COMPASSIONATE USE OF INVESTIGATIONAL DRUG DURING EMERGENCY CONDITIONS AND ASSOCIATED ETHICAL ASPECTS, CHALLENGES, AND BENEFITS
DOI:
https://doi.org/10.22159/ajpcr.2021.v14i7.41808Keywords:
Compassionate use of a drug, Emergency use of an investigational drug, Ethical aspects, Benefits, LimitationsAbstract
“Compassionate Use,” also known as expanded access, is a method by which patients with a life-threatening or seriously debilitating disease that has no satisfactory treatment alternatives can gain access to new drugs outside the context of a clinical trial. Compassionate use (CU) of unlicensed drugs serves the need of patients with the serious debilitating disease in the absence of alternative approved therapies. CU does allow limited access to new products currently in clinical trials. However, it must be remembered that there are strict guidelines to follow. As with any new drug-device or treatment, there are strict guidelines determined by the Food and Drug Administration and study sponsor, especially for CU. This article contains the use of an investigational drug in emergencies, which are the ethical aspects for getting approval, the major challenges in taking a compassionate drug, and the benefits for dying patients.
Downloads
References
Miracle VA. Compassionate use in research. Dimens Crit Care Nurs 2009;28:85-8. DOI: https://doi.org/10.1097/DCC.0b013e318195d6d5
Rej R. US Food and Drug Administration, Center for Devices and Radiological Health; 2003. Available from: http://www.fda.gov/cdrh. clinic.chem.
Finkelstein PE. Expanded access to investigational drugs: What physicians and the public need to know about FDA and corporate processes. AMA J Ethics 2015;17:1142-6. DOI: https://doi.org/10.1001/journalofethics.2015.17.12.stas1-1512
Brower V. Food and drug administration responds to pressure for expanded drug access. J Nat Cancer Ins 2014;106:dju171. DOI: https://doi.org/10.1093/jnci/dju171
Shetty YC, Brahma S, Manjesh PS. Compassionate drug use: Current status in India. Perspect Clin Res 2020;11:3-7. DOI: https://doi.org/10.4103/picr.PICR_119_18
Caplan AL, Bateman-House A. Should patients in need be given access to experimental drugs. Expert Opin Pharmacother 2015;16:1275-9.
Hogan M. (R) evolution: Toward a new paradigm of policy and patient advocacy for expanded access to experimental treatments. BMC Med 2016;14:39. DOI: https://doi.org/10.1186/s12916-016-0586-6
Hyry HI, Manuel J, Cox TM, Roos JC. Compassionate use of orphan drugs. Orphanet J Rare Dis 2015;10:1-9. DOI: https://doi.org/10.1186/s13023-015-0306-x
Calandra GB, Garelik JP, Kohler PT, Brown KR. Problems and benefits of an antibiotic compassionate therapy program. Rev Infect Dis 1987;9:1095-101. DOI: https://doi.org/10.1093/clinids/9.6.1095
Dheda K, Limberis JD, Pietersen E, Phelan J, Esmail A, Lesosky M, et al. Outcomes, infectiousness, and transmission dynamics of patients with extensively drug-resistant tuberculosis and home-discharged patients with programmatically incurable tuberculosis: A prospective cohort study. Lancet Respir Med 2017;5:269-81. DOI: https://doi.org/10.1016/S2213-2600(16)30433-7
Dedicoat M. Using bedaquiline and delamanid in combination and safely. Int J Tuberc Lung Dis 2016;20:1282. DOI: https://doi.org/10.5588/ijtld.16.0522
Hafkin J, Hittel N, Martin A, Gupta R. Early outcomes in MDR-TB and XDR-TB patients treated with delamanid under compassionate use. Eur Respir J 2017;50:1700311. DOI: https://doi.org/10.1183/13993003.00311-2017
World Health Organization. Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis: Emergency Update 2008. Geneva: World Health Organization; 2008.
Udwadia ZF, Ganatra S, Mullerpattan JB. Compassionate use of bedaquiline in highly drug-resistant tuberculosis patients in Mumbai, India. Eur Respir J 2017;49:1601699. DOI: https://doi.org/10.1183/13993003.01699-2016
Conroy S. Unlicensed and off-label drug use. Paediatr Drugs 2002;4:353-9. DOI: https://doi.org/10.2165/00128072-200204060-00002
Sims J, Miracle VA. Phases of a clinical trial. Dimens Crit Care Nurs 2002;21:152-3. DOI: https://doi.org/10.1097/00003465-200207000-00009
Okie S. Access before approval a right to take experimental drugs. N Engl J Med 2006;355:437-40. DOI: https://doi.org/10.1056/NEJMp068132
Lynch HF, Bateman-House A. Facilitating both evidence and access: Improving FDA’s accelerated approval and expanded access pathways. J Law Med Ethics 2020;48:365-72. DOI: https://doi.org/10.1177/1073110520935352
Folkers KM, Bateman-House A, Robertson C. Paying for Unapproved Medical Products. Vol. 11. Winston-Salem, NC: Wake Forest JL and Pol’y; 2020. p. 85.
