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Posts Tagged ‘FDA’


Human Factor Engineering: New Regulations Impact Drug Delivery, Device Design And Human Interaction

Curator: Stephen J. Williams, Ph.D.

Institute of Medicine report brought medical errors to the forefront of healthcare and the American public (Kohn, Corrigan, & Donaldson, 1999) and  estimated that between

44,000 and 98,000 Americans die each year as a result of medical errors

An obstetric nurse connects a bag of pain medication intended for an epidural catheter to the mother’s intravenous (IV) line, resulting in a fatal cardiac arrest. Newborns in a neonatal intensive care unit are given full-dose heparin instead of low-dose flushes, leading to threedeaths from intracranial bleeding. An elderly man experiences cardiac arrest while hospitalized, but when the code blue team arrives, they are unable to administer a potentially life-saving shock because the defibrillator pads and the defibrillator itself cannot be physically connected.

Human factors engineering is the discipline that attempts to identify and address these issues. It is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use.

 

FDA says drug delivery devices need human factors validation testing

Several drug delivery devices are on a draft list of med tech that will be subject to a final guidance calling for the application of human factors and usability engineering to medical devices. The guidance calls called for validation testing of devices, to be collected through interviews, observation, knowledge testing, and in some cases, usability testing of a device under actual conditions of use. The drug delivery devices on the list include anesthesia machines, autoinjectors, dialysis systems, infusion pumps (including implanted ones), hemodialysis systems, insulin pumps and negative pressure wound therapy devices intended for home use. Studieshave consistently shown that patients struggle to properly use drug delivery devices such as autoinjectors, which are becoming increasingly prevalent due to the rise of self-administered injectable biologics. The trend toward home healthcare is another driver of usability issues on the patient side, while professionals sometimes struggle with unclear interfaces or instructions for use.

 

Humanfactors engineering, also called ergonomics, or human engineering, science dealing with the application of information on physical and psychological characteristics to the design of devices and systems for human use. ( for more detail see source@ Britannica.com)

The term human-factors engineering is used to designate equally a body of knowledge, a process, and a profession. As a body of knowledge, human-factors engineering is a collection of data and principles about human characteristics, capabilities, and limitations in relation to machines, jobs, and environments. As a process, it refers to the design of machines, machine systems, work methods, and environments to take into account the safety, comfort, and productiveness of human users and operators. As a profession, human-factors engineering includes a range of scientists and engineers from several disciplines that are concerned with individuals and small groups at work.

The terms human-factors engineering and human engineering are used interchangeably on the North American continent. In Europe, Japan, and most of the rest of the world the prevalent term is ergonomics, a word made up of the Greek words, ergon, meaning “work,” and nomos, meaning “law.” Despite minor differences in emphasis, the terms human-factors engineering and ergonomics may be considered synonymous. Human factors and human engineering were used in the 1920s and ’30s to refer to problems of human relations in industry, an older connotation that has gradually dropped out of use. Some small specialized groups prefer such labels as bioastronautics, biodynamics, bioengineering, and manned-systems technology; these represent special emphases whose differences are much smaller than the similarities in their aims and goals.

The data and principles of human-factors engineering are concerned with human performance, behaviour, and training in man-machine systems; the design and development of man-machine systems; and systems-related biological or medical research. Because of its broad scope, human-factors engineering draws upon parts of such social or physiological sciences as anatomy, anthropometry, applied physiology, environmental medicine, psychology, sociology, and toxicology, as well as parts of engineering, industrial design, and operations research.

source@ Britannica.com

The human-factors approach to design

Two general premises characterize the approach of the human-factors engineer in practical design work. The first is that the engineer must solve the problems of integrating humans into machine systems by rigorous scientific methods and not rely on logic, intuition, or common sense. In the past the typical engineer tended either to ignore the complex and unpredictable nature of human behaviour or to deal with it summarily with educated guesses. Human-factors engineers have tried to show that with appropriate techniques it is possible to identify man-machine mismatches and that it is usually possible to find workable solutions to these mismatches through the use of methods developed in the behavioral sciences.

The second important premise of the human-factors approach is that, typically, design decisions cannot be made without a great deal of trial and error. There are only a few thousand human-factors engineers out of the thousands of thousands of engineers in the world who are designing novel machines, machine systems, and environments much faster than behavioral scientists can accumulate data on how humans will respond to them. More problems, therefore, are created than there are ready answers for them, and the human-factors specialist is almost invariably forced to resort to trying things out with various degrees of rigour to find solutions. Thus, while human-factors engineering aims at substituting scientific method for guesswork, its specific techniques are usually empirical rather than theoretical.

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The Man-Machine Model: Human-factors engineers regard humans as an element in systems

The simple man-machine model provides a convenient way for organizing some of the major concerns of human engineering: the selection and design of machine displays and controls; the layout and design of workplaces; design for maintainability; and the work environment.

Components of the Man-Machine Model

  1. human operator first has to sense what is referred to as a machine display, a signal that tells him something about the condition or the functioning of the machine
  2. Having sensed the display, the operator interprets it, perhaps performs some computation, and reaches a decision. In so doing, the worker may use a number of human abilities, Psychologists commonly refer to these activities as higher mental functions; human-factors engineers generally refer to them as information processing.
  3. Having reached a decision, the human operator normally takes some action. This action is usually exercised on some kind of a control—a pushbutton, lever, crank, pedal, switch, or handle.
  4. action upon one or more of these controls exerts an influence on the machine and on its output, which in turn changes the display, so that the cycle is continuously repeated

 

Driving an automobile is a familiar example of a simple man-machine system. In driving, the operator receives inputs from outside the vehicle (sounds and visual cues from traffic, obstructions, and signals) and from displays inside the vehicle (such as the speedometer, fuel indicator, and temperature gauge). The driver continually evaluates this information, decides on courses of action, and translates those decisions into actions upon the vehicle’s controls—principally the accelerator, steering wheel, and brake. Finally, the driver is influenced by such environmental factors as noise, fumes, and temperature.

 

hfactorconsideroutcomes

How BD Uses Human Factors to Design Drug-Delivery Systems

Posted in Design Services by Jamie Hartford on August 30, 2013

 Human factors testing has been vital to the success of the company’s BD Physioject Disposable Autoinjector.

Improving the administration and compliance of drug delivery is a common lifecycle strategy employed to enhance short- and long-term product adoption in the biotechnology and pharmaceutical industries. With increased competition in the industry and heightened regulatory requirements for end-user safety, significant advances in product improvements have been achieved in the injectable market, for both healthcare professionals and patients. Injection devices that facilitate preparation, ease administration, and ensure safety are increasingly prevalent in the marketplace.

Traditionally, human factors engineering addresses individualized aspects of development for each self-injection device, including the following:

  • Task analysis and design.
  • Device evaluation and usability.
  • Patient acceptance, compliance, and concurrence.
  • Anticipated training and education requirements.
  • System resilience and failure.

To achieve this, human factors scientists and engineers study the disease, patient, and desired outcome across multiple domains, including cognitive and organizational psychology, industrial and systems engineering, human performance, and economic theory—including formative usability testing that starts with the exploratory stage of the device and continues through all stages of conceptual design. Validation testing performed with real users is conducted as the final stage of the process.

To design the BD Physioject Disposable Autoinjector System , BD conducted multiple human factors studies and clinical studies to assess all aspects of performance safety, efficiency, patient acceptance, and ease of use, including pain perception compared with prefilled syringes.5 The studies provided essential insights regarding the overall user-product interface and highlighted that patients had a strong and positive response to both the product design and the user experience.

