Comparison of Duration of Postapproval vs Pivotal Trials for Therapeutic Agents Granted US Food and Drug Administration Accelerated Approval, 2009-2018

This cross-sectional study compares the duration of postapproval trials with that of the pivotal trials used as the basis for the US Food and Drug Administration’s (FDA’s) approval for all indications receiving accelerated approval from 2009-2018.

Long-term safety of secukinumab in patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis: integrated pooled clinical trial and post-marketing surveillance data

BACKGROUND

Secukinumab, a fully human immunoglobulin G1-kappa monoclonal antibody that directly inhibits interleukin (IL)-17A, has been shown to have robust efficacy in the treatment of moderate-to-severe psoriasis (PsO), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) demonstrating a rapid onset of action and sustained long-term clinical responses with a consistently favorable safety profile in multiple Phase 2 and 3 trials. Here, we report longer-term pooled safety and tolerability data for secukinumab across three indications (up to 5 years of treatment in PsO and PsA; up to 4 years in AS).

METHODS

The integrated clinical trial safety dataset included data pooled from 21 randomized controlled clinical trials of secukinumab 300 or 150 or 75 mg in PsO (14 Phase 3 trials and 1 Phase 4 trial), PsA (3 Phase 3 trials), and AS (3 Phase 3 trials), along with post-marketing safety surveillance data with a cut-off date of June 25, 2017. Adverse events (AEs) were reported as exposure-adjusted incident rates (EAIRs) per 100 patient-years. Analyses included all patients who received ≥ 1 dose of secukinumab.

RESULTS

A total of 5181, 1380, and 794 patients from PsO, PsA, and AS clinical trials representing secukinumab exposures of 10,416.9, 3866.9, and 1943.1 patient-years, respectively, and post-marketing data from patients with a cumulative exposure to secukinumab of ~ 96,054 patient-years were included in the analysis. The most frequent AE was upper respiratory tract infection. EAIRs across PsO, PsA, and AS indications were generally low for serious infections (1.4, 1.9, and 1.2, respectively), Candida infections (2.2, 1.5, and 0.7, respectively), inflammatory bowel disease (0.01, 0.05, and 0.1, respectively), and major adverse cardiac events (0.3, 0.4, and 0.6, respectively). No cases of tuberculosis reactivation were reported. The incidence of treatment-emergent anti-drug antibodies was low with secukinumab across all studies, with no discernible loss of efficacy, unexpected alterations in pharmacokinetics, or association with immunogenicity-related AEs.

CONCLUSIONS

Secukinumab demonstrated a favorable safety profile over long-term treatment in patients with PsO, PsA, and AS. This comprehensive assessment demonstrated that the safety profile of secukinumab was consistent with previous reports in patients with PsO, PsA, and AS, supporting its long-term use in these chronic conditions.

Postmarketing studies for novel drugs approved by both the FDA and EMA between 2005 and 2010: a cross-sectional study

OBJECTIVES

To characterise postmarketing studies for drugs that were newly approved by the US Food and Drug Administration and the European Medicines Agency.

DESIGN AND SETTING

Cross-sectional analysis of postmarketing studies registered in ClinicalTrials.gov until September 2014 for all novel drugs approved by both regulators between 2005 and 2010. Regulatory documents from both agencies were used.

PRIMARY AND SECONDARY OUTCOME MEASURES

All identified postmarketing studies were classified according to planned enrolment, funding, status and geographical location, and we determined whether studies studied the originally approved indication.

RESULTS

Overall, 69 novel drugs approved between 2005 and 2010 were eligible for inclusion. A total of 6679 relevant postmarketing studies were identified; 5972 were interventional (89.4%). The median number of studies per drug was 55 (IQR 33-119) and median number of patients to be enrolled per study was 60 (IQR 28-183). Industry was the primary sponsor of 2713 studies (40.6%) and was a primary or secondary sponsor in 4176 studies (62.5%). In all, 2901 studies (43.4%) were completed, 487 (7.3%) terminated, 1013 (15.2%) active yet not recruiting, 1895 (28.4%) recruiting and 319 (4.8%) not yet recruiting. A total of 80% of studies were conducted in only one country and 84.4% took place in Europe and/or North America; 2441 (36.5%) studied another indication than the originally approved indication. Studies designed in the originally approved indication were found to be more industry-sponsored than others 68.7%vs53.7%; P<0.0001.

