Reform of drug regulation--beyond an independent drug-safety board

Evaluating medicines: let's use all the evidence

The current drug regulatory system is outdated and relies primarily on a process of premarketing evaluation, followed by periodic reviews of reported adverse events. While long-term medicine use for chronic conditions is now commonplace, current drug evaluation systems do not incorporate the comprehensive evidence accruing over time in clinical practice. Good quality, routinely collected data on medicines use are now available in some countries. Consistent with international opinion, we propose an expanded and integrated system of medicines regulation for Australia, based on a surveillance system that improves safety monitoring by complementing existing systems, making best use of routinely collected data, and leveraging the power of information technology. Australia is well placed to pilot such a model system.

The Development of a Comprehensive Risk-Management Program for Prescription Opioid Analgesics: Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS®)

OBJECTIVE. Beginning in the late 1990's a marked increase in abuse of OxyContin emerged, which led to the development and establishment of a proactive surveillance program to monitor and characterize abuse, named the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS) System. The main goal of RADARS was to develop proactive, timely and geographically sensitive methods to assess the abuse and diversion of OxyContin, along with a number of other Schedule II and III opioids with the aim of using this information to guide risk reduction interventions. Thus, its major focus was the detection of abuse of OxyContin and other commonly prescribed opioid analgesics at the three-digit ZIP code level across the country utilizing a number of different detection systems.

METHODS

The detection systems selected were: (1) Quarterly-surveys of drug abuse experts who are knowledgeable about cases of prescription drug abuse; (2) Surveys of law enforcement agencies that detect diversion of prescription drugs; and (3) Poison Control Center reports of intentional misuse or abuse of prescription opioids. Collectively, the three systems provide overlapping coverage of over 80% of the nation's 973 three-digit ZIP codes.

RESULTS

Preliminary results indicate that prescription drug abuse is prevalent nationwide, but it seems to be heavily localized in rural, suburban and small urban areas. Our results also indicate that hydrocodone and extended and immediate release oxycodone products are by far the most widely abused drugs in the country, but the abuse of all prescription opioids seems to have grown over the 14 quarters since the inception of RADARS.

CONCLUSION

The next step in these studies is to develop regionally specific, risk-minimization-strategies, which is the goal of all risk-management programs. If successful, RADARS will serve as a prototype of such programs for any new drug approved that has measurable abuse potential.

Nanotechnology in global medicine and human biosecurity: private interests, policy dilemmas, and the calibration of public health law

This paper considers how best to approach dilemmas posed to global health and biosecurity policy by increasing advances in practical applications of nanotechnology. The type of nano-technology policy dilemmas discussed include: (1) expenditure of public funds, (2) public-funded research priorities, (3) public confidence in government and science and, finally, (4) public safety. The article examines the value in this context of a legal obligation that the development of relevant public health law be calibrated against less corporate-influenced norms issuing from bioethics and international human rights.

The role of academia and the research community in assisting the food and drug administration to ensure U.S. drug safety

PURPOSE

Academia can play a prominent role in the drug safety arena, unique from that of industry, and a clearer articulation of how it could positively influence the current system is needed. We sought to examine ways that academia could expand its role in U.S. drug safety.

METHODS

An ad hoc meeting of academic experts in drug safety and risk management was convened at the Institute of Medicine (IOM) in Washington, D.C.

RESULTS

Academia should develop a stronger partnership with the Food and Drug Administration (FDA) to increase research on regulatory issues and public health questions and facilitate the prioritization of critical issues on drug safety. Such a collaboration could also facilitate the development of a network of academic centers of excellence in pharmacoepidemiology to address drug safety and risk management questions from a public health standpoint in a timely fashion. The development and testing of methodologic innovations on drug safety should also be encouraged.

CONCLUSIONS

Greater partnership between academia and the FDA could facilitate the prioritization of important issues on drug safety, allow more research questions on drug safety to be answered in a timely fashion, promote the development of networks for answering these questions, and help generate additional research ideas, ultimately providing enormous benefit to the public health.

