On Remote Control: FDA Issues Draft Guidance to Facilitate Use of Digital Health Technologies for Remote Data Acquisition in Clinical Trials

During the COVID-19 pandemic, decentralized clinical trials and remote patient monitoring and data acquisition became a necessity, accelerating the use of digital health technologies in clinical trials.  Acknowledging that technological advances “have revolutionized the ability to remotely obtain and analyze clinically relevant information from individuals” and that “DHTs [ ] are playing a growing role in health care and offer important opportunities in clinical research,” the FDA issued during the last week of December 2021 a draft guidance, Digital Health Technologies for Remote Data Acquisition in Clinical Investigations, which provides recommendations for sponsors, investigators and other stakeholders to facilitate the use of DHTs for remote data acquisition  in clinical trials, including clinical trials that will be submitted to the FDA in a marketing application for a medical product.

The draft guidance defines a digital health technology (DHT) as a system that uses computing platforms (such as a mobile phone, tablet, or smart watch), connectivity, software, and/or sensors for healthcare and related uses.  Some DHTs may meet the definition of “device” under the Federal Food, Drug and Cosmetic Act, but the draft guidance specifically does not address the circumstances under which a DHT would meet the statutory definition of a device and notes that DHTs used in clinical investigations generally are exempt from premarket clearance or approval requirements, as long as the clinical investigation is compliant with 21 CFR Part 812.

The draft guidance explains that sponsors must foremost ensure that a DHT is “fit-for-purpose” for its proposed use in a specific clinical investigation.  In essence, the level of verification and validation associated with the DHT must be sufficient to support its use and interpretability in the clinical investigation.  This may require sponsors to work with the developer or manufacturer of the DHT, patients, caregivers, and other technical and clinical experts to assure that the DHT is suitable for its intended purpose in the clinical investigation.  The draft guidance advises sponsors to select a DHT that corresponds to the clinical outcome to be assessed, and that considers the clinical trial population and the design/operating characteristics of the DHT that may affect trial participants’ use of the DHT.

Sponsors should also be prepared to describe how they will analyze data collected from DHTs in their statistical analysis plan, including prespecifying “intercurrent events” (defined as events that occur after treatment initiation that result in missing or erroneous data associated with the clinical outcome of interest) that may be related to the DHT and/or the general purpose computing platform, and how these events will be accounted for in the analysis.  To maintain data integrity, FDA recommends that the output of the DHT and associated metadata be transmitted to a durable electronic data repository that is protected from alterations and maintained until the end of the record retention period.  FDA generally will consider data in such a repository to constitute the source data and should be made available for inspection and to reconstruct and evaluate the clinical investigation.

FDA further notes that “unique privacy risks” may arise when DHTs are used in a clinical trial.  Sponsors are advised to evaluate the risk of potential disclosures of personally identifiable information through breaches of the DHT, the general computing platform on which the DHT runs, and/or the durable electronic repository, assure appropriate security safeguards are in place, and consider including such information in the informed consent documents for the clinical trial.

The draft guidance recommends that sponsors:

  • train trial participants and trial personnel on the use of DHTs and develop a plan to provide technical assistance to trial participants and study personnel;
  • develop a risk management plan to address potential problems with the DHT (e.g., interference between mobile applications, or loss, damage and replacement);
  • develop a safety monitoring plan that addresses how abnormal measurements related to participants’ safety measured by DHTs will be reviewed and managed; and
  • develop a contingency plan for any changes to the DHT (e.g., discontinuation of a specific model, operating system updates)

The draft guidance includes appendices with specific examples of how different types of DHTs could be incorporated into a clinical investigation.  Given the particular circumstances of each DHT and clinical investigation, the draft guidance encourages sponsors to engage early with the appropriate FDA Center responsible for the medical product under development to discuss the proposed use of DHT(s) in a clinical investigation and, for DHTs or DHT-collected endpoints that require qualification, engage with an appropriate FDA qualification program, such as the Medical Device Development Tool Qualification Program.

Comments on the draft guidance are due March 23, 2022.

Reality Check: FDA Draft Guidance Outlines Considerations for the Use of Real-World Data and Real-World Evidence to Support Regulatory Decision-Making for Drugs and Biological Products

Last week the FDA issued another draft guidance in its series of recent guidance documents setting forth the agency’s views regarding the generation and use of Real-World Data (RWD) and Real-World Evidence (RWE) for prescription drugs and biological products. (see our recent post on FDA’s draft guidance relating to registries).