CONCLUSIONS

Postmarketing pharmaceutical research was highly variable and predominantly located in North America and Europe. Postmarketing studies were frequently designed to study indications other than the originally approved one. Although some findings were reassuring, others question the lack of coordination of postmarketing research.

Postmarketing Safety Events Relating to New Drugs Approved in Brazil Between 2003 and 2013: A Retrospective Cohort Study

This study investigated postmarketing safety events (PMSEs) for new drugs approved in Brazil and evaluated whether a range of drug characteristics influenced the time between approval and the first PMSE. This retrospective study included new drugs registered between 2003 and 2013 by the National Health Surveillance Agency (ANVISA), which is responsible for medicines approval in Brazil. PMSEs were defined as any drug safety alert or drug withdrawal from the market. The existence of risk evaluation and mitigation strategies (REMS) by the US Food and Drug Administration (FDA) and Brazil were recorded. A Kaplan-Meier survival curve of the period between the date of ANVISA registration and the PMSE was calculated. We found a statistically significant difference between the time to PMSE for drugs with an FDA REMS compared with those without a REMS, with a log rank value (Mantel Cox) of 0.002. There was no association between the time to PMSE and the other drug characteristics investigated. This study demonstrated that the frequency of PMSEs for new drugs approved by ANVISA was statistically associated with the existence of an FDA REMS. The time between approval and first PMSE was shorter for drugs with an FDA REMS, and this finding may contribute to improved awareness of the risk/benefit balance required to ensure continued safe and effective use of new drugs.

The data extraction and longitudinal trend analysis network study of distributed automated postmarket cardiovascular device safety surveillance

BACKGROUND

Current approaches for postmarket medical device safety surveillance are limited in their ability to produce timely and accurate assessments of adverse event rates.

METHODS AND RESULTS

The Data Extraction and Longitudinal Trend Analysis (DELTA) network study was a multicenter prospective observational study designed to evaluate the safety of devices used during percutaneous coronary interventions. All adult patients undergoing percutaneous coronary intervention from January 2008 to December 2012 at 5 participating Massachusetts sites were included. A safety alert was triggered if the cumulative observed adverse event rates for the study device exceeded the upper 95% confidence interval of the event rates of propensity-matched control cohort. Prespecified sensitivity analyses were developed to validate any identified safety signal. A total of 23,805 consecutive percutaneous coronary intervention procedures were evaluated. Two of 24 safety analyses triggered safety alerts. Patients receiving Perclose vascular closure device experienced an increased risk of minor vascular complications (relative risk, 4.14; P<0.01) and any vascular complication (relative risk, 2.06; P=0.01) when compared with propensity-matched patients receiving alternative vascular closure device, a result primarily driven by relatively high event rates at 1 participating center. Sensitivity analyses based on alternative risk adjustment methods confirmed a pattern of increased rate of complications at 1 of the 5 participating sites in their use of Perclose vascular closure device.

CONCLUSIONS

The DELTA network study demonstrates that distributed automated prospective safety surveillance has the potential of providing near real-time assessment of safety risks of newly approved medical devices.

Post-Marketing Safety Monitoring of a New Group B Meningococcal Vaccine in New Zealand, 2004-2006

New Zealand introduced a new outer membrane vesicle vaccine in 2004 to combat an epidemic of group B meningococcal disease. An Independent Safety Monitoring Board oversaw intensive safety monitoring, which included hospital surveillance, health professional reporting (passive and active) and mortality monitoring. With over three million doses administered to individuals aged under 20 years, the monitoring results provide consistent evidence supporting the vaccine's safety.

An investigation into drug products withdrawn from the EU market between 2002 and 2011 for safety reasons and the evidence used to support the decision-making

OBJECTIVES

The objective of this study was to determine the nature of evidence used to support the withdrawal of marketing authorisations of drug products for safety reasons throughout the European Union (EU) between 2002 and 2011.

