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Faust A, Woydack L, Strech D. Should the governance of individual treatment attempts ("Individuelle Heilversuche") include praxis evaluation? Results from qualitative stakeholder interviews. Health Policy 2023; 130:104752. [PMID: 36812859 DOI: 10.1016/j.healthpol.2023.104752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 01/20/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Individual treatment attempts (ITAs) are a German concept for the treatment of individual patients by physicians with nonstandard therapeutic approaches. Due to the lack of evidence, ITAs come with a high amount of uncertainty regarding the risk-benefit ratio. Despite the high uncertainty, no prospective review and no systematic retrospective evaluation of ITAs are required in Germany. Our objective was to explore stakeholders' attitudes toward the retrospective evaluation (monitoring) or prospective evaluation (review) of ITAs. METHODS We conducted a qualitative interview study among relevant stakeholder groups. We used the SWOT framework to represent the stakeholders' attitudes. We applied content analysis to the recorded and transcribed interviews in MAXQDA. RESULTS Twenty interviewees participated and pointed to several arguments in favor of the retrospective evaluation of ITAs (e.g. knowledge gain about circumstances of ITAs). The interviewees expressed concerns regarding the validity and practical relevance of the evaluation results. The viewpoints on review addressed several contextual factors. CONCLUSION The current situation with a complete lack of evaluation insufficiently reflects safety concerns. German health policy decision makers should be more explicit about where and why evaluation is needed. Prospective and retrospective evaluations should be piloted in areas of ITAs with a particularly high uncertainty.
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Affiliation(s)
- Alice Faust
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, QUEST Center for Responsible Research, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany; Medizinische Hochschule Hannover, Institut für Ethik, Geschichte und Philosophie der Medizin, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
| | - Lena Woydack
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, QUEST Center for Responsible Research, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Daniel Strech
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, QUEST Center for Responsible Research, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
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Wexler A. Mapping the Landscape of Do-it-Yourself Medicine. CITIZEN SCIENCE : THEORY AND PRACTICE 2022; 7:38. [PMID: 36632334 PMCID: PMC9830450 DOI: 10.5334/cstp.553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The practice of medicine is typically conceptualized as remaining within the boundaries of a hospital or clinic. However, in recent years, patients have been able to gain access to information about medical research as it is ongoing. As a result, there has been a rise in do-it-yourself (DIY) medicine, where individuals treat themselves for medical conditions outside of clinical settings, often mimicking experimental therapies that remain inaccessible to the wider public. For example, in DIY brain stimulation, individuals suffering from depression build at-home electrical headsets using nine-volt batteries, mimicking an experimental neuroscience technique used in scientific laboratories. In DIY fecal transplantation, those with intestinal disorders like C. Difficile and inflammatory bowel disease transplant stool from donors into themselves with the aid of blenders and enemas. In the open Artificial Pancreas System movement, diabetes patients hacked together an artificial pancreas system from their glucose monitors and insulin pumps, years before such a system was approved by the United States Food and Drug Administration (US FDA). To date, scholarship on DIY medicine has largely been relegated to specific medical domains (e.g., neurology, gastroenterology, infectious disease). In this paper, however, I recognize DIY medicine as a cross-cutting phenomenon that has emerged independently across medical domains but shares common features. I map the varieties of DIY medicine across these domains and suggest that four key factors lead to their creation, growth, and uptake. In doing so, this essay sheds light on an understudied area of biomedical citizen science that is likely to grow substantially in the coming decades.
