Susan Haigney is lead editor of Pharmaceutical Technology and Pharmaceutical Technology Europe.

Susan Haigney

 spoke with Jamie Chasteen, manager of new product development at Cold Chain Technologies, and Rebecca E. Gentile, senior specialist, quality vaccine and biological stability at Merck & Co. about the challenges manufacturers experience when managing the cold chain for biopharmaceuticals and what advances in cold-chain technologies are helping to combat these challenges. 
  
  

 What top challenges do biopharmaceutical companies face when managing the cold chain for biopharmaceuticals? 
  
  

 A top challenge to managing the cold chain for biopharmaceuticals during distribution is temperature excursions, which can affect the safety and efficacy of the product. Reducing or eliminating temperature excursions during shipping is an important task. Clinical-trial material is shipped to multiple locations, typically in smaller packages, so ensuring that the appropriate packaging solution is being used to maintain the necessary temperature ranges is crucial. For commercial supply, it is crucial to understand the typical shipping lanes and what temperature exposures the product might encounter, work with partners to design and qualify appropriate shipping packages, and work with shipping partners to minimize delays and other potential points of temperature excursions. 

Particularly for commercial product, designing the Phase III stability studies and establishing a stability budget, so that the data can be used to support shipping at a temperature range broader than the label storage condition, can be beneficial. For biological products, consideration of shock and vibration effects during shipping should be considered along with stressed stability conditions. This approach allows for a broader and more economical choice of shipping solutions and reduces the chance for temperature excursions, while still ensuring the safety and efficacy of the product through shelf life. When the stability data are included in the regulatory filing, many agencies are supportive of this approach. 
  
  

 A recent Georgia Institute of Technology study highlighted that 90% of failures in the cold chain are attributed to human error. These errors can occur while the product is in transit, but data show the vast majority of errors are occurring during pack-out at the site of shipment origination. It is not uncommon for companies, whether in the commercial or clinical-trial space, to have multiple styles of insulated container for their various shipping needs. These containers can use several different refrigerant types and sizes. In many cases, these refrigerants require multiple stage conditioning or ‘sweating’ prior to use. These sweat and conditioning times can vary based on which refrigerant and system is being used for that particular shipment. Each package can also be packedout in very different ways, requiring employees to learn a myriad of different designs and methodologies. This confusion and complexity directly correlates to human error and costly excursions during shipment. The creation of high-performance modular shipping solutions is greatly reducing these failures. The newest shipping system families employ modular components, simple single-step refrigerant pre-conditioning, system-to-system design synergy, and only two refrigerant sizes across the entire line of payloads and durations. The emergence of simple-to-use high performance shipping systems is reducing the most prevalent cause of error in the industry today.

What are some recent advances in cold-chain technologies? 
  

 Two of the advancements in technologies to better control temperature within the supply chain are analytical thermal modeling tools and advanced phase-change materials (PCMs). The combination has resulted in the industry’s most innovative thermal shipping systems. Historically, empirical testing was the only successful tool for system development. With thermal modeling, we now have the ability to truly understand the internal thermal dynamics at play. System tweaks can be made in minutes and iterative models can be run in hours. Extremely efficient designs are the result. This efficiency is particularly important when working with advanced PCMs. Advanced PCM, at the component level, is more expensive than traditional water-based refrigerant. It is crucial that PCM be used in a very precise and judicious manner. Thermal modeling is the tool to develop PCM-based systems that are less costly than the water-based variants they replace.  

There is a huge shift taking place in the market. PCMs used to be solely considered for use in expensive solutions that combined the refrigerants with exotic insulation materials such as vacuum insulated panels (VIPs). The latest systems on the market combine advanced PCMs with less costly insulation materials such as polyurethane (PUR) and expanded polystyrene (EPS). These solutions are capable of being reused yet are more cost effective for single use than traditional EPS and PUR systems available. Because of the advanced designs and latest PCMs, they are better than previous water-based designs in every measurable category. Advanced PCM allows for smaller and lighter systems. This reduction in size and mass means a significant savings in both incoming and outgoing freight. Warehousing costs and carbon footprint are reduced. Most intriguing is that these new PCM systems are actually less expensive to purchase than traditional systems all while better handling the variability in real-world shipping environments. 

 Can you specify recent industry guidance with respect to supply-chain management?
  

