[Federal Register Volume 62, Number 158 (Friday, August 15, 1997)]
[Proposed Rules]
[Pages 43900-43916]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-21646]
[[Page 43899]]
_______________________________________________________________________
Part V
Department of Health and Human Services
_______________________________________________________________________
Food and Drug Administration
_______________________________________________________________________
21 CFR Parts 201, 312, 314, and 601
Pediatric Patients; Regulations Requiring Manufacturers To Assess the
Safety and Effectiveness of New Drugs and Biological Products; Proposed
Rule
Federal Register / Vol. 62, No. 158 / Friday, August 15, 1997 /
Proposed Rules
[[Page 43900]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
21 CFR Parts 201, 312, 314, and 601
[Docket No. 97N-0165]
RIN 0910-AB20
Regulations Requiring Manufacturers To Assess the Safety and
Effectiveness of New Drugs and Biological Products in Pediatric
Patients
AGENCY: Food and Drug Administration, HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: The Food and Drug Administration (FDA) is proposing new
regulations requiring pediatric studies of certain new drug and
biological products. Many new drugs and biological products represent
treatments that are, at least at times, the best available treatment
for children, but most of them have not been adequately tested in the
pediatric subpopulation. As a result, product labeling frequently fails
to provide directions for safe and effective use in pediatric patients.
The proposed rule would attempt to partially address this lack of
pediatric use information by requiring that manufacturers of a limited
class of new drugs and new biological products provide sufficient data
and information to support directions for pediatric use for the claimed
indications, before or soon after approval. Manufacturers of a limited
class of marketed drugs and biologics would also in compelling
circumstances have to provide such data. This proposed rule is part of
a comprehensive effort to increase the number of new drugs and
biological products with clinically significant use in children that
carry adequate labeling for use in that subpopulation.
DATES: Written comments and recommendations by November 13, 1997.
Written comments on the information collection provisions should be
submitted by September 15, 1997. For further information of the
agency's implementation plan, see section VII of SUPPLEMENTARY
INFORMATION in this document.
ADDRESSES: Submit written comments and recommendations to the Dockets
Management Branch (HFA-305), Food and Drug Administration, 12420
Parklawn Dr., rm. 1-23, Rockville, MD 20857. Submit written comments on
the information collection provision to the Office of Information and
Regulatory Affairs, OMB, New Executive Office Bldg., 725 17th St. NW.,
rm. 10235, Washington, DC 20503, Attn: Desk Officer for FDA.
FOR FURTHER INFORMATION CONTACT: Paula Botstein, Center for Drug
Evaluation and Research (HFD-103), Food and Drug Administration, 5600
Fishers Lane, Rockville, MD 20857, 301-827-3144, and Ann M. Witt,
Office of Policy (HF-22), Food and Drug Administration, 5600 Fishers
Lane, Rockville, MD 20857, 301-827-5321.
SUPPLEMENTARY INFORMATION:
I. Introduction
Children are subject to many of the same diseases as adults, and
are, by necessity, often treated with the same drugs and biological
products as adults. According to the American Academy of Pediatrics,
however, only a small fraction of all drugs and biological products
marketed in the United States have had clinical trials performed in
pediatric patients and a majority of marketed drugs are not labeled for
use in pediatric patients or for use in specific pediatric age groups
(Ref. 1). A recent FDA survey similarly concluded that most products
that are indicated for diseases occurring in both adults and children
have very little information about pediatric use in their labeling
(Ref. 2). For some products, including vaccines and antibiotics,
pediatric use information is generally adequate. Many drugs used in the
treatment of both common childhood illnesses and more serious
conditions, however, carry little information about use in pediatric
patients. Less than half the drugs approved for treatment of human
immunodeficiency virus (HIV) infection or accompanying opportunistic
infections carry any pediatric safety or effectiveness information,
and, of those that do, the data are often incomplete and limited to
certain pediatric age groups. Pediatric labeling is also inadequate for
such drug classes as steroids, drugs to treat gastrointestinal
problems, prescription pain medications, antihypertensives,
antidepressants, antirheumatic drugs, and drugs to treat ulcerative
colitis.
Safety and effectiveness information for some pediatric age groups
is particularly sparse. For example, there is almost no information on
use in patients under 2 years of age for most drug classes (Ref. 2).
Many of the drugs and biological products most widely used in
pediatric patients carry disclaimers stating that safety and
effectiveness in pediatric patients have not been established (Refs. 2
and 3). Based on 1994 data from IMS America, Ltd., a research firm that
provides data on prescription drug usage, FDA compiled a list of the 10
drugs that were most widely prescribed for pediatric patients, on an
outpatient basis, despite inadequate pediatric labeling. In each case,
the label lacked any use information for the age group prescribed to,
or the information was inadequate. The drugs were: Albuterol inhalation
solution for nebulization for treatment of asthma (prescribed 1,626,000
times to pediatric patients under 12); Phenergan for treatment of
allergic reactions (prescribed 663,000 times to pediatric patients
under 2); ampicillin injections for treatment of infection (prescribed
639,000 times to pediatric patients under 12); Auralgan otic solution
for treatment of ear pain (prescribed 600,000 times to pediatric
patients under 16); Lotrisone cream for treatment of topical infections
(prescribed 325,000 times to pediatric patients under 12); Prozac for
treatment of depression and obsessive compulsive disorder (prescribed
349,000 times to pediatric patients under 16, including 3,000 times to
infants under 1); Intal for treatment of asthma (solution prescribed
109,000 times to pediatric patients under 2; aerosol prescribed 399,000
times to pediatric patients under 5); Zoloft for treatment of
depression (prescribed 248,000 times to pediatric patients under 16);
Ritalin for treatment of attention deficit disorders and narcolepsy
(prescribed 226,000 times to pediatric patients under 6); Alupent for
treatment of asthma (184,000 times to pediatric patients under 6).
These 10 drugs were thus prescribed over 5 million times in 1 year for
pediatric patients in age groups for which the label carried a
disclaimer or lacked adequate use information (Ref. 2).
The absence of pediatric labeling information may sometimes require
the physician caring for children to choose between prescribing drugs
without well-founded dosing and safety information or utilizing other,
potentially less effective, therapy.
Inadequate pediatric labeling thus exposes children to the risk of
unexpected adverse reactions or lack of optimal treatment. Even after a
drug has been used in pediatric patients for some time, and there has
been substantial clinical experience with the drug, directions for safe
and effective use in pediatric patients are not provided on the label.
Children were once viewed as a population entirely distinct from
adults, in whom safety and effectiveness of new drugs had to be
established entirely independently. It has become increasingly clear,
however, that children may be considered a
[[Page 43901]]
demographic subpopulation with many similarities to the adult
population. In most cases, drugs and biological products behave
similarly in demographic subgroups, including age and gender subgroups,
even though there may be variations because of differences in, for
example, pharmacokinetics. As FDA has already stated in a Federal
Register document, where the disease and the drug's effects are similar
in adults and children, adequate and well-controlled trials may not be
needed in children to establish pediatric use information (59 FR 64240,
December 13, 1994) (hereinafter referred to as the 1994 rule).
Although use of a drug in children is no longer considered a new
indication (with the exception of specific ``pediatric indications''),
the development of additional information in pediatric patients is
needed to provide appropriate dosing recommendations. Correct pediatric
dosing cannot necessarily be extrapolated from adult dosing information
using an equivalence based either on weight milligrams per kilogram
(mg/kg) or body surface area (mg/square meter (m2)).
Potentially significant differences in pharmacokinetics may alter a
drug's effect in pediatric patients. The effects of growth and
maturation of various organs, maturation of the immune system,
alterations in metabolism throughout infancy and childhood, changes in
body proportions, and other developmental changes may result in
significant differences in the doses needed by pediatric patients and
adults. For example, studies have shown that fentanyl, a potent opioid,
widely used in anesthetic management of infants and small children but
not labeled for use in pediatric patients under 2 years of age,
demonstrates differences in clearance between the neonatal period and 2
or more months of age due to improving hepatic blood flow and hepatic
microsomal maturation (Ref. 4). Comparable doses in adults and neonates
(calculated on a microgram (g)/kg basis) produce twofold to
threefold higher plasma concentrations in neonates (Ref. 5).
Pharmacokinetic differences of this kind demonstrate the importance of
studying the pharmacokinetics of a drug in pediatric patients of
different ages before they are widely exposed to it. Inadequate dosing
information may expose pediatric patients to dangerously high doses or
to ineffective treatment. The absence of pediatric testing may thus
result in less than optimal treatment for many pediatric patients.
Pediatric patients receiving inadequately tested and labeled drugs
are also exposed to the risk of unexpected adverse reactions. One of
the earliest cases in which serious adverse events were observed in
neonates following administration of a drug that had not been
adequately studied in pediatric patients was the development of ``gray
baby syndrome'' from chloramphenicol, an antibiotic (Ref. 6). After an
initial report of 5 deaths and a subsequent report of 18 deaths in
neonates, it was learned that the immature livers of these infants were
unable to clear chloramphenicol from the body, allowing toxic doses of
the drug to accumulate. Other cases in which inadequately studied drugs
have resulted in serious adverse effects in pediatric patients include
teeth staining from tetracycline, kernicterus from sulfa drugs,
withdrawal symptoms following prolonged administration of fentanyl in
infants and small children, seizures and cardiac arrest caused by
bupivacaine toxicity, development of colonic strictures in pediatric
cystic fibrosis patients after exposure to high-dose pancreatic
enzymes, and hazardous interactions between erythromycin and midazolam
(Refs. 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16). Many such adverse
reactions could be avoided if pediatric studies were conducted before
drugs were widely used in pediatric patients.
Failure to conduct pediatric testing may, in unusual cases, deprive
pediatric patients of significant therapeutic advances. Failure to
develop a pediatric formulation of a drug, where younger pediatric
populations cannot take the adult formulation, may also deny pediatric
patients access to important therapeutic advances, or require pediatric
patients to take the drug in homemade, poorly bioavailable
formulations.
II. FDA Initiatives To Improve Pediatric Use Information
FDA has taken a number of steps in recent years to address
inadequate pediatric drug testing and inadequate pediatric use
information in drug labeling. Perhaps the most significant step was the
issuance of the 1994 rule requiring drug manufacturers to survey
existing data and determine whether those data are sufficient to
support additional pediatric use information in the drug's labeling (59
FR 64240). Under the 1994 rule, if a manufacturer determines that
existing data permit modification of the label's pediatric use
information, the manufacturer must submit a supplemental new drug
application (NDA) to FDA seeking approval of the labeling change. The
rule explicitly recognizes that controlled clinical studies to support
pediatric use information need not have been carried out in pediatric
patients where the course of the disease and the effects of the drug
are sufficiently similar in children and adults to permit extrapolation
from the adult effectiveness data to pediatric patients. In these
cases, controlled clinical studies in adults together with
pharmacokinetic and adverse reaction data in pediatric patients may be
sufficient to establish pediatric safety and effectiveness.
Although the preamble to the 1994 rule recognizes FDA's authority
to require drug manufacturers to conduct pediatric studies on a case-
by-case basis, the rule does not impose a general requirement that
manufacturers carry out studies if existing information is not
sufficient to support pediatric use information. Instead, where there
is insufficient information to support a pediatric indication or
pediatric use statement, the rule requires the manufacturer to include
in the drug's labeling the statement: ``Safety and effectiveness in
pediatric patients have not been established.'' Because the rule
focuses on gathering existing information about pediatric use, rather
than carrying out new studies, supplements filed in response to the
rule will be for marketed drugs. The rule does not apply to products
first entering the marketplace, except to the extent that pediatric
studies conducted on such products before approval can take advantage
of the rule's explicit authorization to rely on pharmacokinetic data
rather than adequate and well-controlled studies in pediatric patients,
and that labeling statements about pediatric use must conform to the
rule's labeling requirements.
