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Drug Safety Alert: Risk of Anaphylactic Reaction / Anaphylactic Shock with Diclofenac Sodium Injection

Asad Ullah Safety Alerts, Safety Communication, Safety Info

Drug Safety Alert

Update from Pharmacovigilance Risk Assessment Expert Committee (PRAEC) of Pakistan

Date:10th of November 2022
Target Audience:• Manufacturers and importers of Diclofenac Sodium.
• Healthcare Professionals; and
• Patients, consumers or caregiver
Problem or Issue:The National Pharmacovigilance Centre (NPC), Division of Pharmacy Services, Drug Regulatory Authority of Pakistan (DRAP) through the Provincial Pharmacovigilance Centre (PPC), Directorate of Drugs Control Punjab received two serious cases of anaphylactic reactions upon STAT dose administration of injection Diclofenac Sodium 75mg/3ml intramuscular (IM). The cases were reported by Clinical Pharmacy and Pharmacovigilance Officers (CPPOs) of two public sector hospitals in the Punjab province. The diclofenac injection was used in these cases for the wound pain in the left leg and backache. One of the patients has a history of asthma. The symptoms noted were pruritus, erythema, sweating, apprehension and fainting due to a sudden drop in blood pressure, severe shortness of breath, wheezy chest, hypoxia and hypotension. The adverse drug reactions were assessed for causality using the WHO Causality Assessment Criteria and were categorized as “Possible” and “Probable” based on plausible time to onset (same day immediately after administration), positive dechallenge (recovered on withdrawing) and unable to explain from other drugs/ disease.

The case were, therefore, discussed in the 1st meeting of the Pharmacovigilance Risk Assessment Expert Committee (PRAEC) of the NPC, DRAP which decided to update the warning, precaution & contraindication sections of the prescribing information / safety specification / label of Diclofenac Sodium injection about the occurrence of anaphylactic reaction/ anaphylactic shock and its contraindication in a patient with a history of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
Therapeutic Goods Affected:Diclofenac Sodium injection
Advice for healthcare professionals:Healthcare professionals are informed that Pharmacovigilance Risk Assessment Expert Committee of the DRAP has recommended to update the warning, precaution & contraindication sections of the prescribing information/ safety specification/ label of Diclofenac Sodium injection about the occurrence of anaphylactic reaction/ anaphylactic shock and its contraindication in a patient with a history of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs. Therefore, healthcare professionals should know that are rare chances that anaphylactic reactions may occur with diclofenac sodium injection in patients with the aspirin triad or in patients without prior exposure to diclofenac. Immediately discontinue the diclofenac injection if an anaphylactic reaction occurs. Likewise, Diclofenac is contraindicated in patients with a history of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
Advice for patients:Patients are informed that there are rare chances of the development of anaphylactic reaction/ anaphylactic shock with an injection of diclofenac sodium. Talk to your doctor if you have a history of asthma or urticaria, or if you had previously experienced an anaphylactic reaction/ allergic-type reaction with diclofenac sodium or after taking aspirin or other NSAIDs.
Guidelines for reporting Adverse Drug Reactions (ADRs):Both healthcare professionals and patients are requested to report any suspected adverse drug reaction (ADRs) with Diclofenac Sodium to National Pharmacovigilance Centre, Drug Regulatory Authority of Pakistan through Med Vigilance E-Reporting system available on DRAP website.
Similarly, ADRs can also be reported through MedSafety App that is available for download from App store (for iOS devices) and Google Play (for Android devices).
References:Minutes of 1st meeting of Pharmacovigilance Risk Assessment Expert Committee.
20-Safety-Alert-of-Anaphylactic-reaction-with-Diclofenac-Sodium.Download

Drug Impurity Alert ! Compulsory Testing of Solvents Glycerin, Propylene Glycol & Sorbitol used in Oral Preparations for Presence of any Toxic Impurities (e.g. Diethylene Glycol (DEG) & Ethylene Glycol (EG).

