Intense public scrutiny of drug safety issues is prompting the Food and Drug Administration to take a closer look at its program for establishing Risk Evaluation and Mitigation Strategies (REMS). The most restrictive REMS programs with Elements to Assure Safe Use (ETASU) are intended to apply only to those very high-risk products that cannot come to market without special safety controls. Health care providers, as well as manufacturers, feel that the program is being overused, raising costs and interfering with patient treatment.
The highly-publicized review of the risks associated with GlaxoSmithKline's diabetes treatment Avandia (rosoglitazone) led advisory committee members to recommend keeping the drug on the market, provided that FDA impose strict controls on prescribing through a highly restrictive REMS. Recent scrutiny of new anti-obesity therapies indicates that sponsors of these drugs will need to present fairly extensive REMS plans to get on the market; advisory committee members opposed approval of Vivus's Qnexa at a July advisory meeting largely because its slim REMS outline for a voluntary program to prevent pregnancy was considered inadequate.And the ongoing debate over devising a classwide REMS for long-acting opioids reflects the difficulties in imposing added safeguards on high-risk therapies that are in high demand by patients. Despite more than a year of collaborative efforts by manufacturers and multiple consultations with stakeholders, in July the members of two advisory committees voted overwhelmingly (25 to 10) to reject FDA's proposed classwide REMS plan, which relies on a voluntary educational program for prescribers to curb illegal use of these drugs. The practitioners and academics on the panels said that FDA's plan is too weak and unlikely to really do much to stop unsafe use of these potentially dangerous products; they proposed that sponsors institute mandatory training for prescribers that are linked to assessment of competencies and licensure.
While sponsors are willing to implement these costly and sometimes cumbersome programs to meet FDA postmarketing safety requirements, doctors, pharmacists, and other health care providers are alarmed by the proliferation of new requirements for drug prescribing and dispensing. Health providers regard much of the new educational and patient registration programs as a significant burden on their operations and on the health care system. Payers similarly are concerned about added costs, while consumers are caught between their desire for access to treatment and the need to avoid adverse events.
In addition to advisory committee discussions of REMS for proposed new drugs, these issues were debated at a two-day FDA public meeting in July on the REMS program. Janet Woodcock, director of FDA's Center for Drug Evaluation and Research (CDER), acknowledged that the REMS program established by the FDA Amendments Act of 2007 (FDAAA) "is not perfect" and that FDA is looking for input from all stakeholders on "how we might remodel our house." FDA also published a draft guidance in October 2009 on what information sponsors should include in REMS proposals and is reviewing comments on that document.
Everyone at the meeting acknowledged the importance of REMS in assuring safe drug use. They also highlighted the unintended consequences of added postmarketing requirements at both ends of the REMS spectrum: too many diverse Medication Guides, as well as a growing number of highly-restricted REMS with ETASU. So far, FDA has approved more than 120 REMS, including 15 with ETASU, a number that Woodcock acknowledged has led to a proliferation of restrictions and requirements.
Pharmacists, physicians, and health care leaders outlined a host of burdens and costs imposed by multiple REMS and the paperwork involved in documenting compliance. Physicians complained of redundant and unnecessary educational and training programs and policies that don't make sense. Oncologists have been particularly vocal in opposing added educational requirements, noting that they are well trained to use chemotherapies that can be highly toxic. Pharmacists described how training, tracking compliance, and patient counseling takes time and interferes with pharmacy operations.
Providers similarly complained of too many different MedGuides for patients to review. Woodcock acknowledged that paper MedGuides are not the optimal way to provide patients with information and that FDA hopes to develop an improved patient information leaflet. Manufacturers proposed separating MedGuides from the REMS program, as it was prior to enactment of FDAAA in 2007. Then, MedGuides were considered part of labeling, and manufacturers did not have to establish program goals and develop timetables for assessment. However, pulling MedGuides out of REMS requires Congressional action, as would an FDA effort to establish a single document for describing drug risks and benefits; such proposals could be part of the PDUFA package.
Probably the most objectionable REMS feature for pharmacists and providers is the limited distribution systems for high-risk drugs that permit prescribing by only certain well-informed specialists, and dispensing by designated specialty pharmacies that can verify appropriate use and patient understanding of the risks. Retail pharmacists complain that such systems steer patients away from regular pharmacies, while hospitals and health plans cite added costs and difficulties in obtaining therapies from restricted sources.