The New Drug Approval Requirement Daniel R. Dwyer Stacy L. Ehrlich Kleinfeld, Kaplan & Becker LLP June 14, 2004 1 What does FDA regulate? Drugs Devices Biologics Foods Dietary Supplements Cosmetics Combination Products 2 What is a Drug? Section 201(g)(1): Recognized in USP or other compendia Intended to diagnose, cure, mitigate, treat or prevent disease Intended to affect structure or function Intended as component of these Exceptions for foods and supplements 3 Intended Use 21 CFR 201.128 Objective intent of persons responsible for labeling of product Based on, e.g.: • Labeling claims • Advertising/promotion • Oral or written statements • Circumstances surrounding distribution • Consumer expectations/use? 4 What is a Device? Section 201(h) Instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or component • Recognized in USP or other compendia • Intended for use in diagnosis of disease or other conditions • Intended for use in the cure, mitigation, treatment, or prevention of disease • Intended to affect structure or function 5 Drug vs Device Device definition excludes: Products that achieve their primary intended purpose through chemical action within or on the body Products that are dependent upon being metabolized for the achievement of their primary intended purpose 6 Drug or Device? Sunscreen? Microbubble ultrasound contrast agents? Injectable lubricants? Contact lens solution? 7 What is a Biologic? Section 351 of PHS Act, 21 CFR 600.3(h) Virus, therapeutic serum, toxin, antitoxin, vaccine, blood, blood component or derivative, allergenic Or any analogous product Applicable to the prevention, treatment or cure of disease or condition 8 Drug vs Biologic Definitions not mutually exclusive Large molecules vs small molecules Hormones, e.g., insulin and human growth hormone, regulated as drugs Intercenter agreements between CDER, CBER and CDRH Transfer of review responsibilities for most therapeutic biologics from CBER to CDER (except vaccines, blood products and gene and tissue/cellular product therapies) 9 Combination Products Section 503(g), 21 CFR Part 3 (RFD) MDUFMA required establishment of Office of Combination Products “Primary mode of action” = “the single mode of action of a combination product that provides the most important therapeutic action of the combination product” (May 7, 2004 proposed rule) Assignment algorithm: PMOA, consistency, safety and effectiveness expertise 10 What is a Food? Section 201(f) = used for food or drink, chewing gum, components Structure/function claims based on “nutritive value” Prior authorization for diseaserelated health claims 11 What is a Dietary Supplement? DSHEA, Section 201(ff) Product (other than tobacco) intended to supplement the diet that contains vitamin, mineral, herb/botanical, amino acid, dietary substance, or concentrate, metabolite, constituent or extract 12 What is a Dietary Supplement? Prior authorization for diseaserelated health claims Cannot be represented as a conventional food Cannot contain ingredient approved or authorized for investigation as new drug prior to marketing as food or supplement Can make structure/function claims 13 Drug vs Dietary Supplement Reduces inflammation Improves absentmindedness Maintains cholesterol levels already in the normal range CarpalHealth Supports the body’s ability to resist infection Helps maintain intestinal flora For relief of occasional constipation Dietary support during the cold and flu season 14 Drug vs Dietary Supplement Pharmanex case Street drug alternatives OTC drug-supplement •Combination (Melagesic PM) •Dual use (Tums) 15 What is a Cosmetic? Section 201(i) Rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the body For cleansing, beautifying, promoting attractiveness, or altering appearance Except soap 16 Cosmetic vs Drug Wrinkle and anti-aging products • • • • Face lift without surgery Reduce deep wrinkles Stimulates collagen production Helps skin cells renew and repair themselves Cosmetic-drugs (make-up with SPF claims, antiperspirant/deodorant) Presence of drug ingredient, e.g., fluoride Concentration of ingredient, e.g., AHAs 17 New Drug Section 201(p): All drugs “new drugs” except drugs that are: • GRAS/E = Generally recognized, among experts qualified by scientific training and experience to evaluate the safety and effectiveness of drugs, as safe and effective for use under the conditions prescribed, recommended, or