Thursday 20 March 2014

ICH(International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use)

ICH topics are divided in to 4 major types:

1. "Quality" Topics, i.e., those relating to chemical and pharmaceutical Quality Assurance (Stability Testing, Impurity Testing, etc.)

 2."Safety" Topics, i.e., those relating to in vitro and in vivo pre-clinical studies (Carcinogenicity Testing, Genotoxicity Testing, etc.)

3."Efficacy" Topics, i.e., those relating to clinical studies in human subject (Dose Response Studies, Good Clinical Practices, etc.)

4."Multidisciplinary" Topics, i.e., cross-cutting Topics which do not fit uniquely into one of the above categories (MedDRA, ESTRI, M3, CTD, M5)

 Source:
https://www.ich.org/cache/html/250-272-1.html
ICH - Multidisciplinary Topics
 
Multidisciplinary topics are categorized in to five types:

ICH M1: MedDRA(Medical Dictionary)

ICH M2: ESTRI(Electronic Standards for the Transfer of Regulatory Information)

ICH M3:  Nonclinical Safety Studies for the Conduct of Human Clinical Trials and Marketing Authorisation for Pharmaceuticals

ICH M4: CTD(Common Technical Document)

ICH M5: Data Elements and Standards for Drug Dictionaries

Source:http://www.ich.org/UrlGrpServer.jser?@_ID=2196&@_FORCETEMPLATE=272

Saturday 8 March 2014

MedDRA(Medical Dictionary for Regulatory Activities)
 
MedDRA or Medical Dictionary for Regulatory Activities is a clinically validated international medical terminology used by regulatory authorities and the regulated biopharmaceutical industry throughout the entire regulatory process, from pre-marketing to post-marketing activities, and for data entry, retrieval, evaluation, and presentation. In addition, it is the adverse event classification dictionary endorsed by the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). MedDRA is used in the US, European Union, and Japan. Its use is currently mandated in US, Europe and Japan for safety reporting.

MedDRA was developed by the International Conference on Harmonisation (ICH) and is owned by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) acting as trustee for the ICH steering committee.

MedDRA is managed by the MSSO (Maintenance and Support Services Organization).

Reference: ICH Guidelines
Differences between IND Annual Report and Annual Safety Report
 
IND Annual Report :

Purpose- progress report
Timing- IND anniversary date
Frequency- annual
Recipients- FDA
Content- study data and summary information
Feedback by may be requested regulators: may be requested
Short term end of study report safety report within trials end of study report safety report within trials for all trials within 90 days 1 year of end
Adverse events included: all serious ± associated± expected
Format and Summary: Content, Tabular summary of most frequent and most serious AEs by body system. Summary of all IND expedited reports for the period. Lists of deaths (w/ cause) and dropouts. List of completed non-clinical studies and result summary.

Annual Safety Report:

Purpose-benefit-risk assessment
Timing- Date of 1st authorization of a clinical trial of IMP by authority in member state
Frequency-annual, or on request
Recipients- EMEA, Member States, Ethics Committees
Content- benefit-risk assessment;
Content- supporting tables
Feedback by may be requested regulators:not mentioned
Short term end of study report safety report within trials: safety report within trials for all trials within 90 days
Adverse events included SUSARs; serious,associated; ± expected
Format and Summary Content: Concise global analysis; benefit-risk evaluation; implications for trial subjects; proposed measures to minimize risk; rationale for updates of study documents and procedures; supporting results of non-clinical studies; other considerations.

Thursday 6 March 2014

Product Monograph

Product Monograph should have the information which can communicate with the sections described below:

Health Professional Information: This particular area  covers essential prescribing information, including dosage and strength, indications and clinical uses, warnings and precautions, adverse reactions and drug interactions.

Scientific Information:The Scientific Information section contains more detailed scientific information including toxicology and data from animal studies, clinical trials, pharmaceutical information and pharmacology.

Patient Information: Such a section may or may not be included. It is informative about how to use the medicine safely and most effectively.

