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Precision medicine vs traditional medicine

Precision medicine, also known as personalized medicine (PM), is a specialized form of medicine that utilizes information about an individual’s genes, proteins, environment, and lifestyle to prevent, diagnose, and treat diseases. This approach allows doctors and researchers to more accurately predict which treatments will be most effective for a specific patient. In contrast, traditional medicine focuses on developing treatments for large groups of people with the same illness, without considering individual variations.

Cancer

Cancer is a serious health concern that presents a significant risk to human health. Research in the field of oncology has always prioritized understanding the origins, diagnosis, and treatment of cancer. Cancer develops when abnormal cells proliferate uncontrollably, disrupting the normal function of the body. Unlike healthy cells, cancer cells do not follow the normal process of growth, division, and cell death. There are various types of cancer, including lung, colorectal, stomach, liver, prostate, breast, cervical, and thyroid carcinoma, each with unique characteristics related to the affected organ or tissue, behavior of cancer cells, and potential for metastasis. Despite advancements in cancer treatment, it remains the second leading cause of death globally, resulting in approximately 10 million deaths annually, as reported by the International Agency for Research on Cancer (IARC) [1].

Gene and cancer

Cancer is a genetic disease. Genes are comprised of sequences of DNA and are organized, sequentially, at specific locations on chromosomes within the nucleus of cells. Genes provide instructions for protein synthesis, which is essential for cell function. Every gene contains the code to produce a particular protein, each of which has a specific role within the cell. Cancer arises from genetic alterations of some kind. Cancer cells are abnormal variants of normal cells, indicating that a genetic change occurred in a normal cell to transform it into a cancerous cell. For instance, genes that typically regulate cell growth could be deactivated, or genes that control cell division might be constantly activated. Multiple gene mutations are typically required for cancer to develop. The majority of gene alterations are due to mutations, which can impair gene function. Genes with cancer-associated mutations are often referred to as cancer genes. While most mutations occur during an individual’s lifetime, some can be inherited.

 Precision medicine in cancer

Precision medicine in cancer treatment involves customizing therapies based on an individual patient’s genetic makeup, lifestyle, and the specific features of their tumor and its surrounding environment. This personalized approach offers an alternative to standard treatments like chemotherapy and radiation, which may not be effective for all patients and can cause harm to healthy tissues. Due to the diverse nature of cancer, with numerous subtypes based on molecular characteristics, clinicians rely on precision medicine to identify the most suitable therapies by analyzing genetic mutations and other molecular features of the tumor, often through techniques like next-generation sequencing.  Precision medicine is utilized in certain cancers to determine the most effective tests and treatments. Doctors may use precision medicine to assess cancer risk, detect cancers early, accurately diagnose specific types of cancer, select the best treatment options, and evaluate treatment effectiveness.

How does precision medicine work in cancer?

Precision drugs target specific genetic alterations that drive normal cells to become cancerous. These drugs also address abnormalities in proteins that have changed due to cancer. The goal of treatment is to target the unique characteristics that make cancer cells malignant. Utilizing molecular profiling to analyze a patient’s genetic and immune profile helps match the characteristics of the tumor to the most effective drugs. Molecular profiling involves studying tissue, blood, or fluid samples in a laboratory to identify abnormalities in genes, cell proteins, and specific tumor markers. This process incorporates advanced bioinformatics and analysis of DNA, RNA, proteins, and immune factors. Additionally, environmental and lifestyle factors play a significant role in how an individual’s disease responds to specific treatments.

Types of cancer where precision medicine is utilized

Some of the more prevalent cancers where precision medicine is currently being utilized include: Colorectal cancer,  Breast cancer,  Lung cancer,  Certain types of leukemia,  Certain types of lymphoma,  Melanoma,  Esophageal cancer,  Stomach cancer,  Ovarian cancer,  Thyroid cancer.

Landmark Discoveries in Precision Oncology

The field of precision oncology has made significant advancements since the discovery of the coupling of estrogen-receptor expression to certain types of breast cancer in the 1970s [2]. Understanding of the biological mechanisms underlying tumor development and patient responses to treatment has grown exponentially, leading to the development of a wide range of targeted therapies. Various strategies have been explored to discover precision medicine for cancer, including the inhibition/blockade of receptor tyrosine kinases, specific targeting of KRAS mutations [3], synthetic lethal approaches targeting homologous recombination deficient cancers with PARP inhibitors [4], biomarker-driven enhancement of response rates to immune checkpoint blockade [3], iron-dependent programmed cell death therapies (Ferroptosis) [5], proteolysis targeting chimeras (PROTACs) [6], and CAR-T cell therapies [3]. Several precision anticancer drugs with structure and brand name are presented in Figure 1.

This new era of precision medicine has resulted in the approval of several new cancer therapeutics every year for biomarker-defined subsets of patients. Recent approvals for biomarker-specific solid tumor treatments have demonstrated the rapid progress in biomarker-driven treatment indications between April 2019 and April 2021 in the United States (FDA) and EU (EMA) ([Figure 2) [7]. These approvals highlight the increasing availability of biomarker-driven treatment options for cancer patients. Approvals related to other biomarker testing methods, such as immunohistochemistry assays, are not included in this overview.

