National Health Policy Conference February 6, 2006 Applications of Drug Safety Information – One...
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Transcript of National Health Policy Conference February 6, 2006 Applications of Drug Safety Information – One...
National Health Policy Conference
February 6, 2006
Applications of Drug Safety Information – One Industry Perspective
Tim Franson, MDVice President Global Regulatory Affairs
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
2
Applications of Drug Safety Information – One Industry Perspective
• Framing / introduction– “If it wasn’t for time, everything would happen all at once”
Stephen Hawking or Yogi Berra?
– Safety (or, more appropriately benefit-risk) evolves over time
– Beginning with the end in mind: Patients first Fair, balanced comprehensive (re) assessments Benefit-risk perspectives (neither in isolation)
Future progress depends on Collaboration,
Communication, Common standards clarified, and
Commitment – “4-C Progress”
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
3
Applications of Benefit/Risk Information
• Objectives– Definitions and common assumptions– Moving from “As is” to “Should be”
• Where are “we” today?– Provincial approaches (industry, regulations, academia)– Perceptual flaws
• Industry: current “risk management” practices– Pre NDA– At approval– Post approval – Summary industry overview issues
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
4
Applications of Benefit/Risk Information (cont’d.)
• Where “we” must change – and why
• Conclusions and Ways forward– Glasnost and Perestroika ?
– 4-C’ing progress
– Patients and public health first (the key “what“) and balanced benefit-risk assessments (the key “HOW”)
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
5
Definitions and Common Assumptions
The importance of defining words and their context:
• Applications – “layers”• Safety• Risk• Benefit• Benefit-risk• Risk Management
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
6
Safety – a feeling of being secure, certainty
Safety is the condition of being protected against failure, damage, error, accidents, or harm. Protection involves here both causing and exposure. Safety is often in relation to some guarantee of a standard of insurance to the quality and unharmful function of a thing or organization.
From Wikipedia, the free encyclopedia.
Is totally safe feasible?
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
7
Risk – the possibility that something will go wrong
Risk is the potential harm that may arise from some present process or from some future event. In everyday usage, “risk” is often used synonymously with “probability”, but in professional risk assessments, risk combines the probability of a negative event occurring with how harmful that event would be.
From Wikipedia, the free encyclopedia.
Is zero risk a practical goal?
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
8
Benefit – an advantage, help or aid
• Services or value provided by a program.
• Employee benefits: non-monetary employment compensation.
• Benefit, an album by Jethro Tull.
From Wikipedia, the free encyclopedia.
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
9
Risk-Benefit Analysis
Risk-benefit analysis is the comparison of the risk of a situation to its related benefits.
For research that involves more than minimal risk of harm to the subjects, the investigator must assure that the amount of benefit clearly outweighs the amount of risk. Only if there is favorable risk benefit ratio, a study may be considered ethical.
The Declaration of Helsinki states biomedical research cannot be done legitimately unless the importance of the objective is in proportion to the risk to the subject. The Helsinki Declaration [1] and the CONSORT statement [2] stress a favorable risk benefit ratio.
From Wikipedia, the free encyclopedia.
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
10
Risk Management
Generally, Risk Management is the process of measuring, or assessing risk and then developing strategies to manage the risk. In general, the strategies employed include transferring the risk to another party, avoiding the risk, reducing the negative effect of the risk, and accepting some or all of the consequences of a particular risk.
From Wikipedia, the free encyclopedia.
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
11
Emerging Elements and New Requirements of Risk Management Plans
• Label restrictions
• Toxicology studies
• Restricted drug distribution
• Patient registries
• Educational initiatives
• Restrictions to DTC advertising and/or product promotion
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
12
Moving from “As Is” to “Should Be”
Assessing enablers vs. impediments• People “stakeholders”• Processes• Desired outcomes • Conflicts of (dis) interest
Specificity of “fixes” – systemic vs. focused• Approval• Post-approval
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
13
Where are “we” (Healthcare Enterprise) Today? (As-is Issues)• Approaches pre-approval: more coordinated, NOT public health issue per se
• Provincial approaches (post approval)– Industry RMP
Routine safety surveillance – massive Response to regulator queries (disparity of criteria from FDA vs. MHRA
vs. CHMP, etc. for near-identical issues: results appear “gamed”)
– Agency RMP Labeling Drug Watch – (observations without proposed actions) Other enforcement
– Academia “Publish or Perish”
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
14
As-is Issues (cont’d.)
Perceptual flaws – amplifies concerns for “out of control” systems
The Bill Buckner Syndrome– Every safety finding highlighted – in isolation
– Plenty of “blame and shame” to go around – but NOT representative (and often NOT accurate)
Industry – transparency, AD suicidality in children, Vioxx, etc.
Agency – PDUFA tainted, Vioxx, whistleblowers, etc. Academia – cloning fraud, Lancet-NSAID fabrication,
Hopkins hexamethonium death, IRB “closures” etc. Confounders: counterfeit drugs, nutraceuticals, etc.
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
15
As-is Issues (cont’d.)
All real plus most “spun” – None acceptable
None the mainstream – NOT representative
No audit process across the enterprise• Industry (by regulators – in depth/detail)• Agency (by OIG-periodically)• Academia (highly variable – absent)
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
16
As-is Issues (cont’d.)
Aggregate impact of provincial approaches and perceptual flaws
• Public confusion and erosion of trust
– Stakeholder “mud-wrestling”
• Exceptions viewed as representative
• Health care enterprise appears alarmingly fragmented and out of control – and in need of policy fixes
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
17
Industry – Current Risk Management Practices
• Pre-NDA– 100% data from sponsor
• At approval– Translating volumes of data onto label
• Post approval – Big “R” – little “b”
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
18
Current Practices – Overview & Issues
pre NDA
NDA review
Label
Post-approval Commitments
Label changes
Drug Watch
Benefit
Periodic
By indication (ISE)
Claims
Some
Rare
Brief
Risk
Ongoing (DMB)
Comprehensive (ISS)
Contr/Warn/Prec/AE
Detailed RMPs
Often/detailed
Detailed
Benefit-Risk
Periodic
ISBR Approval Pkg.
NOT routinely
? implied -
NONE
NONE
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
19
Where “we” Must Change – and WhyPolicy initiatives in circulation
– Independent safety office – contrary to benefit-risk integrative view (as usually occurs in practice environment)
– More intensive risk communication – sustains R > b imbalances
Policy options– Glasnost – Perestroika
What are the policy standards (floor vs. ceiling) and set-points for comparisons (ala currency exchange rates, for B/R)?
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
20
Conclusions and Ways Forward
4-C Progress
Collaboration
Communication
Common standards clarified
Commitment
National Health Policy Conference February 6, 2006
Company ConfidentialCopyright © 2000 Eli Lilly and Company
21
• Benefit-risk• Confidence/integrity
Accentuate the positives (collaborate ! )
Eliminate the negatives (clarify standards) and…
Don’t break the rules (compliance ! ) rather revise them: Shaping common standards for patient benefit without impeding innovation/access/care practice (PDUFA-4, Pilots, etc.) via…
Proactive Ways Forward…