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Affiliation(s)
- Anna Wexler
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, US
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Smith AJF, Redic KA. Single-patient expanded access: A primer for pharmacists. Am J Health Syst Pharm 2022; 79:2118-2127. [PMID: 36056791 DOI: 10.1093/ajhp/zxac242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The process of providing treatment with investigational drugs through expanded access is explained. Roles and informational resources for pharmacists are discussed. SUMMARY Expanded access is a regulatory pathway for the treatment of serious or life-threatening diseases or conditions with investigational agents outside of clinical trials. In the setting of no available therapies or ineligibility for clinical trials, a patient and their treating physician may pursue therapies that are not approved by the Food and Drug Administration (FDA). The drug manufacturer, FDA, and institutional review boards are required stakeholders in the expanded access process. Other pathways for obtaining investigational agents outside of clinical trials, including federal Right to Try and emergency use authorization, exist but differ in their level of involvement of these key stakeholders. Pharmacists are equipped to be involved in therapy identification, risk vs benefit evaluations, therapy preparation and administration, supportive care, transitions of care, and regulatory compliance. Specific websites, publications, and organizations can aid in navigating expanded access. CONCLUSION Combining elements of traditional clinical care and research, expanded access involves direct treatment with non-FDA-approved agents outside of a clinical trial. Healthcare providers should be aware of the possibility of providing investigational treatments after all approved options have been exhausted.
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Affiliation(s)
- Andrew J F Smith
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, MI, USA
| | - Kimberly A Redic
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, MI, USA
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Tafesse TB, Bule MH, Khan F, Abdollahi M, Amini M. Developing Novel Anticancer Drugs for Targeted Populations: An Update. Curr Pharm Des 2021; 27:250-262. [PMID: 33234093 DOI: 10.2174/1381612826666201124111748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Due to higher failure rates, lengthy time and high cost of the traditional de novo drug discovery and development process, the rate of opportunity to get new, safe and efficacious drugs for the targeted population, including pediatric patients with cancer, becomes sluggish. OBJECTIVES This paper discusses the development of novel anticancer drugs focusing on the identification and selection of targeted anticancer drug development for the targeted population. METHODS Information presented in this review was obtained from different databases, including PUBMED, SCOPUS, Web of Science, and EMBASE. Various keywords were used as search terms. RESULTS The pharmaceutical companies currently are executing drug repurposing as an alternative means to accelerate the drug development process that reduces the risk of failure, time and cost, which take 3-12 years with almost 25% overall probability of success as compared to de novo drug discovery and development process (10- 17 years) which has less than 10% probability of success. An alternative strategy to the traditional de novo drug discovery and development process, called drug repurposing, is also presented. CONCLUSION Therefore, to continue with the progress of developing novel anticancer drugs for the targeted population, identification and selection of target to specific disease type is important. Considering the aspects of the age of the patient and the disease stages such as each cancer types are different when we study the disease at a molecular level. Drug repurposing technique becomes an influential alternative strategy to discover and develop novel anticancer drug candidates.
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Affiliation(s)
- Tadesse B Tafesse
- Department of Medicinal Chemistry, School of Pharmacy, Drug Design and Development Research Center and The Institute of Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammed H Bule
- Department of Medicinal Chemistry, School of Pharmacy, Drug Design and Development Research Center and The Institute of Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Fazlullah Khan
- Department of Allied Health Sciences, Bashir Institute of Health Sciences, Bhara Kahu Islamabad, Iran
| | - Mohammad Abdollahi
- Toxicology and Diseases Group (TDG), Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), and Department of Toxicology and Pharmacology, School of Pharmacy, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mohsen Amini
- Department of Medicinal Chemistry, School of Pharmacy, Drug Design and Development Research Center and The Institute of Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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Chapman CR, Belli HM, Leach D, Shah LD, Bateman-House A. A survey of pediatric hematologists/oncologists' perspectives on single patient Expanded Access and Right to Try. MEDICINE ACCESS @ POINT OF CARE 2021; 5:23992026211005991. [PMID: 36204503 PMCID: PMC9413614 DOI: 10.1177/23992026211005991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Physicians in the United States play an essential role guiding patients through single patient pre-approval access (PAA) to investigational medical products via either the Food and Drug Administration (FDA)'s Expanded Access (EA) or the federal Right To Try (RTT) pathways. In this study, we sought to better understand pediatric hematologist/oncologists' attitudes about seeking PAA, on behalf of single patients, to investigational drugs outside of clinical trials. Methods A cross-sectional survey was developed and sent to pediatric hematologist/oncologists via St. Baldrick's Foundation's email distribution list. Results Of 73 respondents (10.1% of those who received the survey), 56 met eligibility criteria and are included in the analysis. Over 80% (n = 46) had prior experience with single patient PAA. Respondents were most concerned about the unknown risks and benefits of investigational drugs and financial implications of PAA for patients. One hundred percent and 91.1% of respondents indicated a willingness to support patients through EA and RTT pathways, respectively. When asked about their most recent experience with PAA, 40 out of 46 indicated that they used the FDA's EA pathway to seek PAA and 4 out of 46 indicated that they used the RTT pathway. Of 44 respondents who had used the EA or RTT pathway, 43 indicated that the biotechnology or pharmaceutical company they solicited granted access to the requested product. Conclusion Survey results support other findings suggesting a need for additional physician support and education about PAA and that physicians may have unequal access to information about investigational drugs and concerns about financial implications of PAA for their patients.