FDA's Center for Drug Evaluation and Research (CDER) and Center for
Biologics Evaluation (CBER) and Research have implemented a ``Pediatric
Plan'' designed to focus attention on and encourage voluntary
development of pediatric data both during the drug development process
and after marketing. At specified points during the investigation of a
new drug or biological product, FDA staff discuss with the sponsor the
data needed to support pediatric labeling and encourage them to conduct
needed studies. CDER and CBER have also begun to implement a program in
which, after review of an NDA, biologics license application (BLA), or
supplemental application, the FDA reviewer fills out a ``pediatric
page.'' The pediatric page does not itself
[[Page 43902]]
impose any requirements, but describes the adequacy of product labeling
for pediatric patients and plans for further pediatric studies. If
pediatric labeling is found to be inadequate, the pediatric page states
whether additional pediatric studies are needed. If pediatric studies
are needed, the pediatric page states whether the applicant has agreed
to conduct the necessary studies and, if necessary, to develop a
pediatric formulation. FDA is also developing a draft guidance document
on pediatric pharmacokinetics.
In addition, FDA has taken steps to improve pediatric use
information for marketed drugs under the pediatric plan. CDER has
identified the 10 drugs most used in pediatric populations for which
there is no pediatric use information or for which the pediatric use
information is inadequate given the pattern of use in pediatric
patients. The manufacturers of these drugs have been notified of the
widespread use of their drugs in the pediatric population and asked to
respond to the 1994 rule. CBER is currently identifying the biological
products most frequently used in pediatric patients without labeling
information. FDA has developed guidance to manufacturers on the content
and format for pediatric use supplements under the 1994 rule and is
tracking pediatric use supplements and commitments.
III. Results of Actions to Date and Need for Additional Steps
Although the actions taken by FDA to date have produced some gains
in pediatric labeling, they have not yet substantially increased the
number of drugs and biological products for which there is adequate
pediatric use information. The percentage of new products entering the
marketplace that contain adequate pediatric safety and effectiveness
information has not shown consistent improvement in the last decade. An
informal survey conducted by the American Academy of Pediatrics in 1990
found that of all new molecular entities (NME's) approved between 1984
and 1990, 20 percent had information on pediatric use. Not all NME's
have usefulness in pediatric patients, however. For example, for NME's
approved in the years 1991-1996, 53 percent were regarded by FDA as
having potential usefulness in pediatric patients. Presumably, if only
the NME's with usefulness in pediatric patients had been considered in
the survey, the percentage with pediatric labeling would have been
somewhat higher, and as high as 42 percent.
FDA compared the number of NME's approved in 1991 and 1996 with
potential usefulness in pediatric patients and looked at the adequacy
of pediatric labeling for those drugs. Fifty-six percent (9/16) of the
NME's approved in 1991 with potential usefulness in pediatric patients
had some pediatric labeling at the time of approval. In 1996, only 37
percent (15/40) of the NME's with potential usefulness in pediatric
patients had some pediatric labeling at the time of approval. (For both
1991 and 1996, those drugs counted as having pediatric labeling may not
have been labeled for all age groups in which the drug was useful.) The
manufacturers of an additional 17 drugs promised to conduct pediatric
studies after approval. It is uncertain how many of these promises will
result in pediatric labeling. Of the seven NME's approved in 1991 for
which postapproval pediatric studies were promised, only one now has
pediatric labeling.
These data indicate that voluntary efforts have, thus far, not
substantially increased the number of products entering the marketplace
with adequate pediatric labeling. Therefore, FDA has tentatively
concluded that additional steps are necessary to ensure the safety and
effectiveness of drug and biological products for pediatric patients.
This proposed rule includes provisions that would require the
manufacturers of certain new and marketed drugs and biological products
to evaluate the safety and effectiveness of their products in pediatric
patients, where existing information is not sufficient to support
pediatric use labeling but the product is likely to be commonly used in
pediatric patients, the product is a new drug or biological product
which would provide a meaningful therapeutic benefit to pediatric
patients over existing treatments, or the product is a marketed drug or
biological product which is indicated for a very significant or life
threatening illness.
Although this proposal would address the lack of pediatric labeling
through the imposition of regulatory requirements, the agency solicits
comment on whether there are other ways to assure that manufacturers
reliably conduct pre- or postapproval studies in pediatric patients.
At the same time as it is issuing this proposed rule, FDA has
initiated other actions that it hopes will encourage the development of
adequate pediatric use information. FDA plans to develop guidance on
clinical trial designs for assessing pediatric safety and
effectiveness. The agency has also discussed with the pharmaceutical
industry a policy on user fees for pediatric studies designed to
encourage the submission of these studies. Such a policy could be
implemented through legislation at the time of reauthorization of the
Prescription Drug User Fee Act of 1992. FDA has proposed that user fees
be waived for supplements to add pediatric use labeling, unless the
supplements contain adequate and well-controlled clinical trials. Thus,
supplements that rely on pharmacokinetic data to extrapolate from
existing adult studies would not be subject to user fees. FDA might
also be prepared to waive the user fee for supplements containing
pediatric use studies for which FDA granted a request to defer
submission until after approval.
Finally, FDA has issued a policy statement describing the types of
evidence necessary to support supplements. In that policy, FDA provides
guidance to manufacturers on the circumstances in which FDA may approve
a supplement in which confirmation of the results of an adequate and
well-controlled trial is provided by information other than a second
adequate and well-controlled trial precisely replicating the first
trial, or by studies without the extensive documentation ordinarily
required.
The agency believes that financial and other incentives to
manufacturers, although largely beyond FDA's current authority, could
further increase the number of drugs and biologics with adequate
pediatric labeling.
IV. Public Hearing
Because of the importance of ensuring the safety and effectiveness
of the medications administered to children and the need to address the
absence of pediatric labeling in the most effective manner possible,
FDA intends to hold a public hearing at which recognized experts in the
field, members of the pharmaceutical industry, and other interested
parties will have an opportunity to discuss the issues raised by this
proposal.
V. Description of the Proposed Rule
The proposed rule is designed to ensure that new drugs and
biological products that are likely to be commonly used in children or
that represent a meaningful therapeutic benefit over existing
treatments for children contain adequate pediatric labeling for the
approved indications at the time of, or soon after, approval. The rule
would therefore require a manufacturer of a drug classified as a ``new
chemical entity'' or a new (never-before-approved) biological product
to submit, before approval, safety and effectiveness information on
relevant pediatric age groups for the claimed indications. The
[[Page 43903]]
submission of information could be deferred until after approval if,
for example, pediatric studies should not begin until information on
adults was collected, or where the collection and filing of pediatric
data would delay the availability of a product that provides a
significant therapeutic advantage to adults. The requirement would be
waived for some or all pediatric age groups, if: (1) The product did
not represent a meaningful therapeutic benefit over existing treatments
for pediatric patients and was unlikely to be used in a substantial
number of pediatric patients, (2) studies on the product were
impossible or highly impractical because, for example, the population
was too small or geographically dispersed, (3) the product were likely
to be unsafe or ineffective in pediatric patients, or (4) reasonable
efforts to develop a pediatric formulation (if one were needed) had
failed.
The rule is also intended to assist in improving pediatric use
information for already marketed drugs and biological products where
there is a compelling need for more information. The rule would
therefore codify FDA's authority, discussed in the 1994 rule, to
require, in compelling circumstances, that manufacturers of already
marketed drugs and biological products conduct studies to support
pediatric use labeling for the claimed indications.
The proposed rule also contains provisions designed to encourage
discussions of the need for pediatric studies early in the drug
development process, as well as postmarketing reporting requirements
designed to assist FDA in determining whether pediatric studies are
needed for particular products and whether required studies are being
carried out with due diligence.
FDA notes that the Federal Food, Drug, and Cosmetic Act (the act)
authorizes FDA, under certain circumstances, to grant periods of
exclusive marketing to manufacturers who obtain approval of labeling
supplements adding pediatric use information to a drug's label. First,
a manufacturer is entitled to 3 years of exclusive marketing under
section 505(c)(3)(D)(iii) and (j)(4)(D)(iv) of the act (21 U.S.C.
355(c)(3)(D)(iii) and (j)(4)(D)(iv)) for obtaining approval of
pediatric use labeling based on clinical studies, other than
bioavailability studies. Second, a manufacturer may be entitled to 7
years of exclusive marketing under the Orphan Drug Amendments for
obtaining approval of an application for use of a drug to treat a
disease or condition affecting a pediatric population of less than
200,000.
A. Scope
The proposed rule would cover only original applications for those
drugs classified as ``new chemical entities,'' including antibiotics,
and new biological drug products that have never been approved for any
indication. A ``new chemical entity,'' defined in 21 CFR 314.108(a), is
a drug that contains no previously approved active moiety. (An ``active
moiety,'' also defined in Sec. 314.108(a), is the molecule or ion,
excluding certain appendages, that is responsible for the physiological
or pharmacological action of the drug.) New chemical entities and new
biological products are generally the most innovative and
therapeutically significant of the new drug products approved by FDA.
In an effort to limit the scope of the rule to those products for
which pediatric labeling is most urgently needed and to minimize the
burden on manufacturers and on agency resources available to review new
product applications, FDA has tentatively concluded that the pediatric
study requirement would not apply to subsequent applications for the
drug or biological product, e.g. to supplements for new indications or
dosage forms. FDA recognizes that, in some cases, a change to an
approved product, particularly a new indication, may have clinically
significant use in children. FDA seeks comment on whether the
requirement should apply more broadly, e.g., to applications for minor
chemical variations of approved products, new indications, new dosage
forms or new routes of administration, and, if so, how the rule could
be applied in a manner that does not impose undue burdens on
manufacturers or agency resources.
The proposed rule would require an assessment of safety and
effectiveness in one subpopulation (pediatric patients) only for the
indications already claimed by the manufacturer. It would not require a
manufacturer to study its product for unapproved (``off-label'')
indications, even if the product were widely used in pediatric patients
for those indications. Although the proposed rule would not apply to
unapproved pediatric indications, nothing in the rule would diminish
the physician's power to prescribe drugs and biological products for
such unapproved indications.
B. Not-Yet-Marketed Drug and Biological Products
1. Sections 312.23(a)(3)(v), 312.33(a)(8), and 312.47(b)(1)(i) and
(b)(2) (21 CFR 312.23(a)(3)(v), 312.33(a)(8), and 312.47(b)(1)(i) and
(b)(2))--Early Discussion of Plans for Pediatric Studies
In the development of a new drug or biological product, decisions
about appropriate populations to study and the design of such studies
must often be made well before the submission of an NDA or BLA. FDA has
identified several critical points in the drug development process,
before submission of an NDA or BLA, during which the sponsor and FDA
should focus on the sponsor's plans to assess pediatric safety and
effectiveness. These time points include: Any pre-investigational new
drug application (IND) meeting or ``end of phase 1'' meeting for a drug
designated under subpart E of part 312 (21 CFR part 312), the IND
submission, the IND annual report, any ``end of phase 2'' meeting, the
presentation of the IND to an FDA drug advisory committee, and any pre-
NDA or pre-BLA meeting. Of these, the pre-IND meeting, the ``end of
phase 1'' meeting, the IND submission, the IND annual report, the ``end
of phase 2'' meeting, and the pre-NDA meeting are codified in part 312,
FDA's regulations governing IND's.
FDA has already proposed to amend the IND annual report requirement
to include discussion of pediatric studies (60 FR 46794, September 8,
1995). FDA is proposing to amend the remaining regulations to specify
that these meetings and reports should include discussion of the
assessment of pediatric safety and effectiveness. To assist
manufacturers in planning for studies that may be required under this
proposed rule, FDA is also proposing to inform manufacturers at the
``end of phase 2'' meeting, or at the earliest appropriate opportunity,
of the agency's best judgment, at that time, of the pediatric studies
that will be required for the product and when the studies should be
submitted.
In addition to the discussions of pediatric testing codified in
this proposed rule, FDA will also assist manufacturers by providing
early consultations on chemistry and formulation issues raised by
requirements under this rule.
2. Sections 314.50(g)(1) and 601.27--Required Studies
Under proposed Secs. 314.50(g) and 601.27(a), an original
application for a drug classified as a new chemical entity or an
application for a new biological
[[Page 43904]]
product would be required to contain data adequate to assess the safety
and effectiveness of the drug product for all pediatric age groups for
the claimed indications, unless FDA granted a deferral or full or
partial waiver of the requirement. Assessments required under this
section for a product that represented a meaningful therapeutic benefit
over existing treatments would have to be carried out using appropriate
formulations for the age group(s) for which the assessment is required
(see ``Pediatric Formulations,'' in section V.E of this document),
unless reasonable efforts to produce a pediatric formulation had failed
(see ``Waivers,'' in section V.B.4 of this document).
