You dont have javascript enabled! Please enable it! Good Practice 05: Good Practice on Laboratory Management

Good Practice 05: Good Practice on Laboratory Management

Good Practice 05: Good Practice on Laboratory Management

A. Analytical Laboratory Investigations

B. Foreign Matter Control, Testing and Inspecting of Sterile Products

C. Evaluation and Investigation of Trace Unidentified Chromatographic Peaks

D. Laboratory Documentation

E. Laboratory Management

F. Stability Testing

G. Sterility and Bacterial Endotoxin Testing

H. Sterility Test Isolators

I. Transfer of Analytical Methods

J. Use and Control of Laboratory Reagents and Reference Standards

K. Verification of Compendial Analytical Methodology

L. Microbiology Laboratory Investigations

 

A. Analytical Laboratory Investigations

Responsibilities:

–           All personnel involved in Analytical Testing shall be trained to report and act upon the detection of any Out-of-Specification (OOS) Result or Questionable Result.

–           This guidance applies to all GMP sites where chemical or physical testing of Test Articles intended for commercial distribution is performed.

–           This guidance applies to test results generated during chemical or physical testing of test articles intended for commercial distribution. The scope includes only those tests for which a Regulatory Specification (RS) and/or a regulatory stability Protocol exists. Production Materials are included within this scope if they have regulatory specification. This guidance does not apply to materials tested by biological methods, results generated during instrument set-up, standardization or suitability or to Test Method Validation.

–           Detection of an OOS or Questionable Result shall prompt a review by the Lab Supervisor of the relevant laboratory records.

–           If obvious errors are not found that explain the OOS or Questionable Result, or if obvious errors are found that require generation of new, valid data, an Analytical Laboratory Investigation (LI) is initiated using a Laboratory Investigation Report (LIR) Form. The LIR is designed to document all findings and conclusions.

–           The laboratory must establish a log and numbering system for LIRs.

–           The initial investigation phase of the LI and the Investigational Measurements Protocol (IMP) are performed to determine if an Assignable Cause (AC) (e.g., a Laboratory Error or sampling error) exists that could have caused the OOS or Questionable Result.

–           A Retest Protocol may be prepared if no assignable cause is established following both an Initial Investigation and the execution of an IMP. A retest protocol is used to determine if the original OOS or Questionable Result is valid and representative of the Batch/Lot. However, the OOS or Questionable Result may be accepted as valid following the Initial Investigation with no further testing.

–           All Original and Retest Results must be documented in the LIR, forwarded to the Quality Assurance (QA) Manager and considered in batch/lot release decisions.

–           An Evaluation of the Potential Impact on other samples analysed during the initial testing must also be performed when an assignable cause is found. All test results within the affected run must be assessed for validity. An evaluation of the potential impact on samples that were tested at other times, which may have been affected by the assignable cause, shall also be performed.

The investigation shall extend to other materials or products that may have been associated with the specific failure or discrepancy.

The Site Quality Review Team shall be informed by the Site Quality Team of any of the following events that may result in a potential Market Action:

a. OOS;

b. Questionable Result; or

c. Significant Negative Stability Trend.

On behalf of the Site Quality Review Team, the Site Quality Team is then responsible for:

 Assuring required documentation relevant to the above events are completed and issued in a timely manner;

a. Notification of the responsible quality operations area leader for evaluation and determination of the need for area quality review team review; and

b. Notification of relevant Regulatory Authorities, when required by local regulations.

–           Re-sampling of Drug Products, Active Pharmaceutical Ingredients (API), Medical Devices and Production Materials is not permitted unless documented evidence is provided that the original sample was not representative or was insufficient in quantity. The QA Manager must document and Approve all re-sampling of these materials.

–           LIRs shall be reviewed, at least, once per year to determine if trends are observed that require further corrective action.

–           Any Discovery of an OOS or Questionable Result is to be reported to the Lab Supervisor. This must be done before any investigational measurement or retesting is begun.

The Lab Supervisor shall determine if obvious errors (such as calculation errors) exist that might have caused the OOS or Questionable Result. If such an error is found and the error does not require generation of new raw data, the OOS or Questionable Result is considered an Invalidated Result and no further Investigation is required, unless a systemic error is found that would impact other testing. If such errors are not found, the Lab Supervisor initiates a further investigation. All original sample solutions, standard solutions, glassware, and Reagents used in the analysis, and subsequent investigation, shall be retained to the extent possible, until the LI is completed.

Initial Investigation:

–           Initial investigation must be completed by the end of the next Business Day following discovery of the OOS or Questionable Result, if these test results might impact products currently on the market, which may result in a market action. When an OOS is the result of stability testing, the need to complete the Initial Investigation within one business day only applies to sample stored at labelled storage conditions (i.e., does not apply to sample stored under accelerated conditions.

After opening the LIR, the Initial Investigation to determine assignable cause begins by the Lab Supervisor holding discussions with the Lab Analyst and completing the LIR Form Section “General Information”. In cases where more than one lot of material is investigated for the same problem, only one LIR is required. All affected lots must be clearly listed. The Initial Investigation also includes but is not limited to, examinations of the following (LIR Form Section “Review of Testing Parameters”):

a. Analytical records (raw data/laboratory notebooks),

b. Analytical procedures used,

c. Calculations,

d. Instrumentation, and

e. Sample preparations.

–           The Lab Supervisor completes the Initial Investigation using the LIR Form Section “Findings/Conclusions from Initial Investigation” and Section “Conclusion Summary and Approval of Initial Investigation”.

–           If a Readily Apparent Assignable Cause is determined by the Initial Investigation, the initial OOS or Questionable Result is invalidated. The assignable cause shall be documented in the LIR Form Section “Conclusion Summary and Approval of Initial Investigation”. Testing is then repeated to generate valid, original results.

–           The OOS or Questionable Result may be accepted as valid following the Initial Investigation with no further investigational measurement or retesting.

–           An Evaluation of the Potential Impact on other samples analysed during the initial testing must also be performed when an assignable cause is found. An evaluation of the potential impact on samples that were tested at other times, which may have been affected by the assignable cause, shall also be performed. All test results within the affected run must be assessed for validity. A statement documenting the assessment and the decision must be documented on the LIR Form.

–           If No Readily Apparent Assignable Cause is Determined by the Initial Investigation, it may be necessary to issue an Alert report to notify others of the situation. The Lab Manager shall determine whether an alert report is needed and notify the QA Manager if an alert report is needed. The QA Manager shall ensure that such reports are issued within one business day of discovery if these test results might impact products currently on the market.

Investigational Measurements:

–           If no readily apparent assignable cause is determined by the Initial Investigation and the OOS has not been accepted as valid, an Investigational Measurement Protocol (IMP) shall be developed.

–           The IMP defines the types and number of Investigational Measurements that will be performed. The IMP must be approved by the Lab Supervisor prior to execution.

–           LI Investigational Re-measurements on the Original Solution shall not be conducted prior to approval of the IMP.

–           The IMP typically consists of re-measurements of the original sample solution. Where applicable, re-measurements of sample solutions must be accompanied by standard solution measurements.

–           A stock sample solution and/or solutions of intermediate dilutions, prepared during the preparation of the final sample concentration, may be re-diluted to obtain re-diluted final solutions as part of the IMP.

–           Re-measurements and Measurements of Re-diluted solutions shall be conducted using the same equipment as the original measurement, whenever possible. Use of other equipment is permitted, provided the rationale is fully documented in the LIR.

–           Alternate Test Procedures may be used to provide additional information during an IMP exercise. However, the alternate test procedure shall not be used to approve material that has initially produced any OOS results using the primary test procedure.

Upon completion of the IMP exercise, the Lab Supervisor completes LIR Section “Findings/Conclusions from Investigational Measurements and Alert Evaluation”.

a. If assignable cause is clearly identified as a result of the IMP exercise, the initial OOS result is invalidated. The original testing is repeated to generate valid original results; and

b. If no assignable cause is identified as a result of the investigational measurements, the Lab Manager must evaluate the need for an Alert and if needed, inform the QA Manager who shall issue an Alert Report (as per site procedure).

The Data Generated During the IMP are for investigation only and shall not be used as a valid test result.

Repeating the Test (Assignable Cause Identified):

–           When an assignable cause is identified, by results of either the Initial Investigation or Investigational Measurements, the original OOS result is invalidated.

–           All sample tests that were invalidated by establishment of an assignable cause are repeated. The result will replace the original invalidated results only. The original sample preparation(s) shall be used for this testing if the assignable cause was not due to the sample preparation and if the sample preparations are stable.

–           A single analysis is performed to replace a single initial OOS or Questionable Result. (For example: An assignable cause has been identified for one of the ten results from a Content Uniformity test or one of the six results from a dissolution test. The original single result is invalidated. To replace the single invalidated result, test one additional dosage unit for the content uniformity test or perform a dissolution test using one dosage unit.) LIR Form Section “Repeat/Retest Protocol” and Section “Repeat/Retest Results” shall be used to document the Repeat Tests and the results obtained.

–           An evaluation of the potential impact on other samples analysed during the original testing must also be performed. All test results within the affected run must be assessed for validity. This may be accomplished through the analysis of a Control Sample.

–           An evaluation of the potential impact on samples tested at other times that may have been affected by the assignable cause that was found shall be performed.

Retesting (No Assignable Cause Identified):

 –          A Retest Protocol is prepared.

–           LIR Form Section “Repeat/Retest Protocol” shall be approved by the Lab Supervisor prior to any retesting.

–           The Retest Protocol must be based on the specific problem identified, the history of the product, method and batch/lot and must delineate the number of retests to be performed.

–           Where sample is available, the retest protocol must be executed using the same sample set that was the source of the original OOS or Questionable Result. The retest protocol may include testing on the same composite sample preparation that was the source of the original result, if available, unless there is scientific rationale for not using the same composite sample. The rationale must be documented.

For instance, if an aliquot of a composite grind from a solid sample has one or more OOS or questionable results, testing of the original tablet grind may be included in the retest protocol.

–           A minimum of three (3) retests is required for all types of samples, except: A minimum of five (5) retests is required for formulated products (i.e., In-Process and finished product samples).

–           A Control sample may be used to verify the Accuracy of the analyses. The retest protocol must specify acceptance criteria for the control sample.

–           An analyst other than the one who performed the original test may perform retesting.

–           Uniformity of Dosage Units and Dissolution Tests which progress to the next stage of testing, as defined in the Site documents that identify applicable, current Compendia requirements, are not considered OOS. An LIR is only required when test results are outside Specifications defined for the final stage of testing.

–           Uniformity of Dosage Units and Dissolution Analyses are taken to the next stage of testing per current compendial procedure when applicable, unless assignable cause is clearly identified.

–           If no assignable cause is found for an OOS or Questionable Result for Uniformity of Dosage Units and Dissolution Analyses, testing beyond that required by the applicable, current compendia is not permitted for the purposes of material approval.

Assignable Cause (AC):

Test Results, Whether In-or Out-of-Specification, that are obtained under the following conditions must be invalidated and the test repeated. These are also several of the classifications that are included on the LIR Form to document types of assignable causes:

a. Sample – the original sample was not representative or was insufficient in quantity;

b. Method/Documentation – unclear test method or Standard Operating Procedure (SOP) directions which resulted in incorrect test execution;

c. Analyst Error – examples include, but are not restricted to, incorrect weight of sample used, sample or sample solution spills, dilution errors, or improper test procedure; and

d. Instrument/Mechanical/System Malfunction – examples include, but are not restricted to, interfering electrical surges or spikes, pump stops pumping, or injector stops injecting.

Assignable causes that do not require the determination to be repeated include, and are not limited to:

a. Calculation Error – results that are determined to have been miscalculated. The results shall be recalculated without retesting and without an LIR unless an LIR has already been generated prior to discovery of the error. When error correction results in the discovery of an OOS or Questionable Result and there is no assignable cause, the result must be investigated per this guidance; and

b. Stability Trend – expected result due to existing stability data on that batch or lot.

Resample:

–           If evidence is provided that the original sample was not representative the material is re-sampled per approved sampling procedures established for the material and subjected to the initial testing requirement. If the approved sampling procedure is found to be the cause, an investigation must be initiated to assess the impact of the defective sampling technique on other batches.

–           Data from the original sample are retained in the analytical record, voided and not included in the batch disposition decision when it is established that the original sample was not representative.

–           Obtaining additional stability samples is permitted for confirmatory purposes. However, where possible, the sample that was the source of the initial OOS or Questionable Result must also be included in the retest protocol.

–           All stability samples from the same packaging lot and stored under identical conditions are considered equivalent for the purposes of this guidance.

Evaluation of Results:

–           If assignable cause associated with the original OOS or questionable result is found, the original result is invalidated.

–           If no assignable cause is found to be associated with the original OOS and retesting is performed, all test results shall be documented on the LIR, forwarded to the QA Manager and considered in batch/lot release decisions. All retest results are to be considered in the context of the overall record of the material and/or product being tested.

For Raw Materials (RM), Intermediates and API Samples, all retest results must be within specification to overcome the initial OOS result.

a. If all results obtained are within specification then the mean of the retest results shall be reported as the final valid result; or

b. If any of the results obtained during retesting are outside of the specifications then the original OOS result is confirmed and is reported as the final valid result.

For Formulated Products (i.e., In-Process and Finished Product Samples) and Medical Devices all retest results must be within specification and the original OOS result must be outside three (3) standard deviations of the mean of the retest results to be overcome.

a. If all retest results are within specification and the original OOS result is outside three standard deviations of the mean of the retest results, then the average of the retest results shall be reported as the final valid result;

OR

b. If any of the results obtained during retesting are outside specifications or the original OOS result is within three (3) standard deviations of the mean of the retest results then the original OOS result is confirmed and is reported as the final valid result.

