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Dell'Anno I, Dondi L, Esposito I, Mascolo A, Capuano A, de Marchi G, Cristinziano A, Tarantino D, Pani M, Masini C, Donati C, Rossin E, Serafini A, Bagaglini G, Bonanni G, Gregori T, Cavaliere A, Matocci R, D'Arpino A, Martini N, Piccinni C. The Early Access and the Potential Cost Savings by the Compassionate Use of Onco-haematological Drugs: Results from the Italian Study Compass-O. Clin Drug Investig 2024:10.1007/s40261-024-01381-z. [PMID: 39031332 DOI: 10.1007/s40261-024-01381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Compassionate drug use (CDU) provides early access to not yet authorised medicines and is funded by pharmaceutical companies. The observational retrospective study Compass-O monitored the CDU of onco-haematological drugs, managed by seven Italian units for cytotoxic drug preparations (Unità Farmaci Antiblastici [UFA]), between 1 January, 2016 and 31 December, 2021. OBJECTIVE We aimed to evaluate the CDU of onco-haematological drugs managed by seven Italian UFA, between 2016 and 2021. METHODS The seven UFA provided anonymised data concerning CDU approved in the study period. The early access and potential cost savings for the National Health System (Servizio Sanitario Nazionale [SSN]) were analysed for CDU concerning drug-therapeutic indication combinations with complete data and reimbursed by SSN up to December 2023 (date of study execution), according to the executive decision of the Italian Medicines Agency (Agenzia Italiana del Farmaco [AIFA]). Both analyses distinguished solid/liquid tumours and categorised the combinations as innovative (fully/conditionally) or non-innovative based on AIFA assessments. RESULTS Compass-O collected 783 CDU authorisations, with 572 (73.1%) analysable in terms of early access and cost savings. On average, early access amounted to 514 days and the total cost savings was €376,115,801. Compassionate drug use approvals involved mainly solid tumours (93.7% vs 6.3% for liquid tumours), and the combination of trastuzumab emtansine-breast cancer was the most dispensed (n = 73; early access = 426 days; potential cost savings: €610,388). Out of 572 CDU approvals, 200 (35%) were innovative drug-therapeutic indication combinations, with 598 days of early access and a total potential saving of €113,124,069. CONCLUSIONS The study Compass-O showed a significant economic burden of CDU and a relevant need for early access, particularly for innovative drugs. However, there is currently no structured monitoring of CDU in Italy, suggesting the need for a national observatory, of which Compass-O can be the pilot phase.
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Affiliation(s)
- Irene Dell'Anno
- Fondazione ReS (Ricerca e Salute), Research and Health Foundation, Via dei Due Macelli, 48, 00187, Rome, Italy
| | - Leonardo Dondi
- Fondazione ReS (Ricerca e Salute), Research and Health Foundation, Via dei Due Macelli, 48, 00187, Rome, Italy
| | | | - Annamaria Mascolo
- Dipartimento di Medicina Sperimentale, Sezione di Farmacologia "L. Donatelli", Università della Campania "Luigi Vanvitelli", Naples, Italy
- Centro di Farmacovigilanza e di Farmacoepidemiologia della Regione Campania, Naples, Italy
- Dipartimento di Scienze della Vita, della Salute e delle Professioni Sanitarie, Università Degli Studi Link, Rome, Italy
| | - Annalisa Capuano
- Dipartimento di Medicina Sperimentale, Sezione di Farmacologia "L. Donatelli", Università della Campania "Luigi Vanvitelli", Naples, Italy
- Centro di Farmacovigilanza e di Farmacoepidemiologia della Regione Campania, Naples, Italy
| | | | | | - Domenico Tarantino
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Marcello Pani
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Carla Masini
- Istituto Romagnolo per lo Studio dei Tumori "Dino Amadori", IRCCS, Meldola, Italy
| | - Caterina Donati
- Istituto Romagnolo per lo Studio dei Tumori "Dino Amadori", IRCCS, Meldola, Italy
| | - Elisabetta Rossin
- ASST Valle Olona, Busto Arsizio, Italy
- ASST Fatebenefratelli Sacco, Milan, Italy
| | | | | | | | | | | | - Roberta Matocci
- A.O. di Perugia, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | | | - Nello Martini
- Fondazione ReS (Ricerca e Salute), Research and Health Foundation, Via dei Due Macelli, 48, 00187, Rome, Italy
| | - Carlo Piccinni
- Fondazione ReS (Ricerca e Salute), Research and Health Foundation, Via dei Due Macelli, 48, 00187, Rome, Italy.
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Wang S, Ding J, Du J, Tang Q, Li N. Accelerating the establishment of management systems for compassionate use in China. Drug Discov Today 2024; 29:104054. [PMID: 38838959 DOI: 10.1016/j.drudis.2024.104054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Shuhang Wang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jiatong Ding
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jun Du
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qiyu Tang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ning Li
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
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Yang F, Huang Z, Heng J, Li K. Benefit assessment of extended dosing in cancer patients after their withdrawal from clinical trials. Front Pharmacol 2023; 14:1178002. [PMID: 38161690 PMCID: PMC10757887 DOI: 10.3389/fphar.2023.1178002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Background: Clinical trials have been widely recognized as an effective treatment approach by physicians and cancer patients alike. Physicians' evaluations suggest that many patients are likely to continue experiencing benefits from extended dosing of investigational new drugs even after withdrawing from clinical trials. Objective: Given the uncertainty surrounding the efficacy and safety of investigational new drugs, it is essential to continually assess the benefits of extended dosing for patients. Methods: The trial group for this study comprised patients who requested extended dosing after withdrawing from clinical trials at Hunan Cancer Hospital between 2016 and 2020. The control group consisted of patients who received conventional treatment and were enrolled in a 1:1 ratio. Follow-up assessments were conducted every 3 months for both groups, and included monitoring of patients' health status, survival time, disease control or remission, treatment modalities received, and medical costs. Results: A total of twenty-three patient pairs were successfully matched for this study. The Ethics Committee approved extended dosing for all patients in the trial group, with an average gap period of 16.48 days between their withdrawal from clinical trials and continuous access to the investigational drugs. The median overall survival for patients after withdrawal from clinical trials was 17.3 months in the extended dosing group and 12.9 months in the control group, with no significant difference observed between the two groups (p > 0.250). The median total cost of treatment after the previous clinical trial was 38,006.76 RMB, of which the median cost of therapeutic drugs for conventional treatment was 15,720 RMB, while extended dosing was provided free of charge. Conclusion: Extended dosing can indeed provide benefits, including survival benefits and economic benefits, to cancer patients after their withdrawal from clinical trials and will clinically present an additional treatment option for patients.