Open-Label Extension Studies

The number of open-label extension studies being performed has increased enormously in recent years. Often it is difficult to differentiate between these extension studies and the double-blind, controlled studies that preceded them. If undertaken primarily to gather more patient-years of exposure to the new drug in order to understand and gain confidence in its safety profile, open-label extension studies can play a useful and legitimate role in drug development and therapeutics. However, this can only occur if the open-label extension study is designed, executed, analysed and reported competently. Most of the value accrued in open-label extension studies is gained from a refinement in the perception of the expected incidence of adverse effects that have most likely already been identified as part of the preclinical and clinical trial programme. We still have to rely heavily on post-marketing safety surveillance systems to alert us to type B (unpredictable) adverse reactions because open-label extension studies are unlikely to provide useful information about these types of often serious and relatively rare adverse reactions. Random allocation into test and control groups is needed to produce precise incidence data on pharmacologically expected, or type A, adverse effects. Some increased confidence about incidence rates might result from the open-label extension study; however, as these studies are essentially uncontrolled and biased, the data are not of great value. Other benefits have been proposed to be gained from open-label extension studies. These include ongoing access to an effective but otherwise unobtainable medicine by the volunteers who participated in the phase III pivotal trials. However, there are unappreciated ethical issues about the appropriateness of enrolling patients whose response to previous treatment is uncertain, largely because treatment allocation in the preceding randomised, double-blind, controlled trial has not been revealed at the time of entry into the open-label extension study. Negative aspects of open-label extension studies revolve around their use as a marketing tool, as they build a market for the drug and generate pressure for subsidised access to the drug from consumers and their physicians. Consumers, institutions where these studies are conducted and research ethics committees need to be convinced of the motives, as well as the quality, of the open-label extension study and its execution before supporting such studies. Open-label extension studies do have a legitimate but limited place in the clinical development of new medicines. The negative perceptions about these studies have arisen because of perversion of acceptable rationales for this type of study and a failure to recognise (or disclose) the limitations resulting from the inherent weaknesses in their design. Increased human exposure to a new medicine under reasonably controlled circumstances to increase confidence in the safety of the medicine is an acceptable rationale for an open-label extension study, and a useful activity to increase the knowledge of the safety profile of a new medicine. However, this goal is increasingly being achieved by means other than open-label extension studies.

Public-private partnership models in France and in Europe

The workshop entitled "Public-Private partnerships models in Europe-- comparison between France and European countries" brought together representatives of academia and industry, of national or European health research programs, of regional or national public-private partnership (PPP) initiatives, and of biotechnology with the following objectives: sharing a common vision on the needs, expectations and challenges of public-private partnership, based on the analysis of actual and original cases, and of new initiatives on public-private partnership, drawing conclusions and identifying key success factors, identifying trails for progress and drawing recommendations. The major event in this field is a European public-private partnership initiative between pharmaceutical industry (European Federation of Pharmaceultical Industry and Associations, EFPIA) and the European Commission (DG Research--health priority) resulting in the European Technology Platform project "Innovative Medicines Initiative" (IMI). Its architecture is based on the identification of the main bottlenecks to the development of innovative treatments (predictive pharmacology and toxicology, identification and validation of biomarkers, patients' recruitment, risk evaluation, and cooperation with the regulatory authorities). Simultaneously, initiatives both at the national and regional levels also foster PPP in the therapeutic field. Regional competitivity clusters acting in the biomedical sector, and national PPP calls such as the ANR (National Research Agency) RIB (Research and Innovation in Biotechnology) call are incentives for PPP projects. These regional and national PPP levels help public and private partners to further build consortia able to compete for EU-level calls, thus acting as incubators for EU PPP projects. In spite of incentives and of the regional and national structuring of PPP, weaknesses in the French system are linked to its fragmentation--multiple transfer agencies, multiple research organisations (operator or funding agency)--making contracts more difficult. This requires a simplified organisation, with a single referent per area (health, technology...). Improvement may also result from adaptation in the carreer, recruitment and mobility, from support to scientists in the management of projects, and from consistent support (without maintaining them artificially alive) to emerging companies from concept through clinical development. Pathways have been proposed to improve the efficiency of clinical research in France and Europe, involving the public hospital sector, and this requires the connection of disease-oriented networks and integrated infrastructures in Europe. As stated in the IMI strategic research agenda on efficacy, the quality of public infrastructures in Europe will be a key factor for its competitiveness and attractiveness for both academic and industry projects.

Availability of comparative trials for the assessment of new medicines in the European Union at the moment of market authorization

AIMS

To investigate the availability of information about premarketing randomized active-control trials (RaCTs) involving medicines with a new active substance at the moment of market authorization in the European Union.

METHODS

Information was obtained from the EMEA European Public Assessment Reports and the MEDLINE and EMBASE databases.

RESULTS

Between 1999 and 2005, 48% of recently approved medicines (n = 122) had been studied in comparison with existing medicines at the moment of market authorization. About one-third of these trials were published and publicly available at that moment.