 There are several new guidance documents that have recently been released or are in review for publication. One of the major changes foreseen in the US revolves around distribution in the ‘last mile.’ The last mile is the final leg of distribution to a provider, pharmacy, or directly to a patient. This portion of the industry has to operate under the tightest financial restrictions. There are four factors that are changing the landscape in the last mile: manufacturer’s transitioning from indirect to direct business models, increased pressure in the last mile from bodies such as state boards of pharmacy and accreditors, an increase in manufacturer emphasis in downstream brand protection even when title passes, and end-user awareness of temperature importance and demand for temperature indication. The Parenteral Drug Association recently published 

Technical Report No. 46 Last Mile: Guidance for Good Distribution Practices for Pharmaceutical Products to the End User. 

The adoption of this guidance poses challenges and opportunities for companies in the last mile to differentiate their service to an increasingly informed patient and provider population desiring temperature assurance. 

Articles

Industry experts discuss challenges in managing the cold chain.

Challenges in Managing the Cold Chain

To gain perspective on the implementation of quality by design (QbD) in sterile manufacturing, 

 spoke with key industry experts: Wolfgang Weikmann, vice-president quality assurance at Vetter Pharma-Fertigung GmbH & Co.KG; Hal Baseman COO and principal at ValSource LLC and chair elect of Parenteral Drug Association (PDA)Board of Directors and vice chair of PDA Science Advisory; and James E. Akers, president of Akers Kennedy and Associates.
  
  

In implementing a QbD approach, what would you identify as the critical quality attributes (CQAs) in sterile manufacturing and aseptic processing? 
  
  

: The critical quality attributes are related to the control and prevention of contamination, principally, microbiological, total particulate matter, and endotoxin although clearly the chemical purity and material uniformity issues that are a constant in pharmaceutical manufacturing apply to sterile and aseptic products as well.
  
  

: The potential critical quality attributes of a customer’s drug product in terms of aseptic processing are determined by the nature of the product and by the definition of its target product profile. Most common identified critical attributes refer to physical, chemical, and microbiological properties. We recognize sterility, bacterial endotoxin, and dose accuracy as three of the essential CQAs.
  
  

 Identification and understanding of CQAs are essential to designing a process that establishes and maintains those CQAs. They can be broadly defined as purity, safety, strength, and identity of the product. Therefore, the CQAs associated with aseptic processing and those that need to be established and maintained by the process are:

Those CQAs that assure that nothing is present in the product which should not be there (i.e., foreign material or cross contamination of product or chemical residuals).

Those CQAs whose absence will likely cause harm to the patient, then they would include sterility, sterility assurance, lack of endoxin, lack of particulate contamination.

Those CQAs that must be present to assure the effectiveness of the product, then they would include potency, active ingredient, and functionality

Those CQAs that assure that the product is what it purports to be, then they would include correct and complete indication of product identity, lot number, content, and potency.

 What measurement tools are typically used to measure critical process parameters and the resultant process inputs and outputs, including process analytical technology (PAT) tools, in sterile manufacturing? 

 Many of the key parameters in aseptic and sterile manufacturing can be measured directly and in real time. Sterilization of components, depyrogenation of some materials, fill volumes, and in some cases, package sealing, can be measured in real time. Also, key environmental factors, such as total particulate air quality, pressure differentials, and air-handler operational characteristics can be measured in real time. In modern isolator/aseptic chamber aseptic manufacturing and in terminal sterilization, those parameters listed are the most critical.

 Defining a quantifiable correlation between what can be measured and the intended outcome is particularly challenging for aseptic processing. Some tools and systems that can help better understand and design the process include:

Air profile/smoke studies and material/personnel flow studies to establish first-air principles and their relationship to potentially microbial contamination. These tools are essential for the design and assurance of the process control strategies.  

Environmental monitoring, including continuous nonviable and viable monitoring, to monitor performance of the process.

Risk assessments to better understand the relationship and impact of process control strategies on CQAs and critical process parameters.

Human factors and ergonomics to help create processes that minimize the effect of human performance and fatigue.

Differential pressure and airflow and velocity to maintain cleanliness of the cleanroom environment.

Temperature and humidity monitoring to reduce the potential for microbiological growth in the cleanroom.

Gown and personnel monitoring to assure control of environmental conditions.

  There is, however, a direct and measurable correlation between sterilization parameters, including:

Time, temperature, and pressure monitoring of steam-sterilization cycles to assure control of microbiological contamination of product contact parts and surfaces.