Contents of a product monograph:

1. Pharmacology of the drug
2. Clinical Trials
3. Indications and Clinical Uses
4. Contraindications
5. Warnings and Precautions
6. Adverse Reactions
7. Toxicology and Drug Interactions
8. Dosage and Administration
9. Special Handling Instructions
10. Glossary

Source: http://www.chillibreeze.com/articles/Product-Monograph.asp
Product Monograph Sample: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/monograph/pmappe_mpanne-eng.php
http://www.janssen-ortho.com/JOI/pdf_files/Elmiron_E.pdf

Guidance on the Preparation of PSURs (Periodic Safety Update Reports)

A PSUR should include the following:
1. Details of the MA holder and product (to include names and MA number), and the period covered by the PSUR.
2. An update on any regulatory or MA holder actions taken for safety reasons, if applicable, since the last PSUR.
3. The latest version of the Summary of Product Characteristics (SPC) for the MA concerned.
4. The number of doses or the amount of the product sold in the UK within the period of the report. The sales volume should be expressed per presentation in an appropriate form, e.g. liquid in litres, powder in kilograms, etc. (see Volume 9 guideline above). For PSURs covering more than one year, sales volume should be broken down by calendar year or part year.
5. An estimation of the number of animals treated in the UK within the period of the report. It should be explained how the number of animals treated is derived from the volume sold. For products authorised for use in more than one species, the approximate percentage use per species should be included.
6. The incidence of suspected adverse reactions (SAR) during the period of the PSUR expressed as a percentage. The incidence (%) of adverse reactions (reports assigned a causality of A, B, O or O1) should be calculated by dividing the total number of animals reacting during the period by an estimate of the number of animals treated during the period of the report and multiplying by 100. Adverse reactions (A, B, O and O1) that occur after recommended and off-label use in the
target species should be included in the calculation.
7. For products authorised for use in more than one species, if more than 50% of the adverse reactions are reported in one of the target species, a separate incidence for that species.
8. The incidence of suspected lack of expected efficacy (SLEE) for the period of the PSUR (see 6 above), if there have been any such reports.
9. Individual case histories should be presented as line listings in an appendix to the PSUR,.
For PSURs submitted electronically, the line listings should be provided separately in a format suitable for sorting and analysis, e.g. Excel, to assist assessment of the PSUR.
For PSURs submitted as paper copies, it is helpful if the line listings are first sorted by country.
In addition, adverse reactions considered to have involved the off-label use of a product should be clearly indicated in the column headed ‘Was product used as recommended?’ An explanation as to why the use was off-label should be provided, either in the same column or in the column for the MA holder’s conclusions .
Competent Authority (CA) reference numbers, where they are known by the company. This includes CA references that were sent with acknowledgements of company reports, as well as where the original reports
were received by the CA and copied to the company.
10. A narrative review of individual or group case histories in the overall summary, if more information or explanation is appropriate. For example, discussion of a lack of expected efficacy problem.
11. Reports from other sources, if appropriate. For example, post-authorisation studies or published adverse reaction reports.
12.A literature review for the period covered by the PSUR based on the product.
13. An overall analysis of the data and a critical evaluation of the benefit-risk balance of the product, written by the Qualified Person for Pharmacovigilance (QPPV). This section should include the following:
  •   Evidence of previously unidentified toxicity.
  •   Increased frequency of known toxicity or expected undesirable effects,e.g. incidence greater than 1 in  10,000 animals treated.
  •   Drug interactions.
  •   Adverse reactions associated with off-label use including overdose.
  •   Urgent safety issues that occurred during the period.
13.Any important information received after the data lock point, e.g. a serious adverse reaction which could have an impact on the overall safety evaluation.

Single Case Processing- Pharmacovigilance

The various sources from where we may get information :
a) Spontaneous reports
b) Clinical trial reports, including SAE case narrative writing
c) Special reports (legal, literature)

Following established guidelines, source documents sent to Drug Safety Unit are entered (MedDRA coding) on to a Drug Safety/Pharmacovigilance database, after a duplicate search, on behalf of those clients. This may involve an initial triage and a subsequent medical review/assessment of the report by physicians.

a) Spontaneous reports :These can be serious or non-serious event reports from the following sources, originating after a product has been marketed by the Marketing Authorization Holder (MAH):

Government agencies, Industry, Hospitals, Academia, Medical and Pharmaceutical Associations, Poisons and Medicines Information Centers, Health Professionals, Patients,Consumers,Media

b) Clinical trial reports :These are adverse event reports originating from clinical trials involving investigational products. Only serious events and non-serious events of special interest are reportable to the health authorities. Such events may be considered related or unrelated to the investigational product by the investigator/client.

c) Special reports :
i)Legal reports : These are case reports originating from filed lawsuits. These cases are forwarded to Drug safety typically by the MAH's legal department and contain a list of damages (events that are the subject of the legal action). The source documents includes plaintiff fact sheets, medical records, e-mail communications, jury trial demand notifications, deficiency letters and summons etc.
ii)Literature reports : These are all case reports where an adverse event associated with a marketed or investigational product has been generated from a systematic search of commercial scientific databases of published peer-reviewed journal articles. In these, only a generic name of the marketed or investigational product may have been reported, and quite often the manufacturer cannot be determined.