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Affiliation(s)
- Feng Yang
- Hunan Cancer Hospital, Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
| | - Zhe Huang
- Hunan Cancer Hospital, Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
- Department of Pathology, Immuno-Oncology Laboratory, School of Basic Medicine, Central South University, Changsha, Hunan, China
| | - Jianfu Heng
- Hunan Cancer Hospital, Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
| | - Kunyan Li
- Hunan Cancer Hospital, Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
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4
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Uhlig HH, Booth C, Cho J, Dubinsky M, Griffiths AM, Grimbacher B, Hambleton S, Huang Y, Jones K, Kammermeier J, Kanegane H, Koletzko S, Kotlarz D, Klein C, Lenardo MJ, Lo B, McGovern DPB, Özen A, de Ridder L, Ruemmele F, Shouval DS, Snapper SB, Travis SP, Turner D, Wilson DC, Muise AM. Precision medicine in monogenic inflammatory bowel disease: proposed mIBD REPORT standards. Nat Rev Gastroenterol Hepatol 2023; 20:810-828. [PMID: 37789059 DOI: 10.1038/s41575-023-00838-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 10/05/2023]
Abstract
Owing to advances in genomics that enable differentiation of molecular aetiologies, patients with monogenic inflammatory bowel disease (mIBD) potentially have access to genotype-guided precision medicine. In this Expert Recommendation, we review the therapeutic research landscape of mIBD, the reported response to therapies, the medication-related risks and systematic bias in reporting. The mIBD field is characterized by the absence of randomized controlled trials and is dominated by retrospective observational data based on case series and case reports. More than 25 off-label therapeutics (including small-molecule inhibitors and biologics) as well as cellular therapies (including haematopoietic stem cell transplantation and gene therapy) have been reported. Heterogeneous reporting of outcomes impedes the generation of robust therapeutic evidence as the basis for clinical decision making in mIBD. We discuss therapeutic goals in mIBD and recommend standardized reporting (mIBD REPORT (monogenic Inflammatory Bowel Disease Report Extended Phenotype and Outcome of Treatments) standards) to stratify patients according to a genetic diagnosis and phenotype, to assess treatment effects and to record safety signals. Implementation of these pragmatic standards should help clinicians to assess the therapy responses of individual patients in clinical practice and improve comparability between observational retrospective studies and controlled prospective trials, supporting future meta-analysis.
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Affiliation(s)
- Holm H Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.
- Department of Paediatrics, University of Oxford, Oxford, UK.
- Biomedical Research Centre, University of Oxford, Oxford, UK.
| | - Claire Booth
- UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Paediatric Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Judy Cho
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla Dubinsky
- Department of Paediatric Gastroenterology, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre and Cell Biology Program, Research Institute, Toronto, Canada
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
- Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Sophie Hambleton
- Primary Immunodeficiency Group, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Ying Huang
- Department of Gastroenterology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Kelsey Jones
- Paediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Kennedy Institute, University of Oxford, Oxford, UK
| | - Jochen Kammermeier
- Gastroenterology Department, Evelina London Children's Hospital, London, UK
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Department of Paediatrics, University Hospital, LMU Munich, Munich, Germany
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Daniel Kotlarz
- Dr. von Hauner Children's Hospital, Department of Paediatrics, University Hospital, LMU Munich, Munich, Germany
- German Center for Child and Adolescent Health, Munich, Germany
- Institute of Translational Genomics, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Christoph Klein
- Dr. von Hauner Children's Hospital, Department of Paediatrics, University Hospital, LMU Munich, Munich, Germany
- German Center for Child and Adolescent Health, Munich, Germany
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Bernice Lo
- Research Branch, Sidra Medicine, Doha, Qatar
- College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Dermot P B McGovern
- F. Widjaja Foundation, Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ahmet Özen
- Marmara University Division of Allergy and Immunology, Istanbul, Turkey
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Frank Ruemmele
- Université Paris Cité, APHP, Hôpital Necker Enfants Malades, Service de Gastroentérologie pédiatrique, Paris, France
| | - Dror S Shouval
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Scott B Snapper
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Paediatrics and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Simon P Travis
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
- Biomedical Research Centre, University of Oxford, Oxford, UK
- Kennedy Institute, University of Oxford, Oxford, UK
| | - Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - David C Wilson
- Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Department of Paediatric Gastroenterology, The Royal Hospital for Children, and Young People, Edinburgh, UK
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Centre and Cell Biology Program, Research Institute, Toronto, Canada
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Toronto, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Schaefer GO. If it walks like a duck…: Monitored Emergency Use of Unregistered and Experimental Interventions (MEURI) is research. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109169. [PMID: 38050144 DOI: 10.1136/jme-2023-109169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/12/2023] [Indexed: 12/06/2023]
Abstract
Monitored Emergency Use of Unregistered and Experimental Interventions (MEURI) is an ethical framework developed by the WHO for using unproven interventions in public health emergencies outside the context of medical research. It is mainly intended for use when medical research would be impracticable, but there is still a need to systematically gather data about unproven interventions. As such, it is designed as something of a middle ground between clinical and research ethical frameworks.However, I argue that MEURI does not truly lie at the intersection of clinical care and research. Due to its intent, structure and oversight requirements, it takes on most of the crucial features of research, to the point that it is best understood as a form of research. As a result, cases where MEURI could practicably be applied should instead make use of existing research frameworks. For those circumstances where research is truly impracticable, a more straightforward oversight system than MEURI is needed. While existing practices of compassionate use have some applicability, proposals to make use of clinical ethics committees to oversee unproven interventions may help achieve the right balance in acting in a patient's best interests when the relevant evidence base is weak.
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Affiliation(s)
- G Owen Schaefer
- Centre for Biomedical Ethics, National University Singapore Yong Loo Lin School of Medicine, Singapore
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6
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Hammond TC, Lee RC, Oronsky B, Reid TR, Caroen S, Juarez TM, Gill J, Heng A, Kesari S. Clinical Course of Two Patients with COVID-19 Respiratory Failure After Administration of the Anticancer Small Molecule, RRx-001. Int Med Case Rep J 2022; 15:735-738. [PMID: 36545548 PMCID: PMC9762260 DOI: 10.2147/imcrj.s389690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Two critically ill COVID-19 infected patients, who had exhausted all available treatment options, were treated with the small-molecule RRx-001 with subsequent improvement. RRx-001, a first-in-class small molecule with anti-inflammatory, vascular normalizing and macrophage-repolarizing properties, has been safely administered 300+ patients in clinical trials. This is the first report of RRx-001 treatment of COVID-19.
