The 21st Century Cure Act would demand that the Food and Drug Administration (FDA) add an exemption from informed Consent requirements for those clinical trials that pose no more than minimal risks and the appropriate safeguards protecting the right, safety and welfare of subjects.
The above can be found in section 3024 – Informed Consent Waiver or Alterations for Clinical Investigations.
So what they are saying now they don’t have to obtain informed consents to test vaccinations or drugs on humans beings if it has been determined that the proposed pose no more than minimal risks.
Let’s review the Exemption for Devices for Investigational Use
(g)(1) The purpose of this section to encourage to the extent consistent with the protection of public health and safety and ethical standards, the discovery and development of useful devices intended for human use and to that end to maintain optimum freedom for scientific investigators in their pursuit of that purpose.
In other words, you can get an exemption for certain conditions.
Question: if you don’t have informed consent in clinical trials experimentation on people, then how does anyone knows you are not part of an experiment?
If sponsors and clinical researchers not longer has to tell you that you are part of it or get your consent to informed you what they are doing? That may sound a little crazy.
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Computerized systems are used throughout the life sciences industry to support various regulated activities, which in turn generate many types of electronic records. These electronic records must be maintained according to regulatory requirements contained within FDA’s 21 CFR Part 11 for US jurisdictions and Eudralex Volume 4 Annex 11 for EU jurisdictions. Therefore, we must ensure the GxP system which maintains the electronic record(s) is capable of meeting these regulatory requirements.
What to look for in Audit Trail?
Is the audit trail activated? SOP?
Record of reviews? (most companies trust the electronic systems audit trail and generates electronic paper version of it without a full review)
How to prevent or detect any deletion or modification
of audit trail data? Training of staff?
Filter of audit trail
Can you prove data manipulation did not occur?
Persons must still comply with all applicable predicate rule requirements related to documentation of, for example, date (e.g. 58.130(e)), time, or sequencing of events, as well as any requirements for ensuring that changes to records do not obscure previous entries.
Consideration should be given, based on a risk assessment, to building into the system the creation of a record of all GMP-relevant changes and deletions (a system generated “audit trail”).
Audit trail content:
Audit trail content and reason it is required:
Identification of the User making the entry
This is needed to ensure traceability. This could be a user’s unique ID, however there should be a way of correlating this ID to the person.
Date and Time Stamp
This is a critical element in documenting a sequence of events and vital to establishing an electronic record’s trustworthiness and reliability. It can also be effective deterrent to records falsification.
Link to Record
This is needed to ensure traceability. This could be the record’s unique ID.
This is needed in order to be able to have a complete history and to be able reconstruct the sequence of events
Reason for Change
This is only required if stipulated by the regulations pertaining to the audit trailed record. (See below)
FDA / Regulators findings and complaints during Inspection of Audit Trail Data:
Audit User sometimes is hard to describe (e.g. user123 instead use full names of each user IDs thus requirement additional mapping)
Field IDs or Variables names are used instead of SAS labels or Field Labels (map field names with respective field text (e.g. AETERM displayed instead use Reported Term for the Adverse Event)
Default values should be easily explained or meaningful (see annotated CRF)
Limited access to audit trail files (many systems with different reporting tools or extraction tool. Data is not fully integrated. Too many files and cannot be easily integrated).
No audit trail review process. Be prepared to update SOPs or current working practices to add review time of audit trails. It is expected that at least, every 90 days, qualified staff performed a review of the audit trail for their trials. Proper documentation, filing and signature should be in place.
Avoid using Excel or CSV files. Auditors are now asking for SAS datasets of the audit trails. Auditors are getting trained to generate their own output based on pre-defined set of parameters to allow auditors to summarize data and produce graphs.
Formatting issues when exporting into Excel, for example. Numbers and dates fields change it to text fields.
What data must be “audit trailed”?
When it comes to determining on which data the audit trail must be applied, the regulatory agencies (i.e. FDA and EMA) recommend following a risk based approach.