Some of the aseptic processes, such as lyophilization, may use PAT in their recipe management for process consistency and control outcome CQAs.

Filtration integrity testing to assure integrity and effectiveness of product sterilization methods. 
  

 How is equipment design and operation modified when implementing QbD in sterile and aseptic manufacturing? 
  
  

 Air profile/smoke studies can be used to determine the most optimal shape and configuration for aseptic processing equipment. Human factors can be used to determine and improve interventions. Risk-based evaluation of interventions and use of automation can be used to reduce the impact and risk of interventions on process variation and product quality.
  
  

 Looking first at equipment design, we feel strongly that the design review process has to be mentioned as an essential tool. Design review is a decisive milestone within the development process for a single piece of equipment. It is performed through the adjustment of an initially created design with its particular requirements. This is important to control the results of the former activities, as well as to identify and solve any existing problems prior to the start of the drug-manufacturing process. We primarily execute a design review within the construction phase for each cGMP relevant piece of major process equipment. An example element of this design review is conducting mock-up studies.
  Looking at the operations side, serving multiple customers with different product and process specific requirements, our equipment has to be set-up highly flexible. Such an arrangement offers the benefit that, based on the product specific requirements as well as based on the performed pump studies within the QbD approach, the specific equipment components, such as the most adequate product and process-fitting filling pumps, can be used right away for subsequent production.
  
  

 In the projects I’ve worked on over the past 20 years, I don’t think current emphasis on QbD has altered what we do because we’ve always been focused on arriving at the most effective, efficient, and safe design for a process. I think because of the current regulatory emphasis, we use the description QbD or as we say sterility by design more than in the past. So, there is some additional focus in thinking and speaking in QbD terms, particularly among some clients.
  
  

Challenges in implementing QbD
  PharmTech:

 What are the challenges in applying QbD in sterile manufacturing? 
  
  

 [The challenges are] the lack of quantifiable correlation between what we can measure and monitor, and the desired outcome or the undesired outcome. Also, one must be aware of residual risk and unintended consequences as a result of changes made to address risk and improve process. Each action taken to resolve or address a process risk represents a change that may have the potential to add a new risk or unintended consequence.  These new risks must be evaluated and addressed where possible.
  


  Akers (Akers Kennedy and Associates): 

QbD is not really a new requirement in my experience. I believe in sterile manufacturing; we’ve done QbD before it was formally termed QbD.  I believe much of what we now do as QbD was once part of our design qualification activities.  The design parameters for sterile production facilities in terms of cleanrooms and sanitary designs have been well defined for years.  
  
  

In our experience, the main challenges in applying a QbD approach are due to the intensity of time, cost, and resources in the early-development stage. Another significant challenge is the high degree of expertise that must be in place to run a proper QbD approach.

Regarding timing, a much longer timetable has to be included. As for costs, the higher costs are due to the variety of additionally performed studies. And higher resource management is due to equipment, different materials as well as staff. 

In summation, it is always a product-dependent balancing act between the risks and consequences on one hand, and the cost during the development stage on the other. Even if challenges as previously described appear in the early stages, the gained knowledge will likely result in an economic benefit in the long-term commercial lifecycle.
  
  

What additional understanding is gained through a QbD approach compared to a traditional approach? 
  
  

 The most important understanding gained by running an operation through a QbD approach versus the more traditional approach is to realize the necessary requirements of a customer´s product already in an early-development stage to accommodate the product target profile. These requirements are not limited to product quality only. They include the process performance as well as the applied systems and the environment, for example, optimized and reduced lyophilization process cycles.
  Based on various studies, differing possible cases are evaluated in detail. This examination ultimately leads to a better understanding of the process variations, thus resulting in an acceptable design space. Consequently, using a QbD approach offers the possibility of gaining better process knowledge, resulting in an improved robustness of the entire process.
  

 A better understanding of process variables and impact on risk to product quality [is gained], which will aid to design of the process and process control strategies.
  

Actually, Joseph M. Juran coined the phrase ‘quality by design’ in the early 1990s, and these ideas were widely adopted in aseptic processing before QbD re-entered the industry lexicon a few years ago.  I would estimate that 95% of aseptic product safety in 2013 emanates directly from the proper design of the equipment and the environment.   
  
  

How does QbD improve quality assurance and how can it mitigate problems in  manufacturing? 
  

