Guinea Pig Nation?

by

Here is an irresistible news headline: “Public Policy That Makes Test Subjects of Us All.”(New York Times, April 6, 2009). Then you open to the story only to discover, to your disappointment, that the piece is written by John Tierney, probably the most uninformed and underqualified members of the NYTimes staff.


His argument is ridiculous: that the New York City mayor’s initiative to “pressure” the food industry to cut salt amounts to a big experiment that would normally have to undergo IRB review and informed consent (never mind that the initiative is not an experiment designed to further knowledge.  Never mind that the initiative is not aimed at generalizable knowledge, or that public health initiatives grounded in a state-based interest that are enacted by elected leaders have the “consent of the governed”).

But in the most recent issue of JAMA, a news story (Bridget M. Kuehn, “Rare Neurological Condition Linked to Newer Monoclonal Antibody Biologics,” April 8, 2009) reminds us that, in some small sense, licensure of novel biologics makes guinea pigs of us all.  The report describes how FDA recently issued an advisory on the psoriasis drug efalizumab after reports emerged that it may be associated with a risk of developing a rare and fatal brainwasting disease (progressive multifocal leukoencephalopathy, or PML).  FDA had previously issued warnings on two similar, immunomodulating drugs, and established a restricted distribution system for a third (natalizumab– for multiple sclerosis).

In the case of natalizumab, cases of PML occurred in pre-marketing clinical trials.  For the other drugs, knowledge of the risk emerged only after drug licensing.  Risk of PML was totally unexpected, and is a reminder of the high degree of uncertainty surrounding interventions directed at the immune system.  

Premarketing clinical trials are statistically powered only to detect common, “signature” adverse events.  As we move into an era of biologics-based pharmaceuticals (and accelerated approval), expect that many adverse events will only be discovered once a drug is in widespread use.  Robust systems of pharmacovigilence will be especially critical (photo credit: Peter Guthrie, 2006).

BibTeX

@Manual{stream2009-106,
    title = {Guinea Pig Nation?},
    journal = {STREAM research},
    author = {Jonathan Kimmelman},
    address = {Montreal, Canada},
    date = 2009,
    month = apr,
    day = 8,
    url = {http://www.translationalethics.com/2009/04/08/guinea-pig-nation/}
}

MLA

Jonathan Kimmelman. "Guinea Pig Nation?" Web blog post. STREAM research. 08 Apr 2009. Web. 16 Jan 2021. <http://www.translationalethics.com/2009/04/08/guinea-pig-nation/>

APA

Jonathan Kimmelman. (2009, Apr 08). Guinea Pig Nation? [Web log post]. Retrieved from http://www.translationalethics.com/2009/04/08/guinea-pig-nation/


The Future of Pharmaceutical Regulation

by

The October 2008 issue of Nature Reviews–Drug Discovery contains a very informative perspective piece on how drug regulators negotiate uncertainty, risk, and benefit when making approval decisions (“Balancing early market access to new drugs with the need for benefit/risk data: a mounting dilemma”). I have long argued that novel biologics like gene transfer will require creative approaches from regulators, because on the one hand many types of adverse events might be latent and unpredictable, while on the other hand, many novel biologics will target highly morbid or lethal conditions like primary immunodeficiencies.


The authors (Hans-Georg Eichler et al) are all employees of drug regulatory agencies in Europe. Not surprisingly, then, the article is balanced and presents drug agencies as making appropriate trade-offs between patient access and public safety. The article studiously avoids any criticism of pharmaceutical companies. And it makes some questionable claims. For example, in several passages it suggests that drug regulation is increasingly “risk averse” (it seems to me the opposite, but who knows?). Another is that the article contains ample evidence that premature approval has had important costs in terms of health and economics. Nowhere does it provide clear evidence or anecdotes that delay of approval, or restrictive evidentiary standards have had important public health or economic impacts (it might, but if you are going to suggest that the balance is appropriately struck, one needs a clear picture of the benefit side of the equation).

The article contains a number of observations and policy approaches that cry out for careful ethical analysis. Here are two:

1- Drug regulatory agencies accept greater uncertainty about safety and efficacy when new drugs address serious, unmet health needs. Thus, new cancer drugs can be approved on a weaker evidentiary base than new acid reflux drugs (in several instances, new drugs were approved on the basis of uncontrolled, surrogate endpoints (e.g. gefitinib). Why should evidentiary standards be relaxed in this way? And to what degree? If the disease is serious enough and standard care non-existent, then what is the basis for any drug regulation?

2- The article states that “rare drug reactions will continue to be identified only after wider use in the market,” and that more sophisticated approaches to drug safety will increasingly “blur the line between pre-marketing and post-marketing activities.” How will this affect ethics review and oversight? How will privacy protections be maintained in this gulf-stream of flowing health data? How will trial registries absorb and respond to post-marketing studies?

This article contains multitudes– I highly recommend it to anyone interested, as I am, in the problem of uncertainty, risk, and drug regulation (photo credit: Alincolnt, schedule 5, 2006)

BibTeX

@Manual{stream2008-127,
    title = {The Future of Pharmaceutical Regulation},
    journal = {STREAM research},
    author = {Jonathan Kimmelman},
    address = {Montreal, Canada},
    date = 2008,
    month = oct,
    day = 28,
    url = {http://www.translationalethics.com/2008/10/28/the-future-of-pharmaceutical-regulation/}
}

MLA

Jonathan Kimmelman. "The Future of Pharmaceutical Regulation" Web blog post. STREAM research. 28 Oct 2008. Web. 16 Jan 2021. <http://www.translationalethics.com/2008/10/28/the-future-of-pharmaceutical-regulation/>

APA

Jonathan Kimmelman. (2008, Oct 28). The Future of Pharmaceutical Regulation [Web log post]. Retrieved from http://www.translationalethics.com/2008/10/28/the-future-of-pharmaceutical-regulation/


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