FDA Matters Blog

Archive for the ‘FDA Leadership’ Category

User Fee Reauthorization—Critics Come Out Before the Ink Is Dry

Tuesday, June 26th, 2012

 

The House passed the final user fee reauthorization legislation last week and (as of this evening) the Senate has also passed the bill. It will now go to the President for signature. FDA Matters says: well done, Congress! Despite my fear of delays and bickering, you completed this process on time and with broad bipartisan support.

 

However, critics are already emerging, "before the ink is dry.” The advocacy group, Public Citizen, is complaining that drugs and devices will be less safe as a result of the legislation. At the same time, Dr. Scott Gottlieb, a former FDA official, has published an essay arguing the legislation doesn’t go far enough to expedite review of drugs for serious medical conditions.

 

The Public Citizen Health Research Group’s critique is to be expected. They were founded 40 years ago and have consistently been critical of the agency’s handling of drug and medical device approvals. Their continued opposition rests on three primary points:

 

  1. User fees created by PDFUA have created a conflict of interest because the agency is funded in part by the industry it is supposed to be regulating.
  2. This has led to poor quality reviews of drugs and thus the release of dangerous products. Since PDUFA, more drugs have been approved and then banned, causing needless deaths/injuries.
  3. Working conditions at the FDA have plummeted since PDUFA, resulting in high staff turnover and sweatshop-like conditions.

I, too, wish that FDA were 100% taxpayer funded, but user fees are reality, a compromise that makes it possible for FDA to have the funds to operate. There is no evidence of bias generated by the fees, plus Americans would be far worse off if a quarter of FDA’s budget (user fees) were to suddenly disappear.

 

With regard to the quality of drug reviews, I see no evidence they’ve declined and the methodology of the PDUFA/drug approval study is suspect. Working conditions and staff turnover are definitely a matter of “compared to what?” I don’t think FDA does badly when you look at it that way.

 

Far more of a surprise is the essay by Dr. Scott Gottlieb, former deputy commissioner for medical and scientific affairs at FDA.  Using primarily examples of orphan drugs, he argues that FDA is over-focused on long-term safety and on reining in physician prescribing practices. As a result, the agency is stifling medical innovation and disregarding the needs of patients with serious medical conditions. I don’t agree with him on a number of points, but you can hit the link and judge for yourself.

 

His argument might be more compelling if he referenced large-market products, such as pain killers and obesity drugs. However, by using orphan drug examples, Dr. Gottlieb winds up attacking the new user fee reauthorization legislation as insufficient to expedite review of drugs that target serious medical conditions.

 

FDA Matters has already praised changes affecting orphan drugs and accelerated approval. My view is shared by much of FDA and the FDA stakeholder communities; for example: FDA and other leaders, BIO, the National Health Council and the National Organization for Rare Disorders.

 

So, why attack PDUFA’s bold new efforts on behalf of orphan drugs and patients with serious medical conditions? 

 

To Dr. Gottlieb, these “legislative fixes” are inadequate because “the agency’s staff will still have wide discretion in determining when to employ these [new] tools.” If overcautious, reluctant reviewers are still in charge, then even Congressional changes in the FDA law will not improve the review process to benefit patients with serious medical conditions.

 

His proposed solution is to remove the approval of drugs from the review divisions and give that authority to a panel of senior scientists with the “experience and stature to exercise the policy judgment required to make careful decisions about how to weigh risk and benefits…” An even better solution, in his mind, would be to follow the European Medicine Agency’s model in which staff does analysis and evaluation, but the final approval decisions are made by politically-appointed individuals.

 

I think both of these approaches would severely weaken—if not outright undermine—the existing FDA approval process. This would be particularly unfortunate now, when the new legislation empowers agency leadership to lower the barriers, so that review staff can be more flexible and apply new approaches to evaluating therapies for serious medical conditions.

 

Conclusions. Before more drastic actions are considered, let’s give the new user fee reauthorization legislation time to work. The ink isn’t even dry!

 

Steven

 

 

Many readers were out of town this past Friday and may have missed:

 

Biosimilars Update: Keys for the Next Year and Beyond   June 22nd, 2012

The biosimilars market in the U.S. will not grow large overnight. By a decade from now, sales of biosimilars will be creating new winners and losers in the overall biopharmaceutical marketplace. In light of this, I was recently asked: what should a developer or investor be looking to achieve over the next year in the area of biosimilars? What should they be looking to achieve in the years after that?  Read the rest of this entry

 

Post to Twitter Tweet This Post

OMB, HHS, or FDA: Who Really Makes FDA’s Decisions?