Source: ICH Guidelines

How to Monitor new medicines and vaccines- MHRA

New chemicals and vaccines are effectively put on probation for up to two years and labelled with a black triangle to ensure prescribers are aware of the need to monitor them carefully. The black triangle symbol accompanies new medicines and vaccines in prescribing manuals, product information, and advertising material. It prompts healthcare professionals to report any potential side effects to the MHRA. This information helps to build up a broader picture of how the treatment works in the general population and enables the MHRA to act promptly, should a previously unrecognised and serious side effect come to light. 
The black triangle may also be assigned to a medicine that has already been licensed if it contains a new combination of active chemicals or if it is being used in a new way or for a different condition. The black triangle is not removed until the MHRA is satisfied that the medicine works safely in large numbers of people. Additionally, the MHRA also asks manufacturers to keep a close watch on side effects that may be associated with newly marketed products.
Source: MHRA Guidelines

Wednesday 5 March 2014

Investigator’s Brochure

The investigator’s brochure is a “compilation of the clinical and nonclinical data on the investigational product(s) that is relevant to the study of the investigational product(s) in human subjects.” (ICH E6).

In general, the investigator’s brochure provides more complete background information on the investigational product than is provided in the protocol. The investigator’s brochure assists the investigator in interpreting and implementing the study protocol, and may be of particular importance in helping the investigator determine whether specific adverse events are unanticipated, and accordingly, when and how such events should be reported to the sponsor, IEC/ IRB, and regulators.

Source: ICH E6

Company Core Data Sheet(CCDS)

A document prepared by the marketing authorization holder containing, in addition to safety information, material relating to indications, dosing, pharmacology and other information concerning the product.

The CCDS is required to judge whether an adverse event or adverse drug reaction is labeled / listed or unlabelled / unlisted and is therefore always included in a periodic safety update report (PSUR).

In many countries involved in the international conference on harmonization (ICH) as members or observers, this kind of document is similar to the labelling approved as part of the marketing authorisation, although there are often differences because of differences in the scope of the document, principles for inclusion, indications and / or recommended dosage of the drug, experience drawn from pre-registration studies and from the market, local habits for concomitant drugs and local or ethnic sensitivity. The classification ‘labeled’ or ‘unlabelled’ has many more consequences for expedited reporting than for periodic reporting. The CCDS must be dated, including the date of last revision (or all revision dates).
 
CCDS are usually prepared by an applicant for a drug substance (active ingredient) rather than a drug product because post-marketing PSUR’s and IPSR’s would be based on a drug substance.

Source:  EU Guidelines

Terminologies: Vigimed,Vigiflow,Vigibase and Vigisearch.

Vigibase: The name for the WHO International ADR Database

Vigiflow: is a sophisticated case report management system created by the UMC, complying with GxP requirements.

Vigisearch : is a custom search offered by the UMC to third –party inquirers for which several types of standard presentation are available.

Vigimed: E-mail conferencing facility, exclusive to member countries of the WHO Programme for International Drug Monitoring.

Source: www.who-umc.org/graphics/15338.pdf

Sources of ICSR: Unsolicited Sources

Unsolicited Sources:

Spontaneous Reports: A spontaneous report is an unsolicited communication by healthcare professionals or consumers to a company, regulatory authority or other organization (e.g. WHO, Regional Centers, Poison Control Center) that describes one or more adverse drug reactions in a patient who was given one or more medicinal products and that does not derive from a study or any organized data collection scheme. Stimulated reporting may occur in certain situations, such as a notification by a "Dear Healthcare Professional" letter, a publication in the press, or questioning of healthcare professionals by company representatives. These reports should be considered spontaneous.

Consumer reports:Consumer adverse reaction reports should be handled as spontaneous reports irrespective of any subsequent "medical confirmation", a process required by some authorities for reportability. Even if reports received from consumers do not qualify for regulatory reporting, the cases should be retained. Emphasis should be placed on the quality of the report and not on its source.