–           No Statistical Analysis other than that described in this guidance is acceptable for interpretation of data.

–           If the TM is shown by investigation to be in question, a general review of the method must be conducted and required corrective action taken.

Reporting Results:

–           No OOS Result shall be averaged with retest results for reporting purposes.

–           For reporting results, the value determined to be the final valid result LIR Form Section “Repeat/Retest Results” is to be used (e.g., the average of the retest results, or the confirmed initial OOS).

–           For multi-component analyses in a single run of finished drug product, the impact of retesting must be evaluated for all components.

For example, a product containing two (2) components that are assayed simultaneously may yield an OOS result for one component only. During retesting, results for both components must be calculated. Assuming neither component yields an OOS result during retesting, and that the OOS result is not within three (3) standard deviations of the average retest result, the retest results for the component with the original OOS are averaged and reported. In this situation, the retest results for the second component are also averaged and reported due to the fact that no assignable cause was determined for the original OOS and it is unknown if this cause has impacted the result for the second component.

–           Upon completion of the LI for initial OOS results, the Site Quality Team shall inform the Site Quality Review Team of the outcome of the investigation. The Site Quality Review Team shall determine if issuance of any reports to the relevant Regulatory Authorities is required. This would include an update to any filed initial NDA-Field Alert Reports. .

–           In the event of a confirmed OOS result, it may be necessary to issue an alert report to other departments within the site to notify them of the situation. The QA Manager shall ensure that such reports are issued within one business day following confirmation of an OOS result.

The QA Manager shall also evaluate the need for an investigation into the source of the confirmed OOS result and ensure that any necessary investigations are completed.

Closing the Laboratory Investigation:

–           LIR Form Section “Overall Conclusions” and if relevant, Section “Corrective Action Plan” are completed by the Lab Supervisor. Corrective actions as a

result of LIRs shall be tracked and documented evidence of these activities shall be available.

–           The completed LIR shall be approved by the Lab Manager and the QA Manager, using LIR Form Section “Laboratory Investigation Report Approval”.

All LIRs must be completed and fully approved within twenty (20) business days of the discovery of the initial OOS or Questionable Result. If the laboratory investigation will go beyond twenty (20) business days, an interim status report must be issued to the QA Manager containing, at least, the following:

a. The date of discovery of the OOS or Questionable Result,

b. Reference to the LIR general information,

c. Reason for the delay,

d. Current status of the investigation, and

e. Estimated date for completion of the LIR.

–           The Approved LIR shall be archived by the Quality Team.

–           The Approved LIR shall be distributed as per Site procedures.

–           LIRs shall be reviewed, at least, once per year to determine if trends are observed that require further corrective action.

Figure 1: Laboratory Investigation (LI) Process Flowchart

Example of Laboratory Investigation Report

Report No: _____________________                                     

Section I: General Information
Investigation Type: OOL or Atypical Result       Out-of-Specification (OOS)
Limits: 
  Microcount             Indicator Screening           Procedure Number:
Product/Substance Name: 
RM or BM #: Affected Lot Numbers(s): 
Analyst(s) Name: Date Problem Occurred: 
Dale Problem Discovered: Colleague Reporting Problem: 
Lab Manager: 
OOT/OOS Growth Type:  Bacteria      Yeast          Fungal         Unknown

Reason for Investigation:

Section II: Review of Testing Parameters
Check all that applies below and are reviewed
Review Performed by: Date:
Y = Yes N = No N/A = Not Applicable
Performed technician interview (see below): 
Approved procedure used: 
Instrument(s) within calibration/certification date: 
Procedure clear as written: 
Stability trend: 
Calculations performed correctly: 
Known production problem: 
    

 

Laboratory Controls:

a. Negative control Result

b. Growth promotion/evaluation for all growth media, diluents, filters and rinse fluids used.

c. Other products/materials with growth from the same test day

d. Other microbial results for this product.

Technician Interview:

Date of Interview:Technician(s) Who Performed Assay:
Laboratory Analyst:Others Present:
Discussion Topics: Any “no” or “do not know” response requires a comment in the summary section. NA = Not Applicable, DNK = Do not know.
NAYESNODNK 
    Technician: — Was technician trained and knowledgeable? Quarantined.
    Laboratory Records and Raw Data: — Review samples, weights, transcriptions, rounding, dilutions and raw data. Were all found to be acceptable?
    Calculations: — Were the calculations performed correctly’?
    Media, Diluents, Rinse Fluids: — Were the correct media, diluents, and/or rinse fluids used? Within expiry?
    Equipment/Instruments: — Did equipment function correctly? Was it within calibration range & expiry? List any concerns for equipment not functioning properly?
    Personnel Precautions: — Were precautions such as gloves, lab coats, and hand sanitants used during the testing of the sample?
    Testing Environment Precautions: — Was the testing areas properly sanitized? Was the material prepared / weighed / tested inside a laminar flow hood environment? Was the work environment stable? Were the laminar flow hoods operating properly? Identify any potential steps where the method may not he performing as designed? List areas of concern below.
    Positive Control Organisms: — Is the organism identified from the OOT/OOS a different strain than the positive control test organism used in the laboratory?
    Sample Storage & Handling: — Were the samples stored as per label, the sample container correct, storage correct and no evidence of breached or adulterated sample?
      
Additional Concerns or Unusual Occurrences:
Section III – Findings / Conclusions of Review:
 
Section IV – Conclusion Summary and Approval of Initial Investigation:

 Readily Apparent Assignable Cause

No Readily Apparent Assignable Cause Found

 Sample Method Analyst error
 Instr./equip Calc. error Stability trend
 Other:
Explanation:

 

Section V – Investigational Measurements Protocol (IMP):

(The Data Generated During IMP is for investigation only and

shall not be used as a final reported result)

 Microbial Identification (isolate submitted for identification upon discovery of OOS/atypical result)
 Personnel Monitoring
 Product History Evaluation
 Product Challenge Testing (Attach protocol)
 Other (Attach protocol)
 List additional investigational measurements:
Laboratory Manager:Date:
   

 

Section VI – Findings and Conclusions from Investigational Measurements

Protocol (IMP) and QA Alert Evaluation:

Findings:

 Apparent Assignable Cause

No Apparent Assignable Cause Found

 Sample Method Analyst error
 Instr./equip Calc. error Stability trend
 Other:
Explanation:
QA Notification Needed:       No  Yes
Laboratory Professional/Designee:Date:
    

 

Section VII – Retest Protocol (Use attachments if necessary):
 
Laboratory Professional/Designee:Date:
Section VIII – Retest Protocol Results:
 
Laboratory Professional/Designee:Date:
Section IX – Overall Conclusions and Determination of impact on Other Data
 
Laboratory Professional/Designee:Date:
Section X – Corrective Action Plan:
 
Analyst:Date:
Laboratory Professional/Designee:Date:
Section XI – Analytical Laboratory Investigation Report Approval:
Notification Reference:
Laboratory Manager/Designee:Date:
QA Manager/Designee:Date:

B. Foreign Matter Control, Testing and Inspecting of Sterile Products

–           This guidance applies to visual inspection and testing for and control of Foreign Matter in Sterile Active Pharmaceutical Ingredients (API) and sterile Drug Products intended for human use, as called for by Compendial requirements and/or the regulatory filing in the product market(s).

–           This guidance applies to GMP Production Sites and operations responsible for performing visual inspections and testing for and control of Foreign Matter in sterile APIs and sterile drug products intended for human use.

–           Manufacture of Sterile APIs and Sterile Drug Products shall include controls that minimize the introduction of foreign matter.

–           Parenteral drug product solutions in clear Containers shall be 100 percent inspected for foreign matter visually and/or by a Validated automated electronic inspection system.

–           Sterile API and sterile drug product batches/lots shall be sampled according to an Approved sampling plan and tested for foreign matter as called for by compendial requirements and/or the regulatory filing for the product market(s).

–           Foreign Matter Inspection and Testing shall be performed by Qualified personnel

–           Foreign matter test methods (TM) shall be validated for non-compendial test methods and Verified for compendial test methods. All test methods shall be maintained under change control. Automated systems used to perform foreign matter testing and computer-related laboratory systems shall include Validation of the Computerized Systems.

–           Test Samples of sterile drug product powder and lyophilized drug products shall be constituted and visually inspected prior to foreign matter testing.

Designated samples of sterile drug products shall be evaluated for foreign matter by visual inspection, after which they shall be tested for foreign matter using either:

a. Light obscuration testing; or

b. Microscopic particle counting and sizing.

Laboratory Instruments and Equipment used to perform foreign matter testing shall be Calibrated and/or standardized according to an approved schedule and shall include, and not be limited to:

a. Microscope ocular micrometers, and

b. Light obscuration instruments (e.g., HIAC).

–           A Collection of Photos, Illustrations and/or Actual Defects of foreign matter typically found in product shall be maintained.

Control of foreign matter in sterile APIs and drug products shall include such measures as:

a. Raw Materials and APIs with low particulate levels, if required by Specifications;

b. Raw material transport requirements to exclude gross contaminants (e.g., corrugation, paper, and wood)

c.  Vendor controls or processing steps to remove particulates from containers and Closures

d. Validation and routine maintenance of steam, water, and gas systems

e. Filtration of the product immediately prior to filling, where feasible

f. Personnel gowning procedures and

g. HEPA Filtered unidirectional airflow in Critical Zones

Personnel performing foreign matter testing shall be qualified in, at least, the following:

a. Laboratory procedures,

b. Foreign matter test methods, and

c. Operation of foreign matter test equipment.

Control of foreign matter in sterile APIs and Drug Products shall include such measures as:

a. Raw Materials and APIs with low particulate levels, if required by Specifications;

b. Raw material transport requirements to exclude gross contaminants (e.g., corrugation, paper, and wood)

c. Vendor controls or processing steps to remove particulates from containers and Closures

d. Validation and routine maintenance of steam, water and gas systems

e. Filtration of the product immediately prior to filling, where feasible

f. Personnel gowning procedures, and

g. HEPA Filtered unidirectional airflow in Critical Zones

Personnel performing foreign matter testing shall be qualified in, at least, the following:

a. Laboratory procedures,

b. Foreign matter test methods, and

c. Operation of foreign matter test equipment.

Sampling and Test Procedures for foreign matter determination shall be written and approved and shall include, and not be limited to:

a. Number of samples to be tested per batch/lot;

b. Amount of each sample to be tested;

c. Test methods;

d. Test equipment; and

e. Retest criteria (e.g., equipment malfunction, sampling error, sample spill) and methods.

–           Personnel performing foreign matter testing shall wear a clean, non-shedding garment, powder-free gloves, and clean hair and facial coverings.

–           Test samples designated for foreign matter testing shall have the outside of their containers rinsed with filtered (not greater than 0.45 micron filter) Purified Water

Visual Inspections, using manual inspection methods, for foreign matter in parenteral drug product solutions in clear containers shall be performed as follows:

a. Use inspection stations with illuminated matte black and matte white (BW) backgrounds;

b. Container contents swirled, container inverted and then returned to the upright position, and examined against the black background; and

c. Container contents swirled, container inverted and then returned to the upright position, and examined against the white background.

Test Samples of sterile powders or lyophilized drug products shall be visually inspected for foreign matter in the laboratory as follows:

a. The product shall be constituted or reconstituted according to a written procedure that shall specify the diluent to be used. Measures shall be taken to (PW) or equivalent water prior to test preparation. Foreign matter test samples shall be prepared in a horizontal HEPA filtered unidirectional airflow environment to ensure that foreign matter is not introduced when the sample is constituted or reconstituted;

b. Container contents swirled, container inverted and then returned to the upright position, and examined against the black background; and

c. Container contents swirled, container inverted and then returned to the upright position, and examined against the white background.

–           Sterile ophthalmic ointments shall be sampled and evaluated for metal particles, if required by specifications.

–           Sterile product test sample solutions shall be tested for foreign matter using light obscuration testing or microscopic particle counting and sizing on a membrane filter.

–           Viscous sterile drug products shall be evaluated during Test Method Validation to determine if a quantitative dilution of the drug product is required prior to testing for foreign matter.

Light Obscuration Test Equipment Criteria shall include consideration of the following:

a. Sensor Concentration Limits, and

b. Sensor Dynamic Range.

–           The Sensor concentration limit as certified by the supplier shall be greater than the expected concentration of particles in the samples to be tested.

–           The sensor dynamic range shall bracket the expected particle size range in the samples to be tested.

–           Installation Qualification (IQ) for light obscuration test equipment shall include, and not be limited to:

a. Verification that the equipment meets the manufacturer’s specifications;

b. Identification of utilities (e.g., electrical) and Instruments and Elements (I/Es); and

c. Calibration of I/Es.

–       Operational Qualification (OQ) for light obscuration test equipment shall include, and not be limited to, verification of the sensor concentration limit and sensor dynamic range using spheres of known sizes. OQ shall be conducted using a range of sphere sizes that shall encompass the expected size range of foreign matter and include verification of:

a. Sample volume accuracy,

b. Sample flow rate, and

c. Particle count accuracy (e.g., USP method).

–           Performance Qualification (PQ) shall be performed for light obscuration testing as a part of method verification or validation.

IQ for Microscopic Test Equipment shall include, and not be limited to:

a. Verification that the equipment meets the manufacturer’s specifications;

b. Identification of utilities (e.g., electrical) and I/Es;

c. Calibration of I/Es;

d. Verification of the operation of external and internal illuminators; and Calibration of ocular micrometers.

–           OQ for microscopic test equipment shall include, and not be limited to, performing microscopic particle counting and sizing using gridded membrane filters of different sizes (e.g., 25 mm and 47 mm).