Asad Ullah Safety Alerts, Safety Communication, Safety Info

Drug Safety Alert

Date:21st of October 2022.
Target Audience:• Regulatory Field Force
• Manufacturers of Glycerin containing formulations to control level of Diethylene glycol and Ethylene glycol
• Healthcare Professionals- Physicians, Pharmacists, and Nurses
• General Public
Problem or Issue:Glycerin, Sorbitol & Propylene glycol are widely used in therapeutic goods as solvents. However, recently there has been report in international media related to the adulteration of these materials with highly toxic Diethylene Glycol (DEG) and Ethylene Glycol(EG). These impurities, DEG and EG are poisonous and may lead to severe health injury or death, as recently reported in Gambia, and also being associated with the incident happened in Indonesia due to consumption of syrups containing glycerin. These reports warrant an emergent need of extraordinary measures and vigilant monitoring of these possible contaminants.
Potential Hazards linked to DEG and EG:Toxic effects can include abdominal pain, diarrhea, inability to pass urine, headache, altered mental state, vomiting and acute kidney injury which may lead to death especially in children
Advice for healthcare professionals:DRAP requests increased vigilance within the supply chains of institutions/pharmacies/healthcare facilities to detect any substandard / falsified product in the market. Adverse reactions or quality problems experienced with the use of any product shall be reported to the National Pharmacovigilance Centre(NPC), DRAP using Adverse Event Reporting Form or online through this link.  Further information of reporting problems to DRAP is available on this link.
Advice for Manufacturer’s and Importers of Products containing Glycerin Solvent:Perform test/analysis of for presence of any toxic impurity/contaminants specially when used in oral dosage forms such as syrups/suspensions etc. It is legal responsibility of all manufacturers of therapeutic goods to ensure before marketing that all the manufactured therapeutic goods are safe for consumption. Therefore, it is required that all manufacturers using these solvents must perform proper testing to detect DEG and EG contamination
Advice for General Public: All therapeutic goods must be obtained from the licensed pharmacies, and other authorized retail outlets. The authenticity and condition of products should be carefully checked. Seek advice from your pharmacists or other healthcare professional in case of any doubt.
Guidelines for reporting Adverse Drug Reactions (ADRs):Both healthcare professionals and patients are requested to report any adverse events they have experienced to National Pharmacovigilance Centre, Drug Regulatory Authority of Pakistan through DRAP Med Vigilance E-reporting system or at npc∂dra.gov.pk.

Similarly, adverse events can also be reported through Med Safety Mobile Application that is available for download from the App store (For iOS devices) and Google Play (For Android devices).
References:

DRAP has issued alerting note to all relevant stakeholders for taking effective measures in this regard.

Important-Drugs-Impurity-Alert-21-oct-2022Download

WHO Global Alert on Contaminated Pediatrics Cough Syrups Identified In Gambia-West Africa

Asad Ullah Safety Alerts

Drug Safety Alert

Update from WHO  Global Surveillance and Monitoring System

Date:12th of October 2022.
Target Audience:• Healthcare Professionals- Physicians, Pharmacists, and Nurses.
• Manufacturers and Importers of Glycerin containing formulations to control level of Diethylene glycol and Ethylene glycol
• General Public
Problem or Issue:World Health Organization (WHO) has issued Medical Product Alert No. N°6/2022 dated 05th October 2022 which refers to four substandard products, identified in Gambia. These four products are Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup. Laboratory analysis of samples of each of the four products confirm that they contain unacceptable amounts of diethylene glycol and ethylene glycol as contaminants.
DRAP has never authorized sale of any products from Maiden Pharmaceuticals Limited (Haryana, India) and these four products referred in WHO medical product alert are neither registered nor available on Pakistan market, however these may have been carried for personal use while visiting other countries. Please do not use any of these products as these are substandard products and their use may result in serious injury.  
Potential Hazards linked to DEG and EG:Toxic effects can include abdominal pain, diarrhea, inability to pass urine, headache, altered mental state, vomiting and acute kidney injury which may lead to death especially in children
Advice for healthcare professionals:DRAP requests increased vigilance within the supply chains of institutions/pharmacies/healthcare facilities to detect any substandard / falsified product in the market. Adverse reactions or quality problems experienced with the use of any product shall be reported to the National Pharmacovigilance Centre(NPC), DRAP using Adverse Event Reporting Form or online through this link.  Further information of reporting problems to DRAP is available on this link.
Advice for Manufacturer’s and Importers of Products containing Glycerin Solvent:Unacceptable amounts of Diethylene glycol (DEG) and Ethylene glycol (EG) as contaminants may lead to severe injury or death. You are therefore advised to strictly follow the pharmacopoeia guidelines for excipients and ensure testing of all those products where diethylene glycol and ethylene glycol can appear as impurity, to ensure specifications limits are being comply for all those products where glycerin is used especially cough syrups and other oral products.
Advice for General Public: All therapeutic goods must be obtained from the licensed pharmacies, and other authorized retail outlets. The authenticity and condition of products should be carefully checked. Seek advice from your pharmacists or other healthcare professional in case of any doubt.
Guidelines for reporting Adverse Drug Reactions (ADRs):Both healthcare professionals and patients are requested to report any adverse events they have experienced to the National Pharmacovigilance Centre, Drug Regulatory Authority of Pakistan through DRAP Med Vigilance E-reporting system or at npc∂dra.gov.pk.