 Through a greater importance given to process development activities and the resulting large number of development studies performed within a QbD approach, a better process understanding is gained. Within the risk-management approach, risks are already identified in an early stage. Consequently, risk mitigation activities can be developed, and a risk-based control strategy implemented from the very beginning of the commercial stage, forming the basis for improvement of quality assurance and quality oversight.
  

 I can’t point to a single specific area where I believe QbD has had an impact on sterile product quality assurance. Sterile product manufacturing has always been and will continue to be a detail-oriented endeavor. QbD may have increased awareness of the criticality of getting the facility and process designs right. Maybe we have a better appreciation for the primacy of good engineering and scientific process development in sterile products manufacturing operations. 
  

It can improve process understanding, including the identification and control of process variables. This can lead to improved process and less risk.
  

 How do QbD practices build on or complement approaches taken with respect to parametric release and related terminal sterilization parameters needed for release? 
  

Perhaps QbD, as previously noted, will strengthen the focus on process design and control. However, arriving at a process suitable for consideration for parametric release has always required very thorough science and engineering.  I personally believe that terminally sterilized products, given their robustness and reliability, should be parametrically released more often than not. The alternative to parametric release is the sterility test, which has limitations in terms of microbiological detection and sensitivity as well as in the area of sampling statistics. 
  
  

 Understanding the relationship between those parameters we can control, monitor, and measure, and the desired outcome or CQA is essential to designing effective processes. It may not be enough to know which parameters effect product quality and process performance; we must also know to what extent they do this and how well they are controlled. 
  
  

How is technology transfer improved under a QbD approach? 
  
  

Technology transfer indeed is one area that is especially improved through a QbD approach. It leads to improved possibilities to monitor and evaluate the process. Becoming familiar with a drug product´s frame and its limits through conducting numerous tech runs of varying versions allows one to define the product´s specification in which the process is running robustly. 
  
  A day-to-day business example to showcase the improvement of tech transfer through QbD for customers is by demonstrating the lyophilization cycle development of a customer’s product. For example, by using a QbD approach with gaining the corresponding data based on numerous performed lyophilization tests, we realized a significant reduction of the lyophilization cycle for a particular customer product. This reduction resulted in saving the customer a high amount of capital, primarily within the large-scale commercial production.
  
  

 I honestly don’t see much change. I’ve been fortunate enough to work with firms who always took the development of user-requirement specifications through detailed proof of principal testing very seriously.  
  
  

 It can result in a better understanding of the process and process variables, including which process steps require control--control measures that need to be included in tech transfer. 

Industry experts discuss the application, challenges, and benefits of a quality-by-design approach to sterile manufacturing.

Implementing QbD in Sterile Manufacturing

	Pharmaceutical Research and Manufacturers of America (PhRMA) International Vice-President Jay Taylor has expressed the organization’s concerns over the Office of the United States Trade Representative’s (USTR) 2013 Special 301 Report. The Special 301 Report, released in May 2013, is an annual review of the state of intellectual property (IP) rights protection and enforcement in trading partners around the world and reflects the US Administration’s resolve to maintain IP protection worldwide.

	Expressing appreciation for USTR’s efforts to ensure IP protection, Taylor expressed dismay that an out-of-cycle review was not granted for India. “The deteriorating protections for patented medicines in India have become increasingly concerning,” Taylor said in a PhRMA 

. “Over the past year, the Government of India has issued several intellectual property decisions that have disproportionately impacted US biopharmaceutical companies and a number of other innovative sectors. The IP regime in India has been structured and applied in ways that prop up local industries to the detriment of US jobs and the worlds patients.”

	According to the report, India remains on the Priority Watch List. And with regard to pharmaceuticals and patents, the administration states it has some concerns. “The United States is concerned that the recent decision by India’s Supreme Court with respect to India’s prohibition on patents for certain chemical forms absent a showing of ‘enhanced efficacy’ may have the effect of limiting the patentability of potentially beneficial innovations. Such innovations would include drugs with fewer side effects, decreased toxicity, or improved delivery systems. Moreover, the decision appears to confirm that India’s law creates a special, additional criterion for select technologies, like pharmaceuticals, which could preclude issuance of a patent even if the applicant demonstrates that the invention is new, involves an inventive step, and is capable of industrial application,” the report states.

