A ‘cultural icon’ can be described as ‘an object that represents some aspect of the values, norms or ideals perceived to be inherent in a culture, or section of a culture’ [Wikipedia, 2014]. In ‘The Viagra Phenomenon’ Tiefer asserts ‘certain medicines, such as aspirin, penicillin, birth control pills, mood regulators (Valium and Prozac), and now Viagra, have become cultural icons, reaching far beyond just their impact on human physiology to shape social norms and practices’ [Tiefer, 2006]. In fact, the American English word ‘viaggravated’ is being adopted in the American lexicon, and is an adjective that means ‘exhibiting a degree of sexual interest that is incongruent to one’s age’ [Merriam-Webster, 2014].
For impurity A, all of the samples were observed to be under the qualification threshold. The maximum impurity observed was 174.3 µg for sample lot number SD237. For impurity B, 4 of the 15 samples showed more than 200 µg, with 2 samples more than 6 times the qualification threshold. For impurity C, eight samples showed higher impurity limits than the qualification threshold. Impurity D was observed to be present in only in two samples in minute quantities.
Among all samples, nine samples showed more than 0.5% of the MDD. In four samples, the total impurity quantity was more than the 1% of MDD. In sample #7 (Malegra, lot number E-134), the total impurity quantity was more than the 1.5% of MDD, and for sample #11 (Integra lot number 1003003), the total impurity quantity was more than 2% of MDD. The innovator man up pills product contained relatively low impurity quantities. Impurities C and D were below the limit of detection, and impurities A and B constituted less than 37 µg, which is far below the qualification threshold. Although still a multibillion dollar industry, the market for Viagra and other ‘virility’ drugs has slowed in recent years.
In 2010, the total number of prescriptions for drugs used for erectile dysfunction fell by 5% after growth of only 1% annually the previous 4 years. Specifically, prescriptions for Viagra and Levitra declined 7% and 18%, respectively [James, 2011].
| Product | Dosage | Quantity + Bonus | Price | |
|---|---|---|---|---|
| Viagra Generic | 150mg | 60 + 4 Pills | 111.25€ 105.95€ | |
| Cialis Black | 80mg | 10 Pills | 43.27€ 41.21€ | |
| Tadalista Super Active | 20mg | 10 Pills | 55.64€ 52.99€ | |
| Levitra Generic | 20mg | 30 + 4 Pills | 70.59€ 67.23€ | |
| Cialis Black | 80mg | 20 Pills | 71.83€ 68.41€ | |
| Cialis Generic | 60mg | 270 + 10 Pills | 443.96€ 422.82€ | |
| Viagra Professional | 100mg | 360 + 6 Pills | 527.09€ 501.99€ | |
| Viagra Original | 100mg | 4 Pills | 40.94€ 38.99€ | |
| Apcalis SX Oral Jelly | 20mg | 50 + 6 Sachets | 146.39€ 139.42€ | |
| Viagra Generic | 200mg | 270 + 10 Pills | 379.76€ 361.68€ | |
| Kamagra | 100mg | 20 Pills | 86.09€ 81.99€ | |
| Cialis Generic | 2.5mg | 30 + 4 Pills | 51.95€ 49.48€ | |
| Kamagra Soft Tabs | 100 mg | 60 + 4 Pills | 180.59€ 171.99€ |
This can be contrasted with massive growth of Internet pharmacies, which have made prescription-only medicine, such as Viagra, readily available online, and the growth and popularity does not appear to be declining [Maxwell and Webb, 2008]. For instance, a search for ‘Internet drug store’ revealed 6.4 million hits and of 7000 Internet pharmacies identified by the Verified Internet Pharmacy Practice Sites Program (VIPPS) [Young, 2013].
During January 2010 through July 2010, 15 sample lots were purchased from the US and international markets. The US innovator product was obtained by prescription from Harrel’s Kingsville Pharmacy (Kingsville, TX, USA), and other samples from Internet pharmacy websites. A checklist of attributes was created for each specific drug product (Table 2). For analyses involving HPLC, the pure pharmaceutical grade chemical for sildenafil was obtained from Toronto Research Chemicals Inc. (Toronto, Ontario, Canada; Lot #5-KPA-93-1, Catalog #A617415).
Impurity A was obtained from ChemPacific (Baltimore, MD; Lot #CHP-20-10232-207-6, Catalog #33854), impurity B was obtained from Equinox Chemicals (Albany, GA; Lot EQX-2009-D-030, Catalog #E-03-0316), impurity C was obtained from Specs (The Netherlands; Product ID #AP-312/40633649), impurity D was obtained from Sigma-Aldrich (St. Louis, MO; Lot #04710EH, Product #535524). To prepare standard solutions of active pharmaceutical ingredient (API), 25 mg of sildenafil citrate was accurately weighed and dissolved in 50 ml of mobile phase (500 µg/ml concentration), sonicated for 15 minutes and filtered through 0.45 µm filter. Further dilutions were carried out to obtain sildenafil citrate within a target concentration range of 5–500 µg/ml. To prepare standard solution of impurities, 1 mg each of impurities A, B, C, and D were weighed and dissolved in 100 ml of mobile phase (10 µg/ml concentration), sonicated for 15 minutes, and filtered through a standard 0.45 µm filter.
