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Ollendorf D, Henshall C, Phillips M, Synnott P, Sansom L, Tunis S. Putting meat on the bone: how to fast-track innovative medicines to those who need them and generate data to justify continued use. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae095. [PMID: 39161949 PMCID: PMC11332269 DOI: 10.1093/haschl/qxae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/24/2024] [Accepted: 08/07/2024] [Indexed: 08/21/2024]
Abstract
Regulatory agencies worldwide have taken significant steps to expedite approval and market authorization of medicines based on their potential to address areas of significant unmet medical need and severe disease burden. However, initial approval of such medicines is often accompanied by limited evidence of benefit, posing a conundrum for payers and health systems who may desire greater certainty of their value. This paper describes a system of "accelerated access" to manage these tensions and coordinate activities across stakeholders, based on discussions held at a multi-stakeholder convening in June 2023. We focus on 6 core, near-term actions that can be taken to improve the current system: clarifying criteria for expedited regulatory approval, enhancing stakeholder coordination, creating expedited pathways in payer and health technology assessment settings, developing joint regulatory/payer/health technology assessment guidance on study design and data needs, linking pricing policy to data uncertainty, and improving patient and public understanding of the processes involved as well as the risks and benefits of the relevant medicines. Many of these actions will require additional resources and personnel, and some will necessitate unprecedented levels of coordination. Nevertheless, each action is designed to work with minimal adjustments to the current system rather than demanding an entirely new approach.
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Affiliation(s)
- Daniel Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
- Institute for Clinical and Economic Review, Boston, MA 02108, United States
| | | | - Marie Phillips
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
| | - Patricia Synnott
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
| | - Lloyd Sansom
- University of South Australia, Kent Town, South Australia 5071, Australia
| | - Sean Tunis
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
- Rubix Health, LLC, Baltimore, MD 21210, United States
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2
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Shahzad M, Naci H, Esselen KM, Dottino JA, Wagner AK. Regulatory histories of recently withdrawn ovarian cancer treatment indications of 3 PARP inhibitors in the US and Europe: lessons for the accelerated approval pathway. J Pharm Policy Pract 2024; 17:2351003. [PMID: 38841118 PMCID: PMC11151792 DOI: 10.1080/20523211.2024.2351003] [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] [Indexed: 06/07/2024] Open
Abstract
Background Withdrawals of drug indications may reveal potential inadequacies in the regulatory approval processes of new drugs. Understanding potential weaknesses of the regulatory approval process is paramount given the increasing use of expedited pathways. In this paper, we focus on three poly-ADP-ribose polymerase inhibitors (olaparib, rucaparib and niraparib) for the treatment of women with heavily pretreated, recurrent ovarian cancer, which were eventually withdrawn. Methods We use a comparative case study approach to evaluate the regulatory histories of these drug indications in the US and Europe. Results Two drug indications benefited from the FDA's accelerated approval pathway, which explicitly lowers the bar for evidence of efficacy at the time of approval. Following accelerated approval, manufacturers are mandated to conduct post-marketing studies to confirm clinical benefit. The FDA granted accelerated approval to olaparib and rucaparib based on data on surrogate endpoints and converted the approval to regular approval after the submission of additional data on surrogate endpoints from one of two required confirmatory trials, that is, without data on clinical benefit. Niraparib directly received regular approval based only on data on a surrogate endpoint. By contrast, the EMA granted conditional marketing authorisation to rucaparib and was quicker to restrict usage than the FDA. Conclusion The regulatory histories of these drug indications highlight the need to reform the accelerated approval pathway by ensuring that post-marketing requirements are followed, and that regular approval is only based on evidence of clinical benefit.