Monday, April 23rd, 2012

OMB, White House staff, and the Secretary of HHS review many FDA decisions and their oversight sometimes alters FDA’s positions. This was chronicled in a recent NY Times article and generated a number of editorial comments criticizing anyone tampering with FDA’s integrity. However, the individuals named in the article have the authority (on behalf of the President) to question FDA’s judgments.  

More importantly, FDA Matters observes that the vast majority of FDA-related decisions–and virtually all of the science-related decisions–are made by the FDA. The key is the strong public health and scientific expertise of FDA staff and the credibility this brings to any scientifically-based agency decision.  

The President is in charge.  The President’s responsibility is to “faithfully execute the laws” of the United States. The task is enormous, requiring a $3 trillion annual budget and 1.3 million civilian employees*.  Delegation is necessary and is controlled by having a rigidly hierarchical structure of government that assures, to the extent possible, that decisions made by subordinate departments and agencies reflect the law and the President’s policies.

Department secretaries—those primarily responsible for carrying out the President’s policies—report directly as part of the President’s Cabinet. They also report indirectly through the Office of Management and Budget (OMB), which is the primary administrative structure for assuring that the Executive Branch makes decisions consistent with the President’s wishes. 

FDA is part of the government, not separate from it. The very nature of government makes FDA’s independence an illusion**. The Commissioner is not elected; she is appointed by the President and the Secretary of Health and Human Services. Ultimately, all decisions are the President’s (and the Secretary of HHS’ acting on his behalf).

While oversight and review of FDA’s decisions by White House staff, OMB and the Secretary of HHS is quite real, it is also legitimate. Those named in the NY Times article all have the authority to question FDA’s judgments before they become final.  The positions they took may have been unwise, but they did not exceed their responsibilities.

Oversight and review of FDA is limited in its scope and impact. While FDA cannot escape oversight within the Executive Branch, the NY Times article cited only five examples among thousands of decisions FDA makes every year.

None of the five cases involved overriding the scientific and medical expertise of FDA. Two of the five were labeling issues (caloric content of movie popcorn, sunscreens with relatively low SPF factors). The other three were access issues (emergency hormonal contraceptives, the continued marketing of an asthma inhaler containing fluorocarbons, and whether FDA should waive enforcement against pharmacy compounding of a specific, newly-approved drug).

The most serious of the five was the decision on access to emergency hormonal contraceptives, where it is alleged that HHS overrode FDA’s scientific judgment. Without defending HHS’s actions, it is relevant that neither biological nor medical science was involved. Rather the FDA “science” involved label comprehension studies (can adolescents under-17 understand and properly follow the directions on the label).  As an aside: decisions concerning emergency hormonal contraceptives have an almost-unique history of getting FDA leadership in hot water within the Executive Branch and with Congress and the public. 

FDA’s medical and scientific expertise protects virtually all of its medical and scientific decisions. Since OMB and HHS oversight of FDA is continuous, there are undoubtedly other examples where FDA has compromised or yielded. Given FDA's public accountability for its decisions (correspondence, hearings, reports, advisory committees), there can't be many instances in which the agency's scientific or medical judgments are overruled and it is not publicly known. So, I can’t say that FDA’s scientific judgments are never overruled, but it certainly appears to be rare.  

The alleged problem of intrusions on FDA’s scientific integrity may appear larger because of a misunderstanding about the nature of FDA. Not all FDA decisions are based on scientific or medical expertise. For example, requiring caloric labeling of movie popcorn might create consistency of government policy across multiple food service settings, but it's a policy judgment, not a decision based on science or medicine.

In fact, there is very good reason why White House staff, OMB and HHS will never significantly affect FDA scientific and medical decisions: they lack the credibility and scientifically-trained manpower to do it.

Steven

* Federal government expenditures and number of civilian employees are for 2011. Civilian employees are expressed as full-time equivalents and exclude US postal workers. Source: http://www.whitehouse.gov/omb/budget/Historicals

** Proposals have been made to  re-create FDA as an “independent agency”  that reports directly to the President and not through a Cabinet-level department, much like the U.S. Environmental Protection Agency. However, EPA’s experience is fairly clear: reporting directly to the President and OMB….does not free you from having your decisions questioned and sometimes overruled.

Post to Twitter Tweet This Post

FDA Matters Mailbag: Hatch-Waxman, Biosimilars, User Fees and More

Sunday, February 19th, 2012

 

Over the last month, FDA Matters has covered a wide-range of FDA-related topics: the agency, industry, and Congress, as well as medical innovation, user fee reauthorization legislation, food safety and post-market surveillance. The response has been great: FDA Matters has many new readers and I received a number of interesting questions.

