Drug Approval Process Flashcards

1
Q

T or F. movement of drugs from prescription to over-the-counter status leads to reduced costs

A

T, but the cost burden often shifts from the HMO to the consumer.

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2
Q

How does prescription use in the South compare to the rest of the nation?

A

the mid-south (TN-AR- MS) experiences a higher prescription drug use than does the population in general.

As a general rule, the more drugs a patient is taking concurrently, the greater the risk for adverse drug-drug interactions.

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3
Q

The Food and Drug Administration (FDA) falls under the aegis of the ____.

A

Department of Health and Human Services (DHHS)

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4
Q

Drugs are the responsibility of the ______.

A

Center for Drug Evaluation and Research (CDER)

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5
Q

What did the Pure Food and Drug Act of 1906 do?

A

prohibited mislabeling and adulteration of drugs

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6
Q

What did the Opium Exclusion Act of 1909 do?

A

prohibited importation of opium

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7
Q

What did the Amendment to the Pure Food and Drug Act in 1912 do?

A

prohibited false or fraudulent advertising claims

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8
Q

What did the Harrison Narcotic Act of 1914 do?

A

Established regulations for use of opium, opiates, and cocaine (marijuana added in 1937)

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9
Q

What did the Food, Drug, and Cometic act of 1938 do?

A

required that new drugs be safe as well as pure (no proof of efficacy). Enforcement by FDA

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10
Q

What did the Durham-Humphrey Act of 1952 do?

A

Vested in the FDA the power to determine which products could be sold without prescription

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11
Q

What did the Kefauver-Harris Amendments of 1962 to the Food, Drug, and Cosmetic Act do?

A

Required proof of efficacy as well as safety for new drugs and for drugs released since 1938; established guidelines for reporting of information about adverse reactions, clinical testing, and advertising of new drugs

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12
Q

What did the Comprehensive Drug Abuse Prevention and Control Act of 1970 do?

A

Outlined strict controls for habit-forming drugs; established drug schedules and programs to prevent and treat drug addiction

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13
Q

What did the Orphan Drug Amendments do?

A

Provided incentives for development of drugs that treat rare diseases (less than 200,000 in USA)

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14
Q

What did the Drug Price Competition and Patent Restoration Act of 1984 do?

A

Abbreviated NDAs for generic drugs (bioequivalence data). Patent life extended to account for FDA review process (max less than 5 extra years of 14 years post-NDA approval)

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15
Q

What did the Prescription Drug User Free Act of 1992 (and 2007) do?

A

Manufacturers pay use fees for certain NDAs

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16
Q

What did the Dietary Supplement Health and Education Act of 1994 do?

A

Established standards for dietary supplements prohibited full FDA review as drugs. Required specific ingredient and nutrient information labeling that defines dietary supplements and classifies them as part of the food supply but allows unregulated advertising

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17
Q

What did the Bioterrorism Act of 2002 do?

A

Enhanced controls on dangerous biologic agents and toxins. Seeks to protect safety of food, water, and drug supply

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18
Q

What did the FDA Amendments Act of 2007 do?

A

Grants FDA greater authority over drug marketing, labeling, and direct-to-consumer advertising; requires post-approval studies; established active surveillance systems, makes clinical trial operations and results more visible to the public

governs Phase IV studies and labeling issues and reporting adverse events

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19
Q

T or F. Drugs developed as antidotes to potential terrorism select agents are the one group of drugs that receive approval based solely upon animal tests.

A

T. Clearly it would be unethical to conduct trials of these lethal toxins in humans.

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20
Q

What is a risk/benefit profile?

A

whether or not the potential benefits of a potential drug choice outweigh the risks in that patient.

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21
Q

Are dosing recommendations typically personalized today?

A

Most drug dosing is still based upon the “one size fits all” concept. So dose recommendations try to balance risks/benefits across the patient spectrum. This is increasingly recognized as the wrong approach and a more individualized dosing profile will ultimately be adopted for many drug classes.

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22
Q

The first step in drug development is formulation of a correct, therapeutic compound. How does this work?

