of the medicinal products, physical activity, etc.)
should be standardized to minimize the variability in the bioavailability metrics
unrelated to a possible difference in the formulations. For the same reason of
minimising variability, BE studies are recommended to be carried out in healthy
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The European Union 99

volunteers, of either sex, between 18 and 55 years old having a normal body
weight based on body mass index, preferably nonsmokers, and without a history
of alcohol or drug abuse. For an active substance known to be subject to major
genetic polymorphism in its metabolic elimination, phenotyping/genotyping
“should be considered” according to the EMEA Note for Guidance on the
Investigation of Bioavailability and Bioequivalence when using a parallel design
(7). Phenotyping/genotyping “may be considered” as well for crossover BE
studies for safety or pharmacokinetic reasons (7). Indeed, plasma concentra-
tions of an active substance that is a substrate for an enzyme showing genetic
polymorphism may be much higher and half-lives much longer in poor metab-
olizers, thus necessitating longer sampling schedules compared to extensive
metabolizers (19).
Although, in general, a single-dose study will suffice to show that a generic
drug product is bioequivalent to an approved reference product, according to the
EMEA Note for Guidance on the Investigation of Bioavailability and Bioequiv-
alence there are situations in which steady-state studies may be required or can
be considered (7). These situations may include BE studies for active substances
undergoing dose- or time-dependent kinetics, or for active substances with high
intraindividual variability for which it may be difficult or even impossible to
demonstrate BE in a reasonably sized single-dose study. In addition, steady-state
studies can be considered when problems of analytical sensitivity preclude suf-
ficiently precise measurement of analyte plasma concentrations after single-dose
administration. According to the revised EMEA Guideline on the Investigation
of Bioequivalence, a multiple-dose study as an alternative to a single-dose study
may also be acceptable if problems of sensitivity of the analytical method pre-
clude sufficiently precise plasma concentration measurements after single-dose
administration. However, if possible, Cmax should be determined as a measure
of peak exposure following administration of the first dose of the multiple-dose
study. AUC, a measure of extent of exposure, should be determined at steady
state. Moreover, in a multiple-dose BE study the administration scheme should
preferably follow the highest usual dosage recommendation (10).
Post hoc exclusion of outliers based on pharmacokinetic or statistical rea-
sons alone is not accepted (7,9). Nonstatistical reasons to exclude the data
of a particular subject from the final statistical analysis should have been
prospectively defined in the protocol, or according the EMEA Questions &
Answers document on the bioavailability and BE guideline: “. . . at the very
least, established before reviewing the data.” Acceptable explanations to exclude
pharmacokinetic data or to exclude a subject from the final statistical anal-
ysis would be protocol violations such as vomiting, diarrhoea, analytical
failure, etc.

Reference and Test Products

In a BE study which is carried out as part of an application for marketing
authorization of a generic medicinal product, the bioavailability of the generic
product (test) is compared to the bioavailability of an innovator medicinal
product (reference). The batches of the test and reference product used in the
BE study are called the “biobatches.” The requirements for the test product used
in the BE study are clearly spelled out in the EU guidance. The test product
should usually originate from a batch of at least 1/10 of production scale or
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100,000 units, whichever is greater, unless otherwise justified. As far as the

reference product is concerned, the EMEA guidance specifies that the choice of
the reference product should be justified by the applicant. The reference product
should normally be the innovator, a medicinal product authorized on the basis
of a full dossier. When the innovator is no longer on the market, the product that
is the market leader may be used as the reference product provided that it has
been authorized for marketing and its efficacy, safety, and quality have been fully
established and documented. In the case of a MRP, application for marketing
authorization to numerous member states based on a BE study with a reference
product from one member state, that is, the RMS, can be made. In general, the
qualitative and quantitative composition of the reference product is the same in
all the member states of the EU. However, if the reference products marketed
in the various member states slightly differ in terms of qualitative/quantitative
composition of the excipients as well as the manufacturing process, extrapolation
of the results of the BE study carried out with the reference medicinal product
marketed in one particular member state to BE claims in comparison to reference
products marketed in the other member states is not always straightforward.
Comparative in vitro dissolution profiles between the reference product used in
the BE study and the one registered and marketed in the member state where
marketing authorization is requested may be asked by the assessors. The in vitro
dissolution method should be discriminating and in accordance with the phar-
macopoeial requirements. The in vitro dissolution profiles may be compared by
calculating an f2 similarity factor. An f2 value between 50 and 100 suggests that
the two dissolution profiles are similar. Alternative methods to prove similarity
of dissolution profiles are accepted as long as they are justified. In cases where
more than 85% of the drug is dissolved within 15 minutes, dissolution profiles
are considered to be similar without further mathematical evaluation. In cases
where the composition and/or the manufacturing process of the reference
product used in the BE study compared to the reference product registered and
marketed in the member state(s) where marketing authorization is requested dif-
fer to such an extent that the bioavailability may be affected, a BE study with the
latter may be requested. The EMEA Note for Guidance on the Investigation of
Bioavailability and Bioequivalence, however, is not very helpful in this regard:

Concerned Member States may request information from the first Mem-
ber State on the reference product, namely on the composition, manu-
facturing process and finished product specification. Where additional
bioequivalence studies are required, they should be carried out using
the product registered in the concerned Member State as the reference
product.

Indeed, no indication whatsoever is given as to the nature and/or impor-

tance of the differences in composition and manufacturing process between ref-
erence products marketed in the various member states that would necessitate
a new BE study. Perhaps a series of guidelines such as those issued by the FDA
in the case of scale-up and postapproval changes (SUPAC) would be helpful to
decide when an additional BE study between the generic product versus the
reference medicinal product registered in a particular concerned member state
would be required (20). Although the EMEA Note for Guidance on the Inves-
tigation of Bioavailability and Bioequivalence suggests that in vitro dissolution
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studies can be used as “bioequivalence surrogate inference” to demonstrate sim-

ilarity between the reference products from different member states, they cannot
replace for most active substances an in vivo BE study unless an in vitro/in vivo
correlation (IVIVC) has been demonstrated (21,22).

BE Metrics
The area under the plasma (serum, blood) concentration of the parent compound
versus time curve (AUCt , AUC∞ ) generally serves as a measure of the extent of
absorption. Tmax and the corresponding maximum plasma concentration, Cmax ,
may serve as characteristics of the rate of absorption. However, it should be
emphasized that Cmax is not a pure measure of absorption rate but is confounded
with the extent of absorption (23). Urine excretion data may also be used to
determine the extent of absorption provided elimination is predominantly renal
as intact drug substance and is dose proportional (7,9). In the revised EMEA
Guideline on the Investigation of Bioequivalence the condition that “elimination
is dose-linear and is predominantly renal as intact drug” is no longer mentioned
(10). However, the use of urinary data has to be carefully justified when used to
estimate the rate of absorption (9,10,24).
AUC∞ , the area under the curve extrapolated to infinity, can only be reli-
ably measured if the terminal plasma half-life can be accurately determined,
which is not always the case. AUCt , the area under the curve from the time of
administration to the last measurable plasma concentration at time t, is there-
fore considered to be the most reliable measure of the extent of absorption
provided that it covers at least 80% of AUC∞ . Literature data support the
notion that BE assessment for long half-life drugs is not adversely affected by
using truncated AUC (25–29). Blood sampling time in this case should be suf-
ficiently long to ensure completion of gastrointestinal transit of the drug prod-
uct (approximately two to three days) and consequently the absorption pro-
cess of the drug substance. The Canadian HPFB guidelines, for example, accept
AUC0–72 , the AUC from time 0 to 72 hours following administration, as a mea-
sure of extent of absorption for drug substances with a half-life of more than
12 hours (30).

Moiety To Be Measured: Parent Drug Versus Metabolite(s)

In most cases the evaluation of BE should be based on the measurement of
plasma concentrations of the parent compound. The rationale for this approach
is that the concentration–time profile of the parent drug is more sensitive to
changes in formulation performance than that of the metabolite, which includes
the processes of metabolite formation, distribution and elimination. However,
according to the EMEA Note for Guidance on the Investigation of Bioavailability
and Bioequivalence: “In some situations, however, measurements of an active
or inactive metabolite may be necessary instead of the parent compound.” A
clear consensus on the role of metabolites for the assessment of BE has not
yet been achieved within the scientific community (31–33). This is reflected in
the different views expressed in the current national and international regula-
tory guidelines concerning the role of the measurement of metabolites in BE
assessment. According to the EMEA Note for Guidance on the Investigation
of Bioavailability and Bioequivalence, measurement of metabolites is required
to assess BE between two medicinal products in the following cases: (i) if the
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concentration of the parent compound is too low to be accurately measured and

(ii) if the parent compound is unstable in the biological matrix or its half-life is
too short (7). The same guidelines further state:
In particular if metabolites significantly contribute to the net activity of an
active substance and the pharmacokinetic system is non-linear, it is neces-
sary to measure both parent drug and active metabolite plasma concentra-
tions and evaluate them separately.

The most recent version of the general BE guidance from the FDA requests
that only the parent compound should be measured to assess BE (34). Only when
a metabolite is formed as a result of gut wall or other presystemic metabolism
and the metabolite contributes to safety and efficacy is the metabolite measured
to provide supportive evidence. In all other instances only the parent compound
is measured for BE. According to the guidelines of Canada’s HPFB, the determi-
nation of BE is based on measurement of the active ingredient, or its metabolite,
or both, as a function of time (18). They further specify that normally measure-
ment of the parent compound is sufficient but in some cases measurement of
the metabolite could be required. For example, when a prodrug is administered,
the active metabolite should be measured. The Questions & Answers document
on the Bioavailability and Bioequivalence Guideline which were recently formu-
lated by the CHMP Efficacy Working Party of the EMEA, also deals with the
issue when metabolite data should be used to establish BE (9). This document
stipulates that metabolite data can only be used if the applicant presents state-
of-the-art evidence that measurements of plasma concentrations of the parent
compound are unreliable. In addition, it is pointed out that Cmax of the metabo-
lite is less sensitive to differences in the rate of absorption than Cmax of the parent
compound:
Therefore, when the rate of absorption is considered of clinical importance,
bioequivalence should, if possible, be determined for Cmax of the parent
compound if necessary following administration of a higher dose. (9)

In their excellent review of the topic of measurement of metabolites for

BE assessment, Jackson et al. conclude that the parent compound is the entity
most sensitive to formulation changes (31,33). The continuing belief by some that
activity is important and should be considered for BE assessment is the major
reason for most of the controversy regarding metabolite measurement. Another
argument for using metabolites in BE assessment is that metabolite concentra-
tions are generally associated with a lower intrasubject variability and conse-
quently their use allows a decrease in the number of subjects required to estab-
lish BE. However, analysis of both parent drug and metabolite to assess BE is
problematic since it would decrease Type I error (consumer risk) and increase
Type II error (producer risk) (33).

Calculation of Confidence Interval and Acceptance Limits

Estimation of BE is based on the “two one-sided tests” procedure (35) in which
the 90% confidence interval (CI) around the geometric mean ratio of the test
and reference values of an appropriate bioavailability measure, such as AUC or
Cmax , is required to fall within preset BE limits. One of the important objectives
of BE testing is to assure that two medicinal products containing the same
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active substance are interchangeable in any individual patient. For this reason,
the “two one-sided tests” procedure is based on the intrasubject variability
that is commonly estimated from the mean square error (MSE), also called the
residual mean square, of an analysis of variance in which the fixed effects are
typically formulation, period, sequence, and subject nested within sequence.
The intrasubject variability can be estimated from the MSE by calculating the
CVanova (ANOVA coefficient of variation) as follows:
 
CVanova (%) = e MSE − 1 100

The width of the 90% CI depends on the magnitude of MSE and the number
of subjects in the BE study. Active substances whose AUC and Cmax show a high
intrasubject variability have high values for CVanova (>30%) and are called highly
variable drugs (HVDs). The larger the CVanova , the higher the number of subjects
required to give adequate statistical power (16,17).
The usual acceptance limit for the 90% CI around the geometric mean ratio
for AUC and Cmax , that is, 0.80 to 1.25 (or 80–125%), is based on a consensus
amongst clinical experts that a difference of ±20% in plasma concentrations of
the active substance following administration of two different medicinal prod-
ucts would have no clinical significance for most drugs (36). Since measures
derived from plasma concentrations such as AUC and Cmax are log-normally
distributed, this ±20% translates into an asymmetric acceptance limit, for exam-
ple, 0.80 to 1.25. The EMEA Note for Guidance suggests that in specific cases of
active substances with a narrow therapeutic index (NTI) the acceptance interval
may need to be tightened but does not give more specific information (7). The
draft version of the EMEA revised Guideline on the Investigation of Bioequiva-
lence adds that “. . . the need for narrowing the acceptance interval for both AUC
and Cmax or for AUC only should be determined on a case by case basis.” (10)
The HPFB of Canada has issued Guidance for Industry on the bioequiv-
alence requirements for critical dose drugs (37). According to this guidance,
“critical dose drugs” are defined as those drugs for which comparatively small
differences in dose or concentration lead to dose- and concentration-dependent,
serious therapeutic failures and/or serious adverse drug reactions. For these
“critical dose drugs,” the 90% CI of the relative mean AUC of the test to ref-
erence formulation should lie within 90% to 112%, according to Canada’s HPFB
guidance. In addition, the 90% CI of the relative mean Cmax of the test to ref-
erence formulation for these “critical dose drugs” should be between 80% and
125%. For “uncomplicated” drugs, Canada’s HPFB requires the point estimate of
Cmax to simply lie between 80% and 125%. These requirements for “critical dose
drugs” are to be met in both the fasted and fed states. In an appendix to this
HPFB guidance a list of 9 “critical dose drugs” is given (37). The FDA Guidance
for Industry on Bioavailability and Bioequivalence Studies for Orally Adminis-
tered Drug Products recommends that the usual BE limit of 80% to 125% for non-
NTI drugs remain unchanged for the bioavailability measures (AUC and Cmax )
for NTI drug substances unless otherwise indicated by a specific guidance (34).
On the other hand, wider BE limits for the 90% CI may be acceptable for
Cmax (in certain cases) and for AUC (in rare cases) according to the EMEA Note
for Guidance (7). Indeed, when the intrasubject variability in AUC and Cmax is
high the estimated 90% CI is wide and it is very difficult to be entirely located
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within the usually accepted BE limits of 0.80 to 1.25. Among the methods pro-
posed during recent years in the scientific literature to evaluate the BE of these
highly variable drugs and drug products, scaled average BE and expanding the
usual BE limits to, for example, 0.75 to 1.33, were recently shown to be sensitive
to differences between means and, consequently, highly effective for assessing
the equivalence of average kinetic responses (38–40). Recently, a commentary
was published in which the authors proposed to adjust the BE limits for highly
variable drugs/drug products by scaling to the intrasubject variability of the
reference product in the study (41). The recommendation for the use of reference
scaling is based on the general concept that reference variability should be used
as an index for setting the public standard expressed in the BE limit. The use
of the reference-scaling approach necessitates a study design that evaluates the
reference variability via replicate administration of the reference product to each
subject.
BE studies using a replicate design, for example a three-period or four-
period study, have certain advantages over the classical two-period design. They
allow the comparison of the intrasubject variance and the evaluation of the
subject-by-formulation interaction. Information on these variances associated
with the test and reference formulations allows assessment of the pharmaceu-
tical quality of a new test product compared to the pharmaceutical quality of the
marketed innovator product. At the moment, none of the major health authori-
ties (EMEA, FDA, HPFB), however, provide clear recommendations on how to
assess BE of highly variable drugs or drug products.
The draft version of the revised EMEA Guideline on the Investigation of
Bioequivalence is clear in this respect. According to this guideline, it is accept-
able to widen the 90% acceptance range of Cmax , but not AUC, from 0.80–1.25 to
0.75–1.33 under the following conditions: (i) the 0.75 to 1.33 acceptance range has
been prospectively defined in the study protocol, (ii) it has been prospectively
justified that widening of the acceptance criteria for Cmax does not affect clinical
efficacy or safety, and (iii) the BE study is of a replicate design where it has
been demonstrated that the intrasubject variability for Cmax of the reference
compound in the study is >30% (10).

Exemptions from In Vivo BE Studies (Biowaivers)

The biopharmaceutics classification system (BCS) provides a scientific frame-
work for classifying active substances based on their aqueous solubility and
intestinal permeability (21,42,43). When combined with the in vitro dissolution
characteristics of the drug product, the BCS takes into account the major factors,
that is, solubility and intestinal permeability, which are fundamental in control-
ling the rate and extent of oral drug absorption from immediate release solid
oral dosage forms. In August 2000, the FDA issued a guidance for industry on
waivers of in vivo bioavailability and BE studies for immediate release solid
oral dosage forms (44). This guidance recommends that applicants may request
biowaivers for highly soluble and highly permeable drug substances (BCS class
I) in immediate release solid oral dosage forms provided that they exhibit rapid
in vitro dissolution rates and a few other conditions are met. The methods for
determining solubility, permeability, and in vitro dissolution are described in this
FDA biowaiver guidance as well as the approaches recommended for classifying
drug substances according to the BCS.
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The EMEA Note for Guidance on the Investigation of Bioavailability and

Bioequivalence under certain conditions also allows exemptions from in vivo
BE studies for oral immediate release dosage forms with systemic action (7).
Although this exemption from in vivo BE studies is based on similar consid-
erations as those described in the FDA Guidance for Industry (44), the EMEA
Note for Guidance on the Investigation of Bioavailability and Bioequivalence is
much less detailed in the description of the criteria on which a biowaiver may
be granted. Biowaivers are still rarely used in the EU probably due to uncer-
tainties by both the pharmaceutical companies and the regulatory authorities
regarding the application of the biowaiver principles. An example of a biowaiver,
accepted by the German regulatory authority, that is, the Bundesinstitut für
Arzneimittel und Medizinprodukte in Bonn, has been described in the scien-
tific literature for 80 and 160 mg immediate release tablets containing sotalol
hydrochloride, a BCS class I substance (45). To reach an optimal and harmonized
application based on biowaiver principles, the draft version of the revised EMEA
Guideline on the Investigation of Bioequivalence addresses the issue of BCS-
based biowaivers in much more detail than the current EMEA Note for Guid-
ance (10,46). According to this revised EMEA Guideline on the Investigation
of Bioequivalence, BCS-based biowaivers will be considered not only for BCS
class I drug substances (high solubility, high permeability), but also for BCS
class III substances (high solubility, low permeability), as has been proposed in
multiple scientific commentaries (47–49). In the latter case, special attention will
have to be paid to the excipients since it is known that the absorption of BCS
class III substances is more susceptible to transporter-mediated excipient–drug
interactions (50,51).

Formulation Changes and Variations

Information to document BE following reformulation of an approved generic (or
innovator) drug product or following a modification in its manufacturing pro-
cess or manufacturing equipment used is obviously required. Volume 2 of the
publication “The rules governing medicinal products in the European Union”
contains a list of regulatory guidelines related to procedural and regulatory
requirements such as renewal procedures, dossier requirements for variation
notifications, summary of product characteristics, package information, read-
ability of the label, and package leaflet requirements (51). Since 2003, new cat-
egories of variations, that is, notifications type IA and type IB, have been intro-
duced in the EU (52). Type IA variations are “minor” variations, for example,
a change in the name and/or address of the marketing authorization holder, a
change in the name of the active substance or its ATC (anatomical therapeutic
chemical) code, which do not require a new in vivo BE study. Examples of type
IB notifications are a minor change in the manufacturing process of the active
substance, a minor change in the manufacturing process of the finished prod-
uct, replacement of an excipient with a comparable excipient. For some type IB
notifications, a justification for not submitting a new BE study and/or compar-
ative dissolution data must be provided. Type II variations constitute “major”
changes and an in vivo BE study is required unless a biowaiver can be granted
on the basis of in vitro dissolution tests (BCS-based biowaiver, in vitro–in vivo
correlation).
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106 Verbeeck and Warlin

Unlike the FDA, which has a specific guidance on SUPAC, the EMEA Note
for Guidance on the Investigation of Bioavailability and Bioequivalence only has
a small paragraph on variations:
If a product has been reformulated from the formulation initially approved
or the manufacturing method has been modified by the manufacturer in
ways that could be considered to impact on the bioavailability, a bioe-
quivalence study is required, unless otherwise justified. Any justification
presented should be based upon general considerations . . ., or on whether
an acceptable in vivo/in vitro correlation has been established. (7).
From a regulator’s and sponsor’s point of view it would be desirable to
have clear and more detailed guidelines on this important issue, such as the
SUPAC guidelines of the FDA, to guarantee the continuing quality of a generic
drug product even during the postapproval period.

Bioequivalence of Chiral Drugs

Attempts have been made in the scientific literature to examine the stereo-
chemical aspects of BE and several examples demonstrate that BE between
two medicinal products containing a mixture of stereoisomers based on non-
stereospecific assays alone may not be extended to the pharmacologically rel-
evant stereoisomer(s) (53–55). The results of these studies suggest that stere-
ospecific assays are necessary for at least some chiral drugs. However, at this
time no consensus has been reached regarding the conditions whereby BE of
medicinal products containing a mixture of stereoisomers should be assessed
(56). According to the current EMEA Note for Guidance on the Investigation of
Bioavailability and Bioequivalence:
. . . bioequivalence studies supporting applications for essentially similar
medicinal products containing chiral active substances should be based
upon enantiomeric bio-analytical methods unless (1) both products contain
the same stable single enantiomer; (2) both products contain the racemate
and both enantiomers show linear pharmacokinetics.
The draft version of the revised EMEA Guideline on the Investigation of
Bioequivalence provides much clearer recommendations on this issue (10).

Locally Applied Drug Products

According to the EMEA Note for Guidance on the Investigation of Bioavailability
and Bioequivalence, for drug products for local use (oral, nasal, ocular, dermal,
rectal, vaginal, inhalation, etc.) intended to act without systemic absorption the
approach to assess BE on the basis of systemic concentrations of the active sub-
stance is not applicable and pharmacodynamic or comparative clinical studies
are in principle required (7,57).
The EMEA is currently working on a detailed guideline describing the
requirements for clinical documentation for abridged applications for orally
inhaled formulations and variations/extensions to a marketing authorization
with respect to demonstrating therapeutic equivalence between two inhaled
products for use in the management and treatment of asthma and chronic
obstructive pulmonary disease (58).
As far as the assessment of therapeutic equivalence between topical cor-
ticosteroid products is concerned, the current EMEA guidance in question
has been in operation since 1987 (59). More recently, a Questions & Answers
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document was released by the EMEA dealing more specifically with the vaso-
constriction (human skin blanching) assay that may reduce the need for data
from clinical trials when assessing therapeutic equivalence between topical cor-
ticosteroid products (60). This document refers to the FDA guidance for industry
for a detailed description of how to perform this vasoconstriction assay (61).

MODIFIED RELEASE ORAL AND TRANSDERMAL DOSAGE FORMS

In January 2000, the EMEA Note for Guidance on Modified Release Oral and
Transdermal Dosage Forms: Section II (Pharmacokinetic and Clinical Evaluation)
came into effect (8). The primary purpose of this guidance was
to define the studies necessary to investigate the properties and effects of
the new delivery system in man and to set out general principles for design-
ing, conducting and evaluating such studies.

Although the guidance only deals with oral modified release formulations
and transdermal dosage forms, most recommendations are also applicable to
implants and intramuscular/subcutaneous depot formulations. Paragraph 5 of
this document specifically deals with applications for modified release dosage
forms essentially similar to a marketed modified release form, that is, so-called
generic applications. A distinction is made between prolonged release oral for-
mulations, delayed release oral formulations and transdermal drug delivery sys-
tems (TDDS).

Prolonged Release Oral Formulations

Whereas BE for oral immediate release dosage forms with systemic action is
established on the basis of a single-dose study usually carried out in the fasting
state, the EMEA Note for Guidance on Modified Release Oral and Transdermal
Dosage Forms recommends that assessment of BE of prolonged release oral for-
mulations should be based on single- and multiple-dose studies. Typically, single-
and multiple-dose studies are carried out with the test and reference formulation
following an overnight fast. In addition, a single-dose study has to be carried out
with both test and reference formulation administered after a predefined
high-fat meal. The effect of this high-fat meal on the in vivo bioavailability should
be comparable for both preparations. The conditions to apply for a biowaiver in
case the application concerns multiple strengths are different for single unit and
multiple unit prolonged release oral formulations (8). It is interesting to note that
the FDA guidance recommends only single-dose studies (a fasting study and a
food-effect study) for modified release products submitted as Abbreviated New
Drug Applications (ANDA) (34). Their argument is that single-dose studies are
more sensitive to assess BE between two drug products. Canada’s HPFB guide-
lines for BE assessment on oral modified release formulations also recommend
single-dose BE studies under fasting and fed conditions. In addition, for formu-
lations that are likely to lead to accumulation of the active substance in plasma,
the HPFB also recommends a BE study at steady state, that is, after multiple-dose
administration (62).
According to the EMEA Note for Guidance on Modified Release Oral and
Transdermal Dosage Forms: “Assessment of bioequivalence will be based on
AUC␶ , Cmax , and Cmin applying similar statistical procedures as for the imme-
diate release formulations.” However, in the case of prolonged release formula-
tions, which at steady state may show relatively flat plasma concentration–time
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curves often with multiple peaks, Cmax is of limited value to characterize the rate
of absorption. Therefore, other measures such as the half-value duration, peak-
trough fluctuation (PTF), and percent swing may be useful alternatives (63,64).
Any widening of the usual 0.80 to 1.25 acceptance criterion should be prospec-
tively established in the study protocol and should be clinically justified.

Delayed Release Oral Formulations

An enteric-coated formulation, the most common example of a delayed release
formulation, is designed to protect the active substance from the acid environ-
ment of the stomach or to protect the stomach from the active substance. The
EMEA Note for Guidance on Modified Release Oral and Transdermal Dosage
Forms only specifies for this particular case of a modified release oral dosage
form that (i) BE is assessed using the same main characteristics and statistical
procedures as for immediate release oral formulations and (ii) postprandial bioe-
quivalence studies are necessary. It is not clear, though, whether only a food-
effect study has to be carried out, or whether in addition a fasting study is rec-
ommended (8).

Transdermal Drug Delivery Systems

A TDDS or transdermal patch is defined as a flexible pharmaceutical prepara-
tion of varying size containing one or more active substances to be applied on
the intact skin to provide a slow delivery of the active substance(s) into the sys-
temic circulation. Transdermal patches are often highly variable drug products
and consequently BE studies with replicate designs are recommended by the
EMEA Note for Guidance on Modified Release Oral and Transdermal Dosage
Forms (8). A replicate study is required if the systemic bioavailability of TDDS
with different release mechanisms, for example, reservoir versus matrix, is com-
pared because this design allows the assessment of the subject-by-formulation
interaction. In general, the BE of TDDS should be assessed after single-dose
and multiple-dose administration. When the application for marketing autho-
rization concerns multiple strengths of a TDDS, BE studies can be performed
on the highest strength only provided certain conditions are met such as (i) the
strength is proportional to the effective surface area of the TDDS, and (ii) an
acceptable in vitro release test exists. Finally, test product and reference prod-
uct should demonstrate the same (or less) degree of local irritation, phototox-
icity, sensitization and systemic adverse events, and a similar degree of adhe-
siveness to the skin. Although the EMEA guidance does not further elaborate
on this last point, the FDA has published a guidance for industry specifically
treating skin irritation and sensitization testing of generic transdermal drug
products (65).

FIXED COMBINATION DRUG PRODUCTS

For fixed combination drug products, in vivo BE should be evaluated for each
individual active substance. The study design and BE assessment methodology
and criteria are the same as those applied to oral immediate release formulations.
The reference product used in the BE study should be the originator fixed com-
bination product (7).
A Questions & Answers document was released by the EMEA in 2005
regarding the clinical development of fixed combinations of drugs belonging
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to different therapeutic classes in the field of cardiovascular treatment and pre-

vention (66). This “guideline” discusses what is required in case a new com-
bination product is developed of active substances as substitution therapy for
patients adequately controlled with the same active substances given concur-
rently at the same dose level and dosing interval but as separate single-substance
drug products. In this particular case, only BE should be demonstrated between
the already existing single-substance drug products and the fixed combination
drug product according to the recommendations described in the EMEA Note
for Guidance on the Investigation of Bioavailability and Bioequivalence (7). The
possibility that the active substances may interact pharmacokinetically should be
documented.

CONCLUSION: TOWARD GLOBAL HARMONIZATION?

The generic drug approval process has evolved over the past 30 years and regu-
latory agencies in a number of western countries have now established stringent
requirements for the design, performance and evaluation of BE studies to protect
the consumer of being exposed to drug products of inferior quality. Although the
current BE guidelines and recommendations of the major regional and national
health authorities show a fair degree of consistency, a number of outstanding
BE issues and concerns remain to be resolved. The most obvious of these con-
troversial issues, such as the BE acceptance limits for NTI drugs and HVDs,
the role of metabolites in BE assessment, the use of stereospecific bioanalytical
assays to determine BE of chiral drugs, the choice of the reference product, con-
ditions to grant biowaivers, are not dealt with in the same way by the various
guidelines. For example, the World Health Organization (WHO), which is not a
regulatory body but publishes technical reports and guidelines that are recom-
mendations to national authorities especially in developing countries, not only
allows biowaivers for BCS class I substances but also allows biowaivers under
certain circumstances for class II and class III substances (67). At this moment,
the FDA and the EMEA do not allow biowaivers for BCS class II substances (68).
This creates confusion that in turn leads to suspicion by health care providers
and patients, especially since many national authorities give these WHO reports
regulatory status. All stakeholders in the development and registration of new
drug products must balance the need for scientific rigor in assuring BA/BE (and
hence product quality toward consistent therapeutic outcomes) with the time
and expense of conducting in vivo BE studies, and the overall impact on prod-
uct costs and timely availability to patients. Ideally these guidelines should be
the same worldwide to ensure that patients all over the world can benefit from
affordable and safe medicinal products.
Global harmonization should therefore be the next logical step in the con-
tinuing process to improve the BE guidelines as a means to guarantee safe and
efficacious drug products for the consumer in all parts of the world. Global har-
monization efforts by the International Conference on Harmonization (ICH) and
the WHO should be stepped up in collaboration with the regulatory agencies of
the western world as more nations throughout the world have come to rely on
low-cost, good-quality multisource (generic) pharmaceutical products as means
of providing lower health care costs without sacrificing important public health
goals. However, as already pointed out, a consensus on a number of BE issues
has not even been reached at this point in time among international regulatory
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110 Verbeeck and Warlin

agencies. In addition, differing levels of commitment and resources by the var-

ious countries and regions constitute another formidable barrier that has to
be overcome to harmonize BE approaches to ensure development of optimally
performing and affordable drug products for use by health practitioners and
patients in he global community.

NOTE ADDED IN PROOF

The following important Questions & Answers document was published after
completion of the manuscript: “Positions on specific questions addressed to
the EWP therapeutic subgroup on Pharmacokinetics”, EMEA/618604/2008
Rev. 1, London, 23 July 2009. http://www.emea.europa.eu/pdfs/human/ewp/
61860408en.pdf (accessed on November 9, 2009).

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6 India
Subhash C. Mandal
Directorate of Drugs Control, “NALANDA,” Fartabad, Amtola, Kolkata, India

S. Ravisankar
GVK Biosciences Pvt. Ltd., Ameerpet, Hyderabad, India

INTRODUCTION
Although the concept of bioavailability (BA) and bioequivalence (BE) has been
developed over the decades and such considerations are in practice in different
research centers in academic institutions and industries in India for quite some
time, BE testing was not made mandatory by Drug Regulatory Agencies, until
the 1980s. The introduction of dissolution tests for seven products, chlorpro-
mazine, digitoxin, digoxin, lithium carbonate, quinidine, tetracycline, and
tolbutamide in the Indian Pharmacopoeia in 1985 (1), initiated the process of
framing legislation for regulatory requirements of BE studies. After this phase
(three years), BE studies became mandatory for all new drugs introduced on the
markets in India, by incorporating Schedule Y of the Drugs and Cosmetics Act
in 1988, followed by subsequent amendments of Schedule Y in 1989 and 2005
(2). The term “new drug” in India is defined under 122E of the Rule and includes
both brand and generic.
India has a large number of BA and BE centers, mostly owned and operated
by contract research organizations (CROs), largely in the private sector. More
than 950 new drugs were approved between 1988 and July 2007 in India (3),
following successful completion of necessary trials including BE and BA studies.

Patent Status on Pharmaceuticals

India switched over from a system of granting “process patents,” to “product
patents” from January 1, 2005 (4,5). The salient features of the product patent
system are as follows:

1. Product patents have been extended to pharmaceuticals, which was not pre-
viously permitted as per the Patent Act of 1970.
2. Patent protection has been extended to 20 years from 7 years.
3. The Indian Act denied granting of a patent retrospective to the mailing date
of the submission. Thus Indian companies that had been producing and
selling patented medicines could not be subjected to patent infringement
claims. The Act also provided that even after a patent had been granted,
Indian companies would be able to continue production subject to payment
of reasonable royalties to the patent holders. Subsection 2 of Section 5 of the
act specifies the term “reasonable,” but no explanation is given.

114
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India 115

4. A most significant feature of the Act is that it provides protection from sec-
ondary patenting of the same chemical/pharmaceutical molecule. It forbids
patenting of “salts, esters, polymorphs, metabolites, pure forms, particle size,
isomers, mixtures of isomers, complexes, combinations and other derivatives
of known substances unless they differ significantly in properties with regard
to efficacy.”
5. The Act also provides for pre- and postpatent objection of patents and
describes 11 areas where one can raise objections on the granting of a patent.
This includes objection to a patent based upon existing knowledge in the pub-
lic domain (prior art). This holds good for domestic inventions and also for
imported materials and according to the following “That if the invention so
far as claimed in any claim of the complete specification was publicly known
or publicly used in India before the priority date of the claim” [Section 25 (d)]
such an application is not patentable.
6. The Act has now made a provision under Section 107 A (b), for the import
of patented commodities from any part of the world, where it is cheaper,
even though it is patented in India. This is known as parallel import. For
this purpose, it will also not be required to obtain any authorization from
the patentee. The Act simply says that “who is duly authorized under law to
produce and sell or distribute the product” will become the source for Indian
importers.
7. One of the most important areas of the Act is its provisions for compulsory
licensing. The act clearly directs that a “‘Compulsory’ license is granted with
a predominant purpose of supply in the Indian market and that the licensee
may also export the patented product.” The license shall also be granted to
remedy a practice determined after judicial or administrative process to be
anticompetitive. This particular clause may be carefully used to control exor-
bitantly high prices of patented products.

In the greater interest of a country, the compulsory license process empow-

ers and allows a domestic company to produce a particular medicine if the patent
holder company does not produce or supply the medicine. In contrast to this
the Indian Act has designed the provisions of compulsory licensing, in a man-
ner that is more suitable to the needs and traits of the Indian industry. Section
92A(1) of the Act states that a “Compulsory license will be available for manu-
facture and export of patented pharmaceutical products to any country having
insufficient or no manufacturing capacity in the pharmaceutical sector for the
concerned product to address public heath problems, provided a compulsory
license has been granted by such country or such country has, by notification or
otherwise, allowed importation of the patented pharmaceutical products from
India.” In other words, a country simply needs to announce, by notification,
the need for importing any patented medicine from India. Such products can
then be ordered from any Indian company for manufacturing and exporting if
a compulsory license was granted to that company. The other important section
of the Act is that a compulsory license may be requested on the grounds that the
establishment or development of commercial activities in India is prejudiced. For
such purpose, applicants have to make efforts to obtain a license from the patent
holder on reasonable terms and conditions and when such efforts have not been
successful within six months, they will be granted a compulsory license.
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116 Mandal and Ravisankar

Generic Medicines
In India, generic medicines are those that are labeled with their generic names.
There is no separate law for registering generic medicines. Drugs and drug prod-
ucts are classified as either (i) “new drugs” or (ii) drugs other than new drugs.
However, in general “generic drugs” mean those that are no longer subject to
patent protection and are being marketed by their generic name. To understand
the legislation the concept of new drugs should be clear.
According to Section 122E of Drugs and Cosmetics Act new drugs are
defined as the following:
(a) A drug, as defined in the Act including bulk drug substance that has not
been used in the country to any significant extent (no clarification provided
by the Act—it is the prerogative of the licensing authority) under the condi-
tions prescribed, recommended or suggested in the labeling thereof and has
not been recognized as effective and safe by the licensing authority under
Rule 21 for the purposes claimed; provided that the limited use, if any, has
been with the permission of the licensing authority.
(b) A drug already approved by the licensing authority mentioned in Rule 21
for certain claims, which are now proposed to be marketed with modified or
new claims, namely, indications, dosage, dosage form (including sustained
release dosage form), and route of administration.
(c) A fixed dose combination of two or more drugs, individually approved ear-
lier for certain claims, which are now proposed to be combined for the first
time in a fixed ratio, or if the ratio of ingredients in an already-marketed
combination is proposed to be changed, with certain claims, viz., indica-
tions, dosage, dosage form (including sustained release dosage form) and
route of administration.
It also explained that all vaccines shall be new drugs unless certified other-
wise by the licensing authority under Rule 21 and a new drug shall continue to
be considered as a new drug for a period of four years from the date of its first
approval or its inclusion in the Indian Pharmacopoeia, whichever is earlier (6).
All new drugs are required to comply with the provisions and require-
ments of Schedule Y for registration in India. However some relaxation has been
granted for fixed dose combinations (FDC) to be registered in India (vide Annex-
ure VI of Schedule Y). For this purpose fixed dose combinations are categorized
into the following four groups:
(a) The first group of FDC includes those in which one or more of the active
ingredients are a new drug. Such FDC are treated in the same way as any
other new drug, for both clinical trials and marketing permission.
(b) The second group of FDC includes those in which the active ingredients
are already approved and marketed individually and are combined for the
first time, for a particular claim and where the ingredients are likely to have
significant interaction of a pharmacodynamic or pharmacokinetic nature
For permission to carry out clinical trials with such FDCs, a summary of
available pharmacological, toxicological, and clinical data on the individ-
ual ingredients should be submitted, along with the rationale for combining
them in the proposed ratio. In addition, acute toxicity data (LD 50) and phar-
macological data should also be submitted on the individual ingredients as
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India 117

well as their combination in the proposed ratio. If clinical trials have been
carried out with the FDC in other countries, reports of such trials should be
submitted. If the FDC is marketed abroad, the regulatory trials performed
should be stated.
For marketing permission, the reports of clinical trials carried out with
the FDC in India should be submitted. The nature of the trials depends on
the claims to be made and the data already available.
(c) The third group of FDCs includes those that have already been marketed,
but in which it is proposed either to change the ratio of active ingredients or
to make a new therapeutic claim. For such FDCs, the therapeutic rationale
should be submitted to obtain permission for clinical trials and the reports of
trials should be submitted to obtain marketing permission. The nature of the
trials will depend on the claims to be made and the data already available.
(d) The fourth group of FDCs includes those whose individual active ingre-
dients have been widely used for a particular indication for years, their
concomitant use is often necessary and no claim is proposed to be made
other than convenience. Also, it must be a stable acceptable dosage form
and whose ingredients are unlikely to have significant interaction of a phar-
macodynamic or pharmacokinetic nature.
No additional animal or human data are generally required for those
FDCs, and marketing permission may be granted if the FDC has an accept-
able rationale.
If any drug does not fall under the ambit of a new drug, licenses could be
issued by the state licensing authority. India has a two-tier regulatory system.
One is Central Drugs Standard Control Organization (CDSCO) under the Gov-
ernment of India having certain powers vested in them and each state has its own
drug regulatory system having certain powers. CDSCO is authorized to approve
new drugs as defined under Rule 122E but the state drugs control agency can-
not grant new drug licenses. Therefore it is clear that a BA/BE study is needed
for manufacturing and import of new drugs, where the relevant product is com-
pared against the innovator product.
Several different provisions and sections of the Drugs and Cosmetics Rules
have been modified and amended over the years. A new provision has been
introduced for the registration of manufacturing premises of foreign drug manu-
facturers and for drug products, before their import to India. These amendments
have been in force since January 1, 2003. The notification also introduced addi-
tional provisions, some of which are as follows:
1. An increase in import license fees.
2. Increased validity period of license.
3. Deletion of the clause of exemption relating to the requirement of import
license for bulk drug for actual users.
4. A minimum requirement of 60% of retained shelf life for imported drug.
5. Conditions for the importation of small amounts of new drug products by
Government hospitals for treating their own patients.
Under the existing regulations, foreign manufacturers must apply for reg-
istration certificates for both their manufacturing premises and for individual
drugs to be imported. The applications for these registrations can be filed by the
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118 Mandal and Ravisankar

authorized agents of foreign firms in India, along with the documents required
to be accompanied by the registration application, as specified in the relevant
amendments. The registration certificates are valid for three years from the date
from which they were issued.
A fee of US $1500 is charged for the registration of overseas manufacturer’s
premises and a fee of US $1000 is charged for each individual drug. The rules
now provide for inspection of the premises of a foreign manufacturer by Indian
Drug Authorities, whenever so required. In such cases, an additional fee of US
$5000 is charged. The rules also provide for payment of testing charges by reg-
istration holders. The foreign manufacturer or his authorized agent in India is
liable to report any change in the manufacturing and testing process of a drug.
However, no registration certificate is required for an inactive bulk substance
used as a pharmaceutical aid for the manufacture of the drug formulation. Regis-
tration may be suspended or cancelled in the event of any violation of the condi-
tions of registration. The new registration and import license scheme also covers
diagnostic kits, viz. HIV I and II, hepatitis B surface antigen, and blood group
detection reagents.
According to these rules, an import license is required for all types of drugs.
An import license application submitted on Form 10 is granted after the comple-
tion of the registration of overseas manufacturers and their specific drug prod-
uct(s) to be imported. The import licensee for specific drugs is valid for three
years from the date on which these were granted. The import license fee has
been fixed at Rs. 1000 for a single drug and at the rate of Rs. 100 for any addi-
tional drug. The fee for “import licenses for test and analysis” of a drug has been
kept at Rs. 100 for a single drug and at the rate of Rs. 50 for each additional drug.
Exemption from import licenses for the import of bulk drugs by the formulators
for actual use under Schedule D has been deleted. A provision has been made
that only drugs with a minimum of 60% of retained shelf life will be allowed
to be imported in the country, for example, if a drug product has a shelf life of
30 months, it will not be allowed to be imported into India more than 12 months
after manufacture.
Separate provision has been made to enable the Government hospitals to
import small quantities of essential new drugs for the treatment of their own
patients. The fee for such import licenses has been kept at Rs. 100 for a single
drug and at the rate of Rs. 50 for each additional drug.
The following guidelines describe the requirements of an applica-
tion for permission to import and/or manufacture new drugs for sale
or to conduct clinical trials as per the Drugs and Cosmetics Rules (2):

GUIDELINES FOR THE APPLICATION TO IMPORT

AND/OR MANUFACTURE NEW DRUGS FOR SALE
OR TO CONDUCT CLINICAL TRIALS
(1) Application for permission to import or manufacture new drugs for sale or
to undertake clinical trials shall be made on Form 44 accompanied with the
following data in accordance with the appendices:
(i) Chemical and pharmaceutical information as prescribed in item 2 of
Appendix I.
(ii) Animal pharmacology data as prescribed in item 3 of Appendix I and
Appendix IV.
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(a) Specific pharmacological actions as prescribed in item 3.2 of

Appendix I, and demonstrating therapeutic potential for humans
shall be described according to the animal models and species
used. Wherever possible, dose–response relationships and ED50
shall be submitted. Special studies conducted to elucidate mode
of action shall also be described (Appendix IV).
(b) General pharmacological actions as prescribed in item 3.3 of
Appendix I and item 1.2 of Appendix IV.
(c) Pharmacokinetic data related to the absorption, distribution,
metabolism, and excretion of the test substance as prescribed in
item 3.5 of Appendix I. Wherever possible, the drug effects shall
be correlated to the plasma drug concentrations.
(iii) Animal toxicology data as prescribed in item 4 of Appendix I and
Appendix III.
(iv) Human Clinical Pharmacology Data as prescribed in items 5, 6, and 7
of Appendix I and as stated below
(a) For new drug substances discovered in India, clinical trials are
required to be carried out in India from Phase I and data should
be submitted as required under items 1, 2, 3, 4, 5 (data, if any, from
other countries), and 9 of Appendix I.
(b) For new drug substances discovered in countries other than India,
Phase I data as required under items 1, 2, 3, 4, 5 (data from other
countries), and 9 of Appendix I should be submitted along with
the application. After submission of Phase I data generated out-
side India to the licensing authority, permission may be granted
to repeat Phase I trials and/or to conduct Phase II trials and sub-
sequently Phase III trials concurrently with other global trials for
that drug. Phase III trials are required to be conducted in India
before permission to market the drug in India is granted.
(c) The data required will depend upon the purpose of the new drug
application. The number of study subjects and sites to be involved
in the conduct of a trial will depend upon the nature and objec-
tive of the study. Permission to carry out these trials shall gener-
ally be given in stages, considering the data emerging from earlier
phase(s).
(d) Application for permission to initiate a phase of a clinical trial
should also accompany the Investigator’s brochure, proposed
protocol (Appendix X), case record form, study subject’s informed
consent document(s) (Appendix V), investigator’s undertaking
(Appendix VII) and ethics committee clearance, if available,
(Appendix VIII).
(e) Reports of clinical studies submitted under items 5 to 8 of
Appendix I should be in consonance with the format prescribed
in Appendix II of this schedule. The study report shall be certified
by a principal investigator or, if no principal investigator is desig-
nated, then by each of the investigators participating in the study.
The certification should acknowledge the contents of the report,
the accurate presentation of the study as undertaken and express
agreement with the conclusions. Each page should be numbered.
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120 Mandal and Ravisankar

(v) Regulatory status in other countries as prescribed in item 9.2 of

Appendix I, including information in respect of restrictions imposed,
if any, on the use of the drug in other countries, for example, dosage
limits, exclusion of certain age groups, warning about adverse drug
reactions, etc. (item 9.2 of Appendix I). Likewise, if the drug has
been withdrawn in any country by the manufacturer or by regulatory
authorities, such information should also be furnished along with the
reasons and their relevance, if any, to India. This information must
continue to be submitted by the sponsor to the licensing authority
during the course of marketing of the drug in India.
(vi) The full prescribing information should be submitted as part of
the new drug application for marketing as prescribed in item 10
of Appendix I. The prescribing information (package insert) shall
comprise the following sections: generic name; composition; dosage
form/s; indications; dose and method of administration; use in
special populations (such as pregnant women, lactating women,
pediatric patients, geriatric patients, etc.); contraindications; warnings;
precautions; drug interactions; undesirable effects; overdose; pharma-
codynamic and pharmacokinetic properties; incompatibilities; shelf
life; packaging information; and storage and handling instructions.
All package inserts, promotional literature, and patient education
material subsequently produced are required to be consistent with
the contents of the approved full prescribing information. The drafts
of label and carton texts should comply with provisions of Rules 96
and 97. After submission and approval by the licensing authority, no
changes in the package insert shall be effected without such changes
being approved by the licensing authority;
(vii) Complete testing protocol/s for quality control (QC) testing together
with a complete impurity profile and release specifications for the
product as prescribed in item 11 of Appendix I should be submitted
as part of new drug application for marketing. Samples of the pure
drug substance and finished product are to be submitted when desired
by the regulatory authority.
(2) If the study drug is intended to be imported for the purposes of examination,
test or analysis, the application for import of small quantities of drugs for
such purpose should also be made on Form 12.
(3) For drugs indicated in life-threatening/serious diseases or diseases of spe-
cial relevance to the Indian health scenario, the toxicological and clinical
data requirements may be abbreviated, deferred or omitted, as deemed
appropriate by the licensing authority.

DESIGN AND CONDUCT OF BIOEQUIVALENCE STUDIES FOR ORALLY

ADMINISTERED DRUG PRODUCTS
A draft guideline for the conduct of Bioequivalence studies was released by the
Directorate General of Health Services in 2003 and after review of the comments
from experts, the final “Guidelines for the conduct of Bioavailability and Bioe-
quivalence studies” was released in March 2005 (7). In addition to this guide-
line, it is mandatory to follow Indian GCP (good clinical practice) (8), pertinent
requirements of Schedule Y (9) of the Drugs and Cosmetics Act of India and The
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Ethical Guidelines for biomedical research on human subjects issued by Indian

Council of Medical Research, India (10).
BE studies are necessary for the following drugs products:
For certain drugs and dosage forms, in vivo documentation of equivalence,
through either a BE study, a comparative clinical pharmacodynamic study, or a
comparative clinical trial, is regarded as especially important. These include the
following:
a. Oral immediate release drug formulations with systemic action when one or
more of the following criteria apply:
i. Indicated for serious conditions requiring assured therapeutic response.
ii. Narrow therapeutic window/safety margin; steep dose–response curve.
iii. Pharmacokinetics complicated by variable or incomplete absorption or
narrow absorption window, nonlinear pharmacokinetics, presystemic
elimination/high first-pass metabolism greater than 70%.
iv. Unfavorable physicochemical properties, for example, low solubility,
instability, metastable modifications, poor permeability, etc..
v. Documented evidence of BA problems related to the drug or drugs of
similar chemical structure or formulations.
vi. Where a high ratio of excipients to active ingredients exists.
b. Nonoral and nonparenteral drug formulations designed to act by systemic
absorption (such as transdermal patches, suppositories, etc.).
c. Sustained or otherwise modified-release drug formulations designed to act
by systemic absorption.
d. Fixed dose combination products with systemic action.
e. Nonsolution pharmaceutical products, which are for nonsystemic (oral,
nasal, ocular, dermal, rectal, vaginal, etc., applications) and are intended to
act without systemic absorption. In these cases, the BE concept is not suitable
and comparative clinical or pharmacodynamic studies are required to prove
equivalence. There is a need for drug concentration measurements to assess
unintended partial absorption. BE documentation is also needed to establish
links between:
i. Early and late clinical trial formulations.
ii. Formulations used in clinical trials and stability studies, if different.
iii. Clinical trial formulations and “to be” marketed drug products.
iv. Other comparisons, as appropriate.
There are no specific guidances for the following products:
r Topical corticosteroid products.
r All other topical products (except transdermals) for external application
and not intended to be absorbed, for example, an antifungal cream, topical
creams/ointments for use in the vagina).
r Inhalation products.
r Orally administered products not intended to be absorbed into the systemic
circulation, for example, sulindac, mesalamine, etc.

Study Design
A BE study should be designed in a manner that any formulation effects can
be distinguished from other effects. Typically, if two formulations (one test and
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122 Mandal and Ravisankar

the other reference) are to be compared, a two-period, two-sequence cross-over

design should be chosen, with two phases of treatment separated by an adequate
washout period. Normally the washout period should be equal to or more than
five half-lives of the incorporated drug. Other designs such as a parallel design
for long half-life drug substances and a replicate design for drug substances with
highly variable disposition can be used.
Single-dose studies are generally sufficient although a steady-state study
design may be considered under the following circumstances:
a. Drugs that follow dose- or time-dependent pharmacokinetics.
b. Some modified-release products (in addition to a single-dose study).
c. When problems of sensitivity preclude plasma drug concentration measure-
ments after single-dose administration.
d. If intraindividual variability in the plasma drug concentration or disposi-
tion is reduced at steady state when compared to variability in a single-dose
study.
Studies evaluating food effects are required when there is a possibility that
food may affect the BA of the drug. Food effect BA studies focus on effects of
food on the release of the drug substance from the drug product as well as on the
absorption of the drug substance.

Subjects
Number of Subjects
The number of subjects required for a BE study is determined by considerations
such as the error variance from pilot study data, the expected deviation of the
test product from the reference product, significance level (usually 0.05) and the
power of the study (should be more than 80%). The minimum number of subjects
should not be less than 16, unless justified for ethical reasons. Additional subjects
can be recruited to allow for possible dropouts or removal from the study. The
withdrawn/dropout subjects can be replaced by a substitute (standby) provided
that a substitute subject follows all the study requirements.
Sequential or add-on studies are acceptable in specific cases, for example,
where a large number of subjects are required or where the results of the study
do not convey adequate statistical significance. In all cases, the final statistical
analysis must include data from all subjects, and reasons for not including partial
data as well as the non–included data must be documented in the final report.

Subject Selection
The selection of subjects and standardization is important to minimize intra- and
interindividual variations. The studies should be carried out in healthy male or
female volunteers. The choice of gender should be consistent with usage and
safety criteria. Women of child-bearing potential should be required to give
assurance that they are neither pregnant nor likely to become pregnant until after
the study. This is confirmed by pregnancy tests immediately prior to the first and
last dose of the study. Women taking contraceptive drugs should not normally be
included in the studies. If the drug product is intended to be used in both sexes,
attempts should be made to include similar proportions of males and females
in the studies. The choice of subject may be narrowed when a drug represents a
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potential hazard in one group of users, for example, studies on teratogenic drugs
should be conducted only on males.
For a drug product to be used in a geriatric population, subjects of 60 years
of age or older should be included.
Volunteers are screened for suitability by means of a comprehensive med-
ical examination including clinical laboratory tests, extensive review of medical
history, use of oral contraceptives, alcohol intake, smoking, and use of drugs of
abuse. Additional medical investigations may be required before, during, and
after the study, based upon the therapeutic class of drug and safety profile.

Use of Patients, i.e., Instead of Healthy Subjects

For drugs where the risk of toxicity or side effects is significant, studies are to be
carried out in patients whose disease state is stable.

Phenotyping/Genotyping
While designing a study protocol, adequate care should be taken to consider
pharmacogenomic issues in the context of the Indian population. Phenotyping
and/or genotyping of subjects should be considered for exploratory BA studies
and all studies using parallel group design. It may also be considered in cross-
over studies for safety or pharmacokinetic reasons. If a drug is known to be sub-
ject to a major genetic polymorphism, studies could be performed in panels of
subjects of known phenotype or genotype for the polymorphism in question.

Standardization of Study Conditions

Standardization of the study environment is necessary to minimize variability.
Diet, fluid intake, postdosing postures, exercise, sampling schedules, etc., are to
be stated in the protocol and must be complied with during the conduct of the
study. The subjects should abstain from smoking, drinking alcohol, coffee, tea,
and xanthine-containing foods and beverages and fruit juices during the study
and at least for 48 hours before its commencement.

Fasting and Fed Study Considerations

In a single-dose fasting study, the dose should be administered after an overnight
fast of at least 10 hours, with continuation for a further successive four hours of
fasting after dosing. In a multiple dose fasting study, when the evening dose is
to be administered, fasting of two hours before and two hours after dosing is
acceptable. When the drug is recommended to be administered along with food
or when the drug is a modified-release product, a fed-state study is to be carried
out as well as a fasting study.
For fed-state studies, a high-fat breakfast meal should be designed to pro-
vide 950 to 1000 kcal. Fifty percent of the calories must be from fat, 15% to 20%
from proteins and the rest 30% to 35% from carbohydrates. Because of the vast
ethnic and cultural variations in the Indian subcontinent, any single-standard
high-fat breakfast is not recommended, but can be specified in the protocol and
justified. The high-fat breakfast must be consumed 15minutes before dosing.

Blood/Urine Sample Collection and Times

The duration of blood sample collection in a single-dose study for an imme-
diate release product should be extended for three elimination half-lives. The
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124 Mandal and Ravisankar

sampling should continue until the AUC extrapolated from the time of the last
measured drug concentration to infinity time is only a small percentage (nor-
mally less than 20%) of the total AUC. Truncated AUC may be used when the
presence of enterohepatic recycling does not allow the terminal elimination rate
constant to be accurately calculated. There should be at least three sampling
points in the absorption phase, three to four around the projected Tmax , and four
points in the elimination phase (intervals between successive sampling points
should not be longer than the half-life of the drug, in general). The number of
points used to calculate the terminal elimination rate constant should preferably
be visually determined by inspection of a semilogarithmic plot of drug concen-
tration versus time. For urinary excretion studies, samples must be collected up
to seven or more half-lives.

Parameters To Be Investigated
BA/BE evaluations are based on the measurement of the concentrations of the
drug or its metabolite(s). Measurement of the active or inactive metabolites may
be necessary in certain situations:
(a) The concentration of the drug may be too low to be accurately measured in
the biological matrix.
(b) Unstable drugs.
(c) Drugs with a very short half-life.
(d) The API is a prodrug.
Racemates should be measured by using an achiral method. Measurement
of individual enantiomers is only recommended when
(a) the enantiomers exhibit different pharmacokinetic or pharmacodynamic
characteristics,
(b) primary efficacy/safety resides with the minor enantiomer, and
(c) at least one of the enantiomers undergoes nonlinear absorption.

Blood/Plasma/Serum Concentration Versus Time Profiles

The drug plasma–time concentration curve is mostly used to assess the rate and
extent of absorption of the study drug. These include pharmacokinetic param-
eters such as Cmax , Tmax , AUC0–t , and AUC0–∞ . For steady-state studies, Cmax ,
Cmin , and AUC0–␶ and the degree of fluctuation should be calculated.

Urinary Excretion Profiles

When it is not possible to assess the pharmacokinetic parameters in blood,
plasma, or serum, urinary excretion profiles may be used to compare the BA
of drug products.

Pharmacodynamic Studies
Studies in healthy volunteers or patients using pharmacodynamic parameters
may be used for establishing BE between two pharmaceutical products. These
studies may become necessary if quantitative analysis of the drug and/or
metabolite(s) in plasma or urine cannot be made with sufficient accuracy and
sensitivity. Furthermore, pharmacodynamic studies in humans are required if
measurements of drug concentrations cannot be used as surrogate end points
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for the demonstration of efficacy and safety of the particular pharmaceutical

product; for example, for topical products where the drug is not intended to be
absorbed into the systemic circulation.
When only pharmacodynamic data are used to demonstrate BE, the appli-
cant should outline what other methods were tried and why they were found
unsuitable.
The following requirements should be considered when planning, con-
ducting, and assessing the results from a pharmacodynamic study:

(i) The response measured should be a pharmacological or therapeutic

effect, which is relevant to the claims of efficacy and/or safety of the
drug.
(ii) The methodology adopted for carrying out the study should be validated
for precision, accuracy, reproducibility, and specificity.
(iii) Neither the test nor the reference product should produce a maximal
response in the course of the study, since it may be impossible to dis-
tinguish differences between formulations given in doses that produce
such maximal responses. Investigation of dose–response relationship
may become necessary.
(iv) The response should be measured quantitatively under double-blind
conditions and be recorded with an instrument-produced or instrument-
recorded fashion on a repetitive basis to provide a record of pharmaco-
dynamic events that are a substitute for plasma concentrations.
If such measurements are not possible, recordings on visual-analog
scales may be used. In instances, where data are limited to qualitative
(categorized) measurements, appropriate special statistical analyses will
be required.
(v) Nonresponders should be excluded from the study by prior screening.
The criteria by which responders versus nonresponders are identified
must be stated in the protocol.
(vi) Where an important placebo effect can occur, comparison between prod-
ucts can only be made by a prior consideration of the placebo effect in
the study design. This may be achieved by adding a third period/phase
with placebo treatment, in the design of the study.
(vii) A cross-over or parallel study design should be used, as appropriate.
(viii) When pharmacodynamic studies are to be carried out on patients, the
underlying pathology and natural history of the condition should be
considered in the study design. There should be knowledge of the repro-
ducibility of the baseline conditions.
(ix) In studies where continuous variables can be recorded, the time course of
the intensity of the drug action can be described in the same way as in a
study where plasma concentrations are measured. From this, parameters
can be derived, which describe the area under the effect–time curve, the
maximum response and the time when the maximum response occurred.
(x) Statistical considerations for the assessment of the outcomes are in prin-
ciple, the same as in pharmacokinetic studies.
(xi) A correction for the potential non-linearity of the relationship between
dose and area under the effect–time curve should be made on the basis
of the outcome of the dose-ranging study.
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The conventional acceptance range as applicable to pharmacokinetic stud-

ies and BE is not appropriate (too large) in most cases. This range should there-
fore be defined in the protocol on a case-to-case basis.