As a result of human factors testing, the BD Physioject Disposable Autoinjector System provides multiple features designed to aide in patient safety and ease of use, allowing the patient to control the start of the injection once the autoinjector is placed on the skin and the cap is removed. Specific design features included in the BD Physioject Disposable Autoinjector System include the following:

  • Ergonomic design that is easy to handle and use, especially in patients with limited dexterity.
  • A 360° view of the drug and injection process, allowing the patient to confirm full dose delivery.
  • A simple, one-touch injection button for activation.
  • A hidden needle before and during injection to reduce needle-stick anxiety.
  • A protected needle before and after injection to reduce the risk of needle stick injury.

 

YouTube VIDEO: Integrating Human Factors Engineering (HFE) into Drug Delivery

 

Notes:

 

 

The following is a slideshare presentation on Parental Drug Delivery Issues in the Future

 The Dangers of Medical Devices

The FDA receives on average 100,000 medical device incident reports per year, and more than a third involve user error.

In an FDA recall study, 44% of medical device recalls are due to design problems, and user error is often linked to the poor design of a product.

Drug developers need to take safe drug dosage into consideration, and this consideration requires the application of thorough processes for Risk Management and Human Factors Engineering (HFE).

Although unintended, medical devices can sometimes harm patients or the people administering the healthcare. The potential harm arises from two main sources:

  1. failure of the device and
  2. actions of the user or user-related errors. A number of factors can lead to these user-induced errors, including medical devices are often used under stressful conditions and users may think differently than the device designer.

Human Factors: Identifying the Root Causes of Use Errors

Instead of blaming test participants for use errors, look more carefully at your device’s design.

Great posting on reasons typical design flaws creep up in medical devices and where a company should integrate fixes in product design.
Posted in Design Services by Jamie Hartford on July 8, 2013

 

 

YouTube VIDEO: Integrating Human Factors Engineering into Medical Devices

 

 

Notes:

 

 Regulatory Considerations

  • Unlike other medication dosage forms, combination products require user interaction
  •  Combination products are unique in that their safety profile and product efficacy depends on user interaction
Human Factors Review: FDA Outlines Highest Priority Devices

Posted 02 February 2016By Zachary Brennan on http://www.raps.org/Regulatory-Focus/News/2016/02/02/24233/Human-Factors-Review-FDA-Outlines-Highest-Priority-Devices/ 

The US Food and Drug Administration (FDA) on Tuesday released new draft guidance to inform medical device manufacturers which device types should have human factors data included in premarket submissions, as well final guidance from 2011 on applying human factors and usability engineering to medical devices.

FDA said it believes these device types have “clear potential for serious harm resulting from use error and that review of human factors data in premarket submissions will help FDA evaluate the safety and effectiveness and substantial equivalence of these devices.”

Manufacturers should provide FDA with a report that summarizes the human factors or usability engineering processes they have followed, including any preliminary analyses and evaluations and human factors validation testing, results and conclusions, FDA says.

The list was based on knowledge obtained through Medical Device Reporting (MDRs) and recall data, and includes:

  • Ablation generators (associated with ablation systems, e.g., LPB, OAD, OAE, OCM, OCL)
  • Anesthesia machines (e.g., BSZ)
  • Artificial pancreas systems (e.g., OZO, OZP, OZQ)
  • Auto injectors (when CDRH is lead Center; e.g., KZE, KZH, NSC )
  • Automated external defibrillators
  • Duodenoscopes (on the reprocessing; e.g., FDT) with elevator channels
  • Gastroenterology-urology endoscopic ultrasound systems (on the reprocessing; e.g., ODG) with elevator channels
  • Hemodialysis and peritoneal dialysis systems (e.g., FKP, FKT, FKX, KDI, KPF ODX, ONW)
  • Implanted infusion pumps (e.g., LKK, MDY)
  • Infusion pumps (e.g., FRN, LZH, MEA, MRZ )
  • Insulin delivery systems (e.g., LZG, OPP)
  • Negative-pressure wound therapy (e.g., OKO, OMP) intended for home use
  • Robotic catheter manipulation systems (e.g., DXX)
  • Robotic surgery devices (e.g., NAY)
  • Ventilators (e.g., CBK, NOU, ONZ)
  • Ventricular assist devices (e.g., DSQ, PCK)

Final Guidance

In addition to the draft list, FDA finalized guidance from 2011 on applying human factors and usability engineering to medical devices.

The agency said it received over 600 comments on the draft guidance, which deals mostly with design and user interface, “which were generally supportive of the draft guidance document, but requested clarification in a number of areas. The most frequent types of comments requested revisions to the language or structure of the document, or clarification on risk mitigation and human factors testing methods, user populations for testing, training of test participants, determining the appropriate sample size in human factors testing, reporting of testing results in premarket submissions, and collecting human factors data as part of a clinical study.”

In response to these comments, FDA said it revised the guidance, which supersedes guidance from 2000 entitled “Medical Device Use-Safety: Incorporating Human Factors Engineering into Risk Management,” to clarify “the points identified and restructured the information for better readability and comprehension.”

Details

The goal of the guidance, according to FDA, is to ensure that the device user interface has been designed such that use errors that occur during use of the device that could cause harm or degrade medical treatment are either eliminated or reduced to the extent possible.

FDA said the most effective strategies to employ during device design to reduce or eliminate use-related hazards involve modifications to the device user interface, which should be logical and intuitive.

In its conclusion, FDA also outlined the ways that device manufacturers were able to save money through the use of human factors engineering (HFE) and usability engineering (UE).

– See more at: http://www.raps.org/Regulatory-Focus/News/2016/02/02/24233/Human-Factors-Review-FDA-Outlines-Highest-Priority-Devices/#sthash.cDTr9INl.dpuf

 

Please see an FDA PowerPoint on Human Factors Regulatory Issues for Combination Drug/Device Products here: MFStory_RAPS 2011 – HF of ComboProds_v4

 

 

 

 

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Obesity Pharmaceutics

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

Battling the Bulge

Weight-loss drugs that target newly characterized obesity-related receptors and pathways could finally offer truly effective fat control.

By Bob Grant | November 1, 2015

http://www.the-scientist.com//?articles.view/articleNo/44322/title/Battling-the-Bulge/

http://www.the-scientist.com/November2015/NovBioBiz2_640px.jpg

Several years ago, antiobesity drug development was not looking so hot. In 2007, Sanofi-Aventis failed to win US Food and Drug Administration (FDA) approval for rimonabant—a pill that successfully helped people shed pounds—because the drug carried risks of depression and suicidal thoughts. Then, in 2008, Merck pulled the plug on its Phase 3 trials of taranabant because it also engendered suicidal thoughts and neurological effects in some participants. And a decade before those late-stage disappointments, a couple of FDA-approved weight-loss drugs were making headlines for carrying dangerous side effects. In 1997, the FDA pulled the obesity medications fenfluramine (of the wildly popular fen-phen drug combination) and dexfenfluramine (Redux) off the market after research turned up evidence of heart valve damage in people taking the drugs.

By 2009, Big Pharma was backing out of the weight-loss market, with Merck and Pfizer abandoning their programs to develop drugs similar to rimonabant and taranabant, which block cannabinoid receptors in the brain. Although the antiobesity drug market was big—according to CDC estimates, about 35 percent of adults in the U.S. are obese—a blockbuster weight-loss pill that didn’t have serious side effects was proving elusive.