Literature:The Marketing Authorisation Holder (MAH) is expected to regularly screen the worldwide scientific literature, by accessing widely used systematic literature reviews or reference databases. Cases of ADRs from the scientific and medical literature, including relevant published abstracts from meetings and draft manuscripts, might qualify for expedited reporting. A regulatory reporting form with relevant medical information should be provided for each identifiable patient. The publication reference(s) should be given as the report source; additionally a copy of the article might be requested by the local regulatory authority to accompany the report. All company offices are encouraged to be aware of publications in their local journals and to bring them to the attention of the company safety department as appropriate. The regulatory reporting time clock starts once it is determined that the case meets minimum criteria for reportability. MAHs should search the literature according to local regulation or at least once a month. If the product source, brand, or trade name is not specified, the MAH should assume that it was its product, although reports should indicate that the specific brand was not identified.

Internet:MAHs are not expected to screen external websites for ADR information. However, if an MAH becomes aware of an adverse reaction on a website that it does not manage, the MAH should review the adverse reaction and determine whether it should be reported. Unsolicited cases from the Internet should be handled as spontaneous reports. MAHs should regularly screen their websites for potential ADR case reports. MAHs and regulators should consider utilising their websites to facilitate ADR data collection, e.g. by providing ADR forms for direct reporting or by providing appropriate contact details for direct communication. For the determination of reportability the same criteria should be applied as for cases provided via other ways.

Other Sources:If MAHs become aware of a case report from non-medical sources, it should be handled as a spontaneous report.

Source: ICH Guidelines 

Difference between Protocol Deviation and Protocol Violation

Protocol Deviation- A protocol deviation is any change, divergence, or departure from the study design or procedures of a research protocol that is under the investigator’s control and that has not been approved by the IRB. Upon discovery, the Principal Investigator is responsible for reporting protocol deviations to the IRB using the standard reporting form.

Protocol Violation- A protocol violation is a deviation from the IRB approved protocol that may affect the subject's rights, safety, or well being and/or the completeness, accuracy and reliability of the study data.

If the deviation meets any of the following criteria, it is considered a protocol violation.

I. The deviation has harmed or posed a significant or substantive risk of harm to the research subject.
Examples:
• A research subject received the wrong treatment or incorrect dose.
• A research subject met withdrawal criteria during the study but was not withdrawn.
• A research subject received an excluded concomitant medication.

II. The deviation compromises the scientific integrity of the data collected for the study.
Examples:
• A research subject was enrolled but does not meet the protocol's eligibility criteria.
• Failure to treat research subjects per protocol procedures that specifically relate to primary efficacy outcomes. (if it involves patient safety it meets the first category above)

III. The deviation is a willful or knowing breach of human subject protection regulations, policies, or procedures on the part of the investigator(s).
Examples:
• Failure to obtain informed consent prior to initiation of study-related procedures

IV. The deviation involves a serious or continuing noncompliance with federal, state, local or institutional human subject protection regulations, policies, or procedures.
Examples:
• Working under an expired professional license or certification

V. The deviation is inconsistent with the NIH Human Research Protection Program’s research, medical, and ethical principles.
Examples:
• A breach of confidentiality.

Source: http://www.genome.gov/Pages/Research/Intramural/IRB/Deviation_Violation_examples8-07.pdf

Differences between PSUR and PADER

Preapproval reports include IND Annual Reports in the U.S. and Annual Safety Reports (ASRs) in Europe. Some of these documents may provide cumulative information, while others contain aggregate information specific to the reporting period. Postapproval cumulative reports of safety include NDA Periodic Adverse Drug Experiences Reports (PADERs) in the U.S. and Periodic Safety Update Reports (PSURs) in many other countries, including in Europe. Their purpose is to update and evaluate the worldwide safety experience with a medicine at defined time points after approval.

These reports provide succinct summary information together with an evaluation of the benefit-risk
profile of approved medicines in the light of new or changing postapproval information.This evaluation is designed to help ascertain whether further investigations need to be carried out and whether changes should be made to the approval and/or to the medicine’s labeling.

In summary, the aim of cumulative reports of safety is to:
• Report all the relevant new information from appropriate sources.
• Relate these data to patient exposure to the medicine.
•  Summarize the medicine’s approval status in different countries and any significant variations  related to safety.
• Create periodically the opportunity for an overall reevaluation of safety.
• Indicate whether changes should be made to an approved medicine’s label in order to optimize the use of the product.