Analysis of Samples (Bioanalysis)

Bioanalysis involves the measurement of drug or metabolite in a suitable matrix
for making pharmacokinetic assessments. Bioanalytical methodology is divided
into two distinct phases, viz., prestudy phase, where method validation is done
on the biological matrix (e.g., human plasma) and spiked plasma samples and
the study phase, which involves the analysis of subject samples by the use of a
validated method where the stability, precision, and accuracy of the assay have
been confirmed.
The following are the validation parameters to be established in the
prestudy phase, prior to the analysis of subject samples.

(i) Specificity/selectivity: The method should be capable of demonstrating

that there is no interference with the assay due to the presence of endoge-
nous compounds, degradation products, other drugs or metabolites present
in the subject samples.
(ii) Sensitivity: Sensitivity of an analytical method is indicated by the lowest
limit of quantification (LLOQ) at which the concentration of the analyte is
determined with stated precision and accuracy. This is established based
on the intra- and interday coefficients of variation (CV), which should not
usually be greater than 20%. Concentration values between the LOD and
LOQ are identified as BLQ (below quantification limit).
(iii) Accuracy and Precision: The accuracy of an analytical method describes the
closeness of mean test results obtained by the method to the true value (con-
centration) of the analyte. Precision is the reproducibility of the individual
assays. The precision and accuracy should be established using QC samples
prepared in three different concentrations (low, medium, and high). Low
QC samples in the vicinity of the lowest concentration to be measured, high
QC samples near the Cmax , and the medium QC samples at an intermediate
value to low and high QC samples. The acceptance criteria for intra-assay
and interassay precision should not be more than 20% near the LOQ and
not more than 15% at other levels. The accuracy of the method should be
established in conjunction with precision experiments. The percentage of
accuracy at all levels of QC samples should be within ±15% of nominal
concentrations.
(iv) Range and Linearity: For establishing linearity over a range of concen-
trations expected in the subject samples, a standard curve should be con-
structed by using at least five concentrations. More points are necessary in
order to establish linearity, when the response function is nonlinear. Extrap-
olation of concentration beyond calibration curve should not be made.
(v) Recovery: The recovery of an analyte in an assay is the detector response
obtained from an amount of the analyte added to and extracted from the
biological matrix, compared with the detector response obtained for the
true concentration of the pure authentic standard. Recovery experiments
should be performed by comparing the analytical results for extracted sam-
ples at three concentrations (low, medium, and high) with unextracted
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standards that represent 100% recovery. If the recovery is low, alternate

methods should be applied as such methods are prone to be inconsistent.
Recovery of an internal standard, when used, should also be established.
(vi) Stability: Stability of analytes in the matrix under conditions of the experi-
ments should be established including long-term stability.
At least three freeze–thaw cycles should be assessed. Sorption of drug due
to sampling container and stopper should also be investigated. The analytical
system stability should be established so that the system remains stable through-
out the time course of assay. A suggested design is to run standards at the begin-
ning and end of each run.

Choice of Reference Product

As per the CDSCO guidelines a reference product is a pharmaceutical prod-
uct, which is identified by the licensing authority (Drugs Controller General of
India) as the “designated reference product” and contains the same active ingre-
dient(s) as the new drug (brand/innovator drug product). The designated refer-
ence product (http://cdsco.nic.in/listofdrugapprovedmain.html) will normally
be the innovator’s product. An applicant seeking approval to market a generic
equivalent must refer to the designated reference product to which all generic
versions must be shown to be bioequivalent. For subsequent new drug prod-
uct applications in India the licensing authority may, however approve another
Indian product (which was studied in comparison with an international innova-
tor product), as designated reference product.

Study Products
The investigational medicinal product (test product) should be manufactured
from a production batch. The products should be stored as per storage condi-
tions stated on the label. Randomly selected samples from the shipment by the
manufacturer or sponsor should be used for the study. The number of units pro-
cured should be twice the number required for the tests to be carried out in vivo
as well as for the number of in vitro tests. These samples must be retained (reten-
tion samples) under the recommended storage conditions in the original con-
tainers for a period of three years after the conduct of study or one year after
the period of expiry whichever is earlier. This is to ensure the samples are repre-
sentative of the ones sent by the sponsor and used for all the tests. The reserve
samples should be stored in an area segregated from the area where testing is
conducted and with access limited to authorized personnel.

Data Analysis
The main concern in a BE assessment is to limit the consumer’s risk, that is, erro-
neously accepting BE, and also at the same time, minimize the manufacturer’s
risk, that is, erroneously rejecting BE. This is done by using appropriate statisti-
cal methods for data analysis and adequate sample size.

Statistical Analysis
The statistical procedure should be specified in the protocol. In the case of BE
studies, the procedures should lead to a decision scheme, which is symmetrical
with respect to the two formulations (i.e., leading to the same decision whether
the new formulation is compared to the reference product or the reference
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128 Mandal and Ravisankar

product to the new formulation). The statistical analysis (e.g., ANOVA) should
take into account sources of variation that can be reasonably assumed to have an
effect on the response.
The 90% confidence interval (CI) for the ratio of the population means
(test/reference) and the two one-sided t test with the null hypothesis of non-
BE at the 5% significance level for the parameter under consideration are applied
for assessing BE.
To meet the assumption of normality of data underlying the statistical anal-
ysis, logarithmic transformation of the data should be carried out for the phar-
macokinetic parameters Cmax and AUC before performing statistical analysis.
The analysis of Tmax is desirable if it is clinically relevant. The parameter
Tmax should be analyzed using nonparametric methods. In addition to the above,
summary statistics such as minimum, maximum, and ratio of pharmacokinetic
parameters should be given in the report.
The study protocol should specify the methods for identifying biologically
implausible outliers. Post hoc exclusion of outliers is not recommended. A scien-
tific explanation should be provided to justify the exclusion of a volunteer from
the analysis.

Acceptance Criteria
Single-Dose Studies
To establish BE, the calculated 90% CI for AUC and Cmax should fall within the
BE range, usually 80% to 125%. This is equivalent to the rejection of the two one-
sided t test with the null hypothesis of non-BE at a 5% level of significance. The
nonparametric 90% CI for Tmax should lie within a clinically acceptable range.
Tighter limits for permissible differences in BA may be required for drugs
that have
(i) a narrow therapeutic index,
(ii) a serious, dose-related toxicity,
(iii) a steep dose/effect curve, or
(iv) nonlinear pharmacokinetics within the therapeutic dose range.
A wider acceptance range may be acceptable if it is based on sound clinical
justification.

Steady-State Studies Involving Controlled/Modified-Release Dosage Forms

The following special considerations apply to modified-release drug products
and for the purpose of these guidelines, modified-release products include the
following:
(i) Delayed release
(ii) Sustained release
(iii) Mixed immediate and sustained release
(iv) Mixed delayed and sustained release
(v) Mixed immediate and delayed release
Generally, these products should
(i) act as modified-release formulations and meet the label claim(s),
(ii) preclude the possibility of any dose dumping effect,
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(iii) demonstrate a significant difference between the performance of a

modified-release product and the conventional release product when used
as the reference product,
(iv) provide a therapeutic performance comparable to the reference immediate
release formulation administered by the same route in multiple doses (of an
equivalent daily amount) or to the reference modified-release formulation,
(v) produce consistent pharmacokinetic performance between individual
dosage units, and
(vi) produce plasma levels that lie within the therapeutic range (where appro-
priate) for the proposed dosing intervals at steady state.
If all of the above-mentioned conditions are not met but the applicant
wishes to submit the formulation for consideration, justification for this should
be provided.

Study Parameters
BA data should be obtained for all modified-release drug products although the
type of studies required and the pharmacokinetic parameters that should be eval-
uated may differ depending on the active ingredient involved.
Factors to be considered include whether or not the formulation represents
the first market entry of the drug substance, and the extent of accumulation of
the drug after repeated dosing.
If the formulation is the first market entry of the drug substance, the
product’s pharmacokinetic parameters should be determined. If the formula-
tion is a second or subsequent market entry then comparative BA studies using
an appropriate reference product, should be performed. For the first generic
drug product, the international innovator drug product should be used as
the reference product but for subsequent products, it may be the reference
product approved earlier, which was equivalent to the international innovator
product.

Study Design
The study design should be a single dose or single and multiple dose based
on the modified-release products that are likely to accumulate or unlikely to
accumulate, both in the fasted and nonfasting state. If the effect of food on the
reference product is not known (or it is known that food affects its absorption),
two separate two-way cross-over studies, a fasted and a fed study should be
carried out.
If it is known with certainty (e.g., from published data) that the reference
product is not affected by food, then a three-way cross-over study may be appro-
priate with
r the reference product in the fasting state,
r the test product in the fasted state, and
r the test product in the fed state.

Requirements for Modified-Release Formulations Unlikely to Accumulate

This section outlines the requirements for modified-release formulations that are
used at a dose interval that is not likely to lead to accumulation in the body
(AUC0–␶ /AUC0–∞ ≥ 0.8).
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When the modified-release product is the first market entry of that type of
dosage form, the reference product should normally be the innovator’s immedi-
ate release formulation. The comparison should be between a single dose of the
modified-release formulation and doses of the immediate-release formulation,
which it is intended to replace. The latter must be administered according to the
established dosing regimen.
When the modified-release product is the second or subsequent entry on
the market, comparison should be with the reference modified-release product
for which BE is claimed.
Studies should be performed using single-dose administration in the fast-
ing state as well as following an appropriate meal at a specified time. The fol-
lowing pharmacokinetic parameters should be calculated from plasma (or rele-
vant biological matrix) concentrations of the drug and/or major metabolite(s):
AUC0–␶ , AUC0–t , AUC0–∞ , and Cmax (where the comparison is with an existing
modified-release product), and kel . The 90% CI calculated using log-transformed
data for the ratios (test/reference) of the geometric mean AUC (for both AUC0–␶
and AUC0–t ) and Cmax (where the comparison is with an existing modified-
release product) should generally be within the range 80% to 125% both in the
fasting state and following the administration of an appropriate meal at a speci-
fied time before taking the drug.
The pharmacokinetic parameters should support the claimed dose delivery
attributes of the modified-release dosage form.

Requirements for Modified-Release Formulations Likely to Accumulate

This section outlines the requirements for modified-release formulations that are
used at dose intervals that are likely to lead to accumulation (AUC0–␶ /AUC0–∞
< 0.8).
When a modified-release product is the first market entry of the modified-
release type, the reference formulation is normally the innovator’s immediate
release formulation. Both a single dose and steady-state doses of the modified-
release formulation should be compared with doses of the immediate release for-
mulation which it is intended to replace. The immediate-release product should
be administered according to the conventional dosing regimen.
Studies should be performed with single-dose administration in the fasting
state as well as following an appropriate meal. In addition, studies are required
at steady state. The following pharmacokinetics parameters should be calculated
from single-dose studies: AUC0–␶ , AUC0–t , AUC0–∞ , Cmax (where the comparison
is with an existing modified-release product), and kel . The following parameters
should be calculated from steady-state studies: AUC0–␶ ,(ss), Cmax , Cmin , Cpd , and
degree of fluctuation.
When the modified-release product is the second or subsequent modified-
release entry, single-dose and steady-state comparisons should normally be
made with the reference modified-release product for which BE is claimed. The
90% CI for the ratio of geometric means (test/reference) of AUC (for both AUC0–␶
and AUC0–t ) and Cmax (where the comparison is with an existing modified-
release product) determined using log-transformed data should generally be
within the range 80% to 125% when the products are compared after single-dose
administration in both the fasting state and the fed state.
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The 90% CI for the ratio of geometric means (test/reference drug) for
AUC0–␶ (ss) , Cmax , and Cmin determined using log-transformed data should gen-
erally be within the range 80% to 125% when the formulations are compared at
steady state.
The pharmacokinetic parameters should support the claimed attributes of
the modified-release dosage form. Pharmacodynamic data may reinforce or clar-
ify interpretation of differences in the plasma concentration data. Where these
studies do not show BE, comparative efficacy, and safety data may be required
for the new product.

Reporting of Results
The BE report should give complete documentation with respect to the protocol,
conduct and evaluation of the study. The report should include (as a minimum)
the following information:
4.10.1. Table of contents
4.10.2. Title of the study
4.10.3. Names and credentials of responsible investigators
4.10.4. Signatures of the principal and other responsible investigators authenti-
cating their respective sections of the report
4.10.5. Site of the study and facilities used
4.10.6. The period of dates over which the clinical and analytical steps were con-
ducted
4.10.7. Names, batch numbers, and expiry date of the products compared (for the
test product, an expiry date may not be available prior to conducting the
study)
4.10.8. A signed declaration that this product is identical to that intended for
marketing
4.10.9. Results of assays and other pharmaceutical tests (e.g., physical descrip-
tion, dimensions, mean weight, weight uniformity, and comparative disso-
lution) carried out on the batches of the various products
4.10.10. Full protocol for the study including a copy of the Informed Consent
Form and criteria for inclusion/exclusion or withdrawal of subjects
4.10.11. Report of protocol deviations, violations
4.10.12. Documentary evidence that the study was approved by an independent
ethics committee and was carried out in accordance with good clinical prac-
tice/good laboratory practice.
4.10.13. Demographic data of subjects
4.10.14. Names and addresses of subjects
4.10.15. Details of and justification for protocol deviations
4.10.16. Details of dropout and withdrawals from the study should be fully doc-
umented and accounted for
4.10.17 Details of analytical methods used, full validation data, QC data, and
criteria for accepting or rejecting assay results
4.10.18 Representative chromatograms (normally 20%) covering the whole con-
centration range for all, standard and QC samples as well as specimens
analyzed
4.10.19. Sampling schedules and deviations of the actual times from the sched-
uled times
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4.10.20. Details of how pharmacokinetic parameters were calculated

4.10.21. Documentation related to statistical analysis
(i) Randomization schedule
(ii) Plasma concentration and time points of volunteers for test and reference
products
(iii) AUC0–t , AUC0–∞ , Cmax , Tmax , Kel, and t1/2 for test and reference products
(iv) Logarithmic transformed pharmacokinetic parameters used for BE
demonstration
(v) ANOVA for AUC0–t , AUC0–∞ , and Cmax
(vi) Intersubject, intrasubject, and/or total variability, if possible
(vii) CIs for AUC0–t , AUC0–∞ , Cmax . CI values should not be rounded off;
therefore, to pass a CI range of 80% to 125%, the values should be at
least 80.00 and not more than 125.00)
(viii) Geometric mean, arithmetic mean, ratio of means for AUC0–t , AUC0–∞ ,
Cmax
(ix) Partial AUC, only if it is used
(x) Cmin , Cmax , Cpd , AUC0–␶ degree of fluctuation [(Cmax − Cmin )/Cav ], and
swing [(Cmax − Cmin )/Cmin ], if steady-state studies are employed (where
Cpd is the concentration of predose sample in period 02)

Quality Assurance
Systems and processes established to ensure that the trial is performed and the
data are generated in compliance with GCP must be in place. Quality assurance
(QA) is validated through in-process QC and in- and postprocess auditing of
clinical trial process as well as data.
The sponsor is responsible for the implementation of a system of QA to
ensure that the study is performed and the data are generated, recorded, and
reported in compliance with the protocol, GCP, and other applicable require-
ments. Documented standard operating procedures (SOPs) are a prerequisite
for QA.
All observations and findings should be verifiable for the credibility of the
data and to assure that the conclusions presented are correctly derived from the
raw data. Verification processes must therefore be specified and justified.
Statistically controlled sampling may be an acceptable method of data ver-
ification in each study. QC must be applied to each stage of data handling to
ensure that all data are reliable and have been processed correctly.
Sponsor audits should be conducted by persons independent of those
responsible for the study. Investigational sites, facilities, all data and documen-
tation should be available for inspection and audit by the sponsor’s auditor as
well as by the regulatory authority (ies).
Other considerations for quality documentation are the following:
a. A meticulous and specified plan for the various steps and procedures for the
purpose of controlling and monitoring the study most effectively.
b. Specifications and instructions for anticipated deviations from the protocol.
c. Allocation of duties and responsibilities within the research team and their
coordination.
d. Instructions to staff including study description (the way the study is to be
conducted and the procedures for drug usage and administration).
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e. Addresses and contact numbers, etc., enabling any staff member to contact
the research team at any hour.
f. Considerations of confidentiality problems, if any arise.
g. QC of methods and evaluation procedures.

WHEN BIOAVAILABILITY AND BIOEQUIVALENCE STUDIES ARE NOT

NECESSARY (WAIVERS)
Under the following circumstances, BE between a new drug product and the
reference product may be considered self-evident with no further requirement
for documentation:

(a) When new drug product is to be administered parenterally (e.g., intra-

venous, intramuscular, subcutaneous, intrathecal administration, etc.) as
aqueous solutions and that product contains the same active substance(s)
in the same concentration and incorporates the same excipients in compara-
ble concentrations as the reference product.
(b) When the new drug product is a solution for oral use, and contains the active
substance in the same concentration, and does not contain an excipient that
is known or suspected to affect gastrointestinal transit or absorption of the
active substance.
(c) When the new drug product is a gas.
(d) When the new drug product is a powder for reconstitution as a solution and
the solution meets either criterion (a) or criterion (b) above.
(e) When the new drug product is an otic or ophthalmic or topical product pre-
pared as an aqueous solution and contains the same active substance(s) in
the same concentration(s) and essentially the same excipients in comparable
concentrations to the reference product.
(f) When the new drug product is an inhalation product or a nasal spray, tested
to be administered with or without essentially the same device as the ref-
erence product, prepared as aqueous solutions, and contain the same active
substance(s) in the same concentration and essentially the same excipients in
comparable concentrations as the reference product. Special in vitro testing
is required to document device performance comparison between reference
inhalation product and the new drug product.

For criteria (e) and (f), the applicant is expected to demonstrate that the
excipients in the new drug are essentially the same and in comparable concen-
trations as those in the reference product. In the event that this information about
the reference product cannot be provided by the applicant, in vivo studies need
to be performed.

In Vitro Studies
Under the following circumstances BE may be assessed by the use of in vitro
dissolution testing.

a. Drugs for which the applicant provides data to substantiate all of the
following:
i. Highest dose strength is soluble in 250 mL of an aqueous media over the
pH range of 1 to 7.5 at 37◦ C.
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134 Mandal and Ravisankar

ii. At least 90% of the administered oral dose is absorbed on mass balance
determination or in comparison to an intravenous reference dose.
iii. Speed of dissolution as demonstrated by more than 80% dissolution
within 15 minutes at 37◦ C using IP apparatus 1, at 50 rpm or IP appa-
ratus 2, at 100 rpm in a volume of 900 mL or less in each of the following
media:
1. 0.1 N hydrochloric acid or artificial gastric juice (without enzymes).
2. A pH 4.4 buffer.
3. A pH 6.8 buffer or artificial intestinal juice (without enzymes).
b. Different strength of the drug manufactured by the same manufacturer,
where all of the following criteria are fulfilled:
i. The qualitative compositions between the strength is essentially the
same.
ii. The ratio of active ingredients and excipients between the strength is
essentially the same, or in the case of low strengths, the ratio between
the excipients is the same.
iii. The methods of manufacture is essentially the same.
iv. An appropriate BE study has been performed on at least one of the
strengths of the formulations (usually the highest strengths unless a
lower strength is chosen for reasons of safety).
v. In case of systemic availability—pharmacokinetics have been shown to
be linear over the therapeutic dose range.

In vitro dissolution testing may also be suitable to confirm unchanged

product quality and performance characteristics with minor formulation or man-
ufacturing changes after approval.

SUMMARY AND CONCLUSIONS

In India, generic medicines are those medicines, which are labeled with their
generic names. There is no separate law for registering generic medicines in
India. Drugs and drug products are classified as either (i) “new drugs” or (ii)
drugs other than new drugs. If any drug does not fall under the ambit of a new
drug, licenses may be issued by the state licensing Authority. India has a two-tier
regulatory system, one is CDSCO under the Government of India having certain
powers vested in them and each state has its own drug regulatory system hav-
ing certain powers. CDSCO is authorized to approve new drugs as defined under
Rule 122E of the Drugs and Cosmetic Rules following schedule Y of the Drugs
and Cosmetics Rules but the state drugs control agency cannot grant new drug
licenses. A BA/BE study is needed for manufacturing a new drug (drug product)
in India and to import a new drug (drug product) from another country. If the
formulation is the first market entry of the drug substance, the product’s phar-
macokinetic parameters should be determined. If the formulation is a second
or subsequent market entry then comparative BA studies using an appropriate
reference product, should be performed. For the first generic drug product, the
international innovator drug product should be used as the reference product
but for subsequent products, it may be the product approved earlier, which has
been deemed to be equivalent to the international innovator product.
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REFERENCES
1. Pharmacopoeia of India, Vol I, 3rd ed. Ministry of Health and Family Welfare, Gov-
ernment of India, xvi, 1985.
2. The Drugs and Cosmetics Act 1940 & The Drugs and Cosmetics Rules 1945, Ministry
of Health and Family Welfare, Government of India, 425–459, 2005.
3. Ghosh A, Hazra A, Mandal SC, New Drugs in India over the past 15 years: Analysis
of trends. Natl Med J India 2004; 17(1):10–16.
4. The Patents (Amendment) Act 2005, The Gazette of India: Extraordinary, Part II-Sec.
I, 2005:1–18.
5. The Patents (Amendment) Rules, 2005, The Gazette of India: Extraordinary, Part II-
Sec. 3 (ii), 2004:60–108.
6. The Drugs and Cosmetics Act 1940 & The Drugs and Cosmetics Rules 1945, Ministry
of Health and Family Welfare, Government of India, 97, 2005.
7. Guidelines for Bioavailability & Bioequivalance Studies, Central Drugs Standard
Control Organization, Directorate General of Health Services, Ministry of Health &
Family Welfare, Government of India, New Delhi, March 9–12, 2005.
8. GCP (Good Clinical Practice) Guidelines issued by CDSCO (Central Drugs Standards
Control Organization), Ministry of Health and Family Welfare, India.
9. Schedule Y, and amendment to Drugs & Cosmetic Act & Rules, Ministry of Health
and Family Welfare, India, 2005.
10. The Ethical Guidelines for Biomedical research on human subjects issued by Indian
Council of Medical Research, India, 2006.

APPENDIX I:DATA TO BE SUBMITTED ALONG WITH THE APPLICATION

TO CONDUCT CLINICAL TRIALS/IMPORT/MANUFACTURE OF NEW
DRUGS FOR MARKETING IN INDIA
1. Introduction
A brief description of the drug and the therapeutic class to which it belongs.
2. Chemical and pharmaceutical information
2.1. Information on active ingredients
Drug information (generic name, chemical name, or INN)
2.2. Physicochemical data
a. Chemical name and structure
Empirical formula
Molecular weight
b. Physical properties
Description
Solubility
Rotation
Partition coefficient
Dissociation constant
2.3. Analytical data
Elemental analysis
Mass spectrum
NMR spectra
IR spectra
UV spectra
Polymorphic identification
2.4. Complete monograph specification including:
Identification
Identity/quantification of impurities
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Enantiomeric purity
Assay
2.5. Validation:
Assay method
Impurity estimation method
Residual solvent/other volatile impurities (OVI) estimation method
2.6. Stability studies (for details refer Appendix IX)
Final release specification
Reference standard characterization
Material safety data sheet
2.7. Data on Formulation:
Dosage form
Composition
Master manufacturing formula
Details of the formulation (including inactive ingredients)
In-process quality control check
Finished product specification
Excipient compatibility study
Validation of the analytical method
Comparative evaluation with international brand(s) or approved Indian
brands, if applicable
Pack presentation
Dissolution
Assay
Impurities
Content uniformity
pH
Forced degradation studies
Stability evaluation in market intended pack at proposed storage con-
ditions
Packing specifications
Process validation
When the application is for clinical trials only, the INN or generic name,
drug category, dosage form, and data supporting stability in the intended
container-closure system for the duration of the clinical trial (information
covered in items 2.1, 2.3, 2.6, 2.7) are required.
3. Animal Pharmacology (for details refer Appendix IV)
3.1. Summary
3.2. Specific pharmacological actions
3.3. General pharmacological actions
3.4. Follow-up and Supplemental Safety Pharmacology Studies
3.5. Pharmacokinetics: absorption, distribution; metabolism; excretion
4. Animal toxicology (for details refer Appendix III)
4.1. General aspects
4.2. Systemic toxicity studies
4.3. Male fertility study
4.4. Female reproduction and developmental toxicity studies
4.5. Local toxicity
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4.6. Allergenicity/hypersensitivity
4.7. Genotoxicity
4.8. Carcinogenicity
5. Human/Clinical pharmacology (Phase I)
5.1. Summary
5.2. Specific pharmacological effects
5.3. General pharmacological effects
5.4. Pharmacokinetics, absorption, distribution, metabolism, excretion
5.5. Pharmacodynamics/early measurement of drug activity
6. Therapeutic exploratory trials (Phase II)
6.1. Summary
6.2. Study report(s) as given in Appendix II
7. Therapeutic confirmatory trials (Phase III)
7.1. Summary
7.1. Individual study reports with listing of sites and investigators.
8. Special studies
8.1. Summary
8.1. Bioavailability/Bio-equivalence.
8.1. Other studies, for example, geriatrics, pediatrics, pregnant, or nursing
women
9. Regulatory status in other countries
9.1. Countries where the drug is
a. Marketed
b. Approved
c. Approved as IND
d. Withdrawn, if any, with reasons
9.2 Restrictions on use, if any, in countries where marketed /approved
9.2 Free sale certificate or certificate of analysis, as appropriate.
10. Prescribing information
10.1. Proposed full prescribing information
10.2. Drafts of labels and cartons
11. Samples and testing protocol/s
11.1. Samples of pure drug substance and finished product (an equivalent
of 50 clinical doses, or more number of clinical doses if prescribed by
the licensing authority), with testing protocol/s, full impurity profile,
and release specifications.

Notes:
(1) All items may not be applicable to all drugs. For explanation, refer to text of Schedule Y.
(2) For requirements of data to be submitted with application for clinical trials refer to the text
of this Schedule.

APPENDIX I-A: DATA REQUIRED TO BE SUBMITTED BY AN APPLICANT

FOR PERMISSION TO IMPORT AND/OR MANUFACTURE A NEW DRUG
ALREADY APPROVED IN THE COUNTRY
1. Introduction
A brief description of the drug and the therapeutic class
2. Chemical and pharmaceutical information
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2.1 Chemical name, code name or number, if any; nonproprietary or generic

name, if any, structure; physicochemical properties
2.2 Dosage form and its composition
2.3 Test specifications
(a) Active ingredients
(b) Inactive ingredients
2.4 Tests for identification of the active ingredients and method of its assay
2.5 Outline of the method of manufacture of active ingredients
2.6 Stability data
3. Marketing Information
3.1 Proposed package insert/promotional literature
3.2 Draft specimen of the label and carton
4. Special studies conducted with approval of licensing authority
4.1 Bioavailability/bioequivalence and comparative dissolution studies for
oral dosage forms
4.2 Subacute animal toxicity studies for intravenous infusions and injecta-
bles.

APPENDIX II: STRUCTURE, CONTENTS, AND FORMAT FOR CLINICAL

STUDY REPORTS
1. Title Page:
This page should contain information about the title of the study, the pro-
tocol code, name of the investigational product tested, development
phase, indication studied, a brief description of the trial design, the
start and end date of patient accrual, and the names of the sponsor
and the participating institutes (investigators).
2. Synopsis (one to two pages): A brief overview of the study from the protocol
development to the trial closure should be given here. This section will only
summarize the important conclusions derived from the study.
3. Statement of compliance with the “Guidelines for Clinical Trials on Pharma-
ceutical Products in India—GCP Guidelines” issued by the Central Drugs
Standard Control Organization, Ministry of Health, Government of India.
4. List of abbreviations and definitions
5. Table of contents
6. Ethics committee:
This section should document that the study was conducted in accor-
dance with the ethical principles of Declaration of Helsinki. A
detailed description of the ethics committee constitution and date(s) of
approvals of trial documents for each of the participating sites should
be provided. A declaration should state that EC notifications as per
good clinical practice guidelines issued by Central Drugs Standard
Control Organization and Ethical Guidelines for Biomedical Research
on Human Subjects, issued by Indian Council of Medical Research
have been followed.
7. Study team:
This section will briefly describe the administrative structure of the study
(investigators, site staff, sponsor/designates, central laboratory, etc.).
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8. Introduction:
A brief description of the product development rationale should be given
here.
9. Study objective:
A statement describing the overall purpose of the study and the primary
and secondary objectives to be achieved should be mentioned here.
10. Investigational plan:
This section should describe the overall trial design, the subject selection cri-
teria, the treatment procedures, blinding/randomization techniques
if any, allowed/disallowed concomitant treatment, the efficacy and
safety criteria assessed, the data quality assurance procedures, and the
statistical methods planned for the analysis of the data obtained.
11. Trial subjects:
A clear accounting of all trial subjects who entered the study will be given
here. Mention should also be made of all cases that were dropouts
or protocol deviations. Enumerate the patients screened, randomized,
and prematurely discontinued. State reasons for premature discontin-
uation of therapy in each applicable case.
12. Efficacy evaluation:
The results of evaluation of all the efficacy variables will be described in
this section with appropriate tabular and graphical representation. A
brief description of the demographic characteristics of the trial patients
should also be provided along with a listing of patients and observa-
tions excluded from efficacy analysis.
13. Safety evaluation:
This section should include the complete list of all serious adverse events,
whether expected or unexpected and adverse events whether serious
or not (compiled from data received as per Appendix XI).
The comparison of adverse events across study groups may be presented in
a tabular or graphical form. This section should also give a brief nar-
rative of all important events considered related to the investigational
product.
14. Discussion and overall conclusion:
Discussion of the important conclusions derived from the trial and scope for
further development.
15. List of references
16. Appendices
List of Appendices to the Clinical Trial Report
a. Protocol and amendments
b. Specimen of Case Record Form
c. Investigators’ name(s) with contact addresses, phone, email etc.
d. Patient data listings
e. List of trial participants treated with investigational product
f. Discontinued participants
g. Protocol deviations
h. CRFs of cases involving death and life threatening adverse event cases
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i. Publications from the trial

j. Important publications referenced in the study
k. Audit certificate, if available
l. Investigator’s certificate that he/she has read the report and that the report
accurately describes the conduct and the results of the study.

APPENDIX III: ANIMAL TOXICOLOGY (NONCLINICAL TOXICITY STUDIES)

General Principles
Toxicity studies should comply with the norms of good laboratory practice
(GLP). Briefly, these studies should be performed by suitably trained and qual-
ified staff employing properly calibrated and standardized equipment of ade-
quate size and capacity. Studies should be done as per written protocols with
modifications (if any) verifiable retrospectively. Standard operating procedures
(SOPs) should be followed for all managerial and laboratory tasks related to
these studies. Test substances and test systems (in vitro or in vivo) should
be properly characterized and standardized. All documents belonging to each
study, including its approved protocol, raw data, draft report, final report, and
histology slides and paraffin tissue blocks should be preserved for a minimum
of five years after marketing of the drug.
Toxicokinetic studies (generation of pharmacokinetic data either as an inte-
gral component of the conduct of nonclinical toxicity studies or in specially
designed studies) should be conducted to assess the systemic exposure achieved
in animals and its relationship to dose level and the time course of the toxicity
study. Other objectives of toxicokinetic studies include obtaining data to relate
the exposure achieved in toxicity studies to toxicological findings and contribute
to the assessment of the relevance of these findings to clinical safety, to support
the choice of species and treatment regimen in nonclinical toxicity studies, and to
provide information, which, in conjunction with the toxicity findings, contributes
to the design of subsequent nonclinical toxicity studies.

Systemic Toxicity Studies

Single-Dose Toxicity Studies. These studies (see Appendix I item 4.2) should be
carried out in two rodent species (mice and rats) by using the same route as
intended for humans. In addition, unless the intended route of administration
in humans is only intravenous, at least one more route should be used in one of
the species to ensure systemic absorption of the drug. This route should depend
on the nature of the drug. A limit of 2 g/kg (or 10 times the normal dose that is
intended in humans, whichever is higher) is recommended for oral dosing. Ani-
mals should be observed for 14 days after the drug administration, and minimum
lethal dose (MLD) and maximum tolerated dose (MTD) should be established. If
possible, the target organ of toxicity should also be determined. Mortality should
be observed for up to seven days after parenteral administration and up to 14
days after oral administration. Symptoms, signs, and mode of death should be
reported, with appropriate macroscopic and microscopic findings where neces-
sary. LD10 and LD50 should be reported preferably with 95% confidence limits. If
LD50 s cannot be determined, reasons for the same should be stated.
The dose causing severe toxic manifestations or death should be defined
in the case of cytotoxic anticancer agents, and the postdosing observation period
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should be up to 14 days. Mice should first be used for determination of MTD.

Findings should then be confirmed in rat for establishing linear relationship
between toxicity and body surface area. In case of nonlinearity, data of the more
sensitive species should be used to determine the Phase I starting dose. Where
rodents are known to be poor predictors of human toxicity (e.g., antifolates), or
where the cytotoxic drug acts by a novel mechanism of action, MTD should be
established in non–rodent species.

Repeated-Dose Systemic Toxicity Studies

These studies (see Appendix I, item 4.2) should be carried out in at least two
mammalian species, of which one should be a non–rodent species. Dose-ranging
studies should precede the 14-, 28-, 90-, or 180-day toxicity studies. Duration
of the final systemic toxicity study will depend on the duration, therapeutic
indication, and scale of the proposed clinical trial (see item 1.8). If a species is
known to metabolize the drug in the same way as humans, it should be preferred
for toxicity studies.
In repeated-dose toxicity studies the drug should be administered seven
days a week by the route intended for clinical use. The number of animals
required for these studies, that is, the minimum number of animals on which
data should be available, is shown in item 1.9.
Wherever applicable, a control group of animals given the vehicle alone
should be included, and three other groups should be given graded doses of
the drug. The highest dose should produce observable toxicity; the lowest dose
should not cause observable toxicity, but should be comparable to the intended
therapeutic dose in humans or a multiple of it. To make allowance for the sensi-
tivity of the species the intermediate dose should cause some symptoms, but not
gross toxicity or death, and should be placed logarithmically between the other
two doses.
The parameters to be monitored and recorded in long-term toxicity studies
should include behavioral, physiological, biochemical, and microscopic obser-
vations. In case of parenteral drug administration, the sites of injection should
be subjected to gross and microscopic examination. Initial and final electro-
cardiogram and fundus examination should be carried out in the non–rodent
species.
In the case of cytotoxic anticancer agents, dosing and study design should
be in accordance with the proposed clinical schedule in terms of days of exposure
and number of cycles. Two rodent species may be tested for initiating Phase I
trials. A non–rodent species should be added if the drug has a novel mechanism
of action, or if permission for Phases II, III, or marketing is being sought.
For most compounds, it is expected that single-dose tissue distribution
studies with sufficient sensitivity and specificity will provide an adequate assess-
ment of tissue distribution and the potential for accumulation. Thus, repeated-
dose tissue distribution studies should not be required uniformly for all com-
pounds and should only be conducted when appropriate data cannot be derived
from other sources. Repeated-dose studies may be appropriate under certain cir-
cumstances based on the data from single-dose tissue distribution studies, toxi-
city studies, and toxicokinetic studies. The studies may be most appropriate for
compounds that have an apparently long half-life, incomplete elimination, or
unanticipated organ toxicity.
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Notes:
(i) Single-dose toxicity study: Each group should contain at least five animals of either sex. At
least four graded doses should be given. Animals should be exposed to the test substance
in a single bolus or by continuous infusion or several doses within 24 hours. Animals
should be observed for 14 days. Signs of intoxication, effect on body weight, gross patho-
logical changes should be reported. It is desirable to include histopathology of grossly
affected organs, if any.
(ii) Dose-ranging study: Objectives of this study include the identification of target organ of
toxicity and establishment of MTD for subsequent studies.
(a) Rodents: Study should be performed in one rodent species (preferably rat) by the
proposed clinical route of administration. At least four graded doses including control
should be given, and each dose group as well as the vehicle control should consist of a
minimum of five animals of each sex. Animals should be exposed to the test substance
daily for 10 consecutive days. Highest dose should be the MTD of single-dose study.
Animals should be observed daily for signs of intoxication (general appearance, activity,
and behavior, etc.), and periodically for the body weight and laboratory parameters.
Gross examination of viscera and microscopic examination of affected organs should be
done. (b) Non–rodent species: One male and one female are to be taken for ascending
Phase MTD study. Dosing should start after initial recording of cage-side and laboratory
parameters. Starting dose may be three to five times the extrapolated effective dose or
MTD (whichever is less), and dose escalation in suitable steps should be done every
third day after drawing the samples for laboratory parameters. Dose should be lowered
appropriately when clinical or laboratory evidence of toxicity is observed. Administration
of test substance should then continue for 10 days at the well-tolerated dose level fol-
lowing which, samples for laboratory parameters should be taken. Sacrifice, autopsy, and
microscopic examination of affected tissues should be performed as in the case of rodents.
(iii) 14- to 28-day repeated-dose toxicity studies: One rodent (6–10/sex/group) and one non–
rodent (2–3/sex/group) species are needed. Daily dosing by proposed clinical route at
three dose levels should be done with highest dose having observable toxicity, mid-dose
between high and low dose, and low dose. The doses should preferably be multiples of the
effective doses and free from toxicity. Observation parameters should include cage-side
observations, body weight changes, food/water intake, blood biochemistry, hematology,
and gross and microscopic studies of all viscera and tissues.
(iv) 90-day repeated-dose toxicity studies: One rodent (15–30/sex/group) and one non–rodent
(4–6/sex/group) species are needed. Daily dosing by proposed clinical route at three
graded dose levels should be done. In addition to the control a “high-dose-reversal”
group and its control group should be also included. Parameters should include signs of
intoxication (general appearance, activity, behavior, etc.), body weight, food intake, blood
biochemical parameters, hematological values, urine analysis, organ weights, gross and
microscopic study of viscera and tissues. Half the animals in “reversal” groups (treated
and control) should be sacrificed after 14 days of stopping the treatment. The remaining
animals should be sacrificed after 28 days of stopping the treatment or after the recovery
of signs and/or clinical pathological changes—whichever comes later, and evaluated for
the parameters used for the main study.
(v) 180-day repeated-dose toxicity studies: One rodent (15–30/sex/group) and one non–
rodent (4–6/sex/group) species are needed. At least four groups, including control,
should be taken. Daily dosing by proposed clinical route at three graded dose levels
should be done. Parameters should include signs of intoxication, body weight, food intake,
blood biochemistry, hematology, urine analysis, organ weights, gross and microscopic
examination of organs and tissues.

Male Fertility Study

One rodent species (preferably rat) should be used. Dose selection should be
done from the results of the previous 14- or 28-day toxicity study in rat. Three
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dose groups, the highest one showing minimal toxicity in systemic studies, and
a control group should be taken. Each group should consist of six adult male
animals. Animals should be treated with the test substance by the intended route
of clinical use for minimum 28 days and maximum 70 days before they are paired
with female animals of proven fertility in a ratio of 1:2 for mating.
Drug treatment of the male animals should continue during pairing. Pair-
ing should be continued till the detection of vaginal plug or 10 days, whichever
is earlier. Females thus getting pregnant should be examined for their fertility
index after day 13 of gestation. All the male animals should be sacrificed at the
end of the study. Weights of each testis and epididymis should be separately
recorded. Sperms from one epididymis should be examined for their motility
and morphology. The other epididymis and both testes should be examined for
their histology.

Female Reproduction and Developmental Toxicity Studies

These studies (see Appendix I, item 4.4) need to be carried out for all drugs pro-
posed to be studied or used in women of child-bearing age. Segment I, II, and
III studies (see later) are to be performed in albino mice or rats, and Segment II
study should include albino rabbits also as a second test species.
On the occasion, when the test article is not compatible with the rabbit
(e.g., antibiotics that are effective against gram-positive anaerobic organisms and
protozoas) the Segment II data in the mouse may be substituted.

Female Fertility Study (Segment I)

The study should be done in one rodent species (rat preferred). The drug should
be administered to both males and females, beginning a sufficient number of
days (28 days in males and 14 days in females) before mating. Drug treatment
should continue during mating and, subsequently, during the gestation period.
Three graded doses should be used; the highest dose (usually the MTD obtained
from previous systemic toxicity studies) should not affect general health of the
parent animals. At least 15 males and 15 females should be used per dose group.
Control and the treated groups should be of similar size. The route of adminis-
tration should be the same as intended for therapeutic use.
Dames should be allowed to litter and their medication should be contin-
ued till the weaning of pups. Observations on body weight, food intake, clinical
signs of intoxication, mating behavior, progress of gestation/parturition peri-
ods, length of gestation, parturition, postpartum health, and gross pathology
(and histopathology of affected organs) of dames should be recorded. The pups
from both treated and control groups should be observed for general signs of
intoxication, sex-wise distribution in different treatment groups, body weight,
growth parameters, survival, gross examination, and autopsy. Histopathology of
affected organs should be done.

Teratogenicity Study (Segment II)

One rodent (preferably rat) and one non–rodent (rabbit) species are to be used.
The drug should be administered throughout the period of organogenesis, using
three dose levels as described for Segment I. The highest dose should cause min-
imum maternal toxicity and the lowest one should be proportional to the pro-
posed dose for clinical use in humans or a multiple of it. The route of adminis-
tration should be the same as intended for human therapeutic use.
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The control and the treated groups should consist of at least 20 pregnant
rats (or mice) and 12 rabbits, on each dose level. All fetuses should to be sub-
jected to gross examination, one of the fetuses should be examined for skeletal
abnormalities and the other half for visceral abnormalities. Observation parame-
ters should include (dames) signs of intoxication, effect on body weight, effect on
food intake, examination of uterus, ovaries and uterine contents, number of cor-
pora lutea, implantation sites, resorptions (if any); and for the fetuses, the total
number, gender, body length, weight and gross/visceral/skeletal abnormalities,
if any.

Perinatal Study (Segment III)

This study is specially recommended if the drug is to be given to pregnant
or nursing mothers for long periods or where there are indications of possi-
ble adverse effects on fetal development. One rodent species (preferably rat) is
needed. Dosing at levels comparable to multiples of human dose should be done
by the intended clinical route. At least four groups (including control), each con-
sisting of 15 dames should be used. The drug should be administered through-
out the last trimester of pregnancy (from day 15 of gestation) and then the dose
that causes low fetal loss should be continued throughout lactation and weaning.
Dames should then be sacrificed and examined as described later.
One male and one female from each litter of F1 generation (total 15 males
and 15 females in each group) should be selected at weaning and treated with
vehicle or test substance (at the dose levels already described) throughout their
periods of growth to sexual maturity, pairing, gestation, parturition, and lac-
tation. Mating performance and fertility of F1 generation should thus be eval-
uated to obtain the F2 generation whose growth parameters should be moni-
tored till weaning. The criteria of evaluation should be the same as described
earlier (3.4.1).
Animals should be sacrificed at the end of the study and the observation
parameters should include (dames) body weight, food intake, general signs of
intoxication, progress of gestation/parturition periods, and gross pathology (if
any); and for pups, the clinical signs, sex-wise distribution in dose groups, body
weight, growth parameters, gross examination, survival, and autopsy (if needed)
and where necessary, histopathology.

Local Toxicity
These studies (see Appendix I, item 4.5) are required when the new drug is pro-
posed to be used by some special route (other than oral) in humans. The drug
should be applied to an appropriate site (e.g., skin or vaginal mucous membrane)
to determine local effects in a suitable species. Typical study designs for these
studies should include three dose levels and untreated and/ or vehicle control,
preferably use of two species, and increasing group size with increase in duration
of treatment. Where dosing is restricted due to anatomical or humane reasons, or
the drug concentration cannot be increased beyond a certain level due to the
problems of solubility, pH or tonicity, a clear statement to this effect should be
given. If the drug is absorbed from the site of application, appropriate systemic
toxicity studies will also be required.
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Notes:
(i) Dermal toxicity study: The study should be done in rabbit and rat. Daily topical (dermal)
application of test substance in its clinical dosage form should be done. Test material
should be applied on shaved skin covering not less than 10% of the total body surface
area. Porous gauze dressing should be used to hold liquid material in place. Formulations
with different concentrations (at least three) of test substance, several fold higher than
the clinical dosage form should be used. Period of application may vary from 7 to 90
days depending on the clinical duration of use. Where skin irritation is grossly visible
in the initial studies, a recovery group should be included in the subsequent repeated-
dose study. Local signs (erythema, edema, and eschar formation) as well as histological
examination of sites of application should be used for evaluation of results.
(ii) Photoallergy or dermal phototoxicity: It should be tested by Armstrong/Harber Test in
guinea pig. This test should be done if the drug or a metabolite is related to an agent
causing photosensitivity or the nature of action suggests such a potential (e.g., drugs to
be used in treatment of leucoderma). Pretest in eight animals should screen four con-
centrations (patch application for 2 hours ± 15 minutes) with and without UV expo-
sure (10 J/cm2 ). Observations recorded at 24 and 48 hours should be used to ascertain
highest nonirritant dose. Main test should be performed with 10 test animals and 5 con-
trols. Induction with the dose selected from pretest should use 0.3 mL/patch for 2 hour ±
15 minutes followed by 10 J/cm2 of UV exposure. This should be repeated on day 0, 2, 4,
7, 9, and 11 of the test. Animals should be challenged with the same concentration of test
substance between day 20 and 24 of the test with a similar 2-hour application followed
by exposure to 10 J/cm2 of UV light. Examination and grading of erythema and edema
formation at the challenge sites should be done 24 and 48 hours after the challenge. A
positive control like musk ambrett or psoralin should be used.
(iii) Vaginal toxicity test: Study is to be done in rabbit or dog. Test substance should be applied
topically (vaginal mucosa) in the form of pessary, cream, or ointment. Six to ten animals
per dose group should be taken. Higher concentrations or several daily applications of
test substance should be done to achieve multiples of daily human dose. The minimum
duration of drug treatment is seven days (more according to clinical use), subject to a
maximum of 30 days. Observation parameters should include swelling, closure of introi-
tus, and histopathology of vaginal wall.
(iv) Rectal tolerance test: For all preparations meant for rectal administration this test may be
performed in rabbits or dogs. Six to ten animals per dose group should be taken. Formu-
lation in volume comparable to human dose (or the maximum possible volume) should
be applied once or several times daily, per rectally, to achieve administration of multi-
ples of daily human dose. The minimum duration of application is seven days (more
according to clinical use), Subject to a maximum of 30 days. Size of suppositories may be
smaller, but the drug content should be several folds higher than the proposed human
dose. Observation parameters should include clinical signs (sliding on backside), signs
of pain, blood and/or mucus in feces, condition of anal region/sphincter, gross, and (if
required) histological examination of rectal mucosa.
(v) Parenteral drugs: For products meant for intravenous or intramuscular or subcutaneous
or intradermal injection the sites of injection in systemic toxicity studies should be spe-
cially examined grossly and microscopically. If needed, reversibility of adverse effects
may be determined on a case-to-case basis.
(vi) Ocular toxicity studies (for products meant for ocular instillation): These studies should
be carried out in two species, one of which should be the albino rabbit, which has a
sufficiently large conjunctival sac. Direct delivery of drug onto the cornea in case of
animals having small conjunctival sacs should be ensured. Liquids, ointments, gels, or
soft contact lenses (saturated with drug) should be used. Initial single-dose application
should be done to decide the exposure concentrations for repeated-dose studies and
the need to include a recovery group. Duration of the final study will depend on the
proposed length of human exposure subject to a maximum of 90 days. At least two
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different concentrations exceeding the human dose should be used for demonstrating the
margin of safety. In acute studies, one eye should be used for drug administration and
the other kept as control. A separate control group should be included in repeated-dose
studies.
Slit-lamp examination should be done to detect the changes in cornea, iris, and aque-
ous humor. Fluorescent dyes (sodium fluorescein, 0.25–1.0%) should be used for detecting
the defects in surface epithelium of cornea and conjunctiva. Changes in intraocular ten-
sion should be monitored by a tonometer. Histological examination of eyes should be
done at the end of the study after fixation in Davidson’s or Zenker’s fluid.
(vii) Inhalation toxicity studies: The studies are to be undertaken in one rodent and one
non–rodent species using the formulation that is to be eventually proposed to be mar-
keted. Acute, subacute, and chronic toxicity studies should be performed according to
the intended duration of human exposure. Standard systemic toxicity study designs
(described earlier) should be used. Gases and vapors should be given in whole body
exposure chambers; aerosols are to be given by nose-only method. Exposure time and
concentrations of test substance (limit dose of 5 mg/L) should be adjusted to ensure expo-
sure at levels comparable to multiples of intended human exposure. Three dose groups
and a control (plus vehicle control, if needed) are required. Duration of exposure may
vary subject to a maximum of 6 h/d and five days a week. Food and water should be
withdrawn during the period of exposure to test substance.
Temperature, humidity, and flow rate of exposure chamber should be recorded and
reported. Evidence of exposure with test substance of particle size of 4 ␮m (especially for
aerosols) with not less that 25% being 1 ␮m should be provided. Effects on respiratory
rate, findings of bronchial lavage fluid examination, and histological examination of res-
piratory passages and lung tissue should be included along with the regular parameters
of systemic toxicity studies or assessment of margin of safety.

Allergenicity/Hypersensitivity
Standard tests include guinea pig maximization test (GPMT) and local lymph
node assay (LLNA) in mouse. Any one of the two may be done.

Notes:
(i) Guinea pig maximization test: The test is to be performed in two steps: first, determination
of maximum nonirritant and minimum irritant doses, and second, the main test. The initial
study will also have two components. To determine the intradermal induction dose, four
dose levels should be tested by the same route in a batch of four males and four females
(two of each sex should be given Freund’s adjuvant). The minimum irritant dose should
be used for induction. Similarly, a topical minimum irritant dose should be determined
for challenge. This should be established in two males and two females. A minimum of
six males and six females per group should be used in the main study. One test and one
control group should be used. It is preferable to have one more positive control group.
Intradermal induction (day 1) coupled with topical challenge (day 21) should be done. If
there is no response, re-challenge should be done 7 to 30 days after the primary challenge.
Erythema and edema (individual animal scores as well as maximization grading) should
be used as evaluation criteria.
(ii) Local lymph node assay: Mice used in this test should be of the same sex, either only males
or only females. Drug treatment is to be given on ear skin. Three graded doses, the highest
being maximum nonirritant dose plus vehicle control should be used. A minimum of six
mice per group should be used. Test material should be applied on ear skin on three consec-
utive days and on day 5, the draining auricular lymph nodes should be dissected out five
hours after IV 3 H-thymidine or bromo-deoxy-uridine (BrdU). Increase in 3 H-thymidine or
BrdU incorporation should be used as the criterion for evaluation of results.
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Genotoxicity
Genotoxic compounds, in the absence of other data, shall be presumed to be
transspecies carcinogens, implying a hazard to humans. Such compounds need
not be subjected to long-term carcinogenicity studies. However, if such a drug is
intended to be administered for chronic illnesses or otherwise over a long period
of time—a chronic toxicity study (up to one year) may be necessary to detect
early tumorigenic effects.
Genotoxicity tests are in vitro and in vivo tests conducted to detect com-
pounds, which induce genetic damage directly or indirectly. These tests should
enable hazard identification with respect to damage to DNA and its fixation.
The following standard test battery is generally expected to be conducted:

(i) A test for gene mutation in bacteria.

(ii) An in vitro test with cytogenetic evaluation of chromosomal damage with
mammalian cells or an in vitro mouse lymphoma tic assay.
(iii) An in vivo test for chromosomal damage using rodent hematopoietic cells.

Other genotoxicity tests, for example, tests for measurement of DNA

adducts, DNA strand breaks, DNA repair or recombination serve as options
in addition to the standard battery for further investigation of genotoxicity test
results obtained in the standard battery. Only under extreme conditions in which
one or more tests comprising the standard battery cannot be employed for tech-
nical reasons, alternative validated tests can serve as substitutes provided suffi-
cient scientific justification should be provided to support the argument that a
given standard battery test is not appropriate.
Both in vitro and in vivo studies should be done. In vitro studies should
include Ames’ Salmonella assay and chromosomal aberrations (CA) in cultured
cells. In vivo studies should include micronucleus assay (MNA) or CA in rodent
bone marrow. Data analysis of CA should include analysis of “gaps.’
Cytotoxic anticancer agents: Genotoxicity data are not required before
Phase I and II trials. But these studies should be completed before applying for
Phase III trials.

Notes:
Ames’ Test (Reverse mutation assay in Salmonella): S. typhimurium tester strains such as TA98,
TA100, TA102, TA1535, TA97, or Escherichia coli WP2 uvrA or E. coli WP2 uvrA (pKM101) should
be used.

(i) In vitro exposure (with and without metabolic activation, S9 mix) should be done at a
minimum of five log dose levels. “Solvent” and “positive” control should be used. Posi-
tive control may include 9-amino-acridine, 2-nitrofluorine, sodium azide, and mitomycin
C, respectively, in the tester strains mentioned above. Each set should consist of at least
three replicates. A 2.5-fold (or more) increase in number of revertants in comparison to
spontaneous revertants would be considered positive.
(ii) In vitro cytogenetic assay: The desired level of toxicity for in vitro cytogenetic tests
using cell lines should be greater than 50% reduction in cell number or culture con-
fluency. For lymphocyte cultures, an inhibition of mitotic index by greater than 50% is
considered sufficient. It should be performed in CHO cells or on human lymphocyte
in culture. In vitro exposure (with and without metabolic activation, S9 mix) should be
done using a minimum of three log doses. “Solvent” and “positive” control should be
included. A positive control such as cyclophosphamide with metabolic activation and
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mitomycin C for without metabolic activation should be used to give a reproducible and
detectable increase clastogenic effect over the background, which demonstrates the sen-
sitivity of the test system. Each set should consist of at least three replicates. Increased
number of aberrations in metaphase chromosomes should be used as the criteria for
evaluation.
(iii) In vivo micronucleus assay: One rodent species (preferably mouse) is needed. Route of
administration of test substance should be the same as intended for humans. Five ani-
mals per sex per dose groups should be used. At least three dose levels, plus “solvent”
and “positive” control should be tested. A positive control like mitomycin C or cyclophos-
phamide should be used. Dosing should be done on day 1 and 2 of study followed by
sacrifice of animals six hours after the last injection. Bone marrow from both the femora
should be taken out, flushed with fetal bovine serum (20 minutes), pelletted and smeared
on glass slides. Giemsa–MayGruenwald staining should be done and increased number
of micronuclei in polychromatic erythrocytes (minimum 1000) should be used as the eval-
uation criteria.
(iv) In vivo cytogenetic assay: One rodent species (preferably rat) is to be used. Route of
administration of test substance should be the same as intended for humans. Five ani-
mals/sex/dose groups should be used. At least three dose levels, plus “solvent” and
“positive” control should be tested. Positive control may include cyclophosphamide. Dos-
ing should be done on day 1 followed by intraperitoneal colchicine administration at 22
hours. Animals should be sacrificed two hours after colchicine administration. Bone mar-
row from both the femora should be taken out, flushed with hypotonic saline (20 minutes),
pelletted and resuspended in Carnoy’s fluid. Once again the cells should be pelletted and
dropped on clean glass slides with a Pasteur pipette. Giemsa staining should be done and
increased number of aberrations in metaphase chromosomes (minimum 100) should be
used as the evaluation criteria.

Carcinogenicity (see Appendix I, Item 4.8)

Carcinogenicity studies should be performed for all drugs that are expected to be
clinically used for more than six months as well as for drugs used frequently in an
intermittent manner in the treatment of chronic or recurrent conditions. Carcino-
genicity studies are also to be performed for drugs if there is concern about their
carcinogenic potential emanating from previous demonstration of carcinogenic
potential in the product class that is considered relevant to humans or where
structure–activity relationship suggests carcinogenic risk or when there is evi-
dence of preneoplastic lesions in repeated-dose toxicity studies or when long-
term tissue retention of parent compound or metabolite(s) results in local tissue
reactions or other pathophysiological responses. For pharmaceuticals developed
to treat certain serious diseases, licensing authority may allow carcinogenicity
testing to be conducted after marketing permission has been granted.
In instances where the life expectancy in the indicated population is
short (i.e., less than two to three years), no long-term carcinogenicity studies
may be required. In cases where the therapeutic agent for cancer is generally
successful and life is significantly prolonged there may be later concerns
regarding secondary cancers. When such drugs are intended for adjuvant
therapy in tumor-free patients or for prolonged use in non–cancer indications,
carcinogenicity studies may be/are needed. Completed rodent carcinogenicity
studies are not needed in advance of the conduct of large-scale clinical trials,
unless there is special concern for the patient population.
Carcinogenicity studies should be done in a rodent species (preferably rat).
Mouse may be employed only with proper scientific justification. The selected
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strain of animals should not have a very high or very low incidence of sponta-
neous tumors.
At least three dose levels should be used. The highest dose should be sub-
lethal, and it should not reduce the lifespan of animals by more than 10% of
expected normal. The lowest dose should be comparable to the intended human
therapeutic dose or a multiple of it, for example, 2.5 times; to make allowance for
the sensitivity of the species. The intermediate dose to be placed logarithmically
between the other two doses. An untreated control and (if indicated) a vehicle
control group should be included. The drug should be administered seven days
a week for a fraction of the lifespan comparable to the fraction of human lifespan
over which the drug is likely to be used therapeutically. Generally, the period of
dosing should be 24 months for rats and 18 months for mice.
Observations should include macroscopic changes observed at autopsy
and detailed histopathology of organs and tissues. Additional tests for carcino-
genicity (short-term bioassays, neonatal mouse assay, or tests employing trans-
genic animals) may also be done depending on their applicability on a case to
case basis.

Note:
Each dose group and concurrent control group not intended to be sacrificed early should contain
at least 50 animals of each sex. A high-dose satellite group for evaluation of pathology other than
neoplasia should contain 20 animals of each sex while the satellite control group should contain
10 animals of each sex. Observation parameters should include signs of intoxication, effect on
body weight, food intake, clinical chemistry parameters, hematology parameters, urine analysis,
organ weights, gross pathology, and detailed histopathology. Comprehensive descriptions of
benign and malignant tumor development, time of their detection, site, dimensions, histological
typing, etc. should be given.