This latest draft guidance, Considerations for the Use of Real-World Data and Real-World Evidence to Support Regulatory Decision-Making for Drug and Biological Products, clarifies the agency’s expectations for sponsors submitting new drug applications (NDAs) or biologics license applications (BLAs) with studies using Real-World Data (RWD) to support the safety or effectiveness of drugs or biological products, when such studies are not subject to FDA’s investigational new drug (IND) application requirements under 21 CFR Part 312.  The draft guidance focuses on non-interventional (a.k.a. observational) studies, in which patients receive a drug during routine medical practice, according to a medical provider’s clinical judgment and based on patient characteristics, rather than via assignment to a study arm and according to a clinical trial protocol.

Key considerations outlined in the guidance:

  • Sponsors designing a non-interventional study to support a marketing application should engage early with the relevant FDA review division (e.g., through a Type C meeting) and be prepared to submit draft protocols and SAPs for FDA feedback before conducting the study analyses.
  • To assure the FDA that the results of a non-interventional study were not skewed to favor a particular conclusion, sponsors should provide evidence that the non-interventional study protocol and statistical analysis plan were finalized prior to reviewing outcome data and before performing prespecified analyses. Sponsors should provide a justification for selecting relevant data sources and generate audit trails in their datasets. FDA also recommends that sponsors post their non-interventional study protocols on a publicly available website, such as ClinicalTrials.gov.
  • Sponsors must be able to submit patient-level data from the RWD. Where a third party owns or controls the RWD, sponsors should have agreements with such parties to ensure that patient-level data and source data to verify the RWD can be provided to the FDA for inspection, as applicable. Sponsors should have well-documented programming codes and algorithms that would allow the FDA to replicate the study analysis using the same dataset and analytic approach.
  • Non-interventional studies should be monitored. The FDA advises sponsors to use a risk-based quality management approach, with a focus on preventing or mitigating important and/or likely risks to study quality.  If a non-interventional study does not include any activities or procedures involving patients, monitoring can focus on assuring the data integrity of the RWD, from extraction to analysis to reporting of results.  When a non-interventional study protocol includes ancillary activities or procedures, sponsors should exercise appropriate oversight of processes critical to human subject protection.
  • Adverse events that a sponsor becomes aware of through a non-interventional study must be submitted in accordance with postmarketing safety reporting regulations. However, the agency acknowledges that if a sponsor is conducting a non-interventional study that appropriately utilizes only a subset of a larger dataset, the sponsor will not have to search the entirety of the dataset for adverse events.
  • Sponsors should take responsibility for all activities related to the design, conduct and oversight of a non-interventional study that is being submitted for regulatory review. This includes selecting qualified researchers, ensuring the study is conducted in accordance with the protocol, maintaining and retaining adequate study records, and maintaining an electronic system to manage RWD that complies with 21 CFR Part 11. Where a sponsor engages third parties to perform certain study-related tasks, the responsibilities of each organization should be documented and made readily available to the FDA upon request.

Comments on the guidance should be submitted to the docket by March 9, 2022.

It’s Starting to Register: FDA Draft Guidance Addresses Use of Registries to Support Regulatory Decision-Making for Drugs & Biological Products

Showing no signs of food coma, the FDA issued draft guidance on the Monday following the Thanksgiving holiday weekend that outlines considerations for sponsors proposing to design a registry or use an existing registry to support regulatory decision-making about a drug’s effectiveness or safety.  This draft guidance represents the Agency’s latest response to the mandate in the 21st Century Cures Act to issue guidance on the use of real world evidence in regulatory decision-making, and expands on the Framework for FDA’s Real-World Evidence Program from December 2018.

The draft guidance, Real-World Data: Assessing Registries to Support Regulatory Decision-Making for Drug and Biological Products, defines a registry as “an organized system that collects clinical and other data in a standardized format for a population defined by a particular disease, condition, or exposure,” and identifies three general categories of registries: disease registries, health service registries, and product registries.

Given the range of registry types, FDA notes that registry data can have varying degrees of suitability for use in a regulatory context depending on several factors, including how the data are intended to be used for regulatory purposes, the patient population enrolled, the data collected, and how registry datasets are created, maintained, curated, and analyzed.  FDA advises sponsors to be mindful of both the strengths and limitations of using registries as a source of data to support regulatory decision-making.  In general, the draft guidance advises that (i) a registry that captures objective endpoints, such as death or hospitalization, is more likely to be suitable to support regulatory decision-making than a registry that collects subjective endpoints, such as pain; and (ii) a registry that is specifically designed to answer a particular research question is more likely to be useful to support regulatory decision-making than a registry that was designed for a different purpose.

At the same time, the Agency acknowledges that an existing registry can be used to collect data for purposes other than those originally intended, and that leveraging an existing registry’s infrastructure to support multiple purposes can be efficient.  Therefore, the draft guidance describes factors sponsors can use to assess the relevance and reliability of a registry’s data to determine whether the registry data may be fit-for-use.