 

Today’s column touches on biosimilars, Hatch-Waxman, user fees and FDA management. Keep the questions coming!

 

Is FDA becoming too large for food, drugs and medical devices to be in the same agency?

 

Last summer, the Commissioner re-organized her office to better manage the growing responsibilities and complexity of the agency’s work. She divided the agency’s work into four parts:

  • food and veterinary medicine
  • medical products
  • global outreach and inspection, and
  • administrative matters overseen by a chief operating officer 

The key is that each of these individuals has line authority to manage their part of the agency, rather than being a staff advisor to the Commissioner.  

 

With specific regard to foods, there are proposals to move the Center for Food Safety and Applied Nutrition (CFSAN) out of FDA. I believe the Center is best served by being part of the public health focus of FDA.

 

How do Europe and the US compare in their approaches to biosimilars?

 

Both the European Medicines Agency (EMA) and FDA are acting cautiously, but in different ways. Europe has focused on a limited number of reference products, building their knowledge and experience one therapeutic category at a time.

 

In contrast, FDA has already met with sponsors to discuss 11 reference products, presumably covering a number of therapeutic categories. Given FDA’s broader approach, proceeding case-by-case with strong scientific requirements is the best way for FDA to acquire knowledge and experience.

 

A different comparison was also posed to me: an eager EMA versus a reluctant FDA.  In less than two years, FDA has produced multiple policy speeches and articles, three guidances, held multiple sponsor meetings and allowed several sponsors to begin work. I assure you: FDA is fully committed to biosimilars!

 

As an aside, anyone familiar with the lack of FDA guidance on product-related social media can tell you how FDA behaves when it is reluctant to act. It looks quite different.

 

If the user fee reauthorization legislation has the potential to be a vehicle for any FDA-related provision, might Congress re-open Hatch-Waxman?

 

I shudder at the possibility, but can’t rule it out. I asked a knowledgeable friend what he would propose if given the chance to amend Hatch-Waxman. His reply: get FDA out of the patent enforcement business, yet assure generics the equivalent of the 180-day exclusivity if they win in court.

 

Since this would benefit generics, a trade-off for innovators could be longer exclusivity for new molecular entity (NME) compounds that lack intellectual property (IP) protection. It might be the same 10 years they receive in the EU or the 12 years for biologics. Similarly, a stronger incentive than 5 to 7 years is needed to generate interest in 505 (b)(2) drug applications in the absence of IP protection. 

 

I’m not suggesting this, but thought it interesting enough to give his ideas some visibility.

 

Companies are telling me: it’s hard to justify investing in the US biosimilars market because of the resources it will require. Why is FDA Matters so optimistic?

 

I hear some of this, too. Certainly, the first generation of biosimilar applicants (and there seem to be plenty of them) are going to pay more–and live with more uncertainty for a longer period of time– than those that start 5 years from now when costs have dropped.

 

However, those who are successful are going to be rewarded, as I explored more fully in How Biosimilars Will Transform the Marketplace. Put simply:

 

  • If the first biosimilar approvals from FDA are for solid products with good data and fair pricing, then hospital purchasing groups, pharmaceutical benefit managers and formulary committees are going to move significant market share away from the reference products.

  • In multi-product categories, the market shift may be even greater because there will be therapeutic substitution, not just substitution of the biosimilar for the reference drug.

 I look forward to more reader questions!

 

Steven

Post to Twitter Tweet This Post

Medical Innovation, Food Safety, and Imports: Did FDA Have A Good Year in 2011?

Monday, January 16th, 2012

 Before turning to 2012, FDA Matters wanted to take one more look at FDA’s performance in 2011. So much happens at FDA that it’s easy to lose perspective. And no matter what the agency does, somebody will be unhappy. So, should Commissioner Hamburg feel good about the last 12 months?

 

FDA Matters thinks it comes down to how well FDA handled the three most important challenges it faced:

  • improving the medical product review process, including stimulating innovation;
  • implementing the Food Safety Modernization Act; and
  • advancing the agency’s ability to assure the safety of imports.

Before exploring these particulars, FDA Matters feels FDA staff and Dr. Hamburg should be applauded just for surviving the daily grinding pressure of the agency’s workload. As I have noted previously, FDA’s greatest strength is its people.

Medical Product Review Processes. Was it a good year? The approval process for drugs, biologics and medical devices elicited widespread criticism that FDA was too slow, too risk-averse, underweighted patient benefit, and was demanding certainty where none was possible. The unhappiness was constant and palpable from medical device stakeholders; more muted, but still quite strong among bio-pharmaceutical stakeholders.