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Affiliation(s)
- Carolyn Riley Chapman
- Department of Population Health,
Division of Medical Ethics, New York University Grossman School of Medicine, New
York, NY, USA
| | - Hayley M Belli
- Department of Population Health,
Division of Biostatistics, New York University Grossman School of Medicine, New
York, NY, USA
| | - Danielle Leach
- St. Baldrick’s Foundation, Monrovia,
CA, USA
- National Brain Tumor Society, Newton,
MA, USA
| | - Lesha D Shah
- Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Alison Bateman-House
- Department of Population Health,
Division of Medical Ethics, New York University Grossman School of Medicine, New
York, NY, USA
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Spector-Bagdady K, Weatherwax KJ, Gravelin M, Shuman AG. The Critical Role of Medical Institutions in Expanding Access to Investigational Interventions. Hastings Cent Rep 2020; 49:36-39. [PMID: 30998277 DOI: 10.1002/hast.991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The U.S. federal government provides two tracks for eligible patients to obtain access outside clinical trials to investigational interventions currently under study for potential clinical benefits: the Food and Drug Administration's expanded access pathway and the pathway created by the more recent Right to Try Act. In this issue of the Hastings Center Report, with a critical focus on patients, industry, and the research enterprise, Kelly Folkers and colleagues frame the inherent challenges that these pathways are meant to solve and have also inadvertently created. But an additional key focus is how the relevant situations should be managed at the bedside and how the system risks both inefficient and inequitable access to options at the institutional level. Although either pathway could be helpful to patients, the challenges of having the pathways coexist are greater than the sum of their parts. Individual clinicians represent the front line of the regulatory and eligibility challenges of expanded access and right to try, making clinical education a critical component of a comprehensive approach to using them well. But it is medical institutions that must take the lead on supporting access to investigational options in the most equitable and effective manner possible.
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Pace J, Laba TL, Nisingizwe MP, Lipworth W. Formulating an Ethics of Pharmaceutical Disinvestment. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:75-86. [PMID: 32130652 DOI: 10.1007/s11673-020-09964-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 02/12/2020] [Indexed: 06/10/2023]
Abstract
There is growing interest among pharmaceutical policymakers in how to "disinvest" from subsidized medicines. This is due to both the rapidly rising costs of healthcare and the increasing use of accelerated and conditional reimbursement pathways which mean that medicines are being subsidized on the basis of less robust evidence of safety and efficacy. It is crucial that disinvestment decisions are morally sound and socially legitimate, but there is currently no framework to facilitate this. We therefore reviewed the bioethics literature in order to identify ethical principles and concepts that might be relevant to pharmaceutical disinvestment decisions. This revealed a number of key ethical considerations-both procedural and substantive-that need to be considered when making pharmaceutical disinvestment decisions. These principles do not, however, provide practical guidance so we present a framework outlining how they might be applied to different types of disinvestment decisions. We also argue that, in this context, even the most rigorous ethical reasoning is likely to be overridden by moral intuitions and psychological biases and that disinvestment decisions will need to strike the right balance between respecting justifiable moral intuitions and overriding unjustifiable psychological impulses.