SETTING

Products withdrawn, either by a medicines agency or a marketing authorisation holder, during the period 2002-2011 were identified by conducting detailed searches of the WHO, the European Medicines Agency (EMA) and national medicines agency websites throughout the EU plus Norway, Iceland and Liechtenstein. The scientific evidence used to support the decision was identified from a search within PubMed, the EMA and national medicines agencies websites. Information about spontaneous case reports entered into EudraVigilance and unavailable on the EMA website was received by email from the EMA.

RESULTS

19 drugs were withdrawn from the market, throughout the EU, for safety reasons from 2002 to 2011. Case reports were cited in 95% of withdrawals (18/19) and case-control studies (4/19), cohort studies (4/19), randomised controlled trials (RCTs) (12/19) or meta-analysis (5/19) were cited in 63% of withdrawals (12/19). Cardiovascular events or disorders were the main reason for withdrawal (9/19), followed by hepatic disorders (4/19) and neurological or psychiatric disorders (4/19).

CONCLUSIONS

This study has shown that the level of evidence used to support drug withdrawal has improved during the past 10 years, with an increased use of case-control studies, cohort studies, RCTs and meta-analyses. This research has demonstrated that such studies have contributed to decision-making in almost two-thirds of cases.

A large, multicentre, observational, post-marketing surveillance study of the 2:1 formulation of follitropin alfa and lutropin alfa in routine clinical practice for assisted reproductive technology

BACKGROUND

Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) both have a role to play in follicular development during the natural menstrual cycle. LH supplementation during controlled ovarian stimulation (COS) for assisted reproductive technology (ART) is used for patients with hypogonadotropic hypogonadism. However, the use of exogenous LH in COS in normogonadotropic women undergoing ART is the subject of debate. The aim of this study was to investigate characteristics of infertile women who received the 2:1 formulation of follitropin alfa and lutropin alfa (indicated for stimulation of follicular development in women with severe LH and FSH deficiency) in German clinical practice.

METHODS

A 3-year, multicentre, open-label, observational/non-interventional, post-marketing surveillance study of women (21-45 years) undergoing ART. Primary endpoint: reason for prescribing the 2:1 formulation of follitropin alfa and lutropin alfa. Secondary variables included: COS duration/dose; oocytes retrieved; fertilization; clinical pregnancy; ovarian hyperstimulation syndrome (OHSS).

RESULTS

In total, 2220 cycles were assessed; at least one reason for prescribing the 2:1 formulation was given in 1834/2220 (82.6%) cycles. Most common reasons were: poor ovarian response (POR) (39.4%), low baseline LH (17.8%), and age (13.8%). COS: mean dose of the 2:1 formulation on first day, 183.1/91.5 IU; mean duration, 10.8 days. In 2173/2220 (97.9%) cycles, human chorionic gonadotrophin was administered. Oocyte pick-up (OPU) was attempted in 2108/2220 (95.0%) cycles; mean (standard deviation) 8.0 (5.4) oocytes retrieved/OPU cycle. Fertilization (≥1 oocyte fertilized) rates: in vitro fertilization (IVF), 391/439 (89.1%) cycles; intracytoplasmic sperm injection (ICSI)/IVF + ICSI, 1524/1613 (94.5%) cycles. Clinical pregnancy rate: all cycles, 25.9%; embryo transfer cycles, 31.3%. OHSS: hospitalization for OHSS, 8 (0.36%) cycles, Grade 2, 60 (2.7%), and Grade 3, 1 (0.05%).

CONCLUSIONS

In German routine clinical practice, the most common reasons for using the 2:1 formulation of follitropin alfa and lutropin alfa for women undergoing ART were POR, low baseline LH, and age. Severe OHSS incidence was low and similar to that reported previously.

Trends in diagnostic ultrasound acoustic output from data reported to the US Food and Drug Administration for device indications that include fetal applications

OBJECTIVES

A survey was conducted of acoustic output data received by the US Food and Drug Administration for diagnostic ultrasound devices whose indications for use include fetal applications to assess trends in maximum available acoustic output over time.

METHODS

Data were collected from 124 regulatory submissions received between 1984 and 2010. Data collection excluded transducers not indicated for diagnostic fetal imaging. The output parameters of ultrasonic power, mean center frequency, and bone thermal index (TIB) were extracted or computed from the submissions for 3 periods: 1984-1989, 1992-1997, and 2005-2010. The data were stratified according to the following imaging modes: M-mode, B/M-mode, pulsed wave Doppler, color flow Doppler, and continuous wave Doppler.

