Risk Evaluation and Mitigation Strategies in Organ Transplantation

Current Status of Risk Evaluation and Mitigation Strategies (REMS) in Organ Transplantation

Satish N. Nadig, MD, DPhil

University of Michigan Medical School, Ann Arbor, Michigan

Risk Evaluation and Mitigation Strategies (REMS) are a set of policies put into practice by the US Food and Drug Administration (FDA) Amendments Act of 2007. These strategies provide postmarketing oversight of pharmacotherapeutics to avoid potential or known risks. At this year’s American Transplant Congress (ATC), leaders in pharmacology and medicine provided an overview of the past, present, and future of the drug-approval process and the impact REMS likely will have on the field of solid-organ transplantation. Experts reviewed the elements of REMS and requirements that healthcare providers and patients mftust meet when these strategies are imposed. Speakers also discussed specific strategies related to current immunosuppressive regimens.

Dr. NadigRisk management is of utmost importance in prescribing pharmacologic therapeutics and monitoring their use. Drugs approved by the US Food and Drug Administration (FDA) that are later found to have serious or sometimes fatal ramifications are removed from the market. Thereafter, FDA officials intensely reevaluate the approval process for such products.1 However, some medications that may cause grave side effects are nevertheless granted FDA approval because they provide specific therapeutic benefits or are effective in certain medical situations where no safer therapeutic options are available. Nowhere in medicine is this truer than in organ transplantation.

Despite the carcinogenicity and toxicity of immunosuppressive therapies, they are routinely prescribed to prevent organ rejection. To minimize their deleterious side effects, the need for and risk/benefit ratio of such drugs and biologic agents are continually reviewed by the physicians, pharmacists, and nurses in the transplant community. Since Risk Evaluation and Mitigation Strategies (REMS) were introduced in 2007, each new immunosuppressive medication has carried a set of professional and patient literature by which healthcare workers abide to minimize any risks associated with its use. 2

At this year’s American Transplant Congress, experts in the field of REMS research reviewed the history of pharmaceutical regulation and postmarketing surveillance, discussed the impact REMS have had on the prescription and use of immunosuppressive medication, and provided insight on controversies related to their implementation.

Based, in part, on a presentation by Rita Alloway, PharmD, Research Professor of Internal Medicine, Division of Nephrology and Hypertension, University of Cincinnati College of Medicine, Cincinnati, Ohio

An Historic Perspective
Legislative efforts to protect people in the United States from substances that may harm them date back more than a century.

Pure Food and Drug Act of 1906. The first of over 200 laws passed over the years to regulate the development, manufacture, and distribution of drugs was the Pure Food and Drug Act of 1906.3 This legislation ordered federal inspection of meat products and prevented the use of poisonous and/or habit-forming patent medicines.

Federal Food, Drug, and Cosmetic Act of 1938.  Over the ensuing 3 decades, it became increasingly clear that the Pure Food and Drug Act of 1906 needed to be revamped. In 1938, more than 100 people died after using a medicinal product called Elixir Sulfanilamide; the product contained diethylene glycol as a solvent and was never tested in animals or humans for toxicity. Federal, state, and local agencies worked together to recover over 234 of the 240 gallons manufactured.4

The public outrage stemming from this incident led to enactment of the Federal Food, Drug, and Cosmetic Act of 1938, which outlined a new system of drug control to stimulate medical progress and better protect the public.4 Among new powers given to the FDA were the abilities to demand evidence that new drugs are safe, to regulate processing of food, and to inspect factories.5

Kefauver-Harris Amendments of 1962. Use of the sedative thalidomide in the 1950s and 1960s was linked to thousands of birth defects among infants in Western Europe. News of this horrific problem and efforts to keep the drug off the US market resulted in the Kefauver-Harris Amendments of 1962, which mandated that companies submit the results of adequate, well-controlled studies proving the safety and effectiveness of a drug before it could be marketed. This legislation required the FDA to provide premarketing approval of all new or amended drug applications, that patients give informed consent before taking part in clinical studies, that companies follow good manufacturing practices, and that physicians report adverse events to the government. In addition, power to regulate the advertising of prescription drugs was transferred from the Federal Trade Commission to the FDA.6

Other Federal legislation. Over the years, a number of other Federal laws have been passed to help protect the public and speed approval of new drugs. For example, in 1970, passage of the Controlled Substance Act sought to regulate narcotics and other controlled substances in terms of manufacturing, importation, possession, use, and distribution.7 In 1976, the same year that the Medical Device Amendment mandated safety and efficacy standards for new devices,5 patient package inserts were introduced for distribution with oral contraceptives.8

During the 1980s, the FDA implemented Risk Management Plans to include the standard package insert with a prescription drug; in addition, patients might receive a medication guide or patient package insert with information written for the consumer. For drugs posing more significant risks, various risk-management steps (education; redistricted drug distribution) could be imposed.9,10

