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Center for Drug Evaluation and Research
Pharmacy Compounding Advisory Committee
May 7, 1999
Advisory Committee Conference Room, 1066
Food and Drug Administration
5630 Fishers Lane
Rockville, Maryland 20852
CASET Associates, Ltd.
10201 Lee Highway, Suite 160
Fairfax, Virginia 22030
Randy P. Juhl, Ph.D., Chair
Igor Cerny, Pharm.D.
Judith Martin Riffee, R.Ph.
William J. Rodriguez, M.D., Ph.D.Tony Welder, R.Ph.
Loyd V. Allen, Jr.,, Ph.D.
Carmen A. Catizone, M.S., R.Ph.
Elizabeth I. McBurney, M.D.
Sarah L. Sellers, Pharm.D.
Garnet E. Peck, Ph.D.
Christopher T. Rhodes, Ph.D.
William J. Rusho, R.Ph.
Lawrence Trissel, F.A.S.H.P.
Rose-Ellen M. Hope R.Ph.
Industry Representative (non-voting):
David Liebman, R.Ph.
Industry Representative (non-voting):
Joan M. LaFollette, R.Ph.
Consultants to the Committee (Voting):
Kenneth B. Giddes, B.A., M.B.A. (Patient Representative) (Voting on hydrazine only)
Guest Experts of the Committee (Non-voting):
Sid Gilman, M.D.
Janice Dutcher, M.D.
E. William Rosenberg, M.D.
Christopher T. Bever, Jr., M.D.
Donald Sanders, M.D.
Andrew R. Blight, Ph.D.
Ronald Cohen, M.D.
Sharon Hamm, Pharm.D.
Dr. David Jacobus
TABLE OF CONTENTS
Call to Order 1
Dr. Randy Juhl
Mild Silver Protein 2
Dr. Wiley Chambers
Open Public Hearing 12
Discussion and Vote on Mild Silver Protein 21
Monosodium Aspartate 22
Dr. Norman Stockbridge
Open Public Hearing 32
Discussion and Vote on Monosodium Aspartate 36
Dr. John Feeney
Open Public Hearing 53
Discussion and Vote on Cyclandelate 55
Betahistine Dihydrochloride 56
Dr. John Feeney
Open Public Hearing 62
Discussion and Vote on Betahistine Dihydrochloride 62
Dr. Saul Malozowski 65
Dr. Charles L. Loprinzi (via video tape) 72
Ms. Mary McCabe 84
Discussion and Vote on Hydrazine Sulfate 93
P R O C E E D I N G S [8:30 a.m.]
Agenda Item: Call to Order
DR. JUHL: We will begin. Welcome to day two of the Pharmacy Advisory Committee -- Pharmacy Compounding Advisory Committee. We will continue on today with a review of drug products or drugs that have been nominated for inclusion on the pharmacy compounding bulks list.
I think we will go around the table and have everyone introduce themselves. We have a few new faces at the table. So, if we can start, Judy, with you.
MS. RIFFEE: Good morning. I am Judy Riffee. I am faculty, College of Nursing, University of Florida.
MS. LA FOLLETTE: Joan LaFollette, Bristol-Myers Squibb.
DR. SELLERS: Sarah Sellers, pharmacist, North Carolina.
MR. CATIZONE: Carmen Catizone, representing National Association of Boards of Pharmacy.
MS. HOPE: Rose-Ellen Hope, consumer rep.
MR. RUSHO: William Rusho, University of Utah.
MR. TRISSEL: Lawrence Trissel, the University of Texas, M.D. Anderson Cancer Center.
DR. JUHL: Randy Juhl, University of Pittsburgh, School of Pharmacy.
DR. CERNY: I am Igor Cerny, executive secretary.
DR. MC BURNEY: Elizabeth McBurney, dermatologist from Louisiana.
DR. RODRIGUEZ: Bill Rodriguez from Children's Hospital, National Medical Center in Washington, D.C. and George Washington University.
DR. ALLEN: Loyd Allen, International Journal of Pharmaceutical Compounding, the USP representative.
MS. OGRAM: Lana Ogram, co-chair, FDA.
DR. CHAMBERS: Wiley Chambers, deputy director, Division of Anti-Inflammatory, Analgesic and Ophthalmic Drug Products.
MS. AXELRAD: Jane Axelrad, associate director for policy in the Center for Drugs and co-chair of the Pharmacy Compounding Steering Committee.
DR. BEHRMAN: Rachel Behrman, deputy director, Office of Drug Evaluation 1.