  

As the year went on, this critique of the agency increasingly coalesced under the rubric of innovation. Specifically, FDA was accused of creating processes and making decisions that stifle American innovation and cost American jobs.

FDA formulated its response in several ways:

Optimistically, I believe these actions are the start of a turning point for the agency. The largest barrier is not agency leadership’s willingness to promote innovation…rather it is that combining public health and innovation requires a new identity for the agency, something that can't happen overnight.

 

Food Safety. Was it a good year? At the very end of 2010, Congress passed the Food Safety Modernization Act (FSMA), which creates a sophisticated risk-based food safety system that stretches from the farm to our tables. The new law created or enhanced FDA authority in the following areas: prevention, inspection and compliance, response to problems, imports, and enhanced partnerships with other food safety agencies.

 

Implementing the new law is a complex multi-faceted task that has been made even more difficult by inadequate funding. Further, many of the new law’s mandates became effective quickly, leaving little opportunity for manpower and IT resources to be mustered to the tasks.

 

The agency just released its one-year progress report and there seems to be general consensus that the agency has done a tough job well. Year two (2012) will be at least as challenging, but we are definitely one-year closer to a safer food supply.

Imports. Was it a good year? The third major challenge to FDA in 2011 was continuous rapid globalization of the world markets for food, drugs, and medical devices. Almost every country in the world produces raw materials, ingredients or finished goods that become part of imported products regulated by the FDA.  

 

In July 2011, the FDA issued a special report, Pathway to Global Product Safety and Quality, which describes the enormous impact of globalization on FDA-regulated products. FDA is responding through:

  • closer partnerships with its foreign counterparts and public-and private-sector third parties,
  • development of global data information systems,
  • continued expansion of its capabilities in intelligence gathering, and
  • allocation of agency resources based on the risk of a food safety problem.

During 2011, the agency further expanded its network of overseas offices and reorganized its headquarters oversight. The latter was accomplished by appointing Deborah Autor as the new Deputy Commissioner for Global Regulatory Operations and Policy.   

Conclusions. In upcoming columns, we will be detailing the challenges facing FDA in 2012. Meantime, we urge Dr. Hamburg and all of FDA to take a moment to think back with pride to 2011. You had a good year.

Steven

Post to Twitter Tweet This Post

Post-Market Safety: Can Sentinel Do Some of the Heavy Lifting?

Wednesday, January 4th, 2012

 

In the FDA-regulated world, success is often defined as approval of a new product or indication based on two, well-controlled clinical trials. However, the scrutiny doesn’t end there. FDA’s mission includes determining whether already-approved drugs perform safely and effectively when used by large numbers of patients in routine medical practice. 

 

To understand what happens under these “real world conditions,” FDA has expanded its post-market  efforts, including development of a monitoring system (called Sentinel) that will be able to track drug usage and medical history information on tens of millions of patients. Although such information will be useful, it can only provide post-hoc inferences, not proof of causation. Even with this limitation, FDA Matters thinks developing the system is worthwhile and may provide multiple benefits. 

 

There are multiple tools for assessing post-approval safety and efficacy that fit loosely under the rubric of pharmacovigilance. When approving medical products, FDA mostly relies on data that comes from pre-specified hypotheses that are tested through randomized, placebo-controlled, double-blind clinical trials. In contrast, the data that comes from pharmacovigilance is inherently less rigorous; indeed it constitutes a form of “data dredging” that FDA abhors. The heart of the problem is that:  

Real world data sets = uncontrolled variables + inconsistent data collection + questionable data accuracy.

When FDA and manufacturers collect adverse events reports, they know there will be underreporting of incidents, as well as limited ability to judge whether problems are drug-related. When FDA looks at the Medicare database, they know that information submitted as part of medical claims is unreliable and subject to systemic bias (e.g. medical coding is designed to support reimbursement, not public health analysis).

The Sentinel database should be superior because it incorporates medical records and patient registry information, along with claims data. Still it provides inferences, not proof.

Active surveillance—continuously monitoring millions of health records—is only worthwhile if these limitations are acknowledged. It can never provide certainty about whether drugs are safe and effective. It can tell you what is worth further examination…but can never tell you the cause of any problem that is identified.

As the FDA mantra goes: association is not causation. No matter how many health records and claims data are reviewed, this is still true.

Clinical trials have limitations, also. Trials don’t tell us how a drug will be used by prescribers. They can never provide complete information about patient outcomes for those individuals with several medical conditions (i.e. multi-morbidity) or who take many medications simultaneously (i.e. poly-pharmacy).

