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Developing Risk Management Systems that meet FDA rules --and don’t hurt your product Judith K. Jones President, The Degge Group, Ltd. Louis A. Morris President , Louis A. Morris & Associates Gina Ashe VP Marketing, Infomedics Objectives articipants should appreciate strategic and tactical elements for developing a Risk Management (RM) Plan: – Risk Assessment • Natural History of Disease – Developing a RM Strategy • Designing Distribution control • Developing Communication Objectives – Designing a RM Program • • • • Behavioral Goals and Objectives Selecting and Justifying Tools PreTesting Communications Planning Evaluation FORMAT: PROBLEM SOLVING EXERCISE • Introductions, Background & Goals for Today – (15 minutes) • Form Groups – 8:45-10 AM: Developing a RM Strategy • Problem Identification • Understand Risk Assessment Issues (by example) • Defining Desired Behavioral Outcomes, Communications, Distribution Controls – 10-10:20 AM: Break – 10:20-11:20: Developing the FDA RM Plan • Goals, Objectives, Tools,, Evaluation Planning – 11:20-12:00 Group Presentations and commentary by Audience and Faculty Background FDA: Need to Develop a RM Plan Recent Withdrawals • • • • • • • • • • Seldane (terfenadine) Posicor (mibefradil) Duract (bromphenac) Hismanal (astemizole) Roxar (grepafloxacin) Propulsid (cisapride) Rezulin (troglitazone) Lotronex (alosetron HCl) Raplon (rapcuronium) Baycol (cerivaxtatin) 92 NME’s from 1998-2000 2/98 6/98 6/98 6/99 11/99 3/23/00 3/21/00 8/24/00 3/01 8/8/01 Rezulin Withdrawal “FDA took this action after its review of recent safety data…showed that Rezulin is more toxic to the liver than the other two drugs” [HHS News, 3/21/00] “And we’ve had to withdraw drugs from the market that would have been safe if used according to label instructions” [Janet Woodcock, Temple University, 4/4/00] AUG 09, 2001 Anticholesterol Drug Pulled After Link to 31 Deaths With Baycol, however, reports of serious rhabdomyolysis were about 10 times as frequent as with the other statins, Dr. Jenkins said. "Baycol really stood out as being different," he said. "Baycol did not offer any benefits beyond those of the other statins. But it carried a potential risk, and that leads to a conclusion that it is no longer safe to be marketed." Examples of Drugs with RM Controls • • • • • • • • • • Accutane (isotretinoin) Actiq (fentanyl citrate) Clozaril (clozapine) Lotronex (alosetron hydrochloride) Mifiprex (mifepristone or RU-486) Thalomid (thalidomide) Tikosyn (dofetilide) Tracleer (bosentan) Trovan (trovafloxacin mesylate or alatrofloxacin mesylate injection) Xyrem (sodium oxybate) - severe recalcitrant nodular acne severe cancer pain severe schizophrenia severe irritable bowel syndrome in women termination of early intrauterine pregnancy erythema nodosum leprosum maintenance of normal sinus rhythm severe pulmonary arterial hypertension severe, life-threatening infections narcolepsy Import Alerts- drugs with RM plans Top 20 FDA RM Guidances • Concept Papers Released March 3, 2003 • Hearings April 9 – 11, 2003 • Three Papers: – Premarketing Risk Assessment – Risk Management Programs – Risk Assessment of Observational Data: Good Pharmacovigilance Practices and Pharmacoepidemiologic Assessment • Guidances To Be Finalized September, 2004 Risk Management Guidance • Sponsor proposes a Risk Management Program (RMP) – – – – Background and rationale for RM approach Goals, Objectives and RMP Level (4 levels) Tools and Implementation plan for each tool Evaluation Plan for each tool and for the overall RMP • Analyses to be conducted • Reporting results to FDA Risk Management is the process of minimizing risks throughout a product’s lifecycle to optimize the benefit/risk balance The Four Levels of Risk Management • Level 1 Package Insert only • Level 2 Level 1 + education and outreach to health professionals and patients/consumers • Level 3 Level 2 + systems that guide the prescribing, dispensing, or receipt of a product • Level 4 Level 3 + Access to product requires adherence to program elements Levels may go – concept of progressive interventions will stay Risk Management Unknown Risks •Discovering and interpreting safety signals •Phase IV Commitments •Do I need a study/registry? Known Risks •Designing interventions (tools) •Justifying choice of interventions •Pre-testing Interventions •Implementing interventions •Evaluating interventions •Revising interventions Risk Management Irony Beliefs Safety = Perception of Risk Benefits Risks Perceptions Willingness to Use Unintended Consequences Four Pillars of Risk Management •Risk Assessment •Signal Evaluation •Risk Communication •System Controls Forming Groups: Fair Distribution of Disciplines Reseat if necessary Appoint Leader/Recorder/Reporter Product #1 • A product for diabetic neuropathy shown to be very effective causes severe tachycardia (rapid heart rate) with excess caffeine in a genetically sensitive group. • This group can be identified by a genetic test which is costly (~$3000/person) • The drug’s profile is otherwise benign Product # 2 • An antibiotic product indicated for upper respiratory infections is highly effective with most pathogens, including