The proposed rule does not mandate particular types of studies. The
sponsor should consult with FDA on the types of data that will be
considered adequate to assess pediatric safety and effectiveness. As
described in the 1994 final rule, gathering adequate data to establish
pediatric safety and effectiveness may not require controlled clinical
trials in pediatric patients. Where the course of the disease and the
product's effects are similar in adults and children, FDA may conclude
that pediatric safety and effectiveness can be based on adult
effectiveness data together with pharmacokinetic and safety data in
pediatric patients. The proposed rule also does not necessarily require
separate studies in pediatric patients. In appropriate cases, adequate
data may be gathered by including pediatric patients as well as adults
in the original studies conducted on the product.
3. Sections 314.50(g)(2), 314.81(b)(2)(vii), and 601.27(b)--Deferred
Submission and Postmarketing Reports
In some cases, pediatric testing should not begin until certain
safety and/or effectiveness information in adults has been collected.
FDA believes that in certain cases it may be appropriate to defer
submission of pediatric studies. For example, in such cases, an NDA or
biological product license could be ready for approval for adult use
before pediatric studies were completed. Also, where a product was
needed to treat a serious or life-threatening disease for which there
were not satisfactory alternative therapies or where the product
represented a meaningful therapeutic benefit over existing therapies,
it would be contrary to the public health to delay approval until
pediatric studies were submitted.
Proposed Secs. 314.50(g)(2) and 601.27(b) would permit FDA to defer
the submission of some or all of the required pediatric data until
after approval of the product for adult use, on its own initiative or
at the request of the applicant. If the applicant requested deferral,
the request would be required to contain an adequate justification for
delaying pediatric studies. If FDA concluded that there were adequate
justification for deferring the submission of pediatric use studies,
the agency could approve the product for use in adults subject to a
requirement that the applicant submit the required pediatric studies
within a specified time after approval. FDA would consult with the
sponsor in determining a deadline for the deferred submission, but
would ordinarily require the submission not more than 2 years after the
date of the initial approval. The deadline for submission of studies
would take account of likely or actual difficulties encountered in
recruiting pediatric patients to the study. FDA seeks comment on the
circumstances in which FDA should permit deferral. FDA also seeks
comment on factors that should be considered in determining whether a
product is among those that should be studied in adults before
children.
To ensure that deferral would not unnecessarily delay the
submission of pediatric use information, FDA has tentatively concluded
that a request for deferred submission should include a description of
the planned or ongoing pediatric studies, and evidence that the studies
were being or would be conducted: (1) With due diligence, and (2) at
the earliest possible time. To permit FDA to monitor the conduct of
postapproval studies to ensure that they were carried out with due
diligence, FDA is proposing to amend Sec. 314.81(b)(ii) of the
postmarketing reports requirements to require applicants to include in
their annual reports whether they have been required to conduct
postmarket pediatric studies and, if so, to report the status of those
studies. (Additional postmarketing reporting requirements are described
under ``Remedies,'' in section V.G of this document.) FDA seeks comment
on the types of evidence FDA should examine to ensure that deferred
studies are carried out in a timely fashion.
4. Sections 314.50(g)(3) and 601.27(c)--Waivers
FDA does not intend to require pediatric assessments unless the
product represents a meaningful therapeutic benefit over existing
treatments or is expected to be widely used in pediatric patients. FDA
also does not intend to require pediatric assessments in other
situations where the study(ies) necessary to carry out the assessment
are impossible or highly impractical or would pose undue risks to
pediatric patients. Thus, Secs. 314.50(g)(3) and 601.27(c) would
require FDA to grant a waiver of the pediatric study requirement on its
own initiative or at the request of the applicant if: (1) The product
(a) did not represent a meaningful therapeutic benefit over existing
treatments, and (b) was not likely to be used in a substantial number
of pediatric patients as a whole, or was not likely to be used in a
substantial number of one or more pediatric subpopulations, or (2)
necessary studies were impossible or highly impractical, because, for
example, the number of such patients was so small or geographically
dispersed, or (3) there were evidence strongly suggesting that the
product would be ineffective or unsafe in some or all pediatric
populations. If a waiver were granted because there was evidence that
the product would be ineffective or unsafe in pediatric patients, this
information would be included in the product's labeling.
An applicant could request a full waiver of all pediatric studies
if one or more of the grounds for waiver applied to the pediatric
population as a whole. A partial waiver permitting the applicant to
avoid studies in particular pediatric age groups could be requested if
one or more of the grounds for waiver applied to one or more pediatric
age groups. In addition to the other grounds for waiver, the proposed
rule would authorize FDA to grant a partial waiver for those age groups
for which a pediatric formulation was required (see ``Pediatric
Formulations,'' in section V.E of this document), if reasonable
attempts to produce a pediatric formulation had failed.
The proposed rule would require the applicant to include in the
request for a waiver an adequate justification for not providing
pediatric use information for one or more pediatric populations. For
example, the waiver request could demonstrate that the product was
indicated for a disease that does not occur in a substantial number of
pediatric patients (e.g., drugs for breast or prostate cancer). The
waiver request could demonstrate that the product was a member of a
drug class known to be unsafe in specific pediatric age groups (e.g.,
chloramphenicol, an antibiotic, which has caused serious adverse events
in neonates. Also, it is widely known that, except for serious or life
threatening diseases where alternative therapy is needed, quinolones,
anti-malarial agents, are not recommended in young children due to
concerns about cartilage and bone development).
[[Page 43905]]
Animal toxicity data or imautere metabolic pathways for newborns are
examples of data that may be used to demonstrate that the product was a
member of a drug class known to be unsafe in specific pediatric age
groups.
FDA would grant the waiver request if the agency found that there
was a reasonable basis on which to conclude that any of the grounds for
a waiver had been met. A full waiver would be appropriate where, for
example, the product did not represent a meaningful therapeutic advance
and was not likely to be used in a substantial proportion of any
pediatric age group. A partial waiver would be appropriate where, for
example, the product was likely to be used in substantial numbers in
some pediatric age groups but not others, where the product was likely
to be unsafe or ineffective in some age groups, or where reasonable
efforts to develop a pediatric formulation necessary for some age
groups had failed. If a waiver were granted on the ground that it was
not possible to develop a pediatric formulation, the waiver would cover
only those pediatric age groups requiring a pediatric formulation.
The agency solicits comments on the proposed grounds for waiving
the pediatric study requirement and whether additional grounds may
exist, such as whether cost should justify waiver of the pediatric
study requirement. Additionally, FDA seeks comment on defining the term
``meaningful therapeutic benefit''. Comment is also requested on, what
should be considered a ``substantial number'' of pediatric patients,
i.e., how the agency should establish a level of expected use in
pediatric patients below which pediatric labeling would not be required
for a drug that did not represent a meaningful therapeutic advance. FDA
is considering two possible methods. The first method would focus on
the number of times the drug was expected to be used in pediatric
patients, annually. Under this method, FDA has tentatively concluded
that 100,000 or more prescriptions or uses per year in all pediatric
age groups would be considered a substantial number. Products that
might require studies under this test include anesthetics,
anticonvulsants, asthma drugs, antidepressants, antimicrobials and
antivirals, vaccines, and drugs to treat certain skin conditions. FDA
has also tentatively concluded that a partial waiver for a particular
pediatric age group would be available under this method if the product
were expected to be prescribed or used fewer than 15,000 times per year
in that age group.
The second possible method for establishing the level of expected
use would focus on the number of pediatric patients affected by the
disease or condition for which the product is intended. Physician
mention data from the IMS National Disease and Therapeutic Index
1, shows pediatric use of certain products generally falling
within two ranges (i.e., those products either exceeding 100,000
physician mentions for pediatric use per year or those falling below
15,000 physician mentions for pediatric use per year. Thus, under this
method, FDA has tentatively concluded that 100,000 pediatric patients
affected by the disease or condition for which a product was indicated
would be considered a ``substantial number'' of pediatric patients. A
partial waiver for a particular pediatric age group would be available
under this method if fewer that 15,000 patients in that age group were
affected by the disease or condition. FDA seeks comment on these
methods of assessing expected pediatric exposure and on the specific
numerical thresholds suggested.
---------------------------------------------------------------------------
\1\ IMS, National Disease and Therapeutic Index, IMS America;
Plymouth Meeting, PA.
---------------------------------------------------------------------------
5. Section 314.50(d)(7)--Pediatric Use Section of Application
Under proposed Sec. 314.50(d)(7), applicants would be required to
include in their applications a section summarizing and analyzing the
data supporting pediatric use information for the claimed indications.
The proposed new section of the application would contain an integrated
summary of the clinical pharmacology studies, controlled clinical
studies, uncontrolled clinical studies, or other data or information
that are relevant to the safety and effectiveness, and benefits and
risks of the drug in pediatric populations. Because full descriptions
of all such studies must already be provided under Sec. 314.50 (d)(3)
and (d)(5), the new pediatric use section would be required to contain
only brief summaries of the studies together with a reference to the
full description of each provided elsewhere in the application.
C. Marketed Drug and Biological Products
1. Section 201.23--Required Studies
As discussed in the preamble to the 1994 rule, FDA has the
authority, under certain circumstances, to require the manufacturers of
marketed drugs that are used in pediatric patients to submit pediatric
studies assessing safety and effectiveness for the already approved
indications (59 FR 64240 at 64243). Proposed Sec. 201.23 would
authorize FDA to require a manufacturer of a marketed drug or
biological drug product to submit an application containing data
evaluating the safety and effectiveness of the product in pediatric
populations, in compelling circumstances. FDA has tentatively concluded
that it should impose such a requirement only where the agency made one
of two findings that: (1) The product was widely used in pediatric
populations and the absence of adequate labeling could pose significant
risks to pediatric patients; or (2) the product was indicated for a
very significant or life threatening illness, but additional dosing or
safety information was needed to permit its safe and effective use in
pediatric patients.
Before requiring a study under Sec. 201.23, the appropriate center,
CDER or CBER, would consult with the manufacturer on the type of
studies needed and on the length of time necessary to complete them and
would notify the manufacturer, by letter, of the center's tentative
conclusion that such a study was needed and provide the manufacturer an
opportunity to provide a written response and to have a meeting with
the center. At the center's discretion, such a meeting could be an
advisory committee meeting. If, after reviewing any written response
and conducting any requested meeting, CDER or CBER determined that
additional pediatric use information were necessary, the center
director would issue an order requiring the manufacturer to submit a
supplemental application containing pediatric safety and effectiveness
data within a specified time. The manufacturer would be able to request
reconsideration by the Commissioner for Food and Drugs (the
Commissioner) of the order under the provisions at 21 CFR 10.33.
Proposed Sec. 201.23(c) would require FDA to grant full or partial
waivers of study requirements on their own initiative or at request of
the applicant for reasons analogous to those which would entitle not-
yet-marketed drug and biologic products to waivers.
FDA seeks comment on whether it should codify its authority to
require the manufacturers of marketed drugs to conduct pediatric
studies, and, if so, the circumstances under which the agency should
exercise that authority. The agency also solicits comment on the
proposed grounds for waiving the pediatric study requirement for
already marketed drug and biological products and whether additional
ground may exist, such as whether cost should justify waiver of the
pediatric study requirement. Comment is also sought on
[[Page 43906]]
defining the term ``very significant illness''.
D. Studies in Different Pediatric Age Groups
Because the pharmacokinetics and pharmacodynamics of a drug or
biological product may be different in different pediatric age groups
or stages of development, it could be necessary to conduct studies in
more than one pediatric age group. The following age categories for the
pediatric population are commonly distinguished: (1) Neonates; (2)
infants; (3) children, and (4) adolescents. In the 1994 rule, FDA
defined neonates as birth up to 1 month, infants as 1 month to 2 years,
children as 2 years to 12 years, and adolescents as 12 years to 16
years (59 FR 64242). The need for studies in more than one age group
would depend on whether the drug or biological product was likely to be
used in each age group (see ``Waivers,'' in sections V.B.4 and V.C.1 of
this document) and whether safety and effectiveness in one age group
could be extrapolated to other age groups. The metabolism and
elimination of the drug and the stage of development of the child may
be important in determining which age groups should be tested. There
would generally need to be sufficient data, including pharmacokinetic
data to establish dosing and safety for each group. (Pharmacokinetic
data are generally collected from pediatric patients receiving the drug
or biologic as treatment rather than from healthy children.) In cases
where the product was expected to have similar pharmacokinetics in more
than one age group, pharmacokinetic data from one age group could be
sufficient to support labeling for other age groups. Such extrapolation
would not be routine.
