Category Archives: Regulatory

28Aug/06

What’s More Sterile: the Band-Aid on Your Paper cut or Cardioplegia?

By Daniel R. Matlis

It’s a trick question. Technically both should be sterile. 

But you would think that cardioplegia, the solution used to stop the heart during bypass surgery, would be more stringently tested since it is infused directly into the heart.

According to a recent USA Today article, at least 11 cardiac surgery patients were stricken with an infection during a 10-month period from the end of December 2004 to September 2005, and three of them died at Mary Washington Hospital.  After a thorough investigation, tests confirmed the presence of several types of bacteria in the cardioplegia solution injected into patients’ hearts during surgery. 

I can already hear the cry from the trial lawyers: “Which Pharmaceutical Do We Go After? 

The answer? None, the reason is that the products leaving the Pharmaceutical companies were perfectly safe and sterile, but some drugs, including high-risk sterile preparations, are made in pharmacies under less-restrictive rules than those that drug companies follow.  Almost all hospital pharmacies do some type of drug making, called compounding. Pharmacist duties may range from low-risk procedures, such as grinding tablets to put them into liquid suspension, to high-risk work, such as making sterile treatments from scratch. 

I’m in favor of compounding, and cannot thank Andrew, my local pharmacist, enough for compounding prescriptions when my kids need them. Try to get a 3 year old to swallow an adult size tablet. It goes much smoother when it is ground and suspended in strawberry flavored syrup.

But there is a big difference between grinding tablets and preparing a sterile solution to be injected into the heart.  This is not an issue of qualifications, but one of oversight and facilities. Hospital pharmacies are regulated by each state, and the frequency and thoroughness of state inspections vary widely. The FDA’s role in oversight is hampered by questions of jurisdiction over what’s generally state matter. To make matters worse, in most states hospitals are not required to test the sterility or potency of products made in their own pharmacies or purchased from outside pharmacies.  So while a drug company could not sell saline solution without testing sterility, hospital pharmacies and their suppliers are not required to test for it. 

I am not a big proponent of government regulations, but this is a case of public safety and the proverbial “what’s good for the goose is good for the gander” theory of enforcement.  Having 50 different state statues regulating sterility and potency requirements for drugs is impractical, when the FDA has the mandate, know-how and capabilities to regulate them.  If hospital pharmacies and suppliers want to continue manufacturing sterile solutions, they ought to be held to the same standards as the Sesame Street Band-Aid I put on my kid’s “boo-boo”. 

02Aug/06

Can I make your pacemaker software run faster?

I recently read an article on the Free Software Foundation’s Website entitled “Regulatory compliance is no reason to lock up users” The author states that “Medical devices are (theoretically) programmed to a high standard of safety, and careless modification could cause great harm. Medical device manufacturers want to Tivo-ize their devices so that only they can upgrade the software on them. They claim that this is necessary for compliance with FDA regulations.”

The FDA gives manufacturers the freedom to choose what software to use in medical devices. But with this freedom comes responsibly. The Agency does not require or favor the use of commercial over free software in medical devices.  However, the Quality System Regulation (21CFR§820) does require that Medical Devices automated with computer software be subject to design controls.

FDA’s Guidance on Software Validation states that “where the software is developed by someone other than the device manufacturer (e.g., off-the-shelf software) …the party with regulatory responsibility (i.e., the device manufacturer) needs to assess the adequacy of the off-the-shelf software developer’s activities and determine what additional efforts are needed to establish that the software is validated for the device manufacturer’s intended use.”

The difficulty with Free Software is that it falls into software quality limbo.  After all there is no vendor to audit, or documented evidence that a quality system exists and was followed in the design and testing of the Free Software.

I know that auditing Off the Shelf Software vendors can be hard enough (I tried to audit Microsoft once), but in general you can perform an audit of your software provider to assess the quality systems they have established and to ensure that they are following their quality system. Whom do you audit for your open source code?

Nevertheless, this does not purge the use of Free Software in devices. It does put the burden for proving and documenting that the software meets the intended squarely on the shoulders of the Device Manufacturer. The level of diligence required for Free Software is not unlike that of Custom Software. The cost of the Open source Software (free) may offset the cost of this additional compliance burden, but that is a business decision each manufacturer must make.

Free Software has a place in our industry. You want to run your HTTP server on Apache, go ahead (after you have assessed the impact on you compliance program), but I would not recommend using open source software in Medical Devices.

Device Software is one area where reliability and safety should always come before speed.

After all making a pacemaker run faster is not always a good thing.

13Jul/06

Doctors Don’t Treat Populations, They Treat Individual Patients

This week, Scott Gottlieb, MD Deputy Commissioner for Medical and Scientific Affairs at the Food and Drug Administration made an interesting speech before the 2006 Conference on Adaptive Trial Design in Washington, DC.Dr Gotlieb commented how today’s clinical trials are highly empirical. Drugs are tested on general populations for a response and a treatment effect that is statistically not likely to be a chance result. This approach is rigorous and focused, but inflexible. According to Dr. Gotlieb, “another problem with the empirical approach is that it yields statistical information about how large populations with the same or similar conditions are likely to respond to a treatment. But doctors don’t treat populations, they treat individual patients. Doctors need information about the characteristics that predict which patients are more likely to respond well, or suffer certain side effect. The empirical approach doesn’t tell doctors how to personalize their care to their individual patients.” This results in a highly empirical approach to the practice of medicine. Gone are the days of: Take two off these and call me in the morning. Gottlieb comments “Doctors prescribe treatments knowing full well that only a certain percentage of their patients will receive a benefit from any given medicine.” This approach is akin to: Take all of these and call me if you have a side-effect. 