Animal Toxicity Requirements for Clinical Trials and Marketing of a New Drug
Nonclinical toxicity testing and safety evaluation data of an IND needed for the
conduct of different phases of clinical trials

Note:
Refer Appendix III (points 1.1 through 1.7 and Tables 1.8 and 1.9) for essential features of study
designs of the nonclinical toxicity studies listed below.

For Phase I Clinical Trials

Systemic toxicity studies

i. Single-dose toxicity studies

ii. Dose-ranging studies
iii. Repeat-dose systemic toxicity studies of appropriate duration to support
the duration of proposed human exposure

Male fertility study

In vitro genotoxicity tests
Relevant local toxicity studies with proposed route of clinical application (dura-
tion depending on proposed length of clinical exposure)
Allergenicity/hypersensitivity tests (when there is a cause for concern or for par-
enteral drugs, including dermal application)
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Photoallergy or dermal phototoxicity test (if the drug or a metabolite is related

to an agent causing photosensitivity or the nature of action suggests such a
potential)

For Phase II Clinical Trials

Provide a summary of all the nonclinical safety data (listed earlier) already sub-
mitted while obtaining the permissions for Phase I trial, with appropriate
references
In case of an application for directly starting a Phase II trial—complete details of
the nonclinical safety data needed for obtaining the permission for Phase I
trial, as per the list provided above must be submitted.
Repeat-dose systemic toxicity studies of appropriate duration to support the
duration of proposed human exposure
In vivo genotoxicity tests
Segment II reproductive/developmental toxicity study (if female patients of
child-bearing age are going to be involved)

For Phase III Clinical Trials

Provide a summary of all the nonclinical safety data (listed earlier) already sub-
mitted while obtaining the permissions for Phase I and II trials, with appropriate
references.
In case of an application for directly initiating a Phase III trial, complete
details of the nonclinical safety data needed for obtaining the permissions for
Phase I and II trials, as per the list already provided must be provided.

i. Repeat-dose systemic toxicity studies of appropriate duration to support the

duration of proposed human exposure
ii. Reproductive/developmental toxicity studies
iii. Segment I (if female patients of child-bearing age are going to be involved)
iv. Segment III (for drugs to be given to pregnant or nursing mothers or where
there are indications of possible adverse effects on fetal development)
Carcinogenicity studies (when there is a cause for concern or when the
drug is to be used for more than six months)

For Phase IV Clinical Trials

Provide a summary of all the nonclinical safety data (listed earlier) already sub-
mitted while obtaining the permissions for Phase I, II, and III trials, with appro-
priate references.
In case an application is made for initiating the Phase IV trial, complete
details of the nonclinical safety data needed for obtaining the permissions for
Phase I, II, and III trials, as per the list already provided must be submitted.

Application of Good Laboratory Practices (GLP)

The animal studies are conducted in an accredited laboratory. Where the safety
pharmacology studies are part of toxicology studies, these studies should also be
conducted in an accredited laboratory.
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APPENDIX IV: ANIMAL PHARMACOLOGY

General Principles
Specific and general pharmacological studies should be conducted to support
use of therapeutics in humans. In the early stages of drug development enough
information may not be available to rationally select study design for safety
assessment. In such a situation, a general approach to safety pharmacology stud-
ies can be applied. Safety pharmacology studies are studies that investigate
potential undesirable pharmacodynamic effects of a substance on physiological
functions in relation to exposure within the therapeutic range or above.

Specific Pharmacological Actions

Specific pharmacological actions are those which demonstrate the therapeutic
potential for humans.
The specific studies that should be conducted and their design will be dif-
ferent based on the individual properties and intended uses of investigational
drug. Scientifically validated methods should be used. The use of new technolo-
gies and methodologies in accordance with sound scientific principles should be
preferred.

General Pharmacology
Essential Safety Pharmacology
Safety pharmacology studies need to be conducted to investigate the potential
undesirable pharmacodynamic effects of a substance on physiological functions
in relation to exposure within the therapeutic range and above. These studies
should be designed to identify undesirable pharmacodynamic properties of a
substance that may have relevance to its human safety; to evaluate adverse phar-
macodynamic and/or pathophysiological effects observed in toxicology and/or
clinical studies; and to investigate the mechanism of the adverse pharmacody-
namic effects observed and/or suspected.
The aim of the essential safety pharmacology is to study the effects of the
test drug on vital functions. Vital organ systems such as cardiovascular, respi-
ratory, and central nervous systems should be studied. Essential safety pharma-
cology studies may be excluded or supplemented based on scientific rationale.
Also, the exclusion of certain test(s) or exploration(s) of certain organs, systems
or functions should be scientifically justified.

Cardiovascular System
Effects of the investigational drug should be studied on blood pressure, heart
rate, and the electrocardiogram. If possible in vitro, in vivo, and/or ex vivo meth-
ods including electrophysiology should also be considered.

Central Nervous System

Effects of the investigational drug should be studied on motor activity, behav-
ioral changes, coordination, sensory and motor reflex responses, and body
temperature.
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Respiratory System
Effects of the investigational drug on respiratory rate and other functions such
as tidal volume and hemoglobin oxygen saturation should be studied.

Follow-Up and Supplemental Safety Pharmacology Studies

In addition to the essential safety pharmacological studies, additional supple-
mental and follow-up safety pharmacology studies may need to be conducted as
appropriate. These depend on the pharmacological properties or chemical class
of the test substance, and the data generated from safety pharmacology studies,
clinical trials, pharmacovigilance, experimental in vitro or in vivo studies, or from
literature reports.

Follow-Up Studies for Essential Safety Pharmacology

Follow-up studies provide additional information or a better understanding than
that provided by the essential safety pharmacology.

Cardiovascular System
These include ventricular contractility, vascular resistance, and the effects of
chemical mediators, their agonists and antagonists on the cardiovascular system.

Central Nervous System

These include behavioral studies, learning and memory, electrophysiology stud-
ies, neurochemistry, and ligand-binding studies.

Respiratory System
These include airway resistance, compliance, pulmonary arterial pressure, blood
gases, and blood pH.

Supplemental Safety Pharmacology Studies

These studies are required to investigate the possible adverse pharmacological
effects that are not assessed in the essential safety pharmacological studies and
are a cause for concern.

Urinary System
These include urine volume, specific gravity, osmolality, pH, proteins, cytology
and blood urea nitrogen, creatinine, and plasma proteins estimation.

Autonomic Nervous System

These include binding to receptors relevant for the autonomic nervous system,
and functional response to agonist or antagonist responses in vivo or in vitro,
and effects of direct stimulation of autonomic nerves and their effects on cardio-
vascular responses.

Gastrointestinal System
These include studies on gastric secretion, gastric pH measurement, gastric
mucosal examination, bile secretion, gastric emptying time in vivo, and ileoce-
cal contraction in vitro.
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Other Organ Systems

Effects of the investigational drug on organ systems not investigated elsewhere
should be assessed when there is a cause for concern. For example dependency
potential, skeletal muscle, immune function, and endocrine functions may be
investigated.

Conditions Under Which Safety Pharmacology Studies

Are Not Necessary
Safety pharmacology studies are usually not required for locally applied agents,
for example, dermal or ocular, in cases when the pharmacology of the inves-
tigational drug is well known, and/or when systemic absorption from the
site of application is low. Safety pharmacology testing is also not neces-
sary, in the case of a new derivative having similar pharmacokinetics and
pharmacodynamics.

Timing of Safety Pharmacology Studies in Relation

to Clinical Development
Prior to First Administration in Humans
The effects of an investigational drug on the vital functions listed in the essential
safety pharmacology should be studied prior to first administration in humans.
Any follow-up or supplemental studies identified should be conducted if neces-
sary, based on a cause for concern.

During Clinical Development

Additional investigations may be warranted to clarify observed or suspected
adverse effects in animals and humans during clinical development.

Before Applying for Marketing Approval

Follow-up and supplemental safety pharmacology studies should be assessed
prior to approval unless not required, in which case this should be justified.
Available information from toxicology studies addressing safety pharmacology
endpoints or information from clinical studies can replace such studies.

Application of Good Laboratory Practices

The animal studies are to be conducted in an accredited laboratory. Where the
safety pharmacology studies are part of toxicology studies, these studies should
also be conducted in an accredited laboratory.

APPENDIX V: INFORMED CONSENT

Checklist for Study Subject’s Informed Consent Documents

Essential Elements
1. Statement that the study involves research and explanation of the purpose
of the research
2. Expected duration of the subject’s participation
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3. Description of the procedures to be followed, including all invasive proce-

dures
4. Description of any reasonably foreseeable risks or discomforts to the
subject
5. Description of any benefits to the subject or others reasonably expected
from research. If no benefit is expected subject should be made aware of
this.
6. Disclosure of specific appropriate alternative procedures or therapies avail-
able to the subject.
7. Statement describing the extent to which confidentiality of records identi-
fying the subject will be maintained and who will have access to subject’s
medical records
8. Trial treatment schedule(s) and the probability for random assignment to
each treatment (for randomized trials)
9. Compensation and/or treatment(s) available to the subject in the event of a
trial-related injury
10. An explanation about whom to contact for trial related queries, rights of
subjects and in the event of any injury
11. The anticipated prorated payment, if any, to the subject for participating in
the trial
12. Subject’s responsibilities on participation in the trial
13. Statement that participation is voluntary, that the subject can withdraw
from the study at any time and that refusal to participate will not
involve any penalty or loss of benefits to which the subject is otherwise
entitled
14. Any other pertinent information

Additional Elements That May Be Required

a. Statement of foreseeable circumstances under which the subject’s par-
ticipation may be terminated by the investigator without the subject’s
consent.
b. Additional costs to the subject that may result from participation in the
study.
c. The consequences of a subject’s decision to withdraw from the research and
procedures for orderly termination of participation by subject.
d. Statement that the subject or subject’s representative will be notified in a
timely manner if significant new findings develop during the course of the
research which may affect the subject’s willingness to continue participation
will be provided.
e. A statement that the particular treatment or procedure may involve risks to
the subject (or to the embryo or fetus, if the subject is or may become preg-
nant), which are currently unforeseeable.
f. Approximate number of subjects enrolled in the study.
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Informed Consent form to participate in a clinical trial

Study Title:
Study Number:
Subject’s Initials: Subject’s Name
Date of Birth/Age:

Please initial box (Subject)

I confirm that I have read and understood the information sheet dated []
———- for the above study and have had the opportunity to ask questions.
I understand that my participation in the study is voluntary and that I
am free to withdraw at any time, without giving any reason, without my []
medical care or legal rights being affected.
I understand that the Sponsor of the clinical trial, others working on the []
Sponsor’s behalf, the Ethics Committee and the regulatory authorities
will not need my permission to look at my health records both in respect
of the current study and any further research that may be conducted in
relation to it, even if I withdraw from the trial. I agree to this access. How-
ever, I understand that my identity will not be revealed in any informa-
tion released to third parties or published.
I agree not to restrict the use of any data or results that arise from this []
study provided such a use is only for scientific purpose(s)

I agree to take part in the above study. []

Signature (or Thumb impression) of the Subject/Legally Acceptable

Representative:
Date
Signatory’s Name:
Signature of the Investigator: Date:
Study Investigator’s Name:
Signature of the Witness: Date:
Name of the Witness:

APPENDIX VII: UNDERTAKING BY THE INVESTIGATOR

1. Full name, address and title of the principal investigator (or investigator(s)
when there is no principal investigator)
2. Name and address of the medical college, hospital, or other facility where
the clinical trial will be conducted: Education, training and experience
that qualify the investigator for the clinical trial [Attach details includ-
ing Medical Council registration number, and/or any other statement(s) of
qualification(s)]
3. Name and address of all clinical laboratory facilities to be used in the study.
4. Name and address of the ethics committee that is responsible for approval
and continuing review of the study.
5. Names of the other members of the research team (Co- or subinvestigators)
who will be assisting the investigator in the conduct of the investigation (s).
6. Protocol title and study number (if any) of the clinical trial to be conducted
by the investigator.
7. Commitments:
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(i) I have reviewed the clinical protocol and agree that it contains all the
necessary information to conduct the study. I will not begin the study
until all necessary ethics committee and regulatory approvals have been
obtained.
(ii) I agree to conduct the study in accordance with the current protocol.
I will not implement any deviation from or changes of the protocol
without agreement by the Sponsor and prior review and documented
approval/favorable opinion from the ethics committee of the amend-
ment, except where necessary to eliminate an immediate hazard(s) to
the trial subjects or when the change(s) involved are only logistical or
administrative in nature.
(iii) I agree to personally conduct and/or supervise the clinical trial at
my site.
(iv) I agree to inform all subjects that the drugs are being used for inves-
tigational purposes and I will ensure that the requirements relating to
obtaining informed consent and ethics committee review and approval
specified in the GCP guidelines are met.
(v) I agree to report to the Sponsor all adverse experiences that occur in
the course of the investigation(s) in accordance with the regulatory and
GCP guidelines.
(vi) I have read and understood the information in the investigator’s
brochure, including the potential risks and side effects of the drug.
(vii) I agree to ensure that all associates, colleagues and employees assist-
ing in the conduct of the study are suitably qualified and experienced
and they have been informed about their obligations in meeting their
commitments in the trial.
(viii) I agree to maintain adequate and accurate records and to make those
records available for audit/inspection by the sponsor, ethics committee,
licensing authority, or their authorized representatives, in accordance
with regulatory and GCP provisions. I will fully cooperate with any
study related audit conducted by regulatory officials or authorized rep-
resentatives of the sponsor.
(ix) I agree to promptly report to the ethics committee all changes in the
clinical trial activities and all unanticipated problems involving risks to
human subjects or others.
(x) I agree to inform all unexpected serious adverse events to the sponsor
as well as the ethics committee within seven days of their occurrence.
(xi) I will maintain confidentiality of the identification of all participating
study patients and assure security and confidentiality of study data.
(xii) I agree to comply with all other requirements, guidelines, and statutory
obligations as applicable to clinical investigators participating in clinical
trials
1. Signature of investigator with date

APPENDIX VIII: ETHICS COMMITTEE

The number of persons in an Ethics Committee should have at least seven mem-
bers. Ethics committee should appoint, from among its members, a chairperson
(who is from outside the institution) and a member secretary. Other members
should be a mix of medical/nonmedical, scientific and nonscientific persons,
including lay public, to reflect the different viewpoints.
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For review of each protocol the quorum of ethics committee should be at

least five members with the following representations:
(a) Basic medical scientists (preferably one pharmacologist).
(b) Clinicians
(c) Legal expert
(d) Social scientist/representative of nongovernmental voluntary agency/
philosopher/ethicist/theologian or a similar person
(e) Lay person from the community.
In any case, the ethics committee must include at least one member whose
primary area of interest/specialization is nonscientific and at least one member
who is independent of the institution/trial site. Besides, there should be appro-
priate gender representation on the ethics committee. If required, subject experts
may be invited to offer their views. Further, based on the requirement of research
area, for example, HIV AIDS, genetic disorders, etc., specific patient groups may
also be represented in the ethics committee as far as possible.
Only those ethics committee members who are independent of the clinical
trial and the sponsor of the trial should vote/provide opinion in matters related
to the study.

Example of Format for Approval of Ethics Committee

To:
The Institutional Ethics Committee/Independent Ethics Committee (state name
of the committee, as appropriate) reviewed and discussed your application
to conduct the clinical trial entitled “ . . . . . . ” on . . . . . . . (date).
The following documents were reviewed:
a. Trial Protocol (including protocol amendments), dated——— Version no:
b. Patient Information Sheet and Informed Consent Form (including updates if
any) in English and/or vernacular language.
c. Investigator’s Brochure, dated——— , Version no.———
d. Proposed methods for patient accrual including advertisement (s) etc. pro-
posed to be used for the purpose.
e. Principal Investigator’s current CV.
f. Insurance Policy/Compensation for participation and for serious adverse
events occurring during the study participation.
g. Investigator’s Agreement with the Sponsor.
h. Investigator’s Undertaking (Appendix VII).
The following members of the ethics committee were present at the meeting held
on (date, time, place).
Chairman of the Ethics Committee:
Member secretary of the Ethics Committee:
Name of each member with designation:
APPROVAL GRANTED: YES/NO

The Institutional Ethics Committee/ Independent Ethics Committee expects to

be informed about the progress of the study, any SAE occurring in the course
of the study, any changes in the protocol and patient information/informed
consent and asks to be provided a copy of the final report.
Signed: ———————— Member Secretary, Ethics Committee. Date:
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APPENDIX IX: STABILITY TESTING OF NEW DRUGS

Stability testing is to be performed to provide evidence on how the quality of a
drug substance or formulation varies with time under the influence of various
environmental factors such as temperature, humidity and light, and to establish
shelf life for the formulation and recommended storage conditions.
Stability studies should include testing of those attributes of the drug sub-
stance that are susceptible to change during storage and are likely to influence
quality, safety, and/or efficacy. In case of formulations the testing should cover,
as appropriate, the physical, chemical, biological, and microbiological attributes,
preservative content (e.g., antioxidant, antimicrobial preservative), and function-
ality tests (e.g., for a dose delivery system).
Validated stability-indicating analytical procedures should be applied. For
long-term studies, frequency of testing should be sufficient to establish the sta-
bility profile of the drug substance.
In general, a drug substance should be evaluated under storage conditions
that test its thermal stability and, if applicable, its sensitivity to moisture. The
storage conditions and the length of studies chosen should be sufficient to cover
storage, shipment, and subsequent use.
Stress testing of the drug substance should be conducted to identify the
likely degradation products, which in turn establish the degradation pathways,
evaluate the intrinsic stability of the molecule, and validate the stability, indi-
cating power of the analytical procedures used. The nature of the stress test-
ing will depend on the individual drug substance and the type of formulation
involved.
Stress testing may generally be carried out on a single batch of the drug
substance. It should include the effect of temperatures, humidity where appro-
priate, oxidation, and photolysis on the drug substance.
Data should be provided for (a) photostability on at least one primary batch
of the drug substance as well as the formulation, as the case may be and (b)
the susceptibility of the drug substance to hydrolysis across a wide range of pH
values when in solution or suspension.
Long-term testing should cover a minimum of 12 months’ duration on at
least three primary batches of the drug substance or the formulation at the time
of submission and should be continued for a period of time sufficient to cover the
proposed shelf life. Accelerated testing should cover a minimum of six months
duration at the time of submission.
In case of drug substances, the batches should be manufactured to a min-
imum of pilot scale by the same synthetic route and using a method of man-
ufacture that simulates the final process to be used for production batches. In
case of formulations, two of the three batches should be at least pilot scale and
the third one may be smaller. The manufacturing process(es) used for primary
batches should simulate that to be applied to production batches and should
provide products of the same quality and meeting the same specifications as that
intended for marketing.
The stability studies for drug substances should be conducted either in the
same container—closure system as proposed for storage and distribution or in a
container—closure system that simulates the proposed final packaging. In case
of formulations, the stability studies should be conducted in the final container—
closure system proposed for marketing.
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Stability Testing of New Drug Substances and Formulations

(i) General study storage conditions for testing drug substances and
formulations

Study Study conditions Duration of study

Long term 30◦ C ± 2◦ C/65%RH ± 5% RH 12 months
Accelerated 40◦ C ± 2◦ C/75% RH ± 5% RH 6 months

If at any time during six months testing under the accelerated storage con-
dition, such changes that occur cause the product to fail in complying with
the prescribed standards, additional testing under an intermediate storage
condition should be conducted and evaluated against significant change
criteria.
(ii) Refrigerated study conditions for testing drug substances and formulations

Study Study conditions Duration of study

Long term 5◦ C ± 3◦ C 12 months
Accelerated 25◦ C ± 2◦ C/60% RH ± 5% RH 6 months

(iii) Deep freeze study conditions for testing drug substances and formulations

Study Study conditions Duration of study

Long term −20◦ C ± 5◦ C 12 months

(iv) Drug substances intended for storage below −20◦ C shall be treated on a
case-by-case basis.
(v) Stability testing of the formulation after constitution or dilution, if appli-
cable, should be conducted to provide information for the labeling on
the preparation, storage condition, and in-use period of the constituted or
diluted product. This testing should be performed on the constituted or
diluted product through the proposed in-use period.

APPENDIX X: CONTENTS OF THE PROPOSED PROTOCOL FOR

CONDUCTING CLINICAL TRIALS
1. Title Page
a. Full title of the clinical study
b. Protocol/study number, and protocol version number with date
c. The IND name/number of the investigational drug
d. Complete name and address of the sponsor and contract research orga-
nization if any
e. List of the investigators who are conducting the study, their respective
institutional affiliations, and site locations
f. Name(s) of clinical laboratories and other departments and/or facilities
participating in the study.
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2. Table of Contents
A complete table of contents including a list of all appendices.
i) Background and introduction
a. Preclinical experience
b. Clinical experience
Previous clinical work with the new drug should be reviewed here
and a description of how the current protocol extends existing data
should be provided. If this is an entirely new indication, how this
drug was considered for this should be discussed. Relevant infor-
mation regarding pharmacological, toxicological and other biologi-
cal properties of the drug/biological/medical device, and previous
efficacy and safety experience should be described.
ii) Study Rationale
This section should describe a brief summary of the background infor-
mation relevant to the study design and protocol methodology. The rea-
sons for performing this study in the particular population included by
the protocol should be provided.
iii) Study objective(s) (primary as well as secondary) and their logical rela-
tion to the study design.
3. Study Design
a. Overview of the study design: Including a description of the type of
study (i.e., double-blind, multicenter, placebo-controlled, etc.), a detail
of the specific treatment groups and number of study subjects in each
group and investigative site, subject number assignment, and the type,
sequence and duration of study periods.
b. Flow chart of the study
c. A brief description of the methods and procedures to be used during the
study.
d. Discussion of study design: This discussion details the rationale for the
design chosen for this study.
4. Study Population
The number of subjects required to be enrolled in the study at the investiga-
tive site and by all sites along with a brief description of the nature of the
subject population required is also mentioned.
5. Subject eligibility
a. Inclusion criteria
b. Exclusion criteria
6. Study assessments—plan, procedures and methods to be described in detail
7. Study conduct stating the types of study activities that would be included
in this section would be: medical history, type of physical examina-
tion, blood or urine testing, electrocardiogram (ECG), diagnostic test-
ing such as pulmonary function tests, symptom measurement, dispensa-
tion and retrieval of medication, subject cohort assignment, adverse event
review, etc.
Each visit should be described separately as Visit 1, Visit 2, etc.
Discontinued subjects: Describes the circumstances for subject withdrawal,
dropouts, or other reasons for discontinuation of subjects. State how
dropouts would be managed and if they would be replaced
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Describe the method of handling of protocol waivers, if any. The person(s)

who approves all such waivers should be identified and the criteria used for
specific waivers should be provided.
Describes how protocol violations will be treated, including conditions
where the study will be terminated for noncompliance with the protocol.
8. Study treatment
a. Dosing schedule (dose, frequency, and duration of the experimental
treatment) Describe the administration of placebos and/or dummy med-
ications if they are part of the treatment plan. If applicable, concomitant
drug(s), their doses, frequency, and duration of concomitant treatment
should be stated.
b. Study drug supplies and administration: A statement about who is
going to provide the study medication and that the investigational drug
formulation has been manufactured following all regulations. Details of
the product stability, storage requirements and dispensing requirements
should be provided.
c. Dose modification for study drug toxicity: Rules for changing the dose
or stopping the study drug should be provided.
d. Possible drug interactions
e. Concomitant therapy: The drugs that are permitted during the study
and the conditions under which they may be used are detailed here.
Describe the drugs that a Subject is not allowed to use during parts of
or the entire study. If any washout periods for prohibited medications
are needed prior to enrollment, these should be described here.
f. Blinding procedures: A detailed description of the blinding procedure if
the study employs a blind on the Investigator and/or the Subject
g. Unblinding procedures: If the study is blinded, the circumstances in
which unblinding may be done and the mechanism to be used for
unblinding should be given
9. Adverse events (see Appendix XI): Description of expected adverse events
should be given.
Procedures used to evaluate an adverse event should be described.
10. Ethical Considerations: Give the summary of the following:
a. Risk/benefit assessment:
b. Ethics committee review and communications
c. Informed consent process
d. Statement of subject confidentiality including ownership of data and
coding procedures
11. Study monitoring and supervision: A description of study monitoring poli-
cies and procedures should be provided along with the proposed frequency
of site monitoring visits, and who is expected to perform monitoring.
Case record form (CRF) completion requirements, including who gets which
copies of the forms and any specifics required in filling out the forms CRF
correction requirements, including who is authorized to make corrections
on the CRF and how queries about study data are handled and how errors,
if any, are to be corrected should be stated.
Investigator study files, including what needs to be stored following study
completion should be described.
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12. Investigational product management

a. Give investigational product description and packaging (stating all
ingredients and the formulation of the investigational drug and any
placebos used in the study)
b. The precise dosing required during the study
c. Method of packaging, labeling, and blinding of study substances
d. Method of assigning treatments to subjects and the subject identification
code numbering system
e. Storage conditions for study substances
f. Investigational product accountability: describe instructions for the
receipt, storage, dispensation, and return of the investigational products
to ensure a complete accounting of all investigational products received,
dispensed, and returned/destroyed.
g. Describe policy and procedure for handling unused investigational
products.
13. Data Analysis:
Provide details of the statistical approach to be followed including sample
size, how the sample size was determined, including assumptions made
in making this determination, efficacy endpoints (primary as well as sec-
ondary) and safety endpoints.
Statistical analysis: Give complete details of how the results will be analyzed
and reported along with the description of statistical tests to be used to ana-
lyze the primary and secondary endpoints defined earlier. Describe the level
of significance, statistical tests to be used, and the methods used for miss-
ing data; method of evaluation of the data for treatment failures, noncom-
pliance, and subject withdrawals; rationale and conditions for any interim
analysis if planned.
Describe statistical considerations for pharmacokinetic (PK) analysis, if
applicable.
14. Undertaking by the Investigator (see Appendix VII).
15. Appendices: Provide a study synopsis, copies of the informed consent doc-
uments (patient information sheet, informed consent form, etc.); CRF and
other data collection forms; a summary of relevant preclinical safety infor-
mation and any other documents referenced in the clinical protocol.

APPENDIX XI: EXAMPLE OF FORMAT AND CONTENT

OF CASE REPORT FORM FOR SERIOUS ADVERSE EVENTS
OCCURRING IN A CLINICAL TRIAL
1. Patient details: (Initials and other relevant identifier (hospital/OPD record
number, etc.)∗
Gender
Age and/or date of birth
Weight
Height
2. Suspected drug(s)
Generic name of the drug∗
Indication(s) for which suspect drug was prescribed or tested
Dosage form and strength
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Daily dose and regimen (specify units—e.g., mg, mL, mg/kg)

Route of administration
Starting date and time of day
Stopping date and time, or duration of treatment
3. Other treatment(s)
Provide the same information for concomitant drugs (including nonprescrip-
tion/OTC drugs) and non–drug therapies, as for the suspected drug(s).
4. Details of suspected adverse drug reaction(s)
Full description of reaction(s) including body site and severity, as well as the
criterion (or criteria) for regarding the report as serious. In addition to
a description of the reported signs and symptoms, whenever possible,
describe a specific diagnosis for the reaction. ∗
Start date (and time) of onset of reaction
Stop date (and time) or duration of reaction
De-challenge and re-challenge information
Setting (e.g., hospital, out-patient clinic, home, nursing home)
5. Outcome
Information on recovery and any sequelae; results of specific tests and/or
treatment that may have been conducted
For a fatal outcome, cause of death and a comment on its possible relationship
to the suspected reaction; Postmortem findings to be reported where
relevant.
Other information: anything relevant to facilitate assessment of the case, such
as medical history including allergy, drug or alcohol abuse; family his-
tory; findings from special investigations, etc.
6. Details about the Investigator∗
Name
Address
Telephone number
Profession (specialty)
Date of reporting the event to licensing authority
Date of reporting the event to ethics committee overseeing the site
Signature of the investigator
Note: Information marked with an asterisk (∗ ) must be provided.
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7 Japan
Juichi Riku
Meiji Pharmaceutical University, Tokyo, Japan

INTRODUCTION
Generic drug products make up a relatively small proportion of the total pharma-
ceutical market in Japan. Generic drug products accounted for as little as 17.2%
of the market by volume in 2007 and around 6.2% by value. These figures pale in
comparison with countries such as the United States, Germany, and the United
Kingdom where generic product penetration levels are more than half of the total
pharmaceutical products volume.
Over the past few years, the Japanese government has launched a series
of initiatives designed to boost the use of generic drug products. In 2007, the
Japanese government officially announced a specific program to raise the generic
product volume-based share over the next five years from 17% to more than 30%
by the year 2012. They implemented a Japanese version of a system for generic
substitution in April 2008. Under the reforms, pharmacists are allowed to sub-
stitute the original branded product with a generic product with the patient’s
consent if the prescribing doctor does not mark the “substitution not allowed”
box on the prescription form accompanied by signature. The introduction of the
new prescription form is a significant milestone in encouraging the dispensing
of generic products by pharmacists.
However, not all doctors and pharmacists have been in favor of the generic
substitution initiatives because they remain dubious of generic drug products,
commonly questioning their quality and bioequivalence (BE) to the brand prod-
ucts. It seems that most of their lingering suspicions about generic products
stem from misconceptions and a lack of understanding about rigorous multistep
approval reviews of generic products in Japan.

Approval Process and Review of Generic Product Applications

The Minister of Health, Labor, and Welfare (MHLW) grants approvals to manu-
facture and market generic drug products as well as the originator products in
accordance with the Pharmaceutical Affairs Law in Japan.
Applications are reviewed according to the submission of the product’s

(a) name
(b) ingredients and their quantities
(c) specifications and test methods
(d) manufacturing method and process
(e) storage conditions and expiration date
(f) dosage and administration
(g) indications, etc.

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The quality, BE, and therapeutic equivalence of the generic drug prod-
uct are examined and reviewed for approval of the product as specified by
the MHLW ordinances subject to the “equivalence reviews.” The following data
must be included with the application for marketing approval.
Specifications and test methods
Stability
Bioequivalence
All documents and data are subject to the “compliance reviews” (1)
through written documentation and on-site inspections in accordance with
“Standard for Collections and Preparation of Approval Review Data” (2). The
MHLW may have the equivalence review of the generic drug product and com-
pliance review performed by an independent administrative organization, the
Pharmaceuticals and Medical Devices Agency (PMDA).
The generic drug product must undergo both paper and on-site good
manufacturing practices (GMP) reviews or inspections for each product before
approval, in precisely the same way as the original drug product was reviewed.
The MHLW will not grant an approval for a generic product unless that
product is the same quality as the originator drug, and both formulations are
pharmaceutically equivalent and bioequivalent to be considered therapeutically
equivalent. Therefore, the PMDA will rigorously conduct an Equivalence and
Compliance Review of the generic drug product in comparison with the origi-
nator drug product. The common technical document (CTD), comprising a set
of specifications for inclusion in the application dossier for the registration of
medicines and designed to be used across Europe, Japan, and the United States
does not necessarily apply for use with generic products. Generally, it takes
about a year on average for the generic drug product to be approved after the
time of application.

Patent and Exclusivity

The patent term is 20 years from the time of application as a rule in Japan, but
it can be extended for a maximum of 5 years. There is no limit to the number
of patent extensions, unlike the United States and the European Union (EU).
Applications for approval of generic drug products are acceptable prior to
patent expiration of the brand product based on the “Bolar provision” (3) but
approval will not be granted until the patent term has expired. Although the
“Bolar provision” has not yet been written into law in Japan, the Japanese
Supreme Court ruled in 1999 that research and development on generic drug
products during the life of a patent is not considered to be an infringement. A
system called “re-examination” is in place in Japan where an application for a
generic drug product will, however, not be permitted until the re-examination
period of the innovator drug product, 4 to 10 years, normally 8 years from
its approval date for new chemical entities, has expired. The purpose of the
Japanese re-examination is to verify the efficacy and safety of innovator drug
products through postmarketing surveillance.

BIOEQUIVALENCE STUDIES

Historical Background
In 1971, the MHLW required submission of BE data in support of applications
for generic drug products for the first time, and the Guideline for Bioequivalence
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166 Riku

Studies for Generic Drugs (1971) was released, in which large animals, such as
dogs and rabbits, could be used in BE studies, but humans were not required. In
1981, the 1971 Guideline was revised to require the use of humans in BE studies
on the grounds that animal experiments were considered unreliable to extrapo-
late the results for BE to humans. However, this 1981 Guideline did not resolve all
issues such as those related to validation, methods for statistical analysis, partial
acceptance of animal tests, etc.
In 1997, a thoroughly revised Guideline “The Guideline for Bioequivalence
Studies of Generic Products 1997” (1997 Guideline) (4) was introduced by the
MHLW. Since then, BE studies for generic drug products must be conducted
in accordance with the 1997 Guideline and follow-on guidelines. The Japanese
National Institute of Health Sciences (NIHS) has responsibility for the prepara-
tion of guidelines and has issued several statutory guidelines for BE studies of
generic drug products through the MHLW as follows:

Guidelines
(a) Guideline for Bioequivalence Studies of Generic Products, 1997 (4)
Oral immediate-release (conventional) dosage forms
Enteric-coated products
Oral controlled-release dosage forms
Other dosage forms
Dosage forms exempt from BE studies
(b) Guideline for Bioequivalence Studies for Different Strengths of Oral Solid
Dosage Forms, 2000 (5).
Different strengths of oral solid dosage forms with the same dosage and
administration as previously approved products, for example, 5 mg
tablet as well as a 10 mg tablet
(c) Guideline for Bioequivalence Studies for Additional Dosage Forms of Oral
Solid Dosage Forms, 2001 (6).
Additional dosage forms of oral solid dosage forms with the same dosage
and administration as previously approved products, for example,
addition of 5 mg capsule to 5 mg tablet.
(d) Guideline for Bioequivalence Studies of Generic Products for Topical
Dermal Application, 2003 (7).
Generic products for topical dermal application without systemic
action, such as ointments, skin patches, etc., including steroids, and
others.
(e) Guideline for Bioequivalence Studies for Formulation Changes of Oral Solid
Dosage Forms, 2000 (8).
Postapproval changes in the components and composition of oral solid
dosage forms other than the active ingredients.
(f) Draft Guideline for Bioequivalence Studies for Changes in Manufacturing
of Oral Solid Dosage Forms: Immediate-release (Conventional) and Enteric-
Coated Products, 2002 (9).
Postapproval changes in manufacturing of oral solid dosage forms.
This draft guideline has not been officially implemented as of November,
2009.
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(g) Revision of Guideline for Bioequivalence Studies of Generic Products,

2006 (10).
Partial revision of Guidelines (a), (b), (d), and (e).
In establishing the Japanese guideline for BE studies for generic products
in 1997, the MHLW intended to harmonize it with international guidelines as
much as possible, such as the WHO guideline (11) published in 1996 in the WHO
Technical Repot Series as a fundamental concept. However, some significant dif-
ferences in some test methods, such as dissolution testing, scale-up and postap-
proval changes (SUPAC), the use of the biopharmaceutical classification system
(BCS) and biowaivers, etc., exist between the Japanese and other major countries’
guidelines, although there are similarities in many respects.
The 1997 Guideline describes the principles and procedures relating to BE
studies for generic drug products. The main objective of a BE study is to assure
the therapeutic equivalence of a generic drug product (test) to the innovator
product (reference) by comparing the BAs between an innovator product and
generic drug product. If this is not feasible, pharmacological effects supporting
efficacy (“pharrmacodynamic studies”) or therapeutic effectiveness associated
with the major indications (“clinical studies”) should be compared.
For oral drug products, in Japan, dissolution testing of these dosage forms
is required together with BE studies and plays an important role in selecting
appropriate subjects for the in vivo study and supporting the in vivo equiva-
lence when the dissolution of test and reference products is similar. Such use of
dissolution testing is specific to the Japanese guidelines. Japanese experts have
expressed their opinion in this regard that any difference in bioavailability (BA)
between test and reference products are probably due to a difference in disso-
lution in the gastrointestinal (GI) tract, which is more than likely related to a
difference in formulation characteristics, such as excipients and manufacturing
method, amongst others. In most other countries, a difference in BA between a
test and reference product is generally based only on data from human stud-
ies since apart from biowaivers granted under certain specified conditions, data
from dissolution tests are not employed to assess BA/BE. The argument for the
use of dissolution data to complement and aid in the assessment of BA/BE in
Japan extends to the contention that dissolution tests are generally more sensitive
to a difference in formulation than data from human subjects. Dissolution tests,
for example, can be performed under various simulated GI conditions where pH
or agitation intensity can be changed and the influence thereof investigated. If a
test product shows slower dissolution than the reference product under certain
conditions, the test product may result in lower BA in some subjects, such as, for
example, in achlorhydric subjects. In such cases, BE should carefully be assessed
using appropriate subjects, such as achlorhydric subjects, or in an appropriate
target population. Use of dissolution testing for BA/BE in Japan clearly marks a
distinct difference between Japanese BA/BE guidelines and those of most other
countries.

Oral Immediate-Release Dosage Forms and Enteric-Coated Products

An appropriate BE study protocol including the required number of subjects and
sampling intervals, etc., should be determined according to preliminary studies.
Figures 1–3 show decision trees for BE studies in human subjects.
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168 Riku

Innovator drug Generic drug

A lot of industrial scale or more

Dissolution tests for 3 lots
than 1/10th scale

Reference product Test product

Dissolution test

Yes Is there a significant

Is the use of drug limited Yes
difference* in dissolution under
to a special population?
a certain condition?

No
No

Yes
Is there a significant difference*
in dissolution at a neutral pH ?

No

Normal subjects Achlorhydric subjects Subjects from target population

*Each meaning of “significant difference” is described in the Guideline

FIGURE 1 Bioequivalence test for oral immediate-release dosage forms and enteric-coated
products.

Bioequivalence test

90% confidence No Sample size >20 No Is add-on subject study No

interval: 80-125% (Group >10) performed?

Yes
Yes
Yes
Add-on study No
Sample size n >30
Mean Cmax, AUC:
90-111% No No
(Point estimate) Yes
90% confidence
Yes interval: 80-125% Mean Cmax, AUC:
90-111% No
(Point estimate)
Similar or Equivalent No Yes
dissolution Yes

Yes
Similar or Equivalent No
Yes
Bioequivalent dissolution

Not bioequivalent

FIGURE 2 Decision of bioequivalence.

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Is there a significant
difference between the
Yes Other than
generic and innovator drugs
in size, shape, density and bioequivalence test
release mechanism?

No

Innovator drug Generic drug

A lot of industrial scale or more than

Dissolution tests for 3 lots
1/10th scale

Reference product Test product

Dissolution testing

Is the dissolution simlar to No

reference product?

Yes

Normal subjects

FIGURE 3 Bioequivalence test for oral controlled-release dosage forms.

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Test Methods
Choice of Reference and Test Products
Dissolution tests, the details of which are hereinafter described in “Dissolution
Tests” section (vide infra) should be performed on three lots of the innova-
tor product available on the domestic Japanese market to select an appropri-
ate reference product using the Japanese Pharmacopoeial (12) paddle method at
50 rpm. Among the three lots, the one which shows intermediate dissolution rate
patterns amongst the lots tested should be selected as the reference product. The
generic drug product (test) should be taken from the “Biobatch” lot, produced on
an industrial scale. This batch should be at least 1/10th or larger of the intended
production batch. A difference in drug content or potency between the test and
reference products should be less than 5%.

Study Design
In principle, cross-over studies should be employed with random assignment of
individual subjects to each group. Parallel designs can be employed for a drug
with a long half-life, for example, approximately 72 hours and longer.

Number of Subjects
A sufficient number of subjects for assessing BE should be included but a min-
imum number has not been specified in the guidelines. If BE cannot be demon-
strated because of an insufficient number, an add-on study can be performed
using not less than half the number of subjects in the initial study. Provision for
an add-on must be clearly stated a priori in the study protocol and if undertaken,
no further add-ons are subsequently permissible.

Selection of Subjects
Healthy adult human subjects (volunteers) should be employed, usually male
in practice, although not specified in the guidelines. When the test and ref-
erence products show a significant difference in dissolution around pH 6.8,
subjects with low gastric acidity (achlorhydric subjects) should be employed
unless the application of the drug is limited to a special population. Since
achlorhydria is quite common in Japan, and significant differences in BE may
not be shown in subjects with normal gastric acidity, it is important to confirm
BE in subjects with lesser gastric acidity, such as around pH 6.8. This rule
does not apply to enteric-coated products. If the use of the drug is limited to
a special population and the test and reference products show a significant
difference in dissolution even under one of the conditions of the dissolution
test, the in vivo test should be performed using subjects from the target
population.
When it is unfavorable to use healthy subjects because of potent pharmaco-
logical action or adverse effects, patients should be employed. If the clearance of
the drug differs to a large extent amongst subjects due to genetic polymorphism,
subjects with higher clearance should be employed.

Single- Versus Multiple-Dose Studies

Single-Dose Studies. One dose unit or the usual clinical dose should generally be
administered. A higher dose which does not exceed the maximum dose of the
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dosage regimen may be employed if analytical difficulties relating to detection

sensitivity exist. Generally, BE studies should be performed using single-dose
studies. If necessary, multiple-dose studies may be employed only if such prod-
ucts are intended to be chronically administered to patients.
Immediate-release dosage forms are usually administered to subjects with
100 to 200 mL water (normally 150 mL) after fasting for at least 10 hours. Fasting
should continue for at least 4 hours postdose. If a postprandial dose is specified
in the dosage regimen and if BA in the fasting state is very low or a high incidence
of severe adverse events is anticipated, a fed study could be used. For a fed study
of immediate-release or enteric-coated dosage forms, a low-fat diet of 700 kcal or
less containing not more than 20% by energy of the lipid should be employed.
Although fasting studies are generally used for most oral dosage forms, for
oral controlled-release products both fasted and fed studies are required and a
“high-fat” diet is recommended for such products (see “Test Methods” section
later in the chapter). The meal should be eaten within 20 minutes, and the drug
products administered according to the dosing regimen or 30 minutes after the
meal, if the dosing time is not indicated in the regimen.
Multiple-Dose Studies. Drugs should, in principle, be administered under
fasting conditions as in single-dose studies and when repeatedly given, admin-
istration should be between meals (more than 2 hours after a meal) at reg-
ular intervals. Cmax and AUC␶ are used as BE metrics in multiple-dose
studies.

Measurement of Drug Substances

(a) Biological fluids to be sampled: Generally, blood samples (plasma/serum)
should be employed although urine may be used if there is a rationale to
justify its use.
(b) Sampling schedule: Blood samples should be taken at a frequency suf-
ficient to adequately assess Cmax , AUC, and any other relevant parame-
ters. There should be at least seven sampling points including zero time,
1 point before Cmax , 2 points around Cmax , and 3 points during the elimi-
nation phase. Sampling should be continued until the area under the blood
concentration–time curve at time t (AUCt ) is >80% of AUC∞, normally more
than three times the elimination half-life after tmax . However, when the elim-
ination half-life of the parent drug or active metabolite(s) is extremely long
(>72 hours), blood samples should be collected for at least 72 hours.
(c) Drug substances to be measured: Generally, the parent compound should
be measured although major active metabolite(s) may be measured instead
of the parent under certain circumstances. For example, if the parent com-
pound cannot be measured, in the case of chiral drug compounds, a chi-
ral compound that contributes to major pharmacological effects should be
measured. However, stereoselective analysis is not required if stereoselec-
tive differences in pharmacokinetics is not a concern.
(d) Assay: Analytical methods should be fully validated with respect to speci-
ficity, accuracy, precision, linearity, limit of quantitation (LOQ) limit, and sta-
bility of the analyte. Several references have been cited in the MHLW’s Q&A
(13), but neither specified as formal guidelines nor included in Japanese BE
guidelines.
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Washout Periods
Washout periods in cross-over studies between administration of test and refer-
ence products should usually be more than five times the elimination half-life of
the parent compound or active metabolites.

Bioequivalence Acceptance Range

The acceptance range for BE is 0.80 to 1.25 as the geometric mean ratios of the
average values of AUC and Cmax of the test to reference product, using 90% con-
fidence intervals. These standards must be met on log-transformed parameters
calculated from the measured data.

Parameters to be Assessed
When blood samples are used, AUCt and Cmax should be subjected to the BE
assessment used in single-dose studies.

Logarithmic Transformation
The pharmacokinetic parameters, Cmax and AUCt for immediate-release dosage
forms and Cmax and AUC␶ for oral controlled-release products should be statis-
tically analyzed after logarithmic transformation.

Statistical Analysis
The 90% confidence interval or two one-sided t tests with a significance level of
5% should be used. When an add-on subject study is performed and there are no
fundamental differences between the two studies in formulation, design, assay
and subjects, data from the initial and add-on subject studies can be pooled and
statistically analyzed.
It is interesting to note that in Japan, even though the 90% confidence
interval may be outside the 0.8 to 1.25 acceptance range, test products may be
accepted as bioequivalent, provided the following three conditions have been
satisfied:

(1) The total sample size of the initial BE study is not less than 20 (n = 10/group)
or pooled sample size of the initial and add-on subject studies is not less
than 30.
(2) The differences in average logarithmic values of AUC and Cmax between two
products are between log (0.90) to log (1.11).
(3) Dissolution behavior of test and reference products is evaluated to be similar
under all dissolution testing conditions.

Additional metrics such as AUC∞ , tmax , MRT, kel , etc., should also be
subjected to statistical assessment, and if a significant difference is detected in
these reference or secondary parameters between reference and test products, an
explanation must be given to justify that such a difference(s) is/are not consid-
ered to affect the clinical outcomes.

Dissolution Tests
Dissolution tests should be performed, using suitably validated dissolution test
methods and analytical assay.
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Testing Time
Dissolution testing should generally be performed for two hours in pH 1.2
medium and six hours in other test fluids. However, testing can be terminated
whenever the average dissolution rate of the reference product reaches 85%.

Testing Conditions
Apparatus: Paddle apparatus specified in the JP (12).
Test solutions
(a) Products containing acidic drugs
(i) Test at 50 rpm in the following three types of dissolution media: pH 1.2,
5.5 to 6.5, 6.8 to 7.5, and also in water as well, that is, a single medium
between 5.5 and 6.5, and one between 6.8 and 7.5.
(ii) Test at 100 rpm in either one of the following three types of dissolution
media: pH 1.2, 5.5 to 6.5, 6.8 to 7.5
(b) Products containing neutral or basic drugs, and coated products
(i) Test at 50 rpm in the following three types of dissolution media: pH
1.2, 3.0 to 5.0, 6.8, and also in water as well in each of these media.
(ii) Test at 100 rpm in either one of the following three types of dissolution
media: pH 1.2, 3.0 to 5.0, 6.8
(c) Products containing low-solubility drugs
(i) Test at 50 rpm in the following dissolution media: (1) pH 1.2, (2) pH
4.0, (3) pH 6.8, (4) Water, (5) pH 1.2 + polysorbate 80, (6) pH 4.0 +
polysorbate 80, (7) pH 6.8 + polysorbate 80 and at 100 rpm in either
one of (5) or (6) or (7) above.
(d) Enteric-coated products
(i) Test at 50 rpm in the following dissolution media: (1) pH 1.2,
(2) pH 6.0, (3) pH 6.8, and at 100 rpm in (2) above.

Similarity of Dissolution Profiles

Average dissolution rates of test products should be compared with those of ref-
erence products. If the f 2 function is used for evaluation, the judgment is based
on the annexure appended in the guideline. It should be emphasized that the
judgment of similarity in dissolution rate does not mean BE but rather based on
the thought that there might be less possibility that test products are not bioe-
quivalent if the dissolution rates of test products are similar to the reference
products.
If the results meet any one of the following acceptance criteria under all
testing conditions, the products are judged to be similar.

Acceptance Criteria
The average dissolution from the reference product reaches 85% or greater within
15 minutes: the average dissolution from the test product also reaches 85% or
greater within 15 minutes or does not deviate by more than 15% from that of the
reference product at 15 minute.
The average dissolution from the reference product reaches 85% or greater
between 15 and 30 minutes: the average dissolution from the test product does
not deviate by more than 15% from that of the reference product at two time
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points when the average dissolution from the reference product is around 60%
and 85%.
The average dissolution from the reference product does not reach 85% or
greater within 15 minutes: the criteria are specified in details in the guideline
(10).

PHARMACODYNAMIC STUDIES
These studies are performed to establish the equivalence of products using phar-
macological activity in humans as an assessment index and may be applied to
drug products that do not produce measurable concentrations of the parent drug
or active metabolite in blood or urine or whose BA does not reflect therapeutic
effectiveness.

CLINICAL STUDIES
These studies are performed to establish the therapeutic equivalence of drugs
using clinical endpoints as assessment index. If BE studies and pharmacody-
namic studies are neither possible nor inappropriate, this type of study can be
used.

ORAL CONTROLLED-RELEASE DOSAGE FORMS

Test methods, testing conditions, and assessment of BE studies for oral
controlled-release dosage forms are similar to those of immediate-release oral
dosage forms and enteric-coated products. Figure 3 shows a decision tree of BE
for oral controlled-release dosage forms.

Reference and Test Products

A generic controlled-release dosage forms should not significantly differ from
the reference product in size, shape, specific gravity, and release mechanism. The
dissolution characteristics of the test product must be similar to that of the refer-
ence, as described later.

Test Methods
Bioequivalence studies should be performed using single-dose studies in both
the fasting and fed states. In fed studies, a high-fat diet of 900 kcal or more con-
taining 35% or more lipid content should be used. The meal should be eaten
within 20 minutes, and drugs administered within 10 minutes thereafter.
When the possibility of severe adverse events may occur after dosing in
the fasting state, the fasting dose studies can be replaced with postprandial dose
studies with the low-fat meal employed in the study for immediate-release oral
dosage forms and enteric-coated products (see “Single- Versus Multiple-Dose
Studies” section)

Dissolution Tests
Testing Time
Dissolution testing should generally be performed over a 24-hour period but
may be terminated after two hour in pH 1.2 medium and whenever the average
dissolution rate of the reference product reaches 85%.
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Testing Conditions
The test should be carried out under the following conditions using the paddle
apparatus and either the rotating basket or disintegration testing apparatus.
Paddle apparatus:
Test at 50 rpm using the following dissolution media: pH1.2, (2) pH 3.0–5.0,
(3) pH 6.8–7.5, (4) water, (5) 1% polysorbate 80 added to pH 6.8–7.5 medium and
at 100 rpm and 200 rpm in dissolution medium of pH 6.8–7.5.
Acceptance criteria for similarity and equivalence of dissolution behavior
If the results meet any one of the following criteria under all testing con-
ditions, the test products are judged to be similar or equivalent to the reference
product when the average dissolution from the reference product reaches 80%
or greater at the time specified under at least one testing condition (see “Similar-
ity of Dissolution Profiles” section). If the f 2 function is used for evaluation, the
judgment is based on the Attachment in the Guideline.

Acceptance Criteria
(1) When the average dissolution from the reference product reaches 80% or
greater at the time specified and the average dissolution from the test prod-
uct does not deviate by more than 15% (in this case, judged as similar) or
10% (in this case, judged as equivalent) from those of the reference product
at three time points when the average dissolution from the reference product
is around 30%, 50%, and 80%.
(2) When the average dissolution from the reference product reaches 50% or
greater but does not reach 80% at the time specified and the average disso-
lution from the test product does not deviate by more than 12% (in this case,
judged as similar) or 8% (in this case, judged as equivalent) from those of
the reference product at the appropriate time point when the average disso-
lution from the reference product is half the average dissolution and at the
time specified.
(3) When the average dissolution from the reference product does not reach
50% at the time specified and the dissolution from the test product does not
deviate by more than 9% (in this case, judged as similar) or 6% (in this case,
judged as equivalent) from those of the reference product at the appropriate
time point when the average dissolution from the reference product is half
the dissolution and at the time specified.

OTHER DOSAGE FORMS

Bioequivalence studies for products for topical application to the skin should
follow the Guidance for Bioequivalence Studies of Generic Products for Topical Dermal
Use 2003 (7) and “Revision of Guideline for Bioequivalence Studies of Generic
Products, 2006” (10).

Products for Topical Dermal Use

The following are amongst the tests to be considered for the assessment of the
BE of topical dermal drug products:
Dermatopharmacokinetic test
Pharmacological test
Test for measuring unabsorbed amount
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Pharmacokinetic test
Clinical trial
In vitro efficacy test
Animal test
The most suitable test from those already mentioned should be selected by
considering the characteristics of the topical product. If other alternative appro-
priate tests are available, they may be employed.
The testing procedure, analytical method, stability of drugs during storage
and analysis, etc., should be validated. Detailed standard operating procedures
(SOPs) should be prepared for each test, involving the application and removal
of products, recovery of the sample, measurements of pharmacological response,
skin stripping procedures, and analytical method, because the testing procedures
for topical products are generally complicated.

Dermatopharmacokinetics Test
This test is used to assess BE by comparing the amount of active ingredient from
the test and reference products penetrating into the stratum corneum. Topical
drugs are generally distributed into the stratum corneum and reach the epider-
mal cells. Thus, BA in the skin can be estimated by measuring the amount of the
drug in the stratum corneum by means of skin stripping using adhesive tapes. This
method is applicable to topical drugs whose site of action is the stratum corneum
itself or deeper.
Parameters for BE assessment include drug recovery amount or the mean
drug concentration at a steady state in the stratum corneum. The parameters
should be logarithmically transformed and the 90% confidence interval of the
difference in mean values of parameters between reference and test products
should be calculated by a parametric method.

Pharmacological Test
This test is used to assess BE by using the pharmacological response of the topical
product, which correlates with clinical efficacy or BA. Topically applied corticos-
teroids produce a vasoconstrictor effect depending on the drug uptake into the
skin that results in skin blanching. This pharmacological response correlates with
clinical efficacy of topical corticosteroids and can be used as a measure to assess
the BE of topical corticosteroid products. The AUEC (area under the effect curve)
values are used to assess BE of such products. When an instrumental method
is used such as a, chromameter, to measure the degree of skin blanching, the
AUEC values should not be log-transformed. When a visual assay is employed
to measure skin blanching, the 90% confidence interval of the difference in mean
AUEC values between test and reference products is calculated by a nonpara-
metric method or parametric method after the logarithmic transformation of the
AUEC values (14).

Test for Measuring Unabsorbed Drug

This test is used to estimate the amount of drug absorbed into the skin from the
amount remaining in the product following application. However, the use of this
test is generally limited because the drug uptake from topical products in general
is usually very low, making it difficult to estimate the uptake precisely, although
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this test may be useful if precise measurements can be made. The amount dis-
tributed into the skin following application of the product is used as a measure
of BE. In principle, the data should be logarithmically transformed, and the 90%
confidence interval of the difference of the mean parameter values between test
and reference products is calculated by a parametric method.

Pharmacokinetic Test
This test is used to assess BE by using pharmacokinetic parameters from blood
concentration–time curves after product application. Pivotal tests should be per-
formed according to the 1997 Guideline (4). AUC or Css (steady-state drug con-
centration) is used as the parameter to assess BE. In principle, the data should be
logarithmically transformed, and the 90% confidence interval confidence of the
difference in mean parameter values between test and reference products should
be calculated by a parametric method.

Clinical Endpoint Test

This test is used to assess BE by using a suitable clinical endpoint response,
which should be selected by considering the clinical property of the drug. This
test should be performed using a statistically sufficient number of patients. The
appropriate acceptable range for BE should be established for each drug to judge
the BE of clinical efficacy of reference and test products.

In Vitro Efficacy Test

This test is used to assess BE by using in vitro activity as the index. The test may
be applicable for topical drugs that are not intended to penetrate the stratum
corneum, such as bactericides, disinfectants, and antiseptics whose active site is
on the surface of the skin or which are applied to superficial affected sites. The in
vitro efficacy tests do not include drug release tests for topical drugs where only
physicochemical parameters are measured.

Animal Tests
This test is used to assess BE by using a pharmacological response produced
on the skin. The test may be applicable for topical drugs such as bactericides,
disinfectants, antiseptics, hemostatics, and wound repair agents whose active site
is the surface of the skin and which are not intended to penetrate the stratum
corneum. The appropriate acceptable range for BE should be established for each
drug to assess BE.

ADDITIONAL DOSAGE FORMS, DIFFERENT STRENGTHS,

AND PRODUCT CHANGES (ORAL DOSAGE FORMS)

Additional Dosage Forms

Bioequivalence studies for additional dosage forms of oral solid dosage forms for
example, such as the addition of a 5-mg capsule to an approved product series of
tablets, should follow the “Guideline for Bioequivalence Studies for Additional
Dosage Forms of Oral Solid Dosage Forms 2001” (6). This guideline does not
apply, as a rule, to oral controlled-release dosage forms. In principle, BE studies
should follow the 1997 Guideline except for the following:
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(a) For enteric-coated formulations, postprandial dose administration is

required in addition to a fasting study.
(b) When a difference in the time of onset of action might affect the clinical
usefulness of a drug, acceptance criterion for BE should be determined for
tmax in addition to the usual criteria of Cmax and AUC. According the MHLW
Q&A (15), products may be considered to be equivalent if the difference
in mean tmax between reference and test products is less than 20 minutes
except for anti-inflammatory agents where Cmax and AUCt where an even
narrower difference in mean tmax between reference and test products may
be required in addition to meeting the 90% confidence interval criteria for
Cmax and AUC.

Different Strengths
Bioequivalence studies for different strengths of solid oral dosage forms, such
as additional strength(s) of the same dosage form, for example adding a
5-mg tablet to a series of approved tablets of different strengths, should follow
the “Guideline for Bioequivalence Studies for Different Strengths of Oral Solid
Dosage Forms 2000” (5) and the 2006 revision (10), which applies to products
that contain the same active ingredient, in the same dosage form and used in the
same dosage regimen as the product already approved but differing in strength.

Reference Product
The reference product is the original innovator product that has previously been
approved in Japan on the basis of therapeutic efficacy and safety data established
by clinical trials, and is selected from three batches of the innovator product on
the domestic market. Dissolution tests are generally performed on three lots of
the innovator available on the domestic market to select the appropriate batch for
use as the reference product in the biostudy. Among the three lots, the one which
shows intermediate dissolution patterns between the lots should be selected as
the reference product. It should be noted that the reference product need not
always be the innovator product but can sometimes also be an approved generic
product.
For example, where a range of innovator products, such as say, a 10-mg
and 20-mg tablet are available on the market in Japan, and only a 10-mg generic
product has previously been approved on the basis of a BE study. Should the
same applicant wish to market a 20-mg generic tablet, either the 20-mg innovator
product or the 10 mg previously approved generic can be used as a reference
product.