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Affiliation(s)
- Mahnum Shahzad
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | | | | | - Anita K. Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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3
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Ross DB. The decline of science at the FDA has become unmanageable. BMJ 2023; 381:1061. [PMID: 37188385 DOI: 10.1136/bmj.p1061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- David B Ross
- George Washington University School of Medicine and Health Sciences
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Bi Z, Shi X, Liao S, Li X, Sun C, Liu J. Strategies of immobilizing BMP-2 with 3D-printed scaffolds to improve osteogenesis. Regen Med 2023; 18:425-441. [PMID: 37125508 DOI: 10.2217/rme-2022-0222] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
The management and definitive treatment of critical-size bone defects in severe trauma, tumor resection and congenital malformation are troublesome for orthopedic surgeons and patients worldwide without recognized good treatment strategies. Researchers and clinicians are working to develop new strategies to treat these problems. This review aims to summarize the techniques used by additive manufacturing scaffolds loaded with BMP-2 to promote osteogenesis and to analyze the current status and trends in relevant clinical translation. Optimize composite scaffold design to enhance bone regeneration through printing technology, material selection, structure design and loading methods of BMP-2 to advance the clinical therapeutic bone repair field.
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Affiliation(s)
- Zhiguo Bi
- Department of Orthopaedics, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
| | - Xiaotong Shi
- Department of Orthopaedics, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
| | - Shiyu Liao
- Department of Orthopaedics, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
| | - Xiao Li
- Department of Orthopaedics, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
| | - Chao Sun
- Department of Orthopaedics, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
| | - Jianguo Liu
- Department of Orthopaedics, The First Hospital of Jilin University, Changchun, Jilin Province, 130021, China
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Johnston JL, Ross JS, Ramachandran R. US Food and Drug Administration Approval of Drugs Not Meeting Pivotal Trial Primary End Points, 2018-2021. JAMA Intern Med 2023; 183:376-380. [PMID: 36780148 PMCID: PMC9926353 DOI: 10.1001/jamainternmed.2022.6444] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/28/2022] [Indexed: 02/14/2023]
Abstract
This cross-sectional study determines the frequency of and rationale for US Food and Drug Administration (FDA) approval of drugs not meeting pivotal trial primary efficacy end points.
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Affiliation(s)
- James L. Johnston
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joseph S. Ross
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- National Clinician Scholars Program, Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
| | - Reshma Ramachandran
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- National Clinician Scholars Program, Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
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6
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Rosenkranz GK. A Generalization of the Two Trials Paradigm. Ther Innov Regul Sci 2023; 57:316-320. [PMID: 36289189 DOI: 10.1007/s43441-022-00471-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/14/2022] [Indexed: 11/30/2022]
Abstract
The two trials paradigm plays a prominent role in drug development and has been widely and controversially discussed. Its purpose is to ensure replicability or substantiation of study results. This note investigates a simple generalization of the paradigm to more than two trials that preserves the project wise type-I error rate and power.
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Affiliation(s)
- Gerd K Rosenkranz
- Statistical Consultant, Obereckstrasse 11a, 79539, Lörrach, Germany.
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Ruberg SJ, Beckers F, Hemmings R, Honig P, Irony T, LaVange L, Lieberman G, Mayne J, Moscicki R. Application of Bayesian approaches in drug development: starting a virtuous cycle. Nat Rev Drug Discov 2023; 22:235-250. [PMID: 36792750 PMCID: PMC9931171 DOI: 10.1038/s41573-023-00638-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
The pharmaceutical industry and its global regulators have routinely used frequentist statistical methods, such as null hypothesis significance testing and p values, for evaluation and approval of new treatments. The clinical drug development process, however, with its accumulation of data over time, can be well suited for the use of Bayesian statistical approaches that explicitly incorporate existing data into clinical trial design, analysis and decision-making. Such approaches, if used appropriately, have the potential to substantially reduce the time and cost of bringing innovative medicines to patients, as well as to reduce the exposure of patients in clinical trials to ineffective or unsafe treatment regimens. Nevertheless, despite advances in Bayesian methodology, the availability of the necessary computational power and growing amounts of relevant existing data that could be used, Bayesian methods remain underused in the clinical development and regulatory review of new therapies. Here, we highlight the value of Bayesian methods in drug development, discuss barriers to their application and recommend approaches to address them. Our aim is to engage stakeholders in the process of considering when the use of existing data is appropriate and how Bayesian methods can be implemented more routinely as an effective tool for doing so.