–           PQ shall be performed for microscopic particle counting and sizing as a part of method verification or validation.

–           Prior to performing light obscuration testing or microscopic particle count testing, verify that the background particle level (i.e., filtered water blank count) meets the acceptance criteria.

–           Foreign matter test results shall be determined for each size range according to compendial requirements and/or the regulatory filing applicable to the product filing in the drug product market(s).

–           An Investigation shall be conducted and documented when foreign matter test results exceed specifications.

–           An Investigation shall be conducted and documented after an event that could potentially contaminate the sterile API or drug product with foreign matter (e.g., broken agitator shaft, broken bolts or augers in filling machines).

–           An Investigation shall be conducted and documented when the Acceptable Quality Level (AQL) for visible foreign matter is exceeded as determined by the results of a 100 percent visual inspection or an automated electronic system inspection of the sterile drug product solution. The investigation shall establish, when possible, the identity and source of the foreign matter.

C. Evaluation and Investigation of Trace Unidentified Chromatographic Peaks

–           This guidance defines the process for ensuring consistent evaluation and Investigation of Unidentified Peaks. This guidance applies to all methods used for the assessment of impurities (e.g., Specified Impurities and Unspecified Impurities). This guidance also applies to assay methods for the Active Pharmaceutical Ingredient (API) when a separate method for impurity assessment does not exist. This guidance does not apply to limit or identification tests.

–           If a significant unidentified peak is observed and is not included in the scope of guidance, the peak can be investigated (see Ref 1).

–           This guidance applies to the assessment of impurities for release and stability testing of marketed and clinical research Batches and Lots manufactured in GMP facilities and to complaint samples of the following substances:

a. Ophthalmic, injectable, topical, and ingestible human Drug Products;

b. Ophthalmic, injectable, and ingestible animal drug products;

c. Over-The-Counter (OTC) human ingestible products;

d. APIs;

e. Medical Devices; and

f. Reserve Samples tested within their expiration periods.

This guidance does not apply to the following:

a. Dissolution and Content Uniformity testing;

b. Cleaning verification testing;

c. Topical animal products;

d. Excipients, Raw Materials (RM), In-Process Materials, and Intermediates;

e. Biological or biotechnology products, peptides, oligo-nucleotides, radiopharmaceuticals, fermentation products, semi-synthetic products derived from fermentation, herbal products, and crude products of animal or plant origin;

f. Quality Control Reference Standards qualification;

g. Laboratory Qualification using the Analytical Method Transfer Exercise (AMTE) process; and

h. Test Method Validation Protocols.

–           Unidentified Peaks from the Samples shall be evaluated and investigated. Based on scientific judgment, if an unidentified peak is observed in the standard, it can be evaluated per this guidance.

–           A Laboratory Investigation (LI) shall be conducted into the source and, if necessary, the identification, of unidentified peaks that exceed applicable Investigation Thresholds. If investigation thresholds are provided in the Test

Methods (TM), they shall be applied. If investigation thresholds are not provided in the TM, the thresholds from the International Conference on Harmonization (ICH) guidance shall be followed.

–           The Presence and Amount of all Confirmed Unidentified Peaks Above the Investigation Threshold must be reported. The evaluation, investigation and reporting of such peaks shall be performed according to this. Reports of unidentified peak occurrences shall be reviewed by the responsible Lab Supervisor to determine if subsequent actions are required.

–           The Lab Analyst shall be responsible for the routine evaluation of chromatograms using an expanded scale to enable the signal-to-noise ratio to be determined, and for alerting the Lab Supervisor of the presence of any unidentified peaks above the threshold prior to initiating further investigation.

–           The Lab Supervisor shall be responsible for initiating an LI if one is needed, to confirm the presence of unidentified peaks in the sample chromatograms.

–           The Lab Supervisor shall determine if an internal Alert is needed and shall notify the Quality Team. When an internal alert is required, the site Quality Team shall notify the Site Quality Review Team (SQRT). The SQRT shall review any internal alerts issued for further investigation and determine what actions need to be taken for marketed lots. The SQRT shall review the potential impact of unidentified peaks found in marketed lots within expiration period and determine if an NDA-Field Alert Report is needed.

–           The Lab Supervisor shall assure that the unidentified peak continues to be reported when the peak is observed in any samples of the same material after the original confirmation unless otherwise directed by the SQRT or through a revision to the TM.

–           Each Chromatogram shall be examined on an expanded basis so that small peaks, if present, can be clearly seen. Any retained unidentified peaks above the threshold (i.e., peaks eluting after the Column Void Volume that are not apart of the typical profile of the Solvent blank) shall be noted. Lab Analysts shall routinely include a sample diluent blank with the chromatographic runs to facilitate the evaluation of peaks. The Lab Analyst shall notify the Lab Supervisor immediately if any unidentified peaks are present.

–           When an Integrator is Used, the System Suitability injections shall be collected under full scale conditions while the remaining portion of the runs shall be collected at a lower attenuation level so trace peaks can be observed with the API off-scale.

–           Chromatograms shall be compared with any chromatogram included in the TM, Certificate of Analysis (COA),or other technical document. If the peak observed is listed as a known compound or a characterized entity (i.e., Identified Impurity) in the TM, no further unidentified peak investigation shall be required; and the peak and quantity shall be reported as per the TM.

The Percent of the Unidentified Peak shall be determined following calculations described in the TM or Specification. If instructions are not provided in the TM or specification, one of the following methods shall be used:

a. For Chromatographic Profiles where a single API is present and within detector range, the percent is calculated as the response of the unidentified peak divided by the response (area or height, as defined by the method) of the API in the chromatogram and the result multiplied by one hundred (100);

b. If the chromatographic profile contains multiple APIs, then the percent is calculated as the response of the unidentified peak divided by the response of the smallest main peak in the chromatogram and the result multiplied by one hundred (100); or

c. For chromatographic profiles where the API is either absent from the chromatographic profile or the response from the API exceeds the detector range, the size of the unidentified peak shall be compared to a dilute solution of a known reference material prepared at a concentration near the investigation threshold (an internal standard, or low level external standard can be used to Quantitate). When possible, the API shall be selected as the reference material. When this is not possible, a reference material with a similar response factor and/or structure as the API shall be used (e.g., degradant or process impurity).

–           The Final Numerical Result for the Unidentified Peak shall be rounded to the number of decimal places indicated for the investigation threshold for substance being analyzed.

–           The Percent of the Unidentified Peak shall be compared to the investigation threshold for the analyzed material to determine if the level of the unidentified peak response exceeds the threshold. If the product contains multiple APIs, the investigation threshold that corresponds to the API that was used in the calculation of the level of the unidentified peak shall be used for comparison.

–           If an Investigation Threshold is not defined for the test material in either the TM, specification, or other local Site document, the following default thresholds shall be used:

ICH Thresholds for APIs

Maximum Daily Dose1Threshold 2,3
≤2gper day0.10% or 1.0 mg per day intake
 (whichever is lower)
> 2 g per day0.05%

a. The amount of API administered per day.

b. Lower thresholds can be employed if the impurity is unusually toxic.

c. Higher thresholds must be scientifically justified.

ICH Thresholds for Dosage Forms

Maximum Daily Dose1Threshold 2,3
<1mg1.0% or 5 µg, whichever is lower
1mg-10 mg0.5% or 20 µg, whichever is lower
> 10 mg -2 g0.2% or 2 mg, whichever is lower
> 2 g0.10%

a. The amount of API administered per day.

b. Thresholds for degradation products are expressed either as a percentage of the API or as total daily intake (TDI) of the degradation product. Lower thresholds can be used if the degradation product is unusually toxic.

c. Higher thresholds must be scientifically justified.

The Percent of the Unidentified Peak shall be compared to the investigation threshold. If the percent is less than the investigation threshold no investigation or Laboratory Investigation Report (LIR) is required. Some example comparisons and actions are listed below for a fifty (50) mg maximum daily dose product with an investigation threshold of 0.2 percent:

Unidentified Peak Level Not Rounded, “Raw” Result (%)Reported Result (%)Action
0.04Not ReportedNo investigation required
0.16Not ReportedNo investigation required
0.21430.2No investigation required
0.3490.3Initial investigation
0.5500.6Initial investigation

–           To Verify that the Height of the Unidentified Peak is Greater than Three (3) Times the Baseline Noise expand the chromatogram so that the baseline noise can be clearly seen and its height accurately measured. The height of the unidentified peak is then measured to determine the signal. Calculate the signal-to-noise ratio for the unidentified peak.

–           Unidentified Peak Investigation – when an unidentified peak exceeds the investigation threshold, the signal-to-noise ratio is greater than three (3), and no readily apparent Assigned Cause is found, the Lab Supervisor shall initiate an LIR and complete the initial investigation sections. Indicate N/A for “Readily Apparent Assignable Cause” and proceed to the “Investigational Measurements” section of the LIR.

–           For Each Unidentified Peak, the Relative Retention Time (RRT), amount (e.g., area percent), and threshold limit shall be recorded in the LIR Section III, “Findings/ Conclusions from Preliminary Review”.

–           A New LIR shall not be required for samples that exhibit the same unidentified peak that is the subject of a previous LIR for other batches or lots of the same API, medical device or drug product. In such instances, the original LIR shall be cited in the test record and an explanation included in the test record to explain how the peak was concluded to be the same as that cited in the original LIR (e.g., by RRT agreement).

–           When Completing the Investigational Measurements Portion of the LIR, it is not necessary to complete all steps if one of the steps leads to a conclusion of the investigation. Investigational Measurement steps of an LIR may be completed in any order.

To Determine if the Unidentified Peak is an Artifact, information from the chromatographic sequence in which the peak was observed shall be reviewed. The following steps provide example situations to consider in determining if the unidentified peak is an artifact:

a. To confirm that the unidentified peak is not caused by the sample diluent, inject an aliquot of the sample diluent into the chromatographic system. If a diluent blank was included in the original chromatographic sequence, it is not necessary to repeat the diluent injection. The resulting chromatograms shall be examined to determine if the unidentified peak is present in any of the diluent blank injections. If the peak is observed as a result of injecting the sample diluent into the chromatographic system, this peak is concluded to be an Artifact Peak and shall be documented as such in the test record;

b. If the peak cannot be attributed to the sample diluent, additional injections of the original sample shall be performed. These injections are for “Information Only” and are not to be used for quantitation. The unidentified peak shall be confirmed as being present at the same RRT in each chromatogram, including the original chromatograms where the unidentified peak was first observed; or (To Determine if the Unidentified Peak is an Artifact):

c. Ensure that the observed unidentified peak is not due to a component from an earlier injection of sample or standard that has a longer RRT than the length of each chromatographic run. Ensure the system is clean (for example by flushing), and evaluate the column in use. If the peak is not observed in each injection of the sample preparation and is not reproducibly attributable to an earlier injection, the unidentified peak can be attributed to an artifact of the chromatographic system.

If the Source of the Unidentified Peak was Determined to be an Artifact Peak, the LIR shall be closed. The source of the artifact, if known, shall be documented in the test record and in the LIR. Possible causes of artifact peaks include, and are not limited to, the following:

a. Improperly cleaned glassware;

b. Old or contaminated solvents and Reagents;

c. High Performance Liquid Chromatography (HPLC) column; and

d. Contamination within the HPLC equipment.

Original results shall be reported if the artifact is determined to have no impact on test results.

–           If the Unidentified Peak has not Been Previously Reported, expanded chromatograms from historical data, if available, shall be examined to determine if the unidentified peak is observed in older, marketed lots of API or drug product. If the peak is observed in historical chromatograms and is not present in the new lot at levels that are greater than in the historical data, no further investigation shall be required.

–           If the Source of the Unidentified Peak Cannot be Explained, two additional sample preparations shall be prepared and analyzed according to the original TM. Such injections are for “Information Only” and shall not be used for quantitation. If the unidentified peak is not detected in the new sample preparations, the unidentified peak originally observed shall be attributed to an artifact of the chromatographic system and/or sample preparation technique and shall be noted in the test record; however, the unidentified peak shall not be reported as an impurity in the final result. The LIR shall be closed.

–           If the Unidentified Peak Cannot be Attributed to a Known Impurity or Degradant, an Artifact, an Excipient-Related Peak, and Cannot be Excluded by Comparison to Historical Sample Profiles, it shall be concluded to be a new Unknown Peak. The unknown peak shall be recorded in the test record and identified by its RRT and percent.

–           The LIR shall be closed at the end of the investigation into the source of the unidentified peak. The LIR shall not remain open while subsequent actions determined during SQRT review are completed.

–           If the Unidentified Peak is Confirmed at the Close of the LIR, the Lab Supervisor shall be responsible for notifying the Site Quality Team. When an internal alert is required, the Site Quality Team shall notify the SQRT. The SQRT shall review the LIR and other background information relevant to the lots and product in which the unknown peak was found and shall decide what actions, if any, are required for further identification of the unknown peak. The SQRT shall also be responsible for making a decision about the disposition of the affected lot. The SQRT shall be involved if an unidentified peak is confirmed in a marketed lot within its expiration period.

–           Confirmed Unknown Peaks Found in Stability Studies Under Accelerated Conditions shall be compared to the findings under labeled storage conditions to determine the need for further action. The process for analytical laboratory investigations may be used for this comparison.

–           If a Drug Product or an API is the subject of an active investigation into the identity of an unknown chromatographic peak and the SQRT is in agreement with the investigation, additional lots exhibiting the same peak do not require additional SQRT review. Actions recommended by the SQRT for the initial lot(s) shall be applied to subsequent affected lots. However, if the unknown peak is observed at significantly higher levels in either a different lot or a different stability interval, the peak must again be brought to the attention of the SQRT. The Lab Supervisor from the laboratory from which the LIR was issued shall be responsible for follow-up to identify the peak and completion of the action items.

