Questions & answers on the code of good manufacturing practice for medicinal products

19 June 2017
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General issues

The TGA uses internationally harmonised manufacturing standards to allow manufacturers to operate in an international environment. The TGA maintains its GMP standards in line with updates issued through the PIC/S. Regular updates are necessary to maintain mutual confidence with regulators overseas and to promote quality assurance of inspections and harmonisation of technical standards and procedures with international inspection standards for the production and testing of medicinal products.

Australian manufacturers benefit from reduced regulatory burden where the TGA is able to adopt harmonised international standards and establish mutual recognition agreements and cooperation arrangements with comparable overseas regulatory authorities.

The current Code of GMP was introduced on 29 July 2009 with a transition period up to 30 June 2010. It became mandatory from 1 July 2010.

The most significant changes for manufacturers of medicinal products were:

  • The requirement to prepare annual Product Quality Reviews
  • The requirement to use quality risk management
  • Detailed procedures on stability testing
  • Detailed procedures on reference and retention samples, and
  • Several changes for the manufacture of sterile medicinal products are also included in Annex 1.

Where relevant, annexes also apply to the manufacture of APIs.

There are no impacts on imports, cleared by GMP certificates and other evidence of GMP compliance as outlined in the Guidance on Clearance of Overseas Manufacturers. From 1 July 2010, the TGA has conducted its overseas inspections according to the 2009 Code. This includes inspections of US manufacturers of herbal & vitamin preparations that are not inspected by the US FDA according to medicinal GMP requirements.

If the TGA inspects and grants an 'MRA certificate' to a veterinary product manufacturer to enable their product to be exported to Europe, the TGA will use the relevant parts and Annexes of the 2009 Code, as well as Annexes 4 and 5.

Yes, the APVMA will accept TGA inspections of veterinary manufacture. However, requests for inspections of veterinary medicinal products in addition to human medicinal products must be conveyed to the TGA inspector prior to the commencement of the scheduled inspection.

Sunscreens with an SPF claim of 4 or over are required to be manufactured in compliance with GMP.

Note that cosmetic preparations which contain a sunscreen for a secondary purpose are under certain circumstances excluded from medicines regulation and regulated as cosmetics. More details are given in the Australian Regulatory Guidelines for Sunscreens (ARGS).

Yes, the Technical Guidance documents for Listed Complementary medicines are baseline documents, elements of which can also be applied to other medicines if justified.

The implications for medicinal gases manufacturers are similar to those for other medicines manufacturers. The Guide for interpreting the 2002 Code for manufacturing medicinal gases has been revised to reflect the 2009 Code.

The TGA prepared a preliminary assessment which was reviewed by the Office of Best Practice Regulation. The preliminary assessment recognised the impacts would vary for different classes of manufacturers, and that for many Australian manufacturers exporting abroad or who were part of a multinational group of companies, there would be no impact at all. Overall, the TGA assessed the financial impact as low.

Quality management (Chapter 1)

Marketing Authorisation is a set of regulatory requirements specified on the ARTG and any other requirements imposed by a relevant Delegate of the Secretary upon product listing or registration.

Examples of regulatory requirements include, but are not limited to, compliance with registered formulations, special storage and transportation conditions, shelf life, labelling, batch release testing requirements etc.

The Marketing Authorisation is equivalent to a Certificate of Registration or a Certificate of Listing for a medicinal product under the Therapeutic Goods Act 1989.

Yes.

Release for supply is defined as a manufacturing step for which a TGA licence is required. For this reason, a sponsor can only perform release for supply if the sponsor holds a TGA manufacturing licence. Refer to clause 1.1vii. of the 2009 Code.

Yes - a manufacturer is allowed to have more than one authorised person to perform release for supply.

The Authorised Person of the manufacturer responsible for release for supply should have a full overview of all manufacturing steps, including the ones performed by other manufacturers. Consequently, in most cases it would make sense to make the last manufacturer in the supply chain for each batch of product responsible for release for supply. However, for example where the last manufacturer in the supply chain only performs secondary packaging it would probably be better to have the responsibility for release for supply with the manufacturer performing the more crucial steps in manufacture. It could be any of the manufacturers, as long as the manufacturer's Authorised Person has full overview of all steps performed in the manufacture of the batch involved and has full access to all details of the marketing Authorisation.

The TGA expects that an authorised person must carry out release for supply to ensure the products meet all regulatory requirements. Release for supply must include assurance of compliance with the marketing authorisation, as well as meeting GMP requirements, such as assessing Product Quality Reviews and the effectiveness of the on-going stability program. This applies to both local and overseas manufacturers.