suggested in the labeling and • Have been used for a material time and to a material extent 18 GRAS/E Must be supported by same quantity and quality of scientific evidence required to obtain new drug approval Adequate and well-controlled studies Published scientific literature Construed very narrowly by the courts 19 “Old” Drugs FDA has taken the position that it is very unlikely that any currently marketed product is an “old” drug (Draft CPG on Marketed Unapproved Drugs Oct. 2003) Enforcement Priorities (Draft CPG) • • • • Drugs with potential safety risks Drugs that lack evidence of effectiveness Health fraud drugs Newly approved drugs (e.g., guaifenesin) 20 Grandfathered Drugs Marketed prior to 6/25/38 and no change in formulation, dosage, strength, manufacture, indications, etc. Prior to 10/10/62, • • • • Used or sold commercially in US Not a new drug as defined at that time Not covered by an effective application AND Composition and labeling have not changed Construed narrowly by courts FDA believes that few if any drugs on market are entitled to grandfather status 21 DESI Review Drug Efficacy Study Implementation National Academy of Sciences-National Research Council (NAS-NRC) • Category I (GRAS/E and not misbranded) • Category II (not GRAS/E) • Category III (insufficient data) If Category I, approved NDA or ANDA still required Still ongoing 22 Who Decides? No mechanism for administrative determination of new drug status prior to marketing • Old “not new drug” letters revoked (21 CFR 310.100) • Up to manufacturer to decide whether to market as “old” drug • Penalties if FDA determines it is a new drug marketed without FDA approval Manufacturer’s burden to prove grandfather status (21 CFR 314.200(e)(5)) 23 Legal Standard for New Drug Approval Adequate tests of safety under the conditions prescribed, recommended or suggested in labeling Substantial evidence of effectiveness under the conditions prescribed, recommended or suggested in labeling Manufacturing, processing and packing is inadequate to assure identity, strength, quality and purity -- Section 505(d) 24 Adequate Tests of Safety Policy: • Determine the benefit • Determine the risk • Weigh the benefit against the risk Take into consideration: • Dosage • Intended use • Patient population 25 Adequate Tests of Safety Procedure: • Pharmacology studies • Toxicology studies Acute Subacute Chronic Carcinogenicity Reproductive toxicity ADME • Human pharmacokinetics and bioavailability • Clinical data and adverse events 26 Adequate Tests of Safety Current issues: • How to make risky drugs available: Patient education Dispensing though physicians Evaluating adverse event reports • Pediatric use Opening up access to therapies, while adequately assuring safety • Children in clinical trials These new issues result in constant revision of the old standard requiring “adequate tests” 27 Substantial Evidence of Effectiveness “’Substantial evidence’ means evidence consisting of adequate and well-controlled investigations, including clinical investigations, by experts qualified by scientific training and experience to evaluate the effectiveness of the drug involved, on the basis of which it could fairly and responsibly be concluded by such experts that the drug will have the effect it purports or is represented to have under the conditions of use prescribed, recommended or suggested in the labeling … thereof.” “If [FDA] determines, based on relevant science, that data from one adequate and well-controlled clinical investigation and confirmatory evidence (obtained prior to or after such investigation) are sufficient to establish effectiveness, [FDA] may consider such data and evidence to constitute substantial evidence for purposes of the preceding sentence. -- Section 505(d). 