But a few firms, including several small biotechs, decided to stick with it. “Some of the prior experience with drugs on the market, like fen-phen and Redux, have likely led large pharma to view the therapeutic space with some conservatism,” says Preston Klassen, executive vice president and head of global development at Orexigen Therapeutics, a small, California-based firm. “And generally, when you have that situation, smaller companies will step into that void when the science makes sense.” And their perseverance is starting to pay off. After a years-long drought in approvals for antiobesity medications, in the past few years the FDA has approved four new drugs specifically for general obesity: Belviq and Qsymia in 2012, and Contrave and Saxenda in late 2014. Three of these four were developed by small companies whose success hinges on one or a few compounds aimed directly at treating general obesity.

The recent burst of antiobesity drug approvals reflects an evolving appreciation for the molecular intricacies of this multifaceted, chronic disease. Today’s antiobesity drugs—including the four recent approvals and several more in development—have traded the blunt cudgel of appetite suppression for more precise targeting of pathways known to play roles in obesity. “With our understanding of the complex biology of obesity and all of the different molecules and receptors involved in the process, we’re much better able to target those molecules and receptors,” says Arya Sharma, chair in obesity research and management at the University of Alberta in Canada. “These are very specific agents that are designed for very specific actions. There is renewed enthusiasm in this field.”

Looking to combos

In the mid-20th century, the FDA approved several weight-loss drugs, starting with the appetite suppressant desoxyephedrine (methamphetamine hydrochloride) in 1947. Like the other appetite-suppressing drugs the FDA later approved through the 1950s and ’60s, desoxyephedrine accomplished short-term weight loss, but the transient benefit did not justify the side effects of long-term use, such as addiction, psychosis, and violent behavior. In 1973, as the nation voiced concern about the overuse of amphetamines, the FDA decreed that all obesity drugs were approved only for short-term use. The most recently approved obesity drugs, on the other hand, all have the FDA’s okay for long-term weight management.

Three of the newly approved drugs, Contrave, Belviq, and Qsymia, also aim to suppress appetite, and like many previous weight-loss therapies, all do so by targeting the hypothalamus, the brain region thought to be the seat of appetite control. Although the precise mechanism of Belviq, which is manufactured by San Diego–based Arena Pharmaceuticals, is unknown, researchers think that the key is its activation of serotonin-binding 5-HT2C receptors in proopiomelanocortin (POMC) neurons in the hypothalamus. When activated, these neurons reduce appetite and increase energy expenditure, according to Orexigen’s Klassen. His company’s Contrave also activates POMC neurons in the hypothalamus, while at the same time inhibiting opioid receptors, which would otherwise work to shut down POMC neuron firing, in the brain’s mesolimbic reward pathway. Contrave achieves this one-two punch because it is a combination therapy, incorporating two different compounds into a single weight-loss pill.

“The concept of a silver or magic bullet whereby one drug meets all of the needs within the obesity space has thus far proven to be inadequate,” says Klassen. “Right now I think the predominant opinion is that combination therapy is an appropriate way to go.”

Vivus’s Qsymia is also a combination drug, composed of phentermine—the other half of fen-phen and an activator of a G protein–coupled receptor called TAAR1—and an extended-release form of topiramate, an anticonvulsant with weight-loss side effects. Novo Nordisk—one of the few Big Pharma firms that stayed in the obesity game as others fled—is also turning its attention to combo therapies, testing its pipeline of investigational weight-loss compounds with Saxenda, its recently approved medicine that mimics glucagon peptide-1 (GLP-1), an appetite and calorie-intake regulator in the brain. “You need to combine at least two molecules to get the optimum effect,” says Novo Nordisk executive vice president and chief scientific officer Mads Krogsgaard Thomsen. The company has five other weight-loss compounds in development, and “we’re actually combining Saxenda with all of these new molecules,” he adds.

The University of Alberta’s Sharma agrees that combination therapies are a smart approach for attacking the multilayered mechanisms at play in obesity. “You’re dealing with a system that is very complex and very redundant. When you block one, other molecules or other parallel systems kick in,” he says. “My prediction for the future is that in order to get good results, one will have to move toward combinations . . . of more-specific and more-novel agents.”

On the horizon

On the heels of the recent FDA approvals, several new compounds with novel mechanisms of action are making their way through the drug-development pipeline. While most antiobesity drugs to date have aimed to suppress appetite by targeting brain regions involved in feelings of hunger and satiety, Boston-based Zafgen (for which Sharma serves as a paid advisor) is going after methionine aminopeptidase 2 (MetAP2) receptors in the liver and adipose tissue. “We’ve been one of the first ones to show that there is a significant and major weight-regulation center that the body has that exists outside the hypothalamus,” says Zafgen chief medical officer Dennis Kim. “Our drug [beloranib] is tapping into that mechanism.”

 

Zafgen researchers are investigating beloranib’s mechanism of action in patients that became very obese after their hypothalamus was damaged or removed as a result of craniopharyngioma, a type of brain cancer. “In about half of these cases, patients wake up hungry after surgery and it’s unrelenting, and they become morbidly obese very rapidly,” Kim says. Because the hypothalamus is damaged or missing, antiobesity drugs that target this brain region are ineffective. But beloranib “works just as well in these patients compared to patients with intact hypothalamus,” Kim says. As a result, beloranib may work in isolation without the need to combine different compounds, he adds. “If you can target a nodal point that’s much more upstream of simple circuitry-controlled hunger in the hypothalamus, you have the potential to reset the entire system.”

Meanwhile, another Boston-based firm, Rhythm Pharmaceuticals, is conducting clinical trials on obese patients with rare genetic disorders that compromise the melanocortin-4 (MC4) pathway, known to be involved in body weight regulation. Rhythm’s setmelanotide (RM-493) is a first-in-class drug that activates the MC4 pathway. And several companies, including the Japanese pharma firm Shionogi, are developing compounds that block the receptor of a neurotransmitter called neuropeptide Y, which plays a role in appetite stimulation and meal initiation.

Other new antiobesity targets include cyclic nucleotides, second messengers in signaling cascades such as the 3′-5′-cyclic guanosine monophosphate pathway, which conveys feelings of satiety and ramps up thermogenesis; amylin, a peptide hormone that slows gastric emptying and promotes satiety; ghrelin, a gut hormone that stimulates food intake; and a handful of pathways that affect nutrient absorption and metabolism. As more of obesity’s molecular complexities are sorted out, even more new drug targets will present themselves.

“I think we are on the verge of understanding obesity and the mechanisms underlying obesity,” says Novo Nordisk’s Thomsen. “That means that there is going to be a lot of good news for obesity going forward.”

 

WEIGHT-LOSS DRUG APPROVAL

© ISTOCK.COM/QUISP65Getting a weight-loss treatment approved by the FDA is a little different than the regulatory path taken by other drugs. To earn approval, companies must demonstrate that their drugs afford at least a 5 percent reduction in body weight over a year. And after a therapy reaches the market, companies have to conduct more research, specifically, into the drugs’ safety. Contrave, for example, which was approved in September 2014, is currently subject to rigorous post-marketing surveillance concerning evidence that the drug may lead to suicidal thoughts and behaviors. Other recently approved antiobesity drugs are under similar surveillance regimens.