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Affiliation(s)
- Terese Catherine Hammond
- Providence St. Johns Health Center, Santa Monica, CA, USA,John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Raymond C Lee
- Providence St. Johns Health Center, Santa Monica, CA, USA,Cardiovascular Thoracic Institute, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Bryan Oronsky
- EpicentRx, Inc., La Jolla, CA, USA,Correspondence: Bryan Oronsky, EpicentRx, Inc, 11099 North Torrey Pines Road, La Jolla, CA, 92037, USA, Tel +1 858 947-6635, Fax +1 858 724-3080, Email
| | | | | | | | - Jaya Gill
- Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Annie Heng
- John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Santosh Kesari
- Providence St. Johns Health Center, Santa Monica, CA, USA,John Wayne Cancer Institute, Santa Monica, CA, USA,Pacific Neuroscience Institute, Santa Monica, CA, USA
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Allokation von einmalig zu applizierenden Arzneimitteln bei Kindern in globalen Compassionate Use-Programmen. Ethik Med 2022; 34:497-514. [PMID: 36213336 PMCID: PMC9524342 DOI: 10.1007/s00481-022-00722-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022]
Abstract
Compassionate Use beschreibt die Anwendung zulassungsüberschreitender Arzneimittel für Patient*innengruppen, die an einer lebensbedrohlichen oder zu einer schweren Behinderung führenden Erkrankung leiden, ohne dass eine alternative Therapieoption besteht. An Ärzt*innen vorbei werden solche Programme ausschließlich von Pharmaunternehmen initiiert, was viele ethische Konflikte mit sich bringt. Eine neue Dimension erreichte das 2020 gestartete Programm für Onasemnogenum abeparvovecum zur Therapie von Spinaler Muskelatrophie bei Kindern, welches die Krankheit nach nur einmaliger Gabe stoppen sollte. Die globale Allokation von nur 100 zur Verfügung gestellten Dosierungen per Losverfahren stellte ein Novum bei der Allokation in Compassionate Use-Programmen dar und wurde vielfach kritisiert. Diese Arbeit untersucht mögliche alternative Allokationsprinzipien auf das Beispiel von Onasemnogenum abeparvovecum. Für jedes in Frage kommende Prinzip der Allokation medizinischer Güter bestehen Aspekte, die im Hinblick auf die drängende Zeit und die globale Verteilung bedacht werden müssen. Dies lässt einige Prinzipien wie First-Come-First-Served vernachlässigbar erscheinen. Verbliebene Prinzipien werden hierarchisch geordnet, um einen Algorithmus abzuleiten, der eine Alternative zum Losverfahren darstellen kann. Eine Kombination von Teilnahmebereitschaft bei Forschung, Dringlichkeit und Erfolgsaussicht (bezogen auf die Existenz supportiver Therapieoptionen) kann in ähnlichen Fällen bei zukünftigen globalen Compassionate Use-Programmen bei Kindern erwogen werden. Da universelle Algorithmen nur schwer definierbar sind, sollten Allokationskriterien in jedem Fall durch ein unabhängiges Expert*innengremium diskutiert werden. Sowohl die Konstitution eines solchen Gremiums sowie deren verpflichtende Konsultierung sind gefordert, um für Entlastung aller Beteiligten zu sorgen und Willkür vorzubeugen.
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Naumann-Winter F, Wolter F, Hermes U, Malikova E, Lilienthal N, Meier T, Kalland ME, Magrelli A. Licensing of Orphan Medicinal Products—Use of Real-World Data and Other External Data on Efficacy Aspects in Marketing Authorization Applications Concluded at the European Medicines Agency Between 2019 and 2021. Front Pharmacol 2022; 13:920336. [PMID: 36034814 PMCID: PMC9413272 DOI: 10.3389/fphar.2022.920336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/08/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Reference to so-called real-world data is more often made in marketing authorization applications for medicines intended to diagnose, prevent or treat rare diseases compared to more common diseases. We provide granularity on the type and aim of any external data on efficacy aspects from both real-world data sources and external trial data as discussed in regulatory submissions of orphan designated medicinal products in the EU. By quantifying the contribution of external data according to various regulatory characteristics, we aimed at identifying specific opportunities for external data in the field of orphan conditions. Methods: Information on external data in regulatory documents covering 72 orphan designations was extracted. Our sample comprised public assessment reports for approved, refused, or withdrawn applications concluded from 2019–2021 at the European Medicines Agency. Products with an active orphan designation at the time of submission were scrutinized regarding the role of external data on efficacy aspects in the context of marketing authorization applications, or on the criterion of “significant benefit” for the confirmation of the orphan designation at the time of licensing. The reports allowed a broad distinction between clinical development, regulatory decision making, and intended post-approval data collection. We defined three categories of external data, administrative data, structured clinical data, and external trial data (from clinical trials not sponsored by the applicant), and noted whether external data concerned the therapeutic context of the disease or the product under review. Results: While reference to external data with respect to efficacy aspects was included in 63% of the approved medicinal products in the field of rare diseases, 37% of marketing authorization applications were exclusively based on the dedicated clinical development plan for the product under review. Purely administrative data did not play any role in our sample of reports, but clinical data collected in a structured manner (from routine care or clinical research) were often used to inform on the trial design. Two additional recurrent themes for the use of external data were the contextualization of results, especially to confirm the orphan designation at the time of licensing, and reassurance of a large difference in treatment effect size or consistency of effects observed in clinical trials and practice. External data on the product under review were restricted to either active substances already belonging to the standard of care even before authorization or to compassionate use schemes. Furthermore, external data were considered pivotal for marketing authorization only exceptionally and only for active substances already in use within the specific therapeutic indication. Applications for the rarest conditions and those without authorized treatment alternatives were especially prominent with respect to the use of external data from real-world data sources both in the pre- and post-approval setting. Conclusion: Specific opportunities for external data in the setting of marketing authorizations in the field of rare diseases were identified. Ongoing initiatives of fostering systematic data collection are promising steps for a more efficient medicinal product development in the field of rare diseases.