Chapman CR, Eckman J, Bateman-House AS. Oversight of right-to-try and expanded access requests for off-trial access to investigational drugs. Ethics Res 2020;42:2-13. DOI: https://doi.org/10.1002/eahr.500038
Gabay M. RxLegal: A rapid review of right-to-try. Hosp Pharm 2018;53:234-5. DOI: https://doi.org/10.1177/0018578718783992
Committee for Medicinal Products for Human Use. European Medicines Agency Committee for Medicinal Products for Human Use (CHMP) Guideline on the Evaluation of Anticancer Medicinal Products in Man. London, UK: Committee for Medicinal Products for Human Use; 2006.
European Commission. Regulation (EC) No. 726/2004 of the European Parliament and of the Council of 31 March 2004 Laying down Community Procedures for the Authorisation and Supervision of Medicinal Products for Human and Veterinary Use and Establishing a European Medicines Agency; 2004. p. 1-32.
Balasubramanian G, Morampudi S, Chhabra P, Gowda A, Zomorodi B. An overview of compassionate use programs in the European union member States. Int Rare Dis Res 2016;5:244-54. DOI: https://doi.org/10.5582/irdr.2016.01054
Borysowski J, Górski A. Compassionate use of unauthorized drugs: Legal regulations and ethical challenges. Eur J Int Med 2019;65:12-6. DOI: https://doi.org/10.1016/j.ejim.2019.04.008
Moon S, Bezruki A, Burci GL, Sunyoto T, Vieira M, de la Paix M, et al. The Global Governance of Access to Countermeasures. Graduate Institute of International and Development Studies, Global Health Centre; 2020.
Available from: https://www.ethics.ncdirindia.org/ICMR_Ethical_ Guidelines.aspx [Last accessed on 2021 Jan 05].
Available from: https://www.canada.ca/en/health-canada/services/ drugs-health-products/special-access/drugs/guidance.html [Last accessed on 2021 May 10].
https://www.mytomorrows.com/en. [Last accessed on 2021 Jan 04].
Hollebecque A, Postel-Vinay S, Verweij J, Demetri GD, Flaherty K, Bedard P, et al. Modifying phase I methodology to facilitate enrolment of molecularly selected patients. Eur J Cancer 2013;49:1515-20. DOI: https://doi.org/10.1016/j.ejca.2012.12.012
Kodish E, Lantos JD, Siegler M. The ethics of randomization. CA Cancer J Clin 1991;41:180-6. DOI: https://doi.org/10.3322/canjclin.41.3.180
McCreary EK, Angus DC. Efficacy of remdesivir in COVID-19. JAMA 2020;324:1041-2. DOI: https://doi.org/10.1001/jama.2020.16337
Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna A, et al. Compassionate use of remdesivir for patients with severe Covid-19. Eng J Med 2020;382:2327-36. DOI: https://doi.org/10.1056/NEJMc2015312
Central Drug Standard Control Organization. List of New Drugs Approved in the Year 2020 till Date. Available from: https://www. cdsco.gov.in/opencms/opencms/en/approval_new/approved-new-drugs. [Last accessed on 2021 Jan 05].
Wong JE, Leo YS, Tan CC. COVID-19 in Singapore current experience: Critical global issues that require attention and action. JAMA 2020;323:1243-4. DOI: https://doi.org/10.1001/jama.2020.2467
COVID A. Treatment Trial. Clinical Trials Identifier: NCT04280705; 2020.
Ross W. Ebola Crisis: Doctors in Liberia “Recovering after Taking Zmapp; 2014.
Available from: https://www.who.int/ebola/drc-2018/treatments-approved-for-compassionate-use/en. [Last accessed on 2021 Jan 05].
Available from: https://www.who.int/news/item/23-12-2016-final-trial-results-confirm-ebola-vaccine-provides-high-protection-against-disease. [Last accessed on 2021 Jan 05].
KN, Geisbert TW, Feldmann H, Zhu Z, Feldmann F, Geisbert JB, et al. A neutralizing human monoclonal antibody protects African green monkeys from hendra virus challenge. Sci Trans Med 2011;3:105ra103. DOI: https://doi.org/10.1126/scitranslmed.3002901
Available from: https://www.who.int/blueprint/priority-diseases/ keyaction/Nipah_Draft_Roadmap_publiccomment_MAY2018.pdfua1. [Last accessed on 2021 Jan 05].
Playford EG, Munro T, Mahler SM, Elliott S, Gerometta M, Hoger KL, et al. Safety, tolerability, pharmacokinetics, and immunogenicity of a human monoclonal antibody targeting the G glycoprotein of henipaviruses in healthy adults: A first-in-human, randomised, controlled phase 1 study. Lancet Infect Dis 2020;20:445-54. DOI: https://doi.org/10.1016/S1473-3099(19)30634-6
Sorbello A, Jones SC, Carter W, Struble K, Boucher R, Truffa M, et al. Emergency use authorization for intravenous peramivir: Evaluation of safety in the treatment of hospitalized patients infected with 2009 H1N1 influenza A virus. Clin Infect Dis 2012;55:1-7. DOI: https://doi.org/10.1093/cid/cis351
Yu Y, Garg S, Yu PA, Kim HJ, Patel A, Merlin T, et al. Peramivir use for treatment of hospitalized patients with influenza A (H1N1) pdm09 under emergency use authorization, October 2009-June 2010. Clin Infect Dis 2012;55:8-15. DOI: https://doi.org/10.1093/cid/cis352
Available from: https://www.ema.europa.eu/en/human-regulatory/ research-development/compassionate-use. [Last accessed on 2021 Jan 05].