–           The Lab Supervisor from the Laboratory from which the LIR was issued shall ensure that the unknown peak is documented in the test record related to the API or drug product in which it was found. In addition, the documentation must reflect that the unknown peak has been referred to the relevant technical group for identity investigation.

The Lab Supervisor shall ensure that the unknown peak continues to be reported in the test records when the peak is observed in any additional samples tested after the original confirmation. Reporting continues unless otherwise directed by SQRT or through a revision to the TM.

–           Inclusion of Identified Peaks in the TM or Specification – following confirmation of the source or identity of the unknown peak, updates to the TM or specification shall be considered. The updates which have Regulatory Impact shall be handled through the Product Change Request System.

Updates to the TMs shall include consideration of, and not be limited to, the following:

a. Identification of the confirmed unknown peak along with representative chromatograms;

b. Discussion of how quantitation will be accomplished, as well as, reporting limits for the test results; and

c. Inclusion of peaks routinely observed but which are not due to impurities or degradation products (e.g., peaks caused by product excipients).

Figure: Decision Tree for Unidentified Peak

D. Laboratory Documentation

–           This guidance defines requirements for the handling and control of laboratory documentation (paper-based and electronic) to ensure information is in compliance with regulatory requirements, and is readily available and retrievable.

–           This following practice may be applicable ti laboratories where Analytical Methods are performed that are associated with products in or intended for the marketplace. This includes testing performed to support the evaluation, characterization, or Disposition of Test Articles to assure the data generated in the laboratory are accurately recorded and acceptable for use in assessing the quality of the product. This includes analytical, bioanalytical, and microbiological laboratories.

–           This practice also applies to stability testing, package component testing, and other non-routine testing, and method Validation performed by GMP laboratories. Laboratory Records and Data shall be retained in accordance with the Site Record retention requirements. Standard Operating Procedures (SOP) shall be established at the GMP site to define additional laboratory recordkeeping requirements.

–           Laboratory Records shall be legible, accurate, and complete and shall be recorded in sufficient detail to allow for a complete reanalysis, if required. All Results shall be traceable to the raw (i.e., original) data. Laboratory Records must be checked by a second Qualified person. Review and Approval of Laboratory Records shall be performed and documented in a timely manner and per site SOPs. Laboratory Control Mechanisms [e.g., Specifications, standards, sampling plans, Alert/Action Levels and Test Methods (TM)] shall be approved. Out-Of-Specification (OOS) Results and questionable results shall be addressed, investigated and reported as per site SOP. Deviations Discovered in Laboratory Records shall be Investigated, documented, and approved by the site quality Team.

–           Logbooks or Equivalent Systems shall be utilized to track laboratory instrument maintenance and use.

–           Laboratory Records shall include and not be limited to, the following information:

* A description of the sample received, with:

–           Identification of source;

–           Quantity (e.g., units per Batch or Lot);

–           Batch Number or Lot Number;

–           Date sample was taken; and

–           Date sample was received for testing;

* Batches or samples analyzed;

* Test method(s) and method version(s) used;

* Description of any deviation or a reference to documentation of this deviation;

* Modifications of established methods, if any, employed in testing, (prior approval is required for the use of a modified method);

* Reference Standards and Reagents used;

* Weight or measure of sample(s) and standard(s) used for each test;

* Unique identification of instruments used;

* Calibration information for instrumentation, such as last or next calibration dates;

* Comprehensive records of relevant data secured in the course of each test, including graphs, charts, and spectra from laboratory instrumentation;

* Dates on which analytical work was conducted;

* Relevant calculations;

* Test results and comparisons to specifications;

* Each page containing manual entries shall be signed and dated by the person performing the tests; and

* Signature of a second person, and the date, indicating that the original records were reviewed for accuracy, authenticity, completeness and compliance with established standards.

–           All Paper-Based Laboratory Records shall be recorded in indelible (i.e., permanent) ink, such as blue or black ink.

–           Errors in Recording or Transcribing Laboratory Records shall be corrected in such a way as to show the original data, the corrected data, the initials or signature of the individual correcting the data, the date of the correction, and the reason for the correction if it is not obvious.

–           Use of Informal Transcription on loose, uncontrolled forms, or other unofficial recording media (e.g., scrap paper) is prohibited for data collection. Acceptable alternatives include use of bound or numbered laboratory records or use of an equivalent electronic system [e.g., Laboratory Information Management System (LIMS)].

–                      Review of Laboratory Records requires inspection of legibility, organization and clarity, accuracy, consistency, completeness, compliance with established procedures, and assurance of unambiguous dating of events. The data shall be checked for conformance to specifications when the test is completed, and results of the review documented, signed or initialed and dated.

E. Laboratory Management

This guidance defines laboratory management practices for:

* Personnel training as applicable to the Job Function;

* Hazardous materials;

* Sample handling and testing;

* Laboratory facilities, equipment, and related systems;

* Calibration and maintenance of Laboratory Equipment;

* Control and maintenance of Reagents, Reference Standards, buffers, Microbial Cultures, Microbiological Culture Media,and Biological Indicators (BI);

* Monitoring and control of the microbiology laboratory environment; and

* Documentation and control of test results.

This guidance applies to all analytical and microbiology laboratories at GMP sites where testing is performed on Pharmaceutical or Animal Health products in or intended for the marketplace or on materials used in such products including:

* Raw Materials,

* Regulatory Starting Materials,

* Intermediates,

* Active Pharmaceutical Ingredients (API),

* In-Process Materials,

* Drug Products,

* Biologics, and

* Medical Devices.

–           Analytical and Microbiology Laboratories shall be separate, designated areas with limited access and shall be maintained in a clean and organized state. Practices shall be established at each GMP site to assure laboratory housekeeping is maintained. Work surfaces in the microbiology laboratory (e.g., benches, biosafety cabinets, unidirectional airflow units) shall be cleaned, organized, and disinfected prior to and after use, using a Disinfectant that is effective in cleaning the expected types of organisms.

–           Laboratory Equipment shall be maintained in a clean state and shall be stored in a manner that prevents contamination. Incubators, refrigerators, ovens, and water baths, used in the microbiology laboratory, shall be cleaned and maintained according to an approved schedule.

Laboratory Instruments shall be:

a. Calibrated upon installation and, thereafter, according to an Approved schedule; and

b. Used within the calibration period; or

c. Calibrated upon use.

–           Laboratory Facilities and Equipment shall be Qualified. Automated laboratory equipment and computer-related laboratory systems shall include Validation of the Computerized System.

–           Laboratory Processes (e.g., Sterilization and Depyrogenation) shall be Validated. Equipment and utilities (e.g., vacuum, compressed air, gases) used shall be properly designed, Commissioned and/or qualified.

–           Laboratory Water Systems shall be qualified for their intended use. The water system shall be maintained, monitored on a routine basis and must be suitable for use for the specified Test Method (TM) or test material preparation. In addition, the water system in the microbiology laboratory must, at a minimum, meet the quality attributes for Purified Water (PW).

–             Non-Compendial Test Methods used for release testing and stability testing shall be validated to the established standard in place when the method was developed. The suitability of all test methods used shall nevertheless be qualified under actual conditions of use and documented.

–              Established and previously validated non-compendial methods shall be re-validated to contemporary standards when a regulatory agency requires such re-validation as a condition of filing (e.g., registration recertification, registration amendments, or refiling).

–              All test methods shall be maintained under change control. Other methods, such as in-process test methods, shall be validated as specified by approved procedures.

–           Personnel Performing Testing and personnel approving test results shall be Qualified.

–           Biological, Toxic, and Hazardous Waste Materials shall be handled according to local, regional, and/or national guidelines and Corporate Environmental Health and Safety (EHS) Guidelines.

A Sample Handling System shall be in place and include provisions for:

* Sample receipt, proper sample labeling, and sample log-in;

* Prevention of sample loss, sample mix-ups, and contamination;

* Verification that information on the sample label matches the accompanying document submission;

* Identification of potent, toxic or hazardous compounds requiring special precautionary measures;

* Sample storage at room temperature unless otherwise indicated;

* Tests performed within a defined time period after sample receipt;

* Investigation of sample mix-ups or contamination;

* Sample retention until all tests are completed and there is a determination as to whether a result is valid or invalid; and

* Sample destruction or disposal.

–           Controls for Preventing Cross Contamination shall be available and implemented.

–           Reference Standards used for testing Production Materials, APIs, drug products, and medical devices shall be obtained or established, used, controlled, maintained and approved according to written procedures approved by the Site Quality Team.

–           Laboratory Materials for Testing, such as reagents, buffers, reference standards, microbial cultures, microbiological culture media, and BIs, shall not be used beyond their Expiration Dates. Expired materials shall be discarded promptly. An investigation shall be conducted if expired materials are used in error.

–           The Identity of Microbiological Control Cultures, when purchased from sources other than American Type Culture Collection (ATCC) and National Collection Type Culture (NCTC), shall be verified to, at least, the genus and species level.

–           Every Sterilized Batch/Lot of Media shall be tested for growth promotion, sterility and pH after sterilization.

–           Glassware shall be controlled and cleaned in a manner that ensures the glassware is suitable for its intended use. Glassware used in microbiological tests shall be sterilized and/or depyrogenated, when required, using validated methods. Single use materials (e.g., plastic) shall be disposed of after use.

–           Laboratory Records shall be maintained as per site SOP.

–           Any Out-of-Specification (OOS) Result or Questionable Result shall be investigated

Environmental Monitoring for Sterility Testing shall be conducted according to an approved schedule and shall include, and not be limited to, the following:

* Unidirectional Airflow units, including biosafety cabinets;

* Sterility Test Isolator Systems (STIS):

* Sterility test suites; and

* Gown and glove monitoring of personnel performing sterility testing

Records shall be maintained for each sterilization/ depyrogenation load including:

* Date and time of sterilization/depyrogenation;

* Identification of person performing sterilization/ depyrogenation activities;

* Identification of all equipment and components in the load;

* Cycle identification;

* Sterilization/depyrogenation Batch Number or run number;

* Documentation of the review of sterilization/depyrogenation cycles, including indication of pass/fail status, initials, and date; and

* Sterilization/depyrogenation records retained according to current SITE retention policies.

–           The Use of Contract Testing Laboratories shall be approved by the Site Quality Team and shall be conducted according to a Quality Agreement.

F. Stability Testing

–                      This guidance defines requirements for the stability testing for Drug Products [including: marketed human and animal prescription products and Consumer Over-The-Counter (OTC) drug products], consumer non-drug products (e.g., cosmetics), Active Pharmaceutical Ingredients (API), API Intermediates for Sale and Medical Devices manufactured at a GMP site.

–           The assignment of Expiration Dates is not addressed in this guidance.

–           Protocols, Approved by the Site Quality Team, shall be followed to perform stability studies. The protocol shall be signed by the author of the document. Deviations to approved protocols shall be handled according to site standard operating procedures.

–           Drug Product, API, API Intermediates for sale and Consumer Non-Drug Product Stability Samples shall be stored at the conditions required by the markets where the product is sold and these conditions shall support the product’s Labelled storage conditions.

–           Time Intervals for Testing shall be defined in the stability protocol.

–           Drug Product, API, API Intermediates for Sale, Medical Device and Consumer Non-Drug Product Stability Samples shall be tested using release and/or stability methods. In the case of registered stability methods, the filed methods must be used.

Release Data represent an acceptable alternative for use as “time 0” data (i.e., initial data) if:

* The stability study is initiated within thirty (30) calendar days of the completion of the relevant release tests;

* The release Test Method (TM) is the registered method; and

* There is no regulatory restriction that prohibits the use of release data.

–           New “time 0” data must be generated if the stability study is initiated more than thirty (30) calendar days from the completion of the release data of the material under test.

Note: “time 0” data are initial data that represent the date on which the stability study is started, i.e., the point at which the material is placed in the stability chamber.

–           Stability Data shall be collected, compiled, reviewed and evaluated after each test interval. A Trend analysis shall be performed at least annually, under the direction of the Site Quality Team. Results of ongoing stability studies shall be available at the manufacturing site and shall be made available to the Qualified Person, when applicable.

–           Notification to the Regulatory Authorities shall be considered in all markets as required by the regulations, in the event of a stability failure.

–           Accelerated Conditions can be used to establish the initial Re-evaluation Interval or expiration dating. Expiration dating determined by the use of accelerated conditions shall be verified with long-term data.

–           Stability Programs shall be established using the current version, at the time the study is initiated, of ICH Q1A (R2) ‘Stability Testing of New Drug Substances and Products’ (Ref 10). If subsequent to the initiation of the study, ICH conditions change, the study shall be maintained as initiated.

–           At a Minimum, the First Commercial Production Lot of Each Drug Product shall be put on stability, unless otherwise specified by Regulatory Authorities. A minimum of one lot of each drug product shall be put on stability each year, unless none is produced that year. Additional lots are to be approved by the Site Quality Review Team (SQRT) for inclusion in the stability program to support requirements such as regulatory filings for proposed product changes, lot deviations, or to fulfil commitments made at the time of product filing due to regulatory requirements. If the product is packaged in more than one Container/Closure configuration, at least one lot of each configuration shall be placed on stability each year.

–           Bracketing and Matrixing of Stability Samples (e.g., different product strengths, different package sizes, or different manufacturing Sites) of the same container/closure configuration shall be permitted. If the product is packaged in different container/closure configurations (e.g., blisters and bottles), each packaging configuration shall be subject to stability studies. The applicability of bracketing and matrixing must be assessed by the Site Quality Team on a case-by-case basis [see ICH Q1A (R2) – Ref 10].