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Affiliation(s)
- Frauke Naumann-Winter
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
- *Correspondence: Frauke Naumann-Winter,
| | | | - Ulrike Hermes
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Eva Malikova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Bratislava, Slovakia
- State Institute for Drug Control, Bratislava, Slovakia
| | - Nils Lilienthal
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Tania Meier
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | | | - Armando Magrelli
- National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Żaczek M, Górski A, Weber-Dąbrowska B, Letkiewicz S, Fortuna W, Rogóż P, Pasternak E, Międzybrodzki R. A Thorough Synthesis of Phage Therapy Unit Activity in Poland-Its History, Milestones and International Recognition. Viruses 2022; 14:1170. [PMID: 35746642 PMCID: PMC9227841 DOI: 10.3390/v14061170] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/17/2022] [Accepted: 05/26/2022] [Indexed: 01/27/2023] Open
Abstract
The year 2020 marked 15 years of the Phage Therapy Unit in Poland, the inception of which took place just one year after Poland's accession to the European Union (2004). At first sight, it is hard to find any connection between these two events, but in fact joining the European Union entailed the need to adapt the regulatory provisions concerning experimental treatment in humans to those that were in force in the European Union. These changes were a solid foundation for the first phage therapy center in the European Union to start its activity. As the number of centers conducting phage therapy in Europe and in the world constantly and rapidly grows, we want to grasp the opportunity to take a closer look at the over 15-year operation of our site by analyzing its origins, legal aspects at the local and international levels and the impressive number and diversity of cases that have been investigated and treated during this time. This article is a continuation of our work published in 2020 summarizing a 100-year history of the development of phage research in Poland.
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Affiliation(s)
- Maciej Żaczek
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
| | - Andrzej Górski
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Infant Jesus Teaching Hospital, Medical University of Warsaw, 02-005 Warsaw, Poland
| | - Beata Weber-Dąbrowska
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
| | - Sławomir Letkiewicz
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Department of Health Sciences, Jan Długosz University in Częstochowa, 42-200 Częstochowa, Poland
| | - Wojciech Fortuna
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Department of Neurosurgery, Wrocław Medical University, 50-556 Wrocław, Poland
| | - Paweł Rogóż
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
| | - Edyta Pasternak
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Bioethics Committee, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland
| | - Ryszard Międzybrodzki
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Department of Clinical Immunology, Medical University of Warsaw, 02-006 Warsaw, Poland
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10
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Jurić D, Zlatin M, Marušić A. Inadequate reporting quality of registered genome editing trials: an observational study. BMC Med Res Methodol 2022; 22:131. [PMID: 35501706 PMCID: PMC9063127 DOI: 10.1186/s12874-022-01574-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background To assess registration completeness and safety data of trials on human genome editing (HGE) reported in primary registries and published in journals, as HGE has safety and ethical problems, including the risk of undesirable and unpredictable outcomes. Registration transparency has not been evaluated for clinical trials using these novel and revolutionary techniques in human participants. Methods Observational study of trials involving engineered site-specific nucleases and long-term follow-up observations, identified from the WHO ICTRP HGE Registry in November 2020 and two comprehensive reviews published in the same year. Registration and adverse events (AEs) information were collected from public registries and matching publications. Published data were extracted in May 2021. Results Among 81 eligible trials, most were recruiting (51.9%) phase 1 trials (45.7%). Five trials were withdrawn. Most trials investigated CAR T cells therapies (45.7%) and used CRISPR/Cas9 (35.8%) ex vivo (88.9%). Among 12 trials with protocols both registered and published, eligibility criteria, sample size, and secondary outcome measures were consistently reported for less than a half. Three trials posted results in ClinicalTrials.gov, and one reported serious AEs. Conclusions Incomplete registration and published data give emphasis to the need to increase the transparency of HGE trials. Further improvements in registration requirements, including phase 1 trials, and a more controlled publication procedure, are needed to augment the implementation of this promising technology. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01574-0.
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Affiliation(s)
- Diana Jurić
- Department of Pharmacology, School of Medicine, University of Split, Šoltanska 2, 21000, Split, Croatia.
| | - Michael Zlatin
- School of Medicine, University of Split, Šoltanska 2, 21000, Split, Croatia
| | - Ana Marušić
- Department of Research in Biomedicine and Health, School of Medicine, University of Split, Šoltanska 2, 21000, Split, Croatia
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11
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Garraud O. Anemia in the very aged person: how are treatment options discussed and when is red blood cell component transfusion proposed? Transfus Apher Sci 2022; 61:103361. [DOI: 10.1016/j.transci.2022.103361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Lemmon ME, Wusthoff CJ, Boss RD, Rasmussen LA. Ethical considerations in the care of encephalopathic neonates treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101258. [PMID: 34176763 PMCID: PMC8627487 DOI: 10.1016/j.siny.2021.101258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Engaging with ethical issues is central to the management of neonatal encephalopathy (NE). As treatment for these neonates evolves, new ethical issues will arise and many existing challenges will remain. We highlight three key ethical issues that arise in the care of neonates with NE treated with therapeutic hypothermia: facilitating shared decision making, understanding futility, and defining the boundaries between standard of care and research. Awareness of these issues will help clinicians counsel families in light of evolving treatments and outcomes.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, DUMC 3936, Durham, NC, 27710, USA,Corresponding author. (M.E. Lemmon)
| | - Courtney J. Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Stanford, 750 Welch Road, Suite 317, Palo Alto, CA, 94304, USA
| | - Renee D. Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Berman Institute of Bioethics, 200 N. Wolfe St, Suite 2019, Baltimore, MD, 21287, United States
| | - Lisa Anne Rasmussen
- Division of Palliative Care, Department of Family Medicine, Department of Neurology, Department of Pediatrics, Larner College of Medicine, University of Vermont, UVM Medical Center Palliative Care, 111 Colchester Avenue, Main Campus, Smith 262, Burlington, VT, 05401-1473, USA.
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13
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Bunnik EM, Aarts N. The Role of Physicians in Expanded Access to Investigational Drugs: A Mixed-Methods Study of Physicians' Views and Experiences in The Netherlands. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:319-334. [PMID: 33590374 PMCID: PMC8324586 DOI: 10.1007/s11673-021-10090-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/20/2021] [Indexed: 05/05/2023]
Abstract
Treating physicians have key roles to play in expanded access to investigational drugs, by identifying investigational treatment options, assessing the balance of risks and potential benefits, informing their patients, and applying to the regulatory authorities. This study is the first to explore physicians' experiences and moral views, with the aim of understanding the conditions under which doctors decide to pursue expanded access for their patients and the obstacles and facilitators they encounter in the Netherlands. In this mixed-methods study, semi-structured interviews (n = 14) and a questionnaire (n = 90) were conducted with medical specialists across the country and analysed thematically. Typically, our respondents pursue expanded access in "back against the wall" situations and broadly support its classic requirements. They indicate practical hurdles related to reimbursement, the amount of time and effort required for the application, and unfamiliarity with the regulatory process. Some physicians are morally opposed to expanded access, with an appeal to safety risks, lack of evidence, and "false hope." Some of these moral concerns and practical obstacles may be essential targets for change, if expanded access to unapproved drugs is to become available for wider groups of patients for whom standard treatment options are not-or no longer-available, on a more consistent and equal basis.