RESULTS

Ultrasonic power and maximum TIB values have increased roughly an order of magnitude from pre-1991 to post-1991 periods; the center frequency has decreased somewhat (4.2 to 3.4 MHz). The percentage of Doppler-mode transducers has increased substantially over time, with the majority of the diagnostic fetal imaging transducers currently designed to operate in Doppler modes; this increase is particularly important, since Doppler modes generate much higher TIB levels than B/M-modes. Color flow Doppler ultrasound currently operates at the highest mean ultrasonic power level (with a 14-fold increase over time).

CONCLUSIONS

The observed trends in increased acoustic output for both Doppler and non-Doppler modes underscore the widely recognized importance of adherence to the ALARA (as low as reasonably achievable) principle and prudent use in fetal ultrasound imaging.

An overview of Canadian and U.S. approaches to drug regulation and responses to postmarket adverse drug reactions

Over the years, drug products, including those indicated for diabetes, have been withdrawn from the marketplace because of quality concerns and/or severe adverse drug reactions. While the drug regulatory process is designed to detect, among other things, adverse drug reactions before a drug receives marketing authorization, for various reasons, premarket detection of all potential adverse reactions associated with a drug may not be possible. As such, regulatory authorities must also react to and manage adverse reactions identified at the postmarket stage. In this article, we provide a general overview of drug regulation in Canada and the United States and consider an example of a drug indicated for the treatment of diabetes and how newly identified potential safety concerns were managed in the postmarket environment.

FDA drug safety communications: a narrative review and clinical considerations for older adults

BACKGROUND

The US Food and Drug Administration (FDA) has new regulatory authorities intended to enhance drug safety monitoring in the postmarketing period. This has resulted in an increase in communication from the FDA in recent years about the safety profile of certain drugs. It is important to stay abreast of the current literature on drug risks to effectively communicate these risks to patients, other health care providers, and the general public.

OBJECTIVE

To summarize 4 new FDA drug safety communications by describing the evidence supporting the risks and the clinical implications for older adults.

METHODS

The FDA Web site was reviewed for new drug safety communications from May 2011 to April 2012 that would be relevant to older adults. Approved labeling for each drug or class was obtained from the manufacturer, and PubMed was searched for primary literature that supported the drug safety concern.

RESULTS

FDA drug safety communications for 4 drugs were chosen because of the potential clinical importance in older adults. A warning for citalopram was made because of potential problems with QT prolongation in patients taking less than 40 mg per day. The evidence suggests minor changes in QT interval. Given the flat dose-response curve in treating depression with citalopram, the new 20-mg/d maximum dose in older adults is sensible. Another warning was made for proton pump inhibitors (PPIs) and an increased risk of Clostridium difficile infection. A dose-response relationship was found for this drug risk. With C. difficile infections on the rise in older adults, along with other safety risks of PPI therapy, PPIs should only be used in older adults indicated for therapy for the shortest duration possible. In addition, a warning about dabigatran was made. There is strong evidence from a large clinical trial, as well as case reports, of increased bleeding risk in older adults taking dabigatran, especially in older adults with decreased renal function. This medication should be used with caution in older adults. Finally, several warnings were made about statins. Routine periodic monitoring of liver enzymes does not appear to be effective in detecting or preventing serious liver injury from statin use; thus, liver enzymes are no longer recommended to be routinely monitored. Statin-induced cognitive changes are rare, and insufficient evidence is currently available to establish causality. Statins appear to moderately increase the risk of developing diabetes (versus placebo), and regular screening for diabetes should be considered, especially for patients taking high-dose statins and patients with multiple risk factors for diabetes.

CONCLUSION

FDA drug safety communications incorporate complex methodologies that investigate the risks (and relative benefits) of medication therapy. Clinicians caring for older adults need to be aware of the most current evidence behind these drug risks to effectively communicate with and care for their patients.

The evolving process of European combination product review, Part II

A new European guideline on drug-eluting stents (DES) introduces for the first time detailed information that European drug authorities should review concerning the medicinal substance that is incorporated into this type of drug-device combination product. Part I of this article discussed European requirements that apply to DES. This article discusses the new guideline, other stent guidelines, and the evolving process of drug-device regulatory review in Europe.