FDA recognizes that studies in neonates and young infants present
special problems. On one hand, failure to adequately test drugs in this
age group has led to both under treatment and, conversely, some of the
most serious therapeutic mishaps known to have occurred among pediatric
patients. On the other hand, studies in this age group may be
significantly more difficult to carry out in the period before or soon
after approval than studies in older age groups. However, FDA
recognizes that for some conditions, early study would be advantageous.
FDA would therefore expect to apply the study requirement to patients
in this age group with caution and would, whenever appropriate, permit
such studies to occur after the product has been successfully studied
in older children. The agency seeks comment on the issues raised by
requiring studies in this age group.
E. Pediatric Formulations
In some cases, testing of a product in pediatric patients could
require the development of a pediatric formulation. Many children below
a certain age are unable to swallow pills and may require a liquid,
chewable or injectable form of the product. The need to develop a
pediatric formulation does not necessarily mean that the product would
not have been used in children in its adult dosage form. In many cases,
physicians prescribing tablets to young children direct the parent to
grind up the tablet and sprinkle the powder into the child's food. In
other cases, pharmacists may compound tablets into pediatric
formulations of their own choosing. These methods of administering
adult dosage forms to children may be unsatisfactory, however, because
the bioavailability of any particular product in this form is untested
and dosing may be highly variable. A standardized pediatric formulation
ensures bioavailability and consistency of dosing, and permits
meaningful testing of safety and effectiveness.
FDA has tentatively concluded that it would be reasonable to expect
a manufacturer of a product to produce a pediatric formulation, if one
were necessary, only in those cases where a new drug or new biological
product provided a meaningful therapeutic benefit over existing
treatments, and where the study requirement had not been waived in the
age group requiring the pediatric formulation. Proposed Secs. 201.23,
314.50(g)(1) and 601.27(a) contain this requirement. The type of
formulation needed would vary depending on the age group in which the
product were to be used and the disease being treated. Young children
unaccustomed to taking drugs may need liquid or chewable formulations,
while children with serious and chronic diseases may need only smaller
tablets.
The difficulty and cost of producing a pediatric formulation may
vary greatly depending upon such factors as solubility of the compound
and taste. FDA would waive the requirement for pediatric studies (see
``Waivers,'' in section V.B.4 of this document) in age groups requiring
a pediatric formulation, if the manufacturer provided evidence that
reasonable attempts to produce a pediatric formulation had failed.
FDA solicits comment on whether it is appropriate to require a
manufacturer to develop a pediatric formulation and, if so, the
circumstances in which it would be appropriate to impose such a
requirement. For example, should the cost of developing a pediatric
formulation justify a waiver of the pediatric study requirement? Should
the number of patients affected by the disease or condition in the
relevant age group be considered in determining whether to require the
development of a pediatric formulation for that age group? Is it
appropriate to ask the manufacturer of a not-yet-approved product to
allocate resources to developing pediatric formulation(s)? Where cost
is a significant issue, would it be appropriate to defer development of
a pediatric formulation until after approval of the product? What
should be considered ``reasonable attempts'' to develop a pediatric
formulation?
As noted above, FDA was unable to quantify the potential benefits
of this rule due to the unavailability of relevant data and studies.
Nevertheless, the agency will attempt to assess the benefits of the
final rule and solicits comment on the appropriate design and
methodology of such measurement. In particular, FDA seeks information
and data that would help the agency to: (1) Quantify the societal costs
of the adverse drug events experienced by pediatric populations and (2)
assess the proportion of these adverse drug events that would be
eliminated by the new information that would result from the rule. In
addition, FDA seeks information and data that would help the agency to:
(1) Quantify the societal costs of the underused or inadequate drug
therapies prescribed to pediatric populations and to (2) assess the
proportion of these costs that would be eliminated by the new
information that would result from the rule.
F. Ethical Issues
Ethical concerns may have contributed to reluctance to conduct
studies in pediatric patients. To address these concerns, both the
American Academy of Pediatrics (Ref. 1) and the Department of Health
and Human Services, 45 CFR part 46, subpart D, have developed
guidelines or regulations for the ethical conduct of clinical studies
in pediatric patients. Because pediatric patients represent a
vulnerable population, special protections are needed to protect their
rights and to shield them from undue risk. As the American Academy of
Pediatrics has observed, however, administration of untested drugs
``may place more children at risk than if the drugs were administered
as part of well-designed, controlled clinical trials'' (Ref. 1 at p.
286). The ethical guidelines currently in place are designed to
[[Page 43907]]
protect children's rights and protect them from undue risk. Sponsors
should adhere to these guidelines for pediatric studies conducted under
this rule. The agency seeks comment on ethical issues that may be
raised by this proposal.
G. Remedies
FDA has tentatively concluded that the most practical remedy for
failure to submit a required study is an injunctive action brought
under the ``misbranding'' or ``new drug'' provisions of the act.
Denying or withdrawing approval of an otherwise safe and effective drug
or biological product is not a satisfactory remedy, because removal of
a product from the marketplace could deprive other patients of the
benefits of a useful medical product. FDA does not intend to deny or
withdraw approval of a product for failure to conduct pediatric
studies, except possibly in rare circumstances.
If a manufacturer failed, in the time allowed, to submit adequate
studies to evaluate pediatric safety and effectiveness, under proposed
Secs. 201.23(d) or 314.50(g), FDA could consider the product misbranded
under section 502 of the act (21 U.S.C. 352) or an unapproved new drug
under section 505(a) of the act (see ``Legal Authority,'' in section VI
of this document). When a product is misbranded or an unapproved new
drug, sections 302, 303 and 304 of the act (21 U.S.C. 332, 333, and
334) authorize injunction, prosecution or seizure. For violations of
this rule, should it become final, FDA would ordinarily expect to file
an enforcement action for an injunction, asking a Federal court to
require the company to submit an assessment of pediatric safety and
effectiveness for the product. Violation of the injunction would result
in a contempt proceeding or such other penalties as the court ordered,
e.g., fines.
To assist FDA in determining whether pediatric assessments are
needed or are being carried out with due diligence, FDA is proposing to
amend Sec. 314.81 (other postmarketing reports) to require that annual
reports filed by the manufacturer contain information on labeling
changes that have been initiated in response to new pediatric data,
analysis of clinical data that have been gathered on pediatric use,
assessment of data needed to ensure appropriate labeling for the
pediatric population, and information on the status of ongoing
pediatric studies. Where possible, the annual report would also contain
an estimate of patient exposure to the drug product, with special
reference to the pediatric population.
FDA seeks comment on appropriate remedies for failure to conduct a
required pediatric study and the circumstances, if any, in which the
agency should deny or withdraw approval of a drug product.
VI. Legal Authority
Therapeutic tragedies in pediatric patients have prompted some of
the most important federal legislation to ensure that drugs are safe
and effective. For example, the act was enacted in 1938 in the wake of
a tragedy in which many pediatric patients died after taking an
untested medicine called Elixir of Sulfanilamide. The legislative
history of this enactment demonstrates that Congress intended to ensure
that children, as well as adults, received adequately tested and
appropriately labeled drugs. (See, e.g., 78 Congressional Record 567-
573 (1934) (statement of Sen. Copeland).)
Every mother is anxious that the food and medicine given her
baby shall be above suspicion. The welfare of every man, woman, and
child is involved in the quality and preparation of the foods and
drugs sold in America * * *. [T]he purpose of this legislation * * *
is to protect the public, to protect the mothers and the children *
* *
81 Congressional Record 7312 (1937) (remarks of Rep. Coffee)
The agency has stated, in the context of both pediatric studies and
studies in women, that an application for marketing approval should
contain data on a reasonable sample of the patients likely to be given
a drug or biological product once it is marketed (59 FR 64240 at 64243;
58 FR 39406 at 39409, July 22, 1993). The agency has further stated
that in some cases it could require studies in pediatric patients and
in women for both not-yet-approved products and marketed products (Id).
The primary rationale for such a requirement is the same for women
and pediatric patients. In most cases, drugs and biological products
behave similarly in demographic subgroups, including age and gender
subgroups, even though there may be variations among the subgroups,
based on, for example, differences in pharmacokinetics. Thus, where a
drug or biological product is indicated for a disease suffered equally
by men, women, and children, and is not contraindicated in women or
pediatric patients, the product will be widely prescribed for all three
subgroups even if it were studied only in, or labeled only for, men. As
described above, there is extensive evidence that many drugs labeled
only for adult use are in fact widely used in pediatric patients for
the same indications.
FDA notes that this proposal addresses only use of drug products
for their approved indications in a significant subpopulation. The
proposed rule does not address ``off-label'' or unapproved uses of
approved drugs and biological products, in which an approved product is
used for diseases or conditions other than those in the label. This
rule would apply only where a product was expected to have clinically
significant use in pediatric populations for the indications already
claimed by the manufacturer.
In addition to the provisions cited below as authority for the
proposed rule, the agency relies on section 701(a) of the act (21
U.S.C. 371(a)), which authorizes FDA to issue regulations for the
efficient enforcement of the act.
A. New Drug and Biological Products
Biological drug products are subject both to section 351 of the
Public Health Service Act (the PHS Act) and to the provisions of the
act and implementing regulations applicable to drugs, except that
manufacturers of biological products covered by approved BLA's are not
required to submit NDA's under section 505 of the act. References to
``drugs'' in the following sections include biological drugs.
1. Sections 502(a), 502(f), 505(d)(7), and 201(n) of the Act
A drug is misbranded under section 502(a) of the act if its
labeling is ``false or misleading in any particular.'' Similarly, a new
drug application must contain labeling that is not false or misleading
(section 505(d)(7) of the act). Section 201(n) of the act (21 U.S.C.
321(n)) defines labeling as misleading if it ``fails to reveal facts
material * * * with respect to consequences which may result'' not only
from use of the product as labeled, but ``from the use of the [product]
* * * under such conditions of use as are customary or usual.''
Information on dosing and adverse effects are facts ``material'' to the
consequences that may result from customary use in pediatric patients.
A drug product is misbranded under section 502(f) of the act, if its
label fails to provide adequate directions for each intended use. 21
CFR 201.5 states that adequate directions must be provided for each use
recommended in the labeling and each use ``for which the drug is
commonly used.'' Thus, FDA may require a product to carry labeling that
provides safety and effectiveness information on use in subpopulations
in which the product is customarily or commonly used.
[[Page 43908]]
There is extensive evidence that drugs for diseases that affect
both adults and pediatric patients are routinely used in pediatric
patients despite the absence of pediatric labeling, and even in the
face of disclaimers stating that safety and effectiveness have not been
established in children. FDA may therefore consider pediatric use to be
``customary or usual'' or ``commonly used'' where the drug is indicated
for a disease or condition that affects both adults and children, and
the drug is not contraindicated in pediatric patients. In many cases,
the use in pediatric patients of a drug labeled only for adults will
increase over time, as physicians become aware of the drug's potential
usefulness in children and familiar with the drug's uses and effects.
Thus, FDA may conclude that a drug that was appropriately labeled for
adult use at the time of approval is, at some later date, no longer
appropriately labeled.
2. Sections 201(p), 301(a), and 505(a) of the Act
Under section 301 (a) and (d) of the act (21 U.S.C. 331 (a) and
(d)) and section 505(a) of the act, a drug product is subject to
enforcement action if it is a ``new drug'' for which no NDA has been
approved. A product is a new drug under section 201(p) of the act if it
is not recognized to be safe and effective under the conditions
``prescribed, recommended, or suggested'' in the drug's labeling. There
is widespread evidence that, despite the absence of pediatric labeling,
drugs are routinely used in pediatric patients for the labeled
indications. FDA may therefore consider pediatric use to be
``suggested'' in a drug's labeling where the drug is indicated for a
disease or condition that affects both adults and pediatric patients,
unless the drug is specifically contraindicated for pediatric patients.
