||Risk management is the continuing process of minimizing risks throughout a product's lifecycle to optimize its benefit/risk balance. A risk management program is a strategic safety plan designed to decrease product risk by using one or more interventions or tools. Such tools extend beyond the package insert and routine post-marketing surveillance. An RMP also includes the background, research, rationale, and logic necessary to develop and implement the strategy and tactics for the program.
Developing an RMP requires pharma companies to think through not only how a drug is supposed to be used—the indications, contraindications, precautions, and warnings—but also how it will be used or misused by prescribers, dispensers, and patients throughout its lifecycle. To do so, RMP drafters must seek to influence the behavior of all of the parties responsible for drug safety, particularly patients, physicians, pharmacists, and allied medical staff. This is not an easy task, as evidenced by evaluations of current RMPs such as for Roche's Accutane (isotretinoin). Therefore, a reasonable RMP must demonstrate that the company understands the limits of various tools intended to manage risks, that it will use adequate interventions to control risks, and that it will evaluate the impact of its RMP with sufficient specificity to improve outcomes if it does not reach reasonable effectiveness targets.
Although FDA's risk management concept paper provides pharma companies with a clear set of directions on the format for RMP submissions, to compile the plan, pharma drafters must apply an appropriate analytical framework, along with insights from original research. This article outlines how pharma companies can approach RMP development.
Level of Risk
Although FDA states that pharma companies need to consider an RMP for all drugs, for many drugs, professional labeling, routine post-marketing surveillance, and perhaps some form of patient labeling will be sufficient. For some drugs, however, pharmaceutical companies must plan for a more aggressive RMP. For drugs for serious or life-threatening illnesses, such as cancer and AIDS, there is a great deal more tolerance for personal risk than for drugs used for cosmetic purposes, such as acne or head lice. Yet even for life-saving drugs, when the risk posed has the potential to be prevented, companies must seriously consider an RMP.
The starting point for any RMP is to obtain as complete a knowledge as possible of the product's safety hazards. Some hazards may be suspected and subjected to continuing post-marketing surveillance. There is always debate about which signals denote real risks and which denote false positives. Following the precautionary principle, even suspected risks will likely require some risk intervention, even if it means only notifying prescribers of the possibility. The proposed package insert will serve as the best source of information about the product's known or suspected risks and the be the best basis for risk management planning.
Drugs that have serious or life-threatening contraindications, warnings, precautions, or adverse effects are the most likely candidates for risk management interventions. Patient behaviors that can mitigate risks, such as pregnancy prevention, blood tests, overdose/misuse avoidance, and awareness and action related to specific safety signals (hypersensitivity reaction, depression, and suicide), will also need to be addressed in an RMP. When people other than the patient may be at risk--by using the product inadvertently--an RMP may also be required.
FDA has specified four levels of risk management:
- Level 1: package insert only
- Level 2: level 1 plus education and outreach to health professionals and patients/consumers
- Level 3: level 2 plus systems that guide the prescribing, dispensing, or receipt of a product
- Level 4: level 3 plus patient adherence to program elements.
It is likely FDA will not require any formal specification of risk management levels in its final guidance. In the past, the industry objected to the concept of specifying levels out of concern that a competitor company could mischaracterize a drug's level as a signal of risk. However, the agency will probably presume that the proper application of risk management requires the progressive application (or "layering") of risk management tools. These tools must be targeted at solving the problems associated with particular pharmaceutical risks and applied with sufficient specificity to mitigate the attendant risks.
Step by Step
The concept paper outlines a three-step process for developing an RMP.
First, the paper says that each plan must specify the overall goals of the product's risk management program--the desired endpoints for safe product use. For example, if a drug causes birth defects, a reasonable goal would be that no women who are pregnant be given the drug. A second goal might be that no women should become pregnant while taking the drug. It should be noted that goals may never be fully met. However, making progress toward meeting the goal, rather than actually achieving it, may be an acceptable outcome.
Next, FDA calls for companies to identify a series of objectives for each goal. The objectives must be specific and measurable. They must outline the behaviors and processes necessary for the stated goals to be achieved. For example, if the goal is to prevent pregnancy while taking the product, the RMP may specify an objective that all women must have a pregnancy test within seven days of initiating therapy. Objectives often identify the particular individual--patient, pharmacist, physician, or allied health professional--responsible for the desired behavior. This aids in developing a communications plan directed at that individual, which will likely be a core element of the RMP.
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