The task of implementing a host of new drug safety policies and programs as required by the FDA Amendments Act (FDAAA) is
having a troubling impact on the Food and Drug Administration's capacity to approve new drugs in a timely manner. Janet Woodcock,
director of the Center for Drug Evaluation and Research (CDER), acknowledges that drugs are getting approved, but more slowly.
FDAAA added new requirements for assessing postmarket studies and determining the need for risk evaluation and mitigation
strategies (REMS) at the time of approval, but with no extension in review times. The FDA has hired more staff and is implementing
new procedures to make the review process more efficient, but many reviews go beyond the first review cycle timeframe, or
In fact, the US may be falling behind Europe in approving innovative therapies for patients. At a meeting in September sponsored
by the Institute of Medicine (IOM) to evaluate safety initiatives established by FDAAA, Peter Honig, Merck's executive vice
president, noted that first cycle approval trends are down and that user fee approval dates are "routinely missed" because
of increased scrutiny of safety issues. The FDA is "clearly struggling" with postmarket safety demands, he said, suggesting
that "drug lag" may be rearing up once more as European regulators approve some new drugs for market faster than in the US.
The review slowdown is having a noticeable impact on drugs and biologics granted priority review status by the agency, a designation
traditionally reserved for highly innovative therapies. In the past, about 70% of priority review applications gained first-cycle
approval, but this proportion dropped to 50% in 2008, according to a report from Parexel Consulting (available at
http://www.parexelconsulting.com/our-thinking/). User fee approval targets are 10 months for new drug applications (NDAs) and biologics license applications (BLAs), and
six months for priority applications. It's particularly difficult for reviewers to improve on the six-month review goal.
The good news is that manufacturers are submitting more NDAs and that the approval numbers are going up. Parexel cites 147
NDAs pending at the FDA at the beginning of this year, a notable increase from the 86 under review a year earlier.
The REMS program is the most visible new assignment. CDER has approved 63 new REMS in the last two years: 47 require only
distribution of medication guides for pharmacists to give patients; 10 have additional communication plans involving healthcare
professionals; and six REMS include elements to ensure safe use (ETASU), which limit distribution or require special monitoring.
The process of devising, proposing and negotiating a REMS with the FDA is complex and time-consuming, as revealed in the draft
guidance on REMS content and format for drugs and biologics, issued Sept. 30 (available at
http://www.fda.gov/). Even MedGuide-only programs require a manufacturer to explain why such a moderate strategy is sufficient to ensure safe
product use; more restrictive REMS programs are much more complex to implement. The guidance describes how manufacturers must
submit a REMS proposal to the FDA to explain risks addressed, program goals, materials involved, and how and when the plan
will be implemented. A REMS supporting document should provide a thorough explanation of program rationale and more detail
on how the REMS elements and tools will mitigate risks.
An important part of the REMS proposal is a timetable for assessing the program after 18 months, three years, and seven years,
or more often if warranted. The policy spells out detailed procedures for modifying a REMS after it is adopted if goals are
not met or circumstances change. The FDA also may unilaterally modify a REMS if new safety or effectiveness information emerges.
Assessments assume that sponsors and the FDA can measure whether a REMS is effective or successful. It's fairly straightforward
to conduct surveys, collect prescriber information, or establish active surveillance programs, but much harder to assess how
risk information actually influences prescriber and patient behavior.
The details in the guidance for submitting a REMS to the FDA indicate why vetting these proposals as part of the application
review process takes so much time. Manufacturers thus have to decide whether it's better to propose a REMS voluntarily before
filing an NDA or BLA, or to wait and see if FDA reviewers determine that such a program is needed. No one wants to implement
a REMS if it's not necessary, but the FDA seems to be requiring REMS for most NMEs, and developing a REMS during the review
period will slow the approval process.
Whatever tack a company takes, it's important to get the details of a REMS right and to establish reasonable and practical
goals and timetables. Manufacturers face hefty fines for violating a REMS requirement (up to $10 million) and the possibility
of the FDA pulling the product off the market.