Types of Formulation Changes

The type of formulation change is classified according to five different levels, A,
B, C, D, and E, and is decided by the degree of the change in formulation from
the original formulation, as shown in Table 1 in the case of immediate-release
uncoated products. The tests required for BE assessment differ depending on the
type of change in formulation from the approved product, as shown in Table 2.
This classification is based on the US FDA SUPAC-IR guideline (16).
Level A: When a small change in the amount of excipients (e.g., starch, lac-
tose) is unlikely to alter the quality and/or BA of the product and the
ratios of compositions are identical between test and reference products,
in vivo studies are not required for any products if the test and reference
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TABLE 1 Level of Change in Excipients in Immediate-Release

Uncoated Products
Total Excipient Changes/Original
Level Formulation (w/w%)
A Trace change (color/flavor, etc.)
B 5.0
C 10
D 15

products are shown to be equivalent with respect to dissolution at a

specified pH. If the test and reference products are not equivalent with
respect to their dissolution, BE tests should be performed according to the
1997 Guideline.
Levels B, C, and D: When a formulation change in which the ratios of compo-
sitions are not identical, the changes should be determined according to
levels of changes in individual excipients and categorized excipients. No
in vivo studies are required for any products if the test and reference prod-
ucts are equivalent with respect to dissolution at multiple pHs at Level B.
Products at Levels C and D are classified on the basis of a therapeutic win-
dow range and dissolution rate of the products, where the required tests
differ (Table 2). If the test and reference products are not equivalent with
respect to dissolution or do not meet the criteria described in the guideline,
BE tests should be performed.
Level E: Bioequivalence tests should be performed according to the 1997
Guideline (4).

TABLE 2 Level of Formulation Change and Tests

Dosage Therapeutic
Level form range Solubility Dissolution Test
A – – – – A single-dissolution
test
B – – – – Multiple-dissolution
tests
C IR, DR Not narrow Not low – Multiple-dissolution
tests
IR, DR Not narrow Low – In vivo test
IR, DR Narrow Not low ≥85%, Multiple-dissolution
30 min tests
<85%, In vivo test
30 min

IR, DR Narrow Low – In vivo test

CR Not narrow – – Multiple-dissolution
tests
CR Narrow – – In vivo test
D IR Not narrow Not low ≥85%, Multiple-dissolution
30 min tests
Other IR – – – In vivo test
DR, CR
E – – – – In vivo test
IR: immediate release (conventional), DR: delayed release (enteric coated), CR: controlled release.
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INTRAVENOUS AQUEOUS SOLUTIONS

Intravenous aqueous solutions are exempted from BE studies. However, BE stud-
ies for injectables including intravenous suspension/emulsion solutions other
than intravenous aqueous solutions should follow the usual BE studies required
for extravascular dosage forms.

WAIVERS OF IN VIVO BIOEQUIVALENCE STUDIES

Human BE studies may be waived in certain circumstances such as assessment
of additional dosage forms (see “Additional Dosage Forms” section)/different
strengths (see “Different Strengths” section) of oral solid dosage forms and
intravenous aqueous solutions (see “Intravenous Aqueous Solutions” section).
However, there exists a major difference between the Japanese guidelines and
the SUPAC-IR in the use of the biopharmaceutical classification system (BCS).
Japanese guidelines do not use the BCS to grant waivers on the basis of solubil-
ity and permeability requirements. Conditions for waivers of in vivo studies vary
with the dissolution characteristics upon which greater importance is placed in
Japan (17).

ACCEPTANCE OF FOREIGN BE DATA

According to a notice in 1998 by the MHLW (18), data on human BE studies con-
ducted overseas and submitted for the approval of a generic product in Japan,
requires that sufficient appropriate data should be submitted to assess the pos-
sibility of extrapolating foreign acquired data to Japanese (“bridging studies”)
requirements. However, the MHLW suggests that all BE studies should be con-
ducted preferably in Japan as a basic policy. Furthermore, the reference product
used in BE studies intended for the Japanese market must be the domestic inno-
vator product that has been approved for use in Japan.

SUMMARY AND CONCLUSIONS

Current BE methods in Japan and other countries are designed to provide assur-
ance of therapeutic equivalence of generic drug products with the innovator
drug product; thereby justifying generic substitution. Generic drug products
must be pharmaceutically equivalent and bioequivalent to be considered ther-
apeutically equivalent for approval. In Japan, the requirement that applications
for generic drug products must contain information showing that a generic drug
product is bioequivalent to the innovator drug product was initiated by the
MHLW in 1971. The MHLW announced the fundamental guideline for BE stud-
ies for generic products in 1997, and then followed this by several additional
derived guidelines.
Although the Japanese guidelines are harmonized to international guide-
lines in many ways, there exist some significant differences in some parts, such
as placing more importance on dissolution testing, and not using BCS to permit
biowaivers, etc. (19).
It is however clear that regulatory quality and BE evaluation of generic
products in Japan is quite rigorous through the Equivalence Reviews and the
Compliance Reviews.
It is hoped that the use of generic products will increase as a number of
obstacles are being overcome step by step in Japan, with a better understanding
of the Japanese assessment of BE and the associated requirements of quality,
safety, and efficacy.
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REFERENCES
1. Ministry of Health, Labor and welfare. Enforcement of the partial amendments to
Japanese Pharmaceutical Affairs Law. Yakuhatsu Notification No.421, March 27, 2007.
2. Japanese Pharmaceutical Affairs Law. Article 14, Paragraph 3, June, 1996.
3. Annette Cunningham. Bolar Provision: A global history and the future for Europe.
http://www.genericsweb.com/index.php?object id = 238.
4. Ministry of Health, Labor and Welfare. Guideline for Bioequivalence Stud-
ies of Generic Products, 1997. http://www.nihs.go.jp/drug/be-guide(e)/Generic/
be97E.html.
5. Ministry of Health, Labor and Welfare. Guideline for Bioequivalence Studies for Dif-
ferent Strengths of Oral Solid Dosage Forms, 2000. http://www.nihs.go.jp/drug/be-
guide(e)/strength/strength.html.
6. Ministry of Health, Labor and Welfare. Guideline for Bioequivalence Studies for
Additional Dosage Forms of Oral Solid Dosage Forms, 2001.
7. Ministry of Health, Labor and Welfare. Guideline for Bioequivalence Studies of
Generic Products for Topical Dermal Application, 2003. http://www.nihs.go.jp/
drug/be-guide(e)/Topical BE-E.pdf.
8. Ministry of Health, Labor and Welfare. Guideline for Formulation Changes of Oral
Solid Dosage Forms, 2000. http://www.nihs.go.jp/drug/be-guide(e)/form/form-
change.PDF.
9. Ministry of Health, Labor and Welfare. Draft Guideline for Bioequivalence Stud-
ies for Changes in Manufacturing of Oral Solid Dosage Forms: Immediate-release
(Conventional) and Enteric Coated Products, 2002.
10. Ministry of Health, Labor and Welfare. Revision of Guideline for Bioequivalence
Studies of Generic Products, 2006.
11. WHO Expert Committee. WHO Technical Report Series No. 863: Multisource
(generic) pharmaceutical products: WHO guidelines on registration requirements
to establish interchangeability, 1996. http://apps.who.int/medicinedocs/es/d/
Js5516e/19.html.
12. Ministry of Health, Labor and Welfare. Japanese Pharmacopoeia 15th 2006. English
ed. 116. http://jpdb.nihs.go.jp/jp15e/JP15.pdf.
13. Ministry of Health, Labor and Welfare. Q & A on Revision of Guideline for Bioequiv-
alence Studies of Generic Products, Shinsakanrika, Administrative Communication,
November 24, 2006.
14. Hauschke D, Steinijans VW, Diletti E. A distribution—Free procedure for the statisti-
cal analysis of bioequivalence studies. J Clin Pharmacol Ther Toxicol 1990; 28(2):72–78.
15. Ministry of Health, Labour and Welfare. Q & A on Guideline for Bioequivalence Stud-
ies for Additional Dosage Forms of Oral Solid Dosage Forms, 2001. Shinsakanrika,
Administrative Communication, May 31, 2001.
16. Center for Drug Evaluation and Research. Guidance for Industry, Immediate Release
Solid Oral Dosage Forms—Scale-Up and Postapproval Changes: Chemistry, Man-
ufacturing, and Controls, In Vitro Dissolution Testing, and In Vivo Bioequivalence
Documentation. Center for Drug Evaluation and Research (CDER), November
1995, CMC5. Federal Register, vol. 60, no. 230. http://www.fda.gov/downloads/
Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm070636.pdf
17. Nobuo Aoyagi. Japanese guidance on bioavailability and bioequivalence. Eur J Drug
Metab Pharmacokinet 2000; 27(1):28–31.
18. Ministry of Health, Labor and Welfare. Q & A on Guideline for Bioequivalence
Studies of Generic Products, 1997, Shinsakanrika, Administrative Communication,
October 30, 1998.
19. Kiyoto Nakai, Masahiko Fujita, and Hiroyuki Ogata. International harmonization
of bioequivalence studies and issues shared in common. Yakugaku Zasshi 2000;
120(11):1193–1200.
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8 South Africa
Isadore Kanfer and Roderick B. Walker
Faculty of Pharmacy, Rhodes University, Grahamstown, South Africa

Michael F. Skinner
Biopharmaceutics Research Institute, Rhodes University, Grahamstown,
South Africa

INTRODUCTION
The Medicines Control Council (MCC) in South Africa is a statutory body that
was established in terms of the Medicines and Related Substances Control Act
(MRSCA), 101 of 1965, to oversee the regulation of medicines in South Africa.
Applicants are required to submit evidence of quality, safety, and efficacy for
new drugs and medicinal products as well as for the registration of generic (mul-
tisource) medicinal products. In the latter instance, bioequivalence (BE) data can
be used as a surrogate measure of safety and efficacy. To facilitate the registration
process for generic medicines, guidelines have been prepared to serve as a rec-
ommendation to applicants wishing to submit data in support of the registration
of such medicines (1–4).
The mandate of the South African MCC is to safeguard and protect the pub-
lic through ensuring that all medicines that are sold and used in South Africa
are safe, therapeutically effective, and consistently meet acceptable standards
of quality. In this respect, all submissions must provide the necessary data for
quality, safety, and efficacy to register an interchangeable multisource (generic)
pharmaceutical product (medicine) and thereby infer that it is therapeutically
equivalent.
Several important definitions and specific terms have been described in
the relevant Act (5) as well as in the associated guidelines. For the most part,
these considerations parallel the requirements for multisource interchangeabil-
ity as defined within the United States and the European Union (EU). However,
a notable exception is that the reference (comparator) product used in the BE
study need not be the domestic innovator product. This provision permits BE
data generated between the test (generic) product and a foreign reference prod-
uct to be submitted as proof of safety and efficacy. The implication here is that
a BE study undertaken with the primary objective of gaining market access in a
foreign country is simply “piggy-backed” in the dossier for South African reg-
istration as a secondary consideration. This has resulted in the development of
a market for the sale of dossiers where the same BE data are used by several
generic drug companies to gain access to the South African market without the
need to undertake the necessary studies to establish interchangeability between
that generic and the innovator products being sold in South Africa.

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Historical Background
Proof of safety and efficacy of generic medicines have in the past been based
upon requirements described in “official” notices or circulars issued by the MCC.
In fact, registration requirements for generic medicines, particularly with respect
to safety and efficacy, have not been well defined until fairly recently. For exam-
ple, in some instances BE testing was mentioned as a requirement whereas in
others this requirement has been optional depending on the interpretation of the
MCCs issued notices and/or circulars. In many instances, only in vitro dissolu-
tion testing was required on the basis of Circular 14/95 that was first issued in
the early 1990s and subsequently updated in 1995 (6).
Part 2.2.1 of Circular14/95 (6) (see Appendix 1) provided for the use of
comparative dissolution studies of the test and reference products as a proof of
efficacy. The dissolution requirements were contingent on there being a United
States Pharmacopeia (USP) monograph for the active ingredient, which included
dissolution requirements and provided that the active was not included in a com-
piled list, which contained 96 drugs and drug combinations listed in alphabetic
order (Appendix 1). No reasons were given why those specific compounds were
on the list. The assay results of both the reference and test products were required
as well as content uniformity test results and dissolution testing in three media
where required as follows:

i) The first medium must be that specified in the USP monograph.

ii) The other two media shall generally be from the following, spanning a wide
pH range and not the same as the medium specified in the USP:
a) An acidic medium e.g., Gastric fluid USP
b) Water
c) An alkaline medium e.g., intestinal fluid USP

Dissolution testing was required to be carried out according to the USP dis-
solution requirements specified in the monograph using at least six units of the
product, the apparatus, medium volume, and rotation speed. For the other two
media, a further six units of both the test and reference products were required
to be tested using the specified USP dissolution apparatus, medium volume, and
rotation speed specified in the monograph.
All dissolution testing was required to be multipoint studies and the results
presented in a tabulated and graphical form. However, no indication was given
regarding acceptance criteria for the declaration of BE. In the case where the
active is insoluble in the other two media, a motivation could be submitted to
the MCC for the omission of further testing in the other two media.
Proof of efficacy of vitamins or vitamins and mineral combinations and also
for phenolphthalein and sucralfate products was accepted on the basis of disin-
tegration testing where the disintegration test needed to be carried out according
to the USP disintegration test for nutritional supplements for the vitamins or the
general disintegration test for the other substances.
The requirements for proof of efficacy for the following types of products
are listed here:

1) For all products with an antacid or acid neutralizing claim, the acid neutral-
izing capacity test included in the USP was required.
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2) For all products with a bacteriostatic/bactericidal/antiseptic claim, microbial

growth inhibition zones could be used.
3) For all creams, ointments and gels, proof of release by membrane diffusion
as proof of efficacy was recommended.
4) For inhalations, the Anderson sampler or equivalent apparatus could be used
for particle size distribution.
5) For cortisone containing creams and ointments, the “Blanching test” was
specified for use with these products (it is interesting to note that as bioequiv-
alence testing was not mandated per se in that circular that the Blanching test
was the only comparative test that was required to be undertaken in human
subjects).

This guideline (i.e., Circular 14/95) made provision for the use of any other
method, which an applicant wished to submit, provided the rationale for the
particular method was included.
It is interesting to note that there are still products on the South African
market, which were registered according to the requirements described in Cir-
cular 14/95 (6). A matter of concern here is that in many cases the innovator
product used for the comparison may no longer be on the market and therefore
a generic product that is the market leader and as such required to be used as
the reference product in BE testing may well be a product that has never been
assessed for safety and efficacy in a BE study.
It was only in the early 2000s that the requirements for the registration and
market approval of generic medicines were published as official guidelines. Dur-
ing 2002, legislation that required that multisource (generic) medicines registered
in South Africa must be offered to all patients when a physician prescribes an
innovator product was introduced.
In terms of the Medicines and Related Substances Control Act, 1965 (Act
No. 101 of 1965) as amended by Act No. 90 of 1997 (5) and Act 59 of 2002 (7),
provision is made for generic substitution in Section 22F.
“Subject to subsections (2), (3), and (4) of the Act, a pharmacist or a person
licensed in terms of Section 22C shall:

a) inform all members of the public who visit the pharmacy or any other place where
dispensing takes place, as the case may be, with a prescription for dispensing, of
the benefits of the substitution for a branded medicine by an interchangeable multi-
source medicine; and
b) dispense an interchangeable multi-source medicine prescribed by a medical practi-
tioner, dentist, practitioner, nurse or other person registered under the Health Pro-
fessions Act, 1974, unless expressly forbidden by the patient to do so.”

Furthermore, subsection (4) states that “A pharmacist shall not sell an inter-
changeable multi-source medicine

r if the person prescribing the medicine has written in his or her own hand on the
prescription the words ‘no substitution’ next to the item prescribed;
r if the retail price of the interchangeable multi-source medicine is higher than that of
the prescribed medicine; or
r where the product has been declared not substitutable by the council.” (4)
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The above guidelines therefore preferentially mandate the use of generic

medicines wherever possible. In light of the above guidelines, it is clear that the
intention of this legislation was to make medicines more affordable and available
to the wider South African public.
A notable anomaly is the reference made to a negative list (4) (see earlier,
i.e., where the product has been declared not substitutable by the council”) wherein vari-
ous products are listed as “nonsubstitutable.” The MCC provides regulations and
guidelines on how to conduct a BE assessment of generic medicines and included
are acceptance criteria for such products that are used to declare their eligibility
for registration and marketing on the basis of an acceptable safety and efficacy
profile. Hence, when a generic product is proven to be bioequivalent with the ref-
erence product, it is clearly expected that there are no mitigating or other factors
that can assume otherwise. It is therefore inconsistent that once a generic prod-
uct has been shown to be bioequivalent, further measures taken a posteriori, to
include the product on a nonsubstitutable list, are used to disallow substitution
of that medicine for the innovator product when a BE study has shown it to be
bioequivalent/therapeutically equivalent. Such an action by the MCC to renege
on requirements for substitution, which have been met, questions the validity of
the regulations, guidances and policies. It would be more appropriate that spon-
sors be prospectively informed that a product would/could not be considered
substitutable since that would obviate the efforts and expense of undertaking a
BE trial on such products.

DESIGN AND CONDUCT OF BIOEQUIVALENCE STUDIES FOR

ORALLY ADMINISTERED PHARMACEUTICAL PRODUCTS

Study Design
This is described under Section 3.1 of the Biostudies guidelines (2), which is
introduced with the statement “The study should be designed in such a way
that the formulation effect can be distinguished from other effects. If the num-
ber of formulations to be compared is two, a balanced two-period, two-sequence
crossover design is considered to be the design of choice.” Other designs such
as well-established parallel designs for very long half-life substances may also
be considered provided the study design and the statistical analyses are scientif-
ically sound.
Generally, single-dose studies are recommended but provision is made to
also allow steady-state studies provided such a study can be justified.

Fed or Fasting Conditions

The guidelines state that BE studies for immediate-release dosage forms should
be performed under fasting conditions, unless food effects influence/affect
bioavailability (BA). If the reference product dosage directions specifically state
that the medicine must be administered with food, a food-effect study is
required. If the dosage directions for the reference product state either “with or
without food” or make no statement with respect to food, then a fasting study
only will suffice.
In the case of modified-release dosage forms, both a fasted study and a fed
study are required to demonstrate any possible influence of food and to exclude
any possibility of dose dumping. Since meals that are high in total calories and fat
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content are more likely to affect the gastrointestinal (GI) physiology and thereby
result in a larger effect on BA, the use of high-calorie and high-fat meals during
food-effect studies is recommended.

Number of Subjects
The number of subjects should be justified on the basis of providing at least
80% power of meeting the acceptance criteria. The minimum number of sub-
jects should not be less than 12. If 12 subjects do not provide 80% power, more
subjects should be included.
A minimum of 20 subjects is required for modified-release oral dosage
forms.

Add-On Subjects
If the BE study was performed with the appropriate size but BE cannot be
demonstrated because of a result of a larger than expected random variation or
a relative difference, an add-on subject study can be performed using not more
than the number of subjects in the initial study. Combining is acceptable only
in the case when the same protocol was used and preparations from the same
batches were used.
Provision for an add-on study must be included a priori in the protocol and
carried out strictly according to the study protocol and standard operating pro-
cedures (SOPs), and must be given appropriate statistical treatment, including
consideration of consumer risk.

Dropouts and Withdrawals

A sufficient number of subjects should be initially entered into the study to allow
for possible dropouts or withdrawals. Although dropouts generally should not
be replaced since replacement of subjects could complicate the statistical model
and analysis, replacements may be acceptable provided that this intention had
been indicated in the protocol, the reasons for withdrawal (e.g., adverse drug
reaction, personal reasons) clearly stated and inclusion of replacements moti-
vated and accordingly justified. In addition, it should be stated in the protocol
whether samples from extra subjects will be assayed if not required for statistical
analysis.

Subject Selection
BE studies should normally be performed with healthy volunteers. The inclu-
sion/exclusion criteria should be clearly stated in the protocol.
In general, the following subject characteristics are required:
i) Sex—Both male and female subjects can be included but the risk to women
of childbearing potential should be considered on an individual basis.
ii) Age—Subjects should be between 18 and 55 years.
iii) Body mass—Subjects should have a body mass within the normal range
according to accepted normal values for the body mass index (BMI = mass
in kg divided by height in meters squared, i.e., kg/m2 ), or within 15% of the
ideal body mass, or any other recognized reference.
iv) Informed consent—All subjects participating in the study should be capa-
ble of giving informed consent.
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v) Medical screening—Subjects should be screened for suitability by means of

clinical laboratory tests, an extensive review of medical history, and a com-
prehensive medical examination. Depending on the active pharmaceutical
ingredients (APIs) therapeutic class and safety profile, special medical inves-
tigations may have to be carried out before, during and after the completion
of the study.
vi) Smoking/drug and alcohol abuse—Subjects should preferably be non-
smokers and without a history of alcohol or drug abuse. If moderate smok-
ers are included they should be identified as such and the possible influences
of their inclusion on the study results should be discussed in the protocol.

Inclusion of Patients
If the API under investigation is known to produce adverse effects and the phar-
macological effects or risks are considered unacceptable for healthy volunteers, it
may be necessary to use patients instead, under suitable precautions and super-
vision. In this case the applicant should justify the use of patients instead of
healthy volunteers.

Genetic Phenotyping
Phenotyping and/or genotyping of subjects may be considered in crossover
studies (e.g., BE, dose proportionality, food interaction studies) for safety or
pharmacokinetic reasons. If an API is known to be subject to major genetic poly-
morphism, studies could be performed in cohorts of subjects of known pheno-
type or genotype for the polymorphism in question.

STANDARDIZATION OF STUDY CONDITIONS

Standardization of the diet, fluid intake, and exercise is recommended.

Dosing
The time of day for ingestion of doses should be specified.

Fluid Intake at Dosing

As fluid intake may profoundly influence the gastric transit of orally admin-
istered dosage forms, the volume of fluid administered at the time of dosing
should be constant (e.g., 200 mL).

Food and Fluid Intake

In fasted studies the period of fasting prior to dosing should be standardized and
supervised. All meals and fluids taken after dosing should also be standardized
in regard to composition and time of administration and in accordance with any
specific requirements for each study.

Concomitant Medication
Subjects should not take other medicines for a suitable period prior to, and dur-
ing, the study and should abstain from food and drinks, which may interact with
circulatory, GI, liver, or renal function (e.g., alcoholic or xanthine-containing bev-
erages or certain fruit juices).
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Posture and Physical Activity

The BA of an active moiety from a dosage form can be dependent upon GI transit
times and regional blood flows, hence posture and physical activity may need to
be standardized.

SAMPLE COLLECTION AND SAMPLING TIMES

In most cases the drug/API may be measured in serum or plasma. However, in
some cases, whole blood or urine may be more appropriate for analysis.

Sampling Frequency
The sampling schedule should be planned to provide an adequate estimation
of Cmax and to cover the plasma drug concentration time curve long enough to
provide a reliable estimate of the extent of absorption. This is generally achieved
if the AUC derived from measurements is at least 80% of the AUC extrapolated
to infinity.
If a reliable estimate of terminal half-life is necessary, it should be obtained
by collecting at least three to four samples above the limit of quantitation (LOQ)
during the terminal log-linear phase.
For long half-life drugs/APIs (>24 hours), the study should cover a mini-
mum of 72 hours, unless 80% is recovered before 72 hours. The guidance states
that “for moieties demonstrating high inter-subject variability in distribution and
clearance the use of AUC truncation warrants caution. In these circumstances
sampling periods beyond 72 hours may be required.”
To allow accurate estimation of relevant parameters, sampling points
should be chosen such that the plasma concentration versus time profiles can
be adequately defined.

Blood Sampling
a) The blood sampling frequency and duration should be sufficient to account
for at least 80% of the known AUC to infinity (AUC∞ ), usually approxi-
mately three terminal half-lives of the drug/API.
b) For most drugs/APIs 12 to 18 samples including a predose sample should be
collected per subject per dose.
c) Sample collection should be spaced such that the maximum concentrations
of drug/API in blood (Cmax ) and the terminal elimination rate constant (Kel )
can be estimated.
d) At least three to four samples above the LOQ should be obtained during the
terminal log-linear phase to estimate Kel by linear regression analysis.
e) The actual clock time when samples are collected, as well as the elapsed time
relative to drug/API administration should be recorded.

If drug/API concentrations in blood are too low to be detected and a sub-

stantial amount (>40%) of the drug/API is eliminated unchanged in the urine,
then urine may serve as the biological fluid to be sampled.

Urine Sampling
a) Volumes of each sample should be measured immediately after collection
and included in the report.
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b) Urine should be collected over an extended period and generally no less than
seven times the terminal elimination half-life, so that the amount excreted to
infinity (Ae∞ ) can be estimated.
c) Sufficient samples should be obtained to permit an estimate of the rate and
extent of renal excretion. For a 24-hour study, sampling times of 0 to 2, 2 to 4,
4 to 8, 8 to 12, and 12 to 24 hours postdose are usually appropriate.
d) The actual clock time when samples are collected, as well as the elapsed time
relative to API administration should be recorded.

CHARACTERISTICS TO BE INVESTIGATED

Moieties To Be Measured
Parent or Metabolite(s)
The evaluation of BA and BE should, in general, be based on measured concen-
trations of the parent compound (i.e., the active). The determination of moieties
should be measured in biological fluids to take into account both concentration
and activity.
The guideline recommends that for a BA study, both the parent active and
its major active metabolites should be measured, if analytically feasible. This is
necessary to assess both the concentration and the relative contribution of both
the active parent and its major active metabolite(s) in the biological fluid to the
clinical safety and/or efficacy of the active component(s).
However, for BE determinations, measurement of only the active parent
released from the dosage form, rather than any metabolite(s), is generally recom-
mended. The rationale for this recommendation is that the concentration–time
profile of the active parent is more sensitive to changes in formulation perfor-
mance than a metabolite, which is more reflective of metabolite formation, dis-
tribution, and elimination.
Notwithstanding, it is important to state a priori in the study protocol
which chemical entities (pro-drug, API, metabolite) will be analyzed in the
samples.
In some situations, however, measurements of an active or inactive metabo-
lite may be necessary instead of the parent compound. Instances where this may
be necessary are as follows:

a) If the concentration of the API is too low to be accurately measured in the

biological matrix.
b) If there is a major difficulty with the analytical method.
c) If the parent compound is unstable in the biological matrix.
d) If the half-life of the parent compound is too short, thus, giving rise to signif-
icant variability.

Justification for not measuring the parent compound should be submitted

by the applicant and BE determinations on the basis of metabolites should be
justified in each case.
The following examples are given in the guideline:
r The measurement of concentrations of therapeutically active metabolite is
acceptable if the substance studied is a prodrug.
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r If an active metabolite is formed as a result of gut wall or other presystemic

metabolic process(es) and the metabolite contributes meaningfully to safety
and/or efficacy, either the metabolite or the parent concentrations must be
measured and assessed in accordance with the protocol.

The guideline emphasizes that it is important to note that measurement

of one analyte, either the active pharmaceutical ingredient or metabolite, allows
the risk of making a Type-I error (the consumer risk) to remain at the 5% level.
If more than one of several analytes is selected retrospectively as the BE deter-
minant, then the consumer and producer risks change (8). Furthermore, when
measuring active metabolites, the washout period and sampling times may need
to be adjusted to adequately characterize the pharmacokinetic profile of the
metabolite.

Enantiomers Versus Racemates

Although, generally the measurement of the racemate only using an achiral assay
is recommended, measurement of individual enantiomers in BE studies is recom-
mended only when all of the following conditions are met:

a) The enantiomers exhibit different pharmacodynamic characteristics.

b) The enantiomers exhibit different pharmacokinetic characteristics.
c) Primary efficacy and safety activity resides with the minor enantiomer.
d) Nonlinear absorption is present (as expressed by a change in the enantiomer
concentration ratio with change in the input rate of the drug/API) for at least
one of the enantiomers.

Pharmaceutical Products with Complex Mixtures of APIs

Reference is made to certain pharmaceutical products that may contain complex
active substances (i.e., active moieties or APIs) that are mixtures of multiple syn-
thetic and/or natural source components). It is stated that some or all of the com-
ponents of these complex active mixtures cannot be characterized with regard to
chemical structure and/or biological activity. The guideline then indicates that

quantification of all active or potentially active components in pharmacoki-

netic studies to document BA and BE is neither encouraged nor desirable.
BA and BE studies should rather be based on a small number of markers of
rate and extent of absorption.

PHARMACOKINETIC PARAMETERS

Blood/Plasma/Serum Concentration Versus Time Profiles

The following BA parameters are required to be estimated:

a) AUCt , AUC∞ , Cmax , tmax for plasma concentration versus time profiles.
b) AUC∞ , Cmax , Cmin , fluctuation (% PTF), and swing (% swing) for studies
conducted at steady state.
c) Any other justifiable characteristics as referred to in Appendix I.
d) The method of estimating AUC values should be specified.
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Urinary Excretion Profiles

Justification should be given when these data are to be used to estimate the rate
of absorption. Sampling points should be chosen so that the cumulative urinary
excretion profiles can be adequately defined to allow accurate estimation of rele-
vant parameters.
The following BA parameters are required to be estimated:

a) Aet , Ae∞ as appropriate for urinary excretion studies.

b) Any other justifiable characteristics as referred to in Appendix I.
c) The method of estimating AUC values should be specified.

PHARMACODYNAMIC STUDIES
If pharmacodynamic parameters/effects are used as BE criteria, the applicant
must submit justification for their use. In addition

a) a dose–response relationship should be demonstrated.

b) sufficient measurements should be taken to provide an appropriate pharma-
codynamic response profile.
c) the complete dose–effect curve should remain below the maximum physio-
logical response.
d) all pharmacodynamic measurements/methods should be validated with
respect to specificity, accuracy and reproducibility.

BIOANALYSIS
Bioanalysis of all analytes must be conducted according to good laboratory prac-
tice (GLP) and cGMP. All analytical methods used should be fully validated and
documented. The following characteristics of the assay need to be addressed:

a) Stability of stock solutions.

b) Stability of the analyte(s) in the biological matrix under processing condi-
tions and during the entire period of storage.
c) Specificity.
d) Accuracy.
e) Precision.
f) Limits of detection (LOD) and quantification (LOQ).
g) Response function.
h) Robustness and ruggedness.

Separately prepared quality control (QC) samples should be analyzed with

processed test samples at intervals based on the total number of samples.
All procedures must be performed according to preestablished SOPs and
all relevant procedures, and formulae used to validate the bioanalytical method
should be submitted and discussed.
Any modification of the bioanalytical method, before and during analy-
sis of study samples may require adequate re-validation, and all modifications
should be reported and the scope of re-validation justified.
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STUDY PRODUCTS

Reference Products
Reference to another guideline entitled Pharmaceutical and Analytical (P&A)
Guideline (1) is made under this section. The requirements relating to pharma-
ceutical and analytical information are provided in this guideline, including ele-
ments of pharmaceutical and biological availability in Part 2A—Basis for Regis-
tration and Overview of Application. Although there is a Part 2C section, Quality
Overall Summary (QOS), PART 2B is conspicuously absent. Perusal of the P&A
guideline reveals the following:
Under Section 2.1.3 headed as Study Products and subsection (b) headed
Reference Products (comparators) (see also Biostudies and Dissolution Guidelines), a
statement is made that

products containing chemical entities/active moieties that are not registered in

South Africa cannot be used as reference products in efficacy and safety studies
submitted in support of an application.

It is also stated that the reference product may contain a different chemi-
cal form from that of the proposed generic product (pharmaceutical alternative)
provided it is confirmed that the safety/efficacy profile is not altered. Further-
more, if well known (e.g., hydrochloride, maleate, nitrate, stearate), reference to
a pharmacopoeia accepted by the council (i.e., MCC) may be acceptable. This is
in direct conflict with the provisions of the Medicines and Related Substances
Act as amended (5), wherein it is unambiguously indicated that such compar-
isons do not qualify for assessment as interchangeable medicines, since they are
not pharmaceutically equivalent and thus cannot be declared bioequivalent In
order to make provision for a pharmaceutical alternative, the Act would need to
be amended accordingly to incorporate the new definition, since the guideline is
enabled by the Act and not vice versa.
Product strengths not available in South Africa may be applied for and/or
used in biostudies provided that the dose range is approved/registered in South
Africa.
The reference product should be an innovator product registered by the
MCC and should preferably be procured in South Africa. An exception is an “old
medicine” that may be used as a reference product when no other such product
has been registered provided that it is available on the South African market.
If more than one such product is available the market leader should be used as
the reference (e.g., IMS database) and the applicant has to submit evidence to
substantiate the market leadership claim.
Quite extraordinarily, several options for the selection of the reference
product are given and listed in order of preference:

(i) The innovator product registered and procured in South Africa; or

(ii) The innovator product for which a marketing authorization has been
granted by the health authority of a country with which the council aligns
itself (see General Information guideline 3.1.4 (9), and which is to be pur-
chased from that market, or
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(iii) A product from the latest edition of the WHO International compara-
tor products for equivalent assessment of interchangeable multisource
(generic) products QAS/05.143.a or;
(iv) In the case that no innovator product can be identified—within the context
of (i) to (iii) above, the choice of the reference must be made carefully and
must be comprehensively justified by the applicant.
Although it is noted that “A product that has been approved based on com-
parison with a non-domestic reference product may or may not be interchange-
able with currently marketed domestic products,” the significance and implica-
tion of the foregoing statement is unclear? The guidelines state that in all cases,
the choice of reference product should be justified by the applicant and the coun-
try of origin of the reference product should be reported together with lot num-
ber and expiry date. Recently, an amended guidelineb has included the following
requirements for applicants using a foreign reference product.
(i) The name and address of the manufacturing site where the foreign reference product
is manufactured.
(ii) The qualitative formulation of the foreign reference product.
(iii) Copies of the immediate container label as well as the carton or outer container
label of the foreign reference product.
(iv) For modified release, evidence of the mechanism of modified release of the foreign
reference product.
(v) The method of manufacture of the foreign reference product if claimed by the appli-
cant to be the same.
(vi) Procurement information of the foreign reference product
r Copy of licensing agreement/s
r Distribution arrangements/agreement/s
r Copy of purchase invoice (to reflect date and place of purchase)

It is interesting to note that no other specific conditions for the use of a for-
eign (non-domestic) reference product are mentioned until Section 5.1.2 of the
Biostudies guideline (2). It is therefore highly likely that different generic prod-
ucts may well be or have been approved following comparison to different non-
domestic reference products without comparisons having been made between
different nondomestic reference products (the implications for generic substitu-
tion and therapy, in general are obvious). Section 4.2 of the Dissolution guidelines
and “Foreign Reference Products” section of this chapter describe the provisions
made for the use of a foreign reference product and the comparative dissolution
testing required to determine whether such a foreign reference product complies
with the specified requirements for use in BE studies.
The choice of reference products for combination products makes reference
to the Biostudies (2) and Dissolution guidelines (3) and states that such products

a http://www.who.int/medicines/services/expertcommittees/pharmprep/QAS05 143
Comparator Rev%201.pdf. Accessed June 10, 2009.
b Pharmaceutical and Analytical: Medicines Control Council, Department of Health, 2.02 P&A
Apr09 v3.doc. http://www.mccza.com/documents/2.02 P&A Apr09 v3.doc. Accessed June
11, 2009.
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should, in general, be assessed with respect to BA and BE of individual active

substances:
r either single entity products administered concurrently (in the case of new
clinically justifiable combinations), or
r using an existing combination as the reference provided that the combination
was registered on clinical and not bioequivalence data.

In the former instance, immediate-release oral dosage forms containing a

single API may be used as the reference and that these reference products may
include Old medicines.
The irregular permission of the use of a foreign (non-domestic) reference
product goes entirely against the mandate and intention of the Medicines and
Related Substances Control Act, 1965 (Act No. 101 of 1965) as amended by Act
No. 90 of 1997 (5) and Act 59 of 2002 (7), where provision is made for generic sub-
stitution in Section 22F for the use of interchangeable generic medicines wher-
ever possible. Since it is generally unknown whether the formulation of a foreign
reference product is identical to that innovator’s product being sold in the South
Africa market, in the absence of comparative BA data between the same generic
product and the domestic reference product, that generic product cannot be con-
sidered to be therapeutically equivalent to the domestic reference product. Con-
sequently, such generic products, in spite of the recommendations in the South
African guidelines, cannot be considered interchangeable. Furthermore, when
a generic product intended for South African registration has been compared
with a foreign reference product, compliance with the conditions stipulated in
the South African guidelines for the declaration of BE is therefore questionable.

Retention Samples
A sufficient number of retention samples of both test and reference products used
in the BE study should be kept for one year in excess of the accepted shelf life, or
two years after completion of the trial or until approval, whichever is longer, to
allow re-testing if required by the MCC.

DATA ANALYSIS

Statistical Analysis
The guideline states that “The statistical method for testing relative bioavailabil-
ity (i.e. average bioequivalence) is based upon the 90% confidence interval for the
ratio of the population means (Test/Reference) for the parameters under consid-
eration. Pharmacokinetic parameters derived from measures of concentration,
e.g. AUCt , AUC∞ and Cmax should be analysed using ANOVA. Data for these
parameters should be transformed prior to analysis using a logarithmic transfor-
mation.”
If appropriate to the evaluation, the analysis technique for tmax should be
nonparametric and should be applied to untransformed data.
In addition to the appropriate 90% confidence intervals, summary statistics
such as geometric and arithmetic means, SD and% RSD, as well as ranges for
pharmacokinetic parameters (minimum and maximum), should be provided. A
disk with raw data formatted appropriately for evaluation where the formatting
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is described in “Pharmacokinetic and Statistical Report” section (vide infra) or

Section 3.9.3 (a) of the Biostudies guideline (2).
Acceptance Range for Pharmacokinetic Parameters
All pharmacokinetic parameters to be tested, the procedure for testing and the
acceptance ranges should be stated a priori in the protocol.
a) Single-dose studies—The acceptance criteria are as follows:
i) AUCt ratio—The 90% confidence interval for the test/reference ratio
should lie within the acceptance interval of 0.80 to 1.25 (80–125%).
Provision is made for the use of alternative methods, such as for exam-
ple, scaled average BE (ABE) for highly variable drugs but must be jus-
tified and based on sound scientific principles. The use of alternative
methods must be clearly stated a priori in the protocol and cannot be
added retrospectively.
ii) Cmax ratio—The 90% confidence interval for the test/reference ratio
should lie within an acceptance interval of 75% to 133%, calculated using
log-transformed data, except for narrow therapeutic range APIs when an
acceptance interval of 80% to 125% will apply. It is interesting to note that
a wider acceptance range has been recommended for all products with
the exception only in the case of narrow therapeutic range APIs. No con-
sideration has been given to other classes of drug products where the risk
of accepting such products as bioequivalent using the wider acceptance
range may have serious consequences. Furthermore, the implications of
using this wider acceptance interval to declare BE with a foreign refer-
ence product conjure up food for thought.
As previously indicated, in the case of highly variable APIs, a wider
interval or other appropriate measure may be acceptable, but should be
stated a priori and justified in the protocol.
b) Steady-state studies
i) Immediate-release dosage forms—The guidance states that the accep-
tance criteria are the same as for single-dose studies but using AUC∞
instead of AUCt. No explanation is given for such an unusual choice
for AUC where, clearly, AUC during a dosage interval at steady state
(AUC␶ or AUCss ) has generally been considered as the parameter of
choice for steady-state studies (10). It is also unclear whether only AUC
is required or whether the determination and assessment of Cmax (ss) is to
be included?
ii) Controlled-/modified-release dosage forms—The acceptance criteria are
as follows:
r AUC∞ ratio—Once again, no explanation has been given for the use
of this parameter. The 90% confidence interval for the test/reference
ratio should lie within the acceptance interval of 0.80 to 1.25 (80–
125%).
r Cmax (ss) and Cmin (ss) —The 90% confidence interval for the test/ ref-
erence ratio should lie within the acceptance interval of 0.75 to 1.33
(75–133%) calculated using log-transformed data.
r % Swing and % PTF—The 90% confidence interval for the test/ ref-
erence ratio should lie within the acceptance interval of 0.80 to 1.25
(80–125%) calculated using log-transformed data.
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STUDY REPORT
Complete documentation is required to be submitted including the protocol, con-
duct, and evaluation and evidence of compliance with GCP, GLP, and cGMP.

Clinical Report
The following information must be included in the clinical section of the BE study
report:
a) A statement indicating the independence of the ethics committee.
b) Documented proof of ethical approval of the study.
c) A complete list of the members of the ethics committee, their qualifications,
and affiliations.
d) Names and affiliations of the all investigator(s), the site of the study and the
period of its execution.
e) The names and batch numbers of the products being tested.
f) The name and addresses of the applicants of both the reference and the test
products.
g) Expiry date of the reference product and the date of manufacture of the test
product used in the study.
h) Assay and dissolution profiles for test and reference products.
i) Certificate of analysis of the API used in the test product biobatch.
j) A summary of adverse events, which should be accompanied by a discussion
on the influence of these events on the outcome of the study.
k) A summary of protocol deviations (sampling and nonsampling), which
should be accompanied by a discussion on the influence of these adverse
events on the outcome of the study.
l) Subjects who dropout or are withdrawn from the study should be identified
and their withdrawal fully documented and accounted for.

Analytical Report
The following must be included in the analytical section of the BE report:
a) Validation report.
b) All individual subject concentration data.
c) Calibration data, that is, raw data and back-calculated concentrations for
standards, as well as calibration curve parameters, for the entire study.
d) Quality control samples for the entire study.
e) Chromatograms from analytical runs for 20% of all subjects (or for a min-
imum of four subjects, whichever is the greater) including chromatograms
for the associated standards and QC samples.
f) A summary of protocol deviations, which should be accompanied by a dis-
cussion on the influence of these deviations on the outcome of the study.
Protocol deviations should be justified.

Pharmacokinetic and Statistical Report

The following information must be included:
a) All individual plasma concentration versus time profiles presented on a
linear/linear as well as log/linear scale (or, if appropriate, cumulative uri-
nary excretion data presented on a linear/linear scale).
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These data should be submitted in hard copy and also formatted elec-
tronically in a format compatible for processing by SAS software. Individual
subject data should be in rows and arranged in columns, which reflect the
subject number, phase number, sequence, formulation, and sample concen-
tration versus time data.
b) The method(s) and programmes used to derive the pharmacokinetic param-
eters from the raw data.
c) A detailed ANOVA and/or nonparametric analysis, the point estimates and
corresponding confidence intervals for each parameter of interest.
d) Tabulated summaries of pharmacokinetic and statistical data.
e) The statistical report should contain sufficient detail to enable the statistical
analysis to be repeated, for example, individual demographic data, random-
ization scheme, individual subject concentration versus time data, values of
pharmacokinetic parameters for each subject, descriptive statistics of phar-
macokinetic parameters for each formulation and period.

Quality Assurance
The study report should contain a signed quality assurance (QA) statement con-
firming release of the document. The applicant should indicate whether the
site(s) (clinical and analytical) where the study was performed was subjected
to a prestudy audit to ascertain its/their status of GCP and GLP and/or cGMP
conditions. All audit certificates should clearly indicate the date of audit and
the name(s), address(es) and qualifications of the auditor(s) and, in addition, an
independent monitor’s statement must be included.
Mention is made in the guideline that the applicant must demonstrate
that the excipients in the pharmaceutically equivalent product are essentially
the same and in comparable concentrations as those in the reference product.
Interestingly, no mention is made of the use of a pharmaceutical alternative as
provided in the guideline. In the event that this information about the reference
product cannot be provided by the applicant, it is incumbent upon the appli-
cant to perform in vivo or in vitro studies to demonstrate that the differences in
excipients do not affect product performance.

BIOAVAILABILTY AND BIOEQUIVALENCE REQUIREMENTS

Orally Administered Pharmaceutical Products Intended

for Systemic Action
Solutions
Biowaivers apply to products falling under this category.
Pharmaceutically equivalent solutions for oral use (including syrups,
elixirs, tinctures, or other soluble forms but not suspensions) containing the
active pharmaceutical ingredient in the same molar concentration as the com-
parator product, and containing only excipient(s) known to have no effect on GI
transit, GI permeability, and hence absorption or stability of the active pharma-
ceutical ingredient in the GI tract are considered to be equivalent without the
need for further documentation.
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Pharmaceutically equivalent powders for reconstitution as solution, meet-

ing the solution criteria mentioned earlier, are considered to be equivalent with-
out the need for further documentation.

Suspensions
BE for a suspension should be treated in the same way as for immediate-release
solid oral dosage forms.

Immediate-Release Products—Tablets and Capsules

BE studies are generally required for these dosage forms. Although the guide-
line states that in vivo BE studies should be accompanied by in vitro dissolution
profiles on all strengths of each product, no indication is given relating to the dis-
solution conditions. However, a statement is made regarding waivers for in vivo
BA and BE studies for immediate-release solid oral dosage forms and reference
to the conditions of the dissolution tests required is given. The reference relates
to Section 5 of the Biostudies guideline (2) and is described in Waivers of In Vivo
Bioequivalence Studies for Oral Solid Dosage Forms section (vide infra).

Modified-Release Products
BE studies (single dose) are required for these dosage forms, which include
delayed-release products and extended- (controlled-)release products (as defined
in the P&A guideline). Fasted as well as fed studies are necessary and multiple-
dose studies are generally not recommended.

Fixed-Dose Combination Products (Including Copackaged Products)

Combination products should in general be assessed with respect to BA and BE
of APIs either separately (in the case of a new combination) or as an existing
combination. In the case of a new combination the study should be designed in
such a way that the possibility of a pharmacokinetic and/or pharmacodynamic
active–active interaction could be detected.
The guideline states that the approval of an FDC in general, will be con-
sidered in accordance with the WHO Technical report series 929c “Guidelines
for registration of fixed-dose combination medicinal products 2005” or the latest
revision.
Fixed-dose combinations for antiretroviral compounds will be considered
in accordance with the FDA “Guidance for Industry: Fixed Dose Combinations,
Co-Packaged Drug Products, and Single-Entity Versions of Previously Approved
Antiretrovirals for the Treatment of HIV” October 2006d or the latest revision.

Miscellaneous Oral Dosage Forms

Rapidly dissolving pharmaceutical products, such as buccal and sublingual
dosage forms, should be tested for in vitro dissolution and in vivo BA and/or BE.
Chewable tablets should also be evaluated for in vivo BA and/or BE. Chewable

c http://www.who.int/medicines/publications/pharmprep/en/index.html. Accessed June

10, 2009.
d http://www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDS
Activities/ucm124426.htm. Accessed June 10, 2009.
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tablets (as a whole) should be subject to in vitro dissolution because a patient,

without proper chewing, might swallow them. In general, in vitro dissolution
test conditions for chewable tablets should be the same as for non-chewable
tablets of the same API/moiety.

Medicines Intended for Local Action

This section covers nonsolution pharmaceutical products, which are for non-
systemic use (oral, nasal, ocular, dermal, rectal, vaginal, etc., application) and
are intended to act without systemic absorption. In these cases, BE is estab-
lished through comparative clinical or pharmacodynamic, dermatopharmacoki-
netic studies and/or in vitro studies. In certain cases, active concentration mea-
surement may still be required for safety reasons in order to assess unintended
systemic absorption.

Parenteral Solutions
The applicant must demonstrate that the excipients in the pharmaceutically
equivalent (no mention made of pharmaceutical alternative dosage forms?)
product are essentially the same and in comparable concentrations as those in the
reference product. In the event that this information about the reference product
cannot be provided by the applicant, it is incumbent upon the applicant to per-
form in vivo or in vitro studies to demonstrate that the differences in excipients
do not affect product performance. The nature of such studies are however, not
disclosed.

Aqueous Solutions
Aqueous solutions to be administered by parenteral routes (intravenous,
intramuscular, subcutaneous) containing the same active pharmaceutical ingre-
dient(s) in the same molar concentration and the same or similar excipients
in comparable concentrations as the comparator product are considered to be
equivalent without the need for further documentation.
Certain excipients (e.g., buffer, preservative, antioxidant) may be different
provided the change in these excipients is not expected to affect the safety and/or
efficacy of the medicine product.

Powders for Reconstitution

Pharmaceutically equivalent products that are powders for reconstitution as
solution meeting the criterion for Aqueous Solutions above are considered to
be equivalent without the need for further documentation. No mention is made
of the requirements, if any, for pharmaceutical alternatives.

Other
BE studies are required for all other parenterals and for intramuscular dosage
forms, monitoring is required until at least 80% of the AUC∞ has been covered.

TOPICAL PRODUCTS
The guideline states that “Pharmaceutically equivalent topical products pre-
pared as aqueous solutions containing the same active pharmaceutical ingredi-
ent(s) in the same molar concentration and essentially the same excipients in
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comparable concentrations are considered to be equivalent without the need for

further documentation.”
Reference is again made to the need to demonstrate that the excipients in
the pharmaceutically equivalent product are essentially the same and in compa-
rable concentrations as those in the reference product.

Local Action
For topical preparations containing corticosteroids intended for application to
the skin and scalp, the human vasoconstrictor test (blanching test) is recom-
mended for BE assessment of such products. Either visual or chromameter data
are acceptable but in each case all data must be validated.
For simple topical solutions with bacteriostatic, bactericidal, antiseptic,
and/or antifungal claims, a biowaiver based on appropriate validated in vitro
test methods, for example, microbial growth inhibition zones, is acceptable.
For all other topical formulations, clinical data (comparative clinical effi-
cacy) are required. Proof of release by membrane diffusion is not acceptable
as proof of efficacy, unless data are presented that show a correlation between
release through a membrane and clinical efficacy.
The guideline also states that whenever systemic exposure resulting from
locally applied/locally acting medicinal products entails a risk of systemic
adverse reactions, systemic exposure should be measured.

Systemic Action
A BE study is always required for other locally applied products with systemic
action, for example, transdermal products.

PRODUCTS INTENDED FOR OTHER ROUTES OF ADMINISTRATION

Applicants must demonstrate that the excipients in the pharmaceutically equiv-
alent product are essentially the same and used in comparable concentrations as
those in the reference product.

Otic and Ophthalmic Products

Pharmaceutically equivalent otic or ophthalmic products prepared as aqueous
solutions and containing the same active pharmaceutical ingredient(s) in the
same molar concentration and essentially the same excipients in comparable con-
centrations are considered to be equivalent without the need for further docu-
mentation.
Certain excipients (e.g., preservative, buffer, substance to adjust tonicity
or thickening agent) may be different provided use of these excipients is not
expected to effect safety and/or efficacy of the product.

Aerosols, Nebulizers, and Nasal Sprays

BE assessment is not required for pharmaceutically equivalent solutions for
aerosol or nebulizer inhalation or nasal sprays, tested to be administered with
or without essentially the same device, prepared as aqueous solutions, contain-
ing the same active pharmaceutical ingredient(s) in the same concentration and
essentially the same excipients in comparable concentrations.
The pharmaceutical product may include different excipients provided its
use is not expected to affect safety and/or efficacy of the product.
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Particle size distribution may be used in support of proof of efficacy for

inhalations. The Anderson sampler or equivalent apparatus should be used. In
addition, appropriate information should be submitted to provide evidence of
clinical safety and efficacy.

Gases
Pharmaceutically equivalent gases are considered to be equivalent without the
need for further documentation.

WAIVERS OF IN VIVO BIOEQUIVALENCE STUDIES

FOR ORAL SOLID DOSAGE FORMS
Biowaivers are considered based on the following:

In Vitro Studies—Dissolution Profile Comparison

Under this section, reference is made to another guideline, the Dissolution guide-
line (3).
Comparative dissolution profiles, in three media should be carried out on
the test and the reference product and tested for similarity. The f 2 similarity factor
should be used to compare dissolution profiles from different products and/or
strengths of a product. An f 2 value ≥50 indicates a sufficiently similar dissolu-
tion profile such that further in vivo studies are not necessary. For an f 2 value
<50, it may be necessary to conduct an in vivo study. However, when both test
and reference products dissolve 85% or more of the label amount of the API in
≤15 minutes similarity is accepted without the need to calculate f 2 values.

Proportionally Similar Formulations

Section 2.11 of the Biostudies guideline (2) states:
“Pharmaceutical products are considered proportionally similar in the following
cases:
2.11.1 When all APIs and inactive pharmaceutical ingredients (IPIs) are in
exactly the same proportion between different strengths (e.g., a 100 mg strength
tablet has all API and IPIs exactly half of a 200 mg strength tablet and twice that
of a 50 mg strength tablet).
2.11.2 When the APIs and IPIs are not in exactly the same proportion but the
ratios of IPIs to the total mass of the dosage form are within the limits defined by
the Post-registration Amendment guideline.
2.11.3 When the pharmaceutical products contain a low concentration of the
APIs (e.g., less than 5%) and these products are of different strengths but are of
similar mass.
The difference in API content between strengths may be compensated for by
mass changes in one or more of the IPIs provided that the total mass of the pharma-
ceutical product remains within 10% of the mass of the pharmaceutical product on
which the bioequivalence study was performed. In addition, the same IPIs should
be used for all strengths, provided that the changes remain within the limits defined
by the Post-registration Amendment guideline.”

Hence, a prerequisite for qualification for a biowaiver based on dose-

proportionality of formulations is that
r the multisource product at one strength has been shown to be bioequivalent
to the corresponding strength of the reference product and
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202 Kanfer et al.

r the further strengths of the multisource product are proportionally similar in

formulation to that of the studied strength.
When both of these criteria are met and the dissolution profiles of the fur-
ther dosage strengths are shown to be similar to the one of the studied strength
on a percentage released vs. time basis, a biowaiver procedure can be considered
for the further strengths.
Furthermore, according to the Dissolution guidelines (3), when a biowaiver
is requested for different strengths of test/multisource products which are
r proportionally formulated (see Biostudies guidelines 2.11 and 5.1.1),
r manufactured by the same manufacturer at the same manufacturing site, and
r an appropriate BE study has been performed on at least one of the strengths of
the formulation (usually the highest strength unless a lower strength is chosen
for reasons of safety), either (a) or (b) below applies:
a) If the reference product used in the biostudy is an innovator product procured in
South Africa, then dissolution profiles generated for the test and other strength mul-
tisource products being applied for (i.e., lower and higher strengths) should be com-
pared as described in Section 3 of this guideline for each of the specified media. When
sink conditions do not exist in one or more media, the profiles of the higher and
lower strengths may not be similar in those media due to saturation, in which case
supporting data may be generated with the local innovator of the same strength.
b) If the reference product used in the biostudy is a foreign innovator product, (not
procured in SA) and where the local innovator product and the foreign innovator
product show similar dissolution profiles in the three specified media then, for the
proportionally similar strength(s), dissolution profiles of the test and local innovator
reference products respectively (i.e., strength vs. same strength) should be compared
as described in Section 3 of this guideline for each of the specified media.

Immediate-Release Tablets
When the pharmaceutical product is the same dosage form but of a different
strength and is proportionally similar in its API and inactive pharmaceutical
ingredients (IPIs), a biowaiver may be acceptable.

Modified-Release Products
Beaded Capsules—Lower Strength
For extended-release beaded capsules where the strength differs only in the num-
ber of beads containing the API, a single-dose, fasting BE study should be carried
out on the highest strength. A biowaiver for the lower strength based on disso-
lution studies can be requested.
Dissolution profiles in support of a biowaiver should be generated for each
strength by using the recommended dissolution test methods described in Sec-
tion 3 of the Dissolution guideline (3).
Dissolution of test and reference products should be conducted in each of
the following three media:
r Acidic media such as 0.1 N HCl
r pH 4.5 buffer
r pH 6.8 buffer
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If both the test and reference products show more than 85% dissolution
within 15 minutes, the profiles are considered similar (no calculations required).
If not, the f 2 value must be calculated. If f 2 ≥ 50, the profiles are normally
regarded similar such that further in vivo studies are not necessary. Note that
only one measurement should be considered after 85% dissolution of both prod-
ucts has occurred and excluding point zero.
The similarity factor (f 2 ) is a logarithmic reciprocal square-root transforma-
tion of the sum of squared errors, and is a measurement of the similarity in the
percentage (%) dissolution between the two curves, viz.:

f 2 = 50 log{[1 + (1/n) n
(Rt − Tt)2 ]−0.5 .100}
t=1

where n is the number of time points, Rt is the dissolution value of the reference
batch at time t, and Tt is the dissolution value of the test batch at time t.
The dissolution profile of two products, that is, of the test and reference
products (using 12 units each) should be determined and for f 2 calculations, a
minimum of three time points (excluding point zero) must be used, and only one
measurement included after 85% dissolution of both products has occurred.
Generally, f 2 values greater than 50 (50–100) ensure sameness or equiva-
lence of the two curves and, thus, of the performance of the test and reference
products. For curves to be considered similar, f 2 values should be close to 100.
This model-independent method is considered to be most suitable for dis-
solution profile comparisons when three to four or more dissolution time points
are available. The following recommendations should also be considered:
i) The dissolution measurements of the test and reference batches should be
made under exactly the same conditions. The dissolution time points for
both profiles should be the same (e.g., 10, 15, 20, 30, 45, 60 minutes, etc.).
ii) Only one measurement should be considered after 85% dissolution of both
products have occurred.
iii) To allow use of mean data, the percent coefficient of variation (CV) at the
earlier time points (e.g., 15 minutes) should not be more than 20%, and at
other time points should not be more than 10%.

Tablets—Lower Strength
For extended-release tablets when the pharmaceutical product is
a) in the same dosage form but in a different strength,
b) is proportionally similar in its APIs and IPIs, and
c) has the same drug/API release mechanism.
An in vivo BE determination of one or more lower strengths may be waived
on the basis of dissolution testing as previously described. Dissolution profiles
should be generated on all the strengths of the test and the reference products.
When the highest strength (generally, as usually the highest strength is
used unless a lower strength is chosen for reasons of safety) of the multisource
product is bioequivalent to the highest strength or dosee of the reference product,

e Dose included in the dosage range of the MCC-approved package insert of the innovator
product registered in South Africa.
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204 Kanfer et al.

and other strengths are proportionally similar in formulations and the dissolu-
tion profiles are similar between the dosage strengths, biowaivers can be consid-
ered for the lower/other strengths.

Foreign Reference Products

BE studies submitted where a foreign reference product has been used requires
demonstration of equivalence between the foreign product and the innovator
product marketed in South Africa. If the reference product is not the current
innovator product available in the South African market, then the reference prod-
uct may be procured from another country provided that it complies with the
requirements specified in the P&A guideline as described in Section 2.1.3 (b) of
that guideline and also in “Reference Products” section. Dissolution profiles of
the test and reference products should be compared for similarity as described
in Section 3 of the Dissolution guideline (3) for each of the three specified media
irrespective of the solubility profile, viz.:
r Acidic media such as 0.1 N HCl
r pH 4.5 buffer
r pH 6.8 buffer

Postregistration/Approval Amendments
The Biostudies guideline comments primarily on registration requirements for
multisource pharmaceutical products, however, it also states that in vitro disso-
lution testing may also be suitable to confirm similarity of product quality and
performance characteristics with minor formulation or manufacturing changes
after approval.
Section 4.3 of the Dissolution guideline describes the types of dissolution
testing required when amendments are made to pharmaceutical products, man-
ufacturing procedures, and other associated processes including change of site.
Three different cases are described, viz.:

a) Case A
Dissolution testing should be conducted as a release test according to the original
submission, or in accordance with compendial requirements, for that product.
b) Case B
Dissolution testing should be conducted as a multipoint test in the applica-
tion/compendial medium at intervals such as 10, 15, 20, 30, 45, 60, and 120 min-
utes, or until an asymptote is reached for the proposed and currently registered
formulation.
c) Case C
Dissolution testing should be conducted as a multipoint test in the three dissolu-
tion media as specified above for the proposed, and currently registered formula-
tions, at intervals such as 10, 15, 20, 30, 45, 60, and 120 minutes, or until either
85% dissolution is obtained, or an asymptote is reached.