The FDA also requires companies to test some approved weight-loss drugs specifically for their cardiovascular side effects. “Serious safety concerns have arisen with several obesity drugs in the past, which have informed our approach to drug development,” FDA spokesperson Eric Pahon wrote in an email to The Scientist. “All drugs approved for chronic weight management since 2012 have either had a cardiovascular outcome trial (CVOT) underway at the time of approval or have been required to initiate a CVOT as a post-marketing requirement.”

This additional testing, however, may scare off some drug developers from entering the antiobesity arena, Vivus spokesperson Dana Shinbaum wrote in an email to The Scientist. “The hurdles remain high . . . [and] may discourage innovation in this area.”

But even with the significant regulatory hurdles, it’s tough to deny the potential that exists in the antiobesity drug market. “We view obesity as one of the few remaining untapped therapeutic areas within primary care,” says Preston Klassen of Orexigen Therapeutics. “We think it’s tremendously important from a medical perspective, and we think it’s been well documented that even small reductions in body weight have meaningful and sustained impact on improved health.”

 

 

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What about Theranos?

Curator: Larry H. Bernstein, MD, FCAP

Is Theranos Situation False Crowdfunding Claims at Scale or ‘Outsider’ Naivety?

http://www.mdtmag.com/blog/2015/11/theranos-situation-false-crowdfunding-claims-scale-or-outsider-naivety

If you’ve been following the Theranos situation that involves several damning articles from the Wall Street Journal on the company (see sidebar below video), you know that “something is rotten in the state of Denmark.” That is to say, regardless of whether or not you believe the WSJ articles 100%, believe Theranos 100%, or land somewhere in between, it’s hard not to see that something at the company is definitely creating questions about their original claims. In fact, the company has apparently even tempered some language with regard to its capabilities while “debating” the accuracy of the WSJ articles. It’s really a big mess for a company that was supposedly making significant changes in the way we’d conduct blood testing and the way patients controlled and accessed their own health data (although, I think the idea behind that specific aspect is a very good one).

Due to FDA inspections and findings of concern with Thernos practices, the company is currently only collecting blood for one test using its revolutionary proprietary technology. While the company’s CEO Elizabeth Holmes continues to assure the public that the problems are tied to FDA related procedures and not an issue with the technology itself, stakeholders such as Walgreens put any further interactions with the company on hold.

In the following video from Fortune’s Global Forum, you can see Ms. Holmes discussing the situation over the FDA inspections and the changes that are currently in place with regard to the testing that’s happening at the company.

https://youtu.be/A8qgmGtRMsY

So what’s the story behind this story? Is this a deliberate attempt to deceive on the part of Theranos or is it an example of what can happen when an “outsider” gets involved in the highly regulated medical device industry and faces off with the FDA without the proper experience in place to address potential areas of concern?

In a recent blog, I looked at the crowdfunding of medical devices and what can happen when claims made don’t live up to the reality of the product that’s actually developed. Once enthusiastic investors can quickly (and loudly) turn on a company or project, venting their frustration even directly on the crowdfunding page for all to see. Unfortunately, with the way these sites seem to be set-up, the money is still provided to the company that produces a product, albeit one that does not live up to the initial concept.

Is that what Theranos ultimately is? Were the technology claims taken at face value by significant investment backers? It would seem very unlikely, but given some of the accusations of former Theranos employees in the WSJ articles, it wouldn’t be the only instance of Theranos trying to manipulate testing protocols for the sake of appearing more impressive. Theranos counters those claims by saying the former employees were actually unfamiliar with the actual testing the company performs. Whether or not you believe that is entirely up to you.

Another alternative to blatant deceit on the part of Theranos is the possibility that the company was simply playing in an industry it wasn’t truly experienced enough to handle. In other words, how many FDA savy employees work for Theranos? Did they seek consultants to help with the regulatory processes? Or were they simply naïve to the ways of the regulated industry in which they were entering?

Again, this scenario too seems unlikely, but it also brings in the debate over lab-developed tests and the FDA’s regulation of them. If Theranos testing protocols fall under the realm of LDTs, then they aren’t necessary under the oversight of the FDA. Sure, the blood collection device is (and that’s why changes are currently occurring at the company), but does the FDA have the authority to inspect the company’s tests if they are LDTs?

Ultimately, I think everyone (with the exception of competitors to Theranos perhaps) wants the company to be successful. The ideas and hope embedded within the original claims the company made will only enhance the quality of care that we are able to achieve within our healthcare system. Further, empowering patients to make decisions and get involved with their own healthcare management would likely improve their overall health.

Unfortunately, before any of that will be possible, Theranos is going to have an uphill battle in defending itself, its technology, and its CEO in this very public debate over the realistic capabilities it can provide. Hopefully, it learns from this experience and if the technology truly functions the way they’ve claimed, they’ll bring on the necessary regulatory experts and better navigate the troubled waters in which they currently find themselves.

Single Blood Drop Diagnostics Key to Resolving Healthcare Challenges

At TEDMED 2014, President and CEO of Theranos, Elizabeth Holmes, talked about the importance of enabling early detection of disease through new diagnostic tools and empowering individuals to make educated decisions about their healthcare.

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FDA Cellular & Gene Therapy Guidances: Implications for CRSPR/Cas9 Trials

Reporter: Stephen J. Williams, PhD

The recent announcement by Editas CEO Katrine Bosley to pursue a CRSPR/Cas9 gene therapy trial to correct defects in an yet to be disclosed gene to treat one form of a rare eye disease called Leber congenital amaurosis (multiple mutant genes have been linked to the disease) have put an interesting emphasis on the need for a regulatory framework to initiate these trials. Indeed at the 2015 EmTechMIT Conference Editas CEO Katrine Bosley had mentioned this particular issue: the need for discourse with FDA and regulatory bodies to establish guidelines for design of clinical trials using the CRSPR gene editing tool.

See the LIVE NOTES from Editas CEO Katrine Bosley on using CRSPR as a gene therapy from the 2015 EmTechMIT Conference at https://pharmaceuticalintelligence.com/2015/11/03/live-1132015-130pm-the-15th-annual-emtech-mit-mit-media-lab-top-10-breakthrough-technologies-2015-innovators-under-35/

To this effect, I have listed below, the multiple FDA Guidance Documents surrounding gene therapy to show that, in the past year, the FDA has shown great commitment to devise a regulatory framework for this therapeutic area.

Cellular & Gene Therapy Guidance Documents

Withdrawn Guidance Documents

Three other posts on this site goes into detail into three of the above-mentioned Guidance Documents

FDA Guidance on Use of Xenotransplanted Products in Human: Implications in 3D Printing

New FDA Draft Guidance On Homologous Use of Human Cells, Tissues, and Cellular and Tissue-Based Products – Implications for 3D BioPrinting of Regenerative Tissue

FDA Guidance Documents Update Nov. 2015 on Devices, Animal Studies, Gene Therapy, Liposomes

 

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FDA Guidance On Source Animal, Product, Preclinical and Clinical Issues Concerning the Use of Xenotranspantation Products in Humans – Implications for 3D BioPrinting of Regenerative Tissue

Reporter: Stephen J. Williams, Ph.D.

 

The FDA has submitted Final Guidance on use xeno-transplanted animal tissue, products, and cells into human and their use in medical procedures. Although the draft guidance was to expand on previous guidelines to prevent the introduction, transmission, and spread of communicable diseases, this updated draft may have implications for use of such tissue in the emerging medical 3D printing field.