Figure 2: Genomic biomarker-driven drug approvals by FDA (top half) and EMA (EU) (bottom half) in 2019-2021

Challenges in the implementation of precision oncology

Precision oncology, a rapidly growing field in cancer treatment, is attracting significant interest and investment. However, there is a pressing need for empirical evidence to demonstrate its effectiveness compared to traditional therapies. Several challenges hinder the widespread adoption of precision oncology, including the limited availability of molecular-targeted therapies, the high cost of medications, and the potential risks associated with certain treatments. Tumor heterogeneity and ongoing tumor evolution further complicate treatment decisions, as genetic characteristics may vary between different regions or stages of tumor growth. Patients with multiple genetic alterations present additional challenges, as only a small percentage of advanced cancer patients have actionable mutations that can be targeted with existing drugs. Furthermore, gene expression profiling has not yet become a standard practice in clinical settings.

Conclusion

Precision oncology is rapidly advancing as a research field, leading to a multitude of new therapeutic options based on genomic and molecular biomarkers. The development of precision medicine targeting cancer has significantly increased the potential for cancer patients to extend their lifespan, improve their quality of life, and ultimately survive this devastating disease. This innovative approach to cancer treatment allows for targeted treatment of tumors, reducing side effects and damage to healthy cells while increasing the likelihood of treatment success. Despite the high cost and limited availability of precision medicine for all types of cancer currently, the goal is to eventually customize treatments based on the unique genetic and protein alterations in each individual’s cancer at a more affordable price.

References

[1] Alain Braillon1 and Adam Edward Lang; Eur. J. Epidemiol. 2023, 38, 391
[2] E. V. Jensen, et al; Natl. Cancer Inst. Monogr. 1971, 34, 55-70
[3] Stuart L. Rulten, et al; Int. J. Mol. Sci. 2023, 24, 12613
[4] Juliette Brownlie, et al; Curr. Opin. Pharmacol. 2023, 70, 102381
[5] Tong-Mei Shi, et al; J. Med. Chem. 2024, 67, 2238-2263
[6] Kailee A. Rutherford, et al; Mol. Cancer Ther. 2024, 23, 454-563
[7] Joaquin Mateo, et al; Nat. Med. 2022, 28, 658-665

Messenger RNA (mRNA) possesses extensive clinical potential for a range of therapeutic applications including vaccination, protein replacement, gene editing, immunotherapies, and tissue regeneration. The remarkable clinical utility of mRNA, especially in the context of vaccines, is exemplified by its ability to mitigate the ongoing SARS-CoV-2 pandemic. It is important to note that mRNA is a single-stranded RNA variant involved in protein synthesis and synthesized from a DNA template during transcription (Figure 1) [1]. Its crucial role lies in transporting protein information from the DNA in a cell’s nucleus to the cytoplasm, where the protein-making machinery interprets the mRNA sequence and translates each three-base codon into its corresponding amino acid, forming a growing protein chain. However, mRNA faces challenges such as susceptibility to degradation by serum endonucleases and limited cellular entry due to its negative charge. To maximize therapeutic benefits, it is imperative to protect mRNA molecules from degradation and precisely deliver them to the target cells for the desired protein production. Consequently, diverse strategies have arisen to engineer innovative mRNA delivery vehicles that promote effective transfection while minimizing toxicity.

Figure 1: mRNA is made from a DNA template during the process of transcription.

The transport of naked mRNA across the cell membrane is challenging, leading to the development of various delivery carriers such as lipid-based nanoparticles, polymer-based nanoparticles, peptide-based vehicles, and protein-mRNA complexes. Among them, lipid nanoparticles (LNPs) have emerged as the most advanced vectors. LNPs possess numerous advantages over viral vectors for gene therapy applications. These include their moderate or lower immunogenicity, ability to accommodate a large payload, ease of production, and excellent scalability. Additionally, LNPs can be tailored to specific cell targets and disease-related applications by adjusting the lipid-to-mRNA ratio.  Upon administration, LNPs are internalized by host cells. Consequently, the encapsulated mRNA cargo is delivered intracellularly to the cytosol, where the mRNA sequences are subsequently translated into targeted proteins by the host cell’s ribosome. The utilization of LNPs in COVID-19 mRNA vaccines is gaining significant attention due to their vital role in preserving and effectively delivering the mRNA payload to the targeted cells. Particularly, mRNA-LNP vaccines against COVID-19 are currently in clinical use, representing a groundbreaking approach to mRNA-based treatment.

LNPs are typically spherical structures composed of a lipid bilayer and an enclosed aqueous compartment. These LNPs possess a sophisticated internal arrangement that imparts them with superior physical stability, owing to their distinctive structural characteristics. Traditional LNPs have generally comprised four key elements: an ionizable or cationic lipid for nucleic acid binding and facilitating escape from endosomes, a polyethylene glycol (PEG) lipid to enhance colloidal stability and reduce clearance by the reticuloendothelial system, a cholesterol component to support LNP stability, and an amphipathic phospholipid to encourage fusion with cell and endosomal membranes. While these traditional LNPs have demonstrated safety and efficacy, their administration has been limited to intramuscular use. This limitation primarily arises from their physiochemical resemblance to very-low-density lipoprotein and their tendency to adsorb apolipoprotein E in blood plasma, leading to accumulation in the liver and uptake into hepatocytes via the low-density lipoprotein receptor.

In response to the aforementioned challenge, a methodology known as selective organ targeting (SORT) has been developed. This methodology involves the systematic engineering of nanoparticles to accurately deliver therapeutic molecules to both hepatic and extrahepatic tissues. The mechanistic study discovered that the biophysical class of SORT molecule generates a distinct protein corona when incorporated into the LNP. This corona plays a crucial role in determining the site of mRNA delivery within the body. The objective of organ targeting is not to deliver all doses to the target organs, but rather to deliver a sufficient dose to achieve the desired biological effects while limiting off-target cumulative toxicity. Upon entering the systemic circulation, a majority of the nanoparticles accumulate in the liver. However, targeting organs other than the liver has remained an unresolved issue for a significant period. By incorporating an auxiliary component called selective organ targeting molecules into lipid nanoparticles, it is possible to target selectively the liver, spleen, lungs, and other organs (Figure 2) [2].