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Affiliation(s)
- Jessica Pace
- Sydney Health Ethics, Level 1, Medical Foundation Building, K25, The University of Sydney, NSW, 2006, Australia.
| | - Tracey-Lea Laba
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Broadway, NSW, 2007, Australia
| | - Marie-Paul Nisingizwe
- Graduate School, Faculty of Medicine, University of British Columbia, 170-6371 Crescent Rd, Vancouver, BC V6T 1ZT, Canada
| | - Wendy Lipworth
- Sydney Health Ethics, Level 1, Medical Foundation Building, K25, The University of Sydney, NSW, 2006, Australia
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Chapman CR, Eckman J, Bateman-House AS. Oversight of Right-to-Try and Expanded Access Requests for Off-Trial Access to Investigational Drugs. Ethics Hum Res 2020; 42:2-13. [PMID: 31967412 DOI: 10.1002/eahr.500038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
For decades, the U.S. Food and Drug Administration (FDA) has provided an "expanded access" pathway that allows patients who meet qualifying conditions to gain access outside a clinical trial to an investigational medical product being tested to see if it is safe and effective for a specific use. The Right to Try (RTT) Act, enacted in 2018, created a second mechanism for off-trial, or non-trial, access to investigational drugs. In contrast to the expanded access pathway, the federal RTT pathway does not require the involvement of the FDA or an institutional review board (IRB). Given that physicians, drug manufacturers, and medical institutions now have a choice whether to assist individual patients through the expanded access or the federal RTT pathway, we review the differences between these options and discuss the benefits and burdens of IRB involvement in requests to access interventions through the pathways. We also suggest ways in which IRB oversight may be further improved.
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Affiliation(s)
- Carolyn Riley Chapman
- Faculty affiliate of the Division of Medical Ethics in the Department of Population Health in the NYU School of Medicine at NYU Langone Health
| | - Jared Eckman
- Worked on this article as an intern in the Division of Medical Ethics in the Department of Population Health at NYU School of Medicine at NYU Langone Health and is currently pursuing an MD as well as an MA in bioethics at Emory School of Medicine
| | - Alison S Bateman-House
- Assistant professor in the Division of Medical Ethics in the Department of Population Health in the NYU School of Medicine at NYU Langone Health
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Folkers KM, Leone S, Caplan A. Patient advocacy organizations' information for patients on pre-approval access to investigational treatments. BMC Res Notes 2019; 12:706. [PMID: 31661023 PMCID: PMC6819417 DOI: 10.1186/s13104-019-4745-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/17/2019] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To evaluate the availability of information regarding patient access to investigational treatments through clinical trials and non-trial pre-approval access pathways from a sample of patient advocacy organization (PAO) websites in the United States. RESULTS We systematically analyzed the content of 118 randomly selected PAO websites to assess whether they contained information on clinical trials and non-trial pathways-e.g., the U.S. Food and Drug Administration (FDA) expanded access (EA) program and right to try-over the course of two months from February to March 2019. A majority (81%, n = 96) of PAOs provided a link to ClinicalTrials.gov, and 73% (n = 86) had their own clinical trial finder or list of relevant trials. 23% (n = 27) mentioned EA, with 8% (n = 9) providing specific resources for FDA's EA program. 8% (n = 10) provided a statement on the passage of the federal right to try law. A majority of PAO websites contained information on clinical trials, but a minority discussed non-trial pre-approval access. The lack of information on the latter highlights an area in need of improvement.
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Affiliation(s)
- Kelly McBride Folkers
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, Translational Research Building, 227 E. 30th Street #754B, New York, NY 10016 USA
| | - Sarah Leone
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, Translational Research Building, 227 E. 30th Street #754B, New York, NY 10016 USA
| | - Arthur Caplan
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, Translational Research Building, 227 E. 30th Street #754B, New York, NY 10016 USA
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Fernandez Lynch H, Sarpatwari A, Vonderheide RH, Zettler PJ. Right to Try Requests and Oncologists' Gatekeeping Obligations. J Clin Oncol 2019; 38:111-114. [PMID: 31613694 DOI: 10.1200/jco.19.01741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Ameet Sarpatwari
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Guerrini CJ, Wexler A, Zettler PJ, McGuire AL. Biomedical Citizen Science or Something Else? Reflections on Terms and Definitions. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:17-19. [PMID: 31544641 DOI: 10.1080/15265161.2019.1619880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
| | - Anna Wexler
- Perelman School of Medicine at the University of Pennsylvania
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