In 1992, the Prescription Drug User Fee Act authorized the FDA to collect funds from companies that were developing some human drug and biologic products. 11 These funds could only be used to speed the preapproval process; timelines then were set for regulatory reviews, and drugs were approved and marketed more quickly. As a result, the postmarketing safety system used in the United States gained greater responsibility for detecting safety problems early.11

Recent initiatives. Between 1997 and 2004, 12 drugs were removed from the US market because of safety concerns, resulting in legislative and regulatory initiatives to better ensure the safety of drug therapy.9 In 2005, Risk Minimization Action Plans (RiskMAPS) were initiated to minimize the potential hazards of products posing a clinically important or unusual level of risk when compared with their benefits.7,8,10,12 The FDA issued a guidance recommending methods to develop RiskMAPS, to select tools to minimize risks, to evaluate the use of RiskMAPS and associated monitoring tools, and to provide the FDA with feedback about these plans.13

By 2007, the FDA had learned of many adverse events related to the use of certain heavily prescribed medications, including the nonsteroidal anti-inflammatory drug rofecoxib and the antidiabetic drug rosiglitazone. The Agency teamed with the Institute of Medicine to develop and implement methods for minimizing the risk of drug therapy while preserving its benefits.1,11 In addition, the agencies needed ways to evaluate and improve these tools.14

FDA Amendments Act of 2007. With enactment of a new section of the Food, Drug, and Cosmetics Act known as the FDA Amendments Act of 2007 (FDAAA; Public Law 110-85),15 the FDA could require submission of proposed REMS as part of the application process for any drug or biologic product to ensure that the benefits of the product outweighed its risks. This legislation applied to new drug applications, abbreviated new drug applications, and biologics license applications. In addition, if any new safety information on an established product came to light, companies that already received approval for a drug or biologic agent were required to submit proposed REMS for use of that drug or biologic agent within 120 days of notification. Companies also could voluntarily submit REMS for a drug or biologic during the application process; the FDA would approve the plan only if the strategy was needed.

Thus, the FDAAA effectively established REMS as a method of controlling the investigation of real or potential adverse outcomes related to the use of pharmaceuticals and biologics. These strategies are intended to inform patients about the serious risks related to use of a drug or biologic product, to minimize the chance that such a product might interact adversely with another drug or biologic product or with a disease entity, and to prevent the risk of fetal exposure to certain pharmaceutical or biologic products.12 A fundamental difference between the postmarketing strategies of REMS and previous strategies is that the FDAAA enabled and empowered the FDA to sanction noncompliant drug manufacturers.

Development of REMS
When considering whether REMS must be developed for a particular product, the FDA analyzes the number of patients likely to need the drug or biologic, the severity of the disease being treated with it, the expected treatment duration, the degree of known or potential adverse reactions, and the novel nature of the substance. The company must submit a timetable to assess REMS; it also must present an evaluation of the effectiveness of the REMS at a minimum of 18 months, 3 years, and 7 years after its approval, although the FDA can require additional assessments. For assessment purposes, all REMS also must have a goal.10 The specific components of REMS are listed in Table 1.14

Elements To Assure Safe Use (­ETASU). REMs may specifically require an ETASU component. In such cases, healthcare providers prescribing the drug or biologic must have particular training, experience, or certifications. Special training and certification also is needed for pharmacies, practitioners, or healthcare facilities that dispense the agent, and the drug may be dispensed only in certain healthcare settings and to patients who present evidence of safe-use conditions.

Certified physicians working with the patient must understand how to use the drug or biologic agent safely, keep up with required patient monitoring, and diagnose and treat possible adverse effects; likewise, certified pharmacists dispensing the drug or biologic must be familiar with the agent’s safe use and risks and agree to seek authorization before filling prescriptions. Every patient using such a drug must be monitored and enrolled in a registry. 10

Based, in part, on a presentation by Steven Gabardi, PharmD, BCPS, Abdominal Organ Transplant Clinical Specialist, Departments of Transplant Surgery and Pharmacy Services, Brigham and Women’s Hospital, and Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts

As of June 2012, 92 FDA-approved drugs and biologics were accompanied by REMS. At this time, however, belatacept and everolimus are the only FDA-approved immunosuppressants having REMS.16 Interestingly, sirolimus, a mammalian target of rapamycin inhibitor, had approved REMS as of November 23, 2010, but that REMS later was rescinded. On June 6, 2011, the FDA determined that a medication guide incorporated in the labeling of the drug, independent of REMS, was sufficient and necessary to provide adequate information to patients using this immunosuppressive agent.17

In September 2008, the FDA mandated that manufacturers of mycophenolate mofetil and mycophenolic acid submit REMS to ensure that the benefits of using these drugs outweighed the risks and that any unexpected problems could be managed in an organized fashion. Specifically, this mandate was a response to a boxed warning that highlighted the increased risk of pregnancy loss and congenital malformations that may occur when these drugs are taken during pregnancy (eg, cleft lip and palate; abnormalities of the distal limbs, heart, esophagus, and kidneys).16 A medication guide for these products was approved in December 2008; the full REMS will include other elements, including physician training and certification, patient education, a pregnancy registry, an implementation plan, and a timetable for assessing the REMS.16 This REMS currently is being reviewed.16,18

The issuing of REMS for mycophenolic acid and mycophenolate mofetil may have a tremendous effect on transplant-specific healthcare professionals. Some healthcare personnel believe that implementation of these strategies will impose new obstacles to transplantation, whereas others believe they will improve patient safety and are justifiable.