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Affiliation(s)
- Eline M Bunnik
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.
| | - Nikkie Aarts
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands
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14
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Solbakk JH, Bentzen HB, Holm S, Heggestad AKT, Hofmann B, Robertsen A, Alnæs AH, Cox S, Pedersen R, Bernabe R. Back to WHAT? The role of research ethics in pandemic times. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:3-20. [PMID: 33141289 PMCID: PMC7607543 DOI: 10.1007/s11019-020-09984-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 05/06/2023]
Abstract
The Covid-19 pandemic creates an unprecedented threatening situation worldwide with an urgent need for critical reflection and new knowledge production, but also a need for imminent action despite prevailing knowledge gaps and multilevel uncertainty. With regard to the role of research ethics in these pandemic times some argue in favor of exceptionalism, others, including the authors of this paper, emphasize the urgent need to remain committed to core ethical principles and fundamental human rights obligations all reflected in research regulations and guidelines carefully crafted over time. In this paper we disentangle some of the arguments put forward in the ongoing debate about Covid-19 human challenge studies (CHIs) and the concomitant role of health-related research ethics in pandemic times. We suggest it might be helpful to think through a lens differentiating between risk, strict uncertainty and ignorance. We provide some examples of lessons learned by harm done in the name of research in the past and discuss the relevance of this legacy in the current situation.
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Affiliation(s)
- Jan Helge Solbakk
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway.
| | - Heidi Beate Bentzen
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Faculty of Law, Norwegian Research Center for Computers and Law, University of Oslo, Oslo, Norway
| | - Søren Holm
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Department of Law, School of Social Science, Centre for Social Ethics and Policy, University of Manchester, Manchester, UK
| | - Anne Kari Tolo Heggestad
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Faculty of Health Studies, VID Specialized University, Oslo, Bergen, Stavanger and Sandnes, Norway
| | - Bjørn Hofmann
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Department of Health Sciences, The Norwegian University for Science and Technology, Gjøvik, Norway
| | - Annette Robertsen
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hambro Alnæs
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
| | - Shereen Cox
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
| | - Reidar Pedersen
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
| | - Rose Bernabe
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- The Faculty of Health and Social Sciences, University of Southeastern Norway, Kongsberg, Norway
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15
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Martin DE, Parsons JA, Caskey FJ, Harris DCH, Jha V. Ethics of kidney care in the era of COVID-19. Kidney Int 2020; 98:1424-1433. [PMID: 33038425 PMCID: PMC7539938 DOI: 10.1016/j.kint.2020.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 02/08/2023]
Abstract
The coronavirus disease 2019 pandemic presents significant challenges for health systems globally, including substantive ethical dilemmas that may pose specific concerns in the context of care for people with kidney disease. Ethical concerns may arise as changes in policy and practice affect the ability of all health professionals to fulfill their ethical duties toward their patients in providing best practice care. In this article, we briefly describe such concerns and elaborate on issues of particular ethical complexity in kidney care: equitable access to dialysis during pandemic surges; balancing the risks and benefits of different kidney failure treatments, specifically with regard to suspending kidney transplantation programs and prioritizing home dialysis, and barriers to shared decision-making; and ensuring ethical practice when using unproven interventions. We present preliminary advice on how to approach these issues and recommend urgent efforts to develop resources that will support health professionals and patients in managing them.
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Affiliation(s)
| | - Jordan A Parsons
- Bristol Medical School, University of Bristol, Bristol, UK; Instituts für Geschichte und Ethik der Medizin, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Fergus J Caskey
- Bristol Medical School, University of Bristol, Bristol, UK; The Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, UK
| | - David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, University of New South Wales (UNSW), New Delhi, India; School of Public Health, Imperial College, London, UK; Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
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16
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Borysowski J, Górski A. Ethics framework for treatment use of investigational drugs. BMC Med Ethics 2020; 21:116. [PMID: 33208140 PMCID: PMC7672838 DOI: 10.1186/s12910-020-00560-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Expanded access is the use of investigational drugs (IDs) outside of clinical trials. Generally it is performed in patients with serious and life-threatening diseases who cannot be treated satisfactorily with authorized drugs. Legal regulations of expanded access to IDs have been introduced among others in the USA, the European Union (EU), Canada and Australia. In addition, in the USA an alternative to expanded access is treatment under the Right-to-Try law. However, the treatment use of IDs is inherently associated with a number of ethically relevant problems. MAIN TEXT The objective of this article is to present a coherent framework made up of eight requirements which have to be met for any treatment use of an ID to be ethical. These include a justified need for the use of an ID, no threat to clinical development of the ID, adequate scientific evidence to support the treatment, patient's benefit as the primary goal of the use of an ID, informed decision of a patient, fair access of patients to IDs, independent review, as well as the dissemination of treatment results. CONCLUSIONS While this framework is essentially consistent with the legal regulations of expanded access of the USA, the EU, Canada and Australia, it is substantially wider in scope because it addresses some important issues that are not covered by the regulations. Overall, the framework that we developed minimizes the risks and threats, and maximizes potential benefits to each of the four key stakeholders involved in the treatment use of IDs including patients, doctors, drug manufacturers, and society at large.
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Affiliation(s)
- Jan Borysowski
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka Str. 59, 02-006, Warsaw, Poland.