By inference (although not with certainty), pharmacovigilance and active surveillance could bring us closer to addressing potential problems that can’t be resolved by clinical trials. For example, many years ago, I worked on a drug to treat pre-term labor. As I recollect, there were two instances of respiratory problems in a trial of several hundred women. No one could say for sure whether this effect was caused by the drug or occurred at random. A study large enough to find out was infeasible.

Based on the potential respiratory problem, FDA rejected the drug despite the benefits it might have provided to women experiencing pre-term labor. If this same situation were to come up today…maybe FDA would decide differently, knowing it could collect patient outcomes information through pharmacovigilance, particularly active surveillance.

Ideally, FDA would know everything it needs to know about a drug at the time of its approval. Information derived from review of real world data sets can never be as good. But properly understood and carefully analyzed, the inferences derived from pharmacovigilance can add to our understanding about safety, efficacy, drug interactions and side effects.

 

Instead of just using that capacity to identify post-approval problems, FDA needs to incorporate pharmacovigilance into its thinking about when to approve drugs and with what conditions. FDA’s capacity to do pharmacovigilance and active surveillance should lead to a greater willingness by FDA to approve drugs, particularly those with otherwise solid benefit-risk equations, but burdened by questions that cannot be resolved prospectively or through clinical trials (even in phase 4).

 

Patients would benefit if FDA made this one of the Sentinel priorities.

 

Steven

 

This column first appeared on June 21, 2011. It is one of my favorites from last year.

Post to Twitter Tweet This Post

Understanding FDA—Its Strength Is Its People

Monday, December 26th, 2011

Science is essential and rules and regulations must be followed…but ultimately it is the people of FDA who determine whether the agency functions well and acts in the best interests of the American people.  For that reason, a recurrent theme in FDA Matters is the importance of FDA employees. Their jobs are much more difficult than most of us imagine.

Consider the oft-expressed paradigm: FDA is committed to science-based decisionmaking. Yet, science doesn’t exist in a pure, understandable, easily accessible and unassailable form. Neither do laws and regulations. While law and science are fundamental to FDA decisions, only people can actually make the decisions.

During 2011, FDA Matters explicitly looked at the role of staff three times.

The first column asked: Will the Real FDA Please Stand Up?  It was in response to a widely circulated e-mail appealing for public support to prevent the firing of “courageous, honest FDA scientists who risked their careers to save lives by informing Congress about serious safety concerns involving dangerous, FDA-approved drugs and medical devices.”

Whistle-blowing is sometimes necessary. However, the image of a corrupt, politicized FDA cynically suppressing dissent and putting the American people at risk is inconsistent with the FDA that I have known and followed for over 30 years. Yet, I acknowledged that the claims made in the e-mail are persistent and come from many sources.

Exploring this in the column, I concluded that FDA is making progress in handling dissent and in encouraging managers to be more open-minded. While FDA makes mistakes, there is no conspiracy. The agency is fully committed to serving the American people. 

My second column, People, Not Science, Make Decisions, looked at why decisions take so long, especially product approvals. When asked about bottlenecks at FDA, I had to admit that people slow the process down. I pointed to three factors that cause delays:

  • FDA lacks sufficient resources.  FDA has been dramatically understaffed for decades, although better funding in recent years has improved the situation. Even still, new demands on FDA are increasing faster than staff can be added.
  • FDA’s culture promotes intensive scientific discussion.  Objective science-based decisionmaking is a goal, not a reality. People arrive at decisions with a bundle of perceptions and experiences that render their judgment subjective. Yet, they wouldn’t have much to contribute without those experiences.
  • Science has become more complex and results often unpredictable. Life sciences’ products are increasingly based on cutting edge discoveries. It takes more time, more thought and more knowledge on FDA’s part to make a good decision about them. 

Finally, I devoted a third column, FDA and Things that Might Go Bump in the Night, to exploring what happens when FDA staff has to decide the fate of breakthrough technology that could bring great benefit or great sorrow to humankind. In the current context, I had nanotechnology, genetically-engineered (GE) animals, and synthetic biology in mind.

Thirty years ago, FDA gave a cautious “yes” to the first biotechnology studies that eventually became important medical products to treat cancer, arthritis, MS and many other diseases. The world is a better place as a result.

In retrospect, the decision was right, but at the time, this wasn’t clear. Scary visions of mad scientists and technology run amok were powerful forces in the early days of biotechnology. In response, FDA staff took great care in setting up an appropriate regulatory environment.

Conclusion: Based on my experiences working with FDA and as expressed in these three columns, I believe that FDA staff–the people contributing to and making the decisions at FDA–are its strength. While they are human and make mistakes, FDA’s employees are smart, conscientious and committed.   