Where the manufacturer being inspected is responsible for the release for supply of the product, the inspection scope includes products manufactured by that manufacturer, irrespective of whether the products are manufactured in-house (where the manufacturer is the sponsor) or whether the products are manufactured under contract. This applies to both Australian and overseas manufacturers.

Where another regulatory authority certifies an overseas manufacturer as being compliant with the PIC/S or EU GMP requirements, it will be presumed that the manufacturer meets all requirements and ensures that the marketing authorisations have complied with GMP requirements for all manufactured products.

According to Clauses 1.3(vii) and 8.13 the recording of batch numbers in distribution records is mandatory.

This refers to the manufacturing licence or, in case of overseas manufacturers, the applicable GMP clearances. This implies that domestic manufacturers are expected to conduct PQRs for all medicinal products manufactured under the manufacturing licence and overseas manufacturers are expected to conduct PQRs for all medicinal products for which a clearance is granted. Where no marketing authorisation is available, clauses 1.4.vi and 1.4.x do not apply.

Yes. However, if very few batches of one product are manufactured in one year, it may also be acceptable to conduct a two yearly PQR providing a rationale is documented and scientifically justified. The justification for a reduction in the frequency of reviews should consider whether the medicines are registered, listed or complementary, the number and size of batches manufactured, whether grouping is utilised (see question 19) and the method of manufacture, together with an assessment of the risk associated with the product. The approach taken by the manufacturer will be assessed on a case-by-case basis.

Grouping (sometimes referred to as bracketing or matrixing) of products for the preparation of PQRs may be acceptable, if adequately justified. It is usually only acceptable if the amount of batches manufactured annually for each product within the group is low, the grouped products are of the same pharmaceutical form containing the same or very similar active ingredients and are manufactured using the same equipment. Acceptability will be assessed during inspections on a case-by-case basis.

Yes. For example, also all batches for which the manufacture was terminated, delayed or has failed are expected to be included in the PQRs. When grouping is applied, all batches of all products in each group are expected to be included in the PQR.

The preparation of PQRs is a shared responsibility between the sponsor and the manufacturer(s) of a product. PQRs are expected to be available for review during inspections of manufacturers of products for which the manufacturer is responsible for release for supply. Sponsors are also expected to have access to the PQRs, to ensure product compliance with the marketing authorisation.

The TGA expects PQRs to be prepared as of 2011.

Yes. A separate guidance document on this issue is available on the Technical working groups page.

The PQR requirements for products that are for export only are the same as the PQR requirements for all other products.

Clauses 1.5 and 1.6 of the 2009 Code make it a mandatory requirement for manufacturers to have an operational Quality Risk Management system in place to ensure that the evaluation of a risk to product quality is based on a sound, scientific basis and that risk assessments are appropriately documented. Annex 20 provides guidance only on Quality Risk Management tools that may be applied by a manufacturer when assessing the risk to product quality.

The Australian Regulatory Guidelines for Prescription Medicines (ARGPM), OTC Medicines (ARGOM) and Complementary Medicines (ARGCM) each include requirements for changes to medicines in the ARTG. These requirements are mandatory and cannot be overridden by the 2009 Code. The requirements within the 2009 Code in relation to change control and risk assessment apply to both regulated and other changes.

Personnel (Chapter 2)

'Necessary qualifications' mean having the education, training, experience and skills or any combination of these elements that will ensure that staff can perform assigned duties and functions at an acceptable level.

Training and assessment should be carried out by persons with relevant training, qualifications and experience in the subject matter and training personnel should preferably have been formally qualified in training and assessment.

Training should be given to all people affected by significant change in the Quality Management System, e.g. when SOPs or methods of manufacture change. The requirement for initial and ongoing training should be reflected in procedures, and training records should be generated and kept.

There are a number of people who have a direct bearing on quality outcomes. These include contractors, consultants and casual employees. Therefore, appropriate training and assessment should be provided and recorded.

Manufacturers should define language requirements or standards and ensure personnel are proficient in the required language for their allocated tasks, particularly in relation to documenting and recording. Procedures employed to overcome identifiable deficiencies should also be documented.

Premises and equipment (Chapter 3)

Clause 3.9 describes the physical requirements for the area being used to sample non-sterile starting materials. This sampling should be carried out in a separate room, or appropriately qualified sampling hood, under a filtered air supply to protect product from contamination. The sampling area should be designed with dust extraction or equivalent controls to prevent contamination of adjacent areas.

Sampling hoods may be used provided there are adequate controls in place to ensure that materials are contained. Consideration should be given to the use of appropriate extraction/de-dusting facilities, the qualification of the hood, the possibility of contaminating the sampled material and adjacent storage area and whether materials sampled are hazardous.

Clause 3.9 also describes the physical requirements for the area being used to sample primary packaging material for non-sterile products. As product contact components, primary packaging materials should be sampled within an environment that adequately protects the packaging from contamination. The standard of air quality is optional and HVAC is not expected. However, sampling of primary packaging materials in an open warehouse would not be allowed.