A

Developers begin with a standard compound and alter molecule characteristics including pks, metabolism, solubility, route of administration, etc.- to look at effects on activity. This is driven by modeling studies now and is becoming efficient

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23
Q

Preliminary techniques keep things simple and cheap, involving ___ systems.

A

in vitro.

Animal systems are no longer the first choice for ethical reasons and because they involve the use of larger quantities of the test agent. Synthesis is expensive; you don’t want the time and cost of producing large quantities of a “candidate” only to immediately find it is useless in your assay systems.

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24
Q

How did pharm products used to be made? How is that different today?

A

Once upon time, you began with compounds that produced an effect, then tried (sometime in an incomplete manner) to establish how they worked.

These days, with molecular modeling and molecular biology, one can synthesize “candidates” to specifically interact with a known receptor motif.

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25
Q

What are “first in class” drugs?

A

First the treat a specific thing.

Most often the result of phenotypic analysis, i.e. treating a recognized clinical condition.
However, once the new ‘target” is recognized and the drug comes to market, competitors hone in on the already defined receptor to develop their “me too” drugs.

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26
Q

What are some issues that still need to be figured out even once a drug candidate has been successful in in vitro testing?

A

Just because a “candidate” works in a cell assay or indeed in a cell- free system, it doesn’t mean that, from a physico-chemical perspective, the compound could be administered to patients. There are many considerations, such as solubility, metabolism, and potential drug-drug interactions

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27
Q

What is “high throughput screening” (HTS)?

A

many in vivo issues of a drug (solubility, drug-drug interactions, etc.) are highly automated and are therefore easily reproducible

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28
Q

Why must assays determine in vivo characteristics of a drug candidate such as solubility, etc. still be cheap and easy?

A

most of these “candidates” will fall by the wayside before the process is over!

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29
Q

What are Herg channels?

A

potassium channels in polarized membranes (potassium is an important regulator of membrane polarity-especially in the heart)

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30
Q

What happens if Herg channels are upset by a drug?

A

the membrane can become hyper-responsive, leading to cardiac arrhythmias (QT prolongation)

The most famous example in recent history was the antihistamine drug called terfenadine.

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31
Q

Is Herg channel interaction testing common?

A

In order to spare the financial burden, peer embarrassment and shareholder anger, drug copmanies now test for potential Herg channel interactions before the drug ever moves into clinical trials.

This is often done on a contract basis by specialist companies.

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32
Q

If no Herg channel disruption occurs during experimentation, does that mean it won’t during clinical use?

A

Absence of a reaction in an experimental system in no way guarantees the absence of such interactions in clinical use. This MUST be confirmed by clinical experience

33
Q

T or F. Toxicity testing is time-consuming and expensive.

A

T. Two to 6 years may be required to collect and analyze data on toxicity and estimates of therapeutic index on at least 2 animal species

34
Q

Toxicity testing is typically done via ____.

A

Animals. Large numbers of animals may be needed to obtain valid preclinical data

35
Q

What are some alternatives being tried instead of the use of animals?

A

Cell and tissue culture in vitro methods and computer modeling are increasingly being used, but their predictive value is still limited.

Nevertheless, some segments of the public attempt to halt all animal testing in the unfounded belief that it has become unnecessary.

36
Q

T or F. Extrapolations of therapeutic index and toxicity data from animals to humans are reasonably predictive for all toxicities.

A

F. Many, but not all.

Seeking an improved process, a Predictive Safety Testing Consortium of five of America’s largest pharmaceutical companies with an advisory role by the Food and Drug Administration (FDA) has been formed to share internally developed laboratory methods to predict the safety of new treatments before they are tested in humans.

37
Q

What must first happen for a drug candidate to enter clinical trials?

A

One vital aspect is the review and acceptance by the Institutional Review Board (IRB)

also need informed consent

38
Q

How long does the FDA have to review a clinical trial application?

A

30 days

39
Q

What are some things needed on a clinical trial application for review by the IRB?

A

protocol overview, clear objectives, study design, patient inclusion/exclusion info, etc.

40
Q

The Phase I clinical trial is essentially a ____.

A

dose-finding exercise in humans.T he developer has discovered the Maximum Tolerated Dose (MTD) in animal model systems, but what is it in humans.