Following a “risk based approach”
In 2003, the FDA issued recommendations for compliance with 21 CFR Part 11 in the “Guidance for Industry – Part 11, Electronic Records; Electronic Signatures — Scope and Application” (see reference: Ref. ). This guidance narrowed the scope of 21 CFR Part 11 and identified portions of the regulations where the agency would apply enforcement discretion, including audit trails. The agency recommends considering the following when deciding whether to apply audit trails:
Need to comply with predicate rule requirements
Justified and documented risk assessment to determine the potential effect on product quality
With respect to predicate rule requirements, the agency states, “Persons must still comply with all applicable predicate rule requirements related to documentation of, for example, date (e.g., § 58.130(e)), time, or sequencing of events, as well as any requirements for ensuring that changes to records do not obscure previous entries.” In the docket concerning the 21 CFR Part 11 Final Rule, the FDA states, “in general, the kinds of operator actions that need to be covered by an audit trail are those important enough to memorialize in the electronic record itself.” These are actions which would typically be recorded in corresponding paper records according to existing recordkeeping requirements.
The European regulatory agency also recommends following a risk based approach. The Eudralex Annex 11 regulations state, “consideration should be given, based on a risk assessment, to building into the system the creation of a record of all GMP-relevant changes and deletions (a system generated “audit trail”).”
When does the Audit Trail begin?
The question of when to begin capturing audit trail information comes up quite often, as audit trail initiation requirements differ for data and document records.
For data records:
If the data is recorded directly to electronic storage by a person, the audit trail begins the instant the data hits the durable media. It should be noted, that the audit trail does not need to capture every keystroke that is made before the data is committed to permanent storage. This can be illustrated in the following example involving a system that manages information related to the manufacturing of active pharmaceutical ingredients. If during the process, an operator makes an error while typing the lot number of an ingredient, the audit trail does not need record every time the operator may have pressed the backspace key or the subsequent keystrokes to correct the typing error prior to pressing the ‘‘return key’’ (where pressing the return key would cause the information to be saved to a disk file). However, any subsequent ‘‘saved’’ corrections made after the data is committed to permanent storage, must be part of the audit trail.
For document records:
If the document is subject to review and approval, the audit trail begins upon approval and issuing the document. A document record undergoing routine modifications, must be version controlled and be managed via a controlled change process. However, the interim changes which are performed in a controlled manner, i.e. during drafting or review comments collection do not need to be audit trailed. Once the new version of a document record is issued, it will supersede all previous versions.
Questions from Auditors: Got Answers?
When was data locked? Can you find this information easily on your audit trail files?
When was the database/system released for the trial? Again, how easily can you run a query and find this information?
When did data entry by investigator (site personnel) commence?
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The FDA has recently approved the LifeVest Wearable Cardioverter Defibrillator to be marketed. The Zoll LifeVest is a wearable cardioverter defibrillator to monitor and treat dangerous, abnormally fast heart rhythms. These abnormal rhythms can lead to a complete absence of heartbeat (sudden cardiac arrest) and death (sudden cardiac death) if they are not treated. This device was first approved for patients 18 years of age and over in 2001, and it is now available for children.
The LifeVest is worn outside the body day and night. It treats abnormal rhythms by applying a high energy shock similar to that of a traditional defibrillator.
U.S. Food & Drug Administration (FDA) Clinical Pharmacology Corner Update: FDA Approves PORTRAZZA (necitumumab)
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*FDA Approves PORTRAZZA (necitumumab) in Combination with Gemcitabine and Cisplatin, for First-Line Treatment of Patients with Metastatic Squamous Non-Small Cell Lung Cancer*
On November 24, 2015, the United States Food and Drug Administration (FDA) approved PORTRAZZA (necitumumab) in combination with gemcitabine and cisplatin, for first-line treatment of patients with metastatic squamous non-small cell lung cancer (NSCLC). PORTRAZZA is not indicated for treatment of non squamous NSCLC. The approved recommended dosage of PORTRAZZA is 800 mg as an intravenous infusion over 60 minutes on Days 1 and 8 of each 3-week cycle (Q3W) prior to gemcitabine and cisplatin infusion. Patients receiving PORTRAZZA should be pre-medicated as follows:
* For patients who have experienced a previous Grade 1 or 2 infusion-related reaction (IRR), pre-medicate with diphenhydramine hydrochloride (or equivalent) prior to all subsequent PORTRAZZA infusions.