Emerging Methods in Comparative Effectiveness and Safety

BACKGROUND

Interest in new methods for comparative effectiveness, drug and patient safety, and related studies is burgeoning. The advent of Medicare Part D for outpatient prescription drugs has drawn significant attention to the need for efficient ways to monitor the potential benefits and harms of pharmaceuticals. These trends prompted the Effective Health Care program at the Agency for Healthcare Research and Quality and its DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) network to examine innovative approaches for such investigations through an invitational symposium in June 2006.

RESULTS

Conference papers covered numerous points about ways to structure both interventional and database-oriented studies, particularly those concerned with adverse drug events, to avoid bias in those studies, and to apply advanced statistical tools to exploit the information from these studies to their fullest. Of particular importance are: (1) using new types of experimental designs, including cluster randomization, delayed designs, pragmatic trials, and practice-based investigations that incorporate the natural variation of data from routine clinical practice; (2) finding efficient ways to use different types of databases-eg, Department of Veterans Affairs files, Centers for Disease Control and Prevention surveillance files, Medicaid claims data, and state hospital data-for examining initiation, persistence, and adherence, and the benefits and adverse events of pharmaceutical use; and (3) inventing or refining ways to decrease the threats to validity of analyses relying on administrative or other observational data, particularly through propensity scoring, inverse probability weighting, risk adjustment, and direct or indirect methods for synthesizing comparative effectiveness information.

The challenge of biosimilars

BACKGROUND

The purpose of this report was to review issues associated with the introduction of alternative versions of biosimilars used in the oncology setting.

DESIGN

Data were obtained by searches of MEDLINE, PubMed, references from relevant English-language articles, and guidelines from the European Medicines Agency.

RESULTS

When biosimilars are approved in EU, they will be considered 'comparable' to the reference product, but this does not ensure therapeutic equivalence. Inherent differences between biosimilars may produce dissimilarities in clinical efficacy, safety, and immunogenicity. Switching biosimilars should be considered a change in clinical management. Regulatory guidelines have been established for some biosimilar categories but, because of the limited clinical experience with biosimilars at approval, pharmacovigilance programs will be important to establish clinical databases. Guidelines also provide a mechanism for the extrapolation of clinical indications (approved indications for which the biosimilar has not been studied). This may be of concern where differences in biological activity can result in adverse outcomes or when safety is paramount (e.g. stem cell mobilization in healthy donors). These issues should be addressed in biosimilar labeling.

CONCLUSIONS

Biosimilars should provide cost savings and greater accessibility to biopharmaceuticals. A thorough knowledge surrounding biosimilars will ensure the appropriate use of biopharmaceuticals.

Nurses are increasingly involved in pharmacovigilance in Sweden

INTRODUCTION

In Sweden, voluntary adverse drug reaction (ADR) reporting started over 40 years ago to detect rare, serious, unexpected adverse, mainly type B, reactions. During the period 1965-2004, 92,000 reports were assessed. Since certain nurses are licensed to prescribe a limited number of drugs, nurses also form part of the reporting team.

AIM

To analyse the ADR reporting by nurses in Sweden.

METHODS

All reports by nurses and other health-care personnel entered into the Swedish ADRs database SWEDIS (Swedish Drug Information System) were retrieved for the 10-year period 1995-2004 (Swedish population: 9 million). The intention was to analyse the nurses' reports from a quantitative and qualitative point of view.

RESULTS

The total number of ADR reports has gradually increased during the past 10 years from 3000 to over 4000 in 2004 (465 per million inhabitants), an increase by 28%. All ADR reports originate from health care personnel. The nurses' contribution to the ADR reporting increased from 2-3% in the mid-90s to 12% in 2004. The most common drugs involved in the nurses' reporting were various kinds of vaccines. Skin reactions dominated among the nurses' ADR reports. The ADRs reported by nurses were, as a consequence of many vaccine reports, compared to all reports, not so often classified as serious, but were on the other hand more often assessed with a causal relationship.

CONCLUSIONS

Nurses, in their position as drug administrators who record signs and symptoms of the patients, play an increasingly important role for detection of suspected ADRs and are now contributing to a significant amount of the ADR reporting in Sweden.

