CHRB Emergency Rule on Compounded Drugs Geared to Shield Veterinarians

In an attempt to help shield California's backstretch veterinary community from possible further punitive actions by the Veterinary Medical Board (VMB), the California Horse Racing Board (CHRB) has issued proposed emergency regulations designed to clear up discord between these two agencies about the correct use of compounded medications across California's backstretches.

The Food and Drug Administration (FDA) defines the compounding of drugs as “the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient. Compounding includes the combining of two or more FDA-approved drugs.”

The tranquilizer acepromazine is a prime example of this process, routinely compounded into liquid form to be prescribed and used on fractious dogs and horses. Other commonly used compounded medications across America's backstretches include dantrolene, used on horses that tie-up, and naquasone, for swelling.

Compounded drugs are not FDA-approved, but they are widely used in veterinary medicine provided the compounding process is done according to federal and state guidelines–a dynamic the CHRB has mirrored as a practical regulatory approach for many years, despite the existence of a state statute that essentially forbids drug compounding on CHRB licensed premises.

CHRB's Rule 1867 (b) states that “the possession and/or use on the premises of a facility under the jurisdiction of the Board of any drug, substance or medication that has not been approved by the United States Food and Drug Administration (FDA) for use in the United States.”

The California VMB interprets that rule categorically. Of the roughly 25 backstretch veterinarians currently working in Southern California, nearly all have accusations, are on probation or have record requests pending from the VMB in relation to potential Rule 1867 violations, according to the CHRB.

Last September, the CHRB issued an advisory to its relevant stakeholders stating that the agency's “longstanding interpretation” of rule 1867 “is that lawfully prescribed, compounded medications which are manufactured according to Federal and State guidelines do not violate this regulation.”

But CHRB equine medical director Jeff Blea said that the current Rule 1867 language “falls short of the intention of the rule.” It has been modified “to allow for quality standard care of racehorses by the use of compounded medications provided they are legally manufactured and prescribed in conjunction with a [veterinary client patient relationship].”

The proposed emergency rule making–one along a truncated timeline–appears geared to help shield veterinarians with pending cases by the VMB against them from a potential regulatory trap if they settle with the VMB and return to work under probation: should they then prescribe and administer compounded medications under the current Rule 1867 language, they could face stark professional consequences.

CHRB executive director Scott Chaney explained that the “sole purpose” of the proposed emergency rule making “is to clarify the language both for the vet' med' board but also for the practitioners.”

When asked if Rule 1867 (b)–adopted more than 20 years ago–should have been modified before to avoid the present professional threat that backstretch veterinarians currently face, Chaney pointed to how the CHRB has never cited a veterinarian for a Rule 1867 (b) violation, and that the board wasn't aware of the VMB filing accusations related to the same rule prior to 2020.

“Looking at it today, the easy answer is yes,” said Chaney. “But I think given it's our regulation and we were always purposeful and public about how we interpreted it, there was no reason.”

The proposed new rules modify Rule 1867 with provisions meaning that “possession or use of any compounded drug, substance, or medication, manufactured according to Federal and State laws and regulations, shall not be considered a prohibited veterinary practice” as long as no other human or animal drugs approved by the FDA to do the same job exist and are available, and that the drug is compounded by a California licensed veterinarian or California licensed pharmacy.

The proposed regulations do not differ substantially from any existing comparable federal regulations or statutes, according to the CHRB.

The CHRB has already noticed the proposed emergency regulations, giving interested parties a five-day public comment period. On Feb. 2, the board will submit them to the Office of Administrative Law (OAL). That office then has 10 days to accept or deny the proposed rules.

If the OAL indeed adopts the proposed emergency regulations in this truncated manner, the CHRB has 180 days to formally adopt the rules though its typical rule-making process. If the OAL denies the proposed rules, the CHRB can still adopt them through that normal rule-making process, but they won't go into effect until formally finalized.

The VMB, said Chaney, was involved in the drafting of the proposed regulations.

“We sent them the language we were thinking about, they made some suggestions. We incorporated a few of them but not all,” explained Chaney. “I know they discussed at their last meeting actually commenting, when they had the opportunity, on our regulation.”

The TDN emailed the VMB a series of questions, including whether the agency endorsed the proposed rules, and whether it would urge the OAL to accept or deny it. The VMB has not responded as of publication.