resistant organisms-likely to be used widely. • Its risk is similar to other antibiotics except that if used more than twice in a three month period, it causes severe diarrhea and colitis, particularly toxic to the elderly and children. Tasks for Groups • • 8:45-10:00 Identify and Define 1. Additional Study • Conduct a phase IV study to help identify and characterize the risk (30 min) 2. Developing a RM Strategy • Who, What, How, When, Where and Why? (20 min) 3. How to manage Risks? • • List Key Messages (selected) for each audience (10 min) Assume that FDA believes that communications by themselves will be insufficient. What distribution system controls will be necessary to influence desired behaviors? (15 min) Phase IV Study • Who will we recruit? – Types of people (assume statisticians estimate that at least 2000 people are needed) • How will we recruit them? • What will we measure? – Conceptually, what do we need to know? – How will we measure it? Task: RM Strategy 1. Define the problem – What are the specific risk we are facing in terms of what can happen to which patients under what conditions? 2. Develop the overall RM Strategy: 1. Who do we need to influence? 2. What do we want them to do? (Be specific, define for each audience) 3. When/Where do they need to exhibit this behavior (conditions) 4. How will we get them to do it? What messages will be necessary to influence behavior Will “information” be sufficient? Do we need “behavioral control systems”? Background Risk Communications and Behavioral/Distribution Controls Part I Communications Communications Planning • What to do people need to know? – Message must be sufficient to influence behavior • Must affect Knowledge – Be Understood – May need to motivate audience (personal susceptibility, willingness to overcome barriers to resistance, motivate behavior) • Will “information” be sufficient? Do we need “behavioral control systems”? • How to communicate it? – What are the key primary and secondary messages? (Communication Objectives) – What media will reach intended audience (how much redundancy)? – Will we need a Medication Guide? • How do I know it is working? (next session) – Pretesting – Evaluation Planning Developing Communication Objectives (COs) • What is the most important information for people to know about using this drug? – List in descending order of importance – Assume must provide information relevant to six headers for MedGuides if preparing most patient information documents • What do we need to say to influence advocated behavior? • List for each audience Information Options • HCPs – PI, Label Changes (black box), Dear Doctor letters, Advertisements (medication errors), Fair Balance in ads, MedEd, brochures, etc. • Patients – PPIs, Medication Guide, Informed Consent, Multiple options (Accutane, Thalidomide), refrain from DTC. • Public (PR) – FDA public announcements (talk papers, press releases), website posting, advisory committee meetings Communications Process Goal/Barrier • • • • • • • • • Exposure Attention Interest Understand Accept Memory Decide Behave Learn Measure Distribution Readership Willingness to Read Comprehension Attitude Change Recall/Recognition Tests Decision Making Scenarios Intention to Heed/Behavior Behavior Maintenance Select Vehicles to Maximize Communication Goal May need a combination of Vehicles Risk Communications (1) • Seek Intervention that will force exposure – PPI – voluntary distribution (7% for Darvon) – MG – required by law (39% for Estrogen PPI) – Packaging – systems (93% for OCs) • Risk Messages break through clutter – Clearly identify as risk message (not marketing in disguise) • Redundancy for backup and reminder purpose (not as primary communication purpose) Risk Communications (2) • Assure Understanding of Key Objectives – Will not get sufficient repetition – Test for COs in Comprehension Tests • Understand Factors Controlling Behavior Change – Attitude-Behavior Consistency – Barriers as well as Facilitators • Evaluation Specific Enough to Understand Failures and Recommend Changes Part II Implementing and Evaluating An RM Program RM System Design B/RM Planning & Design Message Development Systems Design B/RM Implementation Evaluation Research/ Testing Distributional Controls How do we slot the risk-control level for any drug? Record Keeping Controlled Substances Closed Special Certification Prior Approvals System Packaging Actiq Fosamax Tikosyn Thalomid Accutane Clozaril Multi-Function Registry Doctor MD Intervention Patient Safety Assessment Multiplatform Delivered Tests RM Evaluation Patient Education & Feedback Patient Experience Feedback Compilation & Reporting MD or Patient Registers Patient Part III Behavioral Outcomes Sample of Desired Behaviors • MDs – Select appropriate patients – Provide RM counseling patients – Oversee compliance with necessary behaviors (lab tests) – Side Effect monitoring • Patients – Understand medication’s risks – Understand avoidance behaviors • behaviors necessary to prevent risks – Behavioral Compliance • Initiating and maintaining behaviors with medication taking requirements to avoid adverse events May need iterative education and motivation “Practicalities” of Engaging