- Centre for Studies on Research Integrity, Institute of Law Studies, Polish Academy of Sciences, Nowy Świat 72, 00-330, Warsaw, Poland.
| | - Andrzej Górski
- Laboratory of Bacteriophages, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Rudolfa Weigla Str. 12, 53-114, Wrocław, Poland
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17
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Rascher W, Klingebiel T, Herting E, Hoffmann GF, Berner R, Krägeloh-Mann I, Gärtner J, Zepp F, Schara U. Arzneimittel für neuartige Therapien – Perspektiven, Chancen, Herausforderungen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01056-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
ZusammenfassungArzneimittel für neuartige Therapien (ATMP) wie somatische Gentherapie und Zelltherapie besitzen ein hohes therapeutisches Potenzial für Krankheiten, die sehr früh im Leben beginnen, und die bisher nicht behandelbar waren. Sie werden oft in einem sehr frühen Entwicklungsstadium zugelassen, wenn an wenigen Betroffenen die Wirksamkeit gezeigt wurde und sich ein bisher nie dagewesener Therapieerfolg auftut, vor allem, wenn die Therapie vor Eintritt von Organschäden greift. Dadurch ergeben sich für Pädiater neue arzneimittelrechtliche und ethische Fragen.Um die neuen Behandlungsmöglichkeiten adäquat einzusetzen, muss die Diagnose früher als bisher gestellt werden, oder neue Screeningmethoden müssen zur Verfügung stehen. Denkbar ist, dass das Neugeborenenscreening in zeitkritische Krankheiten in den ersten 72 h nach Geburt und ein genetisches Screening (z. B. in der 4. bis 5. Lebenswoche) aufgeteilt wird.ATMP sind bei ihrer Zulassung noch nicht in ausreichender Anzahl angewendet worden, sodass die notwendigen Erkenntnisse für Wirksamkeit und Sicherheit noch nicht vorliegen (Nutzen-Risiko-Verhältnis). Deswegen werden sie unter strengen Auflagen in spezialisierten Behandlungszentren nach Qualitätskriterien eingesetzt, die der Gemeinsame Bundesausschuss (G-BA) nach Beratung mit den Fachgesellschaften festlegt. Der Aufwand der Therapie und der Dokumentation des Verlaufes in Registern ist erheblich und muss entsprechend vergütet werden.Der Wert eines ATMP wird erst mit seiner breiteren Anwendung nach der Zulassung klar, ähnlich wie die Sicherheit eines Arzneimittels nicht mit der Zulassung vollumfänglich bekannt ist. Für die Pädiatrie ergeben sich neue Herausforderungen und Chancen.
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18
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Krendyukov A. Early Access Provision for Innovative Medicinal Products in Oncology: Challenges and Opportunities. Front Oncol 2020; 10:1604. [PMID: 32984026 PMCID: PMC7492559 DOI: 10.3389/fonc.2020.01604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022] Open
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Abstract
In the present paper, we discuss the ethics of compassionate psychedelic psychotherapy and argue that it can be morally permissible. When talking about psychedelics, we mean specifically two substances: psilocybin and MDMA. When administered under supportive conditions and in conjunction with psychotherapy, therapies assisted by these substances show promising results. However, given the publicly controversial nature of psychedelics, compassionate psychedelic psychotherapy calls for ethical justification. We thus review the safety and efficacy of psilocybin- and MDMA-assisted therapies and claim that it can be rational for some patients to try psychedelic therapy. We think it can be rational despite the uncertainty of outcomes associated with compassionate use as an unproven treatment regime, as the expected value of psychedelic psychotherapy can be assessed and can outweigh the expected value of routine care, palliative care, or no care at all. Furthermore, we respond to the objection that psychedelic psychotherapy is morally impermissible because it is epistemically harmful. We argue that given the current level of understanding of psychedelics, this objection is unsubstantiated for a number of reasons, but mainly because there is no experimental evidence to suggest that epistemic harm actually takes place.
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Affiliation(s)
- Adam Greif
- Department of Philosophy and History of Philosophy, Faculty of Arts, Comenius University, Šafárikovo námestie 6, 814 99, Bratislava, Slovak Republic.
| | - Martin Šurkala
- Slovak Psychedelic Society, Karpatské námestie 10A, 831 06, Bratislava, Slovak Republic
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20
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Goyal PK, Mathur R, Medhi B. Understanding the challenges and ethical aspects of compassionate use of drugs in emergency situations. Indian J Pharmacol 2020; 52:163-171. [PMID: 32873998 PMCID: PMC7446672 DOI: 10.4103/ijp.ijp_665_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/18/2020] [Accepted: 07/18/2020] [Indexed: 01/12/2023] Open
Affiliation(s)
| | - Roli Mathur
- ICMR Bioethics Unit, ICMR-National Centre for Disease Informatics and Research, Bengaluru, Karnataka, India
| | - Bikash Medhi
- Department of Pharmacology, PGIMER, Chandigarh, India
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21
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Álvarez A, Fernández L, Iglesias B, Rodríguez J, Rodríguez A, García P. Phage therapy: unexpected drawbacks to reach hospitals. Future Virol 2019. [DOI: 10.2217/fvl-2019-0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Andrea Álvarez
- Servicio de Medicina Interna, Hospital San Agustín, 33401 Avilés, Asturias. Spain
| | - Lucía Fernández
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), Paseo Río Linares, 33300 Villaviciosa, Asturias, Spain
- DairySafe Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Asturias, Spain
| | - Beatriz Iglesias
- Servicio de Microbiología, Hospital San Agustín, 33401 Avilés, Asturias. Spain
| | - Javier Rodríguez
- Servicio de Microbiología, Hospital San Agustín, 33401 Avilés, Asturias. Spain
| | - Ana Rodríguez
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), Paseo Río Linares, 33300 Villaviciosa, Asturias, Spain
- DairySafe Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Asturias, Spain
| | - Pilar García
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), Paseo Río Linares, 33300 Villaviciosa, Asturias, Spain
- DairySafe Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Asturias, Spain
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22
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Borysowski J, Górski A. Compassionate use of unauthorized drugs: Legal regulations and ethical challenges. Eur J Intern Med 2019; 65:12-16. [PMID: 31036436 DOI: 10.1016/j.ejim.2019.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/10/2019] [Accepted: 04/19/2019] [Indexed: 12/28/2022]
Abstract
Compassionate use (also referred to as expanded access) is therapeutic use of unauthorized drugs outside of clinical trials. The objective of this review is to discuss practical aspects of the current legal regulations concerning compassionate use that have been introduced in the European Union, the USA (both the Food and Drug Administration regulations and Right-to-try laws), Canada and Australia. We also present main ethical challenges associated with use of unauthorized drugs such as possible difficulties with obtaining informed consent and fair patient selection. Moreover, we discuss guidelines, especially those contained in the Declaration of Helsinki, which may aid doctors in the ethical conduct of compassionate treatments.