–           Assay and Dissolution Results shall be evaluated against results from the previous test interval and release or “time 0” data (initial data), if available. If initial and second stage test Specifications for dissolution are not met, resulting in a third level of testing, and the product under test has no history of requiring a third level of testing, results shall be considered out-of-trend. Results considered out-of-trend will be Investigated.

–           Bulk Solid Dosage Form Products (e.g., capsules or tablets prior to final packaging and capsule and tablet blends) shall be held for no more than thirty (30) calendar days, unless Hold Time Studies have been conducted or historical data are available that support longer hold times in bulk containers.

Bulk liquid and semi-solid dosage form products shall be held for no more than five (5) calendar days, unless hold time studies have been conducted or historical data are available that support longer hold times in bulk containers. Hold time studies shorter than five (5) days must be considered for products that are highly susceptible to the influence of the holding conditions (e.g., held under heat, susceptible to separation with time, or susceptible to microbial growth).

–           A Stability Program shall be established for APIs to support re-evaluation intervals or expiration dates, when required by regulatory commitments. Re-evaluation Dates assigned to API intermediates for sale must be supported by stability data.

–           The First Three (3) Released Batches of Each API shall be placed on the stability monitoring program to confirm the re-evaluation intervals or expiration dates. However, where data from previous studies show that the API is expected to remain stable for at least two (2) years, fewer than three (3) batches can be used, if in accordance with local regulatory requirements (see ICH Q7 – Ref 11).

Potential need for Accelerated Stability Testing must be evaluated in accordance with local regulatory requirements, at all Sites so affected.

–           At Least One Batch per Year of API Manufactured (unless none is produced that year) shall be added to the stability-monitoring program and tested annually to confirm the stability, unless otherwise specified by Regulatory Authorities. Testing protocols for APIs with short re-evaluation dates or expiry periods [less than twenty-four (24) months] shall include more frequent testing up to the re-evaluation date or expiration date. After this date, testing shall be conducted annually for the duration of the study or until Out-Of-Specification (OOS) Results are obtained, whichever occurs sooner.

–           Stability Samples from APIs and API Intermediates for Sale shall be stored in containers that simulate the market container. For example, if the API or API Intermediate for Sale is marketed in bags within fiber drums, stability samples can be packaged in bags of the same material and in smaller scale drums of similar or identical material composition to the market drums.

–           Maximum Allowable Hold Times shall be established for APIs that are held in bulk containers for more than thirty (30) calendar days. APIs which are held in bulk containers prior to final packaging [e.g., blender, tote bin or Intermediate bulk container (IBC)] for thirty (30) calendar days or longer shall be retested prior to use, unless hold time studies have been conducted or historical data are available that support longer hold times in bulk containers. Studies for hold times shorter than thirty (30) days must be considered for APIs that are highly susceptible to the influence of the holding conditions (e.g., held under heat, susceptible to separation with time or susceptible to microbial growth).

Requirements for Consumer Non-Drug Products

–           Freshness Dates are required for all consumer non-drug products which do not bear expiration dates. Freshness dates shall be established from stability testing. Unless required by Regulatory Authorities, freshness dates are not required to appear on the product label.

–           Medical Device Stability Testing Programs shall be conducted to support labelled expiration dating.

–           Stability Monitoring Programs for Medical Devices shall be reviewed upon any changes to the device as part of the change control process within the Design Control systems including, but not limited to: Design Reviews, Post Market Changes and the Design History File (DHF).

–           For Medical Devices, Accelerated Conditions may be used to generate initial expiration dating or to extend expiry dating. Accelerated aging must use the principles and basis as published in the ASTM guide, Standard Guide for Accelerated Aging of Sterile Barrier Systems for Medical Devices, ASTM F1980-07 (Ref 12). Expiration dating determined by the use of accelerated

conditions must be verified with real time data.

–           Medical Devices That Have Been Assigned an Expiration Date shall be tested at least annually and at their expiration date unless otherwise indicated in an approved protocol.

Medical Device Stability Testing shall include:

* Use of finished, packaged, and sterilized (if applicable) devices;

* Testing of those attributes that are susceptible to change during storage and may influence quality, safety and/or efficacy;

* Considerations for the functionality aspect of the device; and

* All devices used for stability testing must be representative of the manufacturing process and the devices distributed to the consumer.

–          For Stability Tables Intended for Regulatory Submission, Laboratory Investigation Report (LIR) Footnotes shall have the following format and content:

* Confirmed OOS results: footnoted as “Confirmed OOS: Documented in LIR xx”; and

* Confirmed Unknown Peaks not covered by existing specifications: footnoted as “Confirmed unknown peak: Documented in LIR xx” on the test where the peak was observed.

Note: “xx” is the LIR number. No other LIR footnotes shall be included in stability tables intended for regulatory submission.

The Actual Pull Date for a Stability Sample at each testing interval shall be within the timeframes defined in the following table.

Time from Start of StudyAllowable Variation of Sample Pull Date from Scheduled Sample Pull Date
< 3 months+/- 4 calendar days
>/= 3 months+/- 7 calendar days

–           Chemical and Physical Testing shall be completed within thirty (30) calendar days from the pull date of the samples. For the purpose of this guidance, “completed” is the date of acquiring the raw data (e.g., date of HPLC injection).

–           Microbiological testing must be initiated within thirty (30) calendar days of the pull date. The time is measured from the actual pull date, not from the scheduled pull date.

–           Drug Products shall be tested, at least annually and at their expiration date, unless otherwise indicated in an approved protocol.

* The stability start date shall commence no later than three (3) months after the packaging date. Exceptions to this shall be approved by the Site Quality Team responsible for release of the product; and

For routine lots, testing can stop at the true expiration date, even if it occurs before the final time point in the protocol, unless otherwise required by regulatory commitments. The stability study start date is the date the samples are placed in the stability chamber. Pull times are calculated on the basis of the stability study start date. A manual pull date at the true expiration date must be documented. Hold Times shall be based on data from bulk dosage form product held under normal production conditions (i.e., no stability chamber required).

–           Hold Time Studies for Bulk Dosage Forms shall include the same physical and chemical tests as performed during stability testing of the packaged drug product. Microbiological testing shall be included if such testing is part of the packaged drug product stability testing or if there is scientific rationale for such testing.

G. Sterility and Bacterial Endotoxin Testing

–           Sterility and Bacterial Endotoxin Test (BET) Methods for Sterile Raw Materials (RM), Drug Products, Medical Devices and Active Pharmaceutical Ingredients (API) shall be developed, Validated and performed in accordance with the regulatory filing for the product market(s).

–           This guidance applies to laboratories performing sterility and BET for release and stability testing of marketed and clinical research Batches and Lots manufactured in GMP facilities and to complaint samples of drug products, APIs and medical devices.

–           If a Non-Compendial Test Method (TM) or Modified Compendial Method is used, the test must yield results equivalent to or superior to a corresponding compendial test method. The justification to perform the non-compendial or modified test method shall be included in the Final Validation Report.

–           All Test Methods (TM), including compendial, modified compendial, and non-compendial, shall be maintained under change control.

–           Performance Capability of the Test Laboratory must be demonstrated under actual use conditions before any test method is implemented.

–           Validation Protocols and Reports shall be approved by the Site Quality Team.

–           Sterility Testing shall be conducted in a Grade A Aseptic Processing Area (APA), a Grade A Air Classification cabinet located within a Grade B APA environment or in a Sterility Test Isolator System (STIS).

–           Qualified Personnel and Qualified Test Laboratories shall be used to perform BET and sterility testing. Sterility test results shall be Trended and reviewed, at least, annually by the Laboratory Manager to identify such issues as the occurrence of false positives and the quality of Laboratory Analyst performance.

Procedures for Sampling and Testing of RMs, APIs, drug products and medical devices shall be written and approved and shall include:

* Number of samples to be tested per batch/lot;

* Amount of each sample to be tested;

* Test methods;

* Test equipment;

* Retest criteria and methods; and

* Test limits.

–           BET and Sterility Test Reagents and Microbiological Culture Media shall be purchased from Approved Suppliers. No decisions regarding disposition shall be made about the materials under test until the reagents and culture media used have been approved for use. Purchased media and reagents must meet all requirements defined in this guidance. Additionally, the manufacturer’s requirements for storage and Expiration Dating must be met.

–           Standard Operating Procedures (SOP) shall describe the preparation, labelling, storage and use of laboratory reagents, volumetric solutions, Reference Standards and microbiological culture media.

–           Sterility Test or BET Failures shall be Investigated and the Laboratory Investigation Report (LIR) approved by the Site Quality Team prior to final batch/lot disposition.

–           Gowning Practices for Personnel Performing Sterility Testing in a Grade A APA environment or a Grade A cabinet located in a Grade B environment shall be, at least, equivalent to the gowning practices for Production APAs.

–           An Environmental Monitoring and Control Program shall be established for the sterility test environment and shall be approved by the Site Quality Team.

Contract Laboratories for Sterility Testing and Bacterial Endotoxin Testing (BET) shall:

* Meet all of the requirements of this guidance;

* Demonstrate performance capabilities;

* Pass an audit; and

* Be approved by the Site Quality Team.

Sterility Test APA Facilities shall include qualification of, at least, the following systems:

* HEPA Filter Laminar Airflow (LAF) (Grade A) benches;

* Room air classification (Grades A & B) and maintenance of Pressure Differential;

* Facility cleaning and disinfectant program using approved sterile Disinfectants;

* Environmental monitoring program including personnel monitoring; and

* Sterilization equipment (i.e., autoclaves).

–           Sterility Test Isolator Systems (STIS) shall be qualified.

–           Laboratory Personnel Performing Sterility Testing must be trained and qualified in all aspects of sterility testing, including sterility test procedures and laboratory techniques. Personnel must demonstrate proficiency in the use of Aseptic Technique prior to performing sterility testing.

Retraining and re-qualification shall be required for all personnel who have not performed sterility testing within a defined time period determined by a documented Site risk-based analysis. Retraining and re-qualification shall

also be required of sterility testing personnel who exhibit atypically high numbers of false positive sterility tests or contaminated Negative Controls or no growth in positive controls.

The Number of Sterility Samples Tested per batch/lot and quantity of material tested from each Container shall be specified and in accordance with compendial or registered methods applicable to the product filing. The following sampling criteria shall be included in procedures:

* Test Samples from Sterile API Batches shall be representative of the batch;

* Test Samples from Aseptically Filled Drug Product Lots shall be equally distributed across each continuous Filling Operation including the beginning and end of the operation. Procedures shall define criteria for inclusion and collection of samples immediately after interruptions and operator interventions during the filling process; and

* Test Samples from Terminal Sterilization Cycles shall be randomly selected from every sterilized load and include samples from the coolest part of the load

Procedures for Introducing Samples and Materials into sterility test laboratories shall be similar to, and equivalent in, efficacy to those used for production APAs including the use of Airlocks and pass-through chambers in APA settings to preclude the ingress of contaminants. All such procedures shall be validated.

–           The outer surfaces of all packages of equipment, vessels, or materials, which are introduced to the testing environment (including vessels of media and packages or containers of materials to be tested) shall be disinfected or sterilized by a validated method. The disinfectant or sterilization method shall be validated to show it does not affect the viability of microorganisms that may be present in the materials to be tested.

–           A Neutralizer or Inhibitor shall be incorporated in the microbiological culture media, if possible, when the product to be tested exhibits antimicrobial properties. The selection of the neutralizer or inhibitor shall be supported with validation studies.

–           Materials Used as Filtration Aids (e.g., sodium myristate, polysorbate 80) for sterility testing shall be tested prior to use for antimicrobial activity. Positive antimicrobial activity shall prohibit use of such filtration aids.

Microbiological Culture Media shall be sterilized using a Validated Process. Every batch/lot (e.g., autoclave load) of prepared media shall be tested and stored as follows:

* Test for pH, sterility, and Growth Promotion;

* Where a batch/lot of media is stored for an extended period of time, growth promotion shall be repeated within three (3) months of use for sealed containers and within two (2) weeks of use for unsealed containers; and

* Sealed media shall not be stored for more than one year and unsealed media shall not be stored for more than one month or the manufacturer’s recommended storage time, whichever is shorter.

–           The Sterility of Each Batch of Media shall be confirmed either prior to use or in parallel with the product sterility test. Each batch of media shall be tested by incubating a portion of the media at the defined temperature range for each media [e.g., Soybean Casein Digest (SCD) at 20-250C and Fluid Thioglycollate Media (FTM) or Alternative FTM at 30-350C] for not less than fourteen (14) days.

–           Compendia Specified Microorganisms (as applicable to the product filing market) and at least one well characterized environmental isolate shall be used in Bacteriostasis, Fungistasis, and growth promotion testing.

Maintenance of Microbiological Control Cultures shall be specified and documented and include, and not be limited to:

* Verification of culture purity and identification at specified time intervals, but not less than annually unless the culture is stored cryogenically. For cultures stored under cryogenic conditions, viability of the frozen organisms shall be periodically tested at intervals determined by documented risk assessment;

* Seed lot culture maintenance techniques to ensure that viable microorganisms are not more than (NMT) five (5) passages removed from the original type culture strain; and

* Culture strains that have been obtained from a recognized reference culture Supplier, such as American Type Culture Collection (ATCC) and National Collection Type Culture (NCTC).

Bacteriostasis and Fungistasis Testing shall be validated and performed as follows:

* Conduct three (3) separate studies;

* Conducted for each test method;

* Reassessed with any formulation change according to compendial requirements applicable to the product filing market; and

* Include a growth promotion test as a positive control.

Where the product or sample exhibits antimicrobial activity, modify the conditions following compendia guidelines (e.g., add antimicrobial inhibitor, modify rinsing) and repeat the stasis test.