* For patients who have experienced a second Grade 1 or 2 occurrence of IRR, pre-medicate for all subsequent infusions, with
diphenhydramine hydrochloride (or equivalent), acetaminophen (or equivalent), and dexamethasone (or equivalent) prior to each PORTRAZZA infusion.
_Mechanism of Action (MOA), General Pharmacokinetics (PK) and Pharmacodynamics (PD) of Necitumumab_
* /MOA:/ Necitumumab is a recombinant human IgG1 monoclonal antibody that binds to the human epidermal growth factor receptor (EGFR) and blocks the binding of EGFR to its ligands.
* /Dose proportionality:/ Necitumumab PK is characterized by a target-mediated drug disposition, exhibiting dose-dependent kinetics on total clearance and steady state volume of distribution. * /Accumulation:/ Steady state exposure is achieved after 3 cycles of treatment.
* /Terminal half-life (mean):/ Approximately 14 days.
* /Exposure-safety:/ No apparent relationship between average serum necitumumab concentrations (C_ss,ave ) and all grades
hypomagnesemia, rash, arterial (ATE) or venous (VTE) thromboembolic events.
_Drug Interaction Potential_
* Coadministration of necitumumab (800 mg) with gemcitabine (1250 mg/m^2 ) and cisplatin increased the geometric mean dose-normalized gemcitabine AUC by 22% and C_max by 63% compared to administration of gemcitabine and cisplatin alone. This increased exposure to gemcitabine may have contributed to the higher toxicity observed with the necitumumab containing arm. The coadministration of necitumumab did not have an effect on the exposure to cisplatin (as measured by dose-normalized AUC_0-5h and dose-normalized Cmax for total platinum) in the presence of gemcitabine.
* Gemcitabine and cisplatin have no effect on the exposure to necitumumab.
_Use in Specific Populations_
The following population characteristics were not associated with a clinically significant effect on the PK of necitumumab: age (range: 19-84 years), sex (75% male), race (85% Whites), renal function [as measured by Cockcroft-Gault creatinine clearance (CL_cr ), range:11-250 mL/min] or hepatic function [as measured by alanine aminotransferase (range: 2-615 U/L), aspartate aminotransferase (range:1.2-619 U/L) and total bilirubin (range: 0.1-106 μmol/L). Body weight is identified as a covariate in the population PK analysis; however, weight-based dosing is not expected to significantly decrease the variability in exposure. No dose adjustment based on body weight is recommended.
_Efficacy and Safety_
The efficacy and safety of necitumumab at the recommended dose were demonstrated in an open-label, global, multi-center, 2-arm, randomized trial in 1093 patients with squamous NSCLC (Trial JFCC [SQUIRE]). A 1.6-month improvement in median overall survival (OS) among patients in the gemcitabine/ cisplatin + necitumumab Arm compared with those in the gemcitabine/cisplatin Arm (HR = 0.842 [0.736, 0.962]; p=0.012) was demonstrated. The most common adverse reactions (all grades) observed in PORTRAZZA-treated patients at a rate of greater than or equal to 30% and greater than or equal to 2% higher than gemcitabine and cisplatin alone arm were rash and hypomagnesemia. Cardiopulmonary arrest and/or sudden death occurred in 3% of patients treated with PORTRAZZA in combination with gemcitabine and cisplatin. Closely monitor serum electrolytes, including serum magnesium, potassium, and calcium, with aggressive replacement when warranted during and after PORTRAZZA administration.
Medical Device Safety and Recalls: eVent Medical LS, 5i, or 7i Inspiration Ventilators May Shut Down without Alarm
A recall has been issued for eVent Medical LS, 5i, or 7i Inspiration Ventilators. eVent Medical is recalling the LS, 5i, or 7i Inspiration ventilators because a faulty switch on the ventilators’ power board may fail, causing the ventilator to shut down without sounding an alarm. If the ventilator shuts down, the patient may not receive enough oxygen and could suffer serious adverse health consequences, including injury or death. The company has received one report of this issue occurring, with no injuries and no deaths. For more information, please see: http://www.fda.gov/MedicalDevices/Safety/ListofRecalls/ucm475862.htm
Medical Device Safety and Recalls: Lubricious Coating Separation from Intravascular Medical Devices: FDA Safety Communication
A safety communication has been posted titled, “Lubricious Coating Separation from Intravascular Medical Devices
The FDA wants to make health care providers aware of the possibility that hydrophilic and/or hydrophobic coatings may separate (e.g., peel, flake, shed, delaminate, slough off) from medical devices and potentially cause serious injuries to patients. Coating separation can be caused by a number of factors, ranging from the difficulty of the procedure and the patient’s anatomy to practitioner technique or using the wrong device for the procedure, to improper preconditioning of the device and improper storage conditions as well as issues with device design or manufacturing processes.
