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process of devising, proposing and negotiating a REMS with the FDA is complex and time-consuming, as revealed in the draft guidance on REMS content and format for drugs and biologics, issued Sept. 30 (available at http://www.fda.gov/).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.