Latest Drugwonks' Blog
From Day Two of FDA’s Part 15 Hearing on communicating risk information.
Day 2 was more energized and useful than Opening Day. This is due in no small part to the panelists acting more like engaged health care advocates rather than website designers. Having a website does not replace having insight. To wit:
Alan Goldhammer (PhRMA) made the point, echoed by many other panelists over the course of the day, that FDA and industry can do a better job communicating risk information by working together rather than (a) covering the same ground separately (which eats up both precious time and spare resources), or (b) acting in an adversarial fashion (which causes messages to be either inappropriately magnified or dangerously ignored). Alan made the very excellent point that it’s very easy to frighten people — and that leads to dangerous unintended consequences.
John Wolleben (Pfizer) commented that risk communication must begin with the thought, “What do patients need to know?” He also verbalized the quandary that it’s hard to turn drugs “on and off” at the right times in the right ways. He suggested that the FDA’s goal should be to develop standardized tools for both agency and industry and suggested a working group to design and test such instruments.
Cherif Bennattia (APhaRC) said that the FDA should learn from the the pharma industry’s success in communicating benefit to better understand how to communicate risk. A good point. Dr. Nancy Ostrove (a member of the FDA panel on the second day) commented that FDA really couldn’t move forward with any industry learnings without supporting data. My comment — boy is that the pot calling the kettle black. Cherif also made the point that as the agency moves forward they need to define their goal — something like “what is the goal of successful risk communications.”
Joe Cranston (AMA) had the most specific recommendations of the day relative to helping docs receive and communicate risk information. His list included: finalize the new physician labeling rule; work more closely with specialist organizations on relevant risk communications issues; use post-market surveillance information for data mining opportunities; and increase funding for same. He also made the point that the big issue for MDs is TIME. How can the FDA help physicians prioritize and deliver relevant risk information to their patients? His other specific suggestions included: a CME initiative on risk communications; a standardized FDA website icon by specialties; more user-friendly “Dear Doctor” letters; electronic “Dear Doctor” letters; having pharma firms incent their sales force to “detail” risk information; and most interestingly — interfacing with (yet-to-come) e-prescribing technologies.
Joe is The Man.
Susan Winckler (APhA) suggested that the debate be about quality rather than quantity — that an increase in volume has resulted in the unintended consequence of pharmacists not being as alert to PIS and medguide issues.
Tom Lawlor (NACDS and Walgreen’s) pointed out that Walgreen’s research shows that volume of risk information reduces compliance among patients, docs, and pharmacists. He also very smartly noted that the debate shouldn’t be about “risk communications” but rather “risk management communications” — and that’s a lot more than just a finesse.
Focusing on prescription drug counterfeiting as international health care terrorism is often trivialized by pols and pundits as “just another scare tactic of Big Pharma.” That argument has never held up under the facts (stubborn things those facts) — and here’s a new truth that should further force those who deny the threat of counterfeits to reconsider their position — efforts to control the spread of bird flu in poultry in Southeast Asia are being hampered by the use of ineffective and often fake agricultural vaccines. This according to Robert Webster, a British virologist, animal flu specialist, and director of the World Health Organization’s Collaborating Centre for Studies on the Ecology of Influenza in Animals and Birds. As a result the threat of the virus evolving and being able to pass to humans, triggering a potentially catastrophic pandemic grows. It’s time to wake up and address prescription drug counterfeiting as what it is — international health care terrorism.
Literally. I’m blogging to you from deep beneath L’Enfant Plaza at Day One the FDA’s two-day Part 15 hearing on “Communication of Drug Safety Information.”
In announcing the meeting in the Federal Register, FDA posed six questions about how to better communicate drug safety information, but it really only boils down to one (posed by me, not the FDA): When the agency’s motive (a better informed consumer) is good, but it’s methods (or lack thereof) are bad — what should be done?
In typical government fashion, the answer is “seek comment.” Herewith some of what was presented today:
Ruth Day (Duke University) gave a very good presentation on why FDA’s communications on drug safety issues create (are you ready for a new term?) “Cognitive inaccessibility.” That means the information is disseminated in a way that is not only not understood by consumers but, worse, is misunderstood leading to unintended consequences. She reckons that only 20% of the information put out by FDA is properly comprehended. Her suggestion (among others) is that FDA initially focus on communicating better with health care providers (read “doctors and pharmacists”).
Michael Wolf (Northwestern University) gave a similar presentation. His take-away point was that 90 million adult Americans are functionally health-illiterate, meaning that 90 million adult Americans misunderstand FDA information and this leads to unintended consequences.
Diana Zuckerman (National Research Center for Women & Families) pointed out that FDA’s attempts to communicate safety information is neither clear nor clearly focused to specific user groups with the result being unintended consequences.