When determining relevance of registry data, the draft guidance advises sponsors to consider, among other things, whether the data elements captured by the registry are sufficient given the intended use or uses of the registry (e.g., external control arm vs. a tool to enroll participants in an interventional study) and whether the methods involved in patient selection may have impacted the representativeness of the population in the registry.

When assessing the reliability of registry data, the draft guidance advises sponsors to assure the registry has appropriate governance measures in place to help ensure the registry can meet its objectives, such as processes and procedures governing the operation of the registry, adequate training of staff, and other recommended practices including:

  • Defined processes and procedures for data collection, management and storage;
  • A data dictionary and rules for validation of queries and edit checks of registry data;
  • Conformance with 21 CFR part 11, as applicable, including access controls and audit trails; and
  • Adherence to applicable human subject protection requirements, including safeguarding the privacy of patient health information.

The draft guidance specifically recommends that sponsors interested in using a registry to support a regulatory decision should meet with the relevant FDA review division (e.g., through a Type C meeting), before conducting a study that will include registry data.  Sponsors also should be prepared to submit protocols and statistical analysis plans for FDA feedback prior to conducting a study that includes data from registries.

Comments on the guidance should be submitted to the docket by February 28, 2022.

Things for Pharma and Biotech Companies to Watch in the Cures 2.0 Proposed Legislation

Last week, Diana DeGette (D-CO) and Fred Upton (R-MI) introduced in the House highly anticipated bill language for “Cures 2.0”, a follow-up to the transformational 21st Century Cures Act enacted in 2016.  For full text of the bill, click here.  The 21st Century Cures Act included a variety of measures seeking to accelerate medical product development and bring advancements and innovations to patients more efficiently. Cures 2.0 seeks to improve and expand on those strides, as well as address pressing public health priorities that became apparent through the COVID-19 pandemic.

The Cures 2.0 bill is structured around five main topics:

  • Title I—Public Health
  • Title II—Patients and Caregivers
  • Title III—Food and Drug Administration
  • Title IV—Centers for Medicare & Medicaid Services
  • Title V—Research

While all of these sections are ripe for further analysis, we selected a few provisions to highlight here that may be of particular interest for the pharmaceutical and biotechnology companies out there.  We’ll keep tracking these as the bill moves through the legislative process:

Section 204: Patient Experience Data

  • Would require sponsors developing a drug under an IND to collect standardized patient experience data during clinical trials and include that patient experience data “and such related data” in an NDA or BLA; and
  • Would direct FDA to consider this patient experience data and “related information” in its approval decision for the NDA or BLA.
  • These proposals to standardize and require patient experience data collection could be significant, and they underscore lawmakers’ continued interest in elevating the relevance of clinical outcomes that are meaningful to patients living with a disease or condition.

Section 302: Grants for Novel Trial Designs and Other Innovations in Drug Development & Section 310: Recommendations to Decentralize Clinical Trials

  • Section 302 would appropriate $25 million annually, for 3 years, for the FDA to award grants to clinical trials conducted under an IND with protocols incorporating complex adaptive or other novel trial designs and that collect patient experience data. The section further specifies that grant awards should prioritize the incorporation of digital health technologies and real world evidence.
  • Section 310 proposes a multi-stakeholder meeting, including industry representatives and patient advocacy groups, to discuss incentives to adopt decentralized clinical trials. The section also would adopt a definition of decentralized trials: “a clinical trial method that includes the use of telemedicine or digital technologies to allow for the remote collection of clinical trial data from subjects, including in the home or office setting.”
  • These provisions reflect a sustained emphasis on fostering clinical trial innovation, including building on the experience with remote clinical trials during the COVID-19 pandemic.

Section 304: Increasing Use of Real World Evidence (RWE) & Section 309: Post-Approval Study Requirements for Accelerated Approval

  • Section 304 would call for new guidance on the use of RWE in post-market review of drugs that were designated as a breakthrough therapy or fast track product, or considered for accelerated approval. Section 309 would further specify that the post-approval study requirements to verify and describe the clinical benefit for products granted accelerated approval could be satisfied through RWE, including analyses of data in clinical care repositories or patient registries.
  • Section 304 also would establish a permanent Real World Evidence Task Force to coordinate programs and activities within the Department of Health and Human Services related to the collection and use of RWE.
  • These and other sections of Cures 2.0 share a common theme of enhancing the use of RWE in regulatory decision-making. Although the inherent variability in RWE likely will continue to present challenges to doing so, the signal is clear that legislators would like to see FDA and HHS continue to move forward in this area.

Last week’s introduction of Cures 2.0 and President Biden’s announcement that he will nominate Robert Califf for FDA Commissioner contributed to a newsworthy week for those of us who follow the FDA.  We look forward to seeing how Cures 2.0 develops and how the Agency’s policy priorities unfold in the coming months.