	Taylor also expressed PhRMA’s disappointment that Canada was moved to the Watch List for 2013. “While PhRMA appreciates the fact that USTR raises serious concerns regarding numerous Canadian pharmaceutical IP measures, we are nonetheless disappointed that USTR has changed Canada’s designation despite the fact that no progress has been made on this front. Canadian policies and judicial opinions continue to harm international innovators to the benefit of domestic industries. Canadian regulators have, for example, created a discriminatory right of appeal regime under which Canadian medicine manufacturers challenging the validity of a medicine patent may appeal an adverse decision through an administrative proceeding while innovative international biopharmaceutical companies cannot. We also are concerned that the heightened standard for patentable utility for pharmaceutical patents is inconsistent with Canada’s trade treaty obligations. USTR and the interagency process should push Canada to provide more adequate IP protections.”

	The report does express concern regarding rights of appeal in Canada. “With respect to pharmaceuticals, the United States continues to have serious concerns about the availability of rights of appeal in Canada’s administrative process for reviewing regulatory approval of pharmaceutical products and also has serious concerns about the impact of the heightened utility requirements for patents that Canadian courts have been adopting recently.”

	Taylor goes on to state support for USTR and the battle for IP protection. “The value of IP protection should not be undermined by discriminatory market access barriers, including discriminatory government pricing and reimbursement policies. We welcome USTR’s recognition of market access barriers faced by US pharmaceutical companies and their efforts to eliminate them in many countries in order to provide for affordable healthcare today and support the innovation that assures improved health care tomorrow.”

	The full Special 301 Report can be found 

 and details positive and negative findings from countries all over the world.

	What do you think? Is the US doing enough to protect the IP rights of pharmaceutical companies in today’s international market?

Pharmaceutical Research and Manufacturers of America (PhRMA) International Vice-President Jay Taylor has expressed the organization’s concerns over the Office of the United States Trade Representative’s (USTR) 2013 Special 301 Report.

PhRMA Dismayed by Special 301 Report

 the deployment of an FDA-developed Counterfeit Detection Device (CD-3) as part of a public-private partnership to identify counterfeit or substandard anti-malarial medicines, including falsified products in Africa and parts of Southeast Asia. FDA has partnered with the Skoll Global Threats Fund, the US Pharmacopeia (USP), the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the multi-agency President’s Malaria Initiative (PMI), led by the US Agency for International Development (USAID). FDA also announced it has signed a letter of intent with Corning Incorporated to refine and improve the CD-3 tool for eventual manufacture on a larger scale. 

“Fake or substandard anti-malarial drugs cause double damage: without adequate, prompt treatment, the malaria parasite can kill a person in a matter of days, and inadequate treatment can also lead to the development of drug resistance, potentially rendering all treatment ineffective,” said FDA Commissioner Margaret A. Hamburg, M.D., in a press release. “The development of the CD-3 and the formation of this important partnership are critical steps toward the FDA’s goal of improving the global product safety net in order to protect consumers in the US and worldwide.”

 that making detection technology more accessible to low- and middle-income countries would be invaluable in controlling the trade in counterfeit, falsified, or substandard medicines. “The proliferation of counterfeit or substandard medicines around the world is a major public health problem and the developing world is disproportionately affected,” said Commissioner Hamburg, in the release. “The FDA is pleased that CD-3 has the potential to be used as a frontline tool in protecting the global supply chain and make a positive impact on public health efforts to combat malaria in developing regions of the world that are particularly hard hit by the disease.”

The CD-3, developed by scientists at FDA’s Forensic Chemistry Center in Cincinnati, Ohio, is a handheld, battery-operated tool that illuminates a product with a variety of wavelengths of light to provide a visual comparison of an unverified product with an authentic sample, allowing inspectors to identify suspect products and remove them from the supply chain. According to FDA, the effectiveness of the tool in detecting counterfeit or substandard versions of two common anti-malarial therapies will be tested in Ghana in 2013 and 2014, and information obtained from the test in Ghana will guide a second testing program.

FDA will use a new anticounterfeiting tool to detect fake medicines.

FDA Creates Partnership to Battle Anti-Malaria Counterfeit Drugs

	Pharmaceutical manufacturing is evolving as the industry adopts the science- and risk-based approach inherent in FDA’s quality-by-design (QbD) initiative. QbD has raised the bar in augmenting process understanding to ensure consistent product quality, and equipment manufacturers, ingredient suppliers, and manufacturers are responding with innovation in their products and services.