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Affiliation(s)
| | | | | | | | - Telba Irony
- Janssen Pharmaceutical Companies of J & J, Titusville, NJ, USA
| | - Lisa LaVange
- University of North Carolina, Chapel Hill, NC, USA
| | | | - James Mayne
- Pharmaceutical Research and Manufacturers of America, Washington, DC, USA
| | - Richard Moscicki
- Pharmaceutical Research and Manufacturers of America, Washington, DC, USA
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Largent EA, Peterson A, Karlawish J, Lynch HF. Aspiring to Reasonableness in Accelerated Approval: Anticipating and Avoiding the Next Aducanumab. Drugs Aging 2022; 39:389-400. [PMID: 35696021 PMCID: PMC9247014 DOI: 10.1007/s40266-022-00949-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
The US Food and Drug Administration's decisions about drug approval-though guided by science, as well as relevant statutes, regulations, and guidance documents-reflect normative judgments about how the agency should exercise its discretion. This is particularly true in the context of the "accelerated approval" pathway, where the agency must balance speeding to market drugs for patients with unmet needs before they have been proven to work and ensuring confidence about the benefits and risks of those drugs. A key challenge in evaluating normative judgments such as these is that reasonable people can disagree, rendering it difficult to proclaim with certainty that a particular decision is right or wrong. Therefore, we propose that it is preferable to ask whether a decision is reasonable. A decision is reasonable when it transparently, comprehensively, and fairly balances the interests of affected parties, within the parameters of the decision maker's legal authority. If a decision achieves these three qualities, it can be viewed as legitimate and worthy of trust and confidence, regardless of whether one agrees with the particular outcome. We recommend that the Food and Drug Administration adopt procedural protections to promote reasonableness in four domains affecting accelerated approval decisions: pathway gatekeeping, endpoint selection, stakeholder engagement, and deliberation. This should aid the agency in minimizing controversies, such as that surrounding the 2021 approval of aducanumab (Aduhelm; Biogen).
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Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Blockley Hall, Room 1403, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | - Andrew Peterson
- Department of Philosophy, Institute for Philosophy and Public Policy, George Mason University, Fairfax, VA, USA
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Blockley Hall, Room 1403, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Holly Fernandez Lynch
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Blockley Hall, Room 1403, 423 Guardian Drive, Philadelphia, PA, 19104, USA
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Daval CJR, Sarpatwari A, Kesselheim AS. Unwanted Advice? Frequency, Characteristics, And Outcomes Of Negative Advisory Committee Votes For FDA-Approved Drugs. Health Aff (Millwood) 2022; 41:713-721. [PMID: 35500185 DOI: 10.1377/hlthaff.2021.01927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Substantial controversy arose in 2021 when the Food and Drug Administration (FDA) approved the Alzheimer's disease drug aducanumab (Aduhelm) under its accelerated approval program despite a nearly unanimous negative advisory committee vote. Advisory committees are convened before some FDA decisions to provide insight for the agency's decision-making process. To understand the frequency, characteristics, and outcomes of cases in which the FDA authorizes a drug against the recommendations of an advisory committee, we reviewed all FDA advisory committee referrals for new drugs approved during the period 2010-21. The fraction of approved drugs that had been referred to an advisory committee decreased from 55 percent to 6 percent annually, with FDA approvals of negatively reviewed drugs occurring about once a year. Qualitative analysis of committee meetings revealed variability in the substance and wording of key voting questions. Reforms such as transparent criteria for when a drug should be subject to external scrutiny, consistent wording of voting questions, and clear regulatory responses to negative recommendations can better ensure public confidence in the FDA approval process.