CONCLUSIONS

For most new medicines evidence-based assessment of the (added) therapeutic value is not really possible at the moment of market authorization.

The rise and fall of Natrecor for congestive heart failure: implications for drug policy

Recent revelations of unexpected side effects of widely prescribed medications have raised questions about several aspects of U.S. drug policy, from initial Food and Drug Administration (FDA) approval to promotion by manufacturers and prescribing by physicians. One prominent example is nesiritide (Natrecor), a treatment for congestive heart failure. We use it as a case study to assess how FDA standards for drug approval, marketing practices by drug manufacturers, and physicians' prescribing choices can shape the risk-benefit relationship of new drugs. Based on the nesiritide experience, we suggest several ways to improve policies for drug approval, postmarketing surveillance, and drug utilization.

Différences et similitudes des promotions industrielles et des promotions institutionnelles

The Délégation à la Recherche Clinique d'Ile-de-France et de l'Assistance Publique/Hôpitaux de Paris (AP-HP) has elaborated a pragmatic approach for the monitoring of institutionally sponsored clinical studies. The mandatory practices aiming at preventing enrolled volunteers from risks and results from fraud and poor quality have been reviewed and a four-stage graduate monitoring has been defined, which is applied since 2002. This system needs to be scientifically assessed and adapted to the permanent evolution of national and international regulations. double dagger.

Regulating the market in human research participants

Lemmens and Miller critically examine "finder's fees" and other recruitment incentives issued to physicians for successfully referring patients to clinical trial investigators.

Toward a treaty on safety and cost-effectiveness of pharmaceuticals and medical devices: enhancing an endangered global public good

Expert evaluations of the safety, efficacy and cost-effectiveness of pharmaceutical and medical devices, prior to marketing approval or reimbursement listing, collectively represent a globally important public good. The scientific processes involved play a major role in protecting the public from product risks such as unintended or adverse events, sub-standard production and unnecessary burdens on individual and governmental healthcare budgets. Most States now have an increasing policy interest in this area, though institutional arrangements, particularly in the area of cost-effectiveness analysis of medical devices, are not uniformly advanced and are fragile in the face of opposing multinational industry pressure to recoup investment and maintain profit margins. This paper examines the possibility, in this context, of States commencing negotiations toward bilateral trade agreement provisions, and ultimately perhaps a multilateral Treaty, on safety, efficacy and cost-effectiveness analysis of pharmaceuticals and medical devices. Such obligations may robustly facilitate a conceptually interlinked, but endangered, global public good, without compromising the capacity of intellectual property laws to facilitate local product innovations.

Classification of error in anatomic pathology: a proposal for an evidence-based standard

Error in anatomic pathology (EAP) is an appropriate problem to consider using the disease model with which all pathologists are familiar. In analogy to medical diseases, diagnostic errors represent a complex constellation of often-baffling deviations from the "normal" condition. Ideally, one would wish to approach such "diseases of diagnosis" with effective treatments or preventative measures, but interventions in the absence of a clear understanding of pathogenesis are often ineffective or even harmful. Medical therapy has its history of "bleeding and purging," and error-prevention has a history of "blaming and shaming." The urge to take action in dealing with either medical illnesses or diagnostic failings is, of course, admirable. However, the principle of primum non nocere should guide one's action in both circumstances. The first step in using the disease model to address EAP is the development of a valid taxonomy to allow for grouping together of abnormalities that have a similar pathogenesis. It is apparent that disease categories such as "tumor" are not valuable until they are further refined by precise and accurate classification. Likewise, "error" is an impossibly broad concept that must be parsed into meaningful subcategories before it can be understood with sufficient clarity to be prevented. One important EAP subtype that has been particularly difficult to understand and classify is knowledge-based interpretative (KBI) error. Not only is the latter sometimes confused with distinctly different error types such as human lapses, but there is danger of mistaking system-wide problems (eg, imprecise or inaccurate diagnostic criteria) for the KBI errors of individual pathologists. This paper presents a theoretically-sound taxonomic system for classification of error that can be used for evidence-based categorization of individual cases. Any taxonomy of error in medicine must distinguish between the various factors that may produce mistakes, and importantly, whether they are individual, small system (e.g., my histology laboratory), or big system (e.g., published diagnostic criteria). Because no overarching governing agency exists to coordinate this initiative, the recognition of need and effective implementation of EAP counter-measures must emanate from our specialty group itself.