Based, in part, on a presentation by Diane M. Cibrik, MD, MS, Clinical Associate Professor of Internal Medicine, Division of Nephrology, University of Michigan Medical School, Ann Arbor

Administrators at regulatory agencies do not hold sole responsibility for assessing the safety of prescription drugs and biologic agents. Healthcare providers and patients must be diligent in using these products according to recommendations outlined by the REMS.

The REMS for everolimus were approved by the FDA on April 20, 2010. They consist of a medication guide and communication plan, offering both “Dear Pharmacist” and “Dear Healthcare Provider” letters. In May 2012, the FDA determined that the medication guide could be maintained as part of the approved labeling and no longer was required as an element of the approved REMS.19

Currently, the healthcare provider letter for everolimus discusses the potential risks of impaired wound healing, hyperlipidemia, proteinuria, and renal allograft thrombosis related to its use.19 It also mentions that possible nephrotoxicity may occur in everolimus-treated patients taking standard doses of cyclosporine adjunctively.

When healthcare professionals receive these informative letters, they are expected to follow the medication guide, heed the warnings in the letters, and dutifully report serious adverse events related to use of the medication. Importantly, all serious adverse events must be reported to both the FDA and the product’s manufacturer, even if they may not be directly related to its use.

Belatacept therapy is indicated only for use in transplant patients who are seropositive for Epstein-Barr virus infection. Its use is associated with the serious and potentially fatal risk of posttransplant lymphoproliferative disorder (PTLD) and progressive multifocal leukoencephalopathy (PML). Patients given belatacept have a greater risk for developing PTLD, which predominantly involves the central nervous system. PML has been noted among patients given higher doses of belatacept than recommended as part of an immunosuppressive regimen.20

The REMS for belatacept—a medication guide and a communication plan with a timetable for implementation—were approved in June 2011. The communication plan for this drug is extensive and includes a Web site* and a “webinar” slide presentation** specifically intended for healthcare providers. Along with letters to healthcare professionals and fact sheets, the REMS mandate use of an infusion specialist letter and preinfusion checklist. Finally, to disseminate information among all groups of transplant providers, a review of guidelines for safely administering belatacept was published in various transplant-specific journals.
*  http://www.nulojix.com/pdf/NulojixApprovalPlus/REMS%20Educational%20Deck.pdf
** http://www.nulojix.com/pdf/NulojixApprovalPlus/REMS%20Educational%20Deck.pdf

REMS are intended to protect patients from serious complications related to drug or biologic therapy. However, they also can prove challenging to healthcare personnel. Some professionals become concerned about enrolling in various programs, needing different certifications, and complying with prescription requirements. The cost of healthcare is currently a hot topic, and many physicians and pharmacists have voiced concerns that REMS may interfere with medical practice and impose costs without supplying a source for reimbursement. In addition, patients worry that they may not be able to obtain particular medicines from any healthcare provider who refuses to participate in REMS. Many professionals also believe that the implementation of REMS may widen the time lapse between drug prescription and delivery to a patient.12

For these and other reasons, officials at the FDA are gathering input from healthcare personnel and patients about developing and implementing REMS. The Agency is planning to hold at least one public meeting by the end of fiscal year 2013 to scrutinize methods of standardizing REMS and reduce the burden imposed upon patients and the healthcare community.12

At the outset, REMS were intended to benefit patients without burdening the transplant practitioner. On the whole, that goal seems to have been met. 1 However, the development of newer, more potent immunosuppressant drugs and the imposition of more REMS for established transplant-related medications—including the imminent approval of REMS for mycophenolate mofetil and mycophenolic acid—may increase the healthcare practitioner’s burden. Further, this burden may increase greatly if ETASUs are added to REMS and healthcare practitioners need certification to administer specific immunosuppressants. Ultimately, healthcare facilities would have to increase staffing and vigilance to ensure that certifications remain up-to-date. 1

On the other hand, the increased oversight imposed by REMS makes it easier to obtain regulatory approval for potent, potentially harmful medications that might otherwise not reach the marketplace, such as immunosuppressants. The use of REMS also allows such medications to remain on the market.6 Overall, these strategies benefit transplantation medicine, although they cause compliant healthcare professionals to navigate a number of obstacles. The advent and popularity of electronic health records among hospitals nationwide hopefully will ease, or even solve, these problems in the future. 22


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Dr. Nadig is a Clinical Lecturer/Fellow in the Section of Transplantation Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan.

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