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Affiliation(s)
- Jan Borysowski
- Centre for Studies on Research Integrity, Institute of Law Studies, Polish Academy of Sciences, Nowy Świat 72, 00-330 Warsaw, Poland; Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka Str. 59, 02-006 Warsaw, Poland.
| | - Andrzej Górski
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka Str. 59, 02-006 Warsaw, Poland; Laboratory of Bacteriophages, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Rudolfa Weigla Str. 12, 53-114 Wrocław, Poland
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Chapman CR, Moch KI, McFadyen A, Kearns L, Watson T, Furlong P, Bateman-House A. What compassionate use means for gene therapies. Nat Biotechnol 2019; 37:352-355. [PMID: 30940936 DOI: 10.1038/s41587-019-0081-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Carolyn Riley Chapman
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, New York, NY, USA.
| | | | | | - Lisa Kearns
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Tom Watson
- Bionical Early Access Programs, Willington, UK
| | - Pat Furlong
- Parent Project Muscular Dystrophy (PPMD), Hackensack, NJ, USA
| | - Alison Bateman-House
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, New York, NY, USA
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McCallin S, Sacher JC, Zheng J, Chan BK. Current State of Compassionate Phage Therapy. Viruses 2019; 11:E343. [PMID: 31013833 PMCID: PMC6521059 DOI: 10.3390/v11040343] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/04/2019] [Accepted: 04/06/2019] [Indexed: 11/24/2022] Open
Abstract
There is a current unmet medical need for the treatment of antibiotic-resistant infections, and in the absence of approved alternatives, some clinicians are turning to empirical ones, such as phage therapy, for compassionate treatment. Phage therapy is ideal for compassionate use due to its long-standing historical use and publications, apparent lack of adverse effects, and solid support by fundamental research. Increased media coverage and peer-reviewed articles have given rise to a more widespread familiarity with its therapeutic potential. However, compassionate phage therapy (cPT) remains limited to a small number of experimental treatment centers or associated with individual physicians and researchers. It is possible, with the creation of guidelines and a greater central coordination, that cPT could reach more of those in need, starting by increasing the availability of phages. Subsequent steps, particularly production and purification, are difficult to scale, and treatment paradigms stand highly variable between cases, or are frequently not reported. This article serves both to synopsize cPT publications to date and to discuss currently available phage sources for cPT. As the antibiotic resistance crisis continues to grow and the future of phage therapy clinical trials remains undetermined, cPT represents a possibility for bridging the gap between current treatment failures and future approved alternatives. Streamlining the process of cPT will help to ensure high quality, therapeutically-beneficial, and safe treatment.
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Affiliation(s)
- Shawna McCallin
- Unit of Regenerative Medicine, Department of Musculoskeletal Medicine, Service of Plastic, Reconstructive, & Hand Surgery, University Hospital of Lausanne (CHUV), 1066 Epalignes, Switzerland.
- Swiss Federal Institute of Technology Lausanne (EPFL), 1015 Lausanne, Switzerland.
| | | | - Jan Zheng
- Phage Directory, Atlanta, GA 30303, USA.
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Chapman CR, Shearston JA, Folkers KM, Redman BK, Caplan A, Bateman-House A. Single-Patient Expanded Access Requests: IRB Professionals' Experiences and Perspectives. AJOB Empir Bioeth 2019; 10:88-99. [PMID: 30964737 DOI: 10.1080/23294515.2019.1577192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND U.S. physicians may treat a patient with an investigational drug outside of a clinical trial by using the expanded access (EA) pathway or the recently created federal right to try (RTT) pathway. The EA pathway requires physicians to get prior permission from the U.S. Food and Drug Administration (FDA) and, except in emergency cases, institutional review board (IRB) approval. The perspectives of IRB professionals on the review of single-patient EA requests have not been empirically studied. METHODS We used a cross-sectional online survey to ascertain IRB professionals' perspectives on IRB experiences with and preparedness for review of single-patient EA requests, as well as their attitudes about the importance of IRB review of such requests. Email invitations were sent to 234 IRB professionals connected to the SMART IRB platform. Approximately half of the survey questions used a Likert scale to assess respondents' agreement with specific statements. RESULTS Eighty-three respondents completed the survey (36.4% response rate, with 228 deliverable e-mail invitations). Of the respondents, 73.5% were affiliated with an academic medical institution; 78.3% of respondents agreed that it is important for a designated member of an IRB to review single-patient EA requests before investigational drugs are used by patients. The majority indicated that local review of the EA request was important and that a single designated reviewer was sufficient (rather than full board). Further, 86.6% felt that their IRBs were prepared to review these requests, and 9.2% indicated that not all the single-patient EA requests reviewed by their IRBs in 2017 were approved. CONCLUSIONS A large majority of IRB professionals affiliated with the SMART IRB platform who responded to this survey felt IRB review of single-patient EA requests is important and that their IRBs were prepared to handle such requests.
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Affiliation(s)
- Carolyn Riley Chapman
- a Division of Medical Ethics, Department of Population Health , NYU School of Medicine, NYU Langone Health , New York , New York , USA
| | - Jenni A Shearston
- b Departments of Population Health, Environmental Medicine, and Pediatrics , NYU School of Medicine, NYU Langone Health , New York , New York , USA
| | - Kelly McBride Folkers
- a Division of Medical Ethics, Department of Population Health , NYU School of Medicine, NYU Langone Health , New York , New York , USA
| | - Barbara K Redman
- a Division of Medical Ethics, Department of Population Health , NYU School of Medicine, NYU Langone Health , New York , New York , USA
| | - Arthur Caplan
- a Division of Medical Ethics, Department of Population Health , NYU School of Medicine, NYU Langone Health , New York , New York , USA
| | - Alison Bateman-House
- a Division of Medical Ethics, Department of Population Health , NYU School of Medicine, NYU Langone Health , New York , New York , USA
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Borysowski J, Ehni H, Górski A. Ethics codes and use of new and innovative drugs. Br J Clin Pharmacol 2019; 85:501-507. [PMID: 30536603 PMCID: PMC6379208 DOI: 10.1111/bcp.13833] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/16/2018] [Accepted: 11/30/2018] [Indexed: 12/20/2022] Open
Abstract
Treatment with new and/or innovative drugs with uncertain safety and efficacy profile is associated with substantial ethical concerns. The main objective of this paper is to present guidance on the use of such drugs contained in: (i) major international codes and guidelines pertaining to medical ethics and biomedical research; (ii) national codes of medical ethics and professional conduct of the USA, Canada, Australia, New Zealand, the UK, Ireland, France and Germany. Out of the four international codes and guidelines analysed, only the Declaration of Helsinki addresses the question of the use of unproven drugs. Among national codes, only two (USA and New Zealand) explicitly allow for use of new or innovative drugs. Moreover, treatment with unproven drugs seems to be permissible under the French code, though this is not stated explicitly. The remaining codes do not contain any articles on the use of new and innovative drugs. An update of existing articles, as well as the addition of new guidelines to the codes, should be considered in view of the rapid pace of development and introduction to clinical practice of new drugs. This work is relevant to innovative off-label applications of approved drugs and expanded access to investigational drugs.