As described above, because pediatric use of new drugs often increases
over time, FDA may conclude that labeling that is appropriate at the
time of approval is later no longer appropriate.
3. Section 502(j) of the Act
Section 502(j) of the act defines as misbranded those drugs that
are dangerous to health when used in the manner prescribed,
recommended, or suggested in their labeling. FDA may consider pediatric
use to be ``suggested'' in a drug's labeling where the drug is
indicated for a disease or condition that affects both adults and
pediatric patients, unless the drug is specifically contraindicated for
pediatric patients. As described earlier in this notice, the absence of
pediatric testing and labeling poses risks to children including the
risk of unanticipated adverse reactions, and under- and over-dosing.
4. Section 505 (i) and (k) of the Act
Section 505(i) of the act that authorizes the issuance of
regulations governing the use of investigational drugs, and the proviso
in 505(k) of the act, which requires regulations issued under 505(i) to
have ``due regard * * * for the interests of patients,'' together
authorize FDA to impose conditions on the investigation of new drugs,
including conditions related to the ethics of a proposed investigation
and to the interests of patients. Fairness in distribution of the
burdens and benefits of research is one of the ethical principles
underlying federal regulations on investigational drugs. (See, e.g., 44
FR 23192 at 23194, April 18, 1979 (``Belmont Report: Ethical Principles
and Guidelines for the Protection of Human Subjects of Research'').)
Because exclusion of pediatric patients from clinical trials may deny
them an equitable share of the benefits of research, section 505 (i)
and (k) authorize FDA to require their inclusion in clinical trials.
5. Section 351 of the Public Health Service Act
Section 351 of the PHS Act (42 U.S.C. 262) provides authority to
regulate the labeling and shipment of biological products. Under
section 351(d), licenses for biological products are to be issued only
upon a showing that they meet standards ``designed to insure the
continued safety, purity, and potency of such products'' prescribed in
regulations. The ``potency'' of a biological product includes its
effectiveness (21 CFR 600.3(s)).
B. Marketed Drug Products
1. Section 502(f) of the Act and 21 CFR 201.5
A drug product is misbranded under section 502(f) of the act, if
its label fails to provide adequate directions for each intended use.
21 CFR 201.5 states that adequate directions must be provided for each
use recommended in the labeling and each use ``for which the drug is
commonly used.'' Where there is evidence that a drug product is widely
used in pediatric patients, failure to provide adequate directions for
the use could misbrand the product.
2. Sections 502(a) and 201(n) of the Act
A drug is misbranded under section 502(a) of the act if its
labeling is false or misleading. Section 201(n) of the act defines
labeling as misleading if it fails to reveal facts that are material in
light of the consequences of the customary or usual use of the product.
Where a drug is widely used in pediatric patients, FDA may consider
pediatric use to be ``customary.'' Failure to provide adequate
information on dosing and adverse effects in the pediatric population
could render the product misbranded, even where the manufacturer does
not promote the product for that subpopulation.
3. Section 502(j) of the Act
Section 502(j) of the act defines as misbranded those drugs that
are dangerous to health when used in the manner prescribed,
recommended, or suggested in their labeling. FDA may consider pediatric
use to be ``suggested'' in a drug's labeling where the drug is
indicated for a disease or condition that affects both adults and
pediatric patients, unless the drug is specifically contraindicated for
pediatric patients. As described earlier in this notice, the absence of
pediatric testing and labeling poses risks to children including the
risk of unanticipated adverse reactions, and under- and over-dosing.
4. Section 505(k) of the Act
Section 505(k) of the act authorizes FDA to order the holder of an
approved NDA to submit reports of data necessary to determine whether
there are grounds to withdraw approval of the NDA. FDA has in the past
issued regulations under section 505(k) of the act (formerly section
505(j) of the act) requiring postapproval studies of certain drugs
(see, e.g., 21 CFR 310.303 (``Continuation of long-term studies,
records, and reports on certain drugs for which new drug applications
have been approved'')(1972); 21 CFR 310.304 (``Drugs that are subjects
of approved new drug applications and that require special studies,
records, and reports'')(1972); and 21 CFR 310.500 (``Digoxin products
for oral use; conditions for marketing'')(1974)). Section 505(k) of the
act also authorizes the agency to require other postmarketing reports
on drug products.
5. Section 351 of the Public Health Service Act
Section 351(d) of the PHS Act authorizes FDA to ensure the
``continued safety, purity, and potency'' of biological products.
Section 351(b) of the PHS Act prohibits false labeling of a biological
product.
VII. Implementation Plan
All applications for drug and biological products covered by the
final rule would be required to contain an assessment of pediatric
safety and effectiveness for the claimed
[[Page 43909]]
indications, unless the applicant has obtained a waiver or deferral of
this requirement from FDA.
FDA proposes that the final rule become effective 90 days after the
date of its publication in the Federal Register. For new drug and
biologic product applications submitted before the effective date of
the final rule, the agency proposes a compliance date of 21 months
after the effective date of the final rule. For new drug and biologic
product applications submitted on or after the effective date of the
final rule, the agency proposes a compliance date of 15 months after
the effective date of the final rule. The agency solicits comments on
the proposed effective date and proposed compliance dates.
VIII. Paperwork Reduction Act of 1995
This proposed rule contains information collection provisions that
are subject to review by the Office of Management and Budget (OMB)
under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
title, description, and respondent description of the information
collection provisions are shown below with an estimate of the annual
reporting and recordkeeping burden. Included in the estimate is the
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
each collection of information.
FDA invites comments on: (1) Whether the proposed collection of
information is necessary for the proper performance of FDA's functions,
including whether the information will have practical utility; (2) the
accuracy of FDA's estimate of the burden of the proposed collection of
information, including the validity of the methodology and assumptions
used; (3) ways to enhance the quality, utility, and clarity of the
information to be collected; and (4) ways to minimize the burden of the
collection of information on respondents, including through the use of
automated collection techniques, when appropriate, and other forms of
information technology.
Title: Pediatric Safety and Effectiveness Reporting Requirements
for Certain Drugs and Biological Products.
Description: FDA is proposing reporting requirements that include:
(1) Reports on planned pediatric studies in investigational new drug
applications (IND's) (proposed Sec. 312.23(a)(10)(iii)); (2) Reports
assessing the safety and effectiveness of certain drugs and biological
products for pediatric use in new drug applications (NDA's) and
biologic license applications (BLA's) or in supplemental applications
(proposed Sec. 314.50(g)(1)); (3) Analyses of data on pediatric safety
and effectiveness in NDA's (proposed Sec. 314.50(d)(7)); (4)
Postmarketing reports of analyses of data on pediatric safety and
effectiveness (proposed Sec. 314.81(b)(2)(vi)(C)); (5) Postmarketing
reports on patient exposure to certain marketed drug products, analyzed
and age (proposed Sec. 314.81(b)(2)(i)); (6) Postmarketing reports on
labeling changes initiated in response to new pediatric data (proposed
Sec. 314.81(b)(2)(vi)(C)); and (7) Postmarketing reports on the status
of required postapproval studies in pediatric patients (proposed
Sec. 314.81(b)(2)(vii)). The purpose of these reporting requirements is
to address the lack of adequate pediatric labeling of drugs and
biological products by requiring the submission of evidence on
pediatric safety and effectiveness for products with clinically
significant use in children.
Description of Respondents: Sponsors and manufacturers of drugs and
biological products.
Table 1.--Estimated Annual Reporting Burden
----------------------------------------------------------------------------------------------------------------
Annual
Number of frequency Total Hours per
CFR section respondents per annual response Total hours
response responses
----------------------------------------------------------------------------------------------------------------
201.23....................................... 2 1 2 16 32
314.50(d)(7)................................. 150 1 150 8 1,200
314.50(g)(1)................................. 10 1 10 16 160
314.50(g)(2)................................. 9 1 9 8 72
314.50(g)(3)................................. 15 1 15 8 120
314.81(b)(2)(i).............................. 625 1 625 1.5 937.5
314.81(b)(2)(vi)(c).......................... 625 1 625 1.5 937.5
314.81(b)(2)(vii)............................ 625 1 625 1.5 937.5
601.27(a).................................... 1 1 1 16 16
601.27(b).................................... 1 1 1 16 16
601.27(c).................................... 1 1 1 16 16
------------------------------------------------------------------
Total:................................... ........... ........... ........... ............ 4,444.5
----------------------------------------------------------------------------------------------------------------
There are no capital or operating and maintenance costs associated with this collection of information.
The agency has submitted the information collection provisions of
this proposed rule to OMB for review. Interested persons are requested
to send comments regarding information collection by September 15, 1997
to the Office of Information and Regulatory Affairs, OMB, New Executive
Office Bldg., 725 17th St. NW., rm. 10235, Washington, DC 20503, Attn:
Desk Officer for FDA.
IX. Environmental Impact
The agency has determined under 21 CFR 25.24 (a)(8), (a)(11), and
(e)(6) that this action is of a type that does not individually or
cumulatively have a significant effect on the human environment.
Therefore, neither an environmental assessment nor an environmental
impact statement is required.
X. Analysis of Impacts
FDA has examined the impacts of the proposed rule under Executive
Order 12866, the Regulatory Flexibility Act (5 U.S.C. 601-612), and the
Unfunded Mandates Reform Act (Pub. L. 104-4). Executive Order 12866
directs agencies to assess all costs and benefits of available
regulatory alternatives and, when regulation is necessary, to select
regulatory approaches that maximize net benefits (including potential
economic, environmental, public health and safety, and other
advantages; distributive impacts; and equity). Under the Regulatory
Flexibility Act, unless an agency certifies that a rule will not have
[[Page 43910]]
a significant economic impact on a substantial number of small
entities, the agency must analyze regulatory options that would
minimize the impact of the rule on small entities. The Unfunded
Mandates Reform Act (Pub. L. 104-4) (in section 202) requires that
agencies prepare an assessment of anticipated costs and benefits before
proposing any rule that may result in an annual expenditure by State,
local, and tribal governments, in the aggregate, or by the private
sector, of $100,000,000 or more (adjusted annually for inflation).
The agency has reviewed this proposed rule and has determined that
the proposed rule is consistent with the regulatory philosophy and
principles identified in Executive Order 12866, and these two statutes.
This proposal is a significant regulatory action as defined by the
Executive Order due to the novel policy issues it raises. With respect
to the Regulatory Flexibility Act, the Commissioner certifies that the
rule will not have a significant economic impact on a substantial
number of small entities. Since the proposed rule does not impose any
mandates on State, local, or tribal governments, or the private sector
that will result in an annual expenditure of $100,000,000 or more, FDA
is not required to perform a cost-benefit analysis according to the
Unfunded Mandates Reform Act.
A. Purpose
The FDA is proposing that a limited class of important new drugs
and biologicals that are likely to be used in pediatric patients
contain sufficient data and information to support directions for this
use. As the approved labeling for many of these new products lack
relevant pediatric information, any use in children greatly increases
the risk of inappropriate dosing, unexpected adverse effects, and
suboptimal therapeutic outcomes. The proposed rule is designed to
ensure that new drugs, including biological drugs, that are
therapeutically important and/or likely to be widely used in children
contain adequate pediatric labeling at the time of, or soon after,
approval.
B. Number of Affected Products and Required Studies
Neither the precise number of new drugs that would require
additional pediatric studies nor the cost of these studies can be
predicted with certainty. To develop plausible estimates, FDA examined
the pediatric labeling status at time of approval for each NME and
important biological approved from 1991 to 1995, and used these
estimates to project the cost that would have occurred had the proposed
rule been in place over that period. The agency assumes that future
costs would be reasonably similar. As shown in Table 2, each new drug
was assigned to one of three categories: (1) Therapeutically important,
some potential pediatric use, (2) other approvals, potential for wide
pediatric use, and (3) all other approvals. (The first two categories
include all products that the agency believes would have met the
therapeutic importance and pediatric use threshold criteria set forth
in this proposed rule. The third category includes all products that
would not have met these criteria.) For NME's, these category
assignments were based on pediatric pages completed by CDER's reviewing
division at the time of each approval, the priority review designation
for each drug, and physician mention data from the IMS National Disease
and Therapeutic Index.2 All priority NME's were assumed to
be therapeutically important, and assigned to the first category,
unless the drug's pediatric page specifically noted a low potential for
pediatric use or the IMS data indicated no pediatric use. For
nonpriority NME's, FDA assumed that wide pediatric use would have been
expected for only those products that exceeded 100,000 physician
mentions for pediatric use during 1995. Assessments of therapeutic
importance for biologicals were developed retrospectively by CBER.