Growth Promotion Testing shall be:

* Performed on each batch/lot of media;

* Conducted prior to or concurrently with product sterility testing;

* Challenged with compendia specified organisms;

* Inoculated with NMT one hundred (100) cfu and the microorganism population verified by viable plate counts; and

* Positive for growth by visual in section within three (3) days for bacteria and five (5) days for fungi. Sterility test results obtained using media that is concurrently undergoing growth promotion testing shall not be used for batch/lot release until the media on test has been approved and released.

–           During Each Working Session in which sterility testing is carried out, at least one negative control consisting of rinse fluids and sterility test media, shall be included.

–           The Membrane Filtration Method shall be used for sterility testing where the nature of the product permits. If the Membrane Filtration Method is not suitable, use the Direct Transfer Method (e.g., Direct Inoculation Method).

–           Diluting and Rinsing Fluids for membrane filtration shall be commercially purchased or prepared and sterilized according to compendial requirements. A record shall be kept of each diluting and rinsing fluid used in each sterility test.

–           Sterile Membrane Filtration Units and the Membranes shall be qualified for use.

–           Sterile Membrane Filtration Units and the Membranes stored in a manner that maintains the performance characteristics of the filter and ensures that the filter and the assembly remain sterile.

Sterility Test Containers shall be incubated for not less than fourteen (14) days at temperatures specified by compendial tests (as applicable to the product filing market) for each test media and include:

* Test containers examined for evidence of microbial growth at documented intervals during the incubation period;

* Observations recorded; and

* If the test container is positive for growth before the end of the incubation period, further incubation is not required.

–           Sterility Test Containers Showing Evidence of Turbidity, Flocculation or Deposit in the Media, indicating the media is positive for microbial growth during the fourteen (14) day incubation period, shall be confirmed microscopically (e.g., Gram stain), subcultured to solid microbiological media, and the microorganisms isolated shall be subjected to species identification methods. Isolated contaminants shall be preserved in a viable state during the subsequent investigative process.

Drug Products, APIs or Raw Materials (RM) That Inherently Produce a Cloudy Appearance in the Sterility Test Media, so that the presence or absence of microbial growth cannot be readily seen, shall be tested as follows:

* Mix the test sample by gentle swirling at each examination period (with the exception of the anaerobic test sample, which must not be agitated);

* Transfer portions of the medium (e.g., 2 to 5 percent) to fresh containers of similar medium, at least once, at a time interval specified in the regulatory filing for the product market(s); and

* Continue incubation of the original and the subcultured containers for not less than the full incubation period required by regulatory filings. If no evidence of microbial growth is found, the test material is considered to comply with the test for sterility.

A Laboratory Investigation (LI) shall be conducted for all positive or questionable sterility test results whether or not the material in question is Rejected. Positive sterility test results shall be considered valid, unless it can be clearly demonstrated that the test was invalid for causes unrelated to the product examined.

A Sterility Test May Be Considered Invalid when an LI reveals any of the following conditions:

* The environmental monitoring data from the sterility test facility shows a fault (e.g., loss of physical integrity of the testing environment);

* A review of the testing procedure used during the sterility test in question reveals a fault leading to contaminated culture media, solutions, or equipment;

* Microbial growth is found in the negative controls and the organisms isolated and identified are identical to those isolated from the product test containers; and/or

* After determination of the identity of the microorganism(s) isolated from the test, the growth of the isolated species may be ascribed unequivocally to faults with respect to the material and/or technique used in conducting the sterility test procedure. Any other proposed reasons for invalidating a sterility test must be evaluated on a case-by-case basis.

An Invalid Sterility Test may be repeated once and include negative controls, using the same number of samples that were initially tested. The sterility test results shall conclude the following:

* If no evidence of microbial growth is found in the Repeat Test, the material examined complies with the test for sterility; or

* If contamination is detected in the repeat test, the material does not comply with the test for sterility and the batch/lot shall be declared non-sterile.

Personnel Performing BET shall wear, at a minimum, gloves, lab coat, and eye protection.

Apparatus Free of Detectable Endotoxin shall be used during BET and include the following:

* Glassware shall be Depyrogenated using a validated procedure;

* Plastic ware shall be shown to be free of detectable endotoxin and of interfering effects for the test; an

* Polypropylene reaction tubes shall never be used.

BET shall be performed using water free of detectable endotoxins [e.g., Limulus Amebocyte Lysate (LAL) Reagent Water (LRW) or sterile Water for Injection (WFI)].

The Label Claim Lysate Sensitivity shall be confirmed according to compendial test (as applicable to the product filing market) and include the following:

* Label claim sensitivity of each new lot of lysate shall be confirmed prior to use or when there is any change in the experimental conditions; and

* One vial of lysate from each lot shall be tested in quadruplicate.

–           Once the Lysate Label Claim is verified, the label claim value shall be used in all future calculations involving that lot.

–           The Lysate shall be prepared, used, and stored according to the manufacturer’s recommendations.

–           A Certificate of Analysis (COA) of the Control Standard Endotoxin (CSE) compared against the Reference Standard Endotoxin (RSE) shall be available

and shall be specific for a particular lysate or bacterial endotoxin lot combination. If the required COA is not available or incomplete, a CSE to RSE comparison shall be performed, using one vial each of CSE and RSE.

Validation of a BET Method for the drug product, API, medical device or RM shall include:

* Determination of the Maximum Valid Dilution (MVD);

Inhibition and enhancement testing of the material for interfering factors;

* Test of the material at a dilution less than or equal to the MVD;

* Test on three (3) batches/lots of material;

* Positive [i.e., material spiked at two (2) times the lysate sensitivity] and negative controls; and

* Evaluation of the types of glassware/plastic ware and associated equipment and materials on BET results.

Inhibition and Enhancement Testing shall be conducted for each material according to compendial requirements (as applicable to the product filing market) to demonstrate that the material does not inhibit or enhance the reaction or otherwise interfere with the test as follows:

* Tests shall be performed on, at least, three (3) Production batches of each finished material;

* Negative controls shall be included; and

* If the material shows inhibition, the material may be diluted, not to exceed the MVD or neutralized and the test repeated.

Inhibition and Enhancement Testing shall be repeated as defined below when the following changes are made:

* Significant formulation changes to product (e.g., change to key ingredient or excipient): repeat testing on three (3) batches/lots of material;

* Any changes made to the BET technique: repeat testing on three (3) batches/lots of material;

* New lysate reagent manufacturer: repeat testing on one batch/lot of material; or

* New BET method: repeat testing on three (3) batches/lots of material.

–           Routine Testing of Materials by BET shall be conducted in duplicate on samples, standards, positive product controls, and negative controls.

–           An Endotoxin Standard Series, prepared from either the RSE or CSE, shall be:

* Prepared daily, or for a longer interval, if validated;

* Diluted with LRW or sterile WFI for BET, for example, to bracket the labeled lysate sensitivity for each lysate or bacterial endotoxin lot; and

* Used in every material testing run.

–           For Routine Testing of Drug Products or Medical Devices by BET, a minimum of three (3) samples shall be tested; one from the beginning, middle, and end of the batch/lot. Samples may be tested individually or pooled. For routine testing of APIs and raw materials (RM) by BET one representative sample from each batch/lot shall be tested.

–           The BET Test shall be valid when the replicate negative control results are negative and the positive control results are positive. Repeat the test with the same number of samples when a positive result is found for a negative control and/or a negative result is found for a positive control.

–           A Laboratory Investigation (LI) shall be conducted for all BET results that do not meet material Specifications.

Laboratories Performing BET shall be qualified by assessing testing variability before any official tests are performed. Lab qualification shall include:

* Use an RSE or CSE of known potency, assay at least three (3) concentrations in triplicate over the desired endotoxin range or as recommended by the supplier;

* Include at least one additional standard to bracket each log increase in the range of the standard curve;

* For automated methods (e.g., turbidimetric or chromogenic) perform Regression-Correlation Analysis on the log reaction time versus the log of the endotoxin concentration for each replicate (do not average the reaction times of the replicates of each standard before performing Regression-Correlation Analysis);

* Ensure that the coefficient of correlation, “r”, is greater than or equal to 0.980. If “r” is less than 0.980 the cause of the non-linearity shall be determined and the test repeated; and

* Qualification of laboratory personnel by successfully completing three (3) independent assays.

Qualification of the Laboratory and Personnel to Perform BET by Gel-Clot shall include, and not be limited to:

* Testing one vial of lysate in quadruplicate;

* Diluting the RSE and CSE to bracket the lysate label claim sensitivity (i.e., 2λ, λ, 0.5λ, and 0.25λ); and

*Verifying the label claim of the geometric mean of the end points confirm the lysate label claim sensitivity by +/-one two-fold dilution.

–           Each Analyst that Performs BET shall be qualified initially by performing lysate label claim sensitivity. Periodic re-qualification shall be performed annually, unless the analyst has been continually and successfully performing lysate label claim sensitivity and documented as a part of the analyst’s training records.

 

H. Sterility Test Isolators

–           Sterility Test Isolator Systems (STIS), that are used to perform sterility testing of Sterile Raw Materials (RM), Active Pharmaceutical Ingredients (API), Medical Devices and Drug Products, shall be designed and operated in a manner that precludes the ingress of microorganisms.

–           This guidance applies to GLP laboratories using sterility test isolator systems to perform sterility testing of sterile raw materials, Components, Intermediates, APIs, In-Process Materials, drug products, Biologics and sterile medical devices for Pharmaceutical and Animal Health.

STIS Configurations shall be classified as follows:

* Stand alone workstation isolators, and

* Workstation isolators having one or more transfer isolators.

–           STIS Surface Sterilization shall be Validated, requalified and routinely performed on a basis defined at the Site.

–           Validation of the STIS shall include provisions for Installation Qualification (IQ), Operational Qualification (OQ), Performance Qualification (PQ), change control, Revalidation, requalification and maintenance. Validation and requalification of Steam Sterilization processes, if used in conjunction with the transfer isolator, shall be conducted with proper guidance.

A Leak Testing Program of the STIS shall be established and shall define:

* Test frequencies;

Types of tests;

Items to test (e.g., half suits, chamber, gloves); and

* Acceptance criteria.

An Environmental Monitoring Program for the STIS shall be established based on a Risk Assessment of the STIS. This risk assessment shall define and document:

* Types of monitoring,

*Monitoring frequencies,

* Monitoring locations, and

* Acceptance criteria for each monitor. Pressure differentials shall be continuously monitored and alarm conditions investigated and documented.

–           STIS Air shall be supplied through HEPA Filters. The HEPA filters shall be Integrity Tested at installation and thereafter at least every 5 to 7months.

–           A Maximum Allowable Time Period shall be established for the use of the STIS before requiring STIS surface re-sterilization. The time periods shall be based upon on-going environmental monitoring data, negative controls data, and isolator equipment maintenance (e.g., glove replacements).

Change Control and Revalidation Measures shall be implemented to identify, document, review and approve all changes prior to implementation that impact the validated state of the STIS including and not limited to, cleaning and/or surface sterilization methods and changes to critical equipment. Additionally, all changes that affect the efficacy of use of the isolator, such as changes to loading patterns or the addition of new Container/Closure combinations, shall be subject to change control. The Validation Committee (VC) shall:

* Perform a periodic review of approved and implemented changes for the STIS, including maintenance and Calibration to determine the cumulative impact on Validated Processes;

* Review and trend routine environmental monitoring data based on a frequency established at the Site (e.g., monthly, quarterly);

* Recommend revalidation and/or requalification requirements; and

* Document the review results.

–           Lab Analysts Performing Sterility Testing in STIS shall be Qualified in Aseptic Techniques, the sterility Test Method (TM) and use of the STIS.

–           Aseptic Technique shall be used for all manipulations after STIS surface sterilization.

–           Preventive Maintenance (PM) Measures For Gloves, Gaskets, Half-Suits and All Critical Equipment in the Isolator shall be implemented at each Site where test isolators are used. Such measures shall be applied according to well defined, written Standard Operating Procedures (SOP) that include replacement frequencies for critical equipment.

 The STIS shall be cleaned and surface sterilized according to Site SOPs following any potential breach of isolator sterility. Conditions that may impact STIS sterility include, but are not limited to, the following:

* Power failures or power level reductions (sometimes called brownouts);

* Critical Process Parameters (e.g., pressure differential) outside of acceptable limits; or

* Breach in physical integrity of the isolator.

Gloves shall be changed on an established frequency based on historical data. Gloves shall be visually examined frequently, prior to and during use for wear or overt tears.

–           The STIS shall be located in a clean, well-organized room that has limited access.

STIS Surface Sterilant Validation Studies for a Stand Alone Workstation Configuration shall include:

* A minimum of 3 distribution studies of the STIS workstation for each Worst Case load configuration (e.g., test sample containers and supplies that will be used during sterility testing);

* Biological Indicators (BI) distributed to comprise the full internal volume of the isolator and additional positions that are potentially less likely to be exposed to the full surface sterilizing process;

* Verification that complete inactivation of BIs under all proposed surface sterilization conditions is achieved;

* Exhaust studies for the removal of surface sterilant from the isolator; and

* Classification to meet particulate air quality requirements of an ISO Class 5 area as defined in ISO 14644 (performed during qualification only).

STIS Surface Sterilant Validation Studies of the Workstation Configuration Using Transfer Isolators shall consist of separate studies for each isolator and shall include:

Empty Workstation Isolator

* A minimum of 3 distribution studies of the empty workstation isolator;

* BIs distributed to comprise the full internal volume of the isolator and additional positions that are potentially less likely to be exposed to the full surface sterilizing process;

* Verification that complete inactivation of BIs under all proposed surface sterilization conditions is achieved;

* Exhaust studies for the removal of surface sterilant from the isolator; and

* Classification to meet particulate air quality requirements of an ISO Class 5 area as defined in ISO 14644 (performed during qualification only).