Jacobson PD, Parmet WE. A new era of unapproved drugs: The case of Abigail Alliance v Von Eschenbach. JAMA 2007;297:205-8. DOI: https://doi.org/10.1001/jama.297.2.205
Rojek AM, Martin GE, Horby PW. Compassionate drug (mis) use during pandemics: Lessons for COVID-19 from 2009. BMC Med 2020;18:265. DOI: https://doi.org/10.1186/s12916-020-01732-5
Rojek AM, Horby PW. Offering patients more: how the West Africa Ebola outbreak can shape innovation in therapeutic research for emerging and epidemic infections. Philos Trans R Soc B Biol Sci 2017;372:20160294. DOI: https://doi.org/10.1098/rstb.2016.0294
Available from: https://www.cnbc.com/2014/08/05/a-case-for-compassionate-use-when-unapproved-drugs-are-the-only-hope.html. [Last accessed on 2021 Jan 06].
Fountzilas E, Said R, Tsimberidou AM. Expanded access to investigational drugs: Balancing patient safety with potential therapeutic benefits. Expert Opin Invest Drugs 2018;27:155-62. DOI: https://doi.org/10.1080/13543784.2018.1430137
Amorosa V, Tebas P. Is it time to rethink the expanded-access programs for HIV infection. J Infect Dis 2007;196:974-7. DOI: https://doi.org/10.1086/521368
Available from: https://www.medium.com/@i3consult.com/ the-benefits-and-costs-of-compassionate-use-programs-cups- 46e622f282cb. [Last accessed on 2021 Jan 06].
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-42. DOI: https://doi.org/10.1001/jama.2020.2648
Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet 2020;395:473-5. DOI: https://doi.org/10.1016/S0140-6736(20)30317-2
Whitfield K, Huemer KH, Winter D, Thirstrup S, Libersa C, Barraud B, et al. Compassionate use of interventions: Results of a European clinical research infrastructures network (ECRIN) survey of ten European countries. Trials 2010;11:1-8. DOI: https://doi.org/10.1186/1745-6215-11-104
Walker MJ, Rogers WA, Entwistle V. Ethical justifications for access to unapproved medical interventions: An argument for (limited) patient obligations. Am J Bioethics 2014;14:3-15. DOI: https://doi.org/10.1080/15265161.2014.957416
Prowell TM, Theoret MR, Pazdur R. Seamless oncology-drug development. Engl J Med 2016;374:2001-3. DOI: https://doi.org/10.1056/NEJMp1603747
Iasonos A, O’quigley J. Early phase clinical trials are dose expansion cohorts needed. Nat Rev Clin Oncol 2015;12:626-8. DOI: https://doi.org/10.1038/nrclinonc.2015.174
Collette L, Tombal B. N-of-1 trials in oncology. Lancet Oncol 2015;16:885. DOI: https://doi.org/10.1016/S1470-2045(15)00062-5
Ananthakrishnan R, Menon S. Design of oncology clinical trials: A review. Crit Rev Oncol Hematol 2013;88:144-53. DOI: https://doi.org/10.1016/j.critrevonc.2013.03.007
Borysowski J, Ehni HJ, Górski A. Ethics review in compassionate use. BMC Med 2017;15:1-7. DOI: https://doi.org/10.1186/s12916-017-0910-9
Available from: https://www.ethics.ncdirindia.org/ICMR_Ethical_ Guidelines.aspx. [Last accessed on 2021 Jan 08].
Available from: https://www.tga.gov.au/form/special-access-scheme. [Last accessed on 2021 Jan 08].
Available from: https://wwww.ethics.ncdirindia.org/asset/pdf/EC_ Guidance_COVID19.pdf. [Last accessed on 2021 Jan 08].
Available from: https://www.cdsco.gov.in/opencms/opencms/en/ approval_new/approved-new-drugs. [Last accessed on 2021 Jan 08].
Available from: https://www.cdsco.gov.in/opencms/ export/sites/CDSCO_WEB/Pdf documents/acts rules/2016DrugsandCosmeticsAct1940Rules1945.pdf. [Last accessed on 2021 Jan 08].
US Food and Drug Administration. Expanded Access (Compassionate Use). Available from: http://www.fda.gov/newsevents/ publichealthfocus/expandedaccesscompassionateuse. [Last accessed on 2017 Apr 18].
Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects. [Last accessed on 2021 Jan 08].
Darrow JJ, Sarpatwari A, Avorn J, Kesselheim AS. Practical