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Affiliation(s)
- Jan Borysowski
- Centre for Studies on Research Integrity, Institute of Law StudiesPolish Academy of SciencesWarsawPoland
- Department of Clinical ImmunologyMedical University of WarsawWarsawPoland
| | - Hans‐Jörg Ehni
- Institute of Ethics and History of MedicineEberhard Karls UniversitätTübingenGermany
| | - Andrzej Górski
- Department of Clinical ImmunologyMedical University of WarsawWarsawPoland
- Laboratory of Bacteriophages, Ludwik Hirszfeld Institute of Immunology and Experimental TherapyPolish Academy of SciencesWrocławPoland
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Folkers KM, Bateman-House A. Improving Expanded Access in the United States: The Role of the Institutional Review Board. Ther Innov Regul Sci 2019; 52:285-293. [PMID: 29723059 DOI: 10.1177/2168479018759661] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The FDA allows patients with a serious or immediately life-threatening illness to use investigational medical products outside of clinical trials through its "expanded access" program. In response to criticism that the process to apply for expanded access is too onerous, numerous changes have been made over the last few years. These have been largely focused on the FDA and the pharmaceutical industry, while institutional review boards (IRBs)-which must approve expanded access protocols, except in emergencies when there is not time to do so-have remained relatively unstudied. We conducted a pilot study to review a sample of publicly available IRB policies from the United States to investigate how these entities handle expanded access. METHODS We performed an online search to find publicly available policies for IRBs operating in the United States, utilizing a convenience sampling strategy, selecting the first 100 eligible policies we identified. RESULTS Of the 95 policies reviewed, the majority (92.6%, n = 88) contained language referencing nonemergency expanded access and/or expanded access for emergency requests for a single patient. Of these 88 policies, 11.4% (n = 19) did not explicitly specify detailed procedures for handling nonemergency single-patient expanded access requests. Of the 88 policies that mentioned expanded access in nonemergency situations, 11.5% did not explicitly specify whether full IRB review was required, as was the rule at that time. There was considerable variation in other aspects of these policies, including charging patients for use of investigational products and the use of data from expanded access. CONCLUSIONS Based on the findings of our pilot, IRB policies on expanded access vary considerably. It is often difficult to find, interpret, and understand IRB policies on expanded access. Further research is needed to determine if and to what extent this negatively impacts patient access to investigational products outside of clinical trials.
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Affiliation(s)
- Kelly McBride Folkers
- 1 Division of Medical Ethics, New York University School of Medicine, New York, NY, USA
| | - Alison Bateman-House
- 1 Division of Medical Ethics, New York University School of Medicine, New York, NY, USA
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Right now, in the right way: U. S. Food and Drug Administration's expanded access program and patient rights. J Clin Transl Sci 2018; 2:115-117. [PMID: 30370061 PMCID: PMC6202008 DOI: 10.1017/cts.2018.318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Yano K, Yamato M. Compassionate use and hospital exemption for regenerative medicine: Something wrong to apply the program for patients in a real world. Regen Ther 2018; 8:63-64. [PMID: 30271867 PMCID: PMC6146111 DOI: 10.1016/j.reth.2018.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/14/2018] [Indexed: 10/25/2022] Open
Abstract
"Compassionate use" or "Hospital exemption" provides an important pathway for patients with life-threatening conditions to gain access to unproved human cells and tissue products. In a real world, any practitioners may not comply with relevant system. Such regulation should establish an international registry of clinical practices of stem cell therapy as well as provide education for patients to prevent deception by the spread of misinformation by testimonials on websites.
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Affiliation(s)
| | - Masayuki Yamato
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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De Panfilis L, Satolli R, Costantini M. Compassionate use programs in Italy: ethical guidelines. BMC Med Ethics 2018; 19:22. [PMID: 29523198 PMCID: PMC5845200 DOI: 10.1186/s12910-018-0263-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/01/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This article proposes a retrospective analysis of a compassionate use (CU), using a case study of request for Avelumab for a patient suffering from Merkel Cell Carcinoma. The study is the result of a discussion within a Provincial Ethics Committee (EC) following the finding of a high number of requests for CU program. The primary objective of the study is to illustrate the specific ethical and clinical profiles that emerge from the compassionate use program (CUP) issue. The secondary goals are: a) to promote a moral reflection among physicians who require approval for the CUP and b) provide the basis for recommendations on how to request CUP. MAIN BODY The instruments for carrying out the analysis of the case study and the discussion are as follows: Analysis of the audio-recording of the EC meeting regarding the selected Case study. In-depth discussion of topics that emerged during the meeting by means of administration of 5 semi-structured interviews with 2 doctors involved in the case (proposing physician and palliative physician) and with 3 components of the EC who played a major role in the EC internal discussion. CONCLUSIONS In an exploration of emerging clinical and ethical issues, four primary themes arise: 1. efficacy, safety of the treatment and patient's quality of life; 2. clear, realistic, adequate communication; 3. right to hope; 4. simultaneous Palliative Care approach. The results of ethical analysis carried out concern two areas: 1) ethical profiles relating to the use of CUP; 2) the role of the EC concerning the compassionate use of drugs and the need to provide recommendations on how to request CUP. With the aim of implementing these conclusions, the provincial EC of Reggio Emilia chose to steer the request for drugs for compassionate use through recommendations for good clinical and ethical practice based on the following assumptions: 1) the "simultaneous care" approach must be preferred. Secondly, 2) the EC's assessment must be part of the decision-making process that the care team conducts before proposing compassionate use to the patient.
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Affiliation(s)
- Ludovica De Panfilis
- Direzione Scientifica, AUSL di Reggio Emilia-IRCCS, Viale Umberto I 50, Reggio Emilia, Italy
| | - Roberto Satolli
- Comitato Etico dell’Area Vasta Emilia Nord, Viale Umberto I 50, Reggio Emilia, Italy
| | - Massimo Costantini
- Direzione Scientifica, AUSL di Reggio Emilia-IRCCS, Viale Umberto I 50, Reggio Emilia, Italy
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