Expect more physicians to wait for a new drug to establish a safety record before prescribing it. What's old and established is in, what's new—and once interpreted as "better"—is out. Currently, the industry thinks large postapproval safety studies pay off only if they don't show a risk. In the future, the reduction in uncertainty gained by doing these studies will be the payoff. Ironically, marketing advantage will go to drugs with a safety benefit as opposed to an efficacy advantage.

Under this paradigm, companies must move away from trying to reach peak sales as quickly as possible. Instead, they must learn to build drug adoption slowly and steadily while increasing physicians' and patients' confidence that they understand a product's risks. And though this method means companies will have to rethink their classical approach to life cycle marketing, the bright side of this new culture of safety is that it will also be harder for the competition to gain acceptance for a substitute product.

In the new Culture of Drug Safety, FDA will perform formal drug safety reviews after approval. Look for scheduled reviews of drug risks every three to five years. Companies will need to formally demonstrate product benefits both before and after approval to receive a fair review of drug safety. (We'll have more to say about reviews in the next installment of this series.)

Expect FDA to do more thorough follow-up to ensure that Phase IV and other study commitments are kept. Bills currently before Congress grant FDA new authority to enforce commitments and delineate processes leading to fines and new drug application (NDA) withdrawal if they are not met.

FDA has already taken steps to improve drug safety by controlling postapproval use. Under a May 2005 guidance, FDA may ask companies (or companies may volunteer) to prepare a Risk Minimization Action Plan (RiskMAP) when new risks are discovered. These plans specify what companies will do and what tools, such as Medication Guides or restricted distribution, they plan to use to mitigate known risks.

The Senate and House bills, however, go a step further and include the requirement that companies submit a Risk Evaluation and Mitigation Strategy (REMS) for all drugs. Like a RiskMAP, a REMS includes plans for continued risk assessment. But a REMS also includes a plan for a postmarketing research agenda to track drug safety.

The Culture of Drug Safety has spoken: Risk-management programs will become the norm. The key for marketers is to find the holy grail of risk mitigation: risk-management tools that protect patients, but whose restrictions don't kill the drug. After all, certain risk-management interventions have been interpreted by doctors as an attempt to transfer liability for drug safety from drug company to physician. That happened with GlaxoSmithKline's Lotronex (alosetron). When physicians were required to sign an agreement stating that they would fully warn the patient—and get the patient to sign an agreement stating that they had—gastroenterologists refused to prescribe Lotronex, and sales plummeted. We are now likely seeing similar liability concerns with Avandia.

In addition to risk-management programs, FDA is looking at new ways to discover drug safety risks at an earlier stage of marketing. For example, FDA recently held hearings on sentinel networks—mechanisms to receive and investigate very early cases that may signal safety concerns.

The problem for drug safety, however, is not usually the identification of new safety signals. Rather, it's qualifying and quantifying these signals so we can understand, or at least hypothesize, which are real concerns and which are only "noise in the system."