This action is the latest in a regulatory standoff between the CHRB and the VMB, ongoing since the VMB took the unprecedented step of suspending the license of equine medical director Blea at the end of 2021, only to reinstate his license the following September after finding him guilty of only fairly minor record-keeping offenses.

The VMB has complaints currently open against a number of Southern California veterinarians citing them for various alleged offenses beyond Rule 1867 violations, including the alleged misuse of misbranded drugs and of record-keeping offenses.

“This is the only CHRB regulation that the vet' med' board was using in its accusations,” said Chaney, when asked if the CHRB was planning on issuing other similar proposed emergency regulations.

“There are other causes of action, this just eliminated one of them,” he added. “The others the CHRB can't address, like problems with the Veterinary Medicine Practice Act and prosecutorial philosophy.”

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Here’s The Difference Between Pioneer, Generic, And Compounded Medications For Horses – And Why It Matters

Compounded medications for horses have been in the headlines in this and other publications a lot in recent years, especially in the wake of the 2020 federal indictments focusing on the use of misbranded drugs in racehorses. For a lot of horsemen though, it's not always clear from looking at a drug bottle or box what type of drug they're dealing with, and whether they should have concerns about its safety and legality.

Dr. Dionne Benson, chief veterinary officer for The Stronach Group and former executive director of the Racing Medication and Testing Consortium, presented a continuing education seminar for trainers in July to help them distinguish the different categories a drug may fall into and to determine if the product they're looking at is illegal.

When dealing with prescription (sometimes called “legend”) drugs, the first approved version of a new drug is called a pioneer drug. This is a substance that has been legally recognized by the Food and Drug Administration as a new animal drug and has been subjected to considerable testing to demonstrate its safety and efficacy, as well as the purity of its manufacturing process and the stability or shelf life of the drug. They also must show that the manufacturing process is consistent, and the concentration and purity of the drug doesn't change from batch to batch. Pioneer drugs also must show considerable research to validate their suggested doses and uses, and must meet rigorous requirements regarding their package labeling and advertising to be sure consumers are being presented with accurate and complete information.

The FDA approval process for new drugs is long, arduous, and expensive, so to give drug makers an incentive to go through it, they are permitted temporary patents on new substances. This means that for a limited number of years, the company that went through the approval process will be the only one that can legally produce the drug, allowing them to better recoup some of their expenditures in the approval process.

A generic medication is subject to all the same requirements regarding safety and efficacy, and may only be legally produced when the patent on the pioneer version of the drug has expired.

Both types of medications are also subject to adverse event reporting, so there is a public record of any negative side effects or bad reactions to a given drug or batch of drugs and those events can be investigated.

Compounded drugs aren't subject to any of that federal oversight.

Compounding may only be legally done in certain narrow parameters. A compounding pharmacy may only make a drug in response to a prescription a veterinarian has written to treat a specific condition in a specific animal, and it should only take place when there is no legend drug (either a pioneer or a generic) available to serve the patient's needs. Compounders can legally add flavoring to drugs to make them easier to administer, or take a drug traditionally offered in one form like a paste and make it into another, like a powder. In some limited circumstances, a compounder may legally mix two medications to reduce the amount of needle sticks a horse has to endure. In none of those situations should a compounder have large amounts of pre-formulated compounds sitting on the shelf awaiting an order – that, in the eyes of the FDA, is manufacturing. If an FDA-approved drug is no longer being manufactured or is on back order though, a compounder may make small batches of it but should not be in the business of mass manufacture.

“Compounded medications are legal under some circumstances,” said Benson. “Your vets use them every day and in the large majority of those cases they're using them appropriately.”

Benson has seen a number of examples of illegal compounds floating around the track however – sometimes sold online and sometimes peddled by sales reps.

One of the biggest areas of confusion seems to be what constitutes a generic drug. Compounded omeprazole products are a favorite of compounding pharmacies to produce in bulk, in part because horsemen are always looking for cheaper alternatives to the pioneer drug. But Benson said the patent on Gastrogard and Ulcergard, the pioneer form of the drug, hasn't run out yet, so all those “knock off” versions which people may think of as “generics” are actually illegal.

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Compounders are also fond of getting around this restriction by combining omeprazole with another ulcer drug like ranitidine, with the result often being priced more cheaply than pioneer omeprazole.

“The funny thing about that one is if you're combining omeprazole and ranitidine you're actually deactivating one of them,” said Benson.