The various types of amendments are also described as follows:

a) Type A
In the event that the Type A change made is such that it is unlikely to have
an effect on the quality and performance of a dosage form, Case A dissolu-
tion testing is appropriate.
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b) Type B
In the event that the changes, which were made, could have a significant
impact on the quality and performance of a dosage form, Case B or C disso-
lution testing is appropriate. Profiles of the currently used product and the
proposed product should be proven to be similar, according to the require-
ments as describe in this Guideline.
c) Type C
In the case of changes that are likely to have a significant impact on for-
mulation quality and performance, in vivo bioequivalence testing should
be conducted unless otherwise justified. Case B or Case C dissolution test-
ing may also be required. Biowaivers may also be considered if a proven in
vitro/in vivo correlation (IVIVC) has been established.

BIOPHARMACEUTICS CLASSIFICATION SYSTEM

Biowaivers may be granted on the basis of the biopharmaceutics classification
system (BCS) under the following conditions:
Dosage forms containing APIs, which are highly soluble and highly per-
meable (i.e., BCS class 1), and are rapidly dissolving are eligible for a biowaiver
based on the BCS provided
r the dosage form is rapidly dissolving (as defined in the Dissolution guideline,
i.e., no less than 85% of the labeled amount of the API dissolves in 30 minutes)
and
r the dissolution profile of the multisource product is similar to that of the ref-
erence product at pH 1.2, pH 4.5, and pH 6.8 buffer using the paddle method
at 75 rpm or the basket method at 100 rpm (as described in the Dissolution
guideline) and meets the criteria of dissolution profile similarity, f 2 ≥ 50 (or
equivalent statistical criterion).
If both the reference and the multisource dosage forms are very rapidly dis-
solving, that is, 85% or more dissolution at 15 minutes or less in all three media
under the above test conditions, the two products are deemed equivalent and a
profile comparison is not necessary.

CONCLUSIONS
A unique and potentially problematic situation currently exists in South Africa.
Generic substitution has been mandated as a means to ensure that accessibility
to affordable medicines is achieved. Prescribers and dispensers of medicines
must therefore inform patients that prescribed medicines may be available at a
lower price than the innovator/Brand product and recommend accordingly. In
other words, where an approved generic medicine exists, the generic medicine
will be substituted for the innovator/brand product unless the dispenser is
prohibited from doing so by the patient. Clearly, the substitution must be
based on the premise that approved generic medicines have been deemed to
be interchangeable following assessment by the MCC. Of particular concern is
the fact that most generic medicines approved and marketed in South Africa do
not comply with internationally accepted requirements for interchangeability as
many/most have not been assessed by comparison with the innovator/brand
product available on the South African market but rather against a “foreign”
reference product as permitted in the national guidelines. A foreign reference
product, although being supplied by the same innovator/brand company, may
not be the same (identical formulation, manufacture etc.) as the innovator/brand
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206 Kanfer et al.

product being sold on the South African market as it well-recognized that in

some cases, innovator/brand products may and are formulated differently
for different markets. For example, Tegretol XR R
tablets, a prolonged action
carbamazepine product, is marketed in the United States as a nondisintegrating
dosage form OROS R
). The same innovator is listed as the manufacturer of
prolonged action carbamazepine dosage forms in various other countries where
those dosage forms are also tablets but which disintegrate in aqueous fluid and
in South Africa is marketed as Tegretol CR R
. The release mechanisms and for-
mulation of the United States reference listed product and the product marketed
by the same innovator in South Africa are clearly different. Hence, in the absence
of specific confirmatory data, a nondomestic innovator/brand product used
as the reference product in a BE study involving a generic medicine intended
for a particular domestic market cannot be assumed to be bioequivalent to the
domestic innovator/brand product. The only data required by the MCC to show
that the foreign reference product is the “same” as the reference product mar-
keted in South Africa are dissolution profiles comparing f 2 values between the
foreign and domestic reference products conducted in three different dissolution
media at pH 1.5, 4.5, and 6.8. Furthermore, applicants are able to conduct such
comparisons for all classes of APIs irrespective of properties such as solubility,
permeability, potency, therapeutic index (e.g., narrow) amongst others and no
risk assessment is apparently required. Therefore a generic product that has been
shown to be bioequivalent to a nondomestic reference may well be usable or
“prescribable” but in the absence of the necessary comparative BA data showing
BE between that same generic product and the domestic reference product, that
generic product cannot be considered to be interchangeable.
It appears that the MCC, by making provision for a foreign or non-domestic
reference product to be used in a BE study has inadvertently created a two-tier
system for the approval of generic medicines in South Africa. The top tier can
therefore be considered to consist of generic products approved on the basis
of comparison with the domestic innovator/brand product as the reference,
whereas another (second or lower) tier includes those generic products approved
on the basis of a comparison of the generic with a nondomestic innovator/brand
as the reference in a BE study. In addition, the latter tier probably also includes
all other generic medicines which have been approved on the basis of in vitro
testing only, apart from those products which incorporate an API classified as
Class 1 according to the BCS (11,12).
A similar situation of ill-conceived interchangeability exists for approved
generic controlled-/modified-release dosage forms as well as non-oral dosage
forms such as topical products for local use, inhalation products and various
other such generic products which are not intended to be absorbed into the sys-
temic circulation.
In summary, it should be emphasized that only when a generic medicine
has been shown to be bioequivalent with the domestic innovator/brand product
used as reference, will substitution be acceptable and appropriate. Clearly, on the
basis of “similar” BA, as would the case be when the generic product has been
shown to be bioequivalent to a nondomestic reference product, a clinical decision
is required to declare a “second-tier” generic product “prescribable” for a patient
who is naı̈ve to that particular medicine, but certainly interchangeability of such
a product is highly questionable.
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REFERENCES
1. Pharmaceutical and Analytical: Medicines Control Council, Department of
Health, 2.02 P&A, Jun07, v2, 2007. http://www.mccza.com/showdocument
.asp?Cat=17&Desc=Guidelines%20-%20Human%20Medicines. Accessed April 29,
2009.
2. Biostudies: Medicines Control Council, Department of Health, 2.06 Biostudies, Jun 07,
v2, 2007. http://www.mccza.com/showdocument.asp?Cat=17&Desc=Guidelines%
20-%20Human%20Medicines. Accessed April 29, 2009.
3. Dissolution: Medicines Control Council, Department of Health, 2.07 Dissolu-
tion, Jun07, v2, 2007. http://www.mccza.com/showdocument.asp?Cat=17&Desc=
Guidelines%20-%20Human%20Medicines. Accessed April 29, 2009.
4. Generic Substitution: Medicines Control Council, Department of Health, December
2003. http://www.mccza.com/showdocument.asp?Cat=17&Desc=Guidelines%20-
%20Human%20Medicines. Accessed April 29, 2009.
5. Medicines and Related Substances Control Act, 1965 (Act No. 101 of 1965) as amended
by Act No. 90 of 1997 and Act No. 59 of 2002. http://www.mccza.com. Accessed April
29, 2009.
6. Circular 14/95, Data Required as Evidence of Efficacy, Annexure 13, Medicines Con-
trol Council, Department of Health, October 2, 1995.
7. Medicines and Related Substances Control Act, 1965 (Act No. 101 of 1965) as amended
by Act No. 59 of 2002. http://www.mccza.com. Accessed April 29, 2009.
8. Midha KK, Rawson MJ, Hubbard JW. Commentary: The role of metabolites in bioe-
quivalence. Pharm Res 2004; 21:1331–1344.
9. General Information: Medicines Control Council, Department of Health, 2.01 General
Information, February 08, v4, April 2008. http://www.mccza.com/showdocument.
asp?Cat=17&Desc=Guidelines%20-%20Human%20Medicines. Accessed April 30,
2009.
10. Gibaldi M, Perrier D. Pharmacokinetics. 2nd ed. New York: Marcel Dekker, 1982.
11. Amidon GL, Lennernas H, Shah V,et al. A theoretical basis for a biopharmaceu-
tics classification: The correlation of in-vitro drug product dissolution and in-vivo
bioavailability. Pharm Res 1995; 12:413–420.
12. Guidance form Industry, Waiver of the in vivo bioavailability and bioequivalence
studies for immediate-release solid oral dosage forms based on a Biopharmaceu-
tics Classification System, Food and Drug Administration, Rockville, MD, USA, 2000.
http://www.fda.gov/cder/guidance/index.htm. Accessed April 30, 2009.

APPENDIX I
The following were the requirements for proof of efficacy of generic medicines
as stated in
Circular 14/95 issued on 2nd October, 1995
Section 2. Proof of Efficacy May be Submitted by Using One of the Following
Methods, Depending on the Relevancy:
2.1 Bioavailability
2.2 Dissolution
2.3 Disintegration
2.4 Acid neutralizing capacity
2.5 Microbial growth inhibition zones
2.6 Proof of release by membrane diffusion
2.7 Particle size distribution
2.8 Blanching test
2.9 Any other method an applicant wishes to submit, provided the rationale for submit-
ting the particular method is included.
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208 Kanfer et al.

2.1 Bioavailability
2.1.1 Bioavailability as proof of efficacy may be used in any instance as proof of
efficacy, but must be used in the following cases:
a) for a modified release tablet or capsule dosage form e.g.; slow release or
sustained release.
b) When a monograph in the USP for an active does not include a method
for dissolution.
c) When the active is mentioned in the attached list A, irrespective of a
monograph being available in the USP.
d) Suspensions, except when a monograph for dissolution is available in
the USP for the active in suspension.
e) Exceptions as indicated under alternative methods of proof of efficacy.
2.1.2 Experimental subjects. Generally speaking 12 subjects are required in a
cross-over study for immediate release tablets or capsules, and 20 subjects
for modified release tablets or capsules.
2.1.3 When bioavailability studies presented for registration purposes were
derived from pilot batches, acceptable data derived from production batches
must be submitted before distribution of the production batches can take
place.
Part 2.2.1 of Circular14/95, viz.;
Dissolution as proof of efficacy may be used in the following instances:
a) When a monograph for the active in the USP includes a dissolution require-
ment and the active is not on the attached list A.
b) When a monograph for a combination of actives in the USP includes dissolu-
tion requirement and the actives are not on the attached list A.
c) When a monograph for a combination of actives is not included in the USP,
but monographs for the individual actives with dissolution requirements are
included in the USP, these individual monographs may be used, provided
that the actives are not on the attached list A.
The “attached list A” contained a number of drug substances listed in
alphabetic order and the list was headed as follows:
“MEDICINES CONTAINING THE FOLLOWING CHEMICAL ENTI-
TIES, CERTAIN COMBINATIONS, SPECIFIC GROUPS OF ENTITIES
OR MEDICINES FALLING INTO A SPECIFIC PHARMACOLOGICAL
GROUP, WHICH WILL USUALLY REQUIRE DATA OTHER THAN COM-
PARATIVE DISSOLUTION DATA AS EVIDENCE OF EFFICACY.”

The following proviso was also included:

“Additions and deletions to the following list may be made by Council from time
to time.”
The list contained 96 drugs and drug combinations listed in alphabetic
order but no reasons provided why those specific names were on the list.
Section 2.2.2 stated the following:
a) Assay results of the reference- and test product must be submitted.
b) Content uniformity test results, if it is a requirement for lot release, alternatively
mass uniformity of the reference and test product must be submitted.
c) Dissolution must be done in 3 media, whereof:
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i) the first medium must be that specified in then USP monograph

ii) the other 2 media shall generally be from the following, spanning a wide pH
range, and not the same as the medium specified in the USP:
ii.i) an acidic medium e.g. Gastric fluid USP
ii.ii) water
ii.iii) an alkaline medium e.g. intestinal fluid USP
d) The USP requirements for at least 6 units of the product, the apparatus, medium
volume, and rotation speed specified in the monograph, for the media required by the
USP, must be followed.
e) For the other 2 media 6 units each must be used for the reference and test product. The
USP requirements for the apparatus, medium volume, and rotation speed specified
in the monograph, for the media required by the USP, may be followed.
f) The method used must be described in full, including media, media volumes, appa-
ratus, rotation speed, filter size (which must not be larger than 1 micrometer if not
specified), assay method and calculations to compensate for dilution of the ingredi-
ents due to withdrawal for dissolution media.
g) The study shall be a multipoint study.
h) The results shall be presented in a tabulated and graphical form. The tabulated form
shall include the individual results of the dosage forms, the mean, and the standard
deviation of the dosage forms. The graphical form will be the mean of the studies of
the reference and test products set out on a graph for each medium.
i) If the active is insoluble in the other 2 media a motivation may be submitted to
Council for the omission of further testing in the other 2 media.”

In addition to the above, the following were also stated as being acceptable
data required as evidence of efficacy.

2.3 Disintegration
2.3.1 Disintegration as proof of efficacy may be used in the following instances:
a) Vitamins or vitamins and mineral combinations when a claim is made
as a supplement.
b) Phenolphthalein
c) Sucralfate
2.3.2 The following are guidelines for the submission of disintegration data:
a) The disintegration test included for Nutritional Supplements in the
USP must be used for the vitamins.
b) The general disintegration test included in the USP may be used for the
other substances.
2.4 Acid neutralising capacity
2.4.1 Acid neutralizing capacity may be as proof of efficacy may be used in the
following instances:
For all products with an antacid or acid neutralizing claim.
2.4.2 The following are guidelines for the submission of acid neutralizing data:
The acid neutralizing capacity test included in the USP must be used.
2.5 Microbial growth inhibition zones
2.5.1 Microbial growth inhibition zones as proof of efficacy may be used in the
following instances:
For all products with a bacteriostatic/bactericidal/antiseptic claim.
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210 Kanfer et al.

2.6 Proof of release by membrane diffusion

2.6.1 Release by membrane diffusion as proof of efficacy may be used in the follow-
ing instances:
For all creams, ointments and gels.
2.7 Particle size distribution
2.7.1 Particle size distribution as proof of efficacy may be used in the following
instances:
For inhalations
2.7.2 The following are guidelines for the submission of particle size distributions:
The Anderson sampler or equivalent apparatus may be used.
2.8 Blanching test
2.8.1 The blanching test as proof of efficacy may be used in the following instances:
For cortisone containing creams and ointments.
2.9 Any other method an applicant wishes to submit, provided the rationale for the
particular method is included.
Please note that it is the prerogative of the applicant to submit any other data as
proof of efficacy, motivating the reason to do so.
Signed: REGISTRAR OF MEDICINES 1995/09/27
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9 South America and Pan American

Health Organization
Silvia Susana Giarcovich
Department of Pharmacology, School of Pharmacy and Biochemistry, University of
Buenos Aires; and DIFFUCAP-EURAND SACIFI, Buenos Aires, Argentina

Ricardo Bolaños
Department of Pharmacology, School of Medicine, University of Buenos Aires;
Department of Projects and Plans, Direction of Planification, National
Administration of Drugs, Food and Medical Technology (ANMAT), Ministry of
Health; and Working Group of Bioequivalence, Pan American Network of Drug
Regulatory Harmonization, PAHO, Buenos Aires, Argentina

INTRODUCTION
Current medicine policies, both in developed and underdeveloped countries,
seek the same objectives of efficacy, safety, and quality of accessible products.
However, different historical, social, and economic circumstances in such coun-
tries have resulted in different scenarios associated with their own internal issues
which have been and are being currently resolved according to each particular
prevailing situation.
The map of registration requirements for pharmaceutical products in the
Americas is heterogeneous. Neither registration of innovator products nor that
of noninnovator ones are identical and the documentation requirements for the
registration of either are different among those countries.
There is currently a competitive market between innovator products and
noninnovator products. The noninnovator products involve both generic prod-
ucts and so-called “similar products.” The term “generic product” was initially
used in those countries that recognized the intellectual property of pharmaceuti-
cal products to refer to products registered by competitors once the patent protec-
tion period had expired. Usually generic products are commercialized without
a brand name although sometimes a brand name is used (the brand generics).
The term “similar product” is used in countries where, historically, no patent
protection rights on pharmaceutical products existed. In those cases, different
commercial brands of the same active drug substances are simultaneously com-
mercialized by different pharmaceutical laboratories. Definitions for both generic
and similar products are included in the multisource product definition (1).
Harmonization efforts seek to ensure medicines availability at both
national and international level by agreement of common requirements for regis-
tration, inspection, control, and vigilance. In this context different harmonization

211
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212 Giarcovich and Bolaños

initiatives has taken place in Europe,a Southeast Asia,b America as well as ICH.c
Particularly, the World Health Organization (WHO)d has provided a number
of guidelines and technical documents related to good manufacturing practices
(GMPs), good clinical practice (GCP), comparator products, essential medicines,
multisource products registration, and so on. WHO has also promoted the
International Conference of Drug Regulatory Authorities (ICDRA). In this con-
text, regional harmonization efforts in the Americas have been carried out by
different economic integration groupse and by PAHO (Pan American Health
Organization) through PANDRH (Pan American Drug Regulatory Harmoniza-
tion). This network grouped Pan-American regulatory authorities since 1997.
Its work has been organized through continuous meetings of different work-
ing groups around the main issues such as GMP, bioavailability/bioequivalence
(BA/BE), GCP, drug registration, phamacopoeia, combat to drug counterfeiting,
GLP, drug classification, botanical products, pharmacovigilance, and vaccines.
Besides the official regulatory authorities, pharmaceutical industry representa-
tives are invited to participate with one observer in each working group. The
Latin-American pharmaceutical companies are thus represented by FIFARMA
(Federación Latinoamericana de la Industria Farmacéutica) and ALIFAR (Asociación
Latinoamericana de Industrias Farmacéuticas). The documents, surveys, and recom-
mendations produced by PANDRH are in the public domain at www.paho.org.
Several papers on drug regulations in the Americas have been recently
published. Homedes and Ugalde (2), reported the results of a preliminary sur-
vey conducted in 10 Latin-American countries. The study aimed to document
the experiences of different countries in defining and implementing generic
drug policies. It focused on determining the cost of registering different types of
pharmaceutical products, the time needed to register them, and uncover incen-
tives that governments have developed to promote the use of multisource drugs
products. The survey instrument was administered in person in Chile, Ecuador,
and Peru and by e-mail in Argentina, Brazil, Bolivia, Colombia, Costa Rica,

a EMEA: European Agency for the Evaluation of Medicinal Products; CADREAC: Collaboration
Agreement of Drug Regulatory European Authorities.
b ASEAN: the Association of Southeast Asian Nations.
c ICH is the International Conference of Harmonization of Technical Requirements for Regis-
tration of Pharmaceuticals for Human Use. It was established in 1990 and is participated by
both regulatory authorities and pharmaceutical industry from the European Union, Japan,
and United States. Today, ICH has a Global Cooperation Group, where different harmoniza-
tion initiatives are represented.
d WHO has an international legal mandate from 191 members to establish global standards for
the promotion and protection of public health.
e The different economic integration groups in the Americas are:
a) TLCN (Tratado de Libre Comercio de Norteamérica): Canada, Estados Unidos, and
Mexico.
b) MERCOSUR: Argentina, Brazil, Paraguay and Uruguay (Chile and Bolivia participate
without being members).
c) SICA (Sistema de la Integración Centroamericana): Guatemala, El Salvador, Honduras,
Nicaragua, and Costa Rica.
d) CAN (Comunidad Andina de Naciones): Bolivia, Colombia, Ecuador, Peru, and Venezuela.
e) CARICOM (Caribbean community): Caribbean Islands.
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South America and Pan American Health Organization 213

Nicaragua, and Uruguay. There were a total of 22 respondents. Survey responses

indicated that countries use the terms generic and BE differently and sug-
gested the need to harmonize definitions and technical concepts. Vacca González
et al. (3) characterized the situation and regulatory tendencies relating competi-
tor products in 14 countries of Latin America and the Caribe and concluded
that harmonization efforts should consider both definitions adopted by differ-
ent countries, and local policies promoting generics acquisitions.
In this chapter, an overview is provided of the current status of drug
registration requirements in South America and the consensus reached under
the sponsorship of PAHO. Associated documents, surveys, proposals, and rec-
ommendations from PANDRH working groups (WG) (drug registration and
BA/BE) are also discussed. The terminology used in this text is in agreement
with WHO definitions unless otherwise stated.
The following documents are referred to in this chapter:
r Survey conducted by PANDRH Drug Registration WG: “Diagnostic Study
on Common Requirements for Pharmaceutical Products Registration in the
Americas.”f
r Survey conducted by PANDRH BE WG: “Diagnostic Study on Implementa-
tion of Bioequivalence Studies in the Americas.”g
r Document prepared by PANDRH Drug Registration WG: “Draft Proposal
of Harmonized Requirements for Pharmaceutical Products Registration in the
Americas,”h which is still under discussion.
r Document prepared by PANDRH BE WG: “Framework for Implementa-
tion of Equivalence Requirements for Pharmaceutical Products,”i which has
been recently approved at the PANDRH V Conference (17–19 November 2008,
Buenos Aires, Argentina).
The discussion is focused specifically on the differences and issues related
to the equivalence requirements for registration of noninnovator products.

REGISTRATION

Background
Since neither physicians nor patients are able to asses the efficacy, safety, and
quality of the medicines that they prescribe and consume, national health author-
ities must establish mechanisms to ensure the various foregoing considerations.
Most countries in the Americas have laws and regulations regarding the registra-
tion, inspection, control, and postmarketing surveillance of medicines. However,
differences can be found, for example in the following:
– Classification.
– Documentation to be submitted for registration.
– Meaning of the terms “new drug substance” and “new drug product.”
– Assessment criteria.

f http://www.paho.org/Spanish/AD/THS/EV/rm-hp.htm.
g http://www.paho.org/Spanish/ad/ths/ev/BE ImpletEstudio04-esp.pdf.
h http://new.paho.org/hq/index.php?option = com content&task = view&id = 1060&Itemid

= 513.
i http://new.paho.org/hq/index.php?option=com content&task=view&id=1052&Itemid=

513&limit=1&limitstart=1.
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214 Giarcovich and Bolaños

– Labelling and package insert requirements.

– Time elapsed from registration application until authorization.
The PANDRH WG on Drug Registration has produced two documents,
which can be found on the web (www.paho.org) and are further discussed:
– A survey to assess the technical and legal drug registration requirements.j
– A proposal of harmonized requirements for drug registration.k
Before presenting these two documents, some critical terms are discussed.

Some Critical Terms

A critical issue that each country must decide upon before applying for any pol-
icy of registration relates to the definitions of terms and explanation of some
particular concepts.
New Drug Substance
Some countries consider a “new drug substance”l as a drug substance (API) that
has never been commercialized in that particular country. However, others have
adopted the concept of “country of reference” and consequently, consider that
“new” is a drug substance (API) that has never been commercialized either in the
country or in the country of reference. Figure 1 helps to explain these differences.

New Drug Product

Similar to the concept of “new drug substance” some countries consider a “new
drug product” as a drug product that has never been commercialized in the
country, and others adopt the concept of “country of reference” and consequently
consider that “new” is a drug product that has never been commercialized either
in the country or in the country of reference. Figure 2 illustrates these differences.

Multisource Pharmaceutical Products

Harmonization efforts have tended to a dual registration concept, that is to say,
the product is either “new” or “generic.” This has been historically so in the
United States and Canada (within PAHO) with the NDA and ANDA criteria
for registration. However, the situation in Latin-American countries shows more
variety of options. Brazil and Mexico on the one hand allow the registration of
either “new,” “generic” or “similar” products, where the generic product must
demonstrate BE to the selected reference product to be declared interchangeable.
However, regulatory authorities have often included similar products in a pro-
gram to require bioequivalence demonstration for registration renewals.
On the other hand, most of the other Latin-American countries do not use
the term “generic” in their registration regulations; usually, they refer to “similar
drug products.” Also, most of these countries require the demonstration of BE of

j http://www.paho.org/Spanish/AD/THS/EV/rm-hp.htm.
k http://new.paho.org/hq/index.php?option = com content&task = view&id = 1060&Itemid
= 513.
l Author’s note: Drug substance is taken in the context of this article as API (active pharma-
ceutical ingredient).
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South America and Pan American Health Organization 215

API locally
commercialized?

Yes No

Commercialized Commercialized
outside? outside?

Yes No Yes No

Reference Reference
country? country?

Yes No Yes No

a b c d e f

FIGURE 1 a, b, c: As the drug substance is already being locally commercialized, it will never
be considered a new one. The differences between a, b, and c take into account whether the
drug substance is being commercialized outside the country and the category of those countries
where reference country categories have been locally established.
d, e, f: As the drug substance is not being locally commercialized, some countries will consider
that the drug substance is a new one. However, countries which accept the concept of country
of reference will consider that the drug substance is a new one only in cases e and f.

similar/multisource drug product to the reference product when the product is

considered to be of high risk.
Lastly, to understand the Latin-American scenario, it is necessary to refer
to the WHO definition of a multisource drug product, that is,“Pharmaceutically
equivalent or pharmaceutically alternative products that may or may not be therapeuti-
cally equivalent. Multisource pharmaceutical products that are therapeutically equiva-
lent are interchangeable.” (1)
In practice, both “generic/multisource drug products” and “simi-
lar/multisource drug products” that demonstrate bioequivalence to the selected
reference product, may be declared interchangeable.

PANDRH Survey: Diagnostic Study of Common Requirements for the

Registration of Pharmaceutical Products in the Americas
The surveym was carried out by the PANDRH WG on Drug Registration and the
full report can be obtained from the PAHO website. The questions were based

m Some parts of the original document are reproduced (italics) in the present chapter whereas
others are summarized.
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216 Giarcovich and Bolaños

Product locally
commercialized?

YES NO

Commercialized Commercialized
outside? outside?

NO
YES NO YES

Reference
Reference
country?
country?

YES NO YES NO

A B C D E F

nA nPF nU nP

abc(d) ef abc(d) ef abc(d) ef abc(d) ef

FIGURE 2 nA, New association (fixed-dose combination); nPF, New pharmaceutical formula-
tion; nU, New use; nP, New potency.
A, B, C: As the drug product is already being locally commercialized, it will never be considered
a new one. The differences between A, B, and C take into account whether the drug product is
being commercialized outside of the country and the category of those countries where reference
countries category has been locally established.
D, E, F: As the drug product is not being locally commercialized, some countries will consider
that the drug product is a new one. However, countries which accept the concept of country of
reference will consider that the drug product is a new one only in cases E and F. Besides, in
cases D, E and F, if the API is an already known one (cases a, b, c, and eventually d of chart
shown in “New Drug Substance” section), documentation requirements for registration of the
new drug product might be different than when the API is unknown.

on a yes or no response and were sent by the PANDRH Secretariat to invited

countries. The percentage of positive responses to the total number of partici-
pating countries was informative. The objective was to obtain information from
local health authorities of each participating country to know the requirements
for medicine registration in the following cases:

– New molecules
– New formulations
– New uses
– New dosage form
– New presentation
– New route of administration
– New association
– Generic equivalent
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South America and Pan American Health Organization 217

– Similar equivalent
– Biologics
– Renewal
The survey implied to answer if the following requirements applied for
registration of the different cases mentioned above:
– General information about the product
– Information about the manufacturing facilities
– Legal documentation supporting the application
– Active Pharmaceutical Ingredient
– Final product
– Biopharmaceutic technical documentation
– Preclinical data
– Clinical data
– Labelling
– Secondary packaging components
– Package Inserts
Observations are summarized as follows mainly taking into account the
information relating to requirements for new molecules (with the knowledge that
new molecules have the strictest requirements of all studied groups):

General Information About the Product

General information required include commercial name, generic name, presen-
tation, potency, dosage form, route of administration, description of the product,
and also cost and time to complete the evaluation of the application. Less than
50% of the countries have already established the required costs and times for
evaluation. The percentage is higher for new molecules than for the rest of the
groups.

Information About the Manufacturing Facilities

The information required includes name of the license holder, API manufac-
turer (mostly for new molecules), pharmaceutical manufacturer (100% for new
molecules), alternative manufacturing and packing sites (almost all countries for
all cases), and responsible person for the release of the batch (15.4–30.8% of the
countries).

Legal Documentation Supporting the Application

This item includes manufacturer authorization (>66.7% for all cases), GMP cer-
tificate for API manufacturer (<30% of countries), GMP certificate for finished
product manufacturer (88.9% is the highest for new molecules), GMP certificate
for out-of-the-country manufacturer (<30% for all cases), outsourcing manufac-
turing contract (maximum of 94.4% for new molecules), patent certificate (maxi-
mum of 27.8%), reference standards (<70%), first batch authorization (maximum
of 38.9% for new molecules).

Secondary Packaging Components

In a high percentage of the participating countries, the information that has to
be present in the secondary packaging material are commercial name, generic
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218 Giarcovich and Bolaños

name (INN or DCI), potency, dosage form, expiration date, storage conditions,
and prescription conditions. Some countries require registration number, instruc-
tions for use, warnings, and contraindications. A fairly low percentage of coun-
tries require manufacturing date, legal representative, name of the responsible
professional, indications, posology, and interactions. Finally, a very small per-
centage of countries require the inclusion of restrictions for use and overdose
data.

Packaging Insert
A package insert for new APIs is required by 69.2% of the countries. A high
percentage of countries require commercial name, generic name, dosage form,
instructions of use, indications, dosage, warnings, contraindications, adverse
reactions, interactions, and overdose in the insert whereas a smaller number of
countries require manufacturer information, expiration date, name of the respon-
sible professional, registration number.

Active Pharmaceutical Ingredient

A high percentage of countries use the INN (94.4% for new molecule), in com-
parison to those that use IUPAC (44.4% for new molecule) or ATC classifica-
tion (33.3% for new molecule). Countries require chemical name, molecular and
structural formula, molecular weight, organoleptic properties, and physicochem-
ical characteristics (>75% for new molecules). The route of synthesis has to be
included for most of the countries (61.1% for new molecules) whereas most of
them also require information on impurities and degradation products as well
as specifications for batch approval (77.8% for new molecules). A high percent-
age of countries require stability data and analytical methodology (94.4% for new
molecules); however, a smaller percentage require documented validation for the
analytical procedures (38.9% for new molecules).

Final Product
A document about the formulation development (44.4% for new molecules),
manufacturing method (61.1% for new molecules), and physicochemical proper-
ties of the excipients (50.0% for new molecules) is required. Formula and storage
conditions are required in 100% of registrations of new molecules. A high per-
centage of countries require stability data and analytical methodology (94.4% for
new molecules) whereas a lower percentage of countries require local analysis
for imported products (50.0% for new molecules).

Preclinical Data
Data relating general and special toxicology, pharmacodynamic, and pharma-
cokinetic studies are required in most countries mainly for new APIs (72.2–
94.4%).

Clinical Data
The percentage of countries requiring clinical data are the following:
◦ New chemical entities: 72.2%
◦ New formulation: 50.0%
◦ New indication: 66.7%
◦ New dosage form: 61.1%
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South America and Pan American Health Organization 219

◦ New strength: 66.7%

◦ New route of administration: 61.1%
◦ New association: 66.7%
◦ Generics: 38.9%
◦ Similars: 57.1%
◦ Biologics (vaccines, recombinant products, blood products): 50.0%
◦ Renewals: 5.6%
Due to the observed differences in registration requirements of the differ-
ent participant countries, it was concluded that a harmonization proposal was
needed.

PANDRH Proposal: Proposal of Harmonized Requirements for the

Registration of Pharmaceutical Products in the Americas
Since some of the differences in the registration requirements were considered to
be critical to ensure public health, a harmonization proposaln was elaborated by
the Drug Registration WG and discussed along with the PANDRH V Conference
although it still remains as a draft document which can be found on the PAHO
website (www.paho.org).
The recommended minimum requirements for drug registration informa-
tion are the following:
1. Commercial name
2. Generic name
3. Strength/potency
4. Pharmaceutical dosage form
5. Technical director
6. Legal representative
7. Product owner
8. API manufacturer
9. Finished product manufacturer
10. Other laboratories participating in the manufacturing process
11. Drug product presentation
12. Route of administration
13. Storage conditions
14. Dispensing conditions
15. Qualitative–quantitative formula
16. Product legal documents
17. Summary of product characteristics
18. Labelling and insert
19. Labelling of primary packaging
20. Labelling of secondary packaging
21. Insert
22. Health professional information
23. Final marketing packaging
24. Samples of the finished product
25. Certificate of analysis
26. Active pharmaceutical ingredient(s)

n Parts of the original document are reproduced (italics) in the present chapter.
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220 Giarcovich and Bolaños

BIOEQUIVALENCE

Introduction
Bioequivalence requirements for registration of noninnovator products in the
Americas are basically divided into three different approaches as follows, United
States/Canada, Brazil/Mexico, and the rest of the Spanish-speaking countries.
On the one hand, United States and Canada will always require demon-
stration of therapeutic equivalence-employing either in vivo or in vitro
methodology- to allow health authorities to declare interchangeability between
the noninnovator product (the generic product) and the reference product (usu-
ally the innovator product). When a noninnovator product fails to demon-
strate therapeutic equivalence, it will not be declared interchangeable and conse-
quently it will not be registered as a generic product in either the United States
or in Canada.
A different approach is taken in Mexico and Brazil. Both countries have
regulations for the registration of generic products from 1999. Mexico was the
first Latin-American country with the Norma Oficial Mexicana NOM-177-SSA1–
1998 and Brazil was the second with the Ley No 9787 from 10.2.99 and the Res. No
391 from 9.8.99. However, both of them allow sponsors to choose between two
types of registration of noninnovator products, interchangeable generic products
and similar products.
Finally, the rest of the Spanish-speaking countries represent the third
approach. In general, they do not have regulations for the registration of generic
products as such.
However, in some of the countries, a bioequivalence study and/or decla-
ration of interchangeability (through either in vitro or in vivo methodology) is
also required as a condition either for registration or commercialization for some
of the noninnovator products, mainly chosen according to high health risk cri-
teria. For example, the following countries use this type of registration and/or
commercialization requirementso :
r Argentina: Disp. No 3185/1999 from ANMAT.
r Chile: Res. No. 726 and 727/2005 from Health Ministry.
r Colombia: Res. No. 1400/2001 from Health Ministry.
r Costa Rica: Pres. Dec. No.32470-S/2005.
r Cuba: Reg. No. 18-07 from Health Ministry.
r Panama: Res. No. 081/2005 from Health Ministry.
r Venezuela: Normas de la Junta Revisora de Productos Farmacéuticos, from Jan-
uary 1999, Chapter XIV and more recently in Res. No. 38.499/2006 from Health
Ministry.
r Uruguay: Pres. Dec. of Interchangeability, 2008.

In some countries, such as Peru and Ecuador, expert groups are discussing
the way to include therapeutic equivalence studies (either in vitro or in vivo)
requirements into their own regulations.

o The following summary states mainly the first or initial regulations where these requirements
can be found. However, in most cases they have been complemented with additional local
regulations.
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South America and Pan American Health Organization 221

Also, it is important to mention that amongst this group of countries there

is a difference which results in two new approaches. Some of these countries
include the concept of “country of reference”p whereas others do not. When the
regulations for registration include the concept of “country of reference,” then
the introduction of a new product into the local market can sometimes proceed in
an abbreviated way. If it can be demonstrated that the new product has already
been registered and commercialized in one of the countries of reference, then
it can be registered as a similar/multisource product. However, when the con-
cept of “country of reference” is not included in the regulations for registration,
then the first pharmaceutical company (usually the innovator), that intends to
introduce a new product into the local market, will have to submit complete and
comprehensive preclinical and clinical data.
The PANDRH WG on BE (WG/BE) has produced two documents that are
discussed later:
r A survey to assess the implementation of BE studies in the Americasq
r A proposal for implementation of equivalence criteria requirementsr

PANDRH Survey: Diagnostic Study on Implementation

of Bioequivalence Studies in the Americas
The present survey was carried out by the PANDRH WG/BE and the full report
(2005), written in Spanish,s can be found on the PAHO website (www.paho.org).
Since the WG/BE of PANDRH makes recommendations about the type of equiv-
alence studies (in vitro/in vivo), prioritization of drugs for BE (in vivo) studies
and criteria to choose a reference product, it was necessary to assess the real
feasibility of carrying out BE studies in Latin America from both regulatory and
operational aspects. Hence, detailed information was obtained from health agen-
cies of each participant country based on a yes-or-no questionnaire regarding the
following:
r Current GCP and BE regulations
r Registration requirements for BE studies
r Prioritization criteriat
r Availability of centers to carry out the studies
r Expertise of the regulatory agency to assess, control, and audit the studies
r Quantity of BE studies already carried out
r Training
The survey was carried out in 2003/2004 and was answered by 20 coun-
tries, 15 Spanish-speaking countries, 4 English-speaking countries, and 1

p Usually the term “country of reference” refers to countries with high surveillance health
agencies.
q http://www.paho.org/Spanish/ad/ths/ev/BE ImpletEstudio04-esp.pdf.
r http://new.paho.org/hq/index.php?option=com content&task=view&id=1052&Itemid=
513&limit=1&limitstart=1.
s Some parts of the original document are reproduced (italics) in the present chapter whereas
others are summarized.
t Prioritization criteria are intended to be useful mainly in countries where BE studies are not
included into registration requirements and refer to criteria to choose which APIs have priority
mainly considering sanitary risk.
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222 Giarcovich and Bolaños

Portuguese-speaking country (Argentina, Brazil, Bahamas, Barbados, Bolivia,

Canada, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador,
Guatemala, Honduras, Mexico, Nicaragua, Panama, Peru, Surinam, United
States, and Venezuela). Since the number of inhabitants of the various coun-
tries largely differ, answers were interpreted considering both the number of
countries that answered positively (% of the total number of participant coun-
tries) and the impact it had on the regional Latin-American/Caribbean number
of inhabitantsu (% of the total population affected belonging to either the Amer-
icas or Latin America). Full results of this survey are published on the web and
are summarized as follows:

GCP and BE Current Regulations

Fifty percent of participating countries (∼22% of Pan-American countries) have
some type of GCP regulations applicable to BE studies, and this impacts on ∼76%
of Latin-American/Caribbean population.

Registration Requirements for BE Studies

Forty-five percent of participating countries (∼20% of Pan American coun-
tries) require BE studies for registration and this impacts on ∼75% of Latin-
American/Caribbean population.

Prioritization Criteria
Thirty-five percent of participating countries (∼16% of Pan American countries)
have already established prioritization criteria with variable number of drugs in
positive lists (countries usually list locally prioritized drugs) and this impacts on
66% of Latin-American/Caribbean population.

Availability of Centers to Carry Out the Studies

Forty percent to fifty-five percent of participating countries (∼18–25% of Pan-
American countries) recognize the participation of local experts, the availabil-
ity of adequate hospitals/clinics and the requirement of protocol approval
by independent ethical committees, and this impacts on ∼70% of Latin-
American/Caribbean population.

Expertise of Regulatory Agency to Assess, Control, and Audit the Studies

Forty percent to forty-five percent of participating countries (∼18% of Pan Amer-
ican countries) declare having adequate resources to assess and authorize studies
and this impacts on 72% of Latin-American/Caribbean population whereas only
20% have adequate resources to inspect the different steps of BE studies. In sev-
eral countries study evaluators have to fulfill other assignments as well. Further-
more, in some cases the health authorities hire external organizations/personnel
in order to complete the evaluation.

u There were 20 participant countries of the survey of 46 countries within all the Americas.
Those 20 countries correspond to 93.6% of the total population of the Americas and 18 of
them correspond to 89.8% of the Latin-American and Caribbean population.
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South America and Pan American Health Organization 223

Number of BE Studies Concluded

Only 25% of participating countries (∼11% of Pan American countries) declare
the larger number of BE studies already carried out, and this impacts on 60% of
Latin-American/Caribbean population.

Training
Forty percent of participating countries (∼18% of Pan-American countries)
report having carried out BE training courses and this impacts on 70% of
Latin-American/Caribbean population.
From the date of the survey until the time of writing this chapter, addi-
tional countries have developed new BE regulations, for example, Chile, Costa
Rica, Cuba, Panama, and Uruguay. Hence, since the start of the present survey,
an increasing number of countries have included BE studies as a registration
requirement affecting about 80% of Latin-American population and about 50%
of the population of the Americas.

PANDRH-Approved Document: Framework for Implementation

of Equivalence Requirements for Pharmaceutical Products
This document was prepared by the WG/BEv and was approved by the
PANDRH V Conferencew in November 2008 (full document can be found on
PAHO website). The objective of the document is to recommend harmonized cri-
teria for the equivalence of drugs and consists of two parts.
The first part refers to the scientific criteria for implementing thera-
peutic equivalence. The WG/BE decided unanimously to endorse the WHO
document “Multisource (generic) pharmaceutical products: Guidelines on
registration requirements to establish interchangeability” (1) and to promote its
implementation in the Americas.
The second part of the document refers to the strategic framework for the
implementation of studies for drug equivalence. This part describes the cur-
rent situation of the Region of the Americas, with particular attention to the spe-
cial features of Latin America considering that most of the multisource products
marketed in the region have been approved in accordance with drug registration
requirements of each country at the time of its registration. The gradual imple-
mentation of BE demonstration requirements based on health risk of a particular
product is recommended. Furthermore, it presents a flow chart integrating both
the requirements of fulfillment of GMP, the validity and reliability of the refer-
ence product, and the concept of gradualism in prioritization according to health
risk and biowaivers.

Equivalence Demonstration and GCP

The WHO document (1) states that multisource pharmaceutical products must
be shown, either directly or indirectly, to be therapeutically equivalent to the

v Some parts of the original document are reproduced in the present chapter (italics) whereas
others are summarized.
w First version of the document was considered during the IV PANDRH Conference, March

2005, Dominican Republic.

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224 Giarcovich and Bolaños

comparator product in order to be considered interchangeable. Suitable test

methods to assess equivalence are
(a) comparative pharmacokinetic studies in humans, in which the active pharmaceu-
tical ingredient and/or its metabolite(s) are measured as a function of time in an
accessible biological fluid such as blood, plasma, serum or urine to obtain phar-
macokinetic measures, such as AUC and Cmax that are reflective of the systemic
exposure;
(b) comparative pharmacodynamic studies in humans;
(c) comparative clinical trials; and
(d) comparative in vitro tests.
The document prepared by the WG/BE recognizes that implementation
has to be decided by the local health regulatory authority when establishing
equivalence requirements for drug registration and commercialization and that
a strategy based on the health risk criteria of each product will facilitate harmonization
of implementing equivalence requirements in the region.

Prioritization According to Sanitary Risk

As part of the proposal, an example of classification in accordance with health
risk has been designed with the aim of helping health authorities only when
needed. Health risk categories have been established and a score from 1 to 3
has been assigned according to sanitary risk. The health risk concept has been
defined in relation to health impact if drug plasma concentrations fall under or
above the therapeutic window (the margin whose limits are the nontoxic maxi-
mum and effective minimum drug concentrations) hence, three risk levels have
been characterized as follows:
HIGH HEALTH RISK: This is the probability of the appearance of threatening complica-
tions of the disease for the life or the psychophysical integrity of the person and/or
serious adverse reactions (death, patient hospitalization, extension of the hospital-
ization, significant or persistent disability, disability or threat of death), when the
blood concentration of the active ingredient is not within the therapeutic window.
For purposes of the selection, this risk level has been assigned a score of 3 (three).
INTERMEDIATE HEALTH RISK: This is the probability of the appearance of non-
threatening complications of the disease for the life or the psychophysical integrity
of the person and/or adverse reactions, not necessarily serious, when the blood
concentration of the active ingredient is not found within the therapeutic window.
For purposes of the selection, this risk level has been assigned a score of 2 (two).
LOW HEALTH RISK: This is the probability of the appearance of a minor complication
of the disease and/or mild adverse reactions, when the blood concentration of the
active ingredient is not within the therapeutic window. For purposes of the selec-
tion, this risk level has been assigned a score of 1 (one).
The table below lists the active ingredientsx and their classification accord-
ing to their health risk, and the table should be continuously updated:

x Taken as an example from API´s listed in: “Multisource (generic) pharmaceutical prod-
ucts: guidelines on registration requirements to establish interchangeability” WHO Technical
Report Series (1996), No. 863, 114–155.
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South America and Pan American Health Organization 225

Active Ingredient Health Risk

Carbamazepine 3
Cyclosporine 3
Digoxin 3
Ethambutol 3
Ethosuximide 3
Griseofulvin 3
Lithium Carbonate 3
Oxcarbazepine 3
Phenytoin 3
Procainamide 3
Quinidine 3
Theophylline 3
Tolbutamide 3
Valproic Acid 3
Verapamil 3
Warfarine 3
6-mercaptopurine 2
Amiloride 2
Amitriptyline 2
Amoxicillin 2
Atenolol 2
Azathioprine 2
Biperiden 2
Chloramphenicol 2
Cimetidine 2
Ciprofloxacin 2
Clofazimine 2
Clomipramine 2
Clorpromazine 2
Co-Trimoxazole 2
Cyclophosphamide 2
Dapsone 2
Diethylcarbamazine 2
Doxycycline 2
Erythromycin 2
Ethinylestradiol 2
Etoposide 2
Flucytosine 2
Fludrocortisone 2
Furosemide 2
Haloperidol 2
Hydrochlorothiazide 2
Indometacin 2
Isoniazid 2
Ketoconazole 2
Levodopa + Inhib. DDC 2
Levonorgestrel 2
Levotiroxine 2
Methotrexate 2
Methyldopa 2
Metoclopramide 2
Metronidazole 2
Nitrofurantoin 2
(Continued )
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226 Giarcovich and Bolaños

Active Ingredient Health Risk

Noretisterone 2
Oxamniquine 2
Paracetamol 2
Penicillamine 2
Piperazine 2
Piridostigmine 2
Procarbazine 2
Promethazine 2
Propranolol 2
Propylthiouracil 2
Pyrimethamine 2
Quinine 2
Rifampicin 2
Salbutamol, sulphate 2
Spironolactone 2
Tamoxifen 2
Tetracycline 2
Acetazolamide 1
Allopurinol 1
Calcium Folinate 1
Captopril 1
Clomifene 1
Cloxacillin 1
Dexamethasone 1
Diazepam 1
Folic Acid + Ferrous Sulfate 1
Ibuprofen 1
Isosorbide Dinitrate 1
Levamisole 1
Mebendazole 1
Mefloquine 1
Nalidixic Acid 1
Niclosamide 1
Nifedipine 1
Nystatin 1
Phenoxymethylpenicillin 1
Phytomenadione 1
Pirantelo 1
Praziquantel 1
Pyrazinamide 1
Sulfasalazine 1
Aminophylline (see Theophylline)
Sulfadoxine (see Pirimetam)

The same document also shows a list of APIs subject to BE in vivo study
requirements in different countries in the American region.

Decision Tree for Implementing Equivalence Studies in the Region

The following flow chart integrates GMP criteria, prioritization according to
health risk, biowaivers according to the BCS (4) and a reliability requirement
for reference products was designed:
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South America and Pan American Health Organization 227

Product Manufacturer
meets GMP
requirements?

YES NO

Must
Product requires meet
equivalence GMP
study?
YES NO

Go to
Is a hhr Register
API? Office

NO
YES

If DRA requires
BE: Elegible for
Has a valid Ref Prod? Biowaver?

YES NO

YES NO

Has a valid
Proceed as
Ref. Prod ?
hhr API
Apply
BE WHO
study criteria and
YES NO
this
document

Biowaver Apply WHO

f2 study* criteria and
this document

FIGURE 3 hhr, high health risk.

∗ If a product does not meet f specifications, DRA will decide case by case.
2

How to Select the Comparator Product in the Region

Generally, local health authorities are responsible for the identification of
the most appropriate reference producty for each drug. Usually most health

y Note of Authors: “Reference product” corresponds to the term “comparator product” as defined
by WHO.
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228 Giarcovich and Bolaños

authorities will accept that the innovator product is the most logical compara-
tor product for a multisource pharmaceutical product because its quality, safety,
and efficacy would have been comprehensively assessed and documented. In
Latin America, however, despite the availability of innovator products in the
local market, national requirements of reliability for a reference product still has
to be assessed. Accordingly, in the light of this complex scenario, the PANDRAH
WG/BE has included a recommended mechanism to help the national health
authority to assess the local particular situation and to establish a reliable refer-
ence product.

Summary of Regulatory Requirements in Argentina

The main characteristics of the Argentinean regulations (5) regarding multi-
source/similar products registration are summarized below:
a) The decision to categorize a new application for registration as an abbre-
viated submission or not is primarily related to the commercialization
antecedents of the pharmaceutical product.
b) If the product to be registered is already being commercialized either locally
or in at least one of the countries of reference,z the product will be catego-
rized as “similar.”
c) There is a list of countries of reference in order to allow an abbreviated pro-
cedure for an imported product registration.aa
d) Noninnovator products are registered as “similar” products. A registration
procedure for generic products as such, does not exist.
e) The requirements for the registration of noninnovator products mainly
involve GMP and equivalence studies (in vitro and/or in vivo).
f) The requirements of either in vitro or in vivo equivalence studies are
not related to different nomenclature (generics, similars, multisource, etc.)
but to the type of API present in the formulation which is submitted for
registration.
g) The corresponding equivalence studies (in vitro and/or in vivo) have been
mainly established on sanitary risk criteria.
h) The criteria used to decide between in vitro and in vivo equivalence studies
are clearly established in the local regulations.
i) The in vivo equivalence studies are referred to as BA and BE studies.
j) Every registered product has to have demonstrated equivalence (in vitro
and/or in vivo) with respect to a reference product.
k) When a noninnovator product has demonstrated Bioequivalence to a ref-
erence product, it can be declared bioequivalent. However, an interchange-
ability declaration does not exist.
l) Injectables and oral aqueous solutions, gases and powders for reconstitution
into solutions are exempted from the need to demonstrate equivalence.
m) Regulations for prescriptions require the use of the generic name of drugs
instead of the brand name when physicians prescribe medicines.

z United States, Japan, Sweden, Swizerland, Israel, Canada, Austria, Germany, France, United
Kingdom, The Netherlands, Belgium, Denmark, Spain, and Italy.
aa Australia, Mexico, Brazil, Cuba, Chile, Finland, Hungary, Irland, China, Luxenburg, Norway,

and New Zealand.

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South America and Pan American Health Organization 229

The authors declare that the contents of this chapter represent their
personal point of view without involving any organizations where they are
associated.

ABBREVIATIONS

ALIFAR Asociación Latinoamericana de Industrias Farmacéuticas

ANDA Abbreviated New Drug Application
ANMAT Administración Nacional de Medicamentos, Alimentos y Tecnologı́a Médica
(Argentinian health authority)
API Active Pharmaceutical Ingredient
ASEAN Association of Southeast Asian Nations
BA/BE Bioavailability/Bioequivalence
BCS Biopharmaceutic Classification System
CADREAC Collaboration Agreement of Drug Regulatory European Authorities
CAN Comunidad Andina de Naciones
CARICOM Caribbean community
DRA Drug Regulatory Authority
EMEA European Agency for the Evaluation of Medicinal Products
FDA Food and Drug Administration
FIFARMA Federación Latinoamericana de la Industria Farmacéutica
GCP Good Clinical Practice
GMP Good Manufacturing Practice
GLP Good Laboratory Pactice
ICDRA International Conference of Drug Regulatory Authorities
ICH International Conference of Harmonization of Technical Requirements for
Registration of Pharmaceuticals for Human Use
INN International Nonproprietary Name
IUPAC International Union of Pure and Applied Chemistry
MERCOSUR Mercado Común del Sur
NDA New Drug Applications
NAFTA North American Free Trade Agreement
PAHO Pan American Health Organization
PANDRH Pan American Network for Drug Regulatory Harmonization
SICA Sistema de la Integración Centroamericana
USA United States of America
WG Working Group/s
WHO World Health Organization

ACKNOWLEDGMENTS
We acknowledge the dedication and professional work of members of PAN-
DRH Working Groups, Drug Registration and Bioequivalence, as well as their
Coordinators: Esperanza Briceño (Venezuela), Marı́a Teresa Ibarz (Venezuela),
and Justina Molzon (United States). In addition, with special deep grati-
tute and respect, we recognize the inestimable help and support of Rosario
D’Alessio, (PANDRH/PAHO secretariat). We specially acknowledge the con-
tinuous support and expertise from Nelly Marı́n (PANDRH/PAHO secretariat)
and the careful revision of this chapter and precise advice from Horacio
Pappa.
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230 Giarcovich and Bolaños

REFERENCES
1. Annex 7 “Multisource (generic) pharmaceutical products: guidelines on registration
requirements to establish interchangeability. WHO Technical Report Series, No. 937,
2006.
2. Homedes N, Ugalde A. Multisource drug policies in Latin America: Survey of 10 coun-
tries. Bull World Health Organ 2005; 83(1):64–70.
3. Vacca González CP, Fitzgerald JF, Bermúdez JAZ. Definición de medicamento genérico
¿un fin o un medio? Análisis de la regulación en 14 paı́ses de la Región de las Américas.
Rev Panam Salud Pública/Pan Am J Public Health 2006; 20(5):314–323.
4. Annex 8. Proposal to waive in vivo bioequivalence requirements for WHO Model List
of Essential Medicines immediate-release, solid oral dosage forms. WHO Technical
Report Series, No. 937, 2006.
5. Argentinean regulations relating medicines registration:
r Dec. ANMAT 150/92

Argentinean regulations relating BE and clinical studies:

r Disp. ANMAT No 5330/97
r Disp. ANMAT No 3436/98
r Disp. ANMAT No 3185/99
r Disp. ANMAT No 3112/00
r Res. SPRS No 229/00
r Res. SPRS No 40/01
r Disp. ANMAT No 3311/01
r Disp. MIN. SALUD-SPRRS-ANMAT No 1383/02
r Disp. ANMAT No 1277/02
r Disp. ANMAT No 2807/02
r Disp. ANMAT No 2814/02
r Disp. ANMAT No 3598/02
r Disp. ANMAT No 4290/02
r Disp. ANMAT No 5318/02
r Disp. ANMAT No 7062/02
r Disp. ANMAT No 7307/02
r Res. Min. Salud No 60/03
r Res. SPRS No 25 y 19/03
r Res. SPRRS No 46/03
r Disp. ANMAT No 3712/04
r Disp. ANMAT No 3757/04
r Disp. ANMAT No 4218/04
r Disp. ANMAT No 690/05
r Disp. ANMAT No 2124/05
r Disp. ANMAT No 2749/05
r Disp. ANMAT No 4844/05
r Disp. ANMAT No 4457/05
r Disp. ANMAT No 5040/06
r Disp. ANMAT No 1746/07
r Res. MS No 35/07
r Res. MS No 1490/07
r Res. MS No 1673/07
r Disp. ANMAT No2446/07
r Disp. ANMAT No 1067/08
r Disp. ANMAT No 6550/08
r Disp. ANMAT No 1861/08
r Disp. ANMAT No 1862/08
r Disp. SP No 6/08
r Disp. MS No 4691/08
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South America and Pan American Health Organization 231

r Res. MS No1062/08
r Disp. ANMAT No 4541/08
r Dec. PEN No 253/08
r Res. MS No 102/09
r Disp. ANMAT No 1310/09
Argentinean regulations relating the use of generic names in prescriptions:
r Res. SP No 326/02
r Ley Esp. Med. No 25.649/02
r Dec. No 987/03
Argentinean regulations relating GMP and current further regulations:
r Disp. ANMAT No 2819/04
r Disp. ANMAT No 3477/05
r Disp. ANMAT No 2372/08
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10 Taiwan
Li-Heng Pao
School of Pharmacy, National Defense Medical Center, Taipei, Taiwan,
Republic of China

Jo-Feng Chi
Bureau of Pharmaceutical Affairs, Department of Health, The Executive Yuan,
Taipei, Taiwan, Republic of China

Oliver Yoa-Pu Hu
National Defense Medical Center, Taipei, Taiwan, Republic of China

INTRODUCTION
The Bureau of Pharmaceutical Affairs (BPA) within the Department of Health
(DOH) is responsible for the regulation of medicinal products in Taiwan. The
mission of the BPA is to ensure that medicinal products that are available for
the people in Taiwan are of the highest quality, safety, and efficacy. On the basis
of BPA statistics, there are over 27,000 active licensed drugs currently available
in the Taiwan market (1). Approximately 20% of Taiwan’s drug products are
imported from abroad, the remainder being manufactured by domestic pharma-
ceutical companies that operate in compliance with current good manufactur-
ing practice (cGMP) standards. Therefore, the need to ensure bioequivalence of
generic drug products with corresponding innovator products is critical in Tai-
wan. The goal of this chapter was to provide an overview of the generic drug
review process and bioequivalence requirements in Taiwan.
Currently the BPA is organized into five sections. Section I is responsible for
the law and regulation of pharmaceutical affairs, pharmacy-related compliance,
and advertising. Section II is involved with the registration of medical devices
and cosmetics. New drug applications (NDAs), clinical trials, and postmarket-
ing surveillance are reviewed and approved according to Section III. Section
IV covers the review of abbreviated new drug applications (ANDAs) and their
approval for marketing whereas Section V deals with registration of biological
and plasma products, radiopharmaceuticals, as well as in vitro diagnostic kits.
The Taiwan Food and Drug administration (TFDA) will be formally inaugurated
Jan. 1, 2010. Additional information on the organization of the BPA can be found
at www.doh.gov.tw.
LEGISLATIVE AND REGULATORY ISSUES
Drug regulation has become more challenging since the advancement of new
technologies, cost pressures, as well as trends of globalization. The drug regu-
latory process and development of the pharmaceutical industry in Taiwan has
changed substantially over the past two decades (2–4). The fundamental law
regulating medicinal products is based on the Law for Control of Medicaments and
Pharmaceutical Firms promulgated in 1970. The Law was extensively revised and

232
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Taiwan 233

renamed the Law of Pharmaceutical Affairs in 1993. The current Law of Pharmaceu-
tical Affairs, with its subsequent amendments in 2004, is the basic law for the
regulation of medicinal products in Taiwan. Implementation of good manufac-
turing practice (GMP) and cGMP had a dramatic impact on Taiwan’s pharma-
ceutical industry. Before advent and implementation of GMP requirements in
1982, there were over 400 domestic pharmaceutical manufactures. Six years later
in 1988, the number of manufactures was reduced to 230. To further improve and
meet the international standards of domestic production of medicinal products,
cGMP regulations were promulgated in 1999. There are currently approximately
160 cGMP pharmaceutical manufactures in Taiwan. Therefore, when applicants
seek approval of generic products in Taiwan, the drug products must comply
with cGMP standards and requirements.
Following successful implementation of the GMP program in Taiwan,
academia, government, and the pharmaceutical industry recognized that data
on bioavailability and bioequivalence (BA/BE) were critical to further improve
the quality of medicinal products in Taiwan. Consequently, the BPA contracted
university professors in 1984 to draft BA/BE guidelines. Through lengthy dis-
cussions and amendments via discourse with academics, scientists from indus-
try, government officers, as well as overseas Chinese scientists, the first Taiwan
guidelines on BA/BE for generic medicines were issued in 1987. A system of
post-marketing safety (PMS) surveillance for new medicinal products was imple-
mented in 1983. All generic products containing new chemical entities (NCEs)
approved under the PMS surveillance were required to provide BA/BE data
when submitting marketing authorization applications since the implementation
of BA/BE guideline in 1987. Since that time, several revisions of the guidelines
have been made on the basis of current BA/BE guidelines used in various coun-
tries and also on relevant practical situations and issues prevailing in the phar-
maceutical industry in Taiwan.
Currently, “generic substitution” is not compulsory in Taiwan.