Empty Transfer Isolator

* A minimum of 3 distribution studies of the empty transfer isolator;

* BIs distributed to comprise the full internal volume of the isolator and additional positions that are potentially less likely to be exposed to the full surface sterilizing process;

* Verification that complete inactivation of BIs under all proposed surface sterilization conditions is achieved;

* Exhaust studies for the removal of surface sterilant from the isolator; and

* Classification to meet particulate air quality requirements of an ISO Class 5 area as defined in ISO 14644 (performed during qualification only)

Loaded Transfer Isolator

* A minimum of 3 distribution studies of the transfer isolator for each worse case load configuration (e.g., test sample containers and supplies that will be used during sterility testing);

* BIs distributed to comprise the full internal volume of the isolator and additional positions that are potentially less likely to be exposed to the full surface sterilizing process;

* Verification that complete inactivation of BIs under all proposed surface sterilization conditions is achieved; and

* Exhaust studies for the removal of surface sterilant from the isolator.

–           Critical STIS Surface Sterilization Parameters shall be defined and recorded during validation studies (i.e., OQ, PQ) and during routine surface sterilizations.

–           Surface Sterilant Ingress Studies shall be performed to ensure that surface sterilization does not adversely affect the ability of the sterility test to detect low levels of contamination. This shall be accomplished by performing Bacteriostasis and Fungistasis tests using actual test samples that have been exposed to all phases of the surface sterilization process.

–           STIS shall be cleaned internally and dried after use to remove dust, debris, dirt, and moisture according to approved procedures.

Exterior Surfaces of Test Sample Containers and Supplies shall be surface sterilized prior to initiating sterility testing by loading the items into a non-surface sterilized STIS workstation (for the stand alone units) or transfer isolator and surface sterilizing the workstation or transfer isolator and exterior surfaces of the items simultaneously. Occluded surfaces shall be wiped with a surface sterilant equal to the efficacy of the sterilant, which is used during routine surface sterilization. Occluded surfaces may include:

* Test supplies,

* Test samples, and

* Isolator components (e.g., half suits).

Special Requirements for preparation of samples prior to placing them in either the transfer or workstation isolator shall be addressed in written and approved SOPs.

–           Acceptance Criteria for STIS Microorganism Monitoring shall be no detectable contamination. An Environmental Monitoring Report (EMR) shall be issued and an Investigation conducted for all positive monitoring samples recovered from isolators.

–           Point of Use Microbial Retentive Filters shall be used with compressed gases, and connections, valves and control instrumentation shall be free of Dead-Legs that cannot be sanitized.

I. Transfer of Analytical Methods

The Purpose of guidance is to establish a documented process for the transfer of analytical methodology. This guidance shall also be used for microbiological and/or bioanalytical method transfer.

–           This guidance applies to GLP laboratories responsible for transferring or receiving methods for analysis of therapeutic products including the methods transfer for New Products originating from different GMP sites.

–           The process described in this guidance applies to the Analytical Method Transfer Exercise (AMTE) to be followed for analytical methods used in the testing of Active Pharmaceutical Ingredients (API), Drug Products and Medical Devices and may be used for the transfer of Approved methods for analysis of regulatory Starting Materials, isolated Intermediates and Raw Materials (RM), as applicable.

–           When contract or non-Site laboratories are involved in an analytical method transfer, the site participants involved shall determine the transfer strategy to be followed.

–           A Review of the Methodology shall be conducted by Qualified personnel at the participating laboratories to determine the mode of transfer.

–           A Transfer Plan Document shall be prepared for methods requiring an AMTE. The Transfer Plan Document(s) must be approved by qualified personnel at the Transferring and Receiving Laboratories prior to executing the transfer.

–           A Transfer Plan Amendment shall be prepared when changes or additions are needed to the Transfer Plan document(s).

–           An Investigation shall be conducted when the acceptance criteria are not met or the results are unexpected. If the investigation justifies additional testing, a Contingency Testing Plan shall be prepared. If Lots that are marketed and within their expiration dating period or clinical lots are used for Comparative Testing and the Qualified laboratory (Transferring Laboratory) obtains an Out-of-Specification (OOS) Result, a Laboratory Investigation (LI) shall be conducted.

–           A Laboratory Qualification Memo shall be generated when the AMTE is complete and the transfer is deemed successful.

J. Use and Control of Laboratory Reagents and Reference Standards

–           This guidance defines the requirements for laboratory Reagents (including Solvents) and Reference Standards used in analyses of Drug Products, Active Pharmaceutical Ingredients (API), Medical Devices and associated materials (including, but not limited to, Raw Materials (RM) and chemical Intermediates).

–           This guidance applies to GLP analytical laboratories responsible for testing materials and products for Pharmaceutical, Animal Health and Consumer Healthcare

–           This guidance applies to reference standards, prepared standards and laboratory reagents, including but not limited to, pH buffers, mobile phases, solvents, non-standardized reagent solutions and commercially available analytical standards (e.g., metals in solution) used in analytical testing laboratories.

–           This guidance does not apply to reagents or reference standards used in microbiology testing laboratories, nor to Microbiological Culture Media or Biological Indicators (BI).

–           The Receipt Date and date of first opening for reagents and reference standards shall be recorded.

–           Reagents shall be labeled at a minimum with material identification and the Batch Number or Lot Number for purchased reagents and solvents. Reagent labels for materials prepared locally on-site shall contain information allowing the reagents to be uniquely identified. Subdivided reagents shall be labeled in a manner that enables tracking the source of the subdivided material. In addition, reagent labels shall meet local regulatory and Site requirements.

–           Labels of Reference Standards Used in the Analytical Testing Laboratory shall contain information allowing the reference standard to be uniquely identified. Subdivided reference standards shall be labeled in a manner that enables tracking the source of the subdivided material.

–           Reference Standards Used in the Analytical Testing Laboratory shall be traceable to the reference standard documentation.

–           Written and Approved Procedures shall describe the preparation, labeling, storage, and use of lab reagents, solutions, buffers, and reference standard solutions, unless such activities are described in a Compendial source. When there are environmental concerns, there shall be written and approved procedures for the disposal of these materials.

–           Records Regarding the Use of Reagents and Reference Standards shall be maintained in accordance with Standard Operating Procedures (SOP) and other Regulatory Team requirements.

–           Storage, Subdivision and Use of reagents and reference standards shall be performed under conditions that ensure the integrity of the material.

–           Reevaluation Dates and/or Expiration Dates shall be assigned to reagents and reference standards. Compendial standards shall be used for a period of time which is consistent with the compendia and with Site requirements.

–           Reagents and Reference Standards prepared by Site shall not be used beyond their expiration date unless there is sufficient rationale, including documentation or other data to justify an extension of the expiration date. Site Quality Team shall approve both the rationale and supporting documentation. Reagents and Reference Standards obtained commercially shall not be used beyond their expiration date.

–           A System shall be established to inform users of the status of reference standards.

–           The Date of Receipt of reagents and reference standards shall be recorded on the label or included on the Container in a permanent manner, upon receipt of the container in the laboratory. If it is not practical to include the receipt date on the container (i.e., due to extreme storage conditions or limited label space) the receipt date shall be recorded on associated documentation [e.g., Certificate of Analysis (COA) or logbook]. At a minimum, the month and year shall be recorded.

If a Differentiation of Multiple Containers of the same Lot in the same shipment is needed, the number of the container (e.g., 1 of 4) shall be written on the container upon receipt. -Labels of Reagents, including containers of subdivided reagents, shall include:

* Material identification;

* Batch or Lot Number;

* Vendor Name;

* Grade or purity, if available;

* Item code, if available;

* Vendor expiration date, or locally assigned expiration date or re-evaluation date with initials;

* Safety information, if needed; and

* Special storage conditions, if other than ambient conditions.

–             A system shall be in place to assure that the temporary use of solvents (such as wash bottles and squeeze bottles) include material identification, expiration date, and safety information, if required.

Labels of Prepared Reagents Including Mobile Phases shall include:

* Identification of the material;

* Identification of the person who prepared the material;

* Date prepared;

* A unique identifier which provides traceability to components and concentration of solution;

* Expiration date or use period;

* Storage conditions, if other than ambient conditions; and

* Safety information, if needed.

Labels of Reference Standards shall include:

* Material identification (i.e., catalogue name);

* Batch or lot number;

* Vendor name on all subdivided bottles of reference standards, and

* Vendor name on bulk containers, if obtained from external Site sources.

Labels of Prepared Sample and Standard Solutions shall include:

* Identification of the material;

* Identification of the person who prepared the material;

* Date prepared;

* Reference to where the preparation is documented [e.g., lab notebook, log system, Laboratory Information Management System (LIMS)]; and Storage conditions, if other than ambient conditions.

–           Flasks that are too small for conventional labels may be grouped and a label made for the group. Each flask shall have a unique identifying mark to distinguish it from other flasks. If sample or standard solutions are transferred to vials, each vial shall have a unique identifying mark to distinguish it from other vials.

–           The Date of First Opening of a reagent or reference standard shall be recorded on the label or included on the container in a permanent manner. The identification of the person opening the container shall also be included. If it is not practical to include the date of first opening on the container (i.e., due to extreme storage conditions or limited label space) the date shall be recorded on the associated documentation. If a Validated Computerized System is available for tracking the date of opening, it is considered equivalent to manually recording.

–           Storage of Reagents and Reference Standards and their preparations, shall be according to label directions, SOPs or other documentation describing the storage practice.

–           Storage Time Periods and Conditions shall be defined in a site SOP for purchased and prepared reagents and reference standards if not defined elsewhere.

–           A Notification System shall be established at each site to ensure lab personnel are aware and informed of what the current standard is, and of any information relating to the change in status of a reference standard, including discontinuance of standards.

K. Verification of Compendial Analytical Methodology

–           This guidance defines the requirements for the Verification of newly implemented Analytical Methodology from Compendia [including but not limited to, United States Pharmacopeia (USP), European Pharmacopoeia (EP), Japanese Pharmacopoeia (JP), British Pharmacopoeia (BP) and Food Chemical Codex (FCC)].

This guidance does not address:

* Verification of microbiological or bioanalytical methods; or

* Test Methods (TM) associated with Equipment Cleaning Validation.

*Compendial monitoring for changes to compendial methods.

*Analytical Methods Validation.

–           This guidance applies to analytical methods included in compendia and which are used for release or stability evaluation of Active Pharmaceutical Ingredients (API) and finished Drug Products in or intended for the market place.

–           Compendial Methods shall be verified to demonstrate that a validated compendial method can be applied to an API or drug product and yield acceptable results under typical test conditions of use (e.g., equipment, personnel, and Reagents).

–           Compendial methods are validated so it is not necessary to repeat the validation process. However, in some cases validated analytical methods require verification, which may include evaluation of some of the same performance characteristics determined during method validation e.g., different impurity profiles (from a different Supplier or synthetic route) or different formulations (versus those of the method originator) or different excipients may affect the performance of an analytical method.

–           If a Compendial Method will be Used in More Than One Laboratory for the same Test Article (i.e., the formulation or synthetic process do not differ) then verification is only required by one laboratory within Site.

This guidance applies to the following types of chemical methods:

* Identification tests;

* Quantitative tests for assay, impurities and/or degradants;

* Limit tests for control of impurities and/or degradants;

* Performance tests (e.g., dissolution, disintegration); and

* Methods used to evaluate physical properties (e.g., particle size).

–           The Need For and Extent of Verification of a Compendial Method shall include consideration of the complexity of both the analytical method and the material to which the method is to be applied. The rationale for, the need for, and extent of verification shall be documented.

–           General Compendial Test Methods (e.g., loss on drying, residue on ignition, and simple instrumental methods such as pH measurement) that are routinely performed in a laboratory require only verification that the method can be successfully executed for the test article under typical conditions of use.

A Method Verification Protocol must be prepared to document:

* Test method(s) under study,

* Number of Lots or Batches to be used,

* Evaluation to be performed, and

* Acceptance criteria.

The protocol must be Approved by the Lab Manager prior to execution of the verification studies.

–           A Method Verification Report shall be prepared following execution of the Method Verification Protocol to document the results of the verification study, including comparison against the acceptance criteria, and a conclusion about the suitability of the compendial method. Any Deviations from the protocol must be documented and the impact of the deviations discussed in the report.

Qualified Personnel shall be identified with the following roles and responsibilities in regard to analytical method verification:

* Laboratory personnel to perform the verification studies using the compendial method;

* The Lab Manager responsible for the verification studies is responsible for assuring analytical methods are verified according to this guidance and for reviewing and approving the verification protocol and report; and

* The Quality Team, independent of the Lab Manager, is responsible for reviewing and approving the Method Verification Report for compliance with applicable Site policies and procedures.

The Need for and Degree of Re-Verification shall be determined by the Lab Manager. Changes for which re-verification shall be considered include, but are not limited to:

* Changes to the compendial method (e.g., new or modified sample preparation procedure, change to separation or detection conditions, change to instrument settings and/or operating conditions);

* Changes to the sample being tested (e.g., process change for API or change in formulation of the product); or

* Changes in compendial or regulatory requirements.

If a Compendial Method Fails to Meet the Acceptance Criteria for verification, an Investigation must be conducted and documented according to the site

Standard Operating Procedure (SOP). If an Assignable Cause for the method failure is identified, corrective action(s) shall be implemented and the verification study repeated.