Ray Bullman (National Council on Patient Information and Education) spoke to the point that incomplete and emerging information can result in unintended consequences. He also called for the development of an FDA research agenda (with request for comments in the Federal Register) so that the agency can design a communications platform based on sound social science that would drive how they communicates drug safety with and to various constituencies.
When your motives are good and your methods are bad (causing cognitive inaccessibility and unintended consequences) what you should do (beyond “seeking comment”) is “first do no harm.”
It’s gonna take a lot more than just fixing how the FDA uses its website.
PS/I should also add that Sid Wolfe was one of the panelists, but he mumbled his way through his presentation and I wasn’t paying attention.
Bob Goldberg’s bark is as sharp as his bite as is illustrated below:
And the Award for Least Curious Journalist Goes To …
Take your pick when it comes to inconsistency on following the so-called conflict of interest issue as it pertains to the FDA. Here’s how it works. If you have “ties” to industry by virtue of talking to companies for nine months or if your wife has ties to a big drug company or if you work for the FDA and your kid babysits for someone who works for a big drug company you are conflicted and therefore should not be allowed to work for the FDA or any issue coming before the FDA according to Charles Grassley and Maurice Hinchey or those eager reporters who define conflict of interest in similar terms. But what if you work at the FDA and happen to also have part ownership in a company that markets products that compete with a drug that you happen to review? No problem! That is, unless you are the company that raises an objection about a possible conflict and then of course you are accused, as was Wyeth, of “targeting” an FDA reviewer of animal medicines. Then the mainstream media (MSM) is all over the issue as yet another example of how big drug companies — who get but 8 percent of all the drugs they develop approved — manhandle the FDA.
To sum up: it’s a conflict and worth reporting if you consulted for a drug company or had lunch with a drug company representative or someone from a drug company attended your kid’s Bar Mitzvah. But if you run business that sells products in direct competition with those you are reviewing, that’s ok because the direct competition is a BIG DRUG COMPANY.
An invitation to babysit for any MSM journalist who can explain their inconsistency on this one or at least has the guts to respond to me at bobgoldberg@yahoo.com
In July 2003 the FDA’s Consumer Health Information for Better Nutrition Initiative announced, as its central focus, the twin goals of making available better, easily understood, up-to-date scientific information about how dietary choices can affect health, as well as encouraging companies to compete based on health and nutrition consequences, in addition to such non-health-related features of products like taste and ease of preparation. According to the press release (which I helped to draft), “A better-informed public — aided by science-based health information — would be able to choose foods that are more nutritious, potentially addressing such urgent public health problems as the rise in obesity and overweight.”
But that was way back in 2003. Today the FDA turned down a request by General Mills to label cereal, bread and other products as a “good source” or “excellent source” of whole grains. Noting that the government’s new dietary guidelines do say that consumers can benefit from increased consumption of whole grains, the FDA said it wants to further consider what the term “whole grain” should include.
Please.
In a lengthy petition filed in May 2004 General Mills asked the FDA to define what it means for a product to be described as “made with” whole grain or an “excellent source” of whole grain or a “good source” of whole grain. It suggested that the FDA use the amount of fiber in a product to determine if it is, indeed, a good source of whole grain. The FDA, in its recent letter, refused.
Hullo?
But the agency has permitted the food makers to declare on the label that eating whole grains can reduce the risk of heart disease and certain cancers, if the foods contain more than 51% of whole grain and the required amount of fiber. Food companies also can make statements, such as “10 grams of whole grains” and “100% whole grain oatmeal.”
The FDA must not be pulled, spiraling downwards, by the dangerous gravitational pull of the Precautionary Principle. Rather than being seen as Dr. No, FDA should step up to the plate (so to speak) and do the right thing — promote good health. And whole grains is a no-brainer.
Some non placebo-coated comments from CMPI advisory board member, Henry Miller — especially timely as we approach the two day Part 15 hearing on communicating drug safety (this Wednesday and Thursday). I will be at this meeting and report on what I encounter. In the meantime — heeeeeeere’s Henry!
Overhaul of Unwieldy Labels on Drugs Isn’t Thorough Enough
By Henry I. Miller
Have you ever tried to read the official FDA-approved labeling for a drug? It’s tough going even for physicians who are trying to find something in a hurry, and almost impossible for non-experts. Although there is a standard format for the subheadings, it is without rhyme or reason, and there is a lack of consistency in fonts and spacing. Both common sense and focus groups tell us that crucial information such as the drug’s uses, warnings and dosage should be up front, but instead it’s buried in the middle of the labeling — and in impenetrable small print.