DRUG QUALITY SURVEILLANCE PROGRAM

Local health authorities conduct regular and unscheduled inspections of man-
ufacturing facilities and sample testing of medicinal products that are manu-
factured, imported and sold in their respective area. The quality of medicinal
products and samples are analyzed by the Bureau of Food and Drug Analysis
(BFDA) and action is taken against manufacturers and agents if their products
do not meet the required standards.

REGULATION AND INSPECTION OF MANUFACTURERS

After implementation of cGMPs in 1999, 160 pharmaceutical plants were eval-
uated and recognized by the DOH as manufacturers that were in compliance
with cGMP. As mentioned earlier, the DOH operates a system of regular and
unscheduled follow-up inspections to ensure that these plants continue to manu-
facture and operate in compliance with cGMP standards. A pharmaceutical plant
is inspected at least once every two years. An unscheduled inspection will be
undertaken if the following issues arise:
Concerns about documents relating to manufacturing control for registration.
A severe defect is found in the marketed products.
A plant has previously violated cGMP regulations.
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234 Pao et al.

The on-site overseas inspection program was established in 2002. Over 100
foreign on-site cGMP inspections in 28 countries have been completed since the
program was implemented in 2003. For imported products, the DOH reviews
the plant master files (PMFs) submitted by the pharmaceutical company as a
substitute for on-site inspection. The requirements for a PMF to be submitted
with marketing authorization applications apply only for those plants without
a PMF approved in Taiwan. The DOH is trying to establish a mutual recogni-
tion policy (PIC/S) amongst countries to ensure the quality and efficacy of for-
eign products and then the submission of the PMF and on-site inspection can
be waived. PIC/GMP standards have been implemented since 2008. All phar-
maceutical manufactures in Taiwan will need to comply with PIC/GMP require-
ments after year 2012. However, translation of the PMF into English requires a
huge effort and is very time consuming. Consideration of the confidentiality of
the PMF submitted to another country is also considered to be an issue of concern
for some pharmaceutical companies in Taiwan.
The PMF for any imported products generally involves the site of manu-
facture and the product dosage form. Marketing authorization applications may
be waived in Taiwan if the imported product consists of the same dosage form
and has been manufactured at the same site with a previously approved PMF.

APPLICATION FOR REGISTRATION OF GENERIC PRODUCTS

In Taiwan, generic medicinal products are reviewed and approved under Sec-
tion IV within the BPA at the DOH. Figure 1 illustrates the generic drug prod-
ucts review process in the BPA. A generic drug product is defined as one that
contains the same active ingredient(s) and is comparable to an approved innova-
tor’s medicinal product in dosage form, strength, route of administration, quality
characteristics, and intended use. The staff in Section IV serve as the application
project manager responsible for the filing review. The applicant needs to certify
to the DOH that the patent in question is not infringed by the generic product.
The current requirements for the authorization of generic products in Taiwan are
listed in Table 1.
The submission of a generic drug product must be filed by the pharmaceu-
tical manufacturer or its representative (agent). The generic sponsor must pro-
vide pertinent patent information and a statement to the BPA. The drug prod-
uct manufacturer must be in compliance with cGMP. This is verified by on-site
inspections for domestic products and a review of PMFs for imported products
without preinspection. Furthermore, to import a medicinal product into Taiwan,
a certificate of origin and a certificate of free sale (CFS) are indispensable docu-
ments for acceptance of the submission.
Once the BPA staff have completed the filing review of the submission and
have verified that the application has met all the necessary regulatory require-
ments, the application is then assigned to technical review that focuses on BE
data and chemistry and manufacture quality.

Labeling Review Process

After the generic drug application has been accepted for filing by the staff in
Section IV, the labeling information is reviewed by the BPA in-house reviewer.
Generic products must be properly labeled to provide comprehensive infor-
mation regarding the pharmaceutical product. The product information should
include the name of the product, components and quantity, indications, usage
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Taiwan 235

Applicant

ANDA
Application
complete ? No

Yes

Labeling
Validation and specifications Chemistry and Bioequivalence
(PMF/cGMP) Manufacture control
Stability data

Review Review Review

by BFDA by BPA by expert
OK ? No OK ? No No OK ?

Yes Yes Yes

Approval Not approval

FIGURE 1 Generic drug review process in Taiwan.

TABLE 1 Checklist of Registration Requirements for Generic Medicinal

Products in Taiwan
A signed application form with a description of the components and
composition of the product
Patent certificate and statement
Comparison of generic and reference listed brand name products
Labeling
BE data
Finished product specifications
Laboratory test methods and results
Specification of raw material and finished products
Description of manufacturing facility and processing instruction
Details of in-process control
Batch records
Packaging and labeling procedures
Characteristics of containers, and
Stability data of finished dosage form.
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236 Pao et al.

and dosage, legal status, permit license number, expiry date, batch number,
name/address of manufacturer or agent, adverse drug reactions, warning, con-
traindications, and storage conditions. The labeling review is based on the ref-
erence drug product labeling to ensure that the essential information already
described is properly labeled.
Chemistry and Manufacture Quality Review Process
Following acceptance for filing by the staff (Section IV), the chemistry and man-
ufacture control and stability of the finished dosage form are reviewed by a BPA
reviewer and the relevant specifications are forwarded to the BFDA, an indepen-
dent institute of the DOH.
Data such as manufacturing process validation, analytical method valida-
tion, and stability of the finished dosage form and PMFs are reviewed by the
BFDA to ensure that the generic product will be manufactured in compliance
with the standards of cGMP and relevant pharmacopoeial specifications when
applicable. In addition, a number of samples of the finished product must also
be supplied for analysis according to its own product specifications by BFDA to
further ensure the quality of the drug.
Bioequivalence Review Process
Subsequently, the BE document is randomly assigned to one external indepen-
dent expert on BA/BE to review. If additional information is required or prob-
lems are raised during the BE review, the reviewer will inform the staff in the
BPA resulting in a document that is issued by the DOH to the applicant who is
required to resolve the deficiency or specified problems and the response time
limit is 70 days. Once the BE review has been completed and all BE requirements
are fulfilled based on the current BE guidelines, an official document, accepting
the BE results, is issued to the applicant by the DOH.
To ensure the quality and credibility of the BE study, the BA/BE inspec-
tion program was established in 2002. During the BE review process, the clinical
and analytical sites are randomly inspected on a case- or problem-oriented basis.
BE studies of imported drug products performed outside Taiwan are currently
acceptable (2008). The certification of foreign BE laboratories and facilities has
not yet been possible. When the review of an ANDA is completed, an official
document is sent to the applicant as notification of marketing approval of the
generic drug product in Taiwan.
BA/BE GUIDELINES IN TAIWAN
Establishing bioequivalence is an important part of the generic review process
and is closely linked to the concepts of essential similarity and product inter-
changeability. Bioequivalence is defined as no significant difference with respect
to the rate and extent of active ingredients or active moiety in pharmaceutical
equivalents or pharmaceutical alternatives that is available at the site of drug
action when given in the same molar dose under similar study conditions. Princi-
pally, in a BE study, pharmacokinetic end points are used to establish equivalence
between the test and reference drug product. If this is not feasible, pharmacody-
namic as well as clinical endpoints may be used only if they can be scientifically
justified.
Additional information can be found at www.doh.gov.tw.
In vivo bioequivalence may be exempted if the drug product meets any of
the following criteria:
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The drug product that

1. is administered intravenously,
2. is an oral solution and if its excipients will not affect the absorption of the
active ingredient,
3. is an intramuscular, subcutaneous or intradermal injection solution where
the pH value and all the ingredients are essentially the same as the inno-
vator product, except for the preservative and the buffer,
4. is a preparation intended for application to the skin (topical dermatolog-
ical product) and which is not intended to be absorbed into the systemic
circulation,
5. is an ophthalmic or otic preparation (usually only “true” solutions are
exempt from BE studies), and the drug is not intended to be absorbed
into the systemic circulation (i.e., the interior of the eye) to produce the
response, such as miotics and mydriatics.

Design and Evaluation of BE Study

Reference and Test Products
The reference product to be used in a BE study is a medicinal product that has
been placed under PMS surveillance, generally the innovator/brand drug prod-
uct marketed in Taiwan or the first approval drug product in Taiwan should be
used as reference products.
If medicinal products are not under PMS surveillance (i.e., those approved
in Taiwan before 1983), the following is the preference order for the choice of
reference products for use in a BE study:
1. Innovator/brand drug product on Taiwan market.
2. The first approved drug product whose BA and quality, safety, and efficacy
have been established in Taiwan. If the innovator product is no longer mar-
keted (withdrawn) after approval in Taiwan, an approved domestic generic
product can then be used as a reference product in BE study.
3. A drug product whose BE with an innovator product has been confirmed or
whose clinical safety and efficacy has been documented and can be justified.
The three points mentioned above are only for medicinal products
approved before 1983 (old products and not placed under PMS surveillance)
in Taiwan. This means that the innovator product is sometimes hard to identify
and in some cases no innovator product is available. Therefore, the innovator
product either from Taiwan or from another country is the first choice. If not,
then the first approved product whose efficacy and safety have been established
in Taiwan should be considered as reference product. When no innovator prod-
uct is available neither in Taiwan nor in other countries, then last option (point 3),
can be chosen.
Hence, either an innovator product which is manufactured domestically
(e.g., in Taiwan) or if not and it is imported and has marketing approval and is
sold in Taiwan, it can be used as the reference product. If an innovator product is
not available on the Taiwan market, then the product purchased from the country
where the innovator product has been granted a national marketing authoriza-
tion can be considered with approval by the DOH in Taiwan.
The test product used in the BE study should be from a batch of at least
1/10 of the production batch size intended for market release, or 10,000 units,
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238 Pao et al.

whichever is higher unless otherwise justified. Quality control based on the prod-
uct specification and test method (i.e., potency and content uniformity) and dis-
solution data of the finished products for both reference and test products should
be submitted as well. A side-by-side comparison of the compositions of test and
reference products is recommended. Dissolution testing should be conducted in
accordance with pharmacopoeial requirements. Alternative methods can be con-
sidered with scientific justified.
Study Design
The study protocol should be approved by an ethics review board and written
informed consent should be obtained from all subjects prior to participation in
the study. In general, the typical randomized cross-over design with appropriate
washout periods is recommended for the BE study. Washout periods between
each treatment should be more than five elimination half-lives of the parent drug
or active metabolite. A parallel study design can be used for oral drug products
with a long half-life, which should be justified by the applicant. In general, sub-
jects should fast for at least 10 hours prior to administration of the drug except for
a food-effect BE study. The drug products should be administered with at least
200 mL of water and water is not allowed at least one hour before and after drug
administration. A standard meal should be provided no less than four hours
after drug administration. The subjects should abstain from other medicines or
alcohol for at least two weeks before and during the study.
Single- Versus Multiple-Dose Studies
A single-dose fasting pharmacokinetic study is generally recommended for con-
ventional immediate-release drug products to demonstrate BE. Multiple-dose
studies may be appropriate for the BE of immediate-release dosage form as
described.
Study subjects are patients.
The assay sensitivity precludes the possibility to adequately characterize the
pharmacokinetic of drug after single-dose administration.
Drugs that exhibit nonlinear kinetics following multiple administrations
For modified-release drug products, either multiple-dose or single-dose
studies under both fasting and fed conditions are required. Omission of either
fasting or fed study should be justified by the applicant. If a multiple-dose study
design is employed, attainment of steady state is essential. At least three consec-
utive trough drug concentrations on three consecutive days should be obtained
to demonstrate that steady-state has been reached.
Number of Subjects
A sufficient number of subjects, which is based on sample-size estimation with
appropriate power calculation should be included in the BE study. Generally,
the minimum number of subjects should be not less than 12 for the assessment
of bioequivalence. An add-on study is not encouraged unless this is anticipated
and should be stated clearly in the protocol as well as details of the proposed
statistical treatment.
Study Population
In general, healthy adult (males, females, or both) volunteers should be
employed and the inclusion of subjects from the target population that the drug
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product is intended to be used is encouraged. The inclusion and exclusion crite-

ria should be clearly stated in the protocol. Generally, subjects should be between
20 and 55 years and whose weights should be within the normal range (i.e., ±20%
of ideal body weight). Subjects should be screened for their eligibility through
medical history, physical examination (electrocardiogram and chest X ray), blood
biochemistry test (including AST, ALT, ␥ -GT, alkaline phosphate, total bilirubin,
glucose, uric acid, BUN, creatinine, albumin, total cholesterol, and triglyceride),
complete blood count test (including hemoglobin, hematocrit, red blood cells,
white blood cells, plates, and differential white blood cells), as well as a routine
urine test (including pH, glucose, blood, and protein). Patients should be con-
sidered for enrollment in BE studies when safety considerations make it unac-
ceptable to use healthy volunteers. Phenotyping and/or genotyping of subjects
is permissible for BE studies on certain drugs.
Bioanalytical Methodology
An accurate, precise, and specific analytical method should be applied for assay-
ing the drug and/or its metabolites in plasma or other suitable matrix. The US
FDA guidance, Bioanalytical Methods Validation for Human Studies 2001 is rec-
ommended for the establishment and validation of bioanalytical methods for BE
studies (5).
Sampling Times and Measurement of Analyte(s)
Generally, measurement of parent drug concentrations in plasma or serum,
rather than in urine, is recommended. If urine samples are used, the reason
should be justified. Measurement of a metabolite may be considered if the con-
centration of the parent drug is too low to be accurately measured in the biolog-
ical matrix. When measurement of a metabolite is used for BE the reason should
be justified. For example, the measurement of the active moiety instead of the
parent may be appropriate for a prodrug. In the case of chiral drugs, the measure-
ment of a specific enantiomer is acceptable when the enantiomers have different
pharmacodynamic or pharmacokinetic characteristics. Use of a stereoselective
assay may also be acceptable when systemic availability of different enantiomers
is nonlinear.
For fixed-combination products, BE is assessed against either an existing
approved combination product as the comparator or if the latter is not available,
then comparisons should be made by dosing with the individual components.
Blood samples should be taken at appropriate times and sufficient fre-
quency to adequately characterize the maximum concentration of the drug in the
blood (Cmax ), the area under the drug concentration versus time curve (AUC) as
well as the terminal elimination rate constant (kel ). The sampling of biological
fluid should continue for longer than three terminal half-lives (t1/2 ) of the drug.
For long half-life drugs with low intrasubject variability (CV% < 30%) in distri-
bution and clearance, an AUC truncated at 72 hours may be used for BE evalua-
tion. In such cases, the applicants should consult the DOH prior to undertaking
studies.
Assessment of BE and Data Submission
Parameters To Be Assessed
For single-dose studies, including a fasting or a food-effect study, Cmax , Tmax ,
the area under the curve to the last quantifiable concentration (AUC0–t ) and to
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240 Pao et al.

infinity (AUC0–∞ ) are used for the evaluation of BE. For multiple-dose studies,
area under the curve of a dosing interval (AUC␶ ), Cmax , Cmin , average concentra-
tion (Cave ), and fluctuation at steady state should be assessed for BE evaluation.
Parameters such as mean residence time (MRT), kel , and t1/2 are recommended
for submission as reference data. These latter secondary parameters help justify
the consistency and quality of the BE data.
When urine samples are used, the urinary excretion rate and cumulative
amount of parent drug can be used to evaluate BE. All results from the BE
study should be presented clearly and all individual data and results should be
reported including dropouts, subject withdrawals, and exclusion of data. Any
exclusion of data including outliers should be scientifically justified.
Chromatograms of at least one-third of the subjects and chromatograms of
the full validation of the analytical method should be submitted as well.

Statistical Analysis
A 90% confidence interval (CI) or two one-sided test with a significance level
of 5% should be used for assessing BE. Analysis of variance (ANOVA) should
be applied to the study data to determine the 90% CI. In general, logarithmic
transformation should be provided for measures used for BE demonstration. The
pharmacokinetic parameters, except for Tmax , obtained from the study should
be analyzed using ANOVA after logarithmic transformation. The variables such
as subject, period, sequence, and treatment should be included in the model of
ANOVA and the results of the ANOVA analysis should also be reported. In addi-
tion to the 90% CI for BE assessment, a summary of the statistics of all the rele-
vant pharmacokinetic parameters should be given. If a BE dossier is submitted
where the biostudy was performed some years previously, the review is consid-
ered on a case-by-case basis depending on the nature of the drug, drug product,
and scientific evidence.

BE Acceptance Criteria
The acceptable range for the declaration of BE is that the 90% CI of the ratios
of AUC0–∞ and Cmax of the test to reference product should be within 0.8 to
1.25 limits. Under the current BE guidelines, the BE limit remains unchanged for
narrow therapeutic range drugs. For drugs with no safety or efficacy concerns
(i.e., for a drug with a wide therapeutic window or flat dose–toxicity relation-
ship and with clinical justification), a wider range, for example, 0.75 to 1.34, for
Cmax may be acceptable whereas the AUC criterion remains at 0.8 to 1.25. In such
cases, scientific justification should be provided by the applicant and consulta-
tion with the DOH is required. Currently, there is no special provision for the BE
acceptance criteria for highly variable drugs.

Special Pharmaceutical Dosage Forms

Currently, there are no special recommendation for drug products not intended
to be absorbed into the systemic circulation such as nasal sprays, nasal aerosols
and inhalers, creams, ointments, gels, lotions, etc. The assessment of these prod-
ucts is considered on a case-to-case basis. The human skin blanching assay, also
known as the vasoconstrictor assay, for BE of topical corticosteroid products as
provided by FDA’s guidance is acceptable.
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WAIVER OF IN VIVO BE STUDIES

For drug products in the same dosage form and which are proportionally similar
in active and inactive ingredients but in a different strength, in vivo BE can be
waived under the following circumstances:
If the BE of the higher strengths have been approved, the lower strengths can be
waived based on dissolution profile comparisons.
If the BE of lower strengths have been approved and linear pharmacokinetics
over the clinical dose range can be demonstrated, the higher strengths can
be waived by acceptable dissolution comparisons.
The similarity of dissolution profiles between higher and lower strengths is
based on the f 2 test in at least three dissolution media (e.g., pH 1.2, 4.5, and 6.8)
or in media that can mimic gastrointestinal physiological pH changes for both
immediate-release and modified-release products. An f 2 value of ≥ 50 suggests
a similar dissolution profile.
A waiver of in vivo BE studies on the basis of the biopharmaceutical clas-
sification system (BCS) has not been adopted in the guidelines at present.

VARIATIONS AND LICENCE RENEWALS

Marketing authorizations are valid for five years and the marketing authoriza-
tion holder must request extension/renewal of the license before the expiry date.
No modifications or alterations of the original registration are allowed with-
out prior approval of the BPA. Regulations regarding scale-up and postapproval
changes (SUPAC) of medicinal products have been revised according to the inter-
national SUPAC guidance (6).
The BPA in Taiwan strives toward deregulation, transparency of regula-
tions, and the streamlining of the review process. The current BE approval pro-
cess and requirements are aimed at ensuring the quality of generic products. The
BPA works with scientists and pharmaceutical companies to provide safe and
effective generic drugs to the people of Taiwan.

REFERENCES
1. Bureau of Pharmaceutical Affairs, Department of Health, Executive Yuan, Taiwan,
Republic of China, 2009.
2. Hsieh YY, Hunag WF. The drug regulatory process of the Republic of China. J Clin
Pharmacol 1998; 28:200–203.
3. Hu O YP, Hsiao ML, Liu LL. Drug regulatory process of the Republic of China-Taiwan’s
experiences in bioavailability and bioequivalence. Drug Inf J 1995; 29:1049–1054.
4. Tzou MC, Chi JF, Hu O YP. Generic drug in Taiwan. Regul Aff J 1999; 11:554–560.
5. Guidance for Industry: Bioanalytical method validation, 2001. http://www.fda.gov/
cder/guidance/4252fnl.htm. Accessed May 9, 2009.
6. SUPAC-IR: Immediate-Release Solid Oral Dosage Forms: Scale-Up and Post-
Approval Changes: Chemistry, Manufacturing and Controls, In Vitro Dissolution
Testing, and In Vivo Bioequivalence Documentation, 1995. http://www.fda.gov/
cder/guidance/cmc5.pdf. Accessed May 9, 2009.
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11 Turkey
Ilker Kanzik
IDE Pharmaceutical Consultancy Ltd. Co., Istanbul, Turkey

A. Atilla Hincal
IDE Pharmaceutical Consultancy Ltd. Co., Ankara, Turkey

INTRODUCTION

Registration
Marketing authorization (registration decisions) for medicinal products for
human use is issued by the Ministry of Health (MoH), but the entire procedure
is managed by the General Directorate of Drug and Pharmacy (GDDP). On the
other hand, for veterinary medicinal products and dietary supplements such as
vitamins and minerals, herbal extracts, and other substances that are generally
found in foods, the Ministry of Agriculture is the relevant authority.
Turkish licensing regulations (regulation) for all (i.e., innovator/brand and
generic drug products) pharmaceutical products published on January 19, 2005
(1), came into force on June 30, 2005. This new legislation brought Turkish law in
line with that of the European Union (EU) and covered all aspects of the registra-
tion procedure. According to this legislation the MoH will take all appropriate
measures to ensure that the procedure for granting an authorization to place a
medicinal product on the market is completed within 210 days of the submission
of a valid application.
Applicants intending to register any drug product must submit an appli-
cation for authorization to the GDDP. Applications for marketing authorization
of an innovator/brand drug product must be accompanied by the appropriate
fees as well as various documents and particulars, including the manufacturer’s
product development methodology and processes, control methods (sterility
tests, stability tests, etc.), and the results of physicochemical, biological or
microbiological, pharmaco-toxicological tests, and clinical trials (1).
Prescription (generic or innovator/brand) and nonprescription medicines
(over the counter, OTC) follow the same marketing authorization procedure. It
is likely that after initial consideration, additional questions will be put to the
applicant and the answers would then be further considered by the Registration
Approval Committee leading to a final opinion on the application. If an applica-
tion is refused, the reasons for the decision will be set out in full. The applicant
has the right to object in written or orally. A marketing authorization will be
refused if it appears that the medicinal product is harmful under normal condi-
tions of use, that it has no or very little therapeutic effect or that it does not have
the stated composition in terms of quality and quantity. Authorization will also
be refused if the information requested is incomplete or not given. Marketing

242
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authorization may be suspended or withdrawn on the same grounds as those

invoked for refusal to grant marketing authorization. Marketing approvals are
valid for a period of five years, and can be renewed for further five-yearly peri-
ods. To do this, the licensee must submit an application to the MoH at least six
months before the license expires.

European Union Relations and Obligations

The rules governing the registration of medicinal products in Turkey have
been considerably modified to approach the EU requirements. In this context,
approval procedures in Turkey are designed to be similar to those existing in the
EU, for example, administrative requirements, structure of the dossier including
use of the common technical document (CTD) (2). All new Turkish regulations
will be, as far as possible, compatible with those of the EU.
It should always be remembered that, Turkey started the Customs Union
with the EU on January 1, 1996, in accordance with the Association Council Deci-
sions No: 1/95 and 2/97 (3,4).
In essence the Customs Union aimed to provide free circulation of indus-
trial products, including pharmaceuticals, between Turkey and the EU. Under
that agreement, Turkey abolished all tariffs on imports by the end of 1996, intro-
duced patent protection by 1999 and was obliged to respect and adopt all EU
international property legislation listed in Annex 8 of the Association Council
Decision 1/95 (4). This included an undertaking to implement the GATT-TRIPS
(5) provisions no later than three years after the agreement was enforced, and to
adopt domestic legislation in line with the EU and its member states.
In summary, Turkish relations with the EU by means of the Customs Union
provided the elimination of physical and technical trade barriers in addition to
harmonizing the policies and standards of the framework governing the phar-
maceutical industry.

Generic Drug Products

A generic medicinal product is defined in the regulations as
Medicinal product for human use which has the same qualitative and
quantitative composition in active substances and the same pharmaceutical
form as the original product, and whose bioequivalence with the reference
medicinal product has been demonstrated by appropriate bioavailability
studies.

After the publication of a regulation on May 27, 1994 (6) bioequivalence

(BE) became compulsory in order for a generic drug product to receive a market-
ing license. It is obvious, therefore, that BE is the key requirement for an abridged
(generic) application of a drug product in Turkey.

Abridged Application
For abridged applications, without prejudice to the provisions of the Decree on
the Protection of the Patent Rights dated 24.06.1995 no: 551 (7), applicants shall
not be required to provide the results of toxicological and pharmacological tests
or the results of clinical trials if they can demonstrate: either that the medici-
nal product is similar to a medicinal product authorized in Turkey and that the
holder of the marketing authorization for the original medicinal product has
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244 Kanzik and Hincal

consented to the toxicological, pharmacological, and/or clinical references con-

tained in the file on the original medicinal product being used for the purpose
of examining the application in question; or that the constituent or constituents
of the medicinal product have a well-established medicinal use, with recognized
efficacy and an acceptable level of safety, supported by means of a detailed sci-
entific bibliography.
The generic or similar biological medicinal product, once authorized, can
however only be placed on the market six years after the authorization of the
reference medicinal product, depending on the exclusivity period applicable for
the reference medicinal product.
However, in the event of a different therapeutic indication, route of admin-
istration, dosage being envisaged compared to the innovator/brand products
which have been introduced into the market, it shall be necessary to provide the
results of appropriate clinical trials and where necessary the results of toxicolog-
ical, pharmacological studies.
With regard to new medicinal products containing known constituents,
but which have not yet been used in combination for therapeutic purposes, it
is necessary to present the results of the relevant toxicological and pharmacolog-
ical tests and clinical trials relating to that combination. However, it shall not be
obligatory to provide references relating to each constituent.

Application and Approval of the Trial

Applications for a BE study can be made either by the sponsor or a legal repre-
sentative (Contract Research Organization, CRO) of the sponsor according to the
Regulations Regarding Clinical Trials published on December 23, 2008 (8). The nec-
essary documents including the “Study Protocol” prepared according to the GCP
and GLP Guidelines are required to be submitted to both ethics committee and
the Pharmaceutical General Directorate of the MoH. Any amendments made to
the protocol should be reported to the general directorate and the relevant ethics
committee by the sponsor or the investigator. Rules encompassing topics such
as the design, conduct, monitoring, budgeting, assessment and reporting of tri-
als, protection of all the rights and bodily integrity of volunteers, preservation of
the safety of trial data must be complied with by all parties participating in the
trial so as to ensure that the trials are conducted at international scientific and
ethical standards are evaluated by the ethics committees. Time frames for the
evaluation by the ethics committee and the MoH are 45 days and 60 days (total),
respectively.
All studies should be monitored in accordance with the regulations. The
general directorate and the relevant ethics committee should be informed by the
sponsor of the trial about any serious, unexpected adverse effects during the clin-
ical trial, which may have resulted in death or are life threatening within a max-
imum of seven days the receipt of the referred information. Monitoring reports
including additional information regarding these cases should be within eight
days as of the receipt of the information.
Centers where bioavailability (BA) and BE studies can be conducted are
evaluated by the MoH and approved if the sites meet the standards. The Ministry
has the right to inspect with or without prior notice, trials conducted in Turkey
and abroad as well as the trial sites, the sponsor and the CRO, the sites where the
investigational products are manufactured, the laboratories where the analyses
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relating to the trial are conducted, for their compliance with the provisions of
this regulation and other relevant legislations. Depending on the result of the
inspection, the trial may be stopped if necessary by the Ministry.

DESIGN AND CONDUCT OF BIOEQUIVALENCE STUDIES

FOR ORALLY ADMINISTERED DRUG PRODUCTS
The design and conduct of the study should follow Turkish and/or EU regu-
lations on good clinical practice (GCP), including the requirements of an ethics
committee, OECD (Organization for Economic Co-Operation and Development),
good laboratory practices (GLP), and ISO 17025 (communication of the MoH
52072/December 03, 2001).
A BE study is basically a comparative BA study designed to establish
equivalence between test and reference products. Several in vivo and in vitro
methods may be appropriate to document BA and BE. In descending order of
preference, the Turkish regulations require pharmacokinetic, pharmacodynamic,
clinical, and in vitro studies.

Definitions
The following definitions are specifically described in the Turkish BE guide-
lines/regulations/laws. However, those BE regulations are relatively old (1994),
hence the relevant definitions in EU Guideline (2001) are also valid for Turkey.

Bioavailability
BA means the rate and extent to which the active substance or its active moiety
is absorbed from a pharmaceutical dosage form and becomes available at the site
of action or biological fluids (usually plasma or plasma) representing the site.

Bioequivalence
Two medicinal products are bioequivalent if they are pharmaceutically equiva-
lent and if their BAs after administration in the same molar dose are similar to
such a degree that their effects, with respect to both efficacy and safety, will be
identical.

Pharmaceutical Equivalence
Medicinal products are pharmaceutically equivalent if they contain the same
amount of the same active substance(s) in the same dosage forms and admin-
istered by the same route and that meet the same or comparable standards.

Therapeutic Equivalence
A medicinal product is therapeutically equivalent with another product if it con-
tains the same active substance or therapeutic moiety and, clinically, shows the
same efficacy and safety as that product, whose efficacy and safety have been
established.

Study Design
The study should be designed in such a way that any formulation effect can
be distinguished from other effects. For oral suspensions and immediate-release
tablets and capsules, a single-dose in vivo fasting study is usually sufficient. To
reduce the variability, a cross-over design is generally the first choice. When
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246 Kanzik and Hincal

a test formulation (generic) is to be compared with a reference formulation

(innovator/brand), a two-period, two-sequence cross-over design is often con-
sidered to be the design of choice. Other designs and methods may be con-
sidered in special cases, but it should be well justified in the study proto-
col. Volunteers (healthy human subjects) should be randomly included in study
periods. Although, single-dose studies for immediate-release products are gen-
erally deemed to be sufficient, in certain cases and for modified-release products,
steady-state studies may be required under the following conditions:
a) If problems of sensitivity preclude sufficiently precise plasma concentration
measurements after single-dose administration.
b) If intraindividual variability in the plasma concentrations and elimination
rate is intrinsically high. A drug product is called highly variable if its intrain-
dividual (i.e., within-subject) variability is greater than 30%. A high CV as
estimated from the ANOVA model is thus an indicator for high within-
subject variability.
c) Dose- or time-dependent pharmacokinetics is prevalent.
d) For prolonged-release products and enteric-coated tablets (in addition to
single-dose investigations).
In these types of steady-state investigations, the drug administration scheme
should comply with the common dosage recommendations.
The number of subjects required to be included in BE studies is determined
by the following:
a) The error variance associated with the primary characteristic to be studied
as estimated from a pilot experiment, or from previous studies or from pub-
lished data.
b) The significance level desired. For the determination of the minimum num-
ber of subjects (n) it is recommended that n is generally based on the criterion
to achieve an 80% probability of concluding BE if the difference between test
and reference treatment is ≤5%. The use of a larger ␣ level with the fewer
variables is also recommended.
c) The expected deviation from the reference product compatible with BE
(delta, i.e., percentage difference from 100%).
d) The required statistical power of the study.
The clinical and analytical standards imposed may also influence the statis-
tically determined number of subjects. However, generally the minimum num-
ber of subjects should not be less than 12.
Subsequent treatments should be separated by adequate washout periods
(at least three times the terminal half-life). In steady-state studies, washout of the
previous treatment last dose can overlap with the build-up of the second treat-
ment, provided the build-up period is sufficiently long (at least three times the
terminal half-life). The sampling schedule should be planned to provide an ade-
quate estimation of Cmax and to cover the plasma concentration–time curve long
enough to provide a reliable estimate of the extent of absorption. This is gener-
ally achieved if the area under the curve (AUC) derived from measurements is at
least 80% of the AUC extrapolated to infinity. To get a reliable estimate of the ter-
minal half-life, it should be obtained by collecting at least three to four samples
during the terminal log linear phase. For drugs with a long half-life (12–24 hours
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or longer) relative BA can be adequately estimated using truncated AUC as long

as the total collection period is appropriately justified. In this case the sample
collection time should be adequate to ensure comparison of the absorption pro-
cess. Cmax and a suitably truncated AUC can be used to characterize peak and
total drug exposure, respectively. For drugs that demonstrate low intrasubject
variability in distribution and clearance, an AUC truncated at 72 hours (AUC0–72
hour) can be used in place of AUC0–t or AUC0–∞ . For drugs demonstrating high
intrasubject variability in distribution and clearance, AUC truncation warrants
caution.

Subjects
Selection of Subjects
The studies should normally be performed using healthy volunteers. The inclu-
sion/exclusion criteria should be clearly stated in the protocol. In general, vol-
unteers suitable for inclusion should be within the age limits (between 18 and
55 years) and of weight within the normal range according to accepted normal
values for the body mass index (BMI), where BMI = mass (kg)/height (m)2 . Sub-
jects should be asked for informed consent and thereafter screened for suitability
by means of clinical laboratory tests, an extensive review of medical history, and
a comprehensive medical examination with respect to inclusion and exclusion
criteria. Subjects should preferably be nonsmokers and without a history of alco-
hol or drug abuse. If moderate smokers are included (less than 10 cigarettes per
day) they should be identified as such and the consequences for the study results
should be discussed.

Standardization of the Study

The test conditions should be standardized to minimize the variability of all fac-
tors involved except any formulation effects. Therefore, standardization of sub-
ject diet, fluid intake and exercise is recommended. Subjects should preferably
be fasting at least during the night prior to administration of the products. If
the summary of product characteristics (SmPC) of the reference product contains
specific recommendations in relation to food intake and implications for interac-
tion with food, the study should be designed accordingly. In other words, if it is
stated that the presence of food will affect the absorption, then the study should
be performed also under fed conditions.
The time of day for ingestion should be specified and as fluid intake may
profoundly influence gastric passage for oral administration dosage forms, the
volume of fluid (at least 240 mL) should be standardized. All meals and fluids
taken after the treatment should also be standardized in regard to composition
and time of administration during the sampling period. The subjects should not
take other medicines during a suitable period before and during the study and
should abstain from food and drinks, which may interact with circulatory, gas-
trointestinal, liver or renal function (e.g., alcoholic or xanthine-containing bev-
erages or certain fruit juices). As the BA of an active moiety from a dosage form
could be dependent upon gastrointestinal transit times and regional blood flows,
posture and physical activity should be standardized.
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Genetic Phenotyping
Phenotyping and/or genotyping of subjects should be considered for
exploratory BA studies and all studies by using parallel group design. It may also
be considered in cross-over studies (e.g., BE, dose proportionality, food interac-
tion studies, etc.) for safety or pharmacokinetic reasons. If a drug is known to be
subject to major genetic polymorphism, studies could be performed in panels of
subjects of known phenotype or genotype for the polymorphism in question.

Characteristics To Be Investigated
Moieties to be measured in BE studies are active drug substances or the active
moiety in the administered dosage form (parent drug). In some situations, how-
ever, measurements of an active or inactive metabolite may be necessary instead
of the parent compound. Such situations include cases where the use of a metabo-
lite may be advantageous to determine the extent of drug input, for example, if
the concentration of the active substance is too low to be accurately measured in
the biological matrix (e.g., major difficulty in analytical method, product unsta-
ble in the biological matrix or half-life of the parent compound too short) thus
giving rise to significant variability.
In BA studies, the shape of, and the area under the plasma concentration
versus time curves are mostly used to assess extent and rate of absorption. The
use of urine excretion data may be advantageous in determining the extent of
drug input in case of products predominately excreted renally, but has to be jus-
tified when used to estimate the rate of absorption. Sampling points or periods
should be chosen such that the time–drug concentration profile is adequately
defined so as to allow the estimation of relevant parameters.
From the primary results, the desirable BA characteristics are estimated,
namely AUCt , AUC∞ , Cmax , tmax , Aet , Ae∞ as appropriate, or any other justi-
fiable characteristics. The method of estimating AUC values should be speci-
fied. For additional information t1/2 and MRT can be estimated. For studies at
steady state, AUC␶ , Cmax , Cmin , and fluctuation [(Cmax − Cmin )/Cav ] should be
provided.
Pharmacodynamic studies are not recommended for orally administered
drugs when the drug is absorbed into the systemic circulation and a pharmacoki-
netic approach can be used to assess systemic exposure and establish BE. How-
ever, in some cases the quantitative measurement of a drug and/or metabolite
in plasma or urine cannot be made with sufficient accuracy and/or reproducibil-
ity. In those cases, studies in healthy volunteers or patients using pharmacody-
namic parameters may be used for establishing equivalence between the test and
reference products. Demonstration of a dose–response relationship may become
necessary. Measurements should be made with sufficient frequency to permit
a reasonable estimate of the total area under the effect–time curve. The baseline
values in each period should be comparable and the complete effect curve should
remain below the maximum physiological response. The methodology used for
carrying out the study should be validated for precision, accuracy, specificity
and reproducibility. Nonresponders should be excluded from the study by prior
screening. A correction for potential nonlinearity of the relationship between the
dose and area under the effect–time curve should be made and also baseline cor-
rections should be considered during data analysis.
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Sample Analysis (Bioanalysis)

The bioanalytical part of BE trials should be conducted in accordance with appli-
cable principles of OECD—GLP, since Turkey is one of the OECD countries. Bio-
analytical methods used to determine the active moiety and/or its biotransfor-
mation product(s) in blood, plasma, serum, or urine or any other suitable matrix
should comply with the requirements to confirm and validate specificity, accu-
racy, sensitivity, and precision A full validation report together with the relevant
data should be reported.
It is a primary requirement to demonstrate the stability of the active ingre-
dient and/or its biotransformation product(s) (in biological fluids to obtain reli-
able data).

Reference and Test Products

Test products (generic) in an application for approval of a generic product are
normally compared with the corresponding dosage form of an innovator medic-
inal product (reference product). The reference product can be chosen from any
drug product of the innovator registered in any EU member state and/or the
United States. The choice of reference product from other regions should be justi-
fied by the applicant. A pharmaceutical product can be used as a reference prod-
uct if it is an imported product of the innovator company from EU or United
States. Products of innovator companies which are manufactured in Turkey are
not permitted to be used as a reference product. In addition, in the process of
choosing a reference product, most of the generic companies run their own dis-
solution studies with the innovator company’s products that were manufactured
and/or distributed in different EU countries, to see if there is any difference
between the dissolution profiles among these products. The best product that
gives similar dissolution profiles with their own products is chosen as the refer-
ence product to be used in the BE study.
Test products used in biostudies must be prepared in accordance with GMP
regulations. Since many parameters, such as hardness of the tablet, friability, dis-
integration, dissolution, and deviation of tablet weight in relation to the declared
tablet average weight, related substances and microbiological limits, etc., may
have minor or major effects on dissolution results, batch control results of the
test product should be reported within the analysis certificate in detail.

Batch Size
In the case of oral solid forms for systemic action, the test product should usu-
ally originate from a batch of at least 1/10 of production scale or 100,000 units,
whichever is greater, unless otherwise justified. The production of batches used
should provide a high level of assurance that the product and process will be
feasible on an industrial scale; in case of a production batch smaller than 100,000
units, a full production batch will be required. If the product is subjected to fur-
ther scale-up this should be properly validated.
Samples of the product from full production batches should be compared
with those of the test batch, and should show similar in vitro dissolution profiles
when employing suitable dissolution test conditions.[see Appendix II of Note for
Guidance on the Investigation of Bioavailability and Bioequivalence, 2001 (9)].
The study sponsor must retain a sufficient number of all investigational
product samples used in the study for one year after the product’s shelf life or
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two years after completion of the trial or until approval whichever is longer to
allow re-testing, if it is requested by the authorities.

Data Analysis
The main goals and objectives of a BE study is to demonstrate equivalency within
a clinically significant acceptance range (80–125%) and to limit the risk of false
acceptance decisions of BE. In certain cases, however, a wider interval may be
acceptable. The interval must be prospectively defined, for example, 0.75 to 1.33,
and justified addressing, in particular any safety or efficacy concerns for patients
switched between formulations. The possibility offered here by the guideline to
widen the acceptance range of 0.80 to 1.25 for the ratio of Cmax (not for AUC)
should be considered exceptional and limited to a small widening (0.75−1.33).
Furthermore, this possibility is restricted to those products for which at least one
of the following criteria applies:
1. Data regarding pharmacokinetic/pharmacodynamic (PK/PD) relationships
for safety and efficacy are adequate to demonstrate that the proposed wider
acceptance range for Cmax does not affect pharmacodynamics in a clinically
significant way.
2. If pharmacokinetic/pharmacodynamic data are either inconclusive or not
available, clinical safety and efficacy data may still be used for the same pur-
pose, but these data should be specific for the compound to be studied and
persuasive.
3. The reference product has a highly variable within-subject BA.
A post hoc justification of an acceptance range wider than defined in the
protocol is not acceptable. Information that would be required to justify results
lying outside the conventional acceptance range at the post hoc stage should
be utilized at the planning stage, either for a scientific justification of a wider
acceptance range for Cmax , or for selecting an experimental approach that allows
the assessment of different sources of variability.
When a parametric approach is used, the statistical method for testing rela-
tive BA (e.g., BE) should be based upon the 90% confidence interval for the ratio
of the population means (test/reference), for the parameters under considera-
tion. This method is equivalent to the corresponding two one-sided test proce-
dures with the null hypothesis of bioinequivalence at the 5% significance level.
In the case of concentration or concentration-related characteristics (e.g., AUC)
the data should be transformed prior to analysis using a logarithmic transforma-
tion. In the parametric approach, if it is doubtful to assume log normal (AUC,
Cmax ) or normal distribution (tmax ), a nonparametric approach is recommended.
This approach may also be selected as a general statistical approach to evaluate
all BA characteristics during a specific investigation.
Currently, Turkey follows this approach, even though it is not mentioned
in its regulation.

In Vitro Dissolution
In vitro dissolution test data obtained with the batches of test and reference
preparations that were used in the BA and BE studies should always be reported.
The similarity of dissolution profiles between the test product and reference
product should be demonstrated in each of the three buffers within the range
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of pH 1 to 8 (preferably at or about pH 1.2, 4.5, 6.8). The similarity/difference

of the in vitro dissolution profiles may be compared by the similarity/difference
factors (e.g., f 2 and f 1 ). A f 2 value between 50 and 100 suggests that two dis-
solution profiles are similar and a f 1 value between 1 and 15 suggests that two
dissolution profiles are within the acceptable differences. In cases where more
than 85% of the drug is dissolved within 15 minutes, dissolution profiles may
be accepted as similar without further evaluation (see Appendix II of Note for
Guidance on the Investigation of Bioavailability and Bioequivalence, 2001) (9).

Reporting of Results
The report of a BA or a BE study should contain complete documentation includ-
ing the study protocol, conduct and evaluation and confirmation (QA) that the
study was in compliance with GCP rules. The authenticity of the whole of the
report is attested by the signature of the principal investigator. Furthermore,
responsible person(s)/investigator involved with any particular section of the
study should sign their respective sections of the report. Names and affiliations
of the responsible person(s)/investigator, site of the study and duration should
be stated. The names and batch numbers of the products used in the study as
well as the composition(s), finished product specifications and comparative dis-
solution profiles should be provided. In addition, the applicant should submit a
signed statement confirming that the test product is the same as the one that is
submitted for registration.
All results should be clearly presented and the method used to derive the
pharmacokinetic parameters (e.g., AUC) from the raw data should be specified.
If pharmacokinetic models are used to evaluate the parameters, the model and
computing procedure used should be justified. The reason for not submitting any
data should be explained. All individual subject data should be included and
individual plasma concentration/time curves presented on a linear/linear and
log/linear scale. All the data from subjects who dropped-out should be included.
Dropouts and withdrawal of subjects should be fully documented and accounted
for. A representative number of chromatograms or other raw data should be
included covering the whole concentration range for all, standard and quality
control samples as well as the specimens analyzed together with the analytical
validation report. Currently, the MoH requests 100% of the chromatograms.

Applications for Generic Products Containing Approved

Active Substances
If it is intended to register a generic product which contains an active substance
of a currently authorized product (original), its BE with this product should be
demonstrated.
If bioinequivalence may pose a risk of therapeutic failure, then BA studies
must be carried out. In other words, if the active substance of a product has,
for example, a narrow therapeutic range and bioinequivalence may pose serious
adverse effects, BE studies will be mandatory.

Steady-State Studies
There are no specific recommendations for this type of study. However, the EU
guidance on Modified Release Oral and Transdermal Dosage Forms: Section II:
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252 Kanzik and Hincal

(Pharmacokinetic and Clinical Evaluation), 1999 (10), is the guideline that is fol-
lowed by the Turkish MoH.

Outliers
Only data for clinically proven outliers can be excluded from the statistical eval-
uations (11,12).

Add-On Studies
Add-on studies are not permitted.

EXEMPTION FROM BIOEQUIVALENCE STUDIES (WAIVERS)

In general, it is not necessary to submit BA studies if
a) products differ only in the strength of active substance provided that the
conditions below are fulfilled:
linear pharmacokinetics
the same qualitative composition
same ratio between active ingredient and excipients or (in the case of low
strength) same ratio of excipients
the two drug products of two different generic companies are manufactured
by the same manufacturer and at the same manufacturing site
- BA and BE studies have been performed with the highest strength of the
product against the original product
similar in vitro dissolution rates under the same testing conditions
b) the product is reformulated with minor changes or the manufacturing pro-
cess has been changed by the same manufacturer and justification is pro-
vided that these changes will not affect BA to any significant degree. In case
of exemption from BE studies, in vitro data should demonstrate the similar-
ity of dissolution profile between the test product and the reference product
in each of three buffers within the range of pH 1 to 8 at 37◦ C (preferably at or
about pH 1.0, 4.6, 6.8).
c) the product is to be administered as an aqueous intravenous solution con-
taining the same active substance in the same concentration as the currently
authorized original product.
d) the product contains the same active substance at the same concentration
as a currently authorized product in the same pharmaceutical dosage form
and does not contain any excipients that could affect the gastric passage of
the active substance such as a solution dosage form for oral administration
(elixir, syrup, or others).
e) an acceptable correlation can be shown between in vivo absorption and in
vitro dissolution and the in vitro dissolution rate of the new product that
is equivalent to the currently authorized generic product under the same
conditions that are used to determine the correlation.
f) dermal products (including corticosteroids) for local use, that is, intended
to act without systemic absorption. However, if there exists a certain degree
of undesired partial absorption, safety evaluations may be requested. For
other products (oral, nasal, inhalation, ocular, dermal, rectal, vaginal, etc.,
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administration) intended to act without systemic absorption, BE and/or

clinical studies are required.
g) a gas for inhalation.

Suprabioavailability
If Suprabioavailability is found, that is, if the new product displays an extent of
absorption appreciably larger than the approved product, reformulation to lower
dosage strength should be considered. In this case, the biopharmaceutical devel-
opment should be reported and a final comparative BA study of the reformulated
new product with the old approved product should be submitted.
In case reformulation is not carried out the dosage recommendations for
the suprabioavailable product will have to be supported by clinical studies. Such
a pharmaceutical product should not be accepted as therapeutically equivalent
to the existing reference product. If marketing authorization is obtained, the new
product may be considered as a new medicinal product.
Finally, it is emphasized that where no specific recommendations are pro-
vided for in the Turkish guidelines, the Turkish MoH requests sponsors to follow
current EU guidelines and recommendations (see Chapter 5 of this book), viz.:
Note for Guidance on the Investigation of Bioavailability and Bioequivalence,
2001; “Questions & Answers on the Bioavailability and Bioequivalence Guide-
line, 2006 and Note for Guidance on Modified Release and Transdermal Dosage
forms: Section II (Pharmacokinetic and Clinical Evaluation), 2000.

REFERENCES
1. Regulation on Licensing for Medicinal Products for Human Use, Official Gazetta No:
25725/19 January 2005.
2. The European Parliament and the Council of the European Union. Directive
2001/83/EC of the European Parliament and of the Council of November 6, 2001
on the Community code relating to medicinal products for human use, CPMP/EWP/
QWP/1401/98. Accessed July 26, 2001.
3. Decision No 1/95 of the EC-Turkey Association Council of 22 December 1995 on
implementing the final phase of the Customs Union (96/142/EC). http://www.
mfa.gov.tr/data/AB/EUAssociationCouncilDecision195CustomsUnionDecision.pdf.
Accessed December 22, 1995.
4. Decision No 2/97 of the EC-Turkey Customs Cooperation Committee. http://www.
avrupa.info.tr/Files/File/RECOURCE CENTRE/key links/DECISION No19.doc.
Accessed May 30, 1997.
5. GATT-TRIPS Implementation. http://www.wto.org. Accessed April 1994.
6. Regulation on the Evaluation of Bioavailability and Bioequivalence of Medicinal
Products Official Gazetta of Turkey No: 21942. Accessed May 27, 1994.
7. Decree on the Protection of the Patent Rights dated 24.06.1995 no: 551; http://
www.tpe.gov.tr/portal/default.jsp. Accessed December 7, 1995.
8. Regulations Regarding Clinical Trials. Official Gaetta of Turkey No: 27089,
December 23, 2008
9. EU Note for Guidance on the Investigation of Bioavailability and Bioequivalence.
CPMP/EWP/1401/98, 2001.
10. EU Note for Guidance on Modified Release Oral and Transdermal Dosage Forms:
Section II: (Pharmacokinetic and Clinical Evaluation). CPMP/EWP/280/96, 1999.
11. Turkish MoH Communication no. 058123 dated 16 November 2006.
12. Turkish MoH Communication no. 038031, June 10, 2008.
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12 United States of America

Barbara M. Davit and Dale P. Conner
Office of Generic Drugs, Center for Drug Evaluation and Research, United States
Food and Drug Administration, Rockville, Maryland, U.S.A.

INTRODUCTION
All prescription and over-the-counter generic drugs marketed in the United
States must meet standards established by the U.S. Food and Drug Administra-
tion (FDA). In approving a new generic drug for marketing, the FDA concludes
that the generic product is therapeutically equivalent to its corresponding ref-
erence product (usually the innovator product, but sometimes another generic
product if the innovator product was withdrawn). The FDA believes that thera-
peutically equivalent drug products can be substituted with the full expectation
that both products will produce the same clinical response (1). A generic drug is
approved by the FDA if it is (i) pharmaceutically equivalent to an approved safe
and effective reference product in that it (a) contains identical amounts of the
same active drug ingredient in the same dosage form and route of administra-
tion, and (b) meets compendial or other applicable standards of strength, quality,
purity, and identify; (ii) bioequivalent to the reference product in that it (a) does
not present a known or potential bioequivalence problem, and it meets an accept-
able in vitro standard (usually dissolution testing), or (b) if it does present such a
known or potential problem, it is shown to meet an appropriate bioequivalence
standard; (iii) adequately labeled; and (iv) manufactured in compliance with cur-
rent good manufacturing practice regulations (1). It is important to note that the
regulatory oversight of generic drug chemistry, manufacturing, and controls is
identical to that imposed upon innovator drug products (2).

BIOEQUIVALENCE
No topic seems so simple but stimulates such intense controversy and misunder-
standing as the topic of bioequivalence. The apparent simplicity of comparing
in vivo performance of two drug products is an illusion that is quickly dispelled
when one considers the difficulties and general public misunderstanding of
the accepted regulatory methodology. In the United States, one often hears
members of the public and medical experts alike stating various opinions on
the unacceptability of approved generic drug products based on misconceptions
regarding the determination of therapeutic equivalence of these products to
the approved reference. These misconceptions include the belief that the U.S.
FDA approves generic products that have mean differences from the reference
product of 20% to 25% and that generic products can differ from each other by
as much as 45%. In addition, some incorrectly assume that, since most bioequiv-
alence testing is carried out in normal volunteers, it does not adequately reflect
bioequivalence and therefore therapeutic equivalence in patients. When the

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United States of America 255

current bioequivalence methods and statistical criteria are clearly understood it

becomes apparent that these methods constitute a strict and robust system that
provides assurance of therapeutic equivalence. In this chapter we discuss the
history, rationale, and methods used for the demonstration of bioequivalence
for regulatory purposes in the United States. In addition, we will touch on some
of the controversial issues and difficulties in demonstrating bioequivalence for
locally acting drug products.

OBJECTIVES OF BIOEQUIVALENCE STUDIES

The most important concept in the understanding of bioequivalence is that the
sole objective is to measure and compare formulation performance between two
or more pharmaceutically equivalent drug products. Formulation performance
is defined as the release of the drug substance from the drug product leading
to bioavailability of the drug substance and eventually leading to one or more
pharmacologic effects, both desirable and undesirable. If equivalent formula-
tion performance from two products can be established then the clinical effects,
within the range of normal clinical variability, should also be equivalent. This is
the same principle that leads to an equivalent response from different lots of the
brand-name product.
When generic drugs are submitted for approval through the abbreviated
new drug application (ANDA) process in the United States, they must be both
pharmaceutically equivalent and bioequivalent to be considered therapeutically
equivalent and therefore approvable. To be considered pharmaceutically equiv-
alent, two products must contain the same amount of the same drug substance
and be of the same dosage form with the same indications and uses. Thus, an
immediate-release tablet would not be considered pharmaceutically equivalent
to an oral liquid suspension, capsule or modified-release tablet. Bioequivalence
means the absence of a significant difference in the rate and extent to which the
active ingredient becomes available at the site of drug action when administered
at the same molar dose under similar conditions in an appropriately designed
study. Two drug products are considered therapeutically equivalent if they are
pharmaceutical equivalents and if they can be expected to have the same clini-
cal effect and safety profile when administered to patients under the conditions
specified in the labeling. The FDA believes that products classified as therapeu-
tically equivalent can be substituted for each other with the full expectation that
the substituted product will produce equivalent clinical effects and safety profile
as the original product.

HISTORY OF BIOEQUIVALENCE EVALUATION IN THE UNITED STATES

Enactment of the Food, Drug, and Cosmetic Act

In 1938, the U.S. Congress enacted the Federal Food Drug and Cosmetic Act. The
new law required, among other things, that a “new drug” product would need
to provide proof of safety before it could be marketed. The new drug applica-
tion (NDA) was established to provide a mechanism for proof of safety of drugs
to be submitted to the FDA. Regulations were promulgated as to the form and
content of the data to be submitted for an NDA. Originally, only toxicity stud-
ies were required along with informative labeling and adequate manufactur-
ing data. These early requirements have since evolved into the comprehensive
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256 Davit and Conner

regulations found in Title 21 of the Code of Federal Regulations Part 300, Sub-
chapter D: Drugs for Human Use (21 CFR Part 300).

The Drug Efficacy Study Implementation

In 1962, The Kefauver–Harris Amendment to the Food Drug and Cosmetic Act
mandated that all new drug products subsequently approved for marketing
must have adequate evidence of effectiveness, as well as safety (3). The FDA
was assigned the responsibility for receiving, reviewing, and evaluating required
data submissions, and enforcing compliance with the law. An applicant submit-
ting an NDA was now required to submit “substantial evidence” in the form
of “adequate and well-controlled studies” to demonstrate the effectiveness of
the drug product under the conditions of use described in its labeling. The new
drug effectiveness provision of the law also applied retrospectively to all drugs
approved between 1938 and 1962 on the basis of safety only. The FDA contracted
with the National Academy of Sciences/National Research Council (NAS/NRC)
to review this group of drugs for effectiveness. The NAS/NRC appointed
30 panels of experts and initiated the Drug Efficacy Study. The panels reviewed
approximately 3400 drug formulations and classified them either effective or less
than effective (4). The FDA reviewed the reports and any supporting data, and
published its conclusions in the Federal Register as Drug Efficacy Study Imple-
mentation (DESI) notices. The DESI notices contained the acceptable marketing
conditions for the class of drug products covered by this notice.
Many drug products had active ingredients and indications that were iden-
tical or very similar to those of drug products found to be effective in the DESI
review but lacked NDAs themselves. Initially, in implementing the DESI pro-
gram, the FDA required that each of these duplicate drug products should have
its own approved NDA before it could be legally marketed. Later, the FDA con-
cluded that a simpler and shorter drug application was adequate for approving
duplicate DESI drugs for marketing, and, in 1970, created the ANDA procedure
for the approval of duplicate DESI drug products (5- -7). The FDA believed that
it was not necessary for firms seeking approval of duplicate DESI drug prod-
ucts to establish the safety and efficacy of each new product identical in active
ingredient and dosage form with a drug product previously approved as safe
and effective. However, many of the DESI notices included, as a requirement
for approval of the duplicate drug application, presentation of evidence that the
“biologic availability” of the test product was similar to that of the innovator’s
product.

Development of FDA’s Bioavailability/Bioequivalence Regulations

Identification of the Need for Regulatory Bioequivalence Studies
Introduction in the late 1960s and early 1970s of the sophisticated bioanalytical
techniques made possible measurements of drugs and metabolites in biologi-
cal fluids at concentrations as low as a few nanograms per milliliter. By using
these methods, the disposition of drugs in the human body could be charac-
terized by determining pharmacokinetic profiles. The rate processes of drug
absorption, distribution, metabolism, and excretion could now be quantified and
related to formulation factors and pharmacodynamic effects. As these techniques
were applied to investigate the relative bioavailability of various marketed drug
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products, it became apparent that many generic formulations were more

bioavailable than the innovator products, while others were less bioavailable.
In the late 1960s and early 1970s, many published studies documented dif-
ferences in the bioavailability of chemically equivalent drug products, notably
chloramphenicol (8), tetracycline (9), phenylbutazone (10), and oxytetracycline
(11). In addition, a number of cases of therapeutic failure occurred in patients
taking digoxin. These patients required unusually high-maintenance doses and
were subsequently found to have low plasma digoxin concentrations (12). A
cross-over study conducted on four digoxin formulations available in the same
hospital at the same time revealed striking differences in bioavailability. The peak
plasma concentrations, following a single dose, varied by as much as seven-
fold among the four formulations. These findings caused considerable concern
because the margin of safety for digoxin is sufficiently narrow that serious tox-
icity or even lethality can result if the systemically available dose is as little as
twice that needed to achieve the therapeutic effect.