41
Q

How is MTD in humans performed during a phase I trial?

A

A dose escalating study

42
Q

How is a drug-escalating study done?

A

only conducted on 10-15 healthy adult volunteers (or terminal cancer patients in development of cancer drugs)

starting from a lower dose than the animal trials (except if cancer patient) and work way up to see when/if adverse events occur to find the MTD

43
Q

What occurs in Phase II trials?

A

The Phase II trial involves more patients (typically 100-300), is more expensive and explores or refines the optimal dosing regimen and dose- pharmacokinetic relationship.

Begin with MTD from Phase I and vary dosing regimen to extend toxicity profile

44
Q

T or F. Phase II trials involve patients with the intended disease for which the drug is being developed

A

T.

45
Q

What happens if a drug gets a positive response from a phase II trial?

A

the trial is extended to 30-40 more patients and further if the activity is again evident in that group

Active, non-toxic groups then proceed to phase III trials

46
Q

What is the major criterion for acceptance of a drug?

A

Will the benefits of the drug outweigh the risks?

47
Q

What occurs in Phase III trials?

A

patient base is extended to close to 1000. This is often conducted in a blinded fashion to eliminate bias. Multi-center trial is common

48
Q

What is a blinded trial? Double blinded?

A

In the former, the patient doesn’t know whether or not they are receiving the candidate drug, in the latter, neither the doctor nor the patient is aware of what is being given to the patient. To avoid bias the comparator is formulated in an identical fashion.

49
Q

Are Phase III trials typically long or short? When can they be stopped short?

A

Long, but can be stopped because of superior efficacy of trial agent or increased risk to users compared to normal practice

50
Q

What is the placebo effect?

A

giving a patient anything can often times improve their outcome regard of what it is. Typically, 30-50% of the placebo group in trials will improve

51
Q

What is the impact of the placebo effect?

A

It can be very hard to prove efficacy in some drug classes like psychiatric therapy

often newly approved drugs fail to be placebos in later studies

52
Q

What happens if all clinical trials are successful?

A

the developer files an NDA with the FDA, sends them the several truckloads of files and, as noted earlier, pays the fee for review. If the risk-benefit ratio fall in favor of benefit, then the FDA can issue an approval notice, the license to market this new patent medicine.

53
Q

What kinds of documentation are required for FDA review following successful clinical trial?

A

drug safety in animal and human trials, evaluation of carcinogenic and teratogenic status, drug stability

54
Q

What three responses can a drug get from FDA review?

A

Approved, Disapproved, and Approvable but more info is needed (i.e. for labeling, effect, etc.)

55
Q

What is Pharmacometrics?

A

simultaneous quantitative understanding of drug dose or exposure and response (pharmacodynamics)

These days the discipline of pharmacometrics (computer modeling) is used to extrapolate data from clinical trials to other scenarios without the need for more or redesigned trials. It’s a relatively recent development in clinical studies, but it will become increasingly important in the future.

56
Q

Pharmacometrics is used for what 3 broad areas?

A

evidence of effectiveness, dose optimization, and improvement in future trial design by gaining insight into causes of clinical trial failure

57
Q

What kinds of situations would warrant accelerated review by the FDA?

A

In order to bring to market drugs that could have an immediate impact upon the lives of patients with serious or life-threatening illness, like cancer, the FDA may grant approval for clinical availability contingent upon confirmation of limited clinical trials.

58
Q

What are generic drugs?

A

Those appearing in the marketplace after the patent on the original drug has expired.

59
Q

Do generic drugs undergo Phase I-III trials? What do they require?

A

No. All they need is abbreviated bioequivalence studies. These are inexpensive, being conducted in a limited number of volunteers.

Essentially the developer is trying to show that the generic drug produces the same plasma concentration vs. time profile as the patent product.

60
Q

How is bioequivalence measured in generic drugs?

A

measure AUC plasma drug levels in 24-36 healthy volunteers and compare with brand name drug. These types of studies must be repeated whenever the manufacturer changes a component of the drug product.

61
Q

Upon approval can anyone buy the drug? Why or why not?

