Consequences to patients, clinicians, and manufacturers when very serious adverse drug reactions are identified (1997-2019): A qualitative analysis from the Southern Network on Adverse Reactions (SONAR)

BACKGROUND

Adverse drug/device reactions (ADRs) can result in severe patient harm. We define very serious ADRs as being associated with severe toxicity, as measured on the Common Toxicity Criteria Adverse Events (CTCAE)) scale, following use of drugs or devices with large sales, large financial settlements, and large numbers of injured persons. We report on impacts on patients, clinicians, and manufacturers following very serious ADR reporting.

METHODS

We reviewed clinician identified very serious ADRs published between 1997 and 2019. Drugs and devices associated with reports of very serious ADRs were identified. Included drugs or devices had market removal discussed at Food and Drug Advisory (FDA) Advisory Committee meetings, were published by clinicians, had sales > $1 billion, were associated with CTCAE Grade 4 or 5 toxicity effects, and had either >$1 billion in settlements or >1,000 injured patients. Data sources included journals, Congressional transcripts, and news reports. We reviewed data on: 1) timing of ADR reports, Boxed warnings, and product withdrawals, and 2) patient, clinician, and manufacturer impacts. Binomial analysis was used to compare sales pre- and post-FDA Advisory Committee meetings.

FINDINGS

Twenty very serious ADRs involved fifteen drugs and one device. Legal settlements totaled $38.4 billion for 753,900 injured persons. Eleven of 18 clinicians (61%) reported harms, including verbal threats from manufacturer (five) and loss of a faculty position (one). Annual sales decreased 94% from $29.1 billion pre-FDA meeting to $4.9 billion afterwards (p<0.0018). Manufacturers of four drugs paid $1.7 billion total in criminal fines for failing to inform the FDA and physicians about very serious ADRs. Following FDA approval, the median time to ADR reporting was 7.5 years (Interquartile range 3,13 years). Twelve drugs received Box warnings and one drug received a warning (median, 7.5 years following ADR reporting (IQR 5,11 years). Six drugs and 1 device were withdrawn from marketing (median, 5 years after ADR reporting (IQR 4,6 years)).

INTERPRETATION

Because very serious ADRs impacts are so large, policy makers should consider developing independently funded pharmacovigilance centers of excellence to assist with clinician investigations.

FUNDING

This work received support from the National Cancer Institute (1R01 CA102713 (CLB), https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-cancer-institute-nci; and two Pilot Project grants from the American Cancer Society's Institutional Grant Award to the University of South Carolina (IRG-13-043-01) https://www.cancer.org/ (SH; BS).

Physician whistle-blower’s experiences in hematology-oncology safety litigation against pharmaceutical companies

2074

Background: Some clinicians have reported initial series of severe or fatal adverse drug reactions (ADRs) that affected large hematology-oncology patient numbers and for which pharmaceutical manufacturers subsequently paid large settlements or fines for allegedly failing to inform physicians about such ADRs. Based on their large human costs ( > 1,000 serious illnesses or deaths) and large financial costs ( > $100 million in settlements or fines), we have termed these ADRs as titanic ADRs. At a Senate hearing on one titanic, Vioxx, (a COX-2 inhibitor that was evaluated for colorectal cancer prevention), the clinician reporter was termed a “whistleblower” by a senator although this individual had not filed a formal whistleblower lawsuit. We identified physicians who would fit this characterization of whistleblowers and had published titanic hematology-oncology ADR reports in high impact journals. Methods: Hematology-oncology titanic ADRs were identified by collaborators with two NIH-funded drug safety networks (RADAR and SONAR (1998-2019)). Exclusion criteria included having also filed a whistleblower lawsuit. Qualitative research analyses evaluated content of statements made by whistleblowers to national reporters or at congressional hearings. Results: 18 physicians who reported titanic hematology/oncology-associated ADRs in peer-reviewed literature and discussed their findings in national news media outlets are included. Titanic ADRs included death, nephrogenic systemic fibrosis, coronary artery disease, and venous thromboembolism related to COX-2 inhibitors, heparin, gadolinium dye, thalidomide, lenalidomide, epoetin, and darbepoetin. Related financial settlements ranged from $100 million to $4.85 billion. Whistleblowers were from the United States, Denmark, and Germany. Primary motivations were public health and medical awareness. Whistleblowers reported having gone through lawsuits and having had executives request that the whistleblowers’ university terminate employment. One whistleblower was quoted saying “I believe that the lawsuit is an attempt to silence me.” Conclusions: Clinician whistleblowers of titanic hematology-oncology ADRs experienced reputational, financial, and personal threats. Motivations for reporting titanic ADRs were mainly public health and medical awareness focused. This differs from our previous study on clinicians publishing on non-titanic ADRs, where the primary motivation was scientific curiosity.

Caveat Medicus: Clinician experiences in publishing reports of serious oncology-associated adverse drug reactions

Oncology-associated adverse drug/device reactions can be fatal. Some clinicians who treat single patients with severe oncology-associated toxicities have researched case series and published this information. We investigated motivations and experiences of select individuals leading such efforts. Clinicians treating individual patients who developed oncology-associated serious adverse drug events were asked to participate. Inclusion criteria included having index patient information, reporting case series, and being collaborative with investigators from two National Institutes of Health funded pharmacovigilance networks. Thirty-minute interviews addressed investigational motivation, feedback from pharmaceutical manufacturers, FDA personnel, and academic leadership, and recommendations for improving pharmacovigilance. Responses were analyzed using constant comparative methods of qualitative analysis. Overall, 18 clinicians met inclusion criteria and 14 interviewees are included. Primary motivations were scientific curiosity, expressed by six clinicians. A less common theme was public health related (three clinicians). Six clinicians received feedback characterized as supportive from academic leaders, while four clinicians received feedback characterized as negative. Three clinicians reported that following the case series publication they were invited to speak at academic institutions worldwide. Responses from pharmaceutical manufacturers were characterized as negative by 12 clinicians. One clinician’s wife called the post-reporting time the “Maalox month,” while another clinician reported that the manufacturer collaboratively offered to identify additional cases of the toxicity. Responses from FDA employees were characterized as collaborative for two clinicians, neutral for five clinicians, unresponsive for negative by six clinicians. Three clinicians endorsed developing improved reporting mechanisms for individual physicians, while 11 clinicians endorsed safety activities that should be undertaken by persons other than a motivated clinician who personally treats a patient with a severe adverse drug/device reaction. Our study provides some of the first reports of clinician motivations and experiences with reporting serious or potentially fatal oncology-associated adverse drug or device reactions. Overall, it appears that negative feedback from pharmaceutical manufacturers and mixed feedback from the academic community and/or the FDA were reported. Big data, registries, Data Safety Monitoring Boards, and pharmacogenetic studies may facilitate improved pharmacovigilance efforts for oncology-associated adverse drug reactions. These initiatives overcome concerns related to complacency, indifference, ignorance, and system-level problems as barriers to documenting and reporting adverse drug events- barriers that have been previously reported for clinician reporting of serious adverse drug reactions.