Creation of an Office of Technology Assessment

To address this problem of bioinequivalence among duplicate drug products,
the U.S. Congress in 1974 created a special Office of Technology Assessment
(OTA) to provide advice on scientific issues, among which was the bioequiva-
lence of drug products. The OTA formed the drug bioequivalence study panel.
The basic charge to the panel was to examine the relationships between chemi-
cal and therapeutic equivalence of drug products, and to assess whether existing
technological capability could assure that drug products with the same physical
and chemical composition would produce comparable therapeutic effects. Fol-
lowing an extensive investigation of the issues, the panel published its findings
to the U.S. Congress in a report, dated July 15, 1974, entitled Drug Bioequiva-
lence (13,14). Notably, the panel concluded that variations in drug bioavailability
were responsible for some instances of therapeutic failures and that analytical
methodology was available for conducting bioavailability studies in man. Sev-
eral recommendations pertained to in vivo bioequivalence evaluation. The panel
recommended that efforts should be made to identify classes of drugs for which
evidence of bioequivalence is critical, that current law requiring manufacturers
to make bioavailability information available to the FDA should be strengthened,
and that additional research aimed at improving the assessment and prediction
of bioequivalence was needed.

Publication of the 1977 Bioavailability and Bioequivalence Regulations

In 1977, the FDA published its Bioavailability and Bioequivalence regulations under
21 CFR. The regulations were divided into subpart A—General Provisions, subpart
B—Procedures for Determining the Bioavailability of Drug Products, and subpart C—
Bioequivalence Requirements (15). The regulations greatly aided the rational devel-
opment of dosage forms of generic drugs, as well as the subsequent evaluation of
their performance. With the publication of these regulations, a generic firm could
file an ANDA that provided demonstration of bioequivalence to an approved
drug product in lieu of clinical trials. Subpart B defined bioavailability in terms
of rate and extent of drug absorption, described procedures for determining
bioavailability of drug products, set forth requirements for submission of in vivo
bioavailability data, and provided general guidelines for the conduct of in vivo
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258 Davit and Conner

bioavailability studies. Subpart C set forth requirements for marketing a drug

product subject to a bioequivalence requirement. ANDAs were generally still
restricted to duplicates of drug products approved prior to October 10, 1962 and
determined to be effective for at least one indication in a DESI notice. A dupli-
cate drug product had to meet bioequivalence requirements if well-controlled
trials showed that it was either not therapeutically equivalent or bioequivalent
to other pharmaceutically equivalent products. Narrow therapeutic index (NTI)
drugs also had to meet bioequivalence requirements, as did drugs with low aque-
ous solubility, poorly absorbed drugs, drugs with nonlinear pharmacokinetics,
drugs that underwent extensive first-pass metabolism, drugs which were unsta-
ble in the gastrointestinal (GI) tract, and drugs for which absorption was limited
to a specific portion of the GI tract. Finally, a duplicate drug product had to meet
bioequivalence requirements if competent medical determination concluded that
a lack of bioequivalence would have a serious adverse effect in the treatment or
prevention of a serious disease or condition.
An important feature of the 1977 regulations was the provision for waiver
of in vivo bioequivalence study requirements (biowaivers) under certain circum-
stances. Applicants could file waiver requests for parenteral solutions, topically
applied preparations, oral dosage forms not intended to be absorbed, gases or
vapors administered by the inhalation route, and oral-solubilized dosage forms.
Waivers could be granted for duplicate DESI-effective parenteral drug prod-
ucts (suspensions excluded) and duplicate DESI-effective immediate-release oral
drug products, which were not on the list of FDA pharmacological classes and
drugs for which in vivo bioequivalence testing was required. Biowaivers could
also be granted for drug products in the same dosage form, but a different
strength, and proportionally similar in active and inactive ingredients to a drug
product from the same manufacturer for which in vivo bioavailability had been
demonstrated. Both drug products were required to meet an appropriate in vitro
test (generally dissolution) approved by the FDA.

Availability of the Paper NDA Route for Duplicate Drug Products

The FDA did allow some duplicate drug versions of post-1962 drug products
to be marketed under a “paper NDA” policy (16). Under this policy, in lieu
of conducting their own tests, manufacturers of such duplicate drug products
could submit safety and effectiveness information derived primarily from pub-
lished reports of well-controlled studies. However, such reports of adequate and
well-controlled studies in the literature were limited, and the FDA staff effort
involved in reviewing paper NDAs became a substantial and often inefficient
use of resources.

Present-Day Bioequivalence Requirements

The 1984 Hatch–Waxman Amendments
In 1984, the Drug Price Competition and Patent Term Restoration Act (the Hatch–
Waxman Amendments) amended the Federal Food, Drug, and Cosmetic Act
by creating Section 505(j) of the Act [21 USC 355 (j)], which established the
present ANDA approval process (17). Section 505(j) extended the ANDA pro-
cess to duplicate versions of post-1962 drugs, but also required that an ANDA
for any new generic drug product shall contain information to show that the
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generic product is bioequivalent to the reference listed drug product. Evidence

of bioequivalence was now required for all dosage forms: tablets, capsules, sus-
pensions, solutions, topical ointments and creams, transdermal patches, oph-
thalmics, injectables, and so on. The new law stated that a drug shall be consid-
ered to be bioequivalent to a listed drug if “the rate and extent of absorption of
the drug do not show a significant difference from the rate and extent of absorp-
tion of the listed drug when administered at the same molar dose and of the
therapeutic ingredient under similar experimental conditions in either a single
dose or multiple doses. . .”

The 1992 Revisions to FDA’s Bioavailability/Bioequivalence Regulations

In 1992, the FDA revised the Bioavailability and Bioequivalence Requirements of
21 CFR Part 320 to implement the Hatch–Waxman Amendments (18). In its
present form, 21 CFR Part 320 consists of subpart A, General Provisions, and sub-
part B, Procedures for Determining the Bioavailability and Bioequivalence of Drug Prod-
ucts. Subpart A describes general provisions including definitions of bioavail-
ability and bioequivalence. Subpart B states the basis for demonstrating in vivo
bioavailability or bioequivalence and lists types of evidence to establish bioavail-
ability or bioequivalence, in descending order of accuracy, sensitivity, and repro-
ducibility. Subpart B also provides guidelines for the conduct and design of an
in vivo bioavailability study and lists criteria for waiving evidence of in vivo
bioequivalence. The present biowaiver regulations now apply to solutions of all
parental solutions, including intraocular, intravenous, subcutaneous, intramus-
cular, intraarterial, intrathecal, intrasternal, and interperitoneal, but no longer
permit automatic biowaivers for all topical and nonsystemically absorbed oral
dosage products (18). Waivers of in vivo testing can now be granted for oph-
thalmic, otic, and topical solutions. A DESI-effective immediate-release oral drug
product can be granted a waiver of in vivo testing, provided it is not listed in the
FDA’s Approved Drug Products with Therapeutic and Equivalence Evaluations as hav-
ing a known or potential bioequivalence problem (1). Other aspects of the present
regulations governing biowaivers are similar to the 1977 regulations.

STATISTICAL EVALUATION OF BIOEQUIVALENCE DATA

Introduction
Statistical evaluation of bioequivalence studies of systemically active drugs is
based on analysis of drug blood or plasma/serum concentration data. The area
under the plasma concentration versus time curve (AUC) is used as an index
of the extent of drug absorption. Generally, both AUC determined until the
last measurable blood sampling time (AUC0–t ) and AUC extrapolated to infin-
ity (AUC∞ ) are evaluated. Drug peak plasma concentration (Cmax ) is used as an
index of the rate of drug absorption.

Early Days of FDA’s Bioequivalence Review Process

Criteria for approval of generic drugs have evolved since the 1970s (19). In the
early 1970s, approval was based on mean data. Mean AUC and Cmax values for
the generic product had to be within ±20% of those of the brand-name prod-
uct. In addition, plasma concentration–time profiles for immediate-release prod-
ucts had to be reasonably superimposable. Beginning in the late 1970s, the 75/75
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(or 75/75–125) rule was added to the criteria. According to the 75/75 rule, the
test/reference ratios of AUC and Cmax had to be within 0.75 to 1.25 for at least
75% of the subjects. This was an attempt to consider individual variability in rate
and extent of absorption. In the early 1980s, the power approach was applied
to AUC and Cmax parameters in conjunction with the 75/75 rule. The power
approach consisted of two statistical tests: (i) a test of the null hypothesis of no
difference between formulations using the F test; and (ii) the evaluation of the
power of a test to detect a 20% mean difference in treatments.
Statistically, the power approach and the 75/75 rule have poor perfor-
mance, and the FDA discontinued the use of these methods in 1986. The prob-
lems with both the 75/75 rule and power approach methods arose from the fact
that they were based on the conventional null hypothesis test of no difference.
Conventional hypothesis testing does not assess the evidence in favor of the con-
clusion that the test and reference means are equivalent, but rather assesses the
evidence in favor of a conclusion that the test and reference means are different,
which is not the question of interest in bioequivalence analysis (20- -22). That is,
the objective of bioequivalence analysis is to establish whether the test and ref-
erence means are equivalent—in other words, is the difference between the two
means an acceptable difference?

THE TWO ONE-SIDED TESTS PROCEDURE

The two one-sided tests procedure, used by the FDA since 1986 for bioequiva-
lence analysis, resolved the problems of hypothesis testing (20). The two one-
sided tests procedure tests two conditions. Stated simply, the first condition tests
if the test product is significantly less bioavailable than the reference product.
The second condition tests if the reference product is significantly less bioavail-
able than the test product. A significant difference is defined as 20% at the alpha
equals 0.05 level. As per these statistical criteria, the mean test/reference ratio of
the data is usually close to one. The criteria above may be re-stated to illustrate
the rationale for the 0.80 to 1.25 (or 80–125%) confidence interval criteria. In the
first case illustrated above, the bioequivalence limit for the test/reference ratio =
0.80. In the second case, the bioequivalence limit for the reference/test ratio =
0.80. Since by convention, bioequivalence ratios are expressed as test/reference,
the second bioequivalence limit = 1.25, that is, the reciprocal of 0.80. This may
be stated in clinical terms as follows. If a patient is currently receiving a brand-
name reference product and is switched to a generic product, the generic prod-
uct should not deliver significantly less drug to the patient than the brand-name
product. Conversely, if a patient is currently receiving the generic product and is
switched to the brand-name reference product the brand-name product should
not deliver significantly less drug to the patient than the generic product.

Logarithmic Transformation of Bioequivalence Data

Until 1992, for bioequivalence statistical analysis, the FDA generally recom-
mended that applicants perform analysis of variance (ANOVA) on untrans-
formed AUC and Cmax data to determine the 90% confidence limits of the dif-
ferences. Following a 1991 meeting of the Generic Drugs Advisory Committee,
which focused on statistical analysis of bioequivalence data, the FDA began to
recommend that applicants perform ANOVA on log-transformed data.
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The Generic Drug Advisory Committee recommended log transformation

for bioequivalence analysis for two reasons. First, the ANOVA used to conduct
the bioequivalence statistics is based on a linear statistical model (23,24). How-
ever, the form of expression for AUC suggests a multiplicative model, since
AUC = (F × D)/(V × Ke ), where F is the fraction of drug absorbed, D the dose, V
the volume of distribution, and Ke the elimination rate constant. For this reason,
FDA statisticians concluded that effects on AUC are not additive if the data are
analyzed on the original scale of measurement. Thus, since ln(AUC) is equal to
ln(F) + ln(D) − ln(V) − ln(Ke ), logarithmic transformation of AUC allows it to be
analyzed using the ANOVA, which assumes a linear statistical model. A similar
argument can be made for Cmax .
The second reason for log transformation is that Cmax and AUC, like
much biological data, correspond more closely to a log-normal distribution
than to a normal distribution (23). Plasma concentration data and derived
pharmacokinetic parameters tend to be skewed, and their variances tend
to increase with the means. Log transformation generally remedies this sit-
uation, and makes the variances independent of the means. In addition,
skewed frequency distributions are often made more symmetrical by log
transformation.
To summarize, since 1992, the FDA has formally recommended that
applicants perform ANOVA on the geometric mean test/reference AUC and
Cmax ratios and determine the 90% confidence interval for the ratios in per-
forming bioequivalence analysis (25). To obtain geometric means, the data are
log-transformed prior to conducting an ANOVA, then back-transformed before
calculating the test/reference ratios. The 90% confidence interval encompasses
the two one-sided tests, each carried out at the ␣ = 0.05 (5%) level. The FDA
requires that bioavailability of the generic formulation relative to the brand
name should be within 0.80 to 1.25 and must be known with a 90% confidence.
The determination of bioequivalence using this approach is termed “average
bioequivalence” (20).

The Role of T max in Bioequivalence Analysis

The FDA does not ask ANDA applicants to use statistical procedures to com-
pare the time to drug peak plasma concentrations (Tmax ) for the test and refer-
ence products. Although theoretically a relatively sensitive measure of absorp-
tion rate, Tmax is thought to have shortcomings as an indirect measure of the rate
of drug absorption (26,27). For example, ANOVA analysis cannot be applied to
Tmax . Unlike Cmax and AUC, which are continuous variables, Tmax is a discrete
measure (28). In addition, most pharmacokinetic studies typically employ irreg-
ular sampling schemes to collect Tmax data, and as a result these data are not rou-
tinely amenable to proper statistical evaluation (29). For these reasons, the FDA
has decided not to impose bioequivalence acceptance criteria on the parameter
Tmax (30). Nonetheless, the FDA believes that Tmax should be considered in bioe-
quivalence decision making, and routinely examines Tmax data in bioequivalence
studies as supportive data to verify that the test and reference products have the
same rate of absorption (31).
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CURRENT METHODS AND CRITERIA FOR

DOCUMENTING BIOEQUIVALENCE

FDA’s General Recommendations for In Vivo

Bioequivalence Study Design
Introduction
Part 320 of Title 21 of the Code of Federal Regulations (21 CFR) contains FDA’s
regulations on procedures for determining bioavailability or bioequivalence
of drug products (32). CDER’s Guidance for Industry: Bioavailability and Bioe-
quivalence Studies for Orally Administered Drug Products—General Considerations
(“BA/BE Guidance”) contains advice on how to meet the bioavailability and
bioequivalence requirements of 21 CFR Part 320 (30). The BA/BE Guidance also
applies to nonorally administered drug products where reliance on systemic
exposure measures is suitable for documenting bioavailability and bioequiva-
lence (e.g., transdermal systems, certain rectal and nasal drug products).

General Bioequivalence Study Design Recommendations

There are several types of designs suitable for in vivo bioequivalence studies.
The preferred design for most orally administered dosage forms is a two-way
cross-over, two-period, two-sequence single-dose study, in healthy subjects, per-
formed under fasting conditions. In this design, each study subject receives each
treatment, test and reference, in random order. Plasma or blood samples are col-
lected for approximately three pharmacokinetic half-lives for determination of
the rate and extent of drug release from the dosage form and absorption by each
subject. A washout period is scheduled between the two periods to allow the
subjects to completely eliminate the drug absorbed from the first dose before
administration of the second dose. Although this design is carried out for most
orally absorbed drug products, it may become impractical for drugs with long
pharmacokinetic half-lives, that is, longer than 30 hours (e.g., nevirapine). In this
case a single-dose parallel design may be used instead (33). For drugs with very
long half-lives, concentration sampling may be carried out for a period of time
corresponding to two times the median Tmax (time to Cmax ) for the product. For
drugs that demonstrate low intrasubject variability in distribution and clearance,
an AUC truncated at 72 hours may be used in place of AUC0–t or AUC∞ (30).

Number of Subjects: Single-Dose Versus Steady-State Bioequivalence Studies

The FDA recommends that investigators enroll a minimum of 12 subjects (25).
Most bioequivalence studies submitted in support of ANDAs enroll from 24 to
36 subjects. The FDA asks investigators to conduct single-dose bioequivalence
studies because it has been shown that these are more sensitive to detecting dif-
ferences in formulation performance than multiple-dose studies (30,34–38).

Appropriate Drug Product Strength for Bioequivalence Studies

Most bioequivalence studies are conducted on the highest strength of a drug
product line, unless it is necessary to use a lower strength for safety reasons. Use
of the highest strength is particularly critical for drugs that display nonlinear
kinetics because of nonlinear (usually capacity-limited) elimination or presys-
temic metabolism, with the result that plasma concentrations increase more than
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proportionally with an increase in dose (39). For such drugs, small differences
in the rate or extent of absorption can potentially have substantial effects on the
AUC (40). Thus, using the highest strength in bioequivalence studies, or, in some
cases, the highest starting dose—so that drug pharmacokinetics are potentially in
the “nonlinear range” ensures that a generic formulation will not pass bioequiv-
alence acceptance criteria unless it is formulated to provide nearly the same rate
and extent of exposure as the corresponding reference product. For drugs for
which rate and/or extent of absorption increases less than proportionally with
an increase in dose (41), the bioequivalence study will be most discriminating
if conducted at the lowest strength or, if only one strength is marketed, at the
lowest recommended dose.

Fed Bioequivalence Studies

Because food can influence the bioavailability of orally administered drugs, the
FDA recommends that applicants conduct bioequivalence studies under fed con-
ditions in most cases. FDA’s Guidance for Industry, Food-Effect Studies and Fed
Bioequivalence Studies (“Food Guidance”), contains recommendations about how
to design, and how to decide whether it is necessary to conduct fed bioequiv-
alence studies (42). Fed bioequivalence studies are generally conducted using
meal conditions expected to provide the greatest effects on formulation perfor-
mance and GI physiology such that systemic drug bioavailability may be max-
imally affected. Typically, the drug is administered to subjects within 30 min-
utes of consuming a high-fat, high-calorie meal. The FDA recommends that these
studies use a randomized, balanced, single-dose, two-treatment (fed vs. fasting),
two-period, two-sequence cross-over design. The acceptance criteria for fed bioe-
quivalence studies is the same as for fasting bioequivalence studies—the 90%
confidence interval of the geometric mean test/reference AUC and Cmax ratios
must fall within the limits of 80% to 125%.
The decision tree for determining when it is necessary to conduct fed bioe-
quivalence studies differs for immediate-release and modified-release products
(42). For immediate-release solid oral dosage forms, fed bioequivalence stud-
ies are recommended whenever the FDA-approved package insert (or label) for
the reference drug contains statements about the effect of food on absorption or
administration. If the label states that the product should be taken only on an
empty stomach, fed bioequivalence studies are not recommended; in such cases
it is necessary to evaluate bioequivalence only under fasting conditions (e.g., rise-
dronate sodium) (43).
For modified-release solid oral dosage forms, fed bioequivalence studies
are always conducted in addition to the fasting bioequivalence studies, with
few exceptions. This is primarily because many excipients used to get modified-
release behavior depend on the environmental conditions of the GI tract to pro-
vide either delayed or extended delivery of the drug (44). Thus, by changing
conditions such as gastric pH, gastric emptying rate, intestinal motility, and
intestinal secretions, food can interact with components of the modified-release
formulation, thereby influencing drug bioavailability. Therefore, for modified-
release products, the generic applicant must demonstrate that food effects on test
product oral bioavailability does not differ from food effects on reference prod-
uct oral bioavailability; in other words, that the test and reference products are
bioequivalent under fed conditions. If the label warns that the modified release
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product must be given on an empty stomach for reasons of safety (45) or efficacy
(46), then the FDA may conclude that bioequivalence need only be determined
under fasting conditions.
In very few cases, bioequivalence is evaluated only under fed conditions
because there are safety concerns associated with administration of the product
on an empty stomach (47).

Study Population in Bioequivalence Studies

The FDA recommends that in vivo bioequivalence studies be conducted in indi-
viduals that are representative of the general population, taking into account
age, sex, and race factors (30). For example, if a drug product is to be used in
both sexes, the sponsor should attempt to include similar proportions of males
and females in the study; if the drug product is to be used predominantly in the
elderly, the applicant should attempt to include as many subjects of 60 years of
age or greater as possible. Restrictions on admission into the study should gen-
erally be based solely on safety considerations.
Bioequivalence studies should be conducted in the intended patient pop-
ulation when there are significant safety concerns associated with use in
healthy subjects. For example, bioequivalence studies of drugs used for cancer
chemotherapy are generally conducted in cancer patients (48,49). These studies
should be conducted in patients who are already stabilized on the medication of
interest.

TYPES OF EVIDENCE TO ESTABLISH BIOAVAILABILITY

AND BIOEQUIVALENCE

What FDA’s Regulations Say

Subpart B of the Bioavailability and Bioequivalence Requirements in 21 CFR Part 320
lists the following in vivo and in vitro approaches to determining bioequivalence
in descending order of accuracy, sensitivity, and reproducibility (32):
r In vivo measurement of active moiety or moieties in biologic fluid;
r In vivo pharmacodynamic comparison;
r In vivo limited clinical comparison;
r In vitro comparison;
r Any other approach deemed appropriate by FDA.

Bioequivalence Studies with Pharmacokinetic Endpoints

Figure 1 illustrates, for a model of oral dosage form performance, why the most
sensitive approach is to measure the drug in biological fluids, such as blood,
plasma, or serum. The active ingredient leaves the solid dosage form and dis-
solves in the GI tract, and following absorption through the gut wall, appears in
the systemic circulation. The step involving dissolution of the drug substance
prior to absorption is the critical step that is determined by the formulation.
Other steps illustrated in the diagram are patient- or subject-determined pro-
cesses not directly related to formulation performance. Variability of the mea-
sured endpoint increases with each additional step in the process. Therefore,
variability of clinical measures is quite high compared to blood concentration
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Pharmacokinetic Clinical/PD
Dosage Form Measurement Measurement
Performance

Dosage Drug in Site of Therapeutic

Gut Wall Blood
Form Solution Activity Effect

Dose ln Dose

FIGURE 1 The most sensitive approach in evaluating bioequivalence of two formulations is

to measure drug concentration in biological fluids, as illustrated in this diagram showing the
relationship between dosage form performance and therapeutic response. Following oral dos-
ing, the active ingredient leaves the solid dosage form, dissolves in the gastrointestinal tract,
and, following absorption through the gut wall, appears in the systemic circulation. Formulation
performance is the major factor determining the critical steps of dosage form disintegration and
drug substance dissolution prior to absorption. All other steps following in vivo drug substance
dissolution are patient- or subject-determined processes not directly related to formulation per-
formance. The variability of the measured endpoint increases with each additional step in the
process, such that variability of clinical measures is quite high compared to that of blood con-
centration measures. As a result, a pharmacodynamic or clinical approach is not as accurate,
sensitive and reproducible as an approach based on plasma concentrations.

measures. Figure 2 shows that the blood concentration of a drug directly reflects
the amount of drug delivered from the dosage form.
Most bioequivalence studies submitted to the FDA are based on mea-
suring drug concentrations in plasma. In certain cases, whole blood or serum
may be more appropriate for analysis. Measurement of only the parent drug
released from the dosage form, rather than a metabolite, is generally recom-
mended because the concentration–time profile of the parent drug is more sen-
sitive to formulation performance than a metabolite, which is more reflective
of metabolite formation, distribution, and elimination (30). Measurement of a
metabolite may be preferred when parent drug concentrations are too low to
permit reliable measurement. In this case, the metabolite data are subjected to a
confidence interval approach for bioequivalence demonstration. Both the parent
and metabolite are measured in cases where the metabolite is formed by presys-
temic or first-pass metabolism and contributes meaningfully to safety and effi-
cacy. In this case, only the parent drug data are analyzed using the confidence
interval approach. The metabolite data are not subjected to confidence interval
analysis but rather used to provide supportive evidence of comparable therapeu-
tic outcome.
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Plasma Concentration

R1

R2

D1 D2
Dose

FIGURE 2 The blood concentration of a drug directly reflects the amount of drug delivered from
the dosage form. The corresponding responses over a wide range of doses will be of adequate
sensitivity to detect differences in bioavailability between two formulations. This is illustrated for
two widely different doses, D 1 and D 2 . Any differences in dosage form performance are reflected
directly by changes in blood concentration (R 1 and R 2 ).

Urine measurements are not as sensitive as plasma measurements, but are

necessary for some drugs such as orally administered potassium chloride (50)
and alendronate sodium (51), because serum concentrations are too low to allow
for accurate measurement of drug absorbed from the dosage form. Both the
cumulative amount of drug excreted (Ae ) and maximum rate of urinary excre-
tion (Rmax ) are evaluated statistically in bioequivalence studies that rely on urine
concentrations.

Bioequivalence Studies with Pharmacodynamic Endpoints

In situations where a drug cannot be reliably measured in blood, it may be appro-
priate to base bioequivalence evaluation on an in vivo test in humans in which
an acute pharmacologic (pharmacodynamic) effect is measured as a function of
time. Generally, the pharmacodynamic response plotted against the logarithm of
dose appears as a sigmoidal curve, as shown in Figure 3. It is assumed that, after
absorption from the site of delivery, the drug or active metabolite is delivered to
the site of activity and, through binding to a receptor or some other mechanism,
elicits a quantifiable pharmacodynamic response. Since additional steps con-
tribute to the observed pharmacodynamic response, a pharmacodynamic assay
is not as sensitive to drug formulation performance as are blood drug concentra-
tions. In developing a pharmacodynamic assay for bioequivalence evaluation, it
is critical to validate the assay by selecting the correct dose. The dose should be
in the range that produces a change in response, as shown in the midportion of
the curve. In other words, the pharmacodynamic assay should be sensitive to
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R2
Clinical/PD Response

R1

D1 D2
Log Dose

FIGURE 3 In evaluating bioequivalence in a study with pharmacodynamic or clinical endpoints,

it is critical to select a dose that falls on the middle ascending portion of the sigmoidal dose–
response curve. The most appropriate dose for a study based on pharmacodynamic or clinical
endpoints should be in the range that produces a change in response (R 1 ), as shown in the
midportion of the curve (D 1 ). A dose that is too high will produce a minimal response at the
plateau phase of the dose–response curve, such that even large differences in dose (D 2 ) will
show little or no change in pharmacodynamic or clinical effect (R 2 ). Thus, two formulations that
are quite different may appear to be bioequivalent.

small changes in dose. A dose that is too high will produce a minimal response
at the plateau phase of the dose–response curve, such that even large differences
in dose will show little or no change in pharmacodynamic effect. A pharma-
codynamic study can be conducted in healthy subjects. The pharmacodynamic
response selected should directly reflect dosage form performance but may not
necessarily directly reflect therapeutic efficacy.
The FDA accepts bioequivalence studies with pharmacodynamic end-
points for locally-acting drug products. To be adequately sensitive to distinguish
between two products that are not bioequivalent, the dose used in the pivotal
bioequivalence study should be on the linear portion of the dose–response curve.
In such cases, it is necessary to conduct a pilot pharmacodynamic study by using
the reference product to determine the optimal dose for the pivotal bioequiv-
alence study. Topical corticosteroids are examples of a drug product class for
which the pharmacodynamic approach is suitable (52). In this case, the pharma-
codynamic endpoint is based on the ability of corticosteroids to produce blanch-
ing or vasoconstriction in the microvasculature of the skin. Acarbose is another
example of a drug product for which bioequivalence can be determined using
a pharmacodynamic approach (53). Acarbose lowers blood glucose by inhibit-
ing the activity of ␣-glucosidase within the GI tract following ingestion of food
or other sources of sugar. In this case, the pharmacodynamic endpoint is based
upon the ability of acarbose to lower serum glucose after administration of a
sucrose load
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Bioequivalence Studies with Clinical Endpoints

If it is not possible to develop reliable bioanalytical or pharmacodynamic assays,
then it may be necessary to evaluate bioequivalence in a well-controlled trial with
clinical endpoints. This type of bioequivalence study is conducted in patients
and is based on evaluation of a therapeutic, that is, clinical, response. The clin-
ical response follows a similar dose-response pattern to the pharmacodynamic
response, as shown in Figure 3. Thus, in designing bioequivalence studies with
clinical endpoints, the same considerations for dose selection apply as for bioe-
quivalence studies with pharmacodynamic endpoints. As with a pharmacody-
namic study, the appropriate dose for a bioequivalence study with clinical end-
points should be on the linear rising portion of the dose–response curve, since
a response in this range will be the most sensitive to changes in formulation
performance. Due to high variability and the subjective nature of clinical eval-
uations, the clinical response is often not as sensitive to differences in drug for-
mulation performance as a pharmacodynamic response. For these reasons, the
clinical approach is the least accurate, sensitive and reproducible of the in vivo
approaches to determine bioequivalence.
Bioequivalence studies with clinical endpoints generally employ a ran-
domized, blinded, balanced, parallel design. Studies compare the efficacy of the
test product, innovator product, and placebo to determine if the two products
containing active ingredient are bioequivalent. The placebo is included to assure
that the two active treatments in the clinical trial actually are being studied at
a dose that affects the therapeutic response(s). Failure to assure that the treat-
ments are clinically active in the trial would show that the trial has no sensitivity
to differences in formulation, i.e. the response is on the flat bottom of the dose–
response curve (Fig. 3). A generic equivalent of the innovator product should
be able to demonstrate bioequivalence for selected clinical endpoint(s) that ade-
quately reflect drug appearance at the site(s) of activity and therefore formula-
tion performance. Fluticasone propionate nasal spray is an example for which
such an approach is suitable. Fluticasone propionate is a corticosteroid, which,
when formulated as a nasal spray, is indicated to treat the nasal symptoms of
nonallergic rhinitis. For this product, the clinical endpoint is based on total nasal
symptom score (TNSS), which is a composite score of patient self-rated symp-
toms, expressed as a mean change from baseline of the TNSS (54). FDA considers
two fluticasone propionate nasal products to have an equivalent clinical response
when the 90% confidence interval for the point estimate (mean ratio between test
and reference product for the change in TNSS relative to baseline) is within an
80% to 125% acceptance interval.

Bioequivalence Studies with In Vitro Endpoints

With suitable justification, bioavailability and bioequivalence may be established
by in vitro studies alone. This approach is suitable for some types of locally acting
resins, such as cholestyramine (55) and sevelamer (56), which produce their cor-
responding therapeutic responses by forming nonabsorbable complexes in the
intestine with bile acids and phosphate salts, respectively. For such products, the
in vitro measures of bioequivalence are based on binding rate studies. The 90%
confidence interval of the test/reference ratios of the equilibrium binding con-
stants should fall within the limits of 0.80 to 1.25.
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Two Bioequivalent Products Will Produce the Same Response in Patients

As already described, most studies determining bioequivalence between generic
products and the corresponding brand-name products are conducted in healthy
subjects. It is true that drug pharmacokinetic profiles may differ between healthy
subjects and particular types of patients. This is because some disease states
affect different aspects of drug substance absorption, distribution, metabolism,
and elimination. However, the effects of disease on relative formulation perfor-
mance, that is, release of the drug substance from the drug product, are rare.
Bioequivalence studies are designed to measure and compare formulation per-
formance between two drug products within the same individuals. It is expected
that any difference between in vivo drug release from the two formulations will
be the same whether the two formulations are tested in patients or normal sub-
jects. Thus, generic and brand-name products which are bioequivalent can be
substituted in patients because they will produce the same effect(s). This is illus-
trated by findings from a recent observational cohort study comparing effective-
ness and safety in patients switched from brand-name warfarin sodium tablets
to generic warfarin sodium tablets (57). The generic product was approved on
the basis of standard bioequivalence studies in normal volunteers. The observa-
tional cohort study showed that the two products had no difference in clinical
outcome measures.

WAIVERS OF IN VIVO BIOEQUIVALENCE BASED ON IN VITRO

DISSOLUTION TESTING

Introduction
Under certain circumstances, product quality bioavailability and bioequivalence
can be documented using in vitro approaches (58). In vitro dissolution testing
to document bioequivalence for nonbioproblem DESI drugs remains acceptable.
In vitro dissolution characterization is encouraged for all product formulations
investigated, including prototype formulations, particularly if in vivo absorp-
tion characteristics are well-defined for the different product formulations. Such
efforts may enable the establishment of an in vitro–in vivo correlation. When
an in vitro–in vivo correlation is available (18), the in vitro test can serve as an
indicator of how the product will perform in vivo.

Immediate-Release Drug Products

For immediate-release products, an in vivo bioequivalence demonstration of one
or more lower strengths can be waived based on acceptable dissolution testing
and an in vivo study on the highest strength (30). All strengths should be propor-
tionally similar in active and inactive ingredients. For reasons of safety of study
subjects, it is sometimes appropriate to conduct the in vivo study on a strength
that is not the highest. In these cases, the FDA will consider a biowaiver request
for a higher strength if elimination kinetics are linear over the dose range, if the
strengths are proportionally similar, and if comparative dissolution testing on all
strengths is acceptable. Examples of drug products for which an in vivo study
is not recommended on the highest strength due to safety include aripiprazole
tablets (59) and lamotrigine tablets (60).
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Modified-Release Drug Products

For modified-release oral drug products, application of dissolution waivers
varies depending on whether the product is formulated as a beaded capsule or
tablet. For capsules in which the strength differs only in the number of iden-
tical beads containing the active moiety, it is not necessary for the applicant
to conduct in vivo testing on lower strengths provided that dissolution test-
ing is acceptable and that bioequivalence is demonstrated in an in vivo study
for the highest strength. For tablets, it may not be necessary to conduct in vivo
studies on lower strengths provided that (i) the lower strengths are proportion-
ally similar in its active and inactive ingredients to the strength that under-
went acceptable in vivo bioequivalence testing; and (ii) the dissolution pro-
files of the lower strengths in at least three media (e.g., pH 1.2, 4.5, and 6.8)
are similar to the profiles of the strength that underwent acceptable in vivo
testing.

The Biopharmaceutics Classification System

Applicants can request biowaivers for immediate-release products based on an
approach termed the biopharmaceutics classification system (BCS) (61). The BCS
is a framework for classifying drug substances based on solubility and intestinal
permeability. With product dissolution, these are the three major factors gov-
erning rate and extent of absorption from immediate-release products. The BCS
classifies drug substances as

Class 1: high solubility, high permeability

Class 2: low solubility, high permeability
Class 3: high solubility, low permeability
Class 4: low solubility, low permeability

The FDA believes that demonstration of in vivo bioequivalence may not

be necessary for immediate-release products containing BCS Class 1 drug sub-
stances, as long as the inactive ingredients do not significantly affect absorption
of the active ingredient(s). This is because, when a drug dissolves rapidly from
the dosage form (in relation to gastric emptying) and has high intestinal perme-
ability, the rate and extent of its absorption is unlikely to depend on dissolution
and/or GI transit time.
The CDER Guidance for Industry: Waiver of In Vivo Bioavailability and
Bioequivalence Studies for Immediate Release Solid Oral Dosage Forms Based on
a Biopharmaceutics Classification System (61), recommends methods for deter-
mining drug solubility and permeability for applicants who wish to request
biowaivers based on BCS. The drug solubility class boundary is based on
the highest dose strength of the product that is the subject of the biowaiver
request. The permeability class can be determined in vivo (mass balance, abso-
lute bioavailability, or intestinal perfusion approaches) or in vitro (permeation
studies using excised tissues or a monolayer of cultured epithelial cells). Test
and reference dissolution profiles should be compared in three media: 0.1 N HCl
or simulated gastric fluid without enzymes; pH 4.5 buffer, and pH 6.8 buffer or
simulated intestinal fluid without enzymes.
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HIGHLY VARIABLE DRUGS

Issues with In Vivo Bioequivalence Studies of Highly Variable Drugs

The width of the 90% confidence interval is proportional to the estimated drug
variability (in particular, within-subject variability for a cross-over design) and
inversely proportional to the number of subjects participating in the study. His-
torically, the FDA has applied the bioequivalence limits of 80% to 125% to almost
all drug products regardless of the size of within-subject variability. As a result,
the number of subjects required for a study of highly variable drugs or drug
products can be much greater than normally needed for a typical BE study.
Highly variable drugs are defined as drugs for which the within-subject vari-
ability in the bioequivalence measures, AUC and Cmax ≥ 30%. At a 2004 meet-
ing of the Pharmaceutical Sciences Advisory Committee, government, academic,
and industry scientists expressed concern that applying the conventional bioe-
quivalence criteria to highly variable drugs/products may unnecessarily expose
a large number of healthy subjects to a drug when this large number of subjects
is not needed for assurance of bioequivalence (62).
It is believed that drugs with high within-subject variability generally have
a wide therapeutic window; in other words, despite high variability, these prod-
ucts have been demonstrated to be both safe and effective (63). For these reasons,
scientists and statisticians at the FDA investigated various approaches available
for determining bioequivalence that would reduce the sample size required for
a bioequivalence study, but prevent therapeutically inequivalent products reach-
ing the market.

Reference-Scaled Average Bioequivalence Approach

For drugs with an expected within-subject variability of 30% or greater, the FDA
recommends using a reference-scaled average bioequivalence approach (64,65).
By using this approach, the bioequivalence study uses a three-period, reference-
replicated, cross-over design with sequences of TRR, RTR, and RRT. Specifically,
subjects receive a single dose of the test product once and reference product twice
on separate occasions with random assignment to the three possible sequences of
product administration. This partial replicate design allows for the estimation of
within-subject variability of the reference product. The three-period design was
selected over a four-period design because of efficiency. The only advantage of
the four-period design is that it allows the calculation of the variability of the
test product. The test product variability is not used in the proposed statistical
method. The minimum number of subjects that would be acceptable is 24.
To analyze the bioequivalence study data by using this approach, measure-
ments of both Cmax and AUC are first log-transformed and the averages, ␮T and
␮R, of the test and reference products are calculated. The within-subject variabil-
ity of the reference product, ␴ 2 WR , is also calculated.
Scaled average bioequivalence for both AUC and Cmax is evaluated by test-
ing the following null hypothesis

(␮T − ␮R )2
H0 : >␪ (1)
␴WR
2

(for given ␪ > 0) versus the alternative hypothesis

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272 Davit and Conner

(␮T − ␮R )2
H1 : ≤␪ (2)
␴WR
2

where ␮T and ␮R are the averages of the log-transformed measures Cmax and
AUC for the test and reference products, respectively; usually testing is done at
level ␣ = 0.05; and ␪ is the scaled average bioequivalence limit. Furthermore,
(ln )2
␪= (3)
␴W0
2

where  is 1.25, the usual average BE upper limit for the untransformed
test/reference ratio of geometric means, and ␴ W0 = 0.25. Rejection of the null
hypothesis H0 supports the conclusion of equivalence.
 2 2
A 95% upper confidence bound for YT − YR /sWR ≤ ␪ determined in
a BE study must be ≤␪, or equivalently, a 95% upper confidence bound for
 2
YT − YR − ␪ sWR2
must be ≤0. The scaling is mixed. If sWR is less than 0.294,
then the two one-sided tests procedure is used to determine bioequivalence. If
sWR is greater than or equal to 0.294, then the reference-scaled procedure is used
to determine bioequivalence. The value of 0.294 is set by the FDA. Additionally,
the point estimate (test/reference geometric mean ratio) must fall within [0.80,
1.25].
Thus there are two parts to the proposed bioequivalence criteria for highly
variable drugs, the scaled average bioequivalence evaluation and a point esti-
mate constraint. The test product must pass both conditions before it is judged
bioequivalent to the reference product.
The FDA believes that the reference-scaled average bioequivalence
approach addresses many of the concerns about the bioequivalence of highly
variable drugs that have been raised for the past several years. The approach
adjusts the bioequivalence limits of highly variable drugs/products by scaling to
the within-subject variability of the reference product in the study. For drugs and
products that are highly variable, reference-scaling effectively decreases the sam-
ple size needed for demonstrating bioequivalence. The additional requirement of
a point-estimate constraint will impose a limit on the difference between the test
and reference means, thereby eliminating the potential that a test product would
enter the market based on a bioequivalence study with a large mean difference.

NARROW THERAPEUTIC INDEX DRUGS

There are no additional approval requirements for generic versions of NTI drugs
versus non-NTI drugs. The FDA does not set specific standards based on thera-
peutic index (30). The bioequivalence criteria, using the 90% confidence interval
approach, are quite strict; there is no need to apply stricter criteria for NTI drugs.
The current FDA position is that any generic product may be switched with its
corresponding reference listed drug.

FAILED BIOEQUIVALENCE STUDIES

Reasons Why Products Fail to Meet Bioequivalence Limits

There are several reasons why bioequivalence studies fail. Figure 4 shows var-
ious scenarios of bioequivalence results for several hypothetical formulations
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F1

F2

F3

F4

F5

F6

F7

0.80 1.25
T/R
FIGURE 4 Hypothetical bioequivalence study results for formulations F1 through F7 illustrate
various scenarios of passing and failing bioequivalence criteria. The width of each 90% confi-
dence interval (CI) is shown as a bar, although in actuality, the log-transformed test/reference
(T/R) ratios are distributed as a bell-shaped curve. F1 and F2 represent results of studies in
which the 90% CIs of the test/reference ratios (T/R) fall between 0.80 and 1.25 (pass bioequiv-
alence criteria). For F1, the ratio of T/R means (point estimate) is near 1.00. For F2, the point
estimate is less than 1.00, but because of low variability, the 90% CI of T/R ratios still falls within
acceptable limits. F3 through F7 show ways in which studies fail to pass CI criteria. With F3, the
point estimate is near 1.00, but because of high variability, the 90% CI is very wide and the drug
does not pass bioequivalence criteria. F3 may pass CI criteria if the number of study subjects is
increased. By contrast, F4 through F7 have variability comparable to F1. F4 represents a failure
on the low side (T is less bioavailable than R), and F5 represents a failure on the high side (R is
less bioavailable than T). Since the point estimates for F3 and F4 are still within the 0.8 to 1.25
range, these formulations may also meet CI criteria if a greater number of subjects are dosed.
F6 does not meet the upper bound of the 90% CI, and the point estimate exceeds 1.25. For F7,
the entire CI is outside the acceptance criteria (bioinequivalence). Formulations F6 and F7 are
so different from the reference that both will still fail CI criteria even if the number of subjects is
increased.

(labeled F1 through F7). For simplicity, the width of the 90% confidence inter-
val is shown as a bar, although it is important to remember that the results are
truly not an even distribution but a normal or log-normal distribution. The log-
transformed test/reference ratios from a bioequivalence study are distributed as
a bell-shaped curve, with most of the subjects’ ratios centered around the cen-
ter or mean, and fewer subjects’ ratios falling at the edges. The top bar in Fig-
ure 4 (F1) represents a study with a 90% confidence interval of the test to refer-
ence ratio falling between the limits of 0.80 to 1.25 and the test/reference ratios
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274 Davit and Conner

centered around 1.00. This is what most applicants would like to achieve with
the to-be-marketed formulation for a given product. The second bar (F2) also
represents a 90% confidence interval of test/reference ratios falling within 0.8 to
1.25. Although the mean test/reference ratio is less than 1.00, the variability is
very low with the result that this product also meets the 90% confidence inter-
val criteria. The remaining bars in Figure 4 show various scenarios of failure to
demonstrate bioequivalence. The third bar (F3) from the top depicts a situation
where the test/reference ratios are still centered around 1.00, but because of high
variability and probably inadequate sample size, the 90% confidence interval is
very wide. This example illustrates how highly variable drugs often need more
subjects to attain sufficient statistical power to pass bioequivalence criteria. It is
very likely that a new study on the same formulation would pass if more sub-
jects were enrolled, thereby increasing the power of the study and decreasing the
resulting width of the 90% confidence interval. The next two bars (F4 and F5)
show results of studies which fail to meet bioequivalence criteria, one a failure
on the low side (test product has lower bioavailability than reference product),
the other a failure on the high side (reference product has lower bioavailability
than test product). These two formulations have comparable variability to the
formulation that passed (F1), but fail because there is a difference between the
test and reference formulations. Because the ratio of means, or point estimate, is
still within the 0.80 to 1.25 limits in each of these two cases, it is also possible
that these two formulations may pass another study if many more subjects were
enrolled. The product represented by the bar that is second from the bottom (F6)
does not meet the upper bound of the 90% confidence interval, and also the point
estimate exceeds 1.25. It is likely that this product will not pass even if the power
of the study is increased by enrolling more subjects. The bottom bar (F7) repre-
sents a very extreme case in which the entire confidence interval is outside the
acceptance criteria. In this extreme case, the two products are bioinequivalent.
The two products are so different that it is highly improbable that repeat studies
would ever demonstrate bioequivalence.
In bioequivalence studies of generic products, the most common reason for
failure is that the study was underpowered with respect to the number of subjects
in the dataset. The width of the confidence interval is controlled by the number
of subjects and by the variability of the pharmacokinetic measures. Studies may
be underpowered for various reasons. The applicant may have failed to enroll an
adequate number of subjects. There may be an excessive number of withdrawals,
or there may be missing data because of lost samples. Sometimes a study may fail
because of subjects who appear to have an aberrant response on a given dosing
day (66). For example, noncompliant subjects may cause the study to fail. The
FDA discourages deletion of outlier values, particularly for nonreplicated study
designs (25).

Need to Require Submission of Failed Bioequivalence

Studies of Generic Drugs
Until recently, applicants did not include failed bioequivalence study data in
ANDA submissions. Although applicants submitting New Drug Applications
(NDAs) are required to submit data from all clinical studies to the FDA, this was
not the case for ANDAs. The Food Drug and Cosmetic Act Section 505(b)(1)(A)
states that, for NDAs, all human investigations made to show whether or not
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a drug is safe for use and whether such drug is effective must be submitted.
Similar language was not included in Section 505(j), the section covering the sub-
mission of ANDAs. Therefore, generic firms for many years interpreted this lan-
guage to mean that failed bioequivalence studies did not have to be submitted in
their ANDAs. In November of 2000, the Advisory Committee for Pharmaceutical
Science recommended that generic applicants submit to the FDA results of all
bioequivalence studies on the to-be-marketed (“final”) formulations (67). The
committee expressed the opinion that applicants should submit the results of
failed bioequivalence studies as complete summaries, further suggesting that the
FDA should do a brief, but careful examination to identify potential problems
worthy of requesting additional information.

The “All Bioequivalence Studies” Rule for Generic Drug Submissions

In 2009, the FDA published a new final rule relating to failed bioequivalence
studies, “Requirements for Submission of Bioequivalence Data” (68). The new
rule amends the Bioavailability/Bioequivalence Regulations of 21 CFR Part 320
to require an ANDA applicant to submit data from all bioequivalence studies that
an applicant conducts on a drug product formulation submitted for approval,
including studies that do not meet the specified bioequivalence criteria. The final
rule also amends portions of 21 CFR Part 314 (Applications for FDA Approval to
Market a New Drug) subpart C, “Abbreviated Applications.” All bioequivalence
studies submitted on the same drug formulation as that submitted for approval
must be submitted to the FDA as either a complete study report or a summary
report of the bioequivalence data. The term “same drug product formulation”
means the formulation of the drug product submitted for approval and any for-
mulations that have minor differences in composition or method of manufacture
from the formulation submitted for approval, but are similar enough to be rele-
vant to the agency’s determination of bioequivalence.

FDA’s Guidance on What Constitutes the “Same Drug Product”

A draft guidance for industry, Submission of Summary Bioequivalence Data for
ANDAs, is intended to assist applicants who are submitting ANDAs in com-
plying with the Requirements for Submission of Bioequivalence Data rule (69).
The guidance provides information on the types of ANDA submissions cov-
ered by the final rule; a recommended format for summary reports of bioequiv-
alence studies; and the types of formulations that FDA considers to be the same
drug product formulation for different dosage forms based on differences in
composition.

SUMMARY
Current bioequivalence methods in the United States and other countries are
designed to provide assurance of therapeutic equivalence of all generic drug
products with their innovator counterparts. The sole objective of bioequiva-
lence testing is to measure and compare formulation performance between two
or more pharmaceutically equivalent drug products. For generic drugs to be
approved in the United States, they must be pharmaceutically equivalent and
bioequivalent to be considered therapeutically equivalent and therefore approv-
able. In the United States, a mechanism for submitting ANDAs for generic prod-
ucts was initiated in 1962 and expanded by the Hatch–Waxman amendment of
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276 Davit and Conner

1984. The requirement that ANDA submissions contain information showing

that a generic drug product is bioequivalent to the innovator product is man-
dated by law, under Section 505(j) of the U.S. Federal Food, Drug, and Cosmetic
Act. Additional Federal laws, published under Title 21 of the Code of Federal
Regulations, implement Section 505(j). Part 320 of 21 CFR, the Bioavailability and
Bioequivalence Requirements, states the basis for demonstrating in vivo bioequiva-
lence, lists the types of evidence to establish bioequivalence (in descending order
of accuracy, sensitivity, and reproducibility), and provides guidelines for the con-
duct and design of an in vivo bioavailability study. The FDA publishes Guid-
ances for Industry to advise the regulated industry on how to meet the Bioavail-
ability and Bioequivalence Requirements set forth in 21 CFR Part 320. The FDA
makes every attempt to update these guidances as the need arises to ensure that
they reflect state-of-the art scientific thinking regarding the most accurate and
sensitive methods available to demonstrate bioequivalence between two prod-
ucts. Consulting with panels of experts such as Advisory Committees, participat-
ing in meetings and workshops with academia and industry (both in the United
States and abroad), and inviting public comment on draft guidances are among
the mechanisms that the FDA employs to keep guidance development current.
Current statistical criteria for determining acceptability of bioequivalence
studies in the United States and in other countries assure that the test product
is not significantly less bioavailable than the reference (usually the innovator)
product, and that the reference product is not significantly less bioavailable than
the test product. The difference for each of these two tests is 20%, with the result
that the test/reference ratios of the bioequivalence measures must fall within
the limits of 0.80 to 1.25. A generic product which does not meet these criteria
is not approved. The FDA holds that the most accurate, sensitive, and repro-
ducible method for determining bioequivalence is to measure drug concentra-
tions in blood/plasma/serum in a single-dose study using human subjects. If it
is not possible to accurately and reproducibly measure drug concentrations in
such biological fluids, other approaches may be used, such as measuring active
metabolite or measuring drug in urine. For locally active drug products with lit-
tle systemic availability, bioequivalence may be evaluated by pharmacodynamic,
clinical-endpoint, or highly specialized in vitro studies. The FDA now requires
ANDA applicants to submit results of all in vivo studies on the to-be-marketed
formulation, whether these studies meet or fail bioequivalence acceptance limits,
to identify potential problems worthy of seeking additional information.
Biowaivers are granted in some circumstances. Conditions under which
waivers may be granted are also stipulated in 21 CFR Part 320. For those drug
products which are systemically available and have demonstrated acceptable in
vivo bioequivalence, the requirement for an in vivo study may be waived for
lower strengths only if the strengths are proportionally similar and show accept-
able in vitro dissolution by a method approved by the FDA. Biowaivers may
also be granted if an applicant satisfactorily demonstrates that a drug dissolves
rapidly from the dosage form and has high intestinal permeability (BCS Class 1).
In approving a generic product, the FDA makes a judgment that it is
therapeutically equivalent to the corresponding reference product. It should be
clear that regulatory bioequivalence evaluation of generic drug products in the
United States is quite rigorous. In fact, surveys of bioequivalence data in ANDAs
approved since the enactment of the Hatch–Waxman Amendments in 1984 show
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that rate and extent of drug exposure from generic drugs differ very little from
that of their corresponding innovator counterparts (70–72). The FDA believes
that a health care provider can substitute an approved generic product for the
brand product with assurance that the two products will produce an equivalent
therapeutic effect in each patient.

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13 The World Health Organizationa,b

John Gordon
Division of Biopharmaceutics Evaluation 2, Bureau of Pharmaceutical Sciences,
Therapeutic Products Directorate, Health Canada, Ottawa, Ontario, Canada

Henrike Potthast
Federal Institute for Drugs and Medical Devices, Bonn, Germany

Matthias Stahl and Lembit Rägo

WHO Medicines Prequalification Programme, Quality Assurance and Safety of
Medicines, Essential Medicines and Pharmaceutical Policies, World Health
Organization, Geneva, Switzerland

BACKGROUND
Much progress has been achieved over the last 50 years in the field of phar-
maceuticals, both in terms of introducing new medicines and improving the
regulation of medicines. This progress involves mostly highly industrialized
countries where citizens can benefit from new innovative drugs and enjoy
access to quality assured multisource (generic) medicines as well. Lack of access
to quality essential drugs, the majority of which are multisource (generic)
medicines, remains a serious health problem and global disequilibrium of
quality continues to threaten patients in many parts of the world (1). The overall
tendency is that resource-constrained or resource-poor countries are less likely
to control the quality of products on the market, enjoy political support for the
regulators, or have properly resourced and functioning regulatory authorities
(2). It is no wonder that in many resource-poor settings patients do not trust
locally authorized multisource (generic) products.
In terms of what is required for regulatory approval of medicines it is
important to distinguish between two major groups, innovative new medicines
(new chemical entities or NCEs) and multisource (generic) medicines. To launch
an innovator product the manufacturer/applicant has to pass rigorous scientific
assessment by the competent regulatory authorities and prove its product’s qual-
ity, safety, and efficacy. The most difficult aspect of these is to prove the safety
and efficacy of the new drug since that has to be based on original preclinical

a The WHO is the directing and coordinating authority for health within the United Nations
system. It is responsible for providing leadership on global health matters, shaping the health
research agenda, setting norms and standards, articulating evidence-based policy options, pro-
viding technical support to countries and monitoring and assessing health trends.
b The views stated in this chapter reflect the views of the authors and not necessarily those of

the WHO.

282
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The World Health Organization 283

and clinical research. Multisource (generic) medicines are formulated when

patent and other exclusivity rights expire. These medicines have an important
role to play in public health as they are well known to the medical community
and are usually more affordable due to competition. The quality of a multisource
(generic) medicine must be the same as that of an originator. In the case of safety
and efficacy, no original research is carried out and reference is made to the
data for the respective innovator product. Thus, the key for using multisource
(generic) medicines is their therapeutic interchangeability with originator
products. To ensure therapeutic interchangeability, multisource products must
be pharmaceutically equivalent and proven to have the same safety and efficacy
pattern as the originator product, that is, be therapeutically interchangeable.
It should be noted that some multisource products may be pharmaceutically
equivalent but may not necessarily be therapeutically interchangeable. The
manufacture of multisource (generic) quality medicines may not be an easy task
and certainly requires the appropriate skills. To ensure that multisource (generic)
products are interchangeable and of good quality, well-resourced regulatory
authorities nowadays require that a multisource (generic) medicine must
r contain the same active ingredients as the innovator drug;
r be identical in strength, dosage form, and route of administration;
r have the same indications of use;
r be bioequivalent (as a marker for therapeutic interchangeability);
r be manufactured under the same strict standards of good manufacturing
practices (GMP) as required for innovator products.

In the case of multisource (generic) medicines, pharmacopoeial mono-

graphs are important as they discourage manufacturers from elaborating their
own specifications but rather encourage them to develop the products to meet
the requirements of pharmacopoeial standards for active pharmaceutical ingre-
dients (APIs) and finished dosage forms. Pharmacopoeial standards and the
work of the World Health Organization (WHO) in this area have been described
in-depth elsewhere (3).
It is important to point out that pharmacopoeial standards should be used
in the framework of all regulatory measures such as good manufacturing practice
inspection of active pharmaceutical ingredient and finished dosage form man-
ufacturing, scientific assessment of all quality specifications, therapeutic inter-
changeability data and labeling information provided by the manufacturer. The
greatest value of pharmacopoeial standards is revealed during postmarketing
surveillance of the quality of multisource (generic) medicines. While the use
of pharmacopoeial standards is critical to ensure the quality of pharmaceutical
products, their use cannot guarantee or predict the performance of these prod-
ucts in vivo.
In the WHO the whole area of work of regulatory standards for medicines,
including bioequivalence, is overseen by the WHO Expert Committee on
Specifications for Pharmaceutical Preparations. The WHO Expert Committee on
Specifications for Pharmaceutical Preparations is the highest level advisory body
to the WHO’s Director-General and its Member States in the area of quality
assurance. They are intended to help national and regional authorities (in
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284 Gordon et al.

particular drug regulatory authorities), procurement agencies, as well as major

international bodies and institutions, such as the global fund, and international
organizations such as UNICEF, to combat problems of substandard medicines
and underpin important initiatives, including the prequalification of medicines,
the Global Malaria Program, and Stop TB Program.
In light of the HIV/AIDS pandemic, the WHO was requested to give advice
on how to ensure the quality of antiretrovirals including fixed-dose combination
(FDC) drugs. The WHO Prequalification Program started in 2001 to assure that
medicinal products supplied for procurement meet WHO norms and standards
with respect to quality, safety, and efficacy (http://www.who.int/medicines/
and http://www.who.int/prequal). The scope was later expanded and today
product dossiers submitted to the program belong to the therapeutic areas of
HIV/AIDS, tuberculosis, malaria, reproductive health, influenza, or zinc for diar-
rhoea and usually involve multisource (generic) products. Such products need to
conform to the same standards of quality, efficacy, and safety as required of the
originator’s (comparator) product. Specifically, the multisource product should
be therapeutically equivalent and interchangeable with the comparator prod-
uct. Testing the bioequivalence between a product and a suitable comparator
in a well standardized pharmacokinetic study with a limited number of usually
healthy subjects is the most common way of demonstrating therapeutic equiva-
lence without having to perform clinical trials involving many patients to prove
safety and efficacy. The bioequivalence study therefore provides indirect evi-
dence of the efficacy and safety of a multisource drug product. It is assumed
that if the concentration patterns of two drugs in the blood of healthy volunteers
are essentially the same, then their safety and efficacy must also be essentially
the same. As mentioned earlier, for multisource drug products bioequivalence
is the only evidence required to show that the product is safe and efficacious. It
is therefore crucial that the bioequivalence study is performed in an appropriate
manner. The following describes the standards for planning, design and analysis
of a bioequivalence study as outlined in the WHO guidance documents and as
applied in the WHO Prequalification Program.

DEFINITIONS AND GENERAL CONSIDERATIONS

Bioavailability and bioequivalence contribute to the so-called biopharmaceutical
characterization of a particular medicinal product. According to Ritschel et al.
(4) the term biopharmaceutics “deals with the physical and chemical properties of
the drug substance, the dosage form, the body and the biological effectiveness
of a drug and/or drug product upon administration, i.e., the drug availability
to the human body from a given dosage form, considered as a drug delivery
system. The time course of the drug in the body and the quantifying of the drug
concentration pattern are explained by pharmacokinetics.”
Thus, the term bioavailability may be considered a link between product
quality and clinical performance as it describes the availability of the drug sub-
stance/API from the dosage form or formulation. Needless to say that should the
API not be available to the biological system following administration, the most
sophisticated dosage form would be of no therapeutic value. According to the
definition, bioavailability is the rate and extent to which an active pharmaceutical
ingredient or an active moiety is delivered from a pharmaceutical dosage form
and becomes available at the site of action. An active moiety is rarely measurable
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The World Health Organization 285

at its site of action but, since it is generally agreed that the API in the systemic
circulation is usually in some kind of equilibrium with its site of action, sys-
temic concentrations may serve to evaluate bioavailability. Accordingly, concen-
trations derived after intravenous administrations define the 100% standard, that
is, “absolute” bioavailability. Therefore, comparing systemic concentrations after
the administration of an oral dosage form to those obtained following intra-
venous administration results in “absolute bioavailability” of the oral product.
However, it is not possible to distinguish between formulation properties and its
impact on the pharmacokinetics of the API by means of investigating absolute
bioavailability. In contrast relative bioavailability is meant to be the comparison
of dosage forms other than intravenous and one of the most interesting is com-
paring an aqueous oral solution with a solid oral dosage form. The result of such
a comparison may serve to describe the formulation impact of the solid dosage
form, for example, possibly formulation-related diminished availability. Hence,
comparing bioavailability becomes basic for the assessment of bioequivalence of
systemically acting (particularly orally administered) generics [i.e., multisource
pharmaceutical drug products (MPPs)]. According to the latest WHO guidance
on the topic, Annex 7 of the Technical Series Report No. 937 (5) the term bioe-
quivalence is defined as similar bioavailabilities of pharmaceutical equivalent or
pharmaceutical alternative products in terms of peak (Cmax and Tmax ) and total
exposure (AUC) after administration of the same molar dose under the same
conditions to such a degree, that their effects can be expected to be essentially the
same. In other words, essentially similar products should be interchangeable.