Consider, for example, the antibiotic Cipro, whose labeling in the
Physicians’ Desk Reference runs to five full, large pages of tiny print. The first paragraph of the first section, “Description,” contains this gem” “Ciprofloxacin hydrochloride, USP, a fluoroquinolone, is the monohydrochloride monohydrate salt of 1-cyclopropyl-t-fluoro-1, 4-dihydro-4-oxo-7-(piperazinyl) — 3 quinolinecarboxylic acid. It is a faintly yellowish to light yellow crystalline substance …”
Just the info you need at your fingertips! And the second section,
“Pharmacology,” is equally unhelpful, discussing absorption, distribution within the body, metabolism, excretion and so on.
It’s not until the third page of the labeling that we finally get to
critical information, “Indications and Usage.” After that follows a
series of discrete sections whose contents overlap significantly (and
problematically): “Contraindications,” “Warnings,” “Precautions,” and
“Adverse Reactions.”
During a recent advisory committee meeting, FDA officials outlined proposed new labeling, which is expected to be published soon. Information will be organized logically and in order of importance: boxed warnings (the most forceful caution that FDA can require), what the drug is used for, and then the dosage and administration. Any major changes in the label will also be prominently featured, and the old sections on contraindications, warnings, precautions and adverse reactions (that is, side effects) will be consolidated. There will also be, we are told, “more clarity in the adverse reaction section.”
The FDA also intends to introduce DailyMed, “an electronic repository of … the most current labeling, vetted, approved, the gold standard of drug information.” I am looking forward to it; the Physician’s Desk Reference on my office bookshelf is the 2004 edition, which means that the data was compiled at least two years ago.
These initiatives will be a marked improvement over the current antiquated system of drug labeling. However, not all of the FDA’s innovations are so inspired.
Much criticized lately for supposed deficiencies in the surveillance and reporting on the safety of drugs, the agency is implementing a wrong-headed scheme for releasing data on drugs’ adverse reactions.
In May, the FDA announced its new Drug Watch program, which will make
“emerging safety information” publicly available. According to the FDA, this program “is intended to identify drugs for which the FDA is actively evaluating early safety signals. The Drug Watch is not intended to be a list of drugs that are particularly risky or dangerous for use; listing of a drug on Drug Watch should not be construed as a statement by the FDA that the drug is dangerous or that it is inappropriate for use. Rather, inclusion on the Drug Watch signifies that FDA is attempting to assess the meaning and potential consequences of emerging safety information.”
FDA further “clarifies” in the same document that Drug Watch is intended “to share emerging safety information before we have fully determined its significance or taken final regulatory action so that patients and health care professionals will have the most current information concerning the potential risks and benefits of a marketed drug product upon which to make individual treatment choices.”
However, it is difficult to fathom how physicians and other health care providers — let alone members of the public — can make good use of such preliminary data, which will be available on the agency’s Web site. There is a difference between indiscriminate data and useful information, and Drug Watch seems destined to provide far more of the former than the latter. Moreover, given the current fervor at FDA for ensuring drug safety, and the difficulty of proving a negative, one wonders how a “suspect” drug could ever clear its name and get off the Drug Watch list.
As FDA Deputy Commissioner Scott Gottlieb has said, “Information that
could influence clinical medical practice needs to be made available more quickly, and more widely, after it has gone through a deliberative scientific process that firms up its meaning and the magnitude and the veracity of its conclusions.” DailyMed, which will provide up-to-the-minute labeling information, meets these criteria, while Drug Watch fails miserably.
Surely, it would be better to rely on what the FDA considers to be
information that is “vetted, approved, gold standard” than on what
Gottlieb himself has dismissed as data “still unscrubbed by scientific rigor.”
My advice to the FDA: Take two aspirin, get a good night’s sleep, and
perform a Drug Watch-ectomy in the morning.
From the always graceful pen of the always graceful Grace-Marie Turner …
As you will recall, the Galen Institute worked hard, along with AEI and Heritage, several years ago to promote an idea for a Medicare prescription drug benefit that would be based upon a funded drug discount card coupled with insurance coverage for large drug expenses. Our idea was adopted in part with the enactment of the temporary drug discount card. The Medicare Modernization Act created a program to allow private plans to offer Medicare-approved discount cards to all beneficiaries and also provided $600 a year to those with low-incomes to help with drug expenses. This was a transitional program designed to provide help in 2004 and 2005 until the permanent drug benefit could be implemented. Opponents of the drug benefit did everything they could at the time to criticize the temporary assistance program, actively discouraging seniors from signing up — and disadvantaging their constituents in the progress. So now, Rep. Henry Waxman asked the Government Accountability Office for a study of the program, and The New York Times reports that “Congressional investigators … found serious, widespread problems.” This is outrageous for a number of reasons:
The GAO’s findings were overblown by Rep. Waxman and the Times. Medicare Administrator Mark McClellan told the Times and the GAO that the number of problems and complaints was relatively small, given the size of the program and how quickly it had to be up and running. “Millions of prescriptions have been filled, with only a tiny fraction of complaints and compliance issues,” McClellan said.