This communication contains important information physicians should consider to reduce the potential of adverse events. Based on current information, the FDA believes the overall benefits of these devices continue to outweigh the risks. However, health care providers should be aware of potential problems and consider certain actions prior to use.
Drug Information Update – FDA moves quickly to approve easy-to-use nasal spray to treat opioid overdose
FDA Division of Drug Information: Know the Moment It Happens
The Division of Drug Information (DDI) is CDER’s focal point for public inquiries. We serve the public by providing information on human drug products and drug product regulation by FDA.
Yesterday the U.S. Food and Drug Administration approved Narcan nasal spray, the first FDA-approved nasal spray version of naloxone hydrochloride, a life-saving medication that can stop or reverse the effects of an opioid overdose. Opioids are a class of drugs that include prescription medications such as oxycodone, hydrocodone, and morphine, as well as the illegal drug heroin.
Drug overdose deaths, driven largely by prescription drug overdoses, are now the leading cause of injury death in the United States – surpassing motor vehicle crashes. In 2013, the Centers for Disease Control and Prevention reported the number of drug overdose deaths had steadily increased for more than a decade. When someone overdoses on an opioid, it can be difficult to awaken the person, and breathing may become shallow or stop – leading to death if there is no medical intervention. If naloxone is administered quickly, it can counter the overdose effects, usually within two minutes.
The use of Narcan nasal spray in patients who are opioid dependent may result in severe opioid withdrawal characterized by body aches, diarrhea, increased heart rate (tachycardia), fever, runny nose, sneezing, goose bumps (piloerection), sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, abdominal cramps, weakness, and increased blood pressure.
The FDA has recently approved the cobas® HCV Test to be marketed. The cobas® HCV is a laboratory test used to measure the
amount of hepatitis C virus (HCV) RNA (ribonucleic acid) in a patient’s blood. Viral RNA is genetic material from HCV.
Hepatitis C is a liver infection caused by HCV. Hepatitis C is transmitted when blood or another body fluid from a person infected with the Hepatitis C virus enters the body of someone who is not infected. This can happen through sharing needles, syringes, or other
drug-injection equipment, from mother to baby at birth, and less commonly, through sexual contact. Approximately 75% – 85% of people who become infected with hepatitis C develop chronic infection. Chronic Hepatitis C can lead to serious health issues, like cirrhosis or liver cancer.
The results from the cobas® HCV must be interpreted within the context of all other relevant clinical and laboratory findings.
The U.S. Food and Drug Administration granted accelerated approval to daratumumab injection (DARZALEX, Janssen Biotech, Inc.), administered as a single agent for the treatment of patients with multiple myeloma who have received at least three prior lines of therapy, including a proteasome inhibitor (PI) and an immunomodulatory agent, or who are double-refractory to a PI and an immunomodulatory agent. November 16, 2015. More Information: http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm472904.htm
U.S. Food & Drug Administration (FDA) Clinical Pharmacology Corner Update: FDA Approves COTELLIC (Cobimetinib)
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*FDA Approves COTELLIC^® (Cobimetinib) for the Treatment of Patients with Unresectable or Metastatic Melanoma with a BRAF V600E or V600K Mutation, in Combination with Vemurafenib *
On November 10, 2015, the United States Food and Drug Administration (FDA) approved COTELLIC (Cobimetinib) in combination with vemurafenib for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600E or V600K Mutation. The approved recommended dosage of COTELLIC tablets is 60 mg orally once daily with or without food for the first 21 days of each 28 day cycle until disease progression or unacceptable toxicity. The dosage of COTELLIC may be reduced to 40 mg or 20 mg once daily for adverse reactions. Clinically relevant QT prolongation has been reported with vemurafenib, further QTc prolongation was not observed when cobimetinib 60 mg daily was co-administered with vemurafenib. Monitor ECG and electrolytes before initiating treatment and routinely during treatment with cobimetinib, when administered with vemurafenib.
