In addition to drug compounding legislation, Congress may consider a bill to mandate a national drug track-and-trace program. Some pharma companies would like action before a California requirement kicks in in 2015, and FDA gets support for adding unique identifiers to individual products from a new Institute of Medicine report on countering fake drugs. There's also talk of legislation to encourage development of abuse-deterrent opioid drugs or to limit access to certain opioid combination products. Some members of Congress want to prohibit "pay-for-delay" brand-generic deals, and medical device makers continue to lobby for repeal of the 2.3% excise tax on sales imposed by the Affordable Care Act.FDA legislation currently is on the back burner, as Congress struggles to address a host of critical issues, starting with the federal budget crisis and the threat of across-the-board cuts in government funding. Congressional health committees, moreover, are focused on Obamacare implementation and funding for Medicare and Medicaid. But a groundswell for doing something to limit illegal drug compounding could prompt action this summer.
More limited approvals
Another candidate for legislative action is a measure authorizing a streamlined development and approval pathway for new antibiotics and other life-saving medicines. A February FDA public hearing and a seminar sponsored by the Pew Charitable Trusts discussed a proposal from the Infectious Diseases Society of America for a Limited Population Antibacterial Drug approval mechanism. This approach also was recommended in a September 2012 report from the President's Council of Advisors on Science and Technology on "propelling innovation in drug discovery, development, and evaluation."
The main idea is to permit FDA approval of a drug for a very narrow indication based on smaller, faster clinical trials for targeted patient populations. Specific labels would limit prescribing to the designated uses, and approval would require postmarket studies and monitoring. Some researchers and advocates say the new pathway is not necessary, given FDASIA provisions that authorized speedier FDA approval for "breakthrough" drugs and added exclusivity for new orphan drugs and antibiotics. FDA officials say they already have considerable authority to approve critical treatments based on streamlined trials and limited evidence. But patient advocates consider the additional incentives provided by LPAD important for developing new treatments for Parkinson's, leukemia, tuberculosis, transplant patients, and various rare conditions, as well as infectious diseases.
It's not clear whether FDA needs additional legislation to implement such a modified approval process, but there is a sense that congressional approval would highlight its importance to the medical community. To move forward, FDA and sponsors need to address a number of issues, starting with what evidence FDA would require for limited population approvals and whether special labels or "limited use" identifiers would discourage inappropriate prescribing. Pharma companies want LPAD to be voluntary and not imposed by FDA, and there's strong opposition to a ban on off-label prescribing from both industry and physicians, who want flexibility to prescribe a new drug for, say, a brain infection, even without studies for that condition.
The role of payers in spurring development of new antibiotics was examined more closely at the Pew meeting. Even with a less costly testing and development process, the limited markets for these therapies means premium prices—high above those for generic antibiotics. Payers said that they will look for data from sponsors on how well the new treatments prevent deaths, shorten hospital stays or reduce readmissions, along with evidence on the severity of the condition and lack of alternative treatments. Yet Pew's Nicole Mahoney noted that payers have less impact on patient management of drug use in hospitals, compared to outpatient settings, and thus may not play a major role in influencing prescribing of limited patient antibiotics.
"Antimicrobial stewardship" programs may do more to discourage inappropriate uses of limited use antibiotics, and monitoring and mining electronic health records and other databases could help track how the drugs are prescribed and their impact. As Paul Huckle, head of regulatory affairs at GlaxoSmithKline, summarized at the FDA meeting, a combination of appropriate FDA labeling, appropriate promotion and education by the sponsor, and underlying stewardship at institutions and by the community should provide "a pretty good way of managing use of these products in the antibiotic space."
Jill Wechsler is Pharm Exec's Washington correspondent. She can be reached at