Clause 5.19 defines campaign manufacture as being a separation in time of production. That is, manufacturing a series of batches of the same product in sequence in a given period of time and/or maximum number of batches followed by an appropriate (validated) cleaning procedure.

There are no standards specific to non-sterile medicine manufacture. Manufacturers are required to demonstrate that the manufacturing environment for non-sterile products affords appropriate protection to the products, and prevents contamination. Through qualification, validation and monitoring processes manufacturers should justify that the air quality is sufficient for their non-sterile manufacturing areas. Manufacturers may wish to consult the World Health Organisation's 'Good manufacturing practice: main principles for pharmaceutical products - Heating, ventilation and air conditioning systems for non-sterile pharmaceutical dosage forms' which provides additional guidance in relation to recommended levels of air filtration.

'Certain' refers to materials known to cause specific (side) effects in low doses. For example, 'certain antibiotics' refers to antibiotics, usually of the beta lactam group, which are known to cause allergic reactions. 'Certain hormones' refers to hormones that can have pharmacological effects if trace amounts cross-contaminate other products. Examples are estrogens and some progesterone-like hormones. Manufacturers should evaluate materials that are processed and ensure that adequate control measures are in place.

The Code is not prescriptive on cleaning and sanitisation, as it considers the manufacturer to be responsible for demonstrating that the applied cleaning and sanitisation procedures are suitable for its intended purpose. This can be demonstrated by qualification, validation or monitoring studies. The level of depth of these studies may depend on the nature and types of products manufactured.

By definition, 'manufacture' includes all steps in bringing the product to its final form and 'release for supply' is considered to be the last step in this process. From a GMP point of view, warehousing and distribution after release for supply and after the product has left the manufacturer's control, is not currently regulated by the TGA. Hence, a licence is not required if a facility is used only for warehousing and distribution. However, there may be State regulatory requirements that are applicable which should be checked with the relevant State Department.

Production (Chapter 5)

A separate guidance document is available for this: Technical guidance on the interpretation of manufacturing standards: Process validation for Listed complementary medicines

A separate guidance document is available for this: Technical guidance on the interpretation of manufacturing standards: Supplier qualification

The issue of batch numbering is dealt with in Therapeutic Goods Order No. 69 General Requirements for Labels for Medicines. The system that a manufacturer adopts for batch numbering may include numerals, letters or symbols (or any combination of these) and must effectively serve to uniquely identify a batch of product, and from which it is possible to trace that batch through all stages of manufacture and distribution. The manufacturer should be able to demonstrate that the system for batch numbering meets these requirements and is effective.

Unpacked bulk products, should have a batch number that is unique to both product and batch, to minimise the potential for mix-ups during manufacturing. For finished products which are easily distinguished, a batch numbering system that only designates batches from that product may be acceptable.

Roll labels must be counted either on receipt or at issue. Supplier counts are not acceptable unless the supplier is specifically qualified and supplier certifies the exact count for each roll. Supplier numbering of labels is an acceptable alternative.

Cut labels must be counted and effectively verified by the manufacturer because of risks of mix-ups.

Quality control (Chapter 6)

A separate guidance document is available for this: Technical guidance on the interpretation of manufacturing standards: Sampling and testing of complementary medicines

No. However, the results from these studies are required to be reliable and meaningful. For that reason, other certificates may be used in lieu of a GMP certification, such as a current Good Laboratory Practice (GLP) certificate or licence issued by a regulatory authority acceptable to the TGA or a current ISO 17025 accreditation certificate. Stability test methods used by the laboratory should be appropriately validated and documented according to the requirements of the Code.

The results from the on-going stability monitoring studies must be considered as part of release for supply, which is the final step in manufacturing.

The responsibility is with both the manufacturer and the sponsor. The manufacturer who carries out release for supply needs to ensure that the batch meets its Marketing Authorisation, and that an on-going stability monitoring program is conducted and data is available to support the expiry date. The sponsor is responsible for the Marketing Authorisation, ensures an on-going stability testing program is performed and has access to the stability results. In the contract manufacturing agreement, the responsibility for on-going stability may be contracted out to the manufacturer or other parties.

No. On-going stability is required to be performed in the packaging material in which the product is marketed in Australia. The overseas bulk manufacturer will use different packaging equipment and processes although the packaging materials might be the same.

Yes. A separate guidance document on this issue is available on the Technical working groups page.

Grouping or bracketing could be acceptable, if appropriately scientifically justified and if the formulation is (nearly) identical. This will be assessed during inspections on a case-by-case basis.