Figure 2: a) The addition of a SORT lipid molecule to typical four-component LNPs alters the in vivo delivery profile of the resultant five-component SORT LNPs, allowing for tissue-specific delivery of mRNA to the liver, lungs, and spleen of mice after IV injections. b) Chemical structures of the lipids used in the protocol, including the ionizable cationic lipids 4A3-SC8 and DLin-MC3-DMA (MC3), the phospholipids DOPE and DSPC, cholesterol, DMG-PEG and the SORT molecules DOTAP, 18PA and DODAP.

Designing nanoparticles that target specific organs is crucial for effective drug delivery. Each organ, including the brain, heart, liver, spleen, lung, kidney, eye, bone, and bowel, possesses unique characteristics. Therefore, tailoring nanoparticles to match these organ-specific characteristics plays a pivotal role in developing organ-targeting nanoparticles. It is generally necessary to employ a comprehensive array of targeting strategies to achieve the most effective organ-targeting outcomes. These strategies include passive targeting through the utilization of unmodified nanoparticles’ surface properties; active targeting achieved by modifying nanoparticles’ surface to facilitate the transportation of therapeutic molecules to the intended location for therapeutic purposes; endogenous targeting by designing nanoparticles that bind to specific plasma proteins in the blood; and stimuli-responsive targeting that leverages the distinct properties of nanomaterials to switch under specific conditions (Figure 3) [3]. There have been significant achievements of delivering mRNA to various organs with the use of LNPs [4].

Figure 3: Targeting strategies using nanoparticles: (A) passive targeting, (B) active targeting, (C) endogenous targeting, and (D) stimuli-responsive targeting.

Engineering the formulation of SORT-LNPs allows them to enhance their selectivity and potency for mRNA delivery towards various organs. For example, the utilization of a permanently cationic quaternary ammonium lipid as a SORT molecule in LNPs enables the lung-specific mRNA delivery and genome editing in both pulmonary endothelial and epithelial cells. The potential for clinical translation of selective organ-targeting nanoparticles is enormous. At present, there is a significant amount of ongoing research focused on the utilization of SORT LNPs for the efficient delivery of mRNA, with the ultimate goal of delivering targeted therapeutics. Significant progress has already been made in ongoing research on SORT LNPs-mediated tissue-specific mRNA delivery. Notable achievements include mRNA delivery to lung for lung cancer and pulmonary lymphangioleiomyomatosis, to spleen for cancer, to liver for polyneuropathy, to eye for inherited retinal degenerations, and to bowel for inflammatory bowel diseases [3,4].

References

[1] https://www.genome.gov/genetics-glossary/messenger-rna, NIH.
[2] Xu Wang, Shuai Liu, Yehui Sun, et al; Nat. protoc. 2023, 18, 265.
[3] Jian Li and Hai Wang; Nanoscale Horiz. 2023, 8, 1155.
[4] Kelly Godbout and Jacques P. Tremblay; Pharmaceutics 2022, 14, 2129.

Skepticism is the cornerstone of science. Much progress has been achieved by questioning established status quo and gathering social support toward finding answers to naturally occurring phenomena. It is hard to envision scientific progress without challenging status quo and finding empirical evidence to dispute established beliefs in favor of more accurate representation of reality. Furthermore, human ability to symbolically represent and challenge ideas affords tremendous opportunity to advance understanding of natural phenomena. It is perhaps most pronounced within the confines of theoretical physics and mathematics where theory most often precedes experimental observation.

Despite being powerful tool when applied judiciously, untethered from reason, skepticism takes form of self-deception. One cannot deceive oneself into believing something while simultaneously knowing it to be false. Hence, literal self-deception cannot exist. In genuine self-deception, people avoid doing things that they have an inkling might reveal what they do not want to know. However, suspecting something is not the same is not knowing it to be true. As long as one does not find out the truth, what one believes is not known to be false. Keeping oneself willfully uninformed about an unwanted truth in the main vehicle of genuine self-deception.

Within physical and life sciences experiments are nuanced and the number of explanatory parameters is large. As such it is quite easy to cast explanatory powers onto obscure experimental conditions employing confounded logic and elaborate causative schemes. Nonetheless scientific method is self-correcting and it is a rare, albeit still observable phenomenon when much effort must be placed into refuting indefensible propositions e.g. flat earth theory, supernatural powers, etc.

However, within the fabric of human interaction self-deception is highly pronounced. By not pursuing courses of action that would reveal the actual state of affairs, individuals keep the knowable unknown. For example, within the contract research services sector it is rare when clients and service providers are completely transparent about the state of business relationship. Service providers are often reluctant to initiate meaningful performance conversation for the fear that they may have to provide additional services at no extra cost or worse they open pandoras box and then have to deal with whatever comes out of it. Instead the common course of actions is to presume all is well and then act surprised when tensions reach inflection point.

From the client standpoint it is customary to treat service providers respectfully but highly tactically. Given that within lower mid-market sector, service providers are in general much smaller than their client base and contribute small but very important inputs to the overall success of client objectives, external partner management practices either do not exist, are not actively implemented or implemented in a haphazard manner. Generally unwritten and unsaid justification for this approach is that the return on meaningful engagement with a small CRO is not justified and therefore the effort is not expended. More strikingly is that partner management methodology is rarely discussed at the client and when discussions do take place the conversations usually center around specific examples from which omnibus extrapolations are made without much concern to logical coherence.