Steven

Post to Twitter Tweet This Post

Beyond Plan B: Scientific Integrity and a Possible Third Class of Drugs

Monday, December 12th, 2011

Patient access to the emergency hormonal contraceptive “Plan B One-Step” has been one of the most combustible issues ever faced by FDA. It received more attention last week when FDA approved expanded access for adolescents under 17 and HHS Secretary Katherine Sebelius promptly overruled the agency because she found inadequate scientific support for the decision. (For my readers outside the US, here is a New York Times article that provides background).

FDA Matters wonders: has FDA’s scientific decisionmaking authority been thwarted in some lasting way, as some have claimed? Is it time to reconsider proposals for a new category of drugs for which pharmacists are the gatekeeper?

Under the Federal Food, Drug and Cosmetic Act and other laws, the Secretary of HHS has the legal authority to make virtually all decisions within the Department’s jurisdiction. Most of this authority has been delegated to subordinates, including the FDA Commissioner, although the delegation can be withdrawn at any time. No one remembers an instance in which the Secretary explicitly overruled FDA.

Was there a lapse in communications between FDA and HHS? Normally, the Secretary and the Commissioner (or their staffs) discuss controversial decisions before they are made and a compromise reached. Had this occurred, FDA would have announced that compromise as the agency’s decision and taken the heat for ignoring its advisors and staff.  

The alternative explanation, which I hope is true, is that there was an understanding that FDA’s voice should be heard and its integrity preserved, while the Secretary would take the heat for the decision by overruling the agency. This would be consistent with an approach that Commissioner Hamburg has championed: that government should be more honest and transparent about disagreements, as long as everyone understands that someone with decisionmaking authority will actually make a decision.

Either way, it is important to recognize that Plan B has proven to be a “one-of-a-kind” controversy, presenting uniquely difficult issues that aren’t present in 99.9% of FDA’s decisions. I see no reason for commentators to be writing, as one did:  “FDA’s medical and scientific integrity has been forever blighted by these frankly political decisions.”

Secretary Sebelius is not going to make a habit of questioning the scientific support for FDA’s decisions. Nor have we any reason to fear the death of FDA’s integrity or to conclude that it can no longer be a scientifically-driven regulatory agency.

Leaving aside the merits of either FDA or HHS’s position, the Plan B controversy provides an impetus to consider whether there should be a third class of drugs that are neither prescription-only (Rx) nor over-the-counter (OTC). The day after the HHS decision, John Jenkins, director of FDA’s Office of New Drugs, suggested just such a connection between Plan B and a potential third class of drugs known as “behind the counter” drugs (BTC).   

BTC, which has been discussed for decades, relies upon pharmacists to dispense these drugs without a prescription and independent of a physician-office visit. Pharmacists are the most widely distributed of all health care professionals, as well as the most readily accessible. BTC would empower them to provide additional education, monitor appropriate use and discourage misuse for a wide variety of drugs. 

Currently, OTC products containing pseudoephedrine are handled as BTC because of their potential use in making methamphetamine. According to Dr. Jenkins, statins are potential candidates for BTC status, as might other drug classes where petitions for Rx to OTC switches have been denied but there is still potential for safe patient self-treatment without a physician office visit.

In sum, accessibility to the emergency contraceptive Plan B continues to be a disruptive and controversial issue for FDA. However, this is a unique issue and there should be no continuing damage to FDA because the agency was overruled by HHS. A third class of drugs could evolve out of this that might be beneficial to patients across a number of diseases and drug classes, including hormonal contraceptives.

 Steven

 

Post to Twitter Tweet This Post

FDA Bashing: The Wrong Way to Improve FDA

Monday, December 5th, 2011

FDA is imperfect in many ways: it can be hard to predict, maddeningly slow to decide, and inflexible in the face of complex situations. Yet, FDA does remarkably well at carrying out its difficult public health mission. Plus, the agency is constantly striving for improvement.

These points seem lost on agency critics bent on bashing the agency. To believe many of them, FDA is bureaucratically and culturally driven to be ineffective…. and heedless of the impact of its actions on industry innovation and patients in medical need. FDA Matters says: nonsense!

FDA bashing is not a victimless crime. It is a slur on the agency’s good name and many accomplishments. It impedes rational efforts to improve FDA process and performance. It is a barrier to fruitful dialog between FDA and its stakeholders. It drains agency resources and threatens its funding.