Similarly, adverse events can also be reported through Med Safety Mobile Application that is available for download from the App store (For iOS devices) and Google Play (For Android devices).
References: Medical Product Alert No. N°6/2022
DRAP response on WHO-Global-Alert-on-Contaminated-Cough-SyrupsDownload

Suspension of Drug Registration: Famotidine Liquid Suspension in the Strengths of 10mg/5mL and 40mg/mL

Asad Ullah Safety Alerts

Drug Safety Alert

Update from Registration Board of Drugs

Date:15th of June 2022.
Target Audience:• Provincial Drugs Control Units and Provincial Pharmacovigilance Centres.
• Manufacturer/registration holders of Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension;
• Healthcare Professionals; and
• Patients, consumers or caregivers.
Problem or Issue:The Registration Board of Drug Regulatory Authority of Pakistan (DRAP) in its 317th meeting held on 16-17th of May 2022 in light of discussions, benefit-risk analysis and public health impact suspended all drug registrations of Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension under Section 7(11)(d) read with Section 42 of the Drugs Act, 1976 in the larger public interest, with immediate effect as these products were neither approved by any Reference Regulatory Authorities nor efficacy data is available with any registration holder. These products will stay suspended for a period of one (01) year; or till the time its efficacy is well established through indigenous clinical trials in accordance with the Bio Study Rules, 2017; or if it is approved by the Reference Regulatory Authorities, whichever is earlier. Likewise, Registration holders were directed to suspend the manufacturing and import of these drug products immediately and to withdraw available stocks from the market in the larger public interest. The decision applies to all registration holders of Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension except those who have obtained interim relief from the Hon’ble Lahore High Court, Lahore or who have registration of Famotidine 40mg/5ml Dry Suspension.
Background:
The Registration Board in its 250th meeting held on 10th July, 2015 had decided that Famotidine 10mg/5ml Suspension is not registered in any reference regulatory agencies and the internationally available formulation is a dry powder for suspension in the strength of 40 mg/ 5 ml and asked applicants to revise their formulation as per innovator (new registration application With complete fee) within six months if the manufacturing facility is approved by Central Licensing Board.

However, DRAP’s Authority in its 70th meeting held on 05th Sep 2019 decided that “For formulations containing “drugs” which were previously registered by the Registration Board and have proof of availability and prescription of last 10 years but are not available in the Reference Regulatory Authorities shall continue to be considered/ registered as drugs until and unless withdrawn on Safety, Efficacy and Quality reasons”.