Novel statistical tools for monitoring the safety of marketed drugs

Robust tools for monitoring the safety of marketed therapeutic products are of paramount importance to public health. In recent years, innovative statistical approaches have been developed to screen large post-marketing safety databases for adverse events (AEs) that occur with disproportionate frequency. These methods, known variously as quantitative signal detection, disproportionality analysis, or safety data mining, facilitate the identification of new safety issues or possible harmful effects of a product. In this article, we describe the statistical concepts behind these methods, as well as their practical application to monitoring the safety of pharmaceutical products using spontaneous AE reports. We also provide examples of how these tools can be used to identify novel drug interactions and demographic risk factors for adverse drug reactions. Challenges, controversies, and frontiers for future research are discussed.

Post-marketing experience with an opioid nasal spray for migraine: lessons for the future

In 1992 a nasal spray formulation of butorphanol, an opioid medication intended for pain relief, was marketed in the USA on an unscheduled basis. Only a few years later, amid widespread reports of abuse and dependence, primarily in migraine patients, its manufacturer voluntarily requested the Food and Drug Administration to reschedule the drug as a Schedule IV narcotic. The events surrounding this episode are reviewed, and four problem areas that might have contributed are identified: (i) inadequate review of previous experience with other formulations of butorphanol; (ii) failure to consider the impact of disease state and drug formulation on the risk of adverse events; (iii) the limited scope of clinical trials prior to approval; and (iv) aggressive marketing efforts. The implications of these lessons for future drug development and post-marketing surveillance in the migraine field are considered.

Postmarketing surveillance of suicidal adverse events with pediatric use of antidepressants

OBJECTIVE

The aim of this analysis was to delineate trends in spontaneous postmarketing reporting data with antidepressant drugs for adverse events involving suicidal behaviors in children and adolescents.

METHODS

The U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) was searched for postmarketing adverse event reports of suicidal thoughts and behaviors occurring in children and adolescents treated with 10 antidepressant drugs. The search covered the period from market launch of each drug through November 2003.

RESULTS

A total of 524 reports were returned by the search. All drugs had reports, and most drugs demonstrated 15 or fewer reports annually, with the following two exceptions. We observed a peak of reporting for fluoxetine in the early 1990s, and another peak of reporting for paroxetine in recent years. Further investigation revealed that the peak in recent paroxetine reporting was accounted for by reports from consumers, whereas reporting by health professionals remained fairly constant. In contrast, the earlier peak in reports for fluoxetine was not accounted for by an increase in consumer reporting.

CONCLUSIONS

Spontaneous reporting data for suicidal events in pediatric patients treated with antidepressant drugs appears to be highly variable and subject to various influences. The most appropriate method to assess an association of antidepressant drug treatment with suicidal behaviors is examination of systematically collected data with appropriate comparison groups, such as randomized, controlled trial data.

Why drugs fail--a study on side effects in new chemical entities

Over 90% of the market withdrawals were caused by drug toxicity. Hepatotoxicity and cardiovascular toxicity proved to be the major causes for two out of three market withdrawals in the respective time period. In clinical phases I-III 43% of drug development project terminations were due to insufficient efficacy of the investigated compound. The second important issue, which caused one third of the projects to be closed, was toxicity. ADME parameters and economic and other reasons played a minor role. The results of our study indicate that compared with previous studies on this subject, no major improvements have been achieved in the last decade.

Medical device evaluation in the United Kingdom: past, present and future

The evaluation of medical devices in the UK has been through many changes since the early hospital equipment assessments in the 1960s. The range of medical devices evaluated has increased and the evaluation reports published have changed, but the evaluation programme continues to be a respected service for the NHS and social care. This review documents the history of the Device Evaluation Service, from its beginnings to the present day, and looks forward to its future. Following an independent strategic review and the Healthcare Industries Task Force (HITF) recommendations, the Device Evaluation Service is now entering a new and exciting developmental phase.

Drug fiasco highlights need for more openness

The recent advice to doctors from the Medicines and Healthcare products Regulatory Agency (MHRA) to stop prescribing a whole class of drugs (selective COX-2 inhibitors) has come as something of a shock to most people. For patients who have been taking these drugs – well over 1million people according to press reports – it has been a source of considerable concern.It will also have further shaken the public’s already weakened trust in the MHRA’s ability to protect them from big business (i.e. pharmaceutical companies).