Yes. During inspections, the operation of an appropriate on-going stability program are reviewed, including the results of on-going stability studies, where appropriate. If there are any concerns, the inspector can refer the evaluation to the regulator.

Although it is acknowledged that some normal variability in the results of on-going stability studies can be expected, all statistically significant departures from established stability profiles must be notified to the regulator.

Yes, the results of the on-going stability program are expected to be available to the Authorised Person who should consider those before releasing a batch for supply.

Complaints and product recall (Chapter 8)

Clauses 8.7 and 8.8 require that the procedures on complaints handling should include an assessment for counterfeit products. If counterfeiting is detected the TGA must be notified.

Manufacture of sterile medicinal products (Annex 1)

The PIC/S has prepared and published a recommendation document for interpretative guidance on the revised Annex 1, which is called Technical interpretation of revised Annex 1 to PIC/S GMP Guide, PI 032-2. This document gives both a detailed overview of the most significant changes in Annex 1, as well as a technical interpretation. The document is endorsed by the TGA: Revised technical interpretation of Annex 1 to PIC/S GMP guide.

Generally, dedicated buildings, facilities and equipment are required for penicillin manufacture. An isolator operating at negative pressure would be regarded as a 'micro-environment' and could be accepted for penicillin manufacture provided that factors such as cleaning, sanitation (noting that if the isolator is opened during cleaning this could present specific concerns), preventative maintenance, environmental monitoring (residues), spillage, etc. are adequately addressed with respect to cross contamination. However, the manufacture of 'other drugs' in the isolator used for penicillin would not be permitted.

Clean room apparel is not a therapeutic good and manufacturers of such apparel are not subject to inspection and licensing under the Therapeutic Goods Act 1989. However, licensed manufacturers of sterile medicinal products should qualify their vendors of critical goods used in the clean rooms, such as clean room apparel.

Manufacture of biological medicinal products (Annex 2)

As a general guide, the following are considered biological medicinal products under the requirements of Annex 2:

  • Animal derived fractionation products
  • Antibiotics produced by fermentation
  • Antigens
  • Antitoxins, antivenenes, enzymes and venoms
  • Allergenic products
  • Biological therapeutics products
  • Cytokines
  • Hormones
  • Human derived fractionation products
  • Immunosera
  • Monoclonal antibodies
  • Somatic cellular products
  • Therapeutic recombinant products
  • Toxoids/toxins

Also, as a general guide, although the following could be considered biological medicinal products, the additional requirements of Annex 2 will not be applied:

  • Beta-carotene
  • Shark cartilage
  • Bee propolis
  • Green lipped mussel
  • Deer antler

Yes. The manufacture of APIs for biological medicinal products for human use is usually performed in immediate conjunction with the manufacture of the biological medicinal product itself. For that reason, Annex 2 is written to cover both the API and the finished product manufacuring steps of biologicals. Additionally, Part II of the Code is applicable to the manufacture of APIs for biological medicinal products.

Manufacture of radiopharmaceuticals (Annex 3)

The implications for radiopharmaceuticals manufacturers are similar to those for other medicines manufacturers. The Guide to interpretation of the 2002 Code for manufacturing the PET radiopharmaceutical Fludeoxyglucose [18F] Injection has been revised to reflect the 2009 Code.

Yes, with one exemption, which is for public hospitals supplying radiopharmaceuticals to other hospitals or public institutions in the same State or Territory. In that case the biomedical engineers, radiochemists and pharmacists employed by those public hospitals are exempted from the requirement to obtain a TGA licence to manufacture radiopharmaceuticals.

Yes, except for radiopharmaceutical cold kits to which a radioisotope is to be added immediately before injection into patients. Registration is not required if the cold kit is manufactured in a public or private hospital for a patient of that hospital or a patient of another public or private hospital in the same State or Territory.

Manufacture of herbal medicinal products (Annex 7)

If a marker compound is selected, a suitable reference material of that compound should be obtained from external or internal sources.

The TGA position on this issue has not changed. Please refer to the Guidance for the use of the term 'quantified by input' for complementary medicines manufacturers.

Sampling of starting and packaging materials (Annex 8)