L Microbiology Laboratory Investigations

(Refer to Page 11 for Laboratory Investigation (LI) Process Flowchart)

Upon Discovery of any OOS or Questionable Result and before initiating any investigational measurement, repeat testing or retesting, the Lab Analyst shall immediately, take the following actions:

* Report the results to the Lab Supervisor;

* Document findings;

* Document obvious errors (e.g., spilling of solutions o incomplete transfer of sample or standard), if known;

* If possible, retain all original samples and test preparations, such as sample solutions, standard solutions, glassware, Microbiological Culture Media and Reagents used in the analysis and subsequent Investigation until the Initial Investigation is completed. Samples shall be retained in a manner that ensures their integrity (e.g., refrigerated).

The Lab Supervisor shall determine if obvious errors (e.g., calculation or dilution errors) exist that might have caused the OOS or Questionable Result. If an obvious error is found, the OOS or Questionable Result is considered an invalidated result. If the error can be corrected without further testing (e.g., miscalculation), the error and resolution shall be documented in a laboratory notebook or test record and no further investigation is required, unless the error would impact other testing. If obvious errors are not found, the Lab Supervisor shall initiate a further investigation.

Initial Investigation

–           LI Report Form Sections I-IV (For an example of Micro. Investigation Process Flow and Laboratory Investigation Form, See Page 12 -17 or bottom of topic 1, of this guidance) must be completed by the end of the next Business Day following discovery of the OOS or Questionable Result, if these test results might impact products currently on the market, which may result in a market action. When an OOS is the result of stability testing, the need to complete the Initial Investigation within one business day only applies to sample stored at labelled storage conditions (i.e., does not apply to sample stored under accelerated conditions.)

–           After Opening the LIR, the Initial Investigation to determine assignable cause begins when the Lab Supervisor holds discussions with the Lab Analyst and completes the LIR Form Section I “General Information”. Section I shall include a clear and concise description of the reason for the Investigation. In cases where more than one lot of material is investigated for the same problem, only one LIR is required. All affected lots must be clearly listed. The Initial Investigation also includes, but is not limited to, examinations of the following (LIR Form Section II, “Review of Testing Parameters”):

* Test records (raw data and/or laboratory notebooks);

* Test procedures used;

* Calculations;

* Dilution schemes;

* Instrumentation or equipment functionality;

* Reference Standards, reagents, and media used;

* Microbial Cultures;

* Sample preparations; and

* Personnel training and qualifications.

The Lab Supervisor completes the Initial Investigation using the LIR Form Section III “Findings/Conclusions from Initial Investigation” and Section IV “Conclusion Summary and Approval of Initial Investigation”.

–           If a Readily Apparent Assignable Cause is determined by the Initial Investigation, the initial OOS or Questionable Result is invalidated. The assignable cause shall be documented in the LIR Form Section IV “Conclusion Summary and Approval of Initial Investigation”. Testing is then repeated to generate valid results.

–           The OOS or Questionable Result may be accepted as valid following the Initial Investigation with no further investigational measurement, repeat testing, or retesting.

–           Upon Discovery and Recovery of Microorganisms that are not specified in the material specification or microbiological method, the Lab Supervisor shall conduct and document a microbiological assessment of the organism.

–           The Potential Impact on other samples analyzed during the initial testing must be evaluated when an assignable cause is found. All related test results must be assessed for validity. A statement documenting the assessment and the decision must be included on the LIR Form Section II “Review of Testing Parameters”, or Section III “Findings/Conclusions from Initial Investigation”.

Investigational Measurements

–           If No Readily Apparent Assignable Cause is determined during the Initial Investigation and the OOS has not been accepted as valid, the Lab Supervisor shall consider preparation of an IMP, Section V of LIR Form, for investigational purposes.

–           The IMP defines the types and number of Investigational Measurements that will be performed. LI Investigational Re-measurements shall not be conducted prior to approval of the IMP by the Lab Supervisor.

–           The IMP typically consists of re-measurements of the original sample preparations. Where applicable, Re-measurements of sample preparations must be accompanied by standard solution measurements.

–           A Stock Sample Solution and/or Solutions of Intermediate Dilutions, prepared during the preparation of the final sample concentration, may be re-diluted to obtain re-diluted final solutions as part of the IMP.

–           Re-measurements and Measurements of Re-Diluted Solutions shall be conducted using the same equipment as the original measurement, whenever possible. Use of other equipment is permitted, provided the rationale is fully documented in the LIR.

–           Alternate Test Procedures may be used to provide additional information during an IMP exercise. However, the alternate test procedure shall not be used to approve material that has initially produced an OOS result using the primary test procedure.

–           Sterility Test Investigational Measurements for aseptically filled liquid antibiotic products shall include consideration of executing the original test method with isolates from the sterility test failure added to the product to determine if the isolate(s) can survive in the product. Such testing shall be considered as investigative to invalidate the data.

Upon Completion of the IMP Exercise, the Lab Supervisor completes LIR Section VI “Findings/Conclusions from Investigational Measurements and Alert Evaluation”:

* If Assignable Cause is Clearly Identified as a result of the IMP exercise, the initial OOS result is invalidated. The original testing is repeated to generate valid original results; or

* If No Assignable Cause is Identified as a result of the investigational measurements, the Lab Manager must evaluate the need for an Alert.

–           The Data Generated During the IMP is for investigation only and shall not be used as a valid test result.

–           If No Readily Apparent Assignable Cause is Determined by either the Initial Investigation or the IMP, it may be necessary to issue an alert report to notify others of the situation. The Lab Manager shall determine whether an alert report is needed and notify the QA Manager that an alert report is needed. The QA Manager shall ensure that such reports are issued within one business day following the completion of Section IV of the LIR Form or Section VI if an IMP was conducted. The Site Quality Team shall inform the Quality Review Team (SQRT)  which shall determine if the issuance of any reports to relevant Regulatory Authorities is required. NDA-Field Alert Reports (when required) must be issued within three business days of the initial observation of an OOS result if no readily apparent assignable cause is found. The SQRT is responsible to act in the event of any proposed market action (e.g., Product Recall), SDN or NDA-Field Alert Reports.

Repeating the Test (Assignable Cause Identified)

All Tests That Were Invalidated by establishment of an assignable cause are repeated. The repeat test result(s) shall replace the original invalidated results only. The original sample preparation(s) shall be used for this testing if:

* There is sufficient quantity of sample remaining to repeat the test;

* The assignable cause was not due to sample preparation;

* The sample preparations are stable and maintained under proper environmental conditions; and

*The sample or the sample preparations are not contaminated.

–           LIR Form Section VII “Repeat/Retest Protocol” and Section VIII “Repeat/Retest Results” shall be used to document the repeat tests and the results obtained. The Repeat/Retest Protocol shall be approved by the Lab Supervisor prior to any repeat testing.

If Assignable Cause Associated With Laboratory Error is Identified, an Invalid Sterility Test may be repeated once, and include negative controls, using the same number of samples that were initially tested. The sterility test results shall conclude the following:

* If no evidence of microbial growth is found in the repeat test, the material examined complies with the test for sterility; or

* If contamination is detected in the repeat test, the material does not comply with the test for sterility and the batch/lot shall be declared non-sterile.

Retesting (No Assignable Cause Identified)

Retesting shall be performed only if retesting is not specifically prohibited by the applicable compendia for the specific test method. If the compendia do not define the retest criteria, the decision to retest shall be made by the QA Manager and must be based on sound scientific rationale and documented in the retest protocol. The objective of the retest is to confirm the original OOS or questionable result.

–           A Retest Protocol – LIR Form Section VII “Repeat/Retest Protocol” shall be approved by the Lab Supervisor prior to any retesting.

–           The Retest Protocol must be based on the specific problem identified, the history of the product, method and batch/lot, any applicable compendial requirements and must delineate the number of retests to be performed.

–           Where Sample is Available, retesting must be executed using the same sample set that was the source of the original OOS or Questionable Result, unless there is scientific rationale for not using the same sample. The rationale must be documented.

–           A Control Lot may be used to verify the Accuracy of the analyses. The retest plan must specify acceptance criteria for the control lot.

–           Microbial Limits may be retested for the purpose of confirming OOS or Questionable Results, using a 25 gram sample for solids or 25 mL for liquids.

Assignable Cause

Test Results, Whether In-or Out-of-Specification, that are obtained under the following conditions must be invalidated and the test repeated. These are examples of the classifications that are included on the LIR Form to document types of assignable causes:

* Sample -the original sample was contaminated or insufficient in quantity;

* Method/Documentation -unclear test method or Standard Operating Procedures (SOP) directions which resulted in incorrect test execution;

*Analyst Error -examples include, but are not limited to:

–           Incorrect sample quantity used;

–           Sample, sample solution, or standard spills;

–           Dilution errors;

–           Poor aseptic technique; or

–           Improper test procedure; and

* Instrument/Mechanical/System Malfunction. Examples include, but are not limited to:

–           Laminar Airflow (LAF) unit failure,

–           Sterility Test Isolator System (STIS),or

–           Insufficient sterilization cycle

–           In Cases Where Assignable Cause is Attributed to the Laboratory, corrective actions shall be taken, documented in the LIR, and approved to prevent re-occurrence of such OOS test results. Corrective actions shall include, but are not limited to:

* Retrain personnel on the sampling and/or testing procedure;

* Re-evaluation of the sampling and/or testing procedures;

* Re-evaluation of the documentation and/or calculation methods for adequacy and accuracy; and

* Re-evaluation of instruments and systems operation, maintenance, and Calibration programs.

Resample

–           If Evidence is Provided that the Original Sample was Contaminated, the material is resampled per approved sampling procedures established for the material and subjected to the initial testing requirement. If the approved sampling procedure is found to be the cause, an Investigation must be initiated to assess the impact of the defective sampling technique on other batches.

–           Obtaining Additional Stability Samples is permitted for confirmatory purposes. However, when possible, the sample that was the source of the initial OOS or

Questionable Result must also be included in the retest plan.

–           All Stability Samples from the Same Packaging Lot and stored under identical conditions are considered equivalent for the purposes of this guidance.

Evaluation of Results

–           If an Assignable Cause is Associated with the Original OOS or Questionable Result, the original result is invalidated and the impact of the assignable cause on other samples in the test must be determined.

–           Data From the Original Sample shall be retained in the test record, invalidated and not included in the batch disposition decision when an assignable cause has been established.

–           A Sterility Test shall not be repeated, and the lot shall be Rejected, if an assignable cause cannot be attributed to the laboratory for the original OOS.

–           If No Assignable Cause is Found to be Associated with the Original OOS, and retesting is performed, all test results shall be documented on the LIR, forwarded to the QA Manager, and considered in batch/lot release decisions.

–           If the Test Method is shown by investigation to be in question, a general review of the method must be conducted, and required corrective action taken.

Reporting Results

–           Invalidated OOS Results shall not be averaged with repeat test results for reporting purposes.

–           LIR Form Section VIII “Repeat/Retest Results” shall be used to report results [i.e., the value determined to be the final valid results (e.g., the repeat results, or the confirmed initial OOS)].

–           Upon Completion of the LI for Initial OOS Results, the

Site Quality Team shall inform the Site Quality Review Team (SQRT) of the

outcome of the Investigation. The SQRT shall determine if issuance of any reports to the relevant Regulatory Authorities is required. This would include an update to any filed initial NDA-Field Alert Reports. The SQRT is responsible to take action in the event of any proposed market action (e.g., product recall), SDN, or initial or follow-up NDA-Field Alert Reports.

–           A Confirmed OOS Microbiological Test Result shall result in rejection of the test article, unless an approved reprocessing method is available and can be implemented.

–           In the Event of a Confirmed OOS Result, it may be necessary to issue an alert report to other departments within the Site to notify them of the situation. The QA Manager shall ensure that such reports are issued within one business day following confirmation of an OOS Result.

–           The QA Manager shall also evaluate the need for an Investigation into the source of the confirmed OOS result and ensure that such Investigations are completed.

Closing the Laboratory Investigation

–           LIR Form Section IX “Overall Conclusions” and if relevant, Section X “Corrective Action Plan”, shall be completed by the Lab Supervisor.

–           The Lab Manager and the QA Manager, using LIR Form Section XI “Laboratory Investigation Report Approval”, shall approve the completed LIR.

–           All LIRs must be completed and fully approved within 30 calendar days of the discovery of the initial OOS or Questionable Result. If the Laboratory Investigation will go beyond 30 calendar days, an interim status report must be issued by the Lab Manager to the QA Manager containing, at least, the following:

* The date of discovery of the OOS or Questionable Result,

* Summary of the LIR general information,

* Reason for the delay,

* Current status of the Investigation, and

* Estimated date for completion of the LIR.

–           The Approved LIR shall be:

* Considered part of the batch record;

* Distributed as per Site procedures; and

* Retained by the Site Quality Team according to Site record retention policies.

–           The Site Quality Team shall track the implementation of corrective and preventive actions identified in LIRs and shall notify the responsible Quality Review Team of any delays in the implementation of the corrective and preventive actions.

–           LIRs shall be reviewed by the Site Quality Team at least once per year to determine if trends are observed that require further corrective action.

–           Distributed Human Drug Products Covered by an NDA or ANDA shall require submission to the FDA of an NDA-Field Alert Report.

Products with a Post-Approval Commitment to the FDA for an Accelerated Stability Study require issuance of an NDA-Field Alert, when an Out-of-Specification (OOS) result is observed under the following conditions:

* Either under accelerated conditions; or

* For products held under ICH storage conditions (Ref 17), its corresponding intermediate condition: (e.g., an OOS result at 30°C ± 2°C and 65% ± %5 RH for a product normally stored under Zone II ICH storage conditions). Note: An Initial Investigation (LIR Form Sections I-IV) must be completed within one business day following discovery of the OOS.