This document is to provide guidance on the production, testing and evaluation of products intended for use in xenotransplantation. The guidance includes scientific questions that should be addressed by sponsors during protocol development and during the preparation of submissions to the Food and Drug Administration (FDA), e.g., Investigational New Drug Application (IND) and Biologics License Application (BLA). This guidance document finalizes the draft guidance of the same title dated February 2001.

For the purpose of this document, xenotransplantation refers to any procedure that involves the transplantation, implantation, or infusion into a human recipient of either (a) live cells, tissues, or organs from a nonhuman animal source, or (b) human body fluids, cells, tissues or organs that have had ex vivo contact with live nonhuman animal cells, tissues or organs. For the purpose of this document, xenotransplantation products include live cells, tissues or organs used in xenotransplantation. (See Definitions in section I.C.)

This document presents issues that should be considered in addressing the safety of viable materials obtained from animal sources and intended for clinical use in humans. The potential threat to both human and animal welfare from zoonotic or other infectious agents warrants careful characterization of animal sources of cells, tissues, and organs. This document addresses issues such as the characterization of source animals, source animal husbandry practices, characterization of xenotransplantation products, considerations for the xenotransplantation product manufacturing facility, appropriate preclinical models for xenotransplantation protocols, and monitoring of recipients of xenotransplantation products. This document recommends specific practices intended to prevent the introduction and spread of infectious agents of animal origin into the human population. FDA expects that new methods proposed by sponsors to address specific issues will be scientifically rigorous and that sufficient data will be presented to justify their use.

Examples of procedures involving xenotransplantation products include:

  • transplantation of xenogeneic hearts, kidneys, or pancreatic tissue to treat organ failure,
  • implantation of neural cells to ameliorate neurological degenerative diseases,
  • administration of human cells previously cultured ex vivo with live nonhuman animal antigen-presenting or feeder cells, and
  • extracorporeal perfusion of a patient’s blood or blood component perfused through an intact animal organ or isolated cells contained in a device to treat liver failure.

The guidance addresses issues such as:

  1. Clinical Protocol Review
  2. Xenotransplantation Site
  3. Criteria for Patient Selection
  4. Risk/Benefit Assessment
  5. Screening for Infectious Agents
  6. Patient Follow-up
  7. Archiving of Patient Plasma and Tissue Specimens
  8. Health Records and Data Management
  9. Informed Consent
  10. Responsibility of the Sponsor in Informing the Patient of New Scientific Information

A full copy of the PDF can be found below for reference:

fdaguidanceanimalsourcesxenotransplatntation

An example of the need for this guidance in conjunction with 3D printing technology can be understood from the below article (source http://www.geneticliteracyproject.org/2015/09/03/pig-us-xenotransplantation-new-age-chimeric-organs/)

Pig in us: Xenotransplantation and new age of chimeric organs

David Warmflash | September 3, 2015 | Genetic Literacy Project

Imagine stripping out the failing components of an old car — the engine, transmission, exhaust system and all of those parts — leaving just the old body and other structural elements. Replace those old mechanical parts with a brand new electric, hydrogen powered, biofuel, nuclear or whatever kind of engine you want and now you have a brand new car. It has an old frame, but that’s okay. The frame wasn’t causing the problem, and it can live on for years, undamaged.

When challenged to design internal organs, tissue engineers are taking a similar approach, particularly with the most complex organs, like the heart, liver and kidneys. These organs have three dimensional structures that are elaborate, not just at the gross anatomic level, but in microscopic anatomy too. Some day, their complex connective tissue scaffolding, the stroma, might be synthesized from the needed collagen proteins with advanced 3-D printing. But biomedical engineering is not there yet, so right now the best candidate for organ scaffolding comes from one of humanity’s favorite farm animals: the pig.

Chimera alarmists connecting with anti-biotechnology movements might cringe at the thought of building new human organs starting with pig tissue, but if you’re using only the organ scaffolding and building a working organ from there, pig organs may actually be more desirable than those donated by humans.

How big is the anti-chimerite movement?

Unlike anti-GMO and anti-vaccination activists, there really aren’t too many anti-chemerites around. Nevertheless, there is a presence on the web of people who express concern about mixing of humans and non-human animals. Presently, much of their concern is focussed on the growing of human organs inside non-human animals, pigs included. One anti-chemerite has written that it could be a problem for the following reason:

Once a human organ is grown inside a pig, that pig is no longer fully a pig. And without a doubt, that organ will no longer be a fully human organ after it is grown inside the pig. Those receiving those organs will be allowing human-animal hybrid organs to be implanted into them. Most people would be absolutely shocked to learn some of the things that are currently being done in the name of science.

The blog goes on to express alarm about the use of human genes in rice and from there morphs into an off the shelf garden variety anti-GMO tirade, though with an an anti-chemeric current running through it. The concern about making pigs a little bit human and humans a little bit pig becomes a concern about making rice a little bit human. But the concern about fusing tissues and genes of humans and other species does not fit with the trend in modern medicine.

Utilization of pig tissue enters a new age 

pigsinus

A porcine human ear for xenotransplantation. source: The Scientist

For decades, pig, bovine and other non-human tissues have been used in medicine. People are walking around with pig and cow heart valves. Diabetics used to get a lot of insulin from pigs and cows, although today, thanks to genetic engineering, they’re getting human insulin produced by microorganisms modified genetically to make human insulin, which is safer and more effective.

When it comes to building new organs from old ones, however, pig organs could actually be superior for a couple of reasons. For one thing, there’s no availability problem with pigs. Their hearts and other organs also have all of the crucial components of the extracellular matrix that makes up an organ’s scaffolding. But unlike human organs, the pig organs don’t tend to carry or transfer human diseases. That is a major advantage that makes them ideal starting material. Plus there is another advantage: typically, the hearts of human cadavers are damaged, either because heart disease is what killed the human owner or because resuscitation efforts aimed at restarting the heart of a dying person using electrical jolts and powerful drugs.

Rebuilding an old organ into a new one

How then does the process work? Whether starting with a donated human or pig organ, there are several possible methods. But what they all have in common is that only the scaffolding of the original organ is retained. Just like the engine and transmission of the old car, the working tissue is removed, usually using detergents. One promising technique that has been applied to engineer new hearts is being tested by researchers at the University of Pittsburgh. Detergents pumped into the aorta attached to a donated heart (donated by a human cadaver, or pig or cow). The pressure keeps the aortic valve closed, so the detergents to into the coronary arteries and through the myocardial (heart muscle) and endocardial (lining over the muscle inside the heart chambers) tissue, which thus gets dissolved over the course of days. What’s left is just the stroma tissue, forming a scaffold. But that scaffold has signaling factors that enable embryonic stem cells, or specially programed adult pleuripotent cells to become all of the needed cells for a new heart.

Eventually, 3-D printing technology may reach the point when no donated scaffolding is needed, but that’s not the case quite yet, plus with a pig scaffolding all of the needed signaling factors are there and they work just as well as those in a human heart scaffold. All of this can lead to a scenario, possibly very soon, in which organs are made using off-the-self scaffolding from pig organs, ready to produce a custom-made heart using stem or other cells donated by new organ’s recipient.

David Warmflash is an astrobiologist, physician, and science writer. Follow @CosmicEvolution to read what he is saying on Twitter.

And a Great Article in The Scientist by Dr. Ed Yong Entitled

Replacement Parts

To cope with a growing shortage of hearts, livers, and lungs suitable for transplant, some scientists are genetically engineering pigs, while others are growing organs in the lab.