Despite being widespread and systemic actors’ self-deception as it relates to service provider-sponsor interactions within the confines of the CRO industry does not cause much concern and is generally not given much attention. We recognize our limited knowledge of the clients we engage with and appreciate the number and complexity of tasks they have to deal with. To that end our approach is to strive toward complete transparency and enable our partners to make the best decisions that yield the most value to them. Whenever we identify and validate an issue that affects our performance we do not hold back and are forthcoming so that corrective measures are taken expediently. We firmly believe and can empirically support our assertions that deliberate effort to stay uninformed will adversely impact our ability to generate value for our clients and is both ethically and morally unacceptable.

It is not unusual to observe a large number of trends affecting everyday life come in and out of vogue. Fashion is a prime example where designs pop in an out of existence and only those that demonstrate a unique functional and aesthetic value are relegated to the iconic status. Especially so in physics, the progress achieved in the last century has been life-changing to billions of people. It is telling that all new discoveries were underpinned by inquisitive mindset and methodical approach toward elucidating the nature of reality with luck sprinkled in for good measure. Herein we explore what it means to practice scientific mindset.

In our own work we are frequently faced with a problem that is difficult to conceptualize and establish a hierarchy of contributing determinants. Many times, there is a significant degree of covariation and high sensitivity to initial conditions such that applying regression analytics is either impractical or simply not possible due to the small sample size. As such synthetic chemistry practitioners are left with the dilemma on how to improve predictive algorithm without trying to “boil the ocean”.

Broadly speaking synthetic chemists can be divided into two camps. In once camp one finds folks who demonstrate action bias and combinatorial mindset. They go and try the reactions because they may have a chance of yielding desired outcome. Literature precedence is incorporated albeit in a superficial capacity and most effort is expended toward conducting the experiments. “Failed” experiments are quickly discarded unless they yield obvious methodological flaws and little time is spent triangulating hypothesis, overall strategy and empirical data.

The second camp contains individuals who are prone to overanalyze and overextrapolate information gathered from preliminary diligence. Much discussion ensues about which experiments are to be conducted and why. Ubiquitously, personal bias is injected into discussion as a justification for a specific argument. Not surprisingly much time and emotive energy can be spent without having anything to show for it. Moreover, once the experiment is actually performed the results are analyzed to extreme degree frequently generating far fetched conclusions on the basis of confounded assumptions.

Through trial and error we came to appreciate the utility of context based approach that generates empirical results without sacrificing strategic rigor. In our view it is critically important to establish definitiveness of purpose and not do anything unless there is sound and rational justification for taking action or not. That is we happily engage in “trial and error” type investigations when the project is characterized by unknown unknowns. To make progress we have to explore and unmask causal connections. Whereas in the case of known unknowns, we can be much more strategic and deliberate. The known knowns paradigms simply call for operation efficiency and disciplined execution.

The greatest challenge to applying a rational methodology within irrational context is the keen awareness of shift in attention from deliberate application of set strategy to simple reactivity to environmental instigators.

At its core AAPharmaSyn is a science company driven by pursuit of knowledge to the benefit of our clients. We are motivated and energized by the conceptual theater that houses pursuit of scientific truths and the primacy of empirical evidence to test hypothesis and subject results to peer review. We find it enormously rewarding to be able to produce a generalizable theory that encapsulates a wide range of observations. Herein we discuss general attributes of scientific inquiry that encompass our approach to solving a novel question with ambiguous link to established conceptual schemes. Due to the nature of our work we will refrain from commenting on social sciences and limit our scope to physical and life sciences.

Based on our experience the scientific inquiry requires incorporation of the empirically verifiable questions, direct investigation of the questions of interest and reproducible and generalizable results. These elements constitute a framework for scientific inquiry resulting in formulation of theories that have predictive, explanatory and operatory powers.

Empirically Verifiable Questions

Asking informed question is critical to making insightful discoveries. If questions do not lead to multiple conjectures that need to be tested and explored much knowledge is unlikely to be gained. On the other side of the sliding scale if the questions are too broad and contain ill-defined themes such as “What is the nature of the Universe” they will invariably lead to highly involved discussion without making discernable progress on the question that generated the discussion in the first place. Thus, a good scientific question allows multiple hypothesis to be tested and is rooted in empirical observation that can be reproduced on command. When we engage in discovery research, we are frequently asking what determinants are causing a specific outcome and how these determinants interact to produce desired result. To that end making an intriguing observation provides us with an inspiration to dig deeper.

Direct Investigation of the Questions is Possible

As Richard Feynman has note in his autobiography: “…you must not fool yourself – and you are the easiest person to fool”.  This statement cannot be more true when the phenomenon is question is not directly observable. For example when investigating determinants of a specific behavioral phenomenon a researcher may make propose a hypothesis that is logically unverifiable by any available methods. Such as instead of relying on controlled stimuli and observing response patterns, one can envision infamous homunculus who is observing the observer and causes specific action to suit his desires. A researcher can spend much time in trying to decipher the hidden desires and ambitions of the homunculus as the subject is ripe with questions that seemingly can be afforded answers via indirect observation. One thing that researcher is clearly incapable of demonstrating directly is proving existence of the homunculus in the first place. Nonetheless human creativity is such that the homunculus theory can be infinitely modified to accommodate perceived challenges until the point at which the theory becomes incomprehensible. Thus, for a theory to have predictive valence, it has to befall to direct scrutiny of its observable determinants. Moreover the theory must avoid logical pitfalls of infinite regression and others similar fallacies such that it has a clear and explicit chain of reasoning.