Source: FDA and EU Guidelines
Understand the SAE process
 
When an SAE report is sent by an investigator, health worker, or employee (clinical research associate or pharm center), it is immediately assigned a number and reviewed to determine whether the event is a reportable SAE. If it is reportable, the company needs to send the SAE to FDA by one of the following methods.
• Form 3500A only (can be filed manually or electronically via the AERS system)
• A narrative report
• VAERS form (vaccines only)
• CIOMS I form (foreign reports only).

A company’s culture and experience dictate the way it meets these reporting requirements. Whatever the method it uses, a company must keep an audit trail, either manual or electronic, that shows:

• the initial receipt date of the SAE
• all changes made to the original SAE by any personnel.
• all supporting documentation requested and sent in from the site.
• any internal or external correspondence.
• any internal notes, such as medical review.
• all attempts to get additional information regarding the event.
• whether the event is open or closed.

We need to code the SAEs in such a way that they become categorical in nature, such as assigning a code for the event and a MedDRA term

Source: FDA Guidelines

Pharmacovigilance software

The EMEA or the European Medicines Agency in Europe develops and maintains the pharmacovigilance database of probable serious adverse effect medicines in the market. This system is called EudraVigilance.
Similarly, the US medical society has its own pharmacovigilance branches namely; the FDA; the academic and non-profit organizations like RADAR and Public Citizen and the pharmaceutical manufacturers. Several companies like Aris Global, Relsys and Workflow have developed pharmacovigilance software to keep track of safety applications in the market.

Kinds of pharmacovigilance software:
PV Works for example is a pharmacovigilance software system that records report safety data keeping track of adverse event reporting. It is a commercial workflow engine providing management control of pharmacovigilance processes. Flexible data entry, risk management, safety system assessment, evaluation and submission of regulatory reports are some of its important features.
PV Works (Vet) is another software system made to support veterinary pharmacovigilance business and technical processes meeting the necessary safety standards. Data entry, reporting, audit trail are some of its main features.

The outsourced pharmacovigilance software develops drug development expertise, safety rules and regulatory necessities, securing client access to data and regular tracking and status updates to clients or to the authority. It is an economical project development process making using of the electronic medium for handling management purposes.

The Assured pharmacovigilance software provides Internet access to the server for the client’s use and operation of the system for management and customer use. This software meets the standards of pharmaceutical companies, regulatory authorities and medical personnel.
How effective is pharmacovigilance software?
  • Pharmacovigilance software minimizes the risk of adverse events (ADR) by using genetic profiles.
  • It makes accurate determinations as to whether a product is safe or not.
  • It determines the benefit-risk ratio quickly
  • It overcomes the challenges that small firms face as far as limited financial and personnel resources are concerned.
  • Pharmacovigilance software helps maintain regulatory compliance and improve operational efficiency.
  • Global information can be easily shared by means of this software.
  • In the age of safety concerns, more need is being felt for software that can avert probable risks and also help in worldwide networking in the medical field. Pharmacovigilance software is designed just for this.

Source: FDA and EMEA Guidelines

Common Terminology Criteria for Adverse Events (CTCAE)

The NCI’s Common Terminology Criteria for Adverse Events (CTCAE; http://ctep.cancer.gov/reporting/ctc.html) is a longstanding empirically developed “dictionary” or lexicon, designed for use in clinical trials to aid clinicians in detecting and documenting an array of adverse events (AEs) commonly encountered in oncology.

An AE is a term that is a unique representation of a specific event used for medical documentation and scientific analyses. Each AE is graded on a scale of 1 (mild) to 5 (death related to AE).

There is growing awareness that collecting symptom data directly from patients using patient-reported outcome (PRO) tools can improve the accuracy and efficiency of symptomatic AE data collection.

The NCI’s Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) system provides a web-based platform to collect patient reports of symptoms they are experiencing while undergoing treatment for the purpose of enhancing adverse event (AE) reporting http://outcomes.cancer.gov/tools/pro-ctcae.html). To date, 81 symptoms of the CTCAE (version 4) have been identified to be amenable to patient reporting. These symptoms have been converted to patient terms (e.g., CTCAE term “myalgia” converted to “aching muscles”).


Source: http://outcomes.cancer.gov/tools/pro-ctcae_fact_sheet.pdf