European medical device regulation: a new era?

By the spring of 2005, the European Commission hopes to present the first draft of the revisions to the Medical Device Directive to the European Council and Parliament. However, these revisions represent only part of the changing European regulatory scenario. This article discusses a tangible shift in European medical device regulatory policy and some actions that companies can take to understand and prepare for these policies.

Psychotropic drug use in psychiatric inpatients: recent trends and changes over time-data from the AMSP study

A considerable number of new drugs were introduced over the last few years. In this report we analyze to what extent they have come to be used in clinical practice and what changes in drug use have resulted from the availability of the new compounds. For this purpose, data on drug use in 1995 and 2001 assessed at two reference days per year and per hospital within the drug safety program AMSP were compared for 10 hospitals that had been participating in both years. Atypical neuroleptics (NL) were used in 59.9 % of patients on NLs in 2001 (16.7 % in 1995), most frequently olanzapine, risperidone, clozapine, and quetiapine, in this order. Thirty-nine percent of patients still received typical NLs in antipsychotic indication (77.1 % in 1995), and 30.8 % received typical hypnosedative NLs (38.1 % in 1995). SSRIs, other new ADs, and TCAs were used in similar rates in 2001, i. e., in 40.5 %, 37.9 %, and 34.8 % of AD patients, respectively (1995 : 24.2 %, 6.2 %, and 72.3 %, respectively). Mirtazapine was the most common AD in 2001, followed by citalopram, sertraline, and doxepin. Hypnotics were prescribed more frequently in 2001 (17.6 % vs. 11.7 %), mostly BZD agonists at that time, whereas overall anxiolytic use (in approximately 30 %) hardly changed over time. Mood stabilizers and anti-dementia drugs were given comparatively rarely, even in pertinent diagnoses. Polypharmacy was observed in about three-quarters of patients on psychotropic drugs, with a trend towards increasing use over time. Combinations of two NLs, of NL + AD, and of NLs + anxiolytic were most common in both years. Twenty percent of patients on atypical NLs received typical antipsychotic NLs additionally; typical hypnosedative NLs were used along with typical antipsychotics and atypical NLs in 20 % and 22 % of patients, respectively. TCAs and either SSRIs or other new ADs were still the most common AD combinations in 2001. Data were also analyzed according to the main diagnostic categories.

Evidence-based medicine and drug-eluting stents

Successful implementation of evidence-based medicine in the development of high-risk medical devices requires a methodical scientific approach. However, even when research evidence is available from randomised controlled studies, it can be difficult to translate clinical evidence into regulatory and clinical decisions. Drug-eluting stents are used as an example to illustrate this principle.

The Weber-curve pitfall: effects of a forced introduction on reporting rates and reported adverse reaction profiles

BACKGROUND

In May 1999 Losec MUPS (MUPS) were granted a marketing authorization in the Netherlands, followed by the withdrawal of the Losec capsules (capsules) in September 1999. Both formulations contain omeprazole as active substance. This forced switch resulted in a large number of spontaneous reports of adverse drug reactions (ADRs) to the Netherlands Pharmacovigilance Centre Lareb.

METHODS

We calculated and compared the reporting rate of both formulations and grouped the reported adverse reactions into system and organ classes (SOCs) in order to analyse possible differences in the type of reported ADRs.

RESULTS

Lareb received 480 reports on omeprazole formulations between May 1997 and December 2000. A quarter of the reports concerned a decrease in therapeutic effect. The reporting rate on MUPS showed a sharp rise after withdrawal of the capsules, but did not differ significantly from the reporting rate on the capsules. A comparison of the type of reported ADRs showed differences in six SOCs. Elimination of the reports concerning a decreased therapeutic effect reduced the number of different SOC reporting rates. Certain gastrointestinal complaints were reported more frequently as an ADR of MUPS.

CONCLUSION

The forced switch caused an increase in reports resembling an early Weber effect rather than a decrease in safety of the newer formulation. However, our analysis cannot exclude differences in pharmacokinetic, pharmacodynamic or safety characteristics.