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Affiliation(s)
- C Joseph Ross Daval
- C. Joseph Ross Daval, Brigham and Women's Hospital and Harvard University, Boston, Massachusetts
| | - Ameet Sarpatwari
- Ameet Sarpatwari, Brigham and Women's Hospital and Harvard University
| | - Aaron S Kesselheim
- Aaron S. Kesselheim , Brigham and Women's Hospital and Harvard University
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McPhail M, Weiss E, Bubela T. Conditional Drug Approval as a Path to Market for Oncology Drugs in Canada: Challenges and Recommendations for Assessing Eligibility and Regulatory Responsiveness. Front Med (Lausanne) 2022; 8:818647. [PMID: 35186979 PMCID: PMC8853442 DOI: 10.3389/fmed.2021.818647] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022] Open
Abstract
International drug regulators use conditional drug approval mechanisms to facilitate faster patient access to drugs based on a lower evidentiary standard typically required of drug approvals. Faster and earlier access is justified by limiting eligibility to drugs intended for serious and life-threatening diseases and by requiring post-market evidence collection to confirm clinical benefit. One such mechanism in Canada, the Notice of Compliance with Conditions (NOC/c) policy, was introduced in 1998. Today, most of the drugs approved under the NOC/c policy are for oncology indications. We analyze oncology drugs approvals under the NOC/c policy to inform discussions of two tradeoffs applied to conditional drug approvals, eligibility criteria and post-market evidence. Our analysis informs recommendations for Canada's proposed regulatory reforms approach to conditional approvals pathways. Our analysis demonstrates that under the current policy, eligibility criteria are insufficiently defined, resulting in their inconsistent application by Health Canada. Regulatory responsiveness to post-market evidence from post-market clinical trial and foreign jurisdiction regulatory decisions is slow and insufficient. In the absence of sufficient regulatory responsiveness, physicians and patients must make clinical decisions without the benefit of the best available evidence. Together, our analysis of the two core tradeoffs in Canada's conditional drug approval provides insight to inform the further development of Canada's proposed agile regulatory approach to drugs and devices that will expand the use of terms and conditions.
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Williams M. Improving Translational Paradigms in Drug Discovery and Development. Curr Protoc 2021; 1:e273. [PMID: 34780124 DOI: 10.1002/cpz1.273] [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] [Indexed: 06/13/2023]
Abstract
Despite improved knowledge regarding disease causality, new drug targets, and enabling technologies, the attrition rate for compounds entering clinical trials has remained consistently high for several decades, with an average 90% failure rate. These failures are manifested in an inability to reproduce efficacy findings from animal models in humans and/or the occurrence of unexpected safety issues, and reflect failures in T1 translation. Similarly, an inability to sequentially demonstrate compound efficacy and safety in Phase IIa, IIb, and III clinical trials represents failures in T2 translation. Accordingly, T1 and T2 translation are colloquially termed 'valleys of death'. Since T2 translation dealt almost exclusively with clinical trials, T3 and T4 translational steps were added, with the former focused on facilitating interactions between laboratory- and population-based research and the latter on 'real world' health outcomes. Factors that potentially lead to T1/T2 compound attrition include: the absence of biomarkers to allow compound effects to be consistently tracked through development; a lack of integration/'de-siloing' of the diverse discipline-based and technical skill sets involved in drug discovery; the industrialization of drug discovery, which via volume-based goals often results in quantity being prioritized over quality; inadequate project governance and strategic oversight; and flawed decision making based on unreliable/irreproducible or incomplete data. A variety of initiatives have addressed this problem, including the NIH National Center for Advancing Translational Sciences (NCATS), which has focused on bringing an unbiased academic perspective to translation, to potentially revitalize the process. This commentary provides an overview of the basic concepts involved in translation, along with suggested changes in the conduct of biomedical research to avoid valleys of death, including the use of Translational Scoring as a tool to avoid translational attrition and the impact of the FDA Accelerated Approval Pathway in lowering the hurdle for drug approval. © 2021 Wiley Periodicals LLC.
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Affiliation(s)
- Michael Williams
- Department of Biological Chemistry and Pharmacology, College of Medicine, Ohio State University, Columbus, Ohio
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