---------------------------------------------------------------------------
\2\ IMS, National Disease and Therapeutic Index, IMS America;
Plymouth Meeting, PA. FDA's analysis does not include data from 1996
because the IMS data are not yet available.
---------------------------------------------------------------------------
As shown, 60 of the 142 approvals (42 percent) over this 5-year
period fell into the first two categories; that is, 47 drugs were
classified as therapeutically important with at least some potential
pediatric use and 13 less therapeutically important drugs were
designated as offering a potential for wide pediatric use based on
physician mentions. The 82 drugs (58 percent) grouped under the third
category would presumably not have met the therapeutic importance and
pediatric use criteria of the proposed rule.
Table 2.--Estimated Number of NME's and Biologicals Approved in 1991-95
[That Would Have Been Affected by the Proposed Rule]
------------------------------------------------------------------------
Number Percent
of of
Pediatric labeling status approved approved
drugs drugs
------------------------------------------------------------------------
Therapeutically important, some potential pediatric
use................................................ 47 33
Some pediatric labeling......................... 16 ........
No pediatric labeling........................... 31 ........
Other approvals, potential for wide pediatric
use............................................ 13 9
Some pediatric labeling......................... 7 ........
No pediatric labeling........................... 6 ........
-------------------
Subtotal.................................... 60 42
Some pediatric labeling......................... 23 ........
No pediatric labeling........................... \1\ 37 ........
All other approvals................................. 82 58
-------------------
Total Approvals............................. 142 100
------------------------------------------------------------------------
\1\ Pediatric page shows seven ongoing pediatric studies.
In assessing the amount of additional research that would have been
required for the 60 drugs from the first two categories (those that
would have potentially been affected by the proposed rule), FDA
believes that most would not have required extensive additional
clinical trials. As FDA explained in the 1994 final rule (59 FR 64240),
extrapolations from adult effectiveness data based on pharmacokinetics
studies and other safety data can be sufficient to provide the
necessary dosing pediatric information for those drugs that work by
similar mechanisms in adults and children. The agency estimates that
the majority of these 60 drugs could, to some extent, rely on such
extrapolations. Although the proposed rule identifies four pediatric
subgroups: (1) Neonates, (2) infants, (3) children, and (4)
adolescents, the need for studies in more than one age group depends on
the likely use of the drug in each age group and on whether relevant
data can be extrapolated to other age groups. As a rule, individual
clinical trials would rarely be required for each age group for a given
drug.
Estimates of the size of the studies that would have been required
to support pediatric labeling for these 60 drugs vary from 20 patients
where the simplest type of pharmacokinetic study
[[Page 43911]]
would be adequate, to 70 to 120 pediatric patients for studies where
some safety and effectiveness data would be needed, to several hundred
pediatric patients for studies where more substantial safety and
effectiveness data would be required. Thus, for the purpose of
developing order-of-magnitude cost estimates, FDA further subdivided
the 60 potentially affected drugs into three distinct groupings. The
first group of 30 drugs would have required the least amount of new
data and includes both the 7 drugs for which the CDER pediatric pages
indicate that pediatric trials were already underway and the 23 drugs
that already had at least some pediatric labeling at the time of
approval. Based on a review of those labels at approval time, FDA
estimated that up to half, or 15 of these 30 drugs may have needed
limited additional data that would have involved new studies with, on
average, 50 pediatric patients each.
Next, FDA assumed that 23 drugs (about three quarters of the
remaining 30) would have required new pediatric studies with data from
about 100 patients each. Finally, FDA assumed that the remaining 7
drugs would have needed more extensive safety and effectiveness data,
requiring 300 pediatric patients for each drug. Consequently, FDA
estimates that, if this proposed rule had been in effect from 1991 to
1995, sponsors of 45 of the 60 potentially affected drugs would have
needed to obtain additional data from about 5,150 pediatric patients
(15 drugs x 50 patients + 23 drugs x 100 patients + 7 drugs x 300
patients). The proposed regulation, therefore, would have required
additional pediatric research for an estimated average of 9 new drugs
and about 1,030 pediatric patients per year.
In addition, the proposed rule permits the agency to request
pediatric data for certain drugs that are already marketed. While the
precise impact of this regulatory provision is uncertain, FDA expects
that it would affect no more than two drugs per year. If the submission
for one of these drugs relied on data from 100 pediatric patients and
the other from 300 pediatric patients, the total number of drugs that
would have required additional research reaches 11 per year and the
total number of pediatric patients about 1,430 per year.
Other costs for pediatric research may accrue to drugs that
ultimately fail to gain regulatory approval. Although many drug
sponsors would wait until they are relatively certain that their
product will be shown safe and effective for the indicated use in
adults before spending substantial resources on pediatric uses, other
sponsors may need to begin pediatric examinations earlier to have data
included with the new drug or product licence application. It is
difficult for FDA to judge how much additional pediatric research would
be directed towards products that are not approvable. The agency notes,
however, that because only about 65 percent of all NME's that enter
phase III trials are eventually approved, the number of drugs entering
phase III trials is about 54 percent greater than the number of actual
approvals (100/65 = 1.54). Since some, but not all, of these
unapprovable drugs would initiate some pediatric research, FDA has
increased its estimate of the annual number of affected drugs and
pediatric patients by 30 percent, to a projected total of 14 drugs and
about 1,850 pediatric patients per year.
The agency is aware that forecasting future trends based on
historical data can be imprecise. For example, over time, even in the
absence of this rule, the percentage of new drugs with labels that
provide adequate pediatric use information could change. At this time,
however, FDA is not aware of any marked trend. Also, the above
estimates ignore those pediatric studies that were promised, but not
yet underway at the time of drug approval. To the extent that these
commitments are honored, the above estimates of research attributable
to the regulation are overstated. Finally, the methodology implies that
the standards used by FDA to judge the 1991-1995 approvals would remain
unchanged. While subsequent change is possible, FDA does not anticipate
that its present views would differ substantially. Thus, while
acknowledging substantial uncertainty, the agency's cost estimates are
based on the assumption that the proposed rule would require additional
research on about 14 drugs, involving a total of 1,850 pediatric
patients per year.
C. Cost of Studies
The agency finds that the cost of conducting clinical research with
pediatric patients varies directly with the size, duration, and
complexity of the clinical research. Although FDA has little detailed
information on the cost to drug sponsors of conducting research on
clinical patients, one private consulting firm reports that the costs
of hiring clinical investigators to conduct phase IV pediatric drug
trials ranges from $300-$500 per patient for studies on vaccines or
fevers to $3,600 and $5,000 per patient for renal disease and epilepsy,
respectively. \3\ Similarly, a number of academic researchers have
reported average costs of from $1,500 to $3,400 per patient for
pediatric trials. These estimates, however, do not account for the many
administrative, monitoring, data analysis, and document preparation
tasks that would be required of a drug sponsor. Since a published study
suggests that a total accounting of all sponsor costs may be three
times as great as investigator costs, \4\ FDA has assumed that the
average costs of conducting the newly required studies would range from
$5,000 to $9,000 per pediatric patient. As a result, the estimated
1,850 additional pediatric patients that would need to be studied
annually suggests new research costs to the pharmaceutical industry of
between $9.25 million and $16.65 million per year.
---------------------------------------------------------------------------
\3\ DataEdge, LLC, Faxed data, March 7, 1997.
\4\ Thomas Hill, ``Calculating the Cost of Clinical Research,''
Scrip Magazine, p. 29, March 1994.
---------------------------------------------------------------------------
In addition, the testing of a new drug in children would sometimes
require the development of a new pediatric dosage form. (Typically a
liquid or suspension formulation in place of a tablet or capsule.) Of
the 47 drugs identified in the first category of Table 2
(therapeutically important with some potential pediatric use), 14 (30
percent) were available only in tablets or hard capsules at the time of
approval. (Manufacturers of 4 of these 14 have since developed oral
suspensions.) It seems reasonable, therefore, to assume that, of the 14
new drugs per year estimated to require additional pediatric research,
about 4 might require new formulations. The agency solicits comment on
the estimate that four new formulations would be required per year.
The effort and cost of developing such formulations could be
substantial. Drug developers and manufacturers would have to find
appropriate solvents and develop additional data for demonstrating
adequate product stability, bioavailability, and production process
validation. While such costs would vary with the particular drug type,
one industry consultant suggests that per drug laboratory costs could
average from $300,000 to $500,000 and corresponding regulatory
requirements could bring this figure close to $1 million. Moreover,
this estimate assumes the availability of adequate preclinical data on
animal toxicity and metabolic rates. Since the proposed rule permits
FDA to waive the requirement for reformulation where reasonable
attempts have failed, the agency assumes that the additional costs
would not exceed $1 million apiece for 4
[[Page 43912]]
drugs, or an additional $4 million per year.
Finally, the rule will impose additional paperwork burdens related
to new label content, postmarket reporting requirements, and written
requests for deferred submissions and waivers. As shown above, FDA
estimates that these paperwork activities will require about 4,400
hours annually. At an average compensation rate of $50 an hour, this
cost amounts to about $220,000 per year.
In sum, FDA anticipates that the annual costs of this proposed rule
will total between $13.5 and $20.9 million per year.
D. Other Impacts
Other potential impacts would occur if the requirements contributed
to delays in the submittal of NDA's. Extended drug development times
would be associated with significant additional industry costs. FDA has
attempted to minimize the likelihood of regulatory delays through plans
for early consultation with drug sponsors and a willingness to consider
deferred submissions for pediatric studies. However, the agency
recognizes the importance of this issue and solicits public comment on
the best means to obtain adequate and timely pediatric information
without slowing the process for bringing new drugs to market. Also, as
noted earlier in this preamble, the agency is aware that new pediatric
supplements could impose additional user fees on drug sponsors and is
considering means to alleviate this added burden. All user fee issues
will be resolved before issuance of the final rule. Overall, therefore,
compared to the hundreds of millions of dollars typically required to
bring a new drug to market, FDA believes that the added regulatory
impact imposed by this rule would be unlikely to threaten the economic
viability of any promising research and development project.
E. Benefits
This proposed rule is aimed at addressing two problems associated
with inadequate directions for pediatric uses of drugs: (1) Avoidable
adverse drug reactions in children, i.e., drug reactions that occur
because of the use of inadvertent drug overdoses or other drug
administration problems that could have been avoided with better
information on appropriate pediatric use; and (2) undertreatment of
children with a potentially safe and effective drug, because the
physician either prescribed an inadequate dosage or regimen, prescribed
a less effective drug, or did not prescribe a drug, due to the
physician's uncertainty about whether the drug or the dose was safe and
effective in children. Thus, the primary benefits expected from this
proposed rule are the reductions in avoidable adverse drug reactions
and undertreatments that would result from better informing physicians
about whether, and in what dosages, a given drug was safe and effective
for use in children.
FDA is aware of no systematic data in the literature that evaluate
the magnitude of harm that results from inadequate information on the
use of drugs in children, although numerous anecdotes and case examples
exist. Physicians who care for HIV-infected children, for example, have
expressed frustration at their inability to treat these children with
drugs known to be effective in adults, because they lack information on
how to do so safely or effectively.5 As mentioned previously
in this preamble, history is replete with examples of children who have
died or suffered other serious adverse effects as a result of the use
of drugs that have not been tested in children and for which better,
alternative treatments were available. Many of these adverse events
(e.g., ``gray baby syndrome'' in babies treated with chloramphenicol)
develop quickly and would be detected in early clinical studies.
---------------------------------------------------------------------------
\5\ Time, March 1997.