APPLICABILITY AND LIMITATIONS OF THE BIOEQUIVALENCE CONCEPT

As it can be seen from the literature on this topic and according to international
guideline documents (5,6), the bioequivalence concept can be understood as a
simplified way to demonstrate the safety and efficacy of a drug product con-
taining the same quantity of a known API as in an innovator product. The basic
underlying assumption is that in the same subject an essentially similar plasma
concentration–time course will result in essentially similar concentrations at the
site(s) of action, that is, the therapeutic outcome is essentially the same. Hence,
evaluating pharmacokinetic measures may be justified as a surrogate method
instead of generating clinical/therapeutic data. Accordingly, as stated by van
Faassen et al., (7) “. . . if the fraction of the dose absorbed is the same, the human
body should always do the same with the absorbed compound—even in a
disease state, this argument is still a valid statement.” Importantly, however, the
rate of absorption must also be included as a consideration in such a statement.
Therefore, if bioequivalence has been demonstrated between a generic and
an innovator product, the clinical/toxicological properties should be valid for
both products, that is, safety and efficacy as originally proven for the innovator
product can be demonstrated for the MPP by means of (e.g., pharmacokinetic)
bioequivalence data. Hence, proof of bioequivalence allows the possibility of
seeking/granting marketing authorization without the need for further clinical
studies. The importance of meaningful bioequivalence study results is obvious
from these explanations.
It is possible that an MPP could exhibit sub- or suprabioavailability
compared to the comparator product. In such cases, the clinical/toxicological
documentation of the comparator cannot be considered valid for the generic
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286 Gordon et al.

product, but it is necessary that it be treated as a new product [see Section 6.11.2
in Ref. (5)].
Another difficulty may arise in cases when no innovator/originator prod-
uct is available for some reason. The appropriate selection of the comparator as
recommended by WHO is discussed in “Choice of Comparator Products” section
(vide infra).
For completeness it should be noted that bioequivalence testing is required
not only for new MPP applications but also in the case of major formulation
changes (variations). For modified MPPs, bioequivalence has to be demonstrated
by comparison against the designated reference comparator product. A study
comparing the modified MPP to the originally approved (unchanged) MPP is
not sufficient as this could lead to “creep” away from the connection between the
reference product and the MPP, the link upon which the evidence for the safety
and efficacy of the MPP is based. The latter comparison is an adequate option
only for innovator products (see “Modified-Release MPPs” section [vide infra]).

In Vivo Equivalence Studies

In Sections 3 and 5 of Annex 7 of the WHO Technical Report of 2006 (5), the neces-
sity to demonstrate bioequivalence of MPPs with an appropriate comparator is
generally stated. Different options to perform in vivo studies are described in
Table 1. However, pharmacokinetic measurements can usually be regarded as the
most sensitive approach for the assessment of bioequivalence. Actually, the final
decision regarding the appropriate approach to demonstrate bioequivalence has
to be taken by considering the characteristics of the particular drug substance
and drug product. This is particularly important as a positive risk assessment
(Table 3) may provide the option to demonstrate bioequivalence by a certain in
vitro approach which is discussed in “In Vitro Approaches/Biowaiver Options”
section later in the chapter.
In case in vivo equivalence studies are carried out, compliance with good
clinical practice (GCP) guidelines including proper ethical review and ethical
clearances should be ensured. Historically bioequivalence studies in healthy
volunteers were often carried out by universities and/or research institutions
having qualified staff for study design, conduct, analytical measurement, and
statistical interpretation of data. Today the majority of bioequivalence studies

TABLE 1 Options to Show Therapeutic Equivalence of MPPs

Experimental setting
Generally regarded most Comparative pharmacokinetic studies in humans –
sensitive evaluation of systemic exposure by means of
pharmacokinetic measures, for example, AUC and
C max (and T max )
Prerequisites should be Comparative in vitro tests—see BCS-based biowaiver
noted
Sensitivity not optimal Comparative pharmacodynamic studies in humans—
evaluation of relevant pharmacodynamic endpoints,
for example, lowered blood pressure in mm Hg
Rarely used for oral MPP Comparative clinical trials—evaluation of, for example,
formulations with noninferiority
systemic actions
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The World Health Organization 287

as well as most clinical research are performed by Contract Research Organiza-

tions (CROs). To facilitate proper conduct of bioequivalence studies the WHO
has issued a specific guidance “Additional Guidance for Organizations Perform-
ing In Vivo Bioequivalence Studies” (8).

Formulation-Related Biowaiver
Section 4 of the WHO Technical Report of 2006, Annex 7 (5) outlines those cases
when bioequivalence studies are not necessary due to the particular formulation
and/or site of administration and/or intended effect. Accordingly, aqueous solu-
tions intended for oral or intravenous/parenteral administration are exempted
from bioequivalence testing since no formulation effect is expected even in the
case when slightly different excipients have been used (i.e., buffer, preserva-
tive, antioxidant). Other soluble formulations (e.g., syrups, tinctures, powders
for reconstitution) except suspensions may be treated likewise.
Exemption of bioequivalence testing is also generally acceptable for phar-
maceutically equivalent products such as gases, otic or ophthalmic formula-
tions, and topical products if they are not intended to be systemically effective,
aqueous nebulizer inhalation products or aqueous-based nasal sprays. Hence,
formulation-related biowaivers may be applicable if pharmaceutical product
quality is deemed sufficient to assure therapeutic equivalence when no formu-
lation effect is expected. Notwithstanding, however, the investigative products
should contain the same API in the same molar concentration, whereas any
possible impact of difference in excipients used will have to be appropriately
addressed by the applicant (Table 2).

TABLE 2 Formulation-Related Biowaiver

Prerequisites

Biowaiver for Active moiety Excipients

Aqueous intravenous and Same molar concentration Same or similar
parenteral solutions as comparator
Pharmaceutical equivalent Same molar concentration Essentially the same
solutions for oral as comparator
use—except suspensions
Pharmaceutical equivalent Same molar concentration Same or similar
powders for reconstitution as comparator
as a solution
Gases Same molar concentration –
as comparator
Pharmaceutical equivalent Same molar concentration Essentially the same;
otic or ophthalmic as comparator preservatives, buffer,
products tonicity or thickening
agents may differ
Pharmaceutical equivalent Same molar concentration Essentially the same in
topicals as aqueous as comparator comparable
solutions concentrations
Pharmaceutical equivalent Same molar concentration Essentially the same device;
aqueous solutions for as comparator essentially the same
nebulizer inhalation or excipients in comparable
nasal sprays concentrations
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CHOICE OF COMPARATOR PRODUCTS

Once a decision has been made with regard to the type of comparisons that must
be made to establish the safety and efficacy of the proposed MPP, for example,
an in vivo bioequivalence study or in vitro comparisons for a biowaiver, it is then
necessary to identify the correct comparator product against which the proposed
MPP must be compared.
In the case of a national regulator employing WHO guidance as a basis
for the investigation and approval of MPPs, it is recommended that the inno-
vator pharmaceutical product be employed as the comparator product since its
quality, safety, and efficacy should have been established both during premar-
ket assessment and postmarket monitoring. The consistent use of the “nationally
authorized innovator” product as the designated comparator product will pro-
vide a consistent anchor for multiple MPPs in a market. A MPP (generic) product
should not be employed as the comparator product if the nationally authorized
innovator product is available, as this process could lead to “creep” away from
the product data on which the original approval was based.
Should a “nationally authorized innovator” not be available, the WHO
guidance Annex 7 (5) proposes a multistepped process for a national regulatory
authority to use to select an alternative comparator product. It is recommended
that the national drug regulatory authority select one of the following as their
comparator product in order of preference:
1. The “WHO comparator product” as described in The WHO Comparator
Product section; or
2. The innovator product currently available on the market in a well-regulated
country.
As a standard for the stringency of regulation of a “well-regulated”
national market, Annex 7 recommends the markets of members of the “Interna-
tional Conference on Harmonisation of Technical Requirements for Registration
of Pharmaceuticals for Human Use” (ICH), that is, the United States, European
Union, or Japan, or countries associated with the ICH, for example, countries
such as Switzerland or Canada.
Should it not be possible to identify a suitable innovator product via these
avenues, a comparator should be selected that has been documented to be safe
and effective based on evidence such as approval in ICH and associated coun-
tries, “prequalification” by the WHO, extensive use in clinical trials reported in
peer-reviewed scientific journals, and/or a long and unproblematic history of
postmarket surveillance. These would be rare occurrences, perhaps limited to
older medicines where the innovative product is no longer produced and the
demand for the medicine in many countries is very limited.
It is important to be aware that should a “nationally authorized innova-
tor” product not be available as the Comparator Product, products approved
on the basis of comparison to the chosen comparator product may or may not
be interchangeable with other products currently available within that particular
market. In other words, actual “generic substitution” cannot be recommended.

WHO Comparator Products

In an effort to assist national drug regulatory authorities and pharmaceutical
companies in selecting appropriate comparator products to which comparisons
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can be made as a part of the authorization process for MPPs, WHO has published
a guidance that includes a list of comparator products derived from information
collected from drug regulatory authorities and the pharmaceutical industry (6).
These “International Comparator Products” or WHO comparator products can
be selected by national authorities when a “nationally authorized innovator” is
not available. This guidance also suggests criteria, in a decision-tree format, that
can be used in the selection of a comparator product.

Selection of Comparator Products—The WHO Prequalification Program

As the prequalification program (PQ) serves a truly international purpose, the
selection of appropriate comparator products for use in comparative studies for
MPPs intended for PQ should be based on the WHO International Compara-
tor Product, as already described and identified by the WHO (7,9). However, to
serve its international purpose, not all of the recommendations made to national
authorities are applicable to the PQ project. For example, the use of a nationally
authorized innovator as comparator product would only be acceptable within
the PQ if that product is the identified WHO International Comparator Product
or, if that product is not defined explicitly, it is the innovator product available in
an ICH—or ICH-associated market.
If such a product cannot be identified, a product that was approved in the
PQ based on an evaluation of full quality documentation and full clinical trial
documentation establishing its safety and efficacy, may serve as a comparator
product (9).

Comparator Products for Fixed-Dose Combination Products

Current FDC products should not be employed as the comparator product for a
proposed FDC product unless approval of the currently available FDC product
was based on full clinical trials establishing the safety and efficacy of the prod-
uct. The use of a FDC product that was approved based on bioequivalence data
to the individual components as a comparator product for other FDCs can lead to
“creep” away from the product performance observed in the original clinical tri-
als. If an appropriate FDC comparator is not available, the individual component
products should be used as the comparator products.

IN VIVO APPROACHES
As discussed earlier, in vivo documentation of bioequivalence is especially
important for certain medicines and dosage forms, and the pharmacokinetic
bioequivalence study is considered to be the most effective and sensitive design
for achieving this purpose.
There are many issues to be considered when designing a bioequivalence
study to compare the in vivo performance of two products, however, the ultimate
goal is to design a study that minimizes the variability that is not attributable to
the formulations being compared and to eliminate any bias in the study. In gen-
eral, studies comparing product performance following a single administration
of each product, that is, single-dose bioequivalence studies, are considered to
be the most effective study designs for the purpose of comparing a MPP to a
comparator product.
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Single-Dose Bioequivalence Studies

Products to Be Compared
Multisource Pharmaceutical Product
For a bioequivalence study to be meaningful for the registration of a product
within a national authority or within the PQ, the batch of the MPP used in the
bioequivalence study (the biobatch) should be identical to the MPP proposed for
commercial market in terms of composition, quality characteristics, and methods
of manufacture, that is, it is not acceptable to employ a developmental batch of
product that differs from the final “for-market” product as the biobatch. Further,
the product units being tested should be taken from batches of industrial scale.
If it is not yet practical to produce production scale batches, the test units should
be taken from pilot scale batches that are not smaller than 10% of the planned
full production batches, or 100,000 units, whichever is larger, and were produced
using methods and equipment of manufacture that is consistent with that pro-
posed for full-scale production.

Comparator Product
The product to which the MPP will be compared in a bioequivalence study
should be determined as discussed in Choice of Comparator Products section.

Study Design
Cross-Over Versus Parallel Designs
Although there are several options to be considered, the study design of choice
for comparing a MPP to a comparator product should generally be a random-
ized, two-period, two-sequence, single-dose, cross-over bioequivalence study
conducted in healthy subjects under fasted conditions. Given that greater vari-
ability is generally observed in pharmacokinetic comparisons made between
subjects than those made repeatedly within a subject, a cross-over study design
is recommended to take advantage of the lower variability associated with intra-
subject comparisons. That is, using an intra-subject comparison to study product
performance will help minimize the variability in the data that is attributable to
factors other than the products themselves. It is recommended that the washout
period between doses in a cross-over design be at least five times the terminal
half-life of the active ingredient.

Long Half-Life Drugs

There are situations where a cross-over study design may not be feasible and a
parallel study design may be appropriate. For example, the use of a cross-over
study design may not be practical when studying products containing a drug
with a long terminal elimination half-life due to the long washout interval
that would be required between drug administrations. WHO Annex 7 (5) sug-
gests that the interval between drug administrations should not exceed three to
four weeks. Establishing bioequivalence by using inter-subject comparisons in a
parallel-design study will typically necessitate a greater number of subjects than
that required to accomplish the same goal with a cross-over study design because
of the increased variability as already mentioned.
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When designing a study, it is necessary to ensure that the duration of blood

sampling be sufficient to characterize drug absorption throughout gastrointesti-
nal (GI) transit of the drug product. Annex 7 (5) recommends that blood samples
be collected for 72 hours following drug administration, unless a shorter period
can be justified based on the pharmacokinetics of the API. It should normally be
ensured that the sampling protocol will permit the capture of 80% of the com-
plete area under the concentration–time curve, that is, AUCT /AUCI ≥ 0.8. How-
ever, for drugs possessing a long half-life, Annex 7 allows the collection of blood
samples for 72 hours as being sufficient.

Food Considerations
As mentioned earlier, one of the primary considerations in the design of a bioe-
quivalence study is minimizing the variability in the data that is attributable to
factors other than the products themselves. The presence of food in the GI tract at
the time of drug administration can introduce considerable variability into phar-
macokinetic data because of the multiple and complicated effects food can have
on both the physiology of the GI tract, the disintegration of the drug product, and
the dissolution of the API. However, although a study conducted under fasted
conditions is preferred, there are circumstances under which a study conducted
under fed conditions may be accepted. For example, if the active ingredient is
known to cause significant GI disturbance when administered under fasted con-
ditions, or if the product labelling clearly restricts administration to the fed state,
then a study conducted under fed conditions should be used to assess bioequiv-
alence. In such fed studies, the test meal selected should be designed to account
for local custom and diet, should be consumed by subjects within a 20-minute
time frame, and drug administration should follow within 30 minutes.
The bioequivalence comparison of a proposed modified-release (MR) for-
mulation is discussed in Modified-Release MPPs section but, briefly with respect
to food, the comparison of a MR formulation to the appropriate comparator
product must be investigated under both fasted and fed conditions. In such situ-
ations, the test meal employed in the fed study should be designed to challenge
the robustness of the proposed MR formulation by promoting a maximal pertur-
bation of the GI conditions relative to the fasted state, for example, a high-fat,
high-calorie meal.

Participants
(a) Number of Subjects: The number of subjects required for a successful bioe-
quivalence study should be determined based on the standards that must
be met (see Section Handling of Study Data below) and the drug products
being compared. The probability that a study of a given size will meet the
applicable standards will depend on the expected mean difference between
the test and reference formulations and variability associated with the drug
involved, that is, the anticipated intrasubject coefficient of variation for a
cross-over design.
A justification for the number of subjects enrolled in a study, which
includes a sample size calculation, should always be provided in the study
protocol. A minimum of 12 subjects is required for all studies.
(b) Subject Selection: Bioequivalence studies should normally employ healthy
volunteers. The volunteers should be standardized based on characteristics
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such as age, height, and weight. If the product under development is pro-
posed for use in both sexes, it is suggested that both male and female vol-
unteers be recruited for the study.
In situations where administration of the study drug to healthy volun-
teers is not acceptable due to its potency or toxicity, a study employing a
patient population may be necessary. Such studies will usually involve a
multiple-dose study design, as discussed below.

Bioanalytical Methods
The validity of the study conclusions depends on the reliability and reproducibil-
ity of the data collected. Therefore, all analytical methods used to measure the
active ingredient in the chosen biological fluid must be well characterized, fully
validated, and documented.
Bioanalytical methods must meet the requirements of specificity, sensi-
tivity, accuracy, precision, and reproducibility. Investigators are encouraged to
adhere to the recommendations of the Bioanalytical Method Validation Confer-
ence (10) with respect to both prestudy method validation and within-study clin-
ical sample analyses and accompanying quality control.
The analytical method, validation procedures, and acceptance/rejection
criteria must be clearly defined in the analytical protocol and associated stan-
dard operating procedures (SOPs) prior to the conduct of a study.
A dossier should include a complete Method Validation Report, copies
of all applicable SOPs, and a complete analytical report. The analytical report
should summarize the results of the analysis of the clinical study samples along
with complete details of the calibration and quality control sample analyses,
repeat analyses as per SOP, and a representative sample of chromatograms from
the study.

Monitoring of Metabolites
The purpose of a bioequivalence study is to compare the performance of two or
more products. The most sensitive approach to achieving this goal is to mon-
itor the parent compound’s disposition in the systemic circulation, that is, the
API being released from the products. Therefore, the API is the analyte of choice
for a bioequivalence study. If, employing up-to-date analytical methodologies,
the API cannot be measured accurately in the biological matrix over a suffi-
cient period of time to properly characterize a concentration–time profile, mea-
surement of the primary, therapeutically active metabolite may be justified. The
choice of analyte must be established a priori and stated in the study protocol.
Should it be found appropriate to monitor the metabolite, the study design, for
example, washout period, should be adjusted appropriately.

Handling of Study Data—Statistical Analysis

Standard pharmacokinetic analysis of the concentration–time data should be
used to generate the following pharmacokinetic parameters for each period of
data from each subject:
r area under the concentration–time curve up to the last sampling time (AUCT )
r area under the concentration–time curve extrapolated to infinity (AUCI )
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r maximal concentration observed (Cmax )

r the time following dosing that Cmax was observed (Tmax )
r elimination half-life (t1/2 ).

Statistical analysis of the concentration-dependent parameters, that is,

AUC and Cmax , should be conducted by ANOVA on log-transformed data. For
a standard cross-over study, the ANOVA model should include formulation,
period, sequence, and subject factors. On the basis of the ANOVA results, the
ratio of geometric means and 90% confidence intervals can be calculated using
generally accepted approaches (11,12).
With regard to the parameters Tmax and t1/2 , descriptive statistics should be
provided. Any statistical analysis of Tmax data should be based on nonparametric
methods applied to untransformed data.

Acceptance Ranges
(a) Area under the curve (AUC): The 90% confidence interval for the relative
mean AUCT of the test to the reference product should be within 0.80 to
1.25. If the therapeutic range is particularly narrow, the acceptance range
may need to be reduced based on a clinical justification. A larger acceptance
range may be acceptable in exceptional cases if justified clinically.
(b) Maximal Concentration (Cmax ): The 90% confidence interval for the rela-
tive mean Cmax of the test to the reference product should be within 0.80 to
1.25. As the measurement of Cmax is inherently more variable than the mea-
surement of AUC, Annex 7 (5) suggests that there are certain cases where
a wider acceptance range may be justified, for example, see “Highly Vari-
able Drugs” section later in the chapter. The range used must be defined
a priori and should be justified, taking into account safety and efficacy
considerations.
(c) Time to Maximal Concentration (Tmax ): The WHO guidances indicate that
the statistical evaluation of Tmax is necessary only if there is a clinically rele-
vant claim with respect to time of onset of action or concerns about adverse
events. In such a case, the nonparametric 90% confidence interval for the
relative Tmax measure should lie within a clinically relevant range.

Highly Variable Drugs

Highly variable drugs are defined as those drug substances that possess a high
intrasubject variability, that is, an intrasubject variability of 30% or greater in
AUC and Cmax as estimated by the intrasubject coefficient of variation from the
ANOVA from a repeated-measures study. Establishing the bioequivalence of two
products containing a highly variable drug can be problematic because the sub-
stantial variability, which is not related to the formulation per se, can cause sig-
nificant widening of calculated 90% confidence intervals. The end result is that
larger numbers of subjects are required to demonstrate the bioequivalence of
products containing a highly variable drug. Should a regulatory authority wish
to make special provision for highly variable drugs, the WHO Annex 7 (5) offers
three approaches that could be employed. An accepted approach, if any, should
be specified/defined by the regulatory authority.
The WHO PQ program will consider the widening of the acceptance range
for the 90% confidence interval on Cmax from 0.75 to 1.33 if it can be clearly
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established that the drug in question is a highly variable drug and that there are
no concentration-related concerns with regard to the safety or efficacy profiles
of the drug. A widening of the acceptance range for AUC may be considered in
exceptional circumstances if justified clinically.

Group Sequential Designs/Add-On Studies

The WHO guidelines do not provide specific advice on the use of “add-on” stud-
ies or group sequential design studies; approaches that are sometimes employed
to address situations where a large number of subjects may be required to
demonstrate bioequivalence between two products due to variability issues.
Should a manufacturer be interested in employing such a design, it is rec-
ommended that a detailed protocol including a complete description of the
proposed data handling and statistics be submitted to the relevant regulatory
authority for comment and discussion prior to undertaking such a study.

Outliers
Any statistical methods to be used for the detection of outlier data must be clearly
defined in the study protocol. The statistical recognition of data as an outlier is
not considered to be a justification for its exclusion but, an indication that a fur-
ther examination of these data is appropriate. The criteria that can be employed
to justify exclusion should be defined a priori and, if an additional examination
is undertaken to investigate outlying data, this examination must be extended to
all subjects to ensure the uniform treatment of the data.
Within-clinical setting issues, for example, significant protocol violations,
and/or physiological/medical explanations for the aberrant data, should be
sought and would be a critical element in a justification for excluding outlier data
from the main dataset. Should exclusion of the outlier data be proposed, com-
plete statistical analyses with and without the outlier data should be included as
an appendix to the study report.

Multiple-Dose Studies
Should it be found necessary to perform a steady-state, multiple-dose study,
the basic study design considerations discussed earlier would be applicable
for the dosing period during which blood samples are collected. Annex 7 (5)
describes situations where a multiple-dose study may be appropriate, for exam-
ple, a multiple-dose study in patients may be required when the API is too potent
or too toxic to be administered in healthy volunteers. Other situations in which
multiple-dose studies might be appropriate include the following:
r Drugs for which assay sensitivity is too low to adequately characterize the
concentration–time disposition profile after a single dose
r Products involving drugs that exhibit nonlinear kinetics at steady state
r MR products with a tendency to accumulate. In the latter case, the multiple-
dose study would be required in addition to single-dose studies.

Each drug product must be administered for a sufficient number of dos-

ing intervals prior to the “sample collection” interval to ensure that the patients
have attained steady state on that product. In a cross-over design, the washout
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period following the last dose of the first product can overlap with the approach
to steady state of the second product provided this period between drug admin-
istrations is sufficiently long, that is, at least three times the terminal half-life of
the API. Blood samples should be collected to establish that steady state has been
achieved.
With regard to metrics for the assessment of bioequivalence, the parame-
ters Cmax , Cmin (the minimum concentration observed in the dosing interval), the
peak-trough fluctuation (the percentage difference between Cmax and Cmin ) and
the AUC of the dosing interval being sampled (AUC␶ ) should be calculated. The
calculated Cmax and AUC parameters should meet the standards discussed ear-
lier, while the relative mean Cmin at steady state of the test to reference product
should not be less than 0.80.

FIXED-DOSE COMBINATION PRODUCTS

The general principles outlined for bioequivalence studies are also applicable
with respect to FDC MPPs [see Section 6.11.1 in Annex 7 (5)]. However, specific
questions may have to be addressed, the most important of which is to define
an appropriate comparator. As discussed in “Comparator Products for Fixed-
Dose Combination Products” section, in the event that an innovator fixed-dose
combination product is available such a product should be the reference for bioe-
quivalence testing. Reference is also made to another WHO guidance document
covering in detail particular aspects relating to the registration of FDC prod-
ucts in general (13). In other cases, only mono-component innovator products
might be available but used together in clinical practice. These mono-component
innovator products should then serve as reference for FDC MPPs together with
sound clinical data that justify the particular combinational use. Respective clin-
ical information should also be available for the summary of product charac-
teristics (SPC) of the fixed-dose combination MPP if the innovator products are
available as separate dosage forms only. In some cases it may also be necessary
to follow the rules for the choice of an acceptable reference product as outlined
earlier.

BIOEQUIVALENCE ASSESSMENT OF MPPs

Immediate-Release MPPs
As discussed above, a single-dose study under fasting conditions is generally
regarded as the most conservative and sensitive approach to assess the rate and
extent of absorption, that is, comparative bioavailability between a test and ref-
erence product. However, when the drug product should not be taken on an
empty stomach and the innovator’s SPC indicates so, it may be appropriate to
do the comparison under standardized fed conditions. Similarly in the case when
there are tolerability concerns under fasting conditions, the study may need to be
conducted under fed conditions. In general, for immediate-release MPPs steady-
state studies are only acceptable in rare cases, that is, they should be performed in
addition to single dose studies if necessary and/or possible (see “Multiple-Dose
Studies” section).
It may be possible to waive the in vivo comparison if the MPP con-
tains a drug substance that has been classified as being eligible in terms
of possible therapeutic risks, solubility and permeability according to the
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Biopharmaceutics Classification System (BCS) as outlined in “BCS-Based

Biowaiver” section.
Furthermore, comparative pharmacodynamic studies or clinical trials may
be appropriate options if the classical pharmacokinetic bioequivalence approach
is not applicable. However, pharmacodynamic and clinical approaches are gen-
erally considered less sensitive for bioequivalence testing.

Modified-Release MPPs
To evaluate the rate and extent of absorption in a most sensitive experimental
setting, single dose studies are also relevant to assess bioequivalence for MR
products. Multiple-dose studies are sometimes required in addition, particularly
if accumulation after multiple dosing is expected or if fluctuation is considered
important. In contrast to the considerations for immediate-release formulations,
the investigation of food effects is relevant for MR products as it is critical to test
the formulation-related performance of the products under fasting and fed con-
ditions, that is, to test both ends of the spectrum of conditions under which the
product may be used once approved. Testing under the range of possible GI con-
ditions is necessary to monitor for significant changes in product performance
under the varying conditions, in particular to exclude the risk of dose dumping,
that is, the unintended immediate drug release from a MR dosage form, due to
the influence of concomitant food intake. Therefore, in addition to fasting stud-
ies, pharmacokinetic bioequivalence studies conducted under fed conditions are
usually required for MR MPPs.
It should be noted that a BCS-based biowaiver is generally not acceptable
for modified-release formulations.
Comparative pharmacodynamic studies or clinical trials are alternatives
when pharmacokinetic bioequivalence studies cannot be performed, for exam-
ple, for safety and/or tolerability reasons.

IN VITRO APPROACHES/BIOWAIVER OPTIONS

BCS-Based Biowaiver
The possibility of “in vitro documentation of bioequivalence” for “certain
medicines and dosage forms” is specified in Section 9 of the WHO guidance
document (5). If the drug substance in question is highly soluble and highly per-
meable (BCS class I) and is manufactured as an immediate-release dosage form,
exemption from an in vivo pharmacokinetic bioequivalence study may be con-
sidered provided that relevant dissolution requirements are fulfilled.
The in vitro approach basically refers to the BCS. Accordingly, active phar-
maceutical ingredients are classified into classes based on their aqueous solubil-
ity and permeability characteristics (Table 3).
It should be noted that solubility is not meant to be the absolute solubility
here. In contrast, high solubility refers to the highest single unit dose to be com-
pletely soluble in 250 mL aqueous buffer medium within the pH range of 1.2 to
6.8 without any stability problems.
As another related physicochemical characteristic, high permeability
should be demonstrated for the particular API demonstrating that the fraction
of the dose absorbed amounts to at least 85%. Accordingly, high permeability
would stand for almost complete absorption of the compound in humans.
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TABLE 3 Drug Substance Classification According to the BCS

BCS classification Solubility Permeability
BCS class I High High
BCS class II Low High
BCS class III High Low
BCS class IV Low Low

Physicochemical measures needed for BCS classification purposes may

be taken from the peer-reviewed literature. The WHO Model List of Essential
Medicines has been reviewed based on the BCS concept and active compounds
are classified accordingly in WHO Technical Report No 937 of 2006, Annex 8
“Proposal to waive in vivo bioequivalence requirements for WHO Model List of
Essential Medicines immediate-release, sold oral dosage forms,” Table 1 of that
document (14).
Prior to attempting to file a BCS-based biowaiver, a theoretical risk assess-
ment is mandatory whereby risk to falsely waive a necessary in vivo study
should be minimized. As an example, narrow therapeutic index drugs are gener-
ally not eligible for the BCS-based biowaiver approach. Other reasons mentioned
in the WHO guidance (5) are outlined in Table 4 below, finally leading to perform
bioequivalence testing in vivo rather than in vitro.
In practice, some of those criteria listed in Table 4 seem to be difficult
to assess, for example, the meaning of “critical use” or “bioavailability prob-
lems,” and are probably not easily defined. However, the published literature
provides valuable examples of how to evaluate the applicability of the BCS-based
biowaiver approach (14–18).
The in vitro dissolution investigations including experimental conditions
and characteristics are outlined in Section 9 of the WHO guideline (5). It is of
utmost importance to note that it is not sufficient to demonstrate the in vitro

TABLE 4 Risk Assessment for a BCS-Based Biowaiver

Situations Where BCS-Based Biowaivers are Not Applicable
Immediate-release dosage forms with
intended systemic action Formulation-related considerations
Critical use medicines (e.g., hormones) Nonoral, Nonparenteral products with
systemic action [e.g., transdermal
therapeutic systems (TTS),
suppositories, etc.]
Narrow therapeutic range (steep MR products with systemic action
dose–response curve) drugs
Where there are documented evidence of Fixed-combination products with at least
bioavailability problems (or one API requiring an in vivo study, that is,
bioinequivalence) this API is not eligible for the BCS-based
biowaiver approach
Polymorphs, certain excipients, or a Nonsolution products with non-systemic
manufacturing process, which may have action (and without systemic
implications for bioavailability absorptiona ), for example, topical, locally
acting emulsions
a Systemic measurements might be necessary for safety reasons in some cases.
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dissolution characteristics for the particular multisource product, but to

ensure “the similarity of dissolution profiles between the test and comparator
products” (5).
The WHO guidance incorporates basic aspects of the U.S. FDA guid-
ance on the biowaiver approach (August 2000) [http://www.fda.gov/cder/
guidance/index.htm]; however, the current scientific discussions in terms of
so called “biowaiver extensions” are also considered. Accordingly, BCS-based
biowaivers may be acceptable for drugs containing BCS class 2 and 3 drug
substances manufactured as immediate-release dosage forms. As an example, a
biowaiver may be possible for BCS class 3 drug products that are “very rapidly”
(i.e., at least 85% dissolution within 15 minutes in all required media) dissolv-
ing. The relevant dissolution criteria are outlined in Section 9.2.1 of the WHO
guideline (5).

Proportionality-Based Biowaivers
Another approach to waive in vivo bioequivalence testing may be taken when
an MPP is intended for marketing in different strengths manufactured in pro-
portionally formulated dosage forms as opposed to an application for a single
strength only. It should be noted that dose proportionality is defined in two
ways according to Section 9.3.1 of the WHO guidance (5). Either exact propor-
tional composition of excipients is evident or different strengths are obtained by
altering only the amount of the API which is solely adequate for high potency
drugs. The latter case applies if the amount of API is relatively low (<10 mg per
dosage unit), the total weight of the dosage form remains nearly the same for
all strengths of the product series, the same excipients are used for all strengths
and the change in strength is obtained by altering the amount of API only (5).
Biowaivers based on dose proportionality may be considered if one in vivo bioe-
quivalence study was performed, usually on the highest dose strength of the
product series in question. Convincing comparative in vitro dissolution data are
required to link the tested biobatch of the MPP, which was proven bioequivalent
to the comparator and the additional proportional strengths.
Proportionality-based biowaivers differ from BCS-based biowaivers in that
the former approach is eligible (in principle) for immediate- and extended-
release formulations whilst the latter can be considered for specific drug sub-
stances in immediate-release oral dosage forms only.

Applicability of In Vitro–In Vivo Correlations

An in vivo–in vitro (iviv) correlation provides insight regarding the relation
between in vitro dissolution and drug input in vivo. It is only applicable if dis-
solution is the rate-limiting step for drug absorption, hence establishing such a
correlation in an early development phase is always appropriate for MR drug
products. This is because the formulation controls the API release. International
guidelines recommend level A iviv correlations (19) to be most appropriate to
waive an in vivo bioequivalence investigation as it represents a point-to-point
relationship between in vitro and in vivo dissolution, that is, the in vitro dissolu-
tion profile is predictive for the drug input in vivo. In this case the respective dis-
solution test may be used as control method with in vivo relevance. Several meth-
ods have been published (and frequently used), which describe how to calculate
correlation characteristics. While details are not discussed in the framework of
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this chapter, it should be mentioned that iviv correlations are always product
related, that is, they cannot replace bioequivalence investigations between dif-
ferent products (e.g., MPP vs. comparator) from different applicants. In contrast,
an iviv correlation established for a particular product may help to set meaning-
ful specifications and also obviate the need for bioequivalence studies for certain
postapproval changes.

CONCLUSIONS
The basic concept of bioequivalence testing has been implemented in interna-
tional guidelines for decades although requirements have become more detailed
and specific over time. In vitro approaches are nowadays considered to further
facilitate production of affordable medicines worldwide. However, meaningful
bioequivalence testing requires thorough planning and a decision regarding the
approach which may be applicable considering the specific characteristics of a
particular drug substance and/or drug product. Development of science, regu-
latory practice, and therapeutic experience will guide the way forward.

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Index

Abbreviated new drug application (ANDA), repeated-dose systemic toxicity studies,

6, 7, 232, 255, 258, 275 141, 142
Abbreviated new drug submission (ANDS), systemic toxicity studies, 140, 141
67, 90 Antiallergic aerosols, 44
Abridged application, 243, 244 Area under the curve (AUC), 83, 246–248, 293
Absolute bioavailability, 285 Argentina, regulatory requirements in, 228,
Acceptance ranges, 293 229
Active pharmaceutical ingredient (API), 1, 19, Australasia (Australia and New Zealand), 2, 3
47, 187, 292 Australasia, 17
Aerosols, 200, 201 bioequivalence requirements
Agencia Nacional de Vigilancia Sanitaria ethical review and approval processes,
(ANVISA), 47–49 22–24
ALIFAR (Asociación Latinoamericana de informed consent, 25
Industrias Farmacéuticas), 212 nasal sprays and inhalers, 41–44
Analysis of variance (ANOVA), 43, 61, 75, participant screening, 25–30
240, 260, 261, 293 participant selection, 24, 25
Animal pharmacology, 151 study design, 30–40
essential safety pharmacology, 151, topical dosage forms, 40, 41
152 history, 17, 18
follow-up studies, 152 marketing applications, 18–21
supplemental safety pharmacology Australia, 17, 18, 22
studies, 152, 153 bioequivalence requirements
good laboratory practices, 153 ethical review and approval processes,
principles, 151 23, 24
safety pharmacology studies, 153 informed consent, 25
in clinical development, 153 nasal sprays and inhalers, 41–44
specific pharmacological actions, participant screening, 25–30
151 participant selection, 24, 25
Animal toxicology, 140 study design, 30–40
principles, 140 topical dosage forms, 40, 41
allergenicity/hypersensitivity, 146 regulatory format for marketing
carcinogenicity, 148, 149 applications in, 18–21
clinical trials and marketing of new drug, Australian Guide to the Registration of Drugs
149, 150 (AGRD), 21
female reproduction and developmental Australian Register of Therapeutic Goods
toxicity studies, 143, 144 (ARTG), 17
genotoxicity, 147, 148 Australian Regulatory Guidelines for
local toxicity, 144–146 Prescription Medicines (ARGPM), 19
male fertility study, 142, 143 “Average bioequivalence”, 261

301
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302 Index

Batch size, 249, 250 PANDRH survey, 221–223

BCS-based biowaiver, 296–298 PANDRH-approved document, 223–228
Beaded capsules, 202, 203 in U.S., 254, 255
Bioanalysis documentation, 262–264
in Brazil, 57 establishment, evidences to, 264–269
in Canada, 73, 74 highly variable drugs, 271, 272
in India, 126, 127 history, 255–259
in South Africa, 191 logarithmic transformation, 260, 261
in Turkey, 249 objectives, 255
Bioavailability (BA), 50, 114, 245, 284, 285 statistical evaluation, 259, 260
Bioavailability/bioequivalence (BA/BE) Biopharmaceutics, 284
guidelines Biopharmaceutics classification system (BCS),
in Japan, 167 54, 89, 205, 270
in Taiwan, 6, 233, 237–240 Biowaiver, 11, 12, 258, 259
in United States of America, 262 in Australasia, 39, 40
investigation, 106 in European Union, 104–106
in vitro studies, in India, 133, 134 in South Africa, 201–205
regulations, 256–258 Blanching test, 184
requirements, in South Africa, 197–199 Body mass index (BMI), 247
Biobatches, 99 “Bolar provision”, 165
Bioequivalence (BE), 8, 50, 114, 245 Brazil, 3, 46, 47
Bioequivalence acceptance range, 172 bioavailability and bioequivalence
Bioequivalence studies requirements
generic products, in Japan orally administered drug products, 62, 63
bioequivalence acceptance range, 172 parenteral solutions and
decision, 168 suspensions/emulsions, 63
dissolution tests, 172–174 routes of administration, products
drug substances, measurement of, 171, intended for, 63
172 topically administered drug products, 63
guidelines, 166, 167 variations/postregistration amendment
historical background, 165, 166 requirements, 63
immediate-release oral dosage forms and generic products in
enteric-coated products, 167–171 bioavailability, 50
oral controlled-release dosage forms, 169 biopharmaceutical classification system,
orally administered drug products, in 54
India, 120 definitions and history, 47
bioanalysis, 126, 127 good manufacturing practices, 51
data analysis, 127, 128 pharmaceutical equivalency, 50, 51
pharmacodynamic studies, in humans, regulations, 47–49
124–126 relative bioavailability and
quality assurance, 132, 133 bioequivalence, 50
reference product, choice of, 127 technical regulations, evolution of,
reporting of results, 131, 132 51–54
study design, 121, 122 in vivo bioequivalence studies, waivers of
study parameters, 129–131 controlled/modified release dosage
study products, 127 forms, 64
subjects, number of, 122 immediate release drug products, 64
subjects, selection of, 122 orally administered drug products, 54
in South America, 219–221 bioanalysis, 57–60
Argentina, regulatory requirements in, blood/urine sample collection and times,
228, 229 56, 57
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Index 303

characteristics to be investigated, 57 Central Drugs Standard Control Organization

choice of reference product, 60 (CDSCO), 4, 117, 127, 134
data analysis, 60, 61 Centralized procedure (CP), 4, 95
results, reporting, 61, 62 Chiral assay, 36
study conditions standardization, 56 Choice of reference products, 89, 74, 75, 193,
study design, 54 194
study products and batch size, 63 Clinical Trial Exemption (CTX) Scheme, 24
subjects, 55, 56 Clinical Trial Notification (CTN) Scheme, 23,
Bronchodilator inhalers, 42, 43 24
Bureau of Food and Drug Analysis (BFDA), Committee for Medicinal Products for
233 Human Use (CHMP), 96
Bureau of Pharmaceutical Affairs (BPA), 6, Committee of Proprietary Medicinal Products
232, 235, 241 (CPMP), 96
Common technical document (CTD), 18, 68,
Canada, 3, 67 79, 165, 243
bioavailability and bioequivalence Comparative bioavailability studies, 89
requirements, 79 Comparator products, 9, 288
MR dosage forms, 81–83 Compulsory license, 115
orally administered drug products “Consent to Distribute”, 18
intended for systemic action, 79–84 Contract Research Organization (CRO), 114,
parenteral solutions and 244
suspensions/emulsions, 84 Controlled/modified-release dosage forms,
postregistration amendment 89, 90
requirements, 88 “Country of reference”, 220, 221
routes of administration, 86, 87 Cross-over versus parallel designs, 290
topical products, 85 Current good manufacturing practice
topically administered drug products, 84, (cGMP), 232, 233
85
in vivo bioequivalence studies, waivers of Data analysis
immediate release drug products, 88–90 in Canada, 75, 76
orally administered drug products, 69 in South Africa, 194, 195
add-on studies, 76 Decentralized procedure (DCP), 4, 95
bioanalysis, 73, 74 Delayed release oral formulations, 108
blood/plasma/serum drug Department of Health (DOH), 232, 233, 236
concentration versus time profiles, 73 Dermal toxicity study, 145
blood/urine sample collection and times, Directorate General of Health Services, 120
72 Dose-ranging study, 142
choice of reference product—C.08.001.1., “Drug Bioequivalence”, 6
74, 89 Drug, definition of, 116
data analysis, 75, 76 Drug Efficacy Study Implementation (DESI)
phenotyping/genotyping, 70, 71 notices, 256
results, reporting, 79 Drug quality surveillance program, in
single-dose studies, 76–78 Taiwan, 233
steady-state studies, 78, 79 Drug Regulatory Agencies, 114
study conditions, 71, 72 Drug Safety and Evaluation Branch (DSEB),
study design, 69, 70 21
study products and batch size, 75 Drug substances, measurement of, 171, 172
subjects/patients, 70, 71 Drugs Cosmetics Act, 114, 116
Canadian Patent Act, 68 Drugs Exhibiting Non-Linear
Canadian Reference Product, 74, 87 Pharmacokinetics, 78, 79
CDER Guidance for Industry, 7, 262 Drugs other than new drugs, 4
SPH SPH
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304 Index

Enantiomers versus racemates, 190 Generic drug review process, in Taiwan, 234
Ethics Committee, 22, 156, 157 bioequivalence review process, 236
Ethics Committee on Assisted Reproductive labeling review process, 235
Technology, 22 quality review process, 235, 236
European Medicines Agency (EMEA), 96, Generic medicines, 116–118
106 Generic substitution, 9–11
European Union (EU), 3, 4, 95, 97 Genetic phenotyping, 248
fixed combination drug products, 108, Global harmonization, 109, 110
109 Global Malaria Program, 284
global harmonization, 109, 110 Good clinical practice (GCP), 212, 286
modified release oral and transdermal Good laboratory practice (GLP), 140
dosage forms, 107 Good manufacturing practice (GMP), 19, 51,
delayed release oral formulations, 108 165, 211, 212, 232, 233
prolonged release oral formulations, 107, Group sequential designs/add-on studies, of
108 WHO, 294
transdermal drug delivery systems, 108 Guinea pig maximization test (GPMT), 146
oral immediate release dosage forms with
systemic action, 97, 98 Hatch–Waxman Amendments (1984), 258, 259
BE metrics, 101–104 Health Canada guidance, 71, 76, 79
exemptions from in vivo BE studies, Health Canada policy, 88
104–106 Health Research Council Ethics Committee
locally applied drug products, 106, 107 (HRCEC), 22
study design, 98–101 Highly variable drugs (HVDs), 34, 271, 272,
Expert Advisory Committee (EAC), 67, 68 293
Expert Advisory Committee on HPFB of Canada, 103
Bioavailability (EAB), 68 HRC Guidelines for Ethics Committee
Accreditation, 23
Failed bioequivalence studies, 272–275 Human Research Ethics Committee (HREC),
Fed bioequivalence studies, 263, 264 23
Fed/fasting studies Human skin blanching assay (HSBA), 40, 73,
in India, 123 85
in South Africa, 185, 186
FIFARMA (Federación Latinoamericana de la In vitro cytogenetic assay, 147, 148
Industria Farmacéutica), 212 In vitro–in vivo correlations, 298, 299
Fixed combination drug products, 108, 109 In vitro studies, in India, 133, 134
Fixed dose combinations (FDC), 116, 117, 198, In vivo bioequivalence studies, waivers of,
289, 295 180
Fluticasone propionate, 268 controlled/modified release dosage forms,
Food and Drug Administration (FDA), 6–8, 64
95, 254–256, 258–260264, 267, 270, 272, immediate release drug products, 64
276 In vivo cytogenetic assay, 148
Foreign bioequivalence data, acceptance of, In vivo micronucleus assay, 148
180 Immediate release drug products, 269
Foreign reference products, 193, 204 Biopharmaceutics Classification System
Formulation performance, 255 (BCS), 89
Formulation-related biowaiver, 287 controlled/modified-release dosage forms,
89, 90
General Directorate of Drug and Pharmacy different strength dosage forms, 88, 89
(GDDP), 242 Immediate-release MPPs, 295, 296
Generic Drug Advisory Committee, 260, 261 Immediate-release products, 198, 202
Generic drug products, 4, 211, 243 Import license application, 118
SPH SPH
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Index 305

India, 4, 114 drug substances, measurement of, 171,

animal pharmacology, 151–153 172
animal toxicology, 140–150 guidelines, 166, 167
bioavailability and bioequivalence studies, historical background, 165, 166
requirement of, 133, 134 immediate-release oral dosage forms and
case report form for clinical trial, 162, 163 enteric-coated products, 167–171
clinical study reports, 138–140 clinical studies, 174
clinical trials/import/manufacture of new dosage forms, 175, 177, 178
drugs, for marketing, 135–137 topical dermal use, 175–177
Ethics Committee, 156, 157 foreign bioequivalence data, 180
generic medicines, 116–118 generic product applications, 164, 165
import/manufacture new drug, 137, 138 in vivo bioequivalence studies, waivers of,
guidelines, 118–120 180
informed consent, 153–155 intravenous aqueous solutions, 180
investigator, undertaking by, 155, 156 oral controlled-release dosage forms,
new drugs, stability testing of, 158, 159 174
orally administered drug products, 120 dissolution tests, 174, 175
bioanalysis, 126, 127 reference and test products, 174
data analysis, 127–129 patent and exclusivity, 165
pharmacodynamic studies, 124–126 pharmacodynamic studies, 174
quality assurance, 132, 133 solid oral dosage forms, different strengths
reference product, choice of, 127 of, 178, 179
reporting of results, 131, 132 Japanese re-examination, 165
selection of subjects, 122–124 Joint Agency, 17
study design, 121, 122
study parameters, 129–131
Law for Control of Medicaments and
study products, 127
Pharmaceutical Firms, 232
subjects, 122
Law, in Turkish, 242, 243
pharmaceuticals, patent status on, 114, 115
Law of Pharmaceutical Affairs, 232
proposed protocol for conducting clinical
Legislative and regulatory issues, in Taiwan,
trials, 159–162
232, 233
Indian Drug Authorities, 118
Limit of quantitation (LOQ), 126, 171,
Informed consent, 153–155
188
Inhalation toxicity study, 146
Local lymph node assay (LLNA), 146
Inhalers, 42
Locally applied drug products, 106–107
Innovator/brand company, 1
Long half-life drugs, 290, 291
Innovator products, 211
Interchangeability, 9–11
International Comparator Products, 289 Maximal Concentration (Cmax ), 293
International Conference of Drug Regulatory McKenzie, 85
Authorities (ICDRA), 212 Medicines and Related Substances Control
International Conference on Harmonisation Act (MRSCA), 5, 182, 184, 194
of Technical Requirements for Medicines Classification Committee, 18
Registration of Pharmaceuticals for Medicines Control Council, 5, 182, 185
Human Use (ICH), 211, 288 Medsafe, 21
Intravenous aqueous solutions, 180 Metered dose inhaler (MDI), 85
Minister of Health, Labor, and Welfare
Japan, 4, 5, 164 (MHLW), 4, 164
bioequivalence studies Ministry of Health (MoH), 6, 242, 244
acceptance range, 172 Modified-release drug products, 198, 202–204,
dissolution tests, 172–174 270
SPH SPH
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306 Index

Modified release oral and transdermal dosage study design, 30–40

forms, 107 topical dosage forms, 40, 41
delayed release oral formulations, 108 regulatory format for marketing
prolonged release oral formulations, 107, applications in, 18, 20, 21
108 New Zealand Public Health and Disability
transdermal drug delivery systems, Act 2000, 22
108 Noninnovator products, 211
MR dosage forms, 81–83 Notice of Compliance (NOC), 68, 69
Multiple-dose studies
in Japan, 170, 171 Ocular toxicity study, 145, 146
in Taiwan, 238 Operational Standard for Ethics Committees,
of WHO, 294, 295 23
Multiple-dose studies, of WHO, 294–295 Oral controlled-release dosage forms, 169, 174
Multiregion Ethics Committee, 22 dissolution tests, 174, 175
Multisource (generic) medicines, 283 reference and test products, 174
Multisource (generic) pharmaceutical Oral conventional dosage forms and
product, 8 enteric-coated products, 168
Multisource pharmaceutical drug products Orally administered drug products
((MPPs), 285, 286, 288 in Brazil, 54–62
Mutual recognition procedure (MRP), 4, 95 in Canada, 69–79
in India, 120–133
Narrow therapeutic index (NTI) drugs, 258, in South Africa, 185–187
272 in Turkey, 245–252
Nasal sprays, 41, 42, 200, 201 Otic/ophthalmic products, 200
National Academy of Sciences/National Over the counter (OTC), 21, 34, 71, 242
Research Council (NAS/NRC), 256
National Advisory Committee on Health PAHO (Pan American Health Organization),
and Disability Support Services Ethics, 5, 6, 212
22 PANDRH (Pan American Network for Drug
National Ethics Application Form, 23 Regulatory Harmonization), 212
National Health and Medical Research and document approval, 223–228
Council (NHMRC), 23 proposal, 219
National Institute of Health Sciences (NIHS), survey, 216–218, 221–223
166 Parallel import, 115
National procedure (NP), 3 Parenteral drugs, 145
Nationally authorized innovator product, Pharmaceutical Affairs Law, in Japan, 4, 164
288 Pharmaceutical alternatives, 8
Nebulizers, 200, 201 Pharmaceutical and Medical Devices Agency
New chemical entities (NCEs), 19 (PMDA), 4, 165
New drug application (NDA), 255, 256 Pharmaceutical Benefits Schedule (PBS), 17
New Drug Submission (NDS), 67, 80 Pharmaceutical equivalence, 50, 51, 245
New drugs, 4 Pharmacodynamic studies, for generic
stability testing, 158, 159 products in Japan, 174
New Zealand, 17, 22, 23 Photoallergy/dermal phototoxicity, 145
bioequivalence requirements Plant master files (PMFs), 233–235
ethical review and approval processes, “Plasma Master File”, 19
22–24 Post-marketing safety (PMS), 233, 237
informed consent, 25 Prequalification project (PQ), 289
nasal sprays and inhalers, 41–44 Product patent system, 114, 115
participant screening, 25–30 Prolonged release oral formulations, 107, 108
participant selection, 24, 25 Proportionality-based biowaivers, 298
SPH SPH
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Index 307

Rectal tolerance test, 145 in Japan, 170, 171

Reference-listed drug (RLD), 7, 12 in South Africa, 195
Reference member state (RMS), 4 of WHO, 290–294
Reference products, 1, 9, 249 Single-dose toxicity study, 142
in South Africa, 192–194 Solid oral dosage forms
and test products, 237, 238 formulation changes, types of, 178, 179
see also Comparator products reference product, 178
Reference-scaled average bioequivalence, South Africa, 5, 182
271, 272 bioanalysis, 191
Regional Health and Disability Ethics bioavailabilty and bioequivalence
Committees, 22 requirements, 197–199
Registration Approval Committee, 242 biopharmaceutics classification system, 205
Registration of pharmaceutical products, in characteristics to be investigated, 189, 190
Americas, 216, 217 data analysis, 194, 195
active pharmaceutical ingredient, 218 historical background, 183–185
clinical data, 218 oral solid dosage forms, 201–205
final product, 218 orally administered pharmaceutical
general information about product, 217 products, 185–187
legal documentation supporting pharmacodynamic studies, 191
application, 217 pharmacokinetic parameters, 190, 191
manufacturing facilities, 217 products intended for other routes of
packaging insert, 217, 218 administration, 200, 201
preclinical data, 218 sample collection and sampling times, 188,
secondary packaging components, 217 189
Regulatory approval, of therapeutic study conditions, standardization of, 187,
equivalents, 2 188
Regulatory format for marketing study products, 192–194
applications, in Australasia, 18–21 study report, 196, 197
“Reg. Vic”, 17 topical products, 199, 200
Relative bioavailability, 50 South America and Pan American Health
Repeated-dose toxicity studies, 142 Organization, 5, 6, 211
Researched Medicines Industry Guideline bioequivalence, 219–221
(RMI), 23 Argentina, regulatory requirements in,
Resolução RDC 210, 51 228, 229
Resolution RDC 16, 50 PANDRH survey, 221–223
PANDRH-approved document, 223–228
Scale-up and postapproval changes (SUPAC), registration, 213
241 background, 213–216
Schedule Y of the Drugs and Cosmetics Act PANDRH proposal, 219
(1988), 4 PANDRH survey, 216–218
Scientific Advisory Committee (SAC), 67 Standard operating procedures (SOPs), 74,
Scientific criteria for implementing 140, 186, 292
therapeutic equivalence, 223 Standing Committee on Therapeutic Trials
Seasonal allergic rhinitis (SAR), 87 (SCOTT), 23
Secondary patenting, 115 Statistical analysis
Semantic issues, 8 in Australasia, 39
Similar product, definition of, 211 in Brazil, 60
Single-dose studies, 82 in Canada, 75, 76
in Brazil, 61 in India, 127, 128
in Canada, 76–78 in Japan, 172
in India, 128 in South Africa, 194, 195
SPH SPH
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308 Index

Statistical analysis (Continued) Topical dermal drug products, 175

in Taiwan, 240 animal test, 177
of WHO, 292, 293 clinical trial, 177
Steady-state studies dermatopharmacokinetic test, 176
in Australasia, 30, 31 in vitro efficacy test, 177
in Brazil, 61 pharmacokinetic test, 177
in Canada, 78, 79 pharmacological test, 176
in India, 128, 129 unabsorbed amount, test for measuring,
in South Africa, 195 176, 177
in Turkey, 251, 252 Topically administered drug products
United States of America, 262 in Brazil, 63
Steroid aerosols, 43 in Canada, 84, 85
Stop TB Program, 284 Total nasal symptom score (TNSS), 42, 87, 268
Stoughton, 85 Transdermal drug delivery systems (TDDS),
Strategic framework for the implementation 108
of studies for drug equivalence, 223 Trans-Tasman Joint Regulatory Authority, 2
Subsequent market-entry (SME), 81 Turkey, 6, 242
Summary of product characteristics (SPC), abridged application, 243, 244
295 bioequivalence studies, exemption from,
Suprabioavailability, 253 252, 253
European Union relations and obligations,
Taiwan, 6, 232 243
BA/BE guidelines, 236 generic drug products, 243
acceptance criteria, 240 orally administered drug products, 245
BE and data submission, assessment of, add-on studies, 252
239, 240 data analysis, 250
bioanalytical methodology, 239 generic products, applications for, 251
design and evaluation, 237–239 in vitro dissolution, 250, 251
pharmaceutical dosage forms, 240, 241 measurements of active moiety, 248
statistical analysis, 240 outliers, 252
drug quality surveillance program, 233 reference products, 249
generic drug review process, 234 results, 251
bioequivalence review process, 236 sample analysis, 249
labeling review process, 235 steady-state studies, 251, 252
quality review process, 235, 236 study design, 245–247
legislative and regulatory issues, 232, 233 subjects, 247, 248
regulation and inspection of test products, 248, 249
manufacturers, 233, 234 registration, 242, 243
variations and licence renewals, 241 suprabioavailability, 253
waiver, of in vivo BE studies, 241 trial, application and approval of, 244, 245
Tegretol CR R
, 10 “Two one-sided tests”, 103
Tegretol XR R
tablets, 10 Two one-sided tests procedure, 260, 261
Test products, 248, 249
Therapeutic equivalence Uniform Scheduling of Drugs and Poisons
in South America, 223–228 (SUSDP), 18
in Turkey, 245 United States of America, 6, 7, 254
Therapeutic Goods Act 1989, 17, 20 bioavailability and bioequivalence
Therapeutic Goods Administration (TGA), establishment
17, 21 clinical endpoints, bioequivalence
Time to Maximal Concentration (Tmax ), studies with, 268
293 FDA’s regulations, 264
SPH SPH
IHBK055-IND IHBK055-Kanfer January 21, 2010 9:56 Char Count=

Index 309

in vitro endpoints, bioequivalence immediate-release drug products, 269

studies with, 268 modified-release drug products, 270
patients, bioequivalent products narrow therapeutic index drugs, 272
response in, 269 two one-sided tests procedure, 260, 261
pharmacodynamic endpoints, United States Pharmacopeia (USP), 183
bioequivalence studies with, 266, 267
pharmacokinetic endpoints, Vaginal toxicity test, 145
bioequivalence studies with, 264–266 Vasoconstrictor assay, 85
bioequivalence, 254, 255
drug efficacy study implementation, 256 WHO comparator products, 288, 289
FDA’s bioavailability/bioequivalence WHO Model List of Essential Medicines,
regulations, development of, 256–258 287
Food, Drug, and Cosmetic Act, WHO Technical Report Series, 167
enactment of, 255, 256 World Health Organization (WHO), 7–9, 109,
objectives, 255 211, 212, 282
present-day bioequivalence bioequivalence concept, 285
requirements, 258, 259 comparator products, choice of, 288
statistical evaluation, 259, 260 fixed-dose combination products, 289
documentation formulation-related biowaiver, 287
FDA’s general recommendations, for in in vivo equivalence studies, 286, 287
vivo bioequivalence study design, 262, prequalification project (PQ), 289
263 WHO comparator products, 288, 289
fed bioequivalence studies, 263, 264 definitions and general considerations, 284,
population studying, in bioequivalence 285
studies, 264 fixed-dose combination products, 295
failed bioequivalence studies, 272–275 in vitro approaches/biowaiver options
highly variable drugs BCS-based biowaiver, 296–298
in vivo bioequivalence studies, 271 in vitro–in vivo correlations, 298, 299
reference-scaled average bioequivalence proportionality-based biowaivers, 298
approach, 271, 272 in vivo approaches, 289
in vivo bioequivalence based on in vitro multiple-dose studies, 294, 295
dissolution testing, waivers of, 269 single-dose bioequivalence studies,
biopharmaceutics classification system, 290–294
270 immediate-release MPPs, 295, 296