_Mechanism of Action (MOA), General Pharmacokinetics (PK) and Pharmacodynamics (PD) of Cobimetinib_
* /MOA:/ Cobimetinib reversibly inhibits mitogen-activated protein kinase (MAPK)/extracellular signal regulated kinase 1 (MEK1) and MEK2. * /Dose proportionality:/ Exhibited dose-proportional increases in systemic exposure over the dose range of 3.5 to 100 mg (i.e., 0.06 to 1.7 times the approved recommended dosage).
* /Accumulation:/ Mean of 2.4-fold at the approved recommended dosage. * /Absorption:/ The absolute bioavailability of COTELLIC was 46% in healthy subjects. The Tmax was 2.4 hours (range:1 to 24 hours) in cancer patients.
* /Plasma protein binding:/ Approximately 95%.
* /Terminal half-life (mean):/ Approximately 44 hours (range: 23 to 70 hours) in cancer patients.
* /Metabolism:/ Primarily metabolized by CYP3A and glucuronidated by UGT2B7.
* /Excretion:/ Approximately 76% of the total recovered radio-labeled cobimetinib dose was eliminated in the feces (with 6.6% as unchanged drug) and 17.8% was eliminated in the urine (with 1.6% as unchanged drug).
_Drug Interaction Potential_
* Avoid strong or moderate CYP3A inhibitors. If concurrent short term (14 days or less) use of moderate CYP3A inhibitors including certain antibiotics (e.g., erythromycin, ciprofloxacin) is unavoidable for patients who are taking COTELLIC 60 mg, reduce COTELLIC dose to 20 mg. After discontinuation of a moderate CYP3A inhibitor, resume COTELLIC at the previous dose. Use an alternative to a strong or moderate CYP3A inhibitor in patients who are taking a reduced dose of COTELLIC (40 or 20 mg daily). Coadministration of the strong CYP3A inhibitor itraconazole increased cobimetinib AUC by 6.7-fold and Cmax by 3.2-fold.
* Avoid strong or moderate CYP3A inducers. Cobimetinib exposures are estimated to decrease by 83% when coadministered with a strong CYP3A inducer and by 73% when coadministered with a moderate CYP3A inducer. * Cobimetinib is a substrate of efflux transporter P-glycoprotein (P-gp) in vitro. Drugs that inhibit P-gp may increase cobimetinib concentrations; however, the clinical relevance of this finding is unknown.
* Clinically relevant pharmacokinetic interactions were not observed following coadministration of COTELLIC with the following medications: vemurafenib, midazolam (sensitive CYP3A substrate), dextromethorphan (sensitive CYP2D6 substrate), or rabeprazole (proton pump inhibitor).
_Use in Specific Populations_
The following population characteristics were not associated with a clinically significant effect on the pharmacokinetics of cobimetinib: sex, age (19 to 88 years), race/ethnicity, mild to moderate renal impairment (creatinine clearance [CLcr] 30 to 89 mL/min), and mild hepatic impairment (total bilirubin ≤ upper limit of normal [ULN] and AST > ULN or total bilirubin > ULN but ≤ 1.5 × ULN and any AST). The effect of moderate to severe hepatic impairment (total bilirubin > 1.5 to 3 × ULN and any AST), severe renal impairment or end-stage renal disease with or without hemodialysis (CLcr less than 29 mL/min) on cobimetinib exposure (i.e., AUC and Cmax) is unknown.
_Safety and Efficacy_
Clinical effectiveness and safety of cobimetinib were demonstrated at the approved recommended dosage in a multicenter, randomized (1:1), double-blinded, placebo-controlled trial in patients with previously untreated, BRAF V600 mutation-positive, unresectable or metastatic, melanoma. The median progression-free survival (PFS) was 12.3 months in patients treated with cobimetinib and vemurafenib compared with 7.2 months in those receiving vemurafenib as a single agent [hazard ratio: 0.56 (0.45, 0.70, p < 0.001)].
The most common adverse reactions were diarrhea, photosensitivity reaction, nausea, and vomiting. Advise patients to avoid sun exposure. Monitor for severe skin rashes and interrupt, reduce, or discontinue COTELLIC if required.