MDs • MD time constraints • The office staff “shield” • Limitations of Distribution channels – Sales Rep as the RM messenger – The clutter of direct mail – Technology limitations • Attitudes toward adopting new (potentially risky) medications into their practice • General risk aversion (on several fronts) Avoid “One Size Fits All” Approach to MDs • Specialists vs. PCPs • Targeting the “right” physicians early in the program (sissy vs. sassy docs) • KOL acceptance • For those interested in the Medicine: – This is an issue of patient safety – This may be a particular necessary medicine – Prescribers need to know this The MD Comfort Zone Too Much RM Personal Liability Too much work to use Comfort Zone Too Little RM Will benefit and protect patient, Willing to try Drug may hurt patient Too risky to try Consider Providing Patient Feedback to Their MDs • Additional knowledge MDs gain about: – – – – – – – patient comprehension of product benefits and risks Benefit/Risk Perceptions Barriers to Use Attitudes about Medication Motivations Behavioral Intentions Compliance Measures Patient Compliance Insight #1: Information is Not Learning % Still on Therapy Example of Cholesterol-Lowering Medication 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline* Breakeven** 71% Statin+ Program++ 0 1 2 3 4 5 6 Months Since Starting Therapy *Scott-Levin data 10/00-3/01 showing 45% of patients continuing on medication each month from prior month. calculations using program costs, expected returns, and Scott-Levin Rx data. +Scott-Levin data from 10/00-3/01 for monthly adherence of statin users. ++Adherence rates observed among Adhere program participants. **Internal Patient Compliance Insight #2: Physicians’ Active Role is Essential • Driven by physician-patient relationship • Deliberate “ask” from MD • Patients increasingly turning to their own sources for information, may be unreliable InfoMedics Survey: Why Do Patients Comply with Programs? • 73% of patients motivated to participate because of doctor-patient relationship • 80% of patients would participate again if asked by physician Patient Compliance Insight #3: Each patient conducts their own individual “risk assessment” • Medication containing estrogen, topically applied for short periods of time only, shown to not enter blood stream • MDs comfortable with remote risk of breast cancer (no documented cases) • MDs recognized significant symptom relief and quality of life improvements that medication delivered • Patient concerns around “HRT therapies” caused MDs concerns--not willing to prescribe Tasks for Groups-2 • 10:20-11:30 • Design: 1. RMP Outline • Goals, Objectives • Choice of Tools and Justification (30 min) 2. Methods of Evaluation: • Individual Tools (Comprehension Test) – List Communication Objectives • The Risk Management Plan (30 min) These tasks should be completed for presentation Background FDA Concept Paper RM Concept Paper • Risk Management Program – A strategic program designed to decrease product risk by using one or more interventions or tools beyond the PI. For example: • Specialized educational materials • Processes or forms to increase compliance or reduce risk • Systems to modify prescribing, dispensing and use RM Program • RM Goals and Objectives – RM Program should have one or more safety related goals…tailored to specific concerns – Goals are broad, conceptual statements of desired outcomes – Objectives are translation of goals into pragmatic, specific and measurable processes or behavioral outcomes • Apply to each audience Part II Tool Selection Form (tools) Distribution Purpose Brochure Physician General Education PPI Package or Pharmacist Broad Risk Communication Medication Guide Package Risk Communication and Methods of Avoidance Informed Consent Physician Acknowledgement of Risks Warning on Package Package Risk “signal”/compliance reminder Wallet Card Starter Kit Reminder Stickers: Medication Vial or Prescription Medication Vial or Prescription Reminder or time sensitive controls Patient Agreement or Contract Physician Behavioral Commitment Decision Aid Physician Choice of Therapy Video Tape or CD Physician or Starter Kit Persuasion or Choice of Therapy Recurring Interventions (telephone calls) Telephone Behavioral Maintenance Sample Tactics Matrix Goal Audience Awareness Motivation Reinforcement Sales Detail Aid Training manual Leave behinds CRM Affirmative Scripts, Q&As Training video Desk Top Media MDs Mailing Sales Rep Material Desk Top Media, poster ER Sales force materials Grand Rounds Training Poster Patients/ Partners Waiting room placard, pharmacy printouts Brochure/Web site, MD materials Materials with logo Theme: Risk Avoidance Involvement Logo as Reminder When is a Medication Guide Needed? • When product poses a “serious and significant public health concern ...” • Translated: when patient information is necessary to safe and effective use • To apply to between 5 and 10 products (drugs and biologics) annually • Not to be used indiscriminately Adapted from Ostrove, 2001 Triggering Circumstances (201.8) • Could help prevent serious adverse effects • When patient needs to know of serious risks, relative to benefits, that might affect decision to use or