---------------------------------------------------------------------------
While FDA could not develop a quantitative estimate of the
potential benefits of the proposed rule, the agency attempted to gain
some more systematic insight into the benefits that might accrue by
examining the rate at which each of 20 NME's (approved between 1991 and
1995) were mentioned in the 1996 IMS National Drug and Therapeutics
Index (an outpatient drug use data base). The drugs examined were all
of those that could be analyzed in this IMS data base, lack full
pediatric labeling, were considered to need further pediatric studies
at the time of approval, and would have been affected by the proposed
rule. FDA found that, after adjusting for the prevalence of the
relevant diagnoses in children and adults, 15 of the 20 drugs were
mentioned less frequently in association with pediatric treatments than
with adult treatments for the same set of approved indications. In 11
of these 15 drugs, pediatric treatment mentions were less than half as
frequent. Although it is not possible to conclude, based on these data,
that children with those diagnoses are necessarily undertreated
relative to adults, these data are consistent with the hypothesis that
the lack of pediatric labeling leads to suboptimal treatment of
children.
FDA also examined the number of adverse drug events (ADE's)
reported to the agency from 1991 through 1996 for all NME's approved
during that time. Of the 25 NME's associated with the highest number of
ADE's in children, 8 NME's (responsible for 1,273 pediatric ADE's
sufficiently severe to be reported to FDA) had no labeling for use in
children at all. An additional 5 NME's (responsible for 434 pediatric
ADE's) were labeled for use only in children age 12 and over.
Furthermore, of these 13 NME's, 11 would probably have been required to
be the subject of further pediatric studies (or of a justification for
the lack of studies) under the conditions of this proposed rule if it
had been in place at the time of the drug's approval. While it is not
possible to conclude that all (or even most) of these ADE's would have
been avoided had these drugs been fully labeled for pediatric use,
these data confirm that there is substantial pediatric use of drugs not
labeled for such use; that this use is associated with ADE's, including
serious ADE's; and that the improved knowledge and labeling that would
result from this proposed rule could bring significant benefits to
children treated with these drugs. The agency solicits information on
any available studies or data related to the incidence and costs of
either undertreatment or avoidable ADE's in pediatric age groups due to
the lack of information on the effects of pharmaceuticals.
F. Small Entities
FDA believes that this proposed rule will not have a significant
economic impact on a substantial number of small entities. New drug
development is typically an activity completed by large multinational
drug firms. FDA reviewed the size of every company that submitted the
60 new drug and biological applications that would likely have been
affected by this rule between 1991 and 1995 (see the first two
categories in Table 1). Over this 5-year period, only two were for
products sponsored by small businesses as defined by the Small Business
Administration. Because so few small firms are likely to be
significantly affected in any given year, the Commissioner certifies
that this rule will not have a significant economic impact on a
substantial number of small entities. Therefore, no further analysis is
required under the Regulatory Flexibility Act. The agency notes,
however, that where pediatric use qualifies as an orphan indication,
some of these added research costs could be
[[Page 43913]]
reimbursed under the various grant and tax deduction provisions of the
Orphan Drug Act.
XI. Request for Comments
Interested persons may, on or before November 13, 1997, submit to
the Dockets Management Branch (address above) written comments
regarding this proposal. Two copies of any comments are to be
submitted, except that individuals may submit one copy. Comments are to
be identified with the docket number found in brackets in the heading
of this document. Received comments may be seen in the Dockets
Management Branch between 9 a.m. and 4 p.m., Monday through Friday.
Submit written comments on the information collection provisions to the
Office of Information and Regulatory Affairs, OMB, New Executive Office
Bldg., 725 17th St. NW., rm. 10235, Washington, DC 20503, Attn: Desk
Officer for FDA.
XII. References
The following references have been placed on display in the Dockets
Management Branch (address above) and may be seen by interested persons
between 9 a.m. and 4 p.m., Monday through Friday.
1. Committee on Drugs, American Academy of Pediatrics,
Guidelines for the Ethical Conduct of Studies to Evaluate Drugs in
Pediatric Populations, Pediatrics, 95(2):286-294, 1995.
2. Pina, L. M., Drugs widely used off label in pediatrics,
Report of the pediatric use survey working group of the pediatric
subcommittee. Draft.
3. Cote, C. J. et al., ``Is the therapeutic orphan about to be
adopted?'' Pediatrics, 98(1):118-123, 1996.
4. Koren, G. et al., ``Unexpected alterations in fentanyl
pharmacokinetics in pediatric patients undergoing cardiac surgery:
age related or disease related?'' Developmental Pharmacology
Therapeutics, 9:183-191, 1986.
5. Gauntlett, I. S. et al., ``Pharmacokinetics of fentanyl in
neonatal humans and lambs: Effects of age,'' Anesthesiology, 69:683-
687, 1988.
6. Powell, D. A. et al., ``Chloramphenicol: New perspectives on
an old drug,'' Drug Intelligences & Clinical Pharmacy, 16:295-300,
1982.
7. Oski, F. A. et al., Principles and Practice of Pediatrics, 2d
Edition, J. B. Lippincott Co., Philadelphia, p. 864, 1994.
8. Nathan, D. G. et al., Hematology of Infancy and Childhood,
4th Edition, W. B. Saunders Co., Philadelphia, p. 92, 1993.
9. Kauffman, R. E., ``Fentanyl, fads, and folly: who will adopt
the therapeutic orphans?'' Journal of Pediatrics, 119:588-589, 1991.
10. McCloskey, J. J. et al., ``Bupivacaine toxicity secondary to
continuous caudal epidural infusion in pediatric patients,''
Anesthesia and Analgesia, 75:287-290, 1992.
11. Fisher, D. M. et al., ``Neuromuscular effects of vecuronium
(ORG NC45) in infants and pediatric patients during N2O
halothane anesthesia,'' Anesthesiology, 58:519-523, 1983.
12. Agarwal, R. et al., ``Seizures occurring in pediatric
patients receiving continuous infusion of bupivacaine,'' Anesthesia
and Analgesia, 75:284-286, 1992.
13. Mevorach, D. L. et al., ``Bupivacaine toxicity secondary to
continuous caudal epidural infusion in pediatric patients,''
Anesthesia and Analgesia, 77:13005-1306, 1993.
14. Editorial: ``Cystic fibrosis and colonic strictures,''
Journal of Clinical Gastroenterology, 21(1):2-5, 1995.
15. Olkkola, K. T. et al., ``A potentially hazardous interaction
between erythromycin and midazolam,'' Clinical Pharmacology
Therapeutics, 53:298-305, 1993.
16. Hiller, A. et al., ``Unconsciousness associated with
midazolam and erythromycin,'' British Journal of Anaesthesia,
65:826-828, 1994.
List of Subjects
21 CFR Part 201
Drugs, Labeling, Reporting and recordkeeping requirements.
21 CFR Part 312
Drugs, Exports, Imports, Investigations, Labeling, Medical
research, Reporting and recordkeeping requirements, and Safety.
21 CFR Part 314
Administrative practice and procedure, Confidential business
information, Drugs, Reporting and recordkeeping requirements.
21 CFR Part 601
Administrative practice and procedure, Biologics, Confidential
business information.
Therefore under the Federal Food, Drug, and Cosmetic Act, the
Public Health Service Act, and under authority delegated to the
Commissioner of Food and Drugs, it is proposed that 21 CFR parts 201,
312, 314, and 601 be amended as follows:
PART 201--LABELING
1. The authority citation for 21 CFR part 201 continues to read as
follows:
Authority: Secs. 201, 301, 501, 502, 503, 505, 506, 507, 508,
510, 512, 530-542, 701, 704, 721 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 321, 331, 351, 352, 353, 355, 356, 357, 358,
360, 360b, 360gg-360ss, 371, 374, 379e); secs. 215, 301, 351, 361 of
the Public Health Service Act (42 U.S.C. 216, 241, 262, 264).
2. New Sec. 201.23 is added to subpart A to read as follows:
Sec. 201.23 Required pediatric studies.
(a) A manufacturer of a drug product, including a biological drug
product, that is widely used in pediatric patients, or that is
indicated for a very significant or life threatening illness, but whose
label does not provide adequate information to support its safe and
effective use in pediatric populations for the claimed indications may,
in compelling circumstances, be required to submit an application
containing data adequate to assess whether the drug product is safe and
effective in pediatric populations. The application may be required to
contain adequate evidence to support dosage and administration in some
or all pediatric subpopulations, including neonates, infants, children,
and adolescents, depending upon the known or appropriate use of the
drug product in such subpopulations. The applicant may be required to
develop a pediatric formulation for a drug product that is indicated
for a very significant or life threatening illness for which a
pediatric formulation is necessary, unless the manufacturer
demonstrates that reasonable attempts to produce a pediatric
formulation have failed.
(b) The Food and Drug Administration (FDA) may, by order issued by
the Center for Drug Evaluation and Research (CDER) or Center for
Biologic Evaluation and Research (CBER) Center Director, after
notifying the manufacturer of its intent and offering an opportunity
for a written response and a meeting, which may include an advisory
committee meeting, require a manufacturer to submit an application
containing the information described in paragraph (a) of this section
within a time specified in the letter, if FDA finds that:
(1) The drug product is widely used in pediatric populations for
the claimed indications and the absence of adequate labeling could pose
significant risks to pediatric patients; or
(2) The drug product is indicated for a very significant or life
threatening illness, but additional dosing or safety information is
needed to permit its safe and effective use in pediatric patients.
(c)(1) FDA may grant a full or partial waiver of the requirements
of paragraph (a) of this section on its own initiative or at the
request of an applicant.
(2) An applicant may request a full waiver of the requirements of
paragraph (a) of this section if the applicant certifies that:
(i) Necessary studies are impossible or highly impractical, e.g.,
because the number of such patients is so small or geographically
dispersed; or
(ii) There is evidence strongly suggesting that the drug product
would
[[Page 43914]]
be ineffective or unsafe in all pediatric age groups.
(3) An applicant may request a partial waiver of the requirements
of paragraph (a) of this section with respect to a specified pediatric
age group, if the applicant certifies that:
(i) The drug product:
(A) Is not indicated for a very significant or life threatening
illness; and
(B) Is not likely to be used in a substantial number of patients in
that age group; or
(ii) Necessary studies are impossible or highly impractical
because, e.g., the number of patients in that age group is so small or
geographically dispersed; or
(iii) There is evidence strongly suggesting that the drug product
would be ineffective or unsafe in that age group; or
(iv) The applicant can demonstrate that reasonable attempts to
produce a pediatric formulation necessary for that age group have
failed.
(4) The request for a waiver must provide an adequate
justification.
(5) FDA shall grant a full or partial waiver, as appropriate, if
the agency finds that there is a reasonable basis on which to conclude
that one or more of the grounds for waiver specified in paragraph
(c)(2) or (c)(3) of this section have been met. If a waiver is granted
on the ground that it is not possible to develop a pediatric
formulation, the waiver will cover only those pediatric age groups
requiring that formulation. If a waiver is granted because there is
evidence that the product would be ineffective or unsafe in pediatric
populations, this information will be included in the product's
labeling.
(d) If a manufacturer fails to submit a supplemental application
containing the evidence described in paragraph (a) of this section
within the time specified by FDA, and the Center Director of CDER or
CBER, under the requirements of paragraph (c) of this section, has not
granted a waiver, the drug product may be considered misbranded or an
unapproved new drug.
PART 312--INVESTIGATIONAL NEW DRUG APPLICATION
3. The authority citation for 21 CFR part 312 continues to read as
follows:
Authority: Secs. 201, 301, 501, 502, 503, 505, 506, 507, 701 of
the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321, 331, 351,
352, 353, 355, 356, 357, 371); sec. 351 of the Public Health Service
Act (42 U.S.C. 262).
4. Section 312.23 is amended by redesignating paragraph
(a)(10)(iii) as paragraph (a)(10)(iv) and adding new paragraph
(a)(10)(iii) to read as follows:
Sec. 312.23 IND content and format.
(a) * * *
(10) * * *
(iii) Pediatric studies. If the drug is a new chemical entity,
plans for assessing pediatric safety and effectiveness.