  • Every container of starting material must be identified if the supplier is not classified as reliable and is not validated according to Annex 8.
  • Requirements for sampling active materials do not differ from those for excipients.
  • The validation of a supplier cannot be accepted without a regular and adequate inspection. Such validation should comprise a number of actions, which may include all or most of the following:
    1. The use of a questionnaire prepared by the potential customer and completed by the potential supplier, concerning the supplier's operating Quality System.
    2. Approval inspection of the potential supplier's operation by the potential customer, or by a third party on their behalf. For example, a sister company located in the same country as the supplier. Reliance on inspection reports of other regulatory authorities by the potential customer is normally not sufficient, unless it can be demonstrated that the inspection covered the specific operations to be used in the processing of materials for the potential customer.
    3. A program to evaluate the quality of each shipment of materials on receipt by the customer. In this regard, sampling of powders should be representative of the container contents. For example, sampling from the top, middle and bottom of drums, in the absence of validated sampling positions. Reduced testing programs should be evaluated by the inspector. Sampling by the suppliers should be validated.
    4. A program for regular re-inspection of the supplier's operation and for ongoing monitoring of the quality of material supplied, for example, through trend analysis of analytical results, periodic full testing.
    5. In the case of active ingredients, the use of brokers as sources should be carefully evaluated. The quality of each batch of material should be confirmed through testing of representative samples.
  • Certification e.g. a Certificate of Suitability of Monographs of the European Pharmacopoeia, does not replace an inspection.

Where a validated procedure is established to justify reduced sampling, and scientific and statistical evidence is presented, √n+1 sampling may be justified as applicable.

Manufacture of investigational medicinal products (Annex 13)

The manufacture of Phase 1 clinical trial medicines is not subject to inspection and licensing by the TGA (specified in Item 1, Schedule 7, Therapeutic Goods Regulations). However, the manufacture of Phase 2 and 3 clinical trial products is subject to inspection (including Annex 13) and licensing by the TGA.

If the dedicated pilot facility is used to manufacture investigational medicinal products for clinical trials in Phase 2 or later (or for commercial supply) the facility is subject to inspecting and a TGA licence or clearance is required.

The 'certain characteristics' in clause 32 refers to non-commercial clinical trials performed by researchers without the participation of the pharmaceutical industry. These trials are usually performed with registered (or listed) products that are obtained from the market for use in a clinical trial. The requirements in this clause relate to the way these products are to be labelled.

Qualification and validation (Annex 15)

These documents are for guidance only. The TGA encourages the use of these Recommendation documents as they expand on clauses 5.21, 5.22, 5.23, 5.24 and Annexes 1 and 15 of the Code.

Validation is required to ensure that therapeutic goods consistently meet product specifications and this principle is to be applied for all products (including complementary medicines). There are some critical processes that must be validated and risk assessment would not justify exemption from validation (e.g. mixing for tablets/capsule/powder dosage forms). For herbal products grouping can be considered and justification included in the VMP. Markers can be used for herbal process validation.

Clause 45 of Annex 15 is quite specific on the issue of revalidation, ie. 'Facilities systems, equipment and processes, including cleaning, should be periodically evaluated to confirm that they remain valid. Where no significant changes have been made to the validated status, a review with evidence that facilities, systems, equipment and processes meet the prescribed requirements fulfils the need for revalidation'.

The frequency of periodic revalidation is intentionally not defined (except for example, sterile media trials under Annex 1, clause 44) because this will vary according to a large range of factors. Manufacturers need to determine and justify their own revalidation frequency based on a risk assessment and other relevant factors.

If the process has not been previously validated, then it should be validated retrospectively according to items 31-35 of Annex 15. When retrospective validation is inadequate, then validation according to Annex 15 is required. The scope and extent of validation should be based on risk assessment and should be conducted according to a validation master plan.

The process must be validated for the smallest and the largest batch sizes. Process validation is not required for intermediate batch sizes if it could be demonstrated, based on risk assessment, that process consistency can be achieved for any intermediate batch size.

Yes, the scope and extent of validation should be based on risk according to the manufacturer's quality risk management procedures. Qualification and validation work is required to control the critical aspects of the particular operation and a common sense approach should be applied.

PQ is required to be preceded by IQ and OQ.

For significant changes to equipment (eg. for new or modified items of equipment), the PQ is separate from and precedes process validation. For minor changes not impacting on already qualified equipment (eg. to processing parameters only), process validation could be integrated in PQ and a repeated IQ and OQ may not be necessary.

A separate guidance document for this is available: Technical guidance on the interpretation of manufacturing standards: Process validation for Listed complementary medicines

Reference and retention samples (Annex 19)

A reference sample is a sample for the purpose of future analysis, which could refer to starting materials, packaging materials or finished products.

A retention sample is a sample representing the batch of finished product as distributed.

No.

Not necessarily. The requirement is that the amount of retention samples is sufficient to carry out analytical work during the entire shelf life of the product.

Specific Q &A's for manufacturers of Dose Administration Aids (DAA)

This section has been prepared to provide information to pharmacists working in community pharmacy. It contains answers to some frequently asked questions in relation to the preparation of Dose Administration Aids (DAA). The information is intended as general information only about the requirements of the therapeutic goods legislation. The contents do not constitute legal advice and should not be relied on as such.