By Ed Yong | August 1, 2012

Source: http://www.the-scientist.com/?articles.view/articleNo/32409/title/Replacement-Parts/

.. where Joseph Vacanti and David Cooper figured that using

“engineered pigs without the a-1,3-galactosyltransferase gene that produces the a-gal residues. In addition, the pigs carry human cell-membrane proteins such as CD55 and CD46 that prevent the host’s complement system from assembling and attacking the foreign cells”

thereby limiting rejection of the xenotransplated tissue.

In addition to issues related to animal virus transmission the issue of optimal scaffolds for organs as well as the advantages which 3D Printing would have in mass production of organs is discussed:

To Vacanti, artificial scaffolds are the future of organ engineering, and the only way in which organs for transplantation could be mass-produced. “You should be able to make them on demand, with low-cost materials and manufacturing technologies,” he says. That is relatively simple for organs like tracheas or bladders, which are just hollow tubes or sacs. Even though it is far more difficult for the lung or liver, which have complicated structures, Vacanti thinks it will be possible to simulate their architecture with computer models, and fabricate them with modern printing technology. (See “3-D Printing,” The Scientist, July 2012.) “They obey very ordered rules, so you can reduce it down to a series of algorithms, which can help you design them,” he says. But Taylor says that even if the architecture is correct, the scaffold would still need to contain the right surface molecules to guide the growth of any added cells. “It seems a bit of an overkill when nature has already done the work for us,” she says.

Other articles of FDA Guidance and 3D Bio Printing on this Open Access Journal Include:

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New FDA Draft Guidance On Homologous Use of Human Cells, Tissues, and Cellular and Tissue-Based Products – Implications for 3D BioPrinting of Regenerative Tissue

Reporter: Stephen J. Williams, Ph.D.

The FDA recently came out with a Draft Guidance on use of human cells, tissues and cellular and tissue-based products (HCT/P) {defined in 21 CFR 1271.3(d)} and their use in medical procedures. Although the draft guidance was to expand on previous guidelines to prevent the introduction, transmission, and spread of communicable diseases, this updated draft may have implications for use of such tissue in the emerging medical 3D printing field.

A full copy of the PDF can be found here for reference but the following is a summary of points of the guidance.FO508ver – 2015-373 HomologousUseGuidanceFinal102715

In 21 CFR 1271.10, the regulations identify the criteria for regulation solely under section 361 of the PHS Act and 21 CFR Part 1271. An HCT/P is regulated solely under section 361 of the PHS Act and 21 CFR Part 1271 if it meets all of the following criteria (21 CFR 1271.10(a)):

  • The HCT/P is minimally manipulated;
  • The HCT/P is intended for homologous use only, as reflected by the labeling, advertising, or other indications of the manufacturer’s objective intent;
  • The manufacture of the HCT/P does not involve the combination of the cells or tissues with another article, except for water, crystalloids, or a sterilizing, preserving, or storage agent, provided that the addition of water, crystalloids, or the sterilizing, preserving, or storage agent does not raise new clinical safety concerns with respect to the HCT/P; and
  • Either:
  1. The HCT/P does not have a systemic effect and is not dependent upon the metabolic activity of living cells for its primary function; or
  2. The HCT/P has a systemic effect or is dependent upon the metabolic activity of living cells for its primary function, and:
  3. Is for autologous use;
  4. Is for allogeneic use in a first-degree or second-degree blood relative; or
  5. Is for reproductive use.

If an HCT/P does not meet all of the criteria in 21 CFR 1271.10(a), and the establishment that manufactures the HCT/P does not qualify for any of the exceptions in 21 CFR 1271.15, the HCT/P will be regulated as a drug, device, and/or biological product under the Federal Food, Drug and Cosmetic Act (FD&C Act), and/or section 351 of the PHS Act, and applicable regulations, including 21 CFR Part 1271, and pre-market review will be required.

1 Examples of HCT/Ps include, but are not limited to, bone, ligament, skin, dura mater, heart valve, cornea, hematopoietic stem/progenitor cells derived from peripheral and cord blood, manipulated autologous chondrocytes, epithelial cells on a synthetic matrix, and semen or other reproductive tissue. The following articles are not considered HCT/Ps: (1) Vascularized human organs for transplantation; (2) Whole blood or blood components or blood derivative products subject to listing under 21 CFR Parts 607 and 207, respectively; (3) Secreted or extracted human products, such as milk, collagen, and cell factors, except that semen is considered an HCT/P; (4) Minimally manipulated bone marrow for homologous use and not combined with another article (except for water, crystalloids, or a sterilizing, preserving, or storage agent, if the addition of the agent does not raise new clinical safety concerns with respect to the bone marrow); (5) Ancillary products used in the manufacture of HCT/P; (6) Cells, tissues, and organs derived from animals other than humans; (7) In vitro diagnostic products as defined in 21 CFR 809.3(a); and (8) Blood vessels recovered with an organ, as defined in 42 CFR 121.2 that are intended for use in organ transplantation and labeled “For use in organ transplantation only.” (21 CFR 1271.3(d))

Contains Nonbinding Recommendations
Draft – Not for Implementation

Section 1271.10(a)(2) (21 CFR 1271.10(a)(2)) provides that one of the criteria for an HCT/P to be regulated solely under section 361 of the PHS Act is that the “HCT/P is intended for homologous use only, as reflected by the labeling, advertising, or other indications of the manufacturer’s objective intent.” As defined in 21 CFR 1271.3(c), homologous use means the repair, reconstruction, replacement, or supplementation of a recipient’s cells or tissues with an HCT/P that performs the same basic function or functions in the recipient as in the donor. This criterion reflects the Agency’s conclusion that there would be increased safety and effectiveness concerns for HCT/Ps that are intended for a non-homologous use, because there is less basis on which to predict the product’s behavior, whereas HCT/Ps for homologous use can reasonably be expected to function appropriately (assuming all of the other criteria are also met).2 In applying the homologous use criterion, FDA will determine what the intended use of the HCT/P is, as reflected by the the labeling, advertising, and other indications of a manufacturer’s objective intent, and will then apply the homologous use definition.

FDA has received many inquiries from manufacturers about whether their HCT/Ps meet the homologous use criterion in 21 CFR 1271.10(a)(2). Additionally, transplant and healthcare providers often need to know this information about the HCT/Ps that they are considering for use in their patients. This guidance provides examples of different types of HCT/Ps and how the regulation in 21 CFR 1271.10(a)(2) applies to them, and provides general principles that can be applied to HCT/Ps that may be developed in the future. In some of the examples, the HCT/Ps may fail to meet more than one of the four criteria in 21 CFR 1271.10(a).

III. QUESTIONS AND ANSWERS

  1. What is the definition of homologous use?

Homologous use means the repair, reconstruction, replacement, or supplementation of a recipient’s cells or tissues with an HCT/P that performs the same basic function or functions in the recipient as in the donor (21 CFR 1271.3(c)), including when such cells or tissues are for autologous use. We generally consider an HCT/P to be for homologous use when it is used to repair, reconstruct, replace, or supplement:

  • Recipient cells or tissues that are identical (e.g., skin for skin) to the donor cells or tissues, and perform one or more of the same basic functions in the recipient as the cells or tissues performed in the donor; or,
  • Recipient cells that may not be identical to the donor’s cells, or recipient tissues that may not be identical to the donor’s tissues, but that perform one or more of the same basic functions in the recipient as the cells or tissues performed in the donor.3

2 Proposed Approach to Regulation of Cellular and Tissue-Based Products, FDA Docket. No. 97N-0068 (February. 28, 1997) page 19. http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/tissue/ ucm062601.pdf.