Accordingly, Registration Board in its 296th meeting held 8th-10th Sep, 2020 decided that “since all such formulations which are not approved by the Reference Regulatory Authorities; the safety and efficacy profile cannot be established in the absence of a well-established system for reporting of adverse events, so a reference shall be forwarded to DRAP’s Authority with the request to review the decision taken in its 70th meeting held on 05-09-2019. In this regard, PE&R Division shall prepare a comprehensive document/agenda for consideration of Authority”. It was also decided that “For all those formulations which are registered/ applied in strengths, different from those approved by reference regulatory authorities, the registration holders/ applicants shall standardize their formulations (by submitting registration application with requisite fee, provided that the firm did not have same registration) in line with those approved by reference regulatory authorities. Meanwhile, the policy of reliance on reference regulatory authorities was approved by the Authority in its 73rd meeting held on 06-11-2019. Subsequently, the registration board in its 313th meetings, dated 16-18th Nov, 2021 decided to issue show-cause notices to registration holders/ manufacturers under Section 7 (11)(d) of the Drug Act, 1976 and opportunity of personal hearings. The decision of the Registration Board was endorsed by Authority in its 128th meeting of Authority held on 14th Dec 2021 and decided that “Drug formulations/strengths which were previously registered by the Registration Board but are not available in any Reference Regulatory Authorities, shall be reviewed and disposed-off keeping in view of safety and efficacy evidence/data in the Reference Regulatory Authorities”.

In line with the decision taken by the Board in its 313th meeting, show-cause/personal hearing notices were issued to registration holders for hearing before the Registration Board on 1st February, 2022 at 2:30 pm. However, due to prevailing cases of COVID-19, personal hearings were postponed. Many of registration holders of Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension challenged the Show Cause Notices issued for cancellation of their drugs stating violation of the decision taken in the 70th Meeting of the DRAP Authority held on the 05-09-2019. However, the decision taken in the 70th Meeting of the DRAP Authority has been reviewed in the 128th Meeting held on 14-12-2021, whereby the Registration Board was allowed to review and dispose of the registration of drugs keeping in view their safety and efficacy. The Registration Board in its 315th meeting held on 1st Feb 2022 noted the information and advised to provide the opportunity of a personal hearing in the next meeting of the Registration Board.

Lastly, the Registration Board in its 317 meetings held on 16-17th May, 2022 gave an opportunity of a personal hearing and after reviewing the discussion of personal hearing, risk-benefit analysis and public health impact suspended all drug registrations of Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension under Section 7(11)(d) read with Section 42 of the Drugs Act, 1976 in the larger public interest, with immediate effect, for 1 year or earlier subject to some conditions, as Famotidine Suspensions in strength/ dosage form other than 40mg/5ml Powder for Oral Suspension are neither approved by any Reference Regulatory Authorities nor efficacy data is available with any registration holder.
Therapeutic Goods Affected:Famotidine 10mg/5ml & 40mg/5ml Liquid Suspension (not Famotidine 40mg/5ml Dry Suspension)
Famotidine is used in gastric and duodenal ulcers, Zollinger-Ellison Syndrom, Gastro-Eesophgeal disease, heart burns, and indigestion. Whereas, in children, it is used for peptic ulcers and gastro oesophagal disease.
Advice for healthcare professionals:Healthcare professionals are informed that the Registration Board of Drug Regulatory Authority of Pakistan (DRAP) in its 317th meeting held on 16-17th of May 2022 in light of discussions, benefit-risk analysis and public health impact suspended all drug registrations of Famotidine 10mg/5ml and 40mg/5ml Liquid Suspensions under Section 7(11)(d) read with Section 42 of the Drugs Act, 1976 in the larger public interest, with immediate effect as these products were neither approved by any Reference Regulatory Authorities nor efficacy data is available with any registration holder. Healthcare professionals may stop prescribing Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension to patients. Famotidine 40mg/5ml Dry Suspension or other treatment options available in the market may be prescribed.
Advice for patients:Patients and consumers are informed that the Registration Board of Drug Regulatory Authority of Pakistan (DRAP) in its 317th meeting held on 16-17th of May 2022 in light of discussions, benefit-risk analysis and public health impact suspended all drug registrations of Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension under Section 7(11)(d) read with Section 42 of the Drugs Act, 1976, therefore, patients who are using the above-mentioned Famotidine suspensions may consult/speak with their healthcare professionals to shift/change their treatment to Famotidine 40mg/5ml Dry Suspension or other treatment options available in the market.
Guidelines for reporting Adverse Drug Reactions (ADRs):Both healthcare professionals and patients are requested to report any adverse events they have experienced with their previous treatment with Famotidine 10mg/5ml and 40mg/5ml Liquid Suspension or even with Famotidine 40mg/5ml Dry Suspension to the National Pharmacovigilance Centre, Drug Regulatory Authority of Pakistan through DRAP Med Vigilance E-reporting system or at npc∂dra.gov.pk.