In addition to the requirements of the therapeutic goods legislation, a pharmacist involved in the preparation of DAAs should consider applicable state and territory requirements, including requirements under the Health Practitioner Regulations Law. In particular, a pharmacist should consider the Pharmacy Board of Australia Guidelines on dose administration aids and staged supply of dispensed medicines.

Persons engaged in the manufacture of therapeutic goods in Australia are generally required to hold a manufacturing licence. There are, however, some circumstances in which a person is exempt from the requirement to hold a manufacturing licence. The exemptions are set out in Schedules 7 and 8 of the Therapeutic Goods Regulations 1990. The Regulations can be accessed from Legislation & legislative instruments on the TGA website. Whether an exemption applies depends on the circumstances of the particular manufacture.

Item 2 of Schedule 8 provides an exemption to pharmacists from the requirement to hold a licence for the manufacture of therapeutic goods if:

  1. "the goods are not:
    1. biologicals; or
    2. medicines that contain a substance covered by an entry in the Poisons Standard mentioned in any of paragraphs 12A(1)(a) to (f); and
  2. the goods are produced by the pharmacist:
    1. in a pharmacy where the pharmacist practices and the pharmacy is open to the public; or
    2. on the premises of a dispensary conducted by a Friendly Society; or
    3. on the premises of a private hospital; and
  3. the goods are for supply (other than by wholesale) on or from those premises."

Item 3 of Schedule 8 provides an exemption to biomedical engineers, radiochemists and pharmacists in public hospitals from the requirement to hold a manufacturing licence for:

"the manufacture of therapeutic goods, other than biologicals, by the person when employed by a public hospital or a public institution and produced by that person for supply in hospitals or public institutions in the same state or territory"

Therapeutic goods manufactured in Australia are generally required to be listed/registered on the Australian Register of Therapeutic Goods (ARTG). There are, however, some circumstances where the goods may be exempt from the requirement to be listed/registered. The exemptions are set out in Schedules 5 and 5A of the Therapeutic Goods Regulations 1990. The Regulations can be accessed from Legislation & legislative instruments on the TGA website. Whether an exemption applies depends on the circumstances of the particular manufacturing activities.

Item 6 of Schedule 5 which provides an exemption for:

"medicines that are dispensed, or extemporaneously compounded, for a particular person for therapeutic application to that person, other than:

  1. medicines that are used for gene therapy; or
  2. medicines that:
    1. contain a substance covered by an entry in the Poisons Standard mentioned in any of paragraphs 12A(1)(a) to (f); and
    2. are not dispensed, or extemporaneously compounded, in a public hospital in a state or a territory for a person who is a patient in a public hospital in the state or territory"

Item 5 of Schedule 5A which provides an exemption for:

"Therapeutic goods, if:

  1. the goods are not any of the following:
    1. biologicals;
    2. goods referred to in item 3;
    3. medicines that contain a substance covered by an entry in the Poisons Standard mentioned in any of paragraphs 12A(1)(a) to (f); and
  2. the goods are manufactured by a person under a contract between the person and a private hospital, a public hospital in a state or territory or a public institution[1] (the relevant institution); and
  3. the manufacture is in accordance with a formulation specified by the relevant institution; and
  4. the goods are for use by, or in connection with, a patient of:
    1. the relevant institution; or
    2. if the relevant institution is a public hospital in a state or territory - another public hospital in the state or territory"

where:

  1. "there are no listed goods or registered goods that, in all relevant respects, are substantially similar[2] to the goods; and
  2. the person:
    1. manufactures the goods at premises in Australia; and
    2. holds a licence, required by the Act, that authorises the manufacture, or a step in the manufacture, of the goods at those premises; and
  3. the person notifies the Secretary, in accordance with a form approved by the Secretary and within 15 days of the end of a quarter, of:
    1. the goods manufactured under the contract during that quarter; and
    2. the relevant institution that entered the contract"

Footnotes

  1. Refer to Appendix 1 for guidance in determining whether an entity could be considered a 'public institution'
  2. Refer to Appendix 2 for guidance regarding the interpretation of 'substantially similar'

Apendix 1: Determination of 'public institution'

The key questions to consider in determining whether an entity is a 'public institution' in the application of Schedule 5A item 5c and Schedule 8 item 3 are:

Key questions to consider: Could be considered a 'public institution' if all three criteria below are met: Would probably not be considered a 'public institution' if any of the criteria below are met:
How is the entity controlled? The institution is controlled by the government or other public entity.
and
It is controlled by private individuals, an independent, commercial company, or a corporate body.
How is the entity funded? The institution is funded by the government or other public entity; and Any profits are directed towards the services the institution provides to the public.
and
The institution is established by a private entity and/or is for profit of particular individuals.
Who has access to its services? The institution serves the public generally or a large proportion of the public.