A

Upon approval the new drug may only have been given to a few thousand people. Genetic diversity being what it is, there is a distinct possibility that safety has NOT been established in all genotypes.

Hence, post-marketing review is essential to gain “confidence” that all is well in the “real world.”

this is called Phase IV

62
Q

Physicians should be very wary of rushing to employ a new drug as soon as it comes on the market, especially if other agents are available to treat the given medical condition. One could argue that it is safer for them to wait for the collective experience to develop and the position of the new drug in the marketplace to be established.

A

Physicians should be very wary of rushing to employ a new drug as soon as it comes on the market, especially if other agents are available to treat the given medical condition. One could argue that it is safer for them to wait for the collective experience to develop and the position of the new drug in the marketplace to be established.

63
Q

Is adverse event reporting mandatory by law?

A

no but it is a vital, voluntary process in maintaining safety.

MedWatch is a system employed for logging such events

64
Q

What is a black box warning?

A

Where a risk is identified, the FDA may require the issuance of a BLACK BOX WARNING. As the name implies this is essential information for the prescriber relating to the risk of serious or life- threatening adverse effects. It denotes restriction in use, increase risks for adverse events or prohibition of use with concurrent drugs.

A black box warning is the STRONGEST WARNING that the FDA can require.

65
Q

What must a physician do to permit possession of and perscription of ‘controlled substances’?

A

To permit possession of and prescription of these agents a physician or pharmacist must apply for and be granted a DEA license. Both individuals have to comply with paperwork requirements.

66
Q

The highest schedule drug that can be legally prescribed is a Schedule __ agent.

A

II. Schedule I drugs have no legitimate clinical use of nationwide approval (heroin, LSD, marijuana, mescaline).

67
Q

Does the FDA monitor drug name?

A

Yes, it also tracks reports of errors in getting similarly named drugs and can require a name change

68
Q

Does the FDA currently require pharmacogenomic labeling?

A

Yes, the FDA requires pertinent pharmacogenomic information to be included in drug labeling to aid in physicians selecting appropriate drugs and doses.

69
Q

What kinds of pharmcogenomic information is typically included on labels?

A

description of polymorphic enzymes

prevalence of alleles, genotypes, etc. and their effect on PK parameters, such as clearance, half life, and AUC

70
Q

How does the FDA monitor Direct To Consumer Advertising (DTCA)?

A

The FDA monitors print and electronic (TV) advertising and is now wrestling with the new media, like tweeting and text messaging.

71
Q

What is off-label use?

A

Drugs are approved by the FDA for specific indications, e.g. migraine, muscle spasm, etc. These are the only indications for which adverts can be produced. However, physicians can prescribe the drug for a legitimate medical use that has not been formally approved by the FDA and this is legitimate and legal.

72
Q

Can a drug company advertise off label uses?

A

No, this is illegal.

73
Q

Off label prescribing is usually done with what kind of medicine?

A

“Off-label” prescribing is most commonly done with older, generic medications that have found new uses but have not had the formal (and often costly) applications and studies required by the FDA to formally approve the drug for these new indications. However, there is usually extensive medical literature to support the off-label use.

74
Q

What are some types of permitted advertising?

A

1) product claim
2) Reminder advertisements
3) Help-seeking advertisements

75
Q

What are the requirements of product claim advertisements?

A

can give name, at least one FDA-approved use for the drug, most significant risks of the drug, and must present balanced description of the benefits and risks

76
Q

What are the requirements of reminder advertisements?

A

can give name, but not drug use, doesn’t contain risk information because the ad does not say what they drug does or how well it works

cannot suggest, in words or pictures, anything about benefits or risks

However, black box drugs must have risks addressed

77
Q

What are the requirements of help-seeking advertisements?

A

describe a disease or condition and does not recommend or suggest a specific drug treatment. Encouraging dialogue with a health care professional and gives telephone number.

78
Q

What are some reasons for drug recall?

A

lack of assurance of sterility, sub-potency, contamination of any kind (microbial, chemical), etc.

79
Q

What is an orphan drug?

A

a drug that doesn’t really have a market of patients because they target rare diseases so they are not produced often