Similarly, adverse events can also be reported through Med Safety Mobile Application that is available for download from the App store (For iOS devices) and Google Play (For Android devices).
References:Partial Minutes of 317th Meeting of Registration Board.
Safety Alerts: Suspension of Registrations of Famotidine 10mg5ml and-40mg5ml Liquid SuspensionDownload

Suspension of Drug Registration: Tablets of Diclofenac Potassium in Strengths of 75mg and 100mg

Asad Ullah Safety Alerts

Drug Safety Alert

Update from Registration Board of Drugs

Date:15th of June 2022.
Target Audience:• Provincial Drugs Control Units and Provincial Pharmacovigilance Centres.
• Manufacturers and Importers of Diclofenac Potassium 75mg and 100mg;
• Healthcare Professionals; and
• Patients, consumers or caregivers.
Problem or Issue:The Registration Board of Drug Regulatory Authority of Pakistan (DRAP) in its 317th meeting held on 16-17th of May 2022 in light of discussions, risk-benefit analysis and public health impact, suspend all drug registrations of Diclofenac Potassium 75mg and 100mg under Section 7 (11) (d) read with Section 42 of the Drugs Act, 1976 due to the reason that these formulations are neither approved by any Reference Regulatory Authority nor any safety and efficacy data regarding these products is available with any registration holder. These formulations will stay suspended for a period of one (01) year; or if safety and efficacy is well established through indigenous clinical trials in accordance with the Bio Study Rules, 2017; or if it is approved by the Reference Regulatory Authorities, whichever is earlier. Likewise, Registration holders were directed to suspend the manufacturing and import of these drug products immediately and to withdraw available stocks from the market in the larger public interest. The decision applies to all registration holders of Diclofenac Potassium 75mg and 100mg except those who have obtained interim relief from the Hon’ble Lahore High Court, Lahore.
Background:The Registration Board in its 258th meeting held on 25th and 26th April, 2016 had decided that Diclofenac Potassium is not registered in any reference country in doses more than 50mg, thus decided to issue show-cause notices to manufacturers of Diclofenac Potassium (75 and 100mg) for de-registration of these products. Subsequently, the registration board in its 288th meeting, dated 14-15th Feb 2019, decided that all registration holders of Diclofenac Potassium 75mg & 100mg shall be called for personal hearings. However, DRAP’s Authority in its 70th meeting heldon 05th Sep 2019 decided that “For formulations containing “drugs” which were previously registered by the Registration Board and have proof of availability and prescription of last 10 years but are not available in the Reference Regulatory Authorities shall continue to be considered/ registered as drugs until and unless withdrawn on Safety, Efficacy and Quality reasons”.

Accordingly, Registration Board in its 296th meeting held on 8-10th Sep, 2020 decided that “Since, all such formulations which are not approved by the Reference Regulatory Authorities; the safety and efficacy profile cannot be established in the absence of a well-established system for reporting of adverse events, so a reference shall be forwarded to DRAP’s Authority with the request to review the decision taken in its 70th meeting held on 05-09-2019. In this regard, PE&R Division shall prepare a comprehensive document/agenda for consideration of Authority, keeping in view the practices adopted by RRA for all such formulations.”

Meanwhile, the policy of reliance on reference regulatory authorities was approved by the Authority in its 73rd meeting held on 06-11-2019. Subsequently, the registration board in its 313th meetings, dated 16-18th Nov, 2021 decided to issue show causes to registration holders/ manufacturers under Section 7 (11)(d) of the Drug Act, 1976 and opportunity of personal hearings. The decision of the Registration Board was endorsed by Authority in its 128th meeting of Authority held on 14th Dec 2021 and decided that “Drug formulations/strengths which were previously registered by the Registration Board but are not available in any Reference Regulatory Authorities, shall be reviewed and disposed-off keeping in view of safety and efficacy evidence/data in the Reference Regulatory Authorities.”