The institution only serves or is accessible by a small portion of the public.
Individuals are selected for reasons of private concern or as members of some private class.

Apendix 2: Determination of 'substantially similar'

Whether a product is substantially similar to another is a factual question. It therefore needs to be considered on a case by case basis.

To determine whether this aspect of the exemption applies, and whether the products are substantially similar to listed or registered goods, the TGA would consider whether these products are separate and distinct from any listed or registered goods, in accordance with section 16(1A) or 16(1) of the Act, respectively. If the products are not separate and distinct from a listed or registered good, they must be entered on the ARTG before they could be lawfully supplied.

To fulfil the requirement of the exemption one of the criteria is that the private hospital or the public hospital in a state or territory, or the public institution, must be able to specify the full formulation of each product, including active ingredients, excipients and their quantities. If the product to be packed into final packaging is already registered or listed on the ARTG, this criterion could be met by providing the ARTG listing or registration number of the medicine.

For example, a manufacturer/pharmacy proposes to repackage registered medicines into webster packs or sachets, and these medicines have been registered on the ARTG with containers types (eg bottles or blister packs) that are different to webster packs or sachets. Because the medicines the manufacturer/pharmacy intends to supply are separate and distinct under section 16(1)(g) of the Act then the products would not be considered to be substantially similar to the registered medicines being re-packaged and would, therefore, be exempt from the ARTG, provided all other criteria and conditions of item 5, Schedule 5A of the Regulations are met.

However, if the manufacturer/pharmacy were to repackage product already supplied in a sachet, it would not be a separate and distinct good under section 16(1)(g) of the Act and consideration will need to be given to other criteria specified in section 16(1) of the Act. If no other criteria apply, then the product would need to be registered on the ARTG. Similarly if the manufacturer/pharmacy were to repackage a listed product into a different container, it would not be a separate and distinct good under section 16(1A) of the Act and subregulation 11(1) of the Regulations as different container types for listed goods do not constitute separate and distinct goods.

Where permitted by applicable state and territory legislation, a pharmacist may engage the services of a third party to pack a DAA on their behalf (e.g. a TGA) licensed facility or another pharmacy).

The supply pharmacist (who supplies the DAA to the patient or their agent):

  • must ensure that the patient's right to privacy is understood, the patient or agent has consented if a third party is to be involved in the packing of the DAA, and a record of the consent is kept
  • is responsible for ensuring the packing pharmacist has accurate details of the medicines to be packed
  • must make an assessment of the measures, techniques and technology used by the packing pharmacist at the third party packing facility to check packed DAAs for accuracy, to determine whether additional checking of a DAA is required prior to its supply to a patient or their agent, and
  • is responsible for the quality use of medicines support for the patient, including provision of accompanying medicines information to the patient or their agent.

The direct supply of the DAA to the patient or their agent from the third-party packing facility is not permitted under the therapeutic goods legislation and must not take place, even if pharmacists are employed at that facility. It is the responsibility of the supply pharmacist to make the supply of the DAA to the patient or their agent.

A packing pharmacist who uses an automated or semi-automated dose packaging system on behalf of a supply pharmacist may need licensing by the Therapeutic Goods Administration in jurisdictions that have laws to complement the Therapeutic Goods Act 1989 (Cth). Please check with the applicable laws in your state or territory.

When permitted by applicable state and territory legislation, a pharmacist may engage the services of a third party to pack a DAA on their behalf (e.g. a Therapeutic Goods Administration (TGA) licensed facility or another pharmacy).

The packing pharmacist at the third party packing facility is responsible for ensuring DAAs are prepared in a timely and accurate manner according to the patient's current medication regimen.

The direct supply of the DAA to the patient or their agent from the third-party packing facility is unlawful and must not take place, even if pharmacists are employed at that facility. It is the responsibility of the supply pharmacist to make the supply of the DAA to the patient or their agent.

A packing pharmacist who uses an automated or semi-automated dose packaging system on behalf of a supply pharmacist may need licensing by the TGA in jurisdictions that have laws to complement the Therapeutic Goods Act 1989 (Cth). Please check with the applicable laws as follows:

In a scenario where both Pharmacies are in the same state and only trade in that state, and are not incorporated bodies such as where one Pharmacy contracts another to pack medicines into Webster packs and supply them only in the same state, then their operation may not come under the scope of Commonwealth law, thus will not require a GMP licence. However, the co-regulatory scheme requires those individual trading entities to comply with all state laws that will apply to them. The DAA must be supplied to the patient from the "supply pharmacy" as they have the prescription and have contracted out the packaging.

In a scenario where the Pharmacies are not in the same state (or are trading across state boundaries) then the operations would come under the scope of the Commonwealth law, and thus a GMP licence would be required. The DAA must be supplied to the patient from the "supply pharmacy" as they have the prescription and have contracted out the packaging.