But with the demands for personalized medicine and the advent of Pharmaco-genomics, there are potentially better alternatives. By enabling more trials to be adapted based on knowledge about gene and protein markers or patient characteristics, we can help predict whether patients will respond well to a new medicine. “These new approaches to clinical trials can result in trial designs that tell us more about safety and benefits of drugs, in potentially shorter time frames, exposing fewer people to experimental treatments, and resulting in clinical trials that may not only be more efficient but are more attractive to patients and their physicians to enroll in.” said Gottlieb. This is only a first step in the process to develop more adaptive clinical trials. This process will lead to more targeted therapies and in turn, Ii is my hope, more personal and personalized medicine.

23Jun/06

What’s your FDA Site Selection Score?

By Daniel R. Matlis

According to the Food, Drug, and Cosmetic Act, FDA statutorily required to inspect domestic drug manufacturing establishments at least once every 2 years.

There is just one problem,  the number or  registered human drug establishments has increased in the last 25 years while the number of FDA human drug inspections has decreased over the same period.   To address this issue, the FDA has implemented the “Risk-Based Method for Prioritizing CGMP Inspections of Pharmaceutical Manufacturing Sites”. This model, commonly known as the Site Selection Model, utilizes a risk-based inspection approach for prioritizing drug manufacturing establishments for routine cGMP inspection. The model is based on a risk-ranking and filtering method that is well-recognized, objective, and rigorously systematic. Currently there are 3 empirical factors used to calculate a site’s selection score. 

They are:

  1. Product Risk: Factors such as sterility, medical gas, and the determination of prescription (Rx) versus over the counter (OTC) currently in the model are crude surrogates to distinguish between products with higher and lower potential for public health consequence should there be a drug defect.
  2. Process Risk: Some processes are more complex and more susceptible to problems than other processes. The key issues in the implementation of the risk-ranking model involves questions concerning the relevant inherent process risk factors, the relevant process control and risk mitigation factors, and how to weigh/rank them
  3. Facility Risk: Currently, the facility component of the risk ranking model includes 4 factors:
    • History of violation (e.g., CGMP deficiencies have higher weights)
    • History of inspection (e.g., no prior inspection, newly registered/licensed or no CGMP inspection in the past 2 years have higher weights than those with recent CGMP inspection)
    • Estimated volume of production output (surrogate for exposure, e.g., higher volume and production output, higher weights)
    • Type of establishment (e.g., manufacturer, repacker, contract lab)
       

According to Joseph Famulare, acting Director of CDER’s office of compliance, in addition to these three empirical factors, “expert elicitation with emphasis on current FDA priorities is used to determine site selection”. “For example, last year trans-dermal patches were a priority at the agency” said Famulare, so the number of inspection in that area increased.

Famulare said “just under 50% of the cGMP inspections last year were based on the Site Selection Model, with the remainder done at the districts discretion.”

Next year, a new category will be factored in the empirical portion of the calculation. Recall data has already been entered in the database and will be used for Site Selection Model.

You heard about your credit score, it’s time to keep and eye on your Site Selection Score.

22Jun/06

Efficiency, Effectiveness and FDA All In The Same Sentence?

By Daniel R. Matlis

In the past few years, CDER has made significant changes to advance and facilitate the review of electronic regulatory submissions. These include spearheading projects to standardize information management processes, publish regulations and guidance documents to support electronic submissions, and facilitate the development of information management project proposals, which will benefit the consumer and the pharmaceutical industry.

As evidence of the positive impact of these changes, over 3000 e-CTDs have been submitted to the FDA since the it began accepting them 2 1/2 years ago.

Many of these improvements are the work of the Office of Business Process Support (OBPS) at CDER.   “Through the use of the Project Development Staff and other resources within OBPS we started to develop more specialized experience so that over time we are able to turn around this projects more quickly and with higher quality” said Gary M. Gensinger Director of Regulatory Review Support Staff, OBPS at CDER. He continued “that’s what it’s all about.”

Another key area addressed by OBPS is standards. “It’s not about doing the same thing for the sake of doing the same thing, but trying to find out what’s the best practice” said Gensinger. To my surprise and delight he went on to say ”it’s about finding what is the most efficient and most effective way to move forward, so that what limited resources we do have, we can spend that in the review process”.

The FDA is making a concerted effort to harmonize internally as well as externally to focus as many resources as possible on the “Receive, Review, Report” process.

With all this talk about doing more with limited resources, and looking for the most efficient and effective ways get things done, can regulatory outsourcing offshore be the next step?

 I certainly hope not. Regulatory Oversight is not a function we want to outsource.