Further dilutions were carried out to obtain impurities with in target concentration range of 5–100 µg/ml. Prior to testing, HPLC analytical equipment was calibrated according to manufacturer’s specifications by certified technicians. Where applicable, the appropriate USP guidelines were applied for testing procedures [United States Pharmacopeial Convention, 2003]. An HPLC methodology for sildenafil analysis has been reported previously by Daraghmeh and colleagues [Daraghmeh et al. 2001], and this analytical method was modified and employed in this study. Of these sites that were identified, only 4% were in proper compliance with regulations.
As per ICH Q2R1 guidelines for analytical procedure validation, the standard plot range should be at least 80–120% of the sample. For sildenafil citrate the standard plot range was 0.8–1.2 mg and for impurities the range was 2–20 µg, fildena 120 which meets the ICH guidelines. A total of 15 sildenafil citrate tablets were obtained for pharmaceutical analysis: 14 generic samples from international Internet pharmacy websites and one sample of the US innovator product (Table 2). For sildenafil, an official assay method for content uniformity using HPLC has not been reported in the United States Pharmacopeia (USP), the British Pharmacopoeia (BP), or European Pharmacopoeia (EP). For the 100 mg tablet dosage form of sildenafil, general acceptable assay limits have been published in scientific journals.
Daraghmeh and colleagues report an assay limit for sildenafil citrate of 98–102% and any individual impurity should not exceed 0.5% of the MDD with total impurity quantity not exceed 1% of the total daily dose [Daraghmeh et al. However, most USP product monographs (as compared with substance monographs) have the standard range for both manufactured products and compounded preparations as 90.0–110.0% [United States Pharmacopeial Convention, 2003; Allen, 2012]. HPLC analysis indicated that 14 of the 15 drug samples were within the general USP range of 90–110% of the labeled claim for each tablet dosage unit. However, for the range of 98–102% of the labeled claim, only six of the drug samples were within this range (Table 3). Note: Bold values are outside the +/- 2% assay range limit.
Using the linear regression method, linear curves were plotted using respective standard compounds for impurities A–D. HPLC analysis of the 15 samples provides variable data about the quantities of impurities (Table 4). Note: Bold values indicate values that are above the ICH qualification threshold. For total impurity levels, bold values indicate total impurity quantity more than 1% of MDD. According to ICH guidelines, the qualification threshold for a dosage form with a MDD of 100 mg, such as sildenafil, is 200 µg. What would be the impact on domestic sales of Viagra? According to Lowe and Costabile, ‘The role Internet pharmacies play in counterfeit PDE5 or abuse is not well documented; however based on easy access, direct patient marketing, and low advertised cost it is likely this role is underreported’ [Lowe and Costabile, 2011]. It is not unreasonable to assume that illegal access to Viagra via the Internet has had a negative impact on sales of Viagra through conventional healthcare channels. The documented risks of taking Viagra include: counterfeit drugs, potentially harmful drug interactions, and accidental overdose, not to mention improper packaging and labeling (Figure 1) [Young, 2013; Webb et al. If one considers the potential harmful effects of drug impurities, perhaps we have added to this list of health risks if a consumer chooses to purchase sildenafil via the Internet.
According to the US Pharmacopeia, when it comes to determining the quality of a drug product, ‘knowing its impurity profile is as important as knowing about the quality of its active pharmaceutical ingredient (API) and excipients’ [The Standard, 2012].
HPLC analysis was performed on a Waters 1525 Binary HPLC pump equipped with an inline degasser AF, a Waters 2487 dual λ absorbance detector, and a Waters 717 plus autosampler. Data was analyzed using Waters Breeze Software. Centrifugation was performed by the Eppendorf Centrifuge 5430, and sonification was performed with the Fisher Scientific Ultrasonic Cleaner FS20. Measurements were made with a 20 µl injection volume at 30°C; the detector wavelength was set at 240 nm and the retention time was 6.4 minutes. Routine analyses were carried out isocratically on a Waters X Bridge C18, 5 µm column (250 mm × 4.6 mm), eluted with a mobile phase consisting of acetonitrile/ammonium acetate buffer (50:50 v/v), pH 7.0, at a flow rate of 1.0 ml/min.
Pure sildenafil (Sigma-Aldrich, St. Louis, MO) acetonitrile (Aldrich Laboratories, Milwaukee, WI), ammonium acetate buffer (Fisher Scientific, Rochester, NY), water (Barnstead Nanopure ultrapure water purification system, Fisher Scientific, Rochester, NY), were used to prepare standard curves for each assay. Quantitation was accomplished through comparison of peak area to a standard curve. All analyses were performed in triplicate lovegra woman and the error expressed as standard deviation. To prepare a solution of tablet samples of 1 mg/ml concentration, 10 tablets were pulverized with mortar and pestle and portions equivalent to 100 mg sildenafil citrate were weighed and transferred into 100 ml standard volumetric flasks.
Upon addition of mobile phase (100 ml), sonication, centrifugation (15 minutes at 3000 rpm), 20 µl of the supernatant was injected into the chromatograph. This analysis was used to calculate the average impurity and average API quantity present in a dosage form one individual sample set. This method can remove the error caused by tablet weight variation in determination of average impurity and API quantities. To quantify the impurity and API levels, the calibration curve method using standard plots was used. For sildenafil, and impurities A, B, C, and D, linear curves were plotted using respective standard compounds.