A description of medicines-related safety issues evaluated through a referral procedure at the EU level after 2012

INTRODUCTION

Important drug safety issues are evaluated through a referral procedure in the EU by the Pharmacovigilance Risk Assessment Committee (PRAC) within the European Medicines Agency. We aim to describe all safety-related referrals assessed by the PRAC by June 2019.

METHODS

Publicly available data on safety issues assessed through referral procedures that reached a final decision during July 2012-June 2019 were identified, analyzed and classified according to predefined criteria.

RESULTS

Fifty-one safety issues were assessed by PRAC for 45 medicines/combinations/therapeutic classes during this timeframe. Referrals were initiated mostly by the European Commission (16) and France (8). Nine medicines were authorized in the last five years, the rest being well-established drugs. In four cases (flupirtine, hydroxyethyl-starch, valproate, codeine) PRAC re-assessed the same risks as previous recommendations have not been effective. Post-referral recommendations consisted of updates of the summary of product characteristics and package leaflet (42), Direct Healthcare Professional Communication (32), and other additional risk minimization measures (RMMs). Withdrawal was recommended for seven active substances.

CONCLUSIONS

PRAC recommended routine or additional RMMs for most referrals. Complete withdrawal of a drug or withdrawal of certain pharmaceutical forms or concentrations was advised only when the risk could not be managed by RMMs.

Predicting Life Expectancy for Older Adults with Cancer in Clinical Practice: Implications for Shared Decision-making

PURPOSE OF REVIEW

The calculation of noncancer-specific life expectancy can guide shared decision-making and avoid over- and undertreatment in older adults with cancer. Several factors determine life expectancy, including socio-demographic background, comorbidities, physical performance, and geriatric assessment variables. We present an overview of existing tools to estimate life expectancy, as well as practical examples of how to take into account the patient's noncancer-specific life expectancy when discussing screening decisions, initiation of treatment, and end-of-life care.

RECENT FINDINGS

Life expectancy prognostication has been recently recommended by international societies as part of the initial assessment of all older adults with cancer. Additionally, online resources have been created in order to make life expectancy calculation tools accessible for clinicians. Understanding available methods to estimate life expectancy, as well as how to utilize them, is a fundamental part of geriatric oncology that should be integrated into everyday clinical practice.

Mesh in POP surgery should be based on the risk of the procedure, not the risk of recurrence

The still unfolding story of mesh use in surgery for pelvic organ prolapse (POP) offers insights into the factors that influence how we interpret evidence in assessing new technology. Our adoption of mesh in prolapse surgery was influenced by a paradigm shift from treating to preventing recurrent prolapse. This shift is largely unsupported by data and fails to account for the added risk associated with mesh use. This commentary explores unconscious factors that influence our interpretation of innovation and proposes a new approach to evaluating new surgical technologies that balances benefit and risk. Counseling patients about treatments using the benefit-risk approach offers a more balanced perspective. Using a formal benefit-risk assessment in the scientific evaluation of treatments will also provide a more balanced approach that supports the scientific process and patients who undergo treatment.

The fast route to evidence development for value in healthcare

Over the past 30 years, our greatest accomplishments in advancing understanding about the safety, effectiveness and value of healthcare interventions have been achieved through the availability and accessibility of health insurance claims for large populations and, more recently, access to pockets of electronic health records that can be linked to information on expenditures, outcomes and patient experience. Although useful, this data lacks clinical detail and patient relevance. Going forward, we need qualified data networks that understand their data, have a research administration in place to evaluate requests, obtain institutional review and transfer data - all on a timely basis. The mecca of health information will be networks with comprehensive electronic health records that are able to collect and link supplementary data collected from clinicians, tissue banks, etc., and/or directly from patients, including information on quality of life and other patient-reported outcomes. A combination of data collected from clinicians, patients and health systems will provide details about treatment use, patient characteristics and health outcomes that are not consistently available in a patient's medical record, including whether prescriptions were actually filled, and if patients were hospitalized or had other costly healthcare that may not have been reported to their network doctors. We need a simple process to serve as a gateway to identify qualified research partners, the types of data each has access to, and how to work with them. The best partners will have established processes for contracting, prompt and informed institutional review, and data integration including supplementation from patients, clinicians and others, as needed, to support evidence generation that is more nuanced than simply choosing treatments based on how the average patient would respond.

[Significance of the German Act on the Reform of the Market for Medicinal Products for psychopharmacotherapy]

The German Act on the Reform of the Market for Medicinal Products (AMNOG) will lead to rapid disappearance of many new psychotropic drugs from the market in Germany over the next few years or their not being introduced in the first place. This article lists the reasons and discusses possible solutions. In the long term, the AMNOG could not only lead to an improvement of psychopharmacology but also contribute to the development of psychiatry as a whole, especially if its standards become an international reference.

The Benefit Risk Assessment of Consumption of Marine Species Based on Benefit-Risk Analysis for Foods (BRAFO)-tiered Approach

OBJECTIVE

To assess the net health effect caused by the consumption of specific marine species based on Benefit-Risk Analysis for Foods (BRAFO)-tiered approach.

METHODS

Twenty species were collected from the Zhoushan Archipelago, China. Concentrations of n-3 long-chain polyunsaturated fatty acids, methyl mercury (MeHg), and dioxin-like compounds (DLCs) in the samples were analyzed for benefit risk assessment based on BRAFO-tiered approach.

RESULTS

Based on the BRAFO-tiered approach, reference scenario (no intake) and alternative scenario (intake of specific species of 200 g/week) were determined. The exposure to MeHg/DLCs via alternative scenario of all studied species did not exceed provisional tolerable weekly/monthly intake. However, the adult population with high DLCs exposure in China would significantly exceed the upper limit of DLCs via an additional alternative scenario of some species such as Auxis thazard. The results of deterministic computation showed that alternative scenario of all studied species generated clear net beneficial effects on death prevention and child IQ gain.

CONCLUSION

The alternative scenario of all studied species could be recommended to population with average DLCs exposure, and the reference scenario of species with relatively high DLCs concentration could be recommended to population exposed to high DLCs.

Uncertainty about effects is a key factor influencing institutional review boards' approval of clinical studies

PURPOSE

To investigate factors, which influence institutional review boards' (IRBs') decision to approve or not approve clinical studies, a nationwide vignette-based online survey of IRB members was conducted.

METHODS

A factorial design was used, whereby seven aspects of each hypothetical study were randomly varied in 15 phrases in each vignette to produce unique vignettes. Participants indicated the degree of study approval and described factors influencing approval decision. Qualitative responses were thematically content analyzed.

RESULTS

Sixteen themes were obtained from 208 participants from 42 institutions. Uncertainty, adherence, study design, and harms were frequently and intensely cited to influence study approval. Analysis of two extreme subgroups (approvers vs. nonapprovers) showed that uncertainty influenced approval decisions, odds ratios (OR) = 3.5 (95% confidence interval [CI], 1.3-9.8) and OR = 3.2 (95% CI, 1.1-8.9), respectively, based on theme frequency and theme intensity, ignoring multiple observations per person. Taking into consideration multiple observations per person, similar results were obtained for uncertainty: OR = 8.9 (95% CI, 0.93-85.4).

CONCLUSIONS

Perceived uncertainty about benefits and harms of a proposed intervention is a key driver in IRB members' approval of clinical trials. This, in turn, calls for improved standardization in the communications of information on benefits and harms in the research protocols considered by the IRBs.