continue use • When drug is important to health, and patient adherence to directions is crucial to effectiveness Adapted from Ostrove, 2001 Six Headers That Patients Need to Know (Adapted Slightly) • What is the most important information I should know? • What does “Drug” do? • Who should not take “Drug”? • How should I take “Drug”? • What should I avoid while taking “Drug”? • What are the possible or reasonably likely side effects? FDA on its initiative…may exempt or defer any MG content or format requirement on the basis that it is inapplicable, unnecessary or contrary to patients’ best interest Tools Selection • Necessary And Sufficient for Influencing Behavior • FDA: Selecting Tools – – – – Input from stakeholders Consistency with existing tools Documented evidence Degree of validity and reproducibility Tools Selection-Suggestions • Have a conceptual model – What is necessary to influence behavior • Type of Behavior (short term or long term) • Reliance on Memory (recall or environmental cues) • Use Clinical/Marketing Data – Describe audience • Demographically and psychographically (motivations) • Justification – Select sufficient/diverse tools to “solve problem” How Many/What Type of Tools? • Just Enough – Too Little RM • FDA perception that company “doesn’t get it” • Physicians unwilling to prescribe (lack of comfort) – Too Much RM can cause a “backlash” • Unintended Consequences (failure to prescribe because of RM obligations) Part III Pre-Testing and Evaluation Comprehension Tests • Need to Test to Determine Understandability – Potential to effect behavioral change – May help with Document Simplification • but not leave out meaningful details • Enhance Liability Protection – Defense against failure to warn • Common for Rx to OTC Switches • Applied to Medication Guides – Informed Consent, Brochures, Videos, etc. • Applied to Physician Labels • Evolving to test decision making, attitudes, intentions Testing Considerations • Do we need actual patients? – May require Clinic Study or screening? • Can we generalize from non-patients? • Are experienced patients too knowledgeable? – Important subpopulations (low literacy, younger) • What documents need to be tested? – Key (Core) Communication Vehicles – Testing in what combination – may need field test • What do we want to know from the tests? • Document diagnostics – Suggestions for improvements • Meet Benchmarks – 80% to 85% for primary COs • RM document longer and more complex, need secondary COs General Procedure • Recruit (n= 400 to 1,200) – Use Shopping Malls/Clinical Trials/Patients – Screen for at-risk population • Disease characteristics • Low Literacy (pronunciation tests) • Design – One Cell Survey – Multi-Cell Comparisons General Procedure (2) • Procedure – Screening – Document Exposure – read as normally would • Interviewer Leaves Room • Questionnaire – Develop Communication Objectives – Funnel Approach – Open ends – Specific Communication Objectives – Follow-up Questions – Document usually present (may be taken away for initial open ends) Evaluation • How can we know the impact of our RM interventions? – Seek behavior change/adherence • If we do not get “sufficient” adherence: – Can we “diagnose” the failure? – Will we be able to revise the plan? – What do we mean by “sufficient” anyway? • Benchmarks or evaluation criteria • Do we need to set these levels a priori? Risk Management Concept Paper • Evaluation of RM Tools – Select well-defined, validated metrics – Use at least 2 different evaluation methods for key objectives or goals – Use qualitative data … when quantitative data are not available or not applicable – Consider using evaluation methods for each RM tool. Evaluation of Goals & Objectives • Evaluation must match specific goals/objectives – Education – measure comprehension, opinions, etc. • Education encompasses knowledge, persuasion, decision making, etc • For example: Detect occurrence of MAADO – Behavior Change – measure by observation & self-report – Limited Use - drug use data base – Reduce ADRs – collect ADR experience • Can we use spontaneous reports? • Data Collection Methods – Questionnaires (multiple sampling methods) – Existing database (administrative, prescribing) • Evaluate Tools pre and/or post launch • Evaluate “unintended consequences” Bi-Directional Evaluation Measure Behavioral Impacts Survey RMP Database Measure, knowledge, beliefs, intentions, reported behavior Existing Databases • Numerous Available – Each has strengths and weaknesses • Some focus on claims (have diagnosis and outcomes) • Some focus on prescribing • Some focus ER visits – May be able to use surrogate indicators • Limits on explanatory variables RM Survey Sampling Methodology • Registry – Theoretically an audit, in reality – low response rate – Time Series (surveys) • Concern about prior surveys biasing response • Concern about running out of sample • Consider – Probability sampling (smaller but scientific sample) • Response rates are in the basement toilet – Bell-Weather (Sentinel Cites) or Quota sampling • smaller, incentivized sample – Multifunction Registry • integrate marketing and safety purposes – Geographical Testing • Base program for all, add-ons tested for impact