FDA bashing is also an incendiary, fostering an environment of “simple, neat and wrong solutions” aimed at fixing the agency.*

FDA bashers make it seem like the world would be a better place if the agency didn’t exist or if its powers were dramatically circumscribed. It’s hard to make FDA a more effective public health and regulatory agency in the midst of such misguided rhetoric. FDA was created–and further empowered over the last 100 years—precisely because regulatory oversight is necessary to assure a safe food supply and safe and effective medical products.

When FDA makes predictable, science-based decisions, patients and consumers benefit from quality products…and industry has the level playing field needed to assure fair competition. This works well most of the time. I’ve heard it said: the world only notices FDA when something goes wrong. That’s largely true.

Believing in FDA and its mission does not require silence or uncritical booster-ism. Let’s all agree that FDA needs to do a lot better before it can be considered the model  for a modern food and drug regulatory agency.

There is a bright dividing line between FDA bashing and working to improve the agency. FDA Matters has praised the Biotechnology Industry Association (BIO) for its positive agenda, even while expressing reservations about BIO’s specific proposals for independent agency status for FDA and a new progressive approval pathway. There have been many positives (and much progress) in the negotiations over medical device user fee reauthorization, even as industry and the agency have bickered privately and in public about the direction of the program.

FDA Matters has been disappointed by many others–industry, patients, Congress, media, and think-tanks–who have emphasized agency bashing at their meetings and in their public communications. Often, the bashing starts with the wrong premise (the agency is largely broken) and concludes with the wrong prescription (break down the agency’s culture and processes and rebuild anew). Not only are these wrong, but they crowd out practical and constructive dialog about agency improvement.

FDA has (in my view) gone out of its way to welcome comments and respond thoughtfully. There is so much more to do….but the agency is not hiding from criticism or arguing reforms are unnecessary.

Other stakeholders seem to be responding in kind. I am involved with at least two efforts to build FDA reform agendas and would welcome the opportunity to participate in others.

FDA Matters believes the right way to improve FDA is through constructive recommendations and thorough discussion. FDA and our nation deserve better than vitriol about how FDA is destroying jobs and is “the enemy.”

Steven

* After H.L. Mencken’s admonition that “for every complex problem, there is a solution that is simple, neat and wrong.”

Post to Twitter Tweet This Post

Animal Research: An Update on One of FDA’s Core Values

Tuesday, November 22nd, 2011

The value of animal research in the life sciences is considered an NIH issue. FDA Matters believes that FDA and its stakeholders should be equally involved.

Animal research is the vital first step in the development of new medical products. Before any safety or efficacy testing is permitted in humans, FDA must be satisfied with animal testing data submitted by the product sponsor. Pick any medical breakthrough and you will find animals were tested prior to humans.

For understandable reasons, we tend to focus on the human part of new products. Which patients will be helped and by how much? By the time a company files a New Drug Application (NDA) or the equivalent in biologics and devices, the headline is the human data. While the animal data is always relevant, it has largely served its purpose as the gateway for human trials.

We talk about the people part without recognizing that the pipeline of innovative drugs and devices would collapse if a broad range of research on animals (e.g. non-human primates, pigs, sheep, dogs, rats, mice, zebrafish, fruit flies, worms) was heavily restricted. Over 96% of the animals used in biomedical research are rodents, birds, fish and invertebrates. As background, there is an excellent summary on the need for animal research available from the advocacy organization, Americans for Medical Progress.

Everybody should be for protecting the welfare of animals. Any means to lessen our dependence on research animals should be welcome. Animals should always be treated ethically and pain reduced or eliminated. The fewest number of animals should be used to reach a conclusion that can be relied upon. Laboratories should be accredited and subject to inspection. Problems should be addressed within a facility under the watchful eye of government, accrediting and licensing agencies and in accordance with the Animal Welfare Act.

Since I last wrote on this topic two years ago, the nature of the animal rights movement in the United States has shifted. Successful prosecutions under the 2006 Animal Enterprise Terrorism Act (AETA) have purged some of the more violent elements of the movement and discouraged others from engaging in destructive acts. However, a small number of activists still use tactics of harassment, intimidation, and vandalism against some research scientists and veterinarians involved in working with laboratory animals.

Many of the research advocacy groups say a greater threat to medical progress is proposed state and federal legislation, often authored by animal rights lobbyists, that has little to do with animal welfare but rather seeks to restrict or raise the cost of animal-based research. An example is The Great Ape Protection and Cost Savings Act legislation, which continues to draw strong support in Congress. As of April 29, 2012, the House version (HR 1513) has 165 sponsors and the Senate version (S 810) has 14 sponsors.  

These bills would virtually eliminate chimpanzee research, which includes work in vaccines, hepatitis, HIV/AIDS, malaria and some types of cancers. Although we use only a comparatively small number of chimpanzees in animal research, I am told that the work often provides essential information that cannot be obtained in any other way.