Manufacture of compounded medicines

This document has been prepared to provide information to pharmacists working in community pharmacy. It contains answers to some frequently asked questions in relation to the compounding or supply of medicines by community pharmacists. The information is intended as general information only about the requirements of the therapeutic goods legislation. The contents do not constitute legal advice and should not be relied on as such.

In addition to the requirements of the therapeutic goods legislation, a pharmacist involved in the compounding of medicines should consider applicable state and territory requirements, including requirements under the Health Practitioner Regulations Law. In particular, a pharmacist should consider the Pharmacy Board of Australia Guidelines on compounding of medicines. These guidelines include detailed guidance on when it is appropriate for a medicine to be compounded and the requirements to be complied with when compounding medicines.

The holding of a manufacturing licence and the inclusion of therapeutic goods in the ARTG are separate matters.

Persons engaged in the manufacture of therapeutic goods in Australia must generally either hold a TGA issued manufacturing licence or be exempt from the requirement. In addition, before therapeutic goods may be imported, exported, manufactured or supplied in Australia, they must be included in the ARTG, unless the goods are exempt under one of the exemptions provided for under the legislation.

Schedule 8 of the Therapeutic Goods Regulations provides exemptions from the requirement to hold a manufacturing licence. Item 2 of Schedule 8 of the Regulations is relevant to compounding by community pharmacists. Item 2 exempts pharmacists from the requirement to hold a manufacturing licence in certain circumstances. For example, when therapeutic goods (other than biological or medicines that contain a substance covered by an entry in the Poisons Standard mentioned in any of paragraphs 12A(1)(a) to (f) of the Regulations) and are produced in a pharmacy where the pharmacist practices and which is open to the public and supplied (other than by wholesale) on or from those premises.

Schedules 5 and 5A of the Regulations provide exemptions from the requirement to include therapeutic goods in the ARTG in particular circumstances. Item 6 of Schedule 5 of the Regulations is relevant to compounding by pharmacists. This item provides an exemption from the requirement for therapeutic goods to be included in the ARTG where the goods are dispensed or extemporaneously compounded for a particular person for therapeutic application to that person.

A copy of the Therapeutic Goods Regulations 1990 can be found at theAustralian Government Federal Register of Legislation website

Yes, if the medicine is extemporaneously compounded for an identified person for therapeutic application to that person.

Yes, provided that the medicine has been extemporaneously compounded for a particular person for therapeutic application to that person.

No, such medicines would usually need to be included in the ARTG in relation to the person manufacturing and supplying the medicine.

A pharmacist is exempt from the requirement to include a medicine in the ARTG where it is extemporaneously compounded for a particular person for therapeutic application to that person. A pharmacist should therefore ensure that there is an identified person for whom a medicine is being compounded before undertaking any steps in manufacture.

The Pharmacy Board decided to delay the implementation of its guidance around parenteral medicine with a shelf-life of more than 24 hours and undertook consultation with stakeholders closing March 2016. Once this consultation process has been completed and the PBA's position ratified, TGA will provide advice regarding any subsequent regulatory requirements.

The Pharmacy Board decided to delay the implementation of its guidance around parenteral medicine with a shelf-life of more than 24 hours and undertook consultation with stakeholders closing March 2016. Once this consultation process has been completed and the PBA's position ratified, TGA will provide advice regarding any subsequent regulatory requirements.

The Pharmacy Board of Australia Guidelines on compounding of medicines includes requirements in relation to batch preparation. In relation to TGA requirements, the Therapeutic Goods Act and Regulations do not specifically deal with batch preparation. If a pharmacist is relying on the exemption in item 6 of Schedule 5 (relating to extemporaneous compounding) to manufacture and supply a medicine that is not included in the ARTG, the pharmacist will need to ensure that there is an identified person for whom a medicine is being compounded.

No, there is not a limited form of a manufacturing licence for pharmacists to compound and dispense medicines. However, there are exemptions from the requirement to hold a manufacturing licence that will apply to pharmacists in certain circumstances. For example, a pharmacist is exempt from the requirement to hold a manufacturing licence to manufacture therapeutic goods (excluding biological or medicines that contain a substance covered by an entry in the Poisons Standard mentioned in any of paragraphs 12A(1)(a) to (f) of the Regulations) when the goods are produced in a pharmacy where the pharmacist practices and which is open to the public and supplied (other than by wholesale) on or from those premises.

Generally yes but the exemption in the Therapeutic Goods Regulations that allows for this has certain requirements, the main ones being that there are no substantially similar goods included in the ARTG and that the medicine is manufactured in accordance with a formulation specified by the hospital.

No, a community pharmacy would not normally be considered a public institution under the therapeutic goods legislation.