* * * * *
5. Section 312.47 is amended by revising paragraph (b)(1)(i) and
the second sentence of paragraph (b)(2) and by adding a new sentence
after the fifth sentence to paragraph (b)(1)(v) to read as follows:
Sec. 312.47 Meetings.
* * * * *
(b) * * *
(1) End-of-Phase 2 meetings--(i) Purpose. The purpose of an end-of-
phase 2 meeting is to determine the safety of proceeding to phase 3, to
evaluate the phase 3 plan and protocols and the adequacy of plans to
assess pediatric safety and effectiveness, and to identify any
additional information necessary to support a marketing application for
the uses under investigation.
* * * * *
(v) Conduct of meeting. * * * FDA will also provide its best
judgment, at that time, of the pediatric studies that will be required
for the drug product and their timing. * * *
(2) ``Pre-NDA'' meetings. * * * The primary purpose of this kind of
exchange is to uncover any major unresolved problems, to identify those
studies that the sponsor is relying on as adequate and well-controlled
to establish the drug's effectiveness, to identify current or planned
studies adequate to assess pediatric safety and effectiveness, to
acquaint FDA reviewers with the general information to be submitted in
the marketing application (including technical information), to discuss
appropriate methods for statistical analysis of the data, and to
discuss the best approach to the presentation and formatting of data in
the marketing application.* * *
* * * * *
6. Section 312.82 is amended by revising the last sentence of
paragraph (a) and the second sentence of paragraph (b) to read as
follows:
Sec. 312.82 Early consultation.
* * * * *
(a) Pre-investigational new drug (IND) meetings. * * * The meeting
may also provide an opportunity for discussing the scope and design of
phase 1 testing, plans for studying the drug product in pediatric
populations, and the best approach for presentation and formatting of
data in the IND.
(b) End-of-phase 1 meetings. * * * The primary purpose of this
meeting is to review and reach agreement on the design of phase 2
controlled clinical trials, with the goal that such testing will be
adequate to provide sufficient data on the drug's safety and
effectiveness to support a decision on its approvability for marketing,
and to discuss the need for, as well as the design and timing of,
studies of the drug in pediatric patients. * * *
PART 314--APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG OR AN
ANTIBIOTIC DRUG
7. The authority citation for 21 CFR part 314 continues to read as
follows:
Authority: Secs. 201, 301, 501, 502, 503, 505, 506, 507, 701,
704, 721 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321,
331, 351, 352, 353, 355, 356, 357, 371, 374, 379e).
8. Section 314.50 is amended in subpart B by redesignating
paragraphs (g) through (k) as paragraphs (h) through (l) and by adding
new paragraphs (d)(7) and (g) to read as follows:
Sec. 314.50 Content and format of an application.
* * * * *
(d) * * *
(7) Pediatric use section. A section describing the investigation
of the drug for use in pediatric populations, including an integrated
summary of the information (the clinical pharmacology studies,
controlled clinical studies, or uncontrolled clinical studies, or other
data or information) that is relevant to the safety and effectiveness
and benefits and risks of the drug in pediatric populations for the
claimed indications, and a reference to the full descriptions of such
studies provided under paragraphs (d)(3) and (d)(5) of this section.
* * * * *
(g) Pediatric use information--(1) General requirements. Except as
provided in paragraphs (d)(2) and (d)(3) of this section, each
application for a new chemical entity shall contain data that are
adequate to assess the safety and effectiveness of the drug product for
the claimed indications in pediatric populations, including neonates,
infants, children, and adolescents, and to support dosing and
administration information for each pediatric subpopulation for which
the drug is safe and effective. Where the course of the disease and the
effects of the drug are sufficiently similar in adults and pediatric
patients, FDA may conclude that pediatric effectiveness can be
extrapolated from adequate and well-
[[Page 43915]]
controlled studies in adults based on other information, such as
pharmacokinetic studies. Studies may not have to be carried out in each
pediatric age group, if data from one age group can be extrapolated to
others. Assessments of safety and effectiveness required under this
section for a drug product that represents a meaningful therapeutic
benefit over existing treatments for pediatric patients must be carried
out using appropriate formulations for each age group(s) for which the
assessment is required.
(2) Deferred submission. FDA may, on its own initiative or at the
request of an applicant, defer submission of some or all assessments of
safety and effectiveness described in paragraph (g)(1) of this section
until after approval of the drug product for use in adults. If an
applicant requests deferred submission, the request must provide a
certification from the applicant of the grounds for delaying pediatric
studies, a description of the planned or ongoing studies, and evidence
that the studies are being or will be conducted with due diligence and
at the earliest possible time. If FDA determines that there is an
adequate justification for temporarily delaying the submission of
assessments of pediatric safety and effectiveness, the drug product may
be approved for use in adults subject to the requirement that the
applicant submit the required assessments within a specified time.
(3) Waivers--(i) FDA may grant a full or partial waiver of the
requirements of paragraph (g)(1) of this section on its own initiative
or at the request of an applicant.
(ii) An applicant may request a full waiver of the requirements of
paragraph (g)(1) of this section if the applicant certifies that:
(A) The drug product:
(1) Does not represent a meaningful therapeutic benefit over
existing treatments for pediatric patients; and
(2) Is not likely to be used in a substantial number of pediatric
patients; or
(B) Necessary studies are impossible or highly impractical, e.g.,
because the number of such patients is so small or geographically
dispersed; or
(C) There is evidence strongly suggesting that the drug product
would be ineffective or unsafe in all pediatric age groups.
(iii) An applicant may request a partial waiver of the requirements
of paragraph (g)(1) of this section with respect to a specified
pediatric age group, if the applicant certifies that:
(A) The drug product:
(1) Does not represent a meaningful therapeutic benefit over
existing treatments for pediatric patients in that age group; and
(2) Is not likely to be used in a substantial number of patients in
that age group; or
(B) Necessary studies are impossible or highly impractical because,
e.g., the number of patients in that age group is so small or
geographically dispersed; or
(C) There is evidence strongly suggesting that the drug product
would be ineffective or unsafe in that age group; or
(D) The applicant can demonstrate that reasonable attempts to
produce a pediatric formulation necessary for that age group have
failed.
(iv) The request for a waiver must provide an adequate
justification.
(v) FDA shall grant a full or partial waiver, as appropriate, if
the agency finds that there is a reasonable basis on which to conclude
that one or more of the grounds for waiver specified in paragraph
(g)(2) or (g)(3) of this section have been met. If a waiver is granted
on the ground that it is not possible to develop a pediatric
formulation, the waiver will cover only those pediatric age groups
requiring that formulation. If a waiver is granted because there is
evidence that the product would be ineffective or unsafe in pediatric
populations, this information will be included in the product's
labeling.
* * * * *
9. Section 314.81 is amended by adding two new sentences at the end
of paragraph (b)(2)(i) and a new paragraph (b)(2)(vi)(c) and by
revising paragraph (b)(2)(vii) to read as follows:
Sec. 314.81 Other postmarketing reports.
* * * * *
(b) * * *
(2) * * *
(i) Summary. * * * The summary shall briefly state whether labeling
supplements for pediatric use have been submitted and whether new
studies in the pediatric population to support appropriate labeling for
the pediatric population have been initiated. Where possible, an
estimate of patient exposure to the drug product, with special
reference to the pediatric population (neonates, infants, children, and
adolescents) should be provided, including dosage form.
* * * * *
(vi) * * *
(c) Analysis of available safety and efficacy data conducted or
obtained by the applicant in the pediatric population and changes
proposed in the label based on this information. An assessment of data
needed to ensure appropriate labeling for the pediatric population
should be included.
(vii) Status reports. A statement on the current status of any
postmarketing studies performed by, or on behalf of, the applicant. The
statement shall include the status of postmarketing clinical studies in
pediatric populations required or agreed to, e.g., to be initiated,
ongoing (with projected completion date), completed (including date),
completed and results submitted to the NDA (including date). To
facilitate communications between FDA and the applicant, the report
may, at the applicant's discretion, also contain a list of any open
regulatory business with FDA concerning the drug product subject to the
application.
* * * * *
PART 601--LICENSING
10. The authority citation for 21 CFR part 601 continues to read as
follows:
Authority: Secs. 201, 501, 502, 503, 505, 510, 513-516, 518-520,
701, 704, 721, 801 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 321, 351, 352, 353, 355, 360, 360c-360f, 360h-360j, 371, 374,
379e, 381); secs. 215, 301, 351, 352 of the Public Health Service
Act (42 U.S.C. 216, 241, 262, 263); secs. 2-12 of the Fair Packaging
and Labeling Act (15 U.S.C. 1451-1461).
11. New Sec. 601.27 is added to subpart C to read as follows:
Sec. 601.27 Pediatric studies.
(a) General requirements. Except as provided in paragraphs (b) and
(c) of this section, each application for a new biological product for
which the applicant has not previously obtained approval shall contain
data that are adequate to assess the safety and effectiveness of the
product for the claimed indications in pediatric populations, including
neonates, infants, children, and adolescents, and to support dosing and
administration information for each pediatric subpopulation for which
the product is safe and effective. Where the course of the disease and
the effects of the product are similar in adults and pediatric
patients, FDA may conclude that pediatric effectiveness can be
extrapolated from adequate and well-controlled effectiveness studies in
adults, based on other information, such as pharmacokinetic studies. In
addition, studies may not have to be carried out in each pediatric age
group, if data from one age group can be extrapolated to others.
Assessments required under this section for a product that represents a
meaningful therapeutic benefit over existing treatments must be carried
out using appropriate formulations for the age group(s) for which the
assessment is required.
[[Page 43916]]
(b) Deferred submission. FDA may, on its own initiative or at the
request of an applicant, defer submission of some or all assessments of
safety and effectiveness described in paragraph (a) of this section
until after licensing of the product for use in adults. If an applicant
requests deferred submission, the request must provide an adequate
justification for delaying pediatric studies, a description of the
planned or ongoing studies, and evidence that the studies are being or
will be conducted with due diligence and at the earliest possible time.
If FDA determines that there is an adequate justification for
temporarily delaying the submission of assessments of pediatric safety
and effectiveness, the product may be licensed for use in adults
subject to the requirement that the applicant submit the required
assessments within a specified time.
(c) Waivers. (1) FDA may grant a full or partial waiver of the
requirements of paragraph (a) of this section on its own initiative or
at the request of an applicant.
(2) An applicant may request a full waiver of the requirements of
paragraph (a) of this section if:
(i) The product:
(A) Does not represent a meaningful therapeutic benefit over
existing therapies for pediatric patients; and
(B) Is not likely to be used in a substantial number of pediatric
patients; or
(ii) Necessary studies are impossible or highly impractical
because, e.g., the number of such patients is so small or
geographically dispersed; or
(iii) There is evidence strongly suggesting that the product would
be ineffective or unsafe in all pediatric age groups.
(3) An applicant may request a partial waiver of the requirements
of paragraph (a) of this section with respect to a specified pediatric
age group, if:
(i) The product:
(A) Does not represent a meaningful therapeutic benefit over
existing therapies for pediatric patients in that age group; and
(B) Is not likely to be used in a substantial number of patients in
that age group; or
(ii) Necessary studies are impossible or highly impractical, e.g.,
because the number of patients in that age group is so small or
geographically dispersed; or
(iii) There is evidence strongly suggesting that the product would
be ineffective or unsafe in that age group; or
(iv) The applicant can demonstrate that reasonable attempts to
produce a pediatric formulation necessary for that age group have
failed.
(4) The request for a waiver must provide an adequate
justification.
(5) FDA shall grant a full or partial waiver, as appropriate, if
the agency finds that there is a reasonable basis on which to conclude
that one or more of the grounds for waiver specified in paragraph (c)
(2) or (3) of this section have been met. If a waiver is granted on the
ground that it is not possible to develop a pediatric formulation, the
waiver will cover only those pediatric age groups requiring that
formulation. If a waiver is granted because there is evidence that the
product would be ineffective or unsafe in pediatric populations, this
information will be included in the product's labeling.
Dated: July 24, 1997.
Michael A. Friedman,
Lead Deputy Commissioner for the Food and Drug Administration.
Donna E. Shalala,
Secretary of Health and Human Services.
[FR Doc. 97-21646 Filed 8-13-97; 2:00 pm]
BILLING CODE 4160-01-P