Reproducible and Generalizable Results

If a theory has beautiful explanatory narrative but fails to make correct predictions, it has no utility beyond pure entertainment value. However if it lends itself to making predictions based on the interplay of various determinants and desired results are consistently observed, much value can be gained with further investigations. In our experience of synthesis methodology development we come across many new reaction schemes and have to make predictions based on triangulation of multiple imperfect concepts. Once we make a prediction and compare empirical and hypothesized outcomes, we make adjustment to the weights of different determinants and in some instances have to reconceptualize our view of specific methodology to accommodate empirical results. This process would not be useful if it was not for generalizability to other systems that share same or similar set of determinants such that our predictive accuracy is increased.

In pursuing our passion, we consistently face environmental instigators that induce self-referent theorizing. We believe this to be a natural and expected consequence of scientific pursuit and that, in general, people are psychologically predisposed toward connecting dots where they do not exist. We find it to be our responsibility to deliberately challenge our own thinking such that we deliver the most objective and rational solutions to our clients. 

The following white paper outlines FDA premise and guidelines to companies aspiring to engage in manufacturing of active pharmaceutical ingredients. The information presented is an introduction to the nuanced nature of the process and is not intended to be an authoritative treatise on the in and outs of the drug manufacturing rules and procedures.

The Center for Drug Evaluation and Research is a division of the U.S. Food and Drug Administration that monitors most drugs as defined in the Food, Drug, and Cosmetic Act. Some biological products are also legally considered drugs, but they are covered by the Center for Biologics Evaluation and Research. CDER established the Office of Pharmaceutical Quality (OPQ) to ensure a uniform drug quality program across all sites of manufacture, whether domestic or foreign,  and across all human drug product areas – new drugs and biologics, generics, and biosimilars—and also over-the-counter drugs and compounded drug products.

CGMP refers to the Current Good Manufacturing Practice regulations enforced by the FDA. CGMPs provide for systems that assure proper design, monitoring, and control of manufacturing processes and facilities. Adherence to the CGMP regulations assures the identity, strength, quality, and purity of drug products by requiring that manufacturers of medications adequately control manufacturing operations. This includes establishing strong quality management systems, obtaining appropriate quality raw materials, establishing robust operating procedures, detecting and investigating product quality deviations, and maintaining reliable testing laboratories. This formal system of controls at a pharmaceutical company, if adequately put into practice, helps to prevent instances of contamination, mix-ups, deviations, failures, and errors. This assures that drug products meet their quality standards.

General CGMP Practices for finished pharmaceuticals are outlined below.