	Shows such as INTERPHEX 2013 enable attendees to come together to share scientific innovation and discuss the trends and topics affecting the industry. One such topic is the QbD initiative and its impact on the pharmaceutical industry. 

 is hosting a panel discussion on implementing QbD during the INTERPHEX sessions, taking place Wednesday, April 24, at 10:15 am. Manufacturing Editor Jennifer Markarian will be moderating a special panel featuring Dr. John Lepore, senior director of Chemical Process Development and Commercialization for Global Pharmaceutical Commercialization at Merck and Co.; Chris Moreton, vice-president pharmaceutical sciences at FinnBrit Consulting; and Jonathon Thompson, technical sales consulting supervisor at Invensys.  The panel will share their insight and practical experience in implementing QbD, including strategies for defining a design space, adaption of manufacturing processes, the feasibility for real-time release testing, and the keys to continuous process verification. The panel will also discuss the benefits and challenges of QbD implementation.

	Another topic that continually impacts the industry is outsourcing. Jim Miller, a member of 

 Editorial Advisory Board and regular Outsourcing Outlook columnist, will present Wednesday’s Keynote Address on Recalibrating the Pharmaceutical Services Opportunity. Don’t miss Jim’s discussion on the implications of the changing bio/pharmaceutical R&D model for contract service providers.

	Bringing suppliers and pharmaceutical/biopharmaceutical companies together is the focus on the Pharmaceutical Technology/BioPharm International

Marketplace, a new Advanstar and Dun & Bradstreet Credibility Corp. Online Marketplace Community, which connects buyers and sellers with the information and insights they need to collaborate and make purchasing decisions. The Marketplace further delivers valuable information through the Pharmaceutical Sciences, Manufacturing, & Marketplace Report, a biweekly newsletter that reports on the latest technical developments in five main communities: solid dosage, semisolid, and specialty dosage forms; parenterals; pharmaceutical analysis; chemical API manufacturing; and biologic API manufacturing. We welcome you to stop by the 

	We hope you find everything you are looking for at this year’s INTERPHEX, and that you will join Pharmaceutical Technology in the years to come in discussing the topics and innovations that shape the industry.

Pharmaceutical manufacturing is evolving as the industry adopts the science- and risk-based approach inherent in FDA’s quality-by-design (QbD) initiative.

Innovation and Quality by Design, PharmTech’s publisher highlights this year’s INTERPHEX show

  on Monday to healthcare providers, hospital supply managers, and pharmacists that sterile-drug products made by ApothéCure and NuVision Pharmacy were produced under conditions that could create a high potential for contamination. Subsequently, both ApothéCure and NuVision announced voluntary recalls of those products. FDA issued the alert based on preliminary findings of ongoing inspections at ApothéCure and NuVision facilities that raised concerns about a lack of sterility assurance.  

NuVision Pharmacy is voluntarily recalling all unexpired lots of lyophilized compounds HcG 5000IU-5 mL and Sermorelin/GHRH6-5 mL to the user level. According to an FDA

, NuVision Pharmacy has received no reports of injury or illness associated with the use of the sterile products. These products were supplied to the offices of licensed medical professionals. NuVision Pharmacy’s sterile products covered under this recall were distributed nationwide. NuVision Pharmacy is notifying its customers by fax or email to return the products to the pharmacy. Consumers or healthcare providers with questions regarding this recall may contact NuVision Pharmacy by phone at 800-914-7435 on Monday through Friday from the hours of 10 am to 6 pm CST, or by e-mail at 

ApothéCure is also voluntarily recalling all lots of sterile products compounded by the pharmacy that are not expired to the user level. According to an FDA 

, ApothéCure has received no reports of injury or illness associated with the use of its sterile products. However, out of abundance of caution, ApothéCure has decided to voluntarily proceed with this recall process. The sterile products include all injectables with the clear message, “Independently tested for sterility,” noted on the vials as well as the ApothéCure name. Consumers or healthcare providers with questions regarding this recall may contact the company by phone at 800-969-6601 or 972-960-6601 from the hours of 9:30 am to 6 pm CST Monday through Friday or by e-mail at 

. 

FDA advises that patients who have received any product distributed by NuVision or ApothéCure and have concerns should contact their healthcare provider.

FDA inspections of compounding pharmacies manufacturing sterile-drug products lead to voluntary recalls.