Omeprazole works by reducing acid secretion, while ranitidine works by neutralizing acid. You don't need both, and they tend to be used in different types of ulcer cases.

Of course, Benson said, it's true that the FDA isn't likely to show up at your barn and ask to examine your prescription bottles (although, the federal case demonstrates they will take an interest in racing now and then). So why should horsemen worry about the technicalities of drug production?

Benson said that the illegal compounds she has seen often come along with safety concerns. Compounders mass producing a legend drug and selling it as a “generic” version aren't having their products tested like approved generic drug manufacturers, and testing by the RMTC suggests the amount of active ingredient in these illegal substances can be wildly mismatched to what's on the label. Benson recalled one bottle of clenbuterol that had ten times the labeled concentration of the drug, which was “getting into toxic ranges.” Another test of a triamcinolone bottle found it contained just .01 percent of its labeled concentration.

Another trouble with unauthorized mass manufacturers of prescription drugs is that there's no assurance of consistency from batch to batch of the medication, so just because a horseman has given a drug from a pharmacy once with no issue doesn't mean the next batch will be the same.

Many of these illegal substances can also be missing key safety information on their packaging. Benson cited Gastrotec, an omeprazole/misoprostol product which she said is still in circulation, despite FDA warnings about it.

“What's terrifying about this medication is the misoprostol,” she said, pointing out that drug is half of the abortion cocktail used in humans. “In veterinary school, you can't touch this stuff without gloves. All the women on the backside, they're given this to give to the horse, and what's the first thing we do? We put the tube in our mouth to pull off the cap and give it to the horse.”

There was no warning about these human health risks on the boxes or tubes of Gastrotec, Benson said.

Benson said she believes trainers have a responsibility to educate themselves about what is and isn't permissible in the drug-making world. Just acquiring a product from a sales representative or a veterinarian isn't a guarantee it is legal.

“Oftentimes we assume whatever the doctor or veterinarian says is right,” she said. “We don't want to make them mad; we just go along with it. But realistically it's your license on the line. Very rarely does a vet get called into a hearing or have to call an owner when a horse dies.”

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FDA Issues Warning Letter To Rapid Equine Solutions After Finding Dirty Compounding Rooms, Potency Issues

The Food and Drug Administration has issued a warning letter to Pennsylvania-based Rapid Equine Solutions following its inspection of the facility last summer, asking the pharmacy to provide more information about what its employees are doing to prevent serious problems at the facility.

The letter, dated June 12 of this year, describes observations made by federal inspectors between July 22 and Aug. 9, 2019 that include “insanitary conditions,” “potency issues,” and misbranding. Inspectors described “an unknown white film on the floor in the sterile production room and debris in the corners of the room” as well as several bugs lingering around the sterile and non-sterile preparation areas, while fly tape hung from the ceiling above the laboratory sink.

Further, the letter notes that a batch of toltrazuril/pyrimethamine paste compounded for the treatment of horses with Equine Protozoal Myeloencephalitis (EPM) was found to have incorrect amounts of both ingredients in it per its labeling. There was only 3 percent of the declared amount of toltrazuril in the paste, but 2,122 percent the amount of pyrimethamine declared on the label. The investigation followed the deaths of three horses in Maine and Ohio who were given the paste.

The drug combination, which has proven a popular choice for treating EPM, is the same one that was formulated incorrectly in 2014 by a Kentucky compounder which released batches with too much pyrimethamine in them. At least four horses died and several more fell ill in that case.

Rapid Equine provided the FDA with responses outlining its plans for eliminating the problems identified by investigators, but the agency writes in its warning letter this month those responses don't include enough specific information about what the facility is doing to improve their processes.

In 2019, Maine regulators suspended Rapid Equine's license after they say they discovered the mail-order facility was acting as a wholesaler for compounded drugs and was selling large amounts of compounds to a harness veterinarian who sold them without a prescription. Compounded drugs are not FDA-approved and are not intended to be produced and sold or stored in bulk; rather, they should be formulated to order for a specific patient to treat a diagnosed condition as prescribed by a veterinarian.

According to the online license verification system for the Pennsylvania State Board of Pharmacy, regulators there have taken no disciplinary action against Rapid Equine's license, which was renewed in August 2019 — on the same day FDA inspectors concluded their observation of the pharmacy's unsanitary conditions.

Read the June 2020 FDA warning letter here.

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