3“Establishment Registration and Listing for Manufacturers of Human Cellular and Tissue-Based Products” 63 FR 26744 at 26749 (May 14, 1998).

Contains Nonbinding Recommendations
Draft – Not for Implementation

1-1. A heart valve is transplanted to replace a dysfunctional heart valve. This is homologous use because the donor heart valve performs the same basic function in the donor as in the recipient of ensuring unidirectional blood flow within the heart.

1-2. Pericardium is intended to be used as a wound covering for dura mater defects. This is homologous use because the pericardium is intended to repair or reconstruct the dura mater and serve as a covering in the recipient, which is one of the basic functions it performs in the donor.

Generally, if an HCT/P is intended for use as an unproven treatment for a myriad of

diseases or conditions, the HCT/P is likely not intended for homologous use only.4

  1. What does FDA mean by repair, reconstruction, replacement, or supplementation of a recipient’s cells or tissues?

Repair generally means the physical or mechanical restoration of tissues, including by covering or protecting. For example, FDA generally would consider skin removed from a donor and then transplanted to a recipient in order to cover a burn wound to be a homologous use. Reconstruction generally means surgical reassembling or re-forming. For example, reconstruction generally would include the reestablishment of the physical integrity of a damaged aorta.5 Replacement generally means substitution of a missing tissue or cell, for example, the replacement of a damaged or diseased cornea with a healthy cornea or the replacement of donor hematopoietic stem/progenitor cells in a recipient with a disorder affecting the hematopoietic system that is inherited, acquired, or the result of myeloablative treatment. Supplementation generally means to add to, or complete. For example, FDA generally would consider homologous uses to be the implantation of dermal matrix into the facial wrinkles to supplement a recipient’s tissues and the use of bone chips to supplement bony defects. Repair, reconstruction, replacement, and supplementation are not mutually exclusive functions and an HCT/P could perform more than one of these functions for a given intended use.

  1. What does FDA mean by “the same basic function or functions” in the definition of homologous use?

For the purpose of applying the regulatory framework, the same basic function or functions of HCT/Ps are considered to be those basic functions the HCT/P performs in the body of the donor, which, when transplanted, implanted, infused, or transferred, the HCT/P would be expected to perform in the recipient. It is not necessary for the HCT/P in the recipient to perform all of the basic functions it performed in the donor, in order to

4 “Human Cells, Tissues, and Cellular and Tissue-Based Products; Establishment Registration and Listing” 66 FR 5447 at 5458 (January 19, 2001).

5 “Current Good Tissue Practice for Human Cell, Tissue, and Cellular and Tissue-Based Product Establishments; Inspection and Enforcement” 69 FR 68612 at 68643 (November 24, 2004) states, “HCT/Ps with claims for “reconstruction or repair” can be regulated solely under section 361 of the PHS Act, provided the HCT/P meets all the criteria in § 1271.10, including minimal manipulation and homologous use.”

Contains Nonbinding Recommendations
Draft – Not for Implementation

meet the definition of homologous use. However, to meet the definition of homologous use, any of the basic functions that the HCT/P is expected to perform in the recipient must be a basic function that the HCT/P performed in the donor.

A homologous use for a structural tissue would generally be to perform a structural function in the recipient, for example, to physically support or serve as a barrier or conduit, or connect, cover, or cushion.

A homologous use for a cellular or nonstructural tissue would generally be a metabolic or biochemical function in the recipient, such as, hematopoietic, immune, and endocrine functions.

3-1. The basic functions of hematopoietic stem/progenitor cells (HPCs) include to form and to replenish the hematopoietic system. Sources of HPCs include cord blood, peripheral blood, and bone marrow.6

  1. HPCs derived from peripheral blood are intended for transplantation into an individual with a disorder affecting the hematopoietic system that is inherited, acquired, or the result of myeloablative treatment. This is homologous use because the peripheral blood product performs the same basic function of reconstituting the hematopoietic system in the recipient.
  2. HPCs derived from bone marrow are infused into an artery with a balloon catheter for the purpose of limiting ventricular remodeling following acute myocardial infarction. This is not homologous use because limiting ventricular remodeling is not a basic function of bone marrow.
  3. A manufacturer provides HPCs derived from cord blood with a package insert stating that cord blood may be infused intravenously to differentiate into neuronal cells for treatment of cerebral palsy. This is not homologous use because there is insufficient evidence to support that such differentiation is a basic function of these cells in the donor.

3-2. The basic functions of the cornea include protecting the eye by forming its outermost layer and serving as the refracting medium of the eye. A corneal graft is transplanted to restore sight in a patient with corneal blindness. This is homologous use because a corneal graft performs the same basic functions in the donor as in the recipient.

3-3. The basic functions of a vein or artery include serving as a conduit for blood flow throughout the body. A cryopreserved vein or artery is used for arteriovenous access during hemodialysis. This is homologous use because the vein or artery is supplementing the vessel as a conduit for blood flow.

3-4. The basic functions of amniotic membrane include covering, protecting, serving as a selective barrier for the movement of nutrients between the external and in utero

6 Bone marrow meets the definition of an HCT/P only if is it more than minimally manipulated; intended by the manufacturer for a non-homologous use, or combined with certain drugs or devices.

Contains Nonbinding Recommendations
Draft – Not for Implementation

environment, and to retain fluid in utero. Amniotic membrane is used for bone tissue replacement to support bone regeneration following surgery to repair or replace bone defects. This is not a homologous use because bone regeneration is not a basic function of amniotic membrane.

3-5. The basic functions of pericardium include covering, protecting against infection, fixing the heart to the mediastinum, and providing lubrication to allow normal heart movement within chest. Autologous pericardium is used to replace a dysfunctional heart valve in the same patient. This is not homologous use because facilitating unidirectional blood flow is not a basic function of pericardium.

  1. Does my HCT/P have to be used in the same anatomic location to perform the same basic function or functions?

An HCT/P may perform the same basic function or functions even when it is not used in the same anatomic location where it existed in the donor.7 A transplanted HCT/P could replace missing tissue, or repair, reconstruct, or supplement tissue that is missing or damaged, either when placed in the same or different anatomic location, as long as it performs the same basic function(s) in the recipient as in the donor.

4-1. The basic functions of skin include covering, protecting the body from external force, and serving as a water-resistant barrier to pathogens or other damaging agents in the external environment. The dermis is the elastic connective tissue layer of the skin that provides a supportive layer of the integument and protects the body from mechanical stress.

  1. An acellular dermal product is used for supplemental support, protection, reinforcement, or covering for a tendon. This is homologous use because in both anatomic locations, the dermis provides support and protects the soft tissue structure from mechanical stress.
  2. An acellular dermal product is used for tendon replacement or repair. This is not homologous use because serving as a connection between muscle and bone is not a basic function of dermis.

4-2. The basic functions of amniotic membrane include serving as a selective barrier for the movement of nutrients between the external and in utero environment and to retain fluid in utero. An amniotic membrane product is used for wound healing of dermal ulcers and defects. This is not homologous use because wound healing of dermal lesions is not a basic function of amniotic membrane.

