Call for review for chemically synthesised and biological medicinal products Marketing authorisation holders should review their manufacturing processes for all products containing chemically synthesised or biological active substances to identify and, if necessary, mitigate the risk of presence of nitrosamine impurities. The call for review was extended to biological active substances in July 2020, as an outcome of CHMP’s Article 5(3) opinion. This complements the review of chemically synthetised active substances, which has been ongoing since September 2019. To allow marketing authorisation holders enough time to implement the Article 5(3) opinion, the European medicines regulatory network agreed new deadlines. Further details and guidance are available below. The European medicines regulatory network encourages marketing authorisation holders to submit the outcome of step 1 before the deadlines if they complete the risk evaluation or identify a risk in their products.  Marketing authorisation holders should inform the national competent authorities for nationally authorised products or EMA for centrally authorised products as soon as possible if tests confirm the presence of nitrosamine, irrespective of the amount detected.  They should also assess the immediate risk to patients and take appropriate action to avoid or minimise the exposure of patients to nitrosamines. At all steps, timelines should be shortened and marketing authorisation holders should immediately inform authorities if findings indicate an immediate risk to public health. Step 1: Risk evaluation Conduct a risk evaluation to identify active substances and finished products at risk of N-nitrosamine formation or (cross-)contamination and report the outcome by:   31 March 2021 for chemical medicines; 1 July 2021 for biological medicines. If a risk is identified for an active substance, marketing authorisation holders should submit the step 1 response template and proceed with step 2 confirmatory testing of the finished product. If no risk is identified for an active substance, marketing authorisation holders should conduct a risk evaluation of the finished product and submit the outcome of step 1 only when they reach a final conclusion on the active substance and finished product. Marketing authorisation holders can submit a single email notification grouping products with identical outcome of step 1. For more information, see Questions and answers for marketing authorisation holders / applicants on the CHMP opinion for the Article 5(3) referral. Marketing authorisation holders should use the templates below in their responses:   Step 1 – No risk identified response template Step 1 – Risk identified response template (doc) Step 1 – Risk identified response template (xls) Step 2: Confirmatory testing Perform further confirmatory testing on the products identified to be at risk of N-nitrosamine formation or (cross-)contamination and report confirmed presence of nitrosamines as soon as possible. For more information on the development of analytical methods, see below Questions and answers for marketing authorisation holders / applicants on the CHMP opinion for the Article 5(3) referral. Marketing authorisation holders should use the templates below in their responses. Marketing authorisation holders should only use the »Step 2 – Nitrosamine detected above acceptable intake or new nitrosamine detected response template’ if they have detected a nitrosamine in their product and it meets at least one of the following criteria:    it exceeds the acceptable intake limit; it exceeds the lifetime excess cancer risk of 1:100,000; it is a newly identified nitrosamine that is not covered in CHMP article 5 (3) opinion or EMA/CMDh Q&A, irrespective of the amount detected. In these cases, they should submit this template in addition to the ‘Step 2 – Nitrosamine detected response template’. If they have detected a nitrosamine, but it does not meet any of the above criteria, they should only use the ‘Step 2 Nitrosamine detected response template’. The deadline for completing confirmatory testing for chemical medicines is 26 September 2022.   Step 2 – No nitrosamine detected response template Step 2 – Nitrosamine detected response template (docx) Step 2 – Nitrosamine detected above acceptable intake or new nitrosamine detected response template (xls) For more information on the response template(s) to be used, see below CMDh practical guidance for Marketing Authorisation Holders of nationally authorised products (incl. MRP/DCP) in relation to the Art. 5(3) Referral on Nitrosamines   Assessment report template for the nitrosamine risk assessment for the outcome of step 2 – “nitrosamine detected” (April 2023) Step 3: Update marketing authorisations Apply for any necessary changes to the manufacturing process resulting from this review,  by requesting a variation to the marketing authorisation via standard regulatory procedures. Marketing authorisation holders should complete the confirmatory testing and submit their variation applications by:   1 October 2023 for chemical medicines  1 July 2023 for biological medicines. The CHMP and CMDh extended the deadline for submitting variation applications for chemical medicines from 26 September 2022 to 1 October 2023 in July 2022.  The extension aims to enable companies to perform a thorough investigation and to establish any required risk mitigating actions in light of new scientific developments since 2020, in particular those concerning active substance-derived nitrosamines. This extension does not affect the deadline for completing the step 2 confirmatory testing for chemical medicines, which remains 26 September 2022. Marketing authorisation holders should submit complete step 2 outcomes by this deadline. The European medicines regulatory network encourages marketing authorisation holders to submit variation applications as soon as they conclude their investigations, and before the extended deadline.  The deadlines of the call for review (steps 1, 2 and 3) for medicines containing chemically synthesised and biological active substances have passed. Any marketing authorisation holder (MAH) that has not notified relevant competent authority about identified nitrosamine impurities should report them as a matter of priority in line with the CHMP’s Article 5(3) opinion as well as any updates to previous notifications, using the response templates and available reporting mechanisms previously established. MAHs are reminded of their responsibilities to ensure the quality, safety and efficacy of their medicines and to adhere to the nitrosamines guidance outlined by the EU Network. MAHs and Manufacturers should work together and take precautionary measures to mitigate the risk of presence of nitrosamines during the manufacturing and storage of all authorised medicinal products. Authorities in the EU will continue to take all necessary measures to protect patients and ensure that medicines in the EU meet the required quality standards. Active substance-derived nitrosamines Authorities in the EU are aware that some active substances are at a higher risk of formation of active substance derived nitrosamine impurities.  Such active substances contain vulnerable amine functional groups that can undergo a reaction called nitrosation (often a secondary amine). Nitrosamines are thought to form when the nitrosatable amine group in the active substances and trace nitrite impurities in the inactive ingredients (excipients) react. Active substances that contain secondary amines appear particularly vulnerable to this reaction, although some cases involving active substances with tertiary amines have also been observed. More information on the root causes of nitrosamine impurities is available in Question-and-answer document on the Article 5(3) CHMP opinion (Question 4).  All marketing authorisation holders for EU medicines should consider this risk factor in their risk evaluations as a matter of priority, if they have not already done so. If a risk is confirmed, they should prioritise confirmatory testing. If testing confirms the presence of nitrosamines, companies should immediately report their findings to the relevant competent authority.  Guidance for marketing authorisation holders on confirmatory testing is available (see above). This is a precautionary step to ensure early detection of any potential risk, and to enable prompt regulatory action if necessary.  There is no immediate risk to patients who are taking these medicines. Patients who have any questions about their treatment should speak to their doctor.  Authorities will provide updates as necessary. Questions and answers A question-and-answer document is available for marketing authorisation holders on implementing the Article 5(3) CHMP opinion. It covers the:   outcome of the Article 5(3) referral; instructions, scope and timelines of the product review process; principles and methodology for confirmatory and release testing; approaches for determining limits for nitrosamines; changes to marketing authorisations and requirements for new applications; outcome of the Article 5(3) referral and its relation to the recently published report on lessons learnt exercise from presence of nitrosamines in sartans.