Many of registration holders of Diclofenac Potassium 75mg and 100mg challenged the Show Cause Notices issued for cancellation of their drugs stating violation of the decision taken in 70th Meeting of the DRAP Authority held on the 05-09-2019. However, the decision taken in the 70th Meeting of the DRAP Authority has been reviewed in the 128th Meeting held on 14-12-2021, whereby the Registration Board was allowed to review and dispose of the registration of drugs keeping in view their safety and efficacy. The Registration Board in its 315th meeting held on 1st Feb 2022 noted the information and advised to provide the opportunity of a personal hearing in the next meeting of the Registration Board.

Meanwhile, the Pharmaceutical Evaluation and Registration Division of the DRAP reviewed all the available facts and finding along with the product monograph of diclofenac potassium in stringent regulatory authorities which depicts that the daily dose of diclofenac potassium is from 75- to 200mg in divided doses, whereas the maximum strength of available diclofenac potassium tablet is 50mg. The Division also prepared two questions that were communicated for guidance to various RRA’s including USFDA, Health Canada, MHRA UK, Sweden, TGA Australia and BNF.

Lastly, the registration board in its meeting 317th meeting dated 16th to 17th May, 2022 after giving personal hearings to registration holders of diclofenac potassium 75-100mg, discussion during the meeting, risk-benefit analysis and public health impact of the Diclofenac Potassium 75mg and 100mg, decided to suspend drug registrations of Diclofenac Potassium 75mg and 100mg under Section 7 (11) (d) read with Section 42 of the Drugs Act, 1976 in the larger public interest for 1 year or earlier subject to some conditions.
Therapeutic Goods Affected:Diclofenac Potassium 75MG and 100MG (Not 50mg or below)

Diclofenac potassium is used in divided doses for treatment of pain or primary dysmenorrhea; relief of osteoarthritis, relief of rheumatoid arthritis etc. It is approved by various reference regulatory authorities in 12.5mg, 25mg and 50mg tablet strengths. A daily dose of diclofenac potassium is from 75-200mg in divided doses, whereas the maximum strength of available diclofenac potassium tablet is 50mg. However, in Pakistan, as per the PER Division, it was also approved in the strength of 75 and 100mg.
Advice for healthcare professionals:Healthcare professionals are informed that the Registration Board of Drug Regulatory Authority of Pakistan (DRAP) in its 317th meeting held on 16-17th of May 2022 in light of discussions, risk-benefit analysis and public health impact suspended all drug registrations of Diclofenac Potassium 75mg and 100mg under Section 7 (11) (d) read with Section 42 of the Drugs Act, 1976 due to the reason that these formulations are neither approved by any Reference Regulatory Authority nor any safety and efficacy data regarding these products is available. Healthcare professionals may stop prescribing diclofenac potassium having a strength of 75mg and 100mg to patients. Diclofenac Potassium in the strength of 50mg may be prescribed to the patient instead of Diclofenac Potassium of 75mg and 100mg.
Advice for patients:Patients and consumers are informed that the Registration Board of Drug Regulatory Authority of Pakistan (DRAP) in its 317th meeting held on 16-17th of May 2022 in light of discussions, risk-benefit analysis and public health impact suspended all drug registrations of Diclofenac Potassium 75mg and 100mg, therefore, those patients who are using diclofenac potassium in the aforementioned strengths may consult/ speak with their healthcare professionals to shift/change their treatment to standard strength of 50mg of diclofenac potassium or other treatment options available in the market.
Guidelines for reporting Adverse Drug Reactions (ADRs):Both healthcare professionals and patients are requested to report any adverse events they have experienced with Diclofenac Potassium (75mg, 100mg or even 50mg & below) to the National Pharmacovigilance Centre, Drug Regulatory Authority of Pakistan through DRAP Med Vigilance E-reporting system or at npc∂dra.gov.pk
Similarly, adverse events can also be reported through Med Safety Mobile Application that is available for download from the App store (For iOS devices) and Google Play (For Android devices).
References:Partial Minutes of 317th Meeting of Registration Board.
Safety Alert-Suspended Drug Registration of Diclofenac Potassium 75mg and 100mg (PDF)Download