28 Substantial Evidence of Effectiveness Adequate and well-controlled studies: • • • • • • Clear protocol Control (e.g., placebo, alternative treatment) Careful selection of subjects Procedures to minimize bias (e.g., blinding) Reliable means of assessing effectiveness Statistical analysis -- 21 CFR 314.50, 314.126 29 Substantial Evidence of Effectiveness Adequate and well-controlled studies: • Standardized product (identity, strength, quality, purity, dosage form • Must be conducted in conformance with: IRB regulations Informed consent regulations Or, for foreign studies, the Declaration of Helsinki or more rigorous local requirements -- 21 CFR 314.50, 314.126 30 Substantial Evidence of Effectiveness Key: Judgment of experts Senate Report on 1962 Amendments: • When a drug has been adequately tested by qualified experts, a claim should be permitted, even if there is preponderant evidence to the contrary • A claim may be made to the medical profession with a proper explanation of the basis on which it rests 31 Substantial Evidence of Effectiveness “Relative Efficacy” – FDA may not disapprove a drug on the ground that a more effective option is available Often use “intent-to-treat” analysis: • All randomized patients • Limited exclusions may be permissible (“modified intent-to-treat”) • Defined in advance, based on indication 32 Substantial Evidence of Effectiveness Drugs for serious or life-threatening illnesses FDA must grant “fast track” approval of drug if • Intended for treatment of serious or life-threatening illness, and • Drug demonstrates potential to address unmet needs FDA may grant approval based on – • Surrogate endpoint I.e., an endpoint other than survival or irreversible morbidity that is reasonably likely to predict clinical benefit Subject to requirement for postmarketing study • Restrictions, e.g. – Specially trained physicians Performance of specified medical procedures • Includes special procedures for prompt withdrawal 33 -- Section 506 and 21 CFR 314.500 et seq. Substantial Evidence of Effectiveness Drugs for use in treating serious or lifethreatening conditions caused by exposure to biological, chemical, radiological or nuclear substances may be approved based on animal studies if human exposure would be unethical Requires: • Postmarketing studies • Approval with restrictions • Information provided to patients Includes special procedures for prompt withdrawal -- 21 CFR 314.600 et seq. 34 Types of Applications Full NDA, or 505(b)(1) NDA • Data required: Chemistry, manufacturing, and controls (CMC) data Nonclinical pharmacology and toxicology Human pharmacokinetics and bioavailability Clinical data Statistical analysis Pediatric data Labeling Case report forms and tabulations • May be eligible for exclusivity, and must provide patent information • Approval not delayed by patent or exclusivity rights of other drugs 35 Types of Applications 505(b)(2) NDA, or “Paper NDA” • Same as full NDA except – The NDA is based on “investigations … relied on by the applicant for approval of the application [that] were not conducted by or for the applicant and for which the applicant has not obtained a right of reference or use” Applicant can rely on: • Published literature • FDA’s prior safety and effectiveness determination 36 Types of Applications 505(b)(2) NDA, or “Paper NDA” -- continued • Same as full NDA except – Often used for changes to an approved drug that are not eligible for approval under an ANDA, e.g.: • • • • Dosage form Strength Route of administration Change of active ingredient • May be eligible for exclusivity, and must provide patent information • Approval may be delayed by patent or exclusivity rights of reference listed drug 37 Types of Applications • Abbreviated New Drug Application (ANDA), or 505(j) application Only for “generic” drugs, i.e., exact or close copies of already approved drugs • Identical in active ingredients, dosage form, strength, route of administration, conditions of use (some changes in inactive ingredients are permitted) • Petition may be submitted for changes in route of administration, dosage form, and strength, or substitution of an active ingredient in a combination product 38 Types of Applications • ANDA – continued Data required • Basis for ANDA (conditions of use, active ingredients, route of administration) • CMC data • Bioequivalence data • Labeling May be eligible for generic exclusivity Approval may be delayed by patent or exclusivity rights of reference listed drug 39 Biologics and Antibiotics • Biologics Virus, therapeutic serum, toxin, antitoxin, or analogous product Regulated under §351 of the Public Health Service Act and 21 CFR Part 600 et seq. Biologics License Application (BLA) instead of NDA CDER: most therapeutic biologics, with certain exceptions (e.g., cell and gene therapy products and therapeutic vaccines) CBER: blood and blood products, vaccines, cell/gene therapy, certain human tissue for transplantation, and certain devices for use with blood products • Antibiotics: regulated as drugs 40