4-3. The basic functions of pancreatic islets include regulating glucose homeostasis within the body. Pancreatic islets are transplanted into the liver through the portal vein,

7 “Human Cells, Tissues, and Cellular and Tissue-Based Products; Establishment Registration and Listing” 66 FR 5447 at 5458 (January 19, 2001).

6

Contains Nonbinding Recommendations
Draft – Not for Implementation

for preservation of endocrine function after pancreatectomy. This is homologous use because the regulation of glucose homeostasis is a basic function of pancreatic islets.

  1. What does FDA mean by “intended for homologous use” in 21 CFR 1271.10(a)(2)?

The regulatory criterion in 21 CFR 1271.10(a)(2) states that the HCT/P is intended for homologous use only, as reflected by the labeling, advertising, or other indications of the manufacturer’s objective intent.

Labeling includes the HCT/P label and any written, printed, or graphic materials that supplement, explain, or are textually related to the product, and which are disseminated by or on behalf of its manufacturer.8 Advertising includes information, other than labeling, that originates from the same source as the product and that is intended to supplement, explain, or be textually related to the product (e.g., print advertising, broadcast advertising, electronic advertising (including the Internet), statements of company representatives).9

An HCT/P is intended for homologous use when its labeling, advertising, or other indications of the manufacturer’s objective intent refer to only homologous uses for the HCT/P. When an HCT/P’s labeling, advertising, or other indications of the manufacturer’s objective intent refer to non-homologous uses, the HCT/P would not meet the homologous use criterion in 21 CFR 1271.10(a)(2).

  1. What does FDA mean by “manufacturer’s objective intent” in 21 CFR 1271.10(a)(2)?

A manufacturer’s objective intent is determined by the expressions of the manufacturer or its representatives, or may be shown by the circumstances surrounding the distribution of the article. A manufacturer’s objective intent may, for example, be shown by labeling claims, advertising matter, or oral or written statements by the manufacturer or its representatives. It may be shown by the circumstances that the HCT/P is, with the knowledge of the manufacturer or its representatives, offered for a purpose for which it is neither labeled nor advertised.

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cancer-hunting virus

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

A ‘huge milestone’: approval of cancer-hunting virus signals new treatment era

Imlygic programs viruses to attack only cancer cells and gives patients more humane options – potentially ‘a complete change in the game’ in treatment
http://www.theguardian.com/society/2015/nov/02/fda-approval-imlygic-cancer-hunting-viral-treatment

 

Microscopic view of pancreatic cancer cells

https://i.guim.co.uk/img/static/sys-images/Guardian/Pix/pictures/2015/10/1/1443727412538/

Microscopic view of pancreatic cancer cells. Photograph: Stocktrek Images, Inc. / Alamy S/Alamy Stock Photo

 

A new cancer treatment strategy is on the horizon that experts say could be a game-changer and spare patients the extreme side effects of existing options such as chemotherapy.

Chemotherapy and other current cancer treatments are brutal, scorched-earth affairs that work because cancer cells are slightly – but not much – more susceptible to the havoc they wreak than the rest of the body. Their side effects are legion, and in many cases horrifying – from hair loss and internal bleeding to chronic nausea and even death.

But last week the Food and Drug Administration (FDA) for the first time approved a single treatment that can intelligently target cancer cells while leaving healthy ones alone, and simultaneously stimulate the immune system to fight the cancer itself.

The treatment, which is called T-VEC (for talimogene laherparepvec) but will be sold under the brand name Imlygic, uses a modified virus to hunt cancer cells in what experts said was an important and significant step in the battle against the deadly disease.

It works by introducing a specially modified form of the herpes virus by injection directly into a tumour – specifically skin cancer, the indication for which the drug has been cleared for use.

 

 

The FDA is allowing the injectable drug Imlygic, made by Amgen Inc, to be used at first only on melanomas that cannot be removed surgically. The company said a single course would cost about $65,000 depending on the length of the treatment.

The drug is injected directly into tumour tissue, where it uses herpes as a Trojan horse to slip past and rupture cancer cells. The drug combines a gene snippet meant to stimulate the immune system with a modified version of the herpes simplex virus — the kind that causes mouth cold sores.

Despite the drug’s groundbreaking approach FDA officials stressed it had not been shown to extend life. Instead company studies showed that about 16% of patients injected with the drug saw their tumours shrink, compared with 2% of patients who took more conventional cancer drugs. That effect lasted at least six months.

Regulators stressed that Imlygic had no effect on melanoma that had spread to the brain, lungs or other internal organs.

Amgen said patients should be treated with the drug for at least six months, or until there were no more tumours left to treat.

The drug — known chemically as talimogene laherparepvec or T-VEC — divides into copies repeatedly until the membranes, or outer layers, of the cancer cells burst. Meanwhile the gene snippet produces a protein to stimulate an immune response to kill melanoma cells in the tumour and elsewhere in the body.

A 2013 review in the journal Molecular Cancer concluded that cancer-fighting viruses armed with genes that stimulate the immune system “are potent therapeutic cancer vaccines”.

 

It was developed by the Massachusetts-based biotech company BioVex, which was acquired in 2011 by biotech behemoth Amgen for $1bn. The genetic code of the virus – which was originally taken from the cold sore of a BioVex employee – has been modified so it can kill only cancer cells.

Cancer-hunting viruses have long been thought of as a potential source of a more humane and targeted treatment for cancer. Unlike current oncological treatments like chemotherapy and radiotherapy, which kill cancer cells but also damage the rest of the body, viruses can be programmed to attack only the cancer cells, leaving patients to suffer the equivalent of just a day or two’s flu.

Treatments such as Imlygic have two modes of action: first, the virus directly attacks the cancer cells; and second, it triggers the body’s immune system to attack the rogue cells too once it detects the virus’s presence.

Dr Stephen Russell, a researcher at the Mayo Clinic who specialises in oncolytic virotherapy – as these treatments are known – says that the FDA’s clearance of Imlygic represents “a huge milestone” in cancer treatment development.

Viruses are “nature’s last untapped bioresource”, Russell said. Imlygic itself has an officially fairly modest effect coming out of its clinical studies – an average lifespan increase of less than five months. But underneath that data, Russell said anecdotally that in his Mayo clinic studies in mice, some programmable viruses saw “large tumours completely disappearing”.

The goal, he said, was to get to the point where the clinical trials would see similarly dramatic outcomes, so that chemotherapy and radiotherapy could finally be consigned to medical history.

John Bell, a researcher into viral cancer therapies at the Ottawa Hospital Research Institute in Ottawa, Canada, said that while T-VEC was designed to be directly injected into a tumour – as opposed to being delivered to the whole body as a systemic treatment would be – the results showed systemic effects in some cases.

Some of the treatments use a modified version of measles, rather than herpes, as a vehicle. Both Russell and Bell pointed to a trial participant of Russell’s named Stacy Erholtz, whose incurable myeloma – blood cancer – disappeared, largely side effect free, in 36 hours after a treatment using a modified measles virus, an example of the kind of miraculous results that viral oncology researchers hope to replicate.

Of course, individual success stories like Erholtz’s are relatively meaningless without the hard data that come with replicable and repeated clinical trials. There are currently a number of similar treatments at the third stage of clinical testing – still several years of work behind Imlygic in terms of development – but progress is being made.

Russell is hopeful that Imlygic represents “a first step in the direction of a complete change in the game” in how we treat cancer. “We can’t prematurely claim that we’ve achieved our ultimate goal, because we haven’t; this really is a single step along that path,” he said. “But it’s a very important and very significant step.”

 

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