Opponents of the drug benefit discouraged their constituents from signing up, and surprise, surprise, enrollment was much less than it could have been (6.4 million beneficiaries, including 1.9 million who received the $600 annual credit).
The temporary program provided an important learning experience both for the Medicare agency and for private plans now enrolling beneficiaries in the permanent benefit plan. When administrators learned of problems, they acted to correct them. Reports like this feed the other side’s mantra that the permanent drug benefit is too complicated and offers too many choices, with the implication that seniors simply won’t be able to figure out how to pick a plan that provides them the drugs they need at the best prices for the lowest premiums. This is frustrating, but perhaps these are the growing pains of implementing a new entitlement through a system of choice involving private plans. The unspoken alternative — a one-size-fits-all government plan — would simply have been unable to meet the complex and diverse needs of seniors. If there is howling now over choice, imaging the howling there would have been over no choice!
The following entry from Bob Goldberg …
Geeta’s Self-Promoting Genzyme Jihad
Geeta Anand is a Pulitzer winning reporter for the Wall Street Journal who has made her mark as a clone of former WSJer Gardiner Harris who now owns the “hate the drug company” corner at The New York Times, otherwise known as the print media’s version of Lord of the Flies. That is, Geeta connects the dots in breathless fashion about misdeeds and dangers aplenty in the pharmaceutical industry, particularly self-dealing financial conflicts that place profits ahead of the public health. One of her more famous articles involved revealing that Sam Waksal who headed up Imclone, had overstated his medical credentials. The point she tried to make at the time: both the drug (Erbitux) and the company’s chief were overpromoted to bilk shareholders. Ms. Anand has never written a follow up story about how effective Erbitux has turned out to be. But I digress.
Now she is going after Genzyme for charging too much for their drugs. (Through Charities, Drug Makers Help People — and Themselves, The Wall Street Journal. 12/1/2005). Genzyme is a fairly diversified biotech concern that started out and is still involved in develop biotech products for rare diseases. Most recently she pounded Genzyme for charging $250,000 a year for Fabrazyme, a disease that less than 100,000 people in America have. Genzyme recently became profitable and is still investing in drugs for other rare diseases. But Anand ignores these two facts in her most recent screed against Genzyme. More interesting, (I can breathlessly connect the dots too!) Anand did a piece on how a father with two daughters suffering from another orphan illness called Pompe Disease, created a biotech firm and needing more funding to develop a drug for the illness, sold the company to none other than Genzyme for about $140 million. Genzyme has taken the drug through clinical trials and has invested hundreds of millions in developing production processes required to produce the drug (if it is approved) on a mass scale.
Geeta ignores all these facts in her attack on Genzyme’s pricing policies. She does so not only to fit her jihad against drug companies as price gougers. She also has a book and movie deal based on her article about Genzyme’s involvement in the search for a Pompe cure. (Insideré¾ note: Harrison Ford is slated to play the father.) Given the politics and inner workings of Hollywood — it makes sense to have the author of the book upon which the movie is based to portray Genzyme — which didn’t have to invest in the drug — as evil. And of course, it doesn’t hurt to pick on Genzyme in the run-up to the book’s release next June. Finally when was the last time Hollywood or Geeta ever portrayed a drug company that made money in a favorable light? I wonder if she will give her advance back if the film/book doesn’t turn a profit? Then again, I am sure am missing something because I am just connecting the dots!
Whenever politicians and pundits want to trash the MMA’s federal non-interference clause (originally drafted, FYI, by Senators Kennedy and Daschle for the Clinton health care reform plan), they point to the rock-bottom prices charged by the Veterans Administration. What these folks always fail to mention is that the VA doesn’t have to add any additional costs for pharmacist services — often upwards of 30% or more of a drug’s cost to the average consumer. Facts are stubborn things and war is hell.
Despite a scary headline, “Poisonings from a Popular Pain Reliever Are Rising,” (The New York Times, November 29) is a good example of solid journalism raising consumer awareness of an important public health problem. At last! In this instance, the topic is the increase in unintentional poisoning from too much acetaminophen. It’s an issue the FDA has consistently tried to promote (most recently in partnership with the National Consumers League) — but to a collective yawn from most media. The New York Times article will reach more consumers, pharmacists, and physicians than any well-intentioned (and under-funded) government outreach program. What is, unfortunately, surprising is that the story relies on (gasp!) balanced reporting! No hyperbole. No blaming “Big Pharma.” No political posturing. Just a newspaper article that will reach millions of people with an important health message, “use as directed.” Well done.
Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.