While the legislation is purportedly about animal welfare, these bills are really designed to limit the biomedical research that we all support and which, we hope, results in FDA-approved medical products.

For me, the choice is easy. I want a product or procedure tested in animals before it is given to me or my loved ones. I believe in protecting animals, but human rights come first.

The importance of animal research needs to be a core value for FDA. Those who benefit from animal research (including patients and industry) need to provide the manpower and financial resources to counter the animal rights movement in America and its threat to medical progress for humans.

Steven

Post to Twitter Tweet This Post

By Whose Standards: FDA’s Identity Crisis and the Level Playing Field

Monday, November 7th, 2011

 

FDA advances public health, protects consumers, regulates products and is an important force in our national economy. Now, FDA is being challenged by Congress and the President to justify itself as a positive force in the advancement of American innovation and as a contributor to US competitiveness.

 

This is precipitating an identity crisis at FDA. The agency is constantly establishing new standards (and revising old ones) that will protect consumers and bring new therapies to patients. Now it must also consider whether it is unduly impeding American industry.  As this forces FDA to rethink who it is and what it stands for, FDA Matters believes a different FDA will emerge.

 

The Need for Standards.  Most of FDA’s authority has been granted by Congress in response to marketplace abuses that had led to harmful products becoming commonplace. In each case, FDA has used that authority to set standards that all products must meet, creating a level playing field for industry. As a result, producers of quality products are assured that their competitors will also have to meet standards. 

 

How important is this effect? A manufacturer in a highly-competitive, FDA- regulated industry once told me: to survive as a business, our upper boundary is limited by what our most foolish competitor offers for sale. FDA standards (and enforcement of those standards) are what assures that both the well-intended and the foolish deliver products that are at or above a defined level of quality and surety.

 

We mostly take the benefits of a level playing field for granted. Yet, greed, carelessness and malevolence are always at work behind the scenes trying to create a profitable advantage out of substandard products (e.g. counterfeiting, ingredient substitution).  

 

Abuses aren’t limited to product manufacturing and distribution. Unsafe and ineffective products also result if standards aren’t created and enforced for clinical trial management, proof of efficacy, acceptable clinical trial designs, food additives, data reporting integrity, post-market surveillance and so on. Having these standards also assures fair competition among companies.

 

The Standards Crisis. By creating, applying and enforcing the highest standards, FDA wants to be seen as the primary force in assuring that Americans have the safest food supply and the safest and most effective therapies anywhere in the world. The agency aspires to always be “the gold standard” for the world.

 

Two sets of circumstances are forcing the FDA to rethink this particular sense of purpose and self-image. As a result, an identity crisis is slowly building within the agency. 

 

First, the “highest” standard is rarely the best way to stimulate innovation. If FDA had chosen the toughest, most protective and most restrictive standards in the late 1970’s and early 1980’s, the biotechnology industry might not exist today. (see FDA and Things that Might Go Bump in the Night).

 

The agency faces this same challenge in creating the highest standards that nonetheless help advance nanotechnology, open new vistas in diagnostics and genomics, and encourage breakthroughs in drugs or medical devices. The tension between the “highest standards” and “reasonable and appropriate standards” is a visible and palpable part of the current controversy over revising medical device categories and approval standards. (see Medical Device Melodrama: A Great Story With a New Plot Twist)

 

Second, there is no global force that levels the playing field among each nation’s regulatory agencies…the way FDA levels the playing field for companies and products in the US market. Efforts at international harmonization of regulatory standards have stretched into decades. Without global standards, there are differences in requirements and even greater differences in interpretation in each national marketplace.

 

FDA knows that setting standards substantially higher than other nations creates the risk that other countries will introduce new products first. It also makes it more likely those countries can attract more industry, capital and jobs in the global economy. Apart from the issue of bragging rights over whether a drug or device was approved first in the US, considerations of international competition (versus cooperation) have been peripheral, at best, to FDA’s identity.

 

Conclusion. Right now, FDA is struggling to show that it can be all these things: the gold standard, the toughest, the best, the stimulator of innovation and the advocate for companies and products that meet American standards.

 

Ultimately, FDA will reconcile these roles because it has no choice. The resulting FDA will not necessarily be better or worse. The change may be dramatic or subtle. The only certainty is FDA’s identity will be different.  

 

Steven

Post to Twitter Tweet This Post

© 2009-2012 by HPS Group. All rights reserved. Permission is hereby granted to those wishing to quote or reprint from this site, providing it is properly attributed to FDA Matters: The Grossman FDA Report™.