1. Organization and Personnel
2. The quality control unit shall be responsible for approving or rejecting elements involved in the drug producing process, drug products manufactured, processed, packed, or held under contract by another company.
3. Each person engaged in the manufacture, processing, packing, or holding of a drug product shall have education, training, and experience, or any combination thereof, to enable that person to perform the assigned functions.
4. Personnel engaged in the manufacture, processing, packing, or holding of a drug product shall wear clean clothing appropriate for the duties they perform. 
5. Only personnel authorized by supervisory personnel shall enter those areas of the buildings and facilities designated as limited-access areas.
6. Personnel with any health conditions that may have an adverse effect on drug products should not involved in the drug producing process.
7. Consultants advising on the manufacture, processing, packing, or holding of drug products shall have sufficient education, training, and experience, or any combination thereof, to advise on the subject for which they are retained. 
8. Building and Facilities
9. Any building or buildings used in the manufacture, processing, packing, or holding of a drug product shall be of suitable size, construction and location to facilitate cleaning, maintenance, and proper operations.
10. There shall be separate or defined areas or such other control systems for the firm’s operations as are necessary to prevent contamination or mixups
11. Operations relating to the manufacture, processing, and packing of penicillin shall be performed in facilities separate from those used for other drug products for human use.
12. Adequate lighting shall be provided in all areas.
13. Adequate ventilation shall be provided.
14. Equipment for adequate control over air pressure, micro-organisms, dust, humidity, and temperature shall be provided when appropriate for the manufacture, processing, packing, or holding of a drug product.
15. Air filtration systems, including prefilters and particulate matter air filters, shall be used when appropriate on air supplies to production areas. 
16. Air-handling systems for the manufacture, processing, and packing of penicillin shall be completely separate from those for other drug products for human use.
17. Potable water shall be supplied under continuous positive pressure in a plumbing system free of defects that could contribute contamination to any drug product. 
18. Drains shall be of adequate size and, where connected directly to a sewer, shall be provided with an air break or other mechanical device to prevent back-siphonage.
19. Sewage, trash, and other refuse in and from the building and immediate premises shall be disposed of in a safe and sanitary manner.
20. Adequate washing facilities shall be provided, including hot and cold water, soap or detergent, air driers or single-service towels, and clean toilet facilities easily accesible to working areas.
21. Any building used in the manufacture, processing, packing, or holding of a drug product shall be maintained in a clean and sanitary condition, Any such building shall be free of infestation by rodents, birds, insects, and other vermin (other than laboratory animals). Trash and organic waste matter shall be held and disposed of in a timely and sanitary manner.
22. There shall be written procedures assigning responsibility for sanitation and describing in sufficient detail
23. Sanitation procedures shall apply to work performed by contractors or temporary employees as well as work performed by full-time employees during the ordinary course of operations.
24. Any building used in the manufacture, processing, packing, or holding of a drug product shall be maintained in a good state of repair.
25. Equipment
26. Equipment used in the manufacture, processing, packing, or holding of a drug product shall be of appropriate design, adequate size, and suitably located to facilitate operations for its intended use and for its cleaning and maintenance.
27. Any substances required for operation, such as lubricants or coolants, shall not come into contact with components, drug product containers, closures, in-process materials, or drug products so as to alter the safety, identity, strength, quality, or purity of the drug product beyond the official or other established requirements.
28. Equipment and utensils shall be cleaned, maintained, and, as appropriate for the nature of the drug, sanitized and/or sterilized at appropriate intervals to prevent malfunctions or contamination 
29. Written procedures shall be established and followed for cleaning and maintenance of equipment
30. Automatic, mechanical, or electronic equipment or other types of equipment, including computers, or related systems that will perform a function satisfactorily, may be used in the manufacture, processing, packing, and holding of a drug product.
31. Appropriate controls shall be exercised over computer or related systems to assure that changes in master production and control records or other records are instituted only by authorized personnel.
32. Filters for liquid filtration used in the manufacture, processing, or packing of injectable drug products intended for human use shall not release fibers into such products. 
33. Control of Components and Drug Product Containers and Closures
34. There shall be written procedures describing in sufficient detail the receipt, identification, storage, handling, sampling, testing, and approval or rejection of components and drug product containers and closures; such written procedures shall be followed.
35. Each container or grouping of containers for components or drug product containers, or closures shall be identified with a distinctive code for each lot in each shipment received. 
36. Upon receipt and before acceptance, each container or grouping of containers of components, drug product containers, and closures shall be examined visually for appropriate labeling as to contents, container damage or broken seals, and contamination.
37.  Each lot of components, drug product containers, and closures shall be withheld from use until the lot has been sampled, tested, or examined, as appropriate, and released for use by the quality control unit.
38. Representative samples of each shipment of each lot shall be collected for testing or examination. Sample meets the appropriate specifications of identity, strength, quality, and purity shall be approved, otherwise will be rejected.
39. Components, drug product containers, and closures approved for use shall be rotated so that the oldest approved stock is used first. Deviation from this requirement is permitted if such deviation is temporary and appropriate.
40. Components, drug product containers, and closures shall be retested or reexamined as necessary, e.g., after storage for long periods or after exposure to air, heat or other conditions that might adversely affect the component, drug product container, or closure.
41. Rejected components, drug product containers, and closures shall be identified and controlled under a quarantine system designed to prevent their use in manufacturing or processing operations for which they are unsuitable.
42. Drug product containers and closures shall not be reactive, additive, or absorptive so as to alter the safety, identity, strength, quality, or purity of the drug beyond the official or established requirements.
43. Container closure systems shall provide adequate protection against foreseeable external factors in storage and use that can cause deterioration or contamination of the drug product.
44.  Drug product containers and closures shall be clean and, where indicated by the nature of the drug, sterilized and processed to remove pyrogenic properties to assure that they are suitable for their intended use.
45. Standards or specifications, methods of testing, and, where indicated, methods of cleaning, sterilizing, and processing to remove pyrogenic properties shall be written and followed for drug product containers and closures.
46. Production and Process Control
47. There shall be written procedures for production and process control designed to assure that the drug products have the identity, strength, quality, and purity they purport or are represented to possess. It should include:
48. The batch shall be formulated with the intent to provide not less than 100 percent of the labeled or established amount of active ingredient.
49. Components for drug product manufacturing shall be weighed, measured, or subdivided as appropriate, and the process should be supervised
50. Actual yields and percentages of theoretical yield shall be determined at the conclusion of each appropriate phase of manufacturing, processing, packaging, or holding of the drug product.
51. All compounding and storage containers, processing lines, and major equipment used during the production of a batch of a drug product shall be properly identified at all times to indicate their contents and, when necessary, the phase of processing of the batch.