DR. JUHL: Thank you.
Agenda Item: Mild Silver Protein
Our first drug this morning is mild silver protein. And Dr. Chambers will give a presentation on behalf of the Agency.
DR. CHAMBERS: Good morning.
My name is Wiley Chambers. I am an ophthalmologist with the Division of Anti-Inflammatory, Analgesics and Ophthalmic Drug Products. I am going to talk about mild silver protein.
Mild silver protein has been marketed in the past. It was developed prior to 1938 so that it came into effect or it was used prior to the enactment of the Food, Drug and Cosmetic Act of 1938. It was marketed under the names Argyrol and Protargol and came in a variety of different formulations, including formulations that were marketed as OTC products in a 10 percent solution, both in 15 and 30 ml containers, an Rx product that was 20 percent solution marketed with EDTA in a 1 milliliter dropperette.
While it was being marketed, and to my knowledge it is not currently marketed, it was marketed by Cooper Laboratories and when Cooper Laboratories sold all their products to IOLAB, IOLAB continued to market it for a period of time until IOLAB stopped marketing products and the product was not picked up following the marketing by IOLAB.
The indications that it was marketed under included the treatment of eye infections, preoperatively for eye surgery and as a dye as part of the preop surgical procedure.
There is no question it has been well-known that silver ion is perfectly capable of killing microorganisms. It is also perfectly capable of killing cells and tissues. It was, therefore, considered to be a useful anti-infective agent as long as it was possible to kill the microorganisms without damaging the surrounding tissue.
One of the ways to make it a little bit safer so that it would not damage any of the surrounding tissue was to bind it in a protein complex and that was what the creation of mild silver protein was, was a binding of the silver ion in a mild -- in a protein complex. This made it less harmful to tissues, but, unfortunately, also made it less effective.
It has been studied in a number of different ways, including back in 1937, this slide shows a comparison of the concentration in the number of organisms surviving. Obviously, the fewer the number of organisms surviving, the more effective the product is. And this is a comparison of a number of different products that were available in 1937.
As can be seen on this slide, Argyrol was not one of the more affective products even in 1937. It was used fairly widely during that period of time and because it was continuing to be used, additional studies were done at different points in time. In 1986, another comparison was published in the literature with a variety of different products. Again, the lower the number, the better off it is. And as you can see, mild silver protein with an MIC90 at 200 is far less effective than even thiomersal.
There are also clinical studies in which the product has been evaluated, published in the Archives of Ophthalmology was a comparison between an untreated eye and using mild silver protein, both before irrigating and after irrigating. As you can see, the results are very similar between untreated and treated and, in fact, if you do the wash afterward to wash the mild silver protein out, either in the controlled or uncontrolled, you increase the number of organisms that are found in the eye.
A number of investigators looking back in the literature did not understand why they were continuing to use mild silver protein at their institution and people in New York decided to put together a trial to find out what the true incidence was of endophthalmitis, which is the particular disease that they were trying to prevent.
Endophthalmitis is what destroys eyes. So, it is why we use prophylactic antimicrobials prior to surgery. They looked at a comparison between povidone-iodine, which was being touted as a product that potentially should be used and silver protein, which was the standard at the time.
As you can see, the percentage of positive endophthalmitis cases was considerably lower when using povidone-iodine than it was with silver protein. From the side effect perspective -- this doesn't project, I think, quite as well as the handout did but there is the possibility of silver staining even with a single administration, although it is not particularly common to occur with a single administration of this. It is much more common after repeated administrations.
But as you can see in this picture, the slight gray, bluish gray area in the conjunctiva is the result of repeated administration of mild silver protein. This also does not project as well as the handout, but there is depositing in the lacrimal sac and that will trace then through the skin of a grayish area.
If you look on a slit lamp and look at the cornea itself, you can detect the deposition of the silver protein in the cornea. And if you look on electromicroscopy, look at the basement membrane, you can see the thick black line that is along there is not a normal process. That thick black line is the deposition of silver protein.
This is not the first time that this product has been reviewed. As was discussed a couple of different times, the agency does not frequently completely rule out products at any point in time. We do periodically relook at products and that is what is being done here. There was an OTC review of this product between 1973 and 1979. At that time, the external OTC panel reviewed the data that was available. Some of the slides that I presented were presented at that time and the authors at that time had given me permission to go in and reuse those articles.
From a safety perspective, the panel concluded that there were not toxicity concerns as an OTC product, provided that everybody was warned of the potential deposition of silver. The efficacy to the best that they were able to determine was not supported in any way and they looked and were unable to find any data to support the efficacy. So, the overall conclusion was that it might be useful but it requires clinical studies to show that it was useful.
The literature review that I have done, as well as reviewing the Agency files have not found anything since this time to support the efficacy.
There are a number of alternatives that have been developed and this is a partial list of a number of the anti-infectives that are all currently approved and are available to treat the same types of infections that mild silver protein was originally developed for.
Goodman and Gilman provided a summary of the efficacy and safety that they determined for mild silver protein and I have quoted just a couple of excerpts from the end of Goodman and Gilman's discussion on mild silver protein. They also did not conclude that there was any efficacy, but noted that these products -- and I will -- as listed within the book, "Fortunately, the colloidal silver preparations are now in a deserved oblivion." That was at least the conclusion that the textbook made.
I will be happy to take any questions.
DR. JUHL: Questions for Dr. Chambers?
DR. MC BURNEY: I have a question.
Dr. Chambers, are there any conditions in which you could consider using this silver preparation that these other preparations would not be effective?
DR. CHAMBERS: I am not aware of any conditions that the other products are not clearly more effective.
DR. RODRIGUEZ: Having grown up in another area of the world, did you come into the use of Argyrol for, quote, unquote, strep throat?
DR. CHAMBERS: For strep throat?
DR. RODRIGUEZ: That is right.
DR. CHAMBERS: I did not review anything other than the eye indications.
DR. RODRIGUEZ: It used to be used as a painting solution on the tonsils to, quote, unquote, take care of strep throat with similar results.
DR. CHAMBERS: Thank you.
MR. TRISSEL: In looking at the two papers that you presented in here, there seems to be a conflict in the relative efficacy in relation to merthiolate or thiomersal. In one study it shows it is better. In the other study it shows it is much worse.
At least as you have characterized it, I would argue that the second study in 1986 actually compares -- is really a comparison of equivalent activity doses rather than one being better than another. But merthiolate and thiomersal are the same things, right?
By your characterization in one place it would be better and in the other place it would be worse. So, it would be conflicting information.
DR. CHAMBERS: I am sorry. Which are you referring to?
MR. TRISSEL: The 1937 article by Thompson, Isaacs, et cetera, merthiolate is worse by the comparison they have here, is the worst in the category, as I understand this table, right?
DR. CHAMBERS: Correct.
MR. TRISSEL: And Argyrol is the next to the worst.
DR. CHAMBERS: Correct.
MR. TRISSEL: In the next paper in 1986, thiomersal by your characterization is better because it is used in a lower dose, but -- and what I am saying is that I wouldn't characterize this second study in 1986. It is really a study of what doses are equally effective among these different agents.
DR. CHAMBERS: Correct. This is -- they are looking at slightly different avenues. They are looking at slightly different bugs. I mean, this is only a comparison of Neisseria on the 1986 slide, but the orders of magnitude that they are compared to other agents that we have available --
MR. TRISSEL: But it is just a dose equivalency and it doesn't necessarily mean one is superior to the other. You would have to take into account the relative toxicities as well.
DR. CHAMBERS: Absolutely and I would put much more weight on the clinical studies that were done afterwards than I would on the in vitro studies that were done earlier on.
MS. RUSHO: In the study by Isenberg, where the colonies actually increased, doesn't that indicate two things; number one, the solution was not sterile and, number two, it was ineffective?
DR. CHAMBERS: When you wash the eye afterward and it was not well-known before the study was published, what you do is you potentially wash other areas of the eye that were not necessarily covered by the initial drops that you put in -- now, in the conjunctiva. So, that was probably what leads to the increased count. And everybody is trying to wash just the areas where they thought they had already cleansed, but as shown by the data, that is not necessarily the case. It leads to the conclusion that you should not be trying a wash after you attempt to go in and cleanse the area. That is probably the biggest message that that study shows.
MS. RIFFEE: I just have a comment. I appreciate Goodman and Gilman's comment about oblivion, but there is a silver -- a colloidal silver solution that is now being promoted in a non-prescription area among health food stores. I did a seminar and was presented a whole batch of literature on it.
So, just in case we think silver is not out of the picture, it looks like it is coming back in and this is for internal use. And I have none of that material with me, but just as a comment.
DR. CHAMBERS: I am not questioning that products resurface multiple different times. And we discuss the products and what is known about them at the time. Absolutely.
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