52. Major equipment shall be identified by a distinctive identification number or code that shall be recorded in the batch production record to show the specific equipment used in the manufacture of each batch of a drug product.
53. To assure batch uniformity and integrity of drug products, written procedures shall be established and followed that describe the in-process controls, and tests, or examinations to be conducted on appropriate samples of in-process materials of each batch. 
54. Valid in-process specifications for such characteristics shall be consistent with drug product final specifications and shall be derived from previous acceptable process average and process variability estimates where possible and determined by the application of suitable statistical procedures where appropriate.
55. In-process materials shall be tested for identity, strength, quality, and purity as appropriate, and approved or rejected by the quality control unit, during the production process.
56. When appropriate, time limits for the completion of each phase of production shall be established to assure the quality of the drug product.
57.  Appropriate written procedures, designed to prevent objectionable microorganisms in drug products not required to be sterile, shall be established and followed.
58.  Written procedures shall be established and followed prescribing a system for reprocessing batches that do not conform to standards or specifications and the steps to be taken to insure that the reprocessed batches will conform with all established standards, specifications, and characteristics.
59. Reprocessing shall not be performed without the review and approval of the quality control unit.
60. Packaging and Labeling Control
61. There shall be written procedures describing in sufficient detail the receipt, identification, storage, handling, sampling, examination, and/or testing of labeling and packaging materials; such written procedures shall be followed. Labeling and packaging materials shall be representatively sampled, and examined or tested upon receipt and before use in packaging or labeling of a drug product.
62. Records shall be maintained for each shipment received of each different labeling and packaging material indicating receipt, examination or testing, and whether accepted or rejected.
63. Labels and other labeling materials for each different drug product, strength, dosage form, or quantity of contents shall be stored separately with suitable identification. Access to the storage area shall be limited to authorized personnel.
64. Use of gang-printed labeling for different drug products, or different strengths or net contents of the same drug product, is prohibited unless the labeling from gang-printed sheets is adequately differentiated by size, shape, or color.
65. If cut labeling is used for immediate container labels, individual unit cartons, or multiunit cartons containing immediate containers that are not packaged in individual unit cartons, packaging and labeling operations shall include one of the following special control procedures:
66. Dedication of labeling and packaging lines to each different strength of each different drug product;
67. Use of appropriate electronic or electromechanical equipment to conduct a 100-percent examination for correct labeling during or after completion of finishing operations; or
68. Use of visual inspection to conduct a 100-percent examination for correct labeling during or after completion of finishing operations for hand-applied labeling. Such examination shall be performed by one person and independently verified by a second person.
69. Use of any automated technique, including differentiation by labeling size and shape, that physically prevents incorrect labeling from being processed by labeling and packaging equipment.
70. Labeling materials issued for a batch shall be carefully examined for identity and conformity to the labeling specified in the master or batch production records.
71. Procedures shall be used to reconcile the quantities of labeling issued, used, and returned, and shall require evaluation of discrepancies found between the quantity of drug product finished and the quantity of labeling issued when such discrepancies are outside narrow preset limits based on historical operating data.
72. All excess labeling bearing lot or control numbers shall be destroyed.
73. Returned labeling shall be maintained and stored in a manner to prevent mixups and provide proper identification.
74. Procedures shall be written describing in sufficient detail the control procedures employed for the issuance of labeling; such written procedures shall be followed.
75. There shall be written procedures designed to assure that correct labels, labeling, and packaging materials are used for drug products; such written procedures shall be followed:
76. Prevention of mixups and cross-contamination by physical or spatial separation from operations on other drug products.
77.  Identification and handling of filled drug product containers that are set aside and held in unlabeled condition for future labeling operations to preclude mislabeling of individual containers, lots, or portions of lot
78. Identification of the drug product with a lot or control number that permits determination of the history of the manufacture and control of the batch.
79. Examination of packaging and labeling materials for suitability and correctness before packaging operations, and documentation of such examination in the batch production record.
80. Inspection of the packaging and labeling facilities immediately before use to assure that all drug products have been removed from previous operations.
81. Packaged and labeled products shall be examined during finishing operations to provide assurance that containers and packages in the lot have the correct label.
82. A representative sample of units shall be collected at the completion of finishing operations and shall be visually examined for correct labeling.
83. Results of these examinations shall be recorded in the batch production or control records.
84. To assure that a drug product meets applicable standards of identity, strength, quality, and purity at the time of use, it shall bear an expiration date determined by appropriate stability testing
85. If the drug product is to be reconstituted at the time of dispensing, its labeling shall bear expiration information for both the reconstituted and unreconstituted drug product
86. Homeopathic drug products, Allergenic extracts that are labeled “No U.S. Standard of Potency”, New drug products for investigational shall be exempt from the requirements of this section.
87. Holding and Distribution
88. Written procedures describing the warehousing of drug products shall be established and followed. 
89. Quarantine of drug products before release by the quality control unit.
90. Storage of drug products under appropriate conditions of temperature, humidity, and light so that the identity, strength, quality, and purity of the drug products are not affected.
91. Written procedures shall be established, and followed, describing the distribution of drug products. 
92. A procedure whereby the oldest approved stock of a drug product is distributed first. Deviation from this requirement is permitted if such deviation is temporary and appropriate.
93. A system by which the distribution of each lot of drug product can be readily determined to facilitate its recall if necessary.
94. Laboratory Controls
95. Laboratory controls shall include the establishment of scientifically sound and appropriate specifications, standards, sampling plans, and test procedures designed to assure that components, drug product containers, closures, in-process materials, labeling, and drug products conform to appropriate standards of identity, strength, quality, and purity. 
96. For each batch of drug product, there shall be appropriate laboratory determination of satisfactory conformance to final specifications for the drug product, including the identity and strength of each active ingredient, prior to release. 
97. There shall be appropriate laboratory testing, as necessary, of each batch of drug product required to be free of objectionable microorganisms.
98. Any sampling and testing plans shall be described in written procedures that shall include the method of sampling and the number of units per batch to be tested; such written procedure shall be followed.
99. Acceptance criteria for the sampling and testing conducted by the quality control unit shall be adequate to assure that batches of drug products meet each appropriate specification and appropriate statistical quality control criteria as a condition for their approval and release. The statistical quality control criteria shall include appropriate acceptance levels and/or appropriate rejection levels.
100. There shall be a written testing program designed to assess the stability characteristics of drug products:
101. Sample size and test intervals based on statistical criteria for each attribute examined to assure valid estimates of stability;
102. Storage conditions for samples retained for testing;
103. Reliable, meaningful, and specific test methods;
104. Testing of the drug product in the same container-closure system as that in which the drug product is marketed;
105. Testing of drug products for reconstitution at the time of dispensing (as directed in the labeling) as well as after they are reconstituted.
106. An adequate number of batches of each drug product shall be tested to determine an appropriate expiration date and a record of such data shall be maintained.
107. For each batch of drug product purporting to be sterile and/or pyrogen-free, there shall be appropriate laboratory testing to determine conformance to such requirements. The test procedures shall be in writing and shall be followed.
108. For each batch of ophthalmic ointment, there shall be appropriate testing to determine conformance to specifications regarding the presence of foreign particles and harsh or abrasive substances. The test procedures shall be in writing and shall be followed.
109. For each batch of controlled-release dosage form, there shall be appropriate laboratory testing to determine conformance to the specifications for the rate of release of each active ingredient. The test procedures shall be in writing and shall be followed.
110. An appropriately identified reserve sample that is representative of each lot in each shipment of each active ingredient shall be retained. The reserve sample consists of at least twice the quantity necessary for all tests required to determine whether the active ingredient meets its established specifications, except for sterility and pyrogen testing.
111. An appropriately identified reserve sample that is representative of each lot or batch of drug product shall be retained and stored under conditions consistent with product labeling. 
112. Animals used in testing components, in-process materials, or drug products for compliance with established specifications shall be maintained and controlled in a manner that assures their suitability for their intended use. They shall be identified, and adequate records shall be maintained showing the history of their use.
113. Records and Reports
114. Any production, control, or distribution record that is required to be maintained in compliance with this part and is specifically associated with a batch of a drug product shall be retained for at least 1 year after the expiration date of the batch or, in the case of certain OTC drug products lacking expiration dating 
115. All records required under this part, or copies of such records, shall be readily available for authorized inspection during the retention period at the establishment where the activities described in such records occurred. 
116. A written record of major equipment cleaning, maintenance (except routine maintenance such as lubrication and adjustments), and use shall be included in individual equipment logs that show the date, time, product, and lot number of each batch processed.
117. Component, drug product container, closure, and labeling records shall include:
118. The identity and quantity of each shipment of each lot of components, drug product containers, closures, and labeling; the name of the supplier; the supplier’s lot number(s) if known; the receiving code and the date of receipt.
119. The results of any test or examination performed and the conclusion derived therefrom
120. An individual inventory record of each component, drug product container, and closure and, for each component, a reconciliation of the use of each lot of such component. The inventory record shall contain sufficient information to allow determination of any batch or lot of drug product associated with the use of each component, drug product container, and closure.
121. Documentation of the examination and review of labels and labeling for conformity with established specifications
122. The disposition of rejected components, drug product containers, closure, and labeling.
123. Master production and control records for each drug product, including each batch size thereof, shall be prepared, dated, and signed (full signature, handwritten) by one person and independently checked, dated, and signed by a second person.
124. Master production and control records shall include:
125. The name and strength of the product and a description of the dosage form;
126. The name and weight or measure of each active ingredient per dosage unit or per unit of weight or measure of the drug product, and a statement of the total weight or measure of any dosage unit;
127. A complete list of components designated by names or codes sufficiently specific to indicate any special quality characteristic;
128. An accurate statement of the weight or measure of each component, using the same weight system (metric, avoirdupois, or apothecary) for each component. Reasonable variations may be permitted, however, in the amount of components necessary for the preparation in the dosage form, provided they are justified in the master production and control records;
129. A statement concerning any calculated excess of component;
130. A statement of theoretical weight or measure at appropriate phases of processing;
131. A statement of theoretical yield, including the maximum and minimum percentages of theoretical yield beyond requirement
132. A description of the drug product containers, closures, and packaging materials, including a specimen or copy of each label and all other labeling signed and dated by the person or persons responsible for approval of such labeling;
133. Complete manufacturing and control instructions, sampling and testing procedures, specifications, special notations, and precautions to be followed.
134. Batch production and control records include:
135. An accurate reproduction of the appropriate master production or control record, checked for accuracy, dated, and signed;
136. Documentation that each significant step in the manufacture, processing, packing, or holding of the batch was accomplished
137. All drug product production and control records, including those for packaging and labeling, shall be reviewed and approved by the quality control unit to determine compliance with all established, approved written procedures before a batch is released or distributed. Any unexplained discrepancy (including a percentage of theoretical yield exceeding the maximum or minimum percentages established in master production and control records) or the failure of a batch or any of its components to meet any of its specifications shall be thoroughly investigated, whether or not the batch has already been distributed. The investigation shall extend to other batches of the same drug product and other drug products that may have been associated with the specific failure or discrepancy. A written record of the investigation shall be made and shall include the conclusions and followup.
138. Laboratory records shall include complete data derived from all tests necessary to assure compliance with established specifications and standards, including examinations and assays
139. Distribution records shall contain the name and strength of the product and description of the dosage form, name and address of the consignee, date and quantity shipped, and lot or control number of the drug product. For compressed medical gas products, distribution records are not required to contain lot or control numbers.
140. Returned and Salvaged Drug Products
141. Returned drug products shall be identified as such and held. If the conditions under which returned drug products have been held, stored, or shipped before or during their return, or if the condition of the drug product, its container, carton, or labeling, as a result of storage or shipping, casts doubt on the safety, identity, strength, quality or purity of the drug product, the returned drug product shall be destroyed unless examination, testing, or other investigations prove the drug product meets appropriate standards of safety, identity, strength, quality, or purity.
142. Drug products that have been subjected to improper storage conditions including extremes in temperature, humidity, smoke, fumes, pressure, age, or radiation due to natural disasters, fires, accidents, or equipment failures shall not be salvaged and returned to the marketplace.

Online References:

1. https://www.fda.gov/drugs/development-approval-process-drugs/pharmaceutical-quality-resources
2. https://www.fdareader.com/blog/introduction-to-gmps
3. https://www.naturalproductsinsider.com/manufacturing/cost-gmp-compliance
4. https://www.registrarcorp.com/fda-announces-higher-re-inspection-fees-for-fy-2020/
5. https://public-library.safetyculture.io/products/general-gmp-checklist?src=sc&amp_dev=d8263e90-79f2-4a4e-ae6b-c11fe32f727aR?src=sc&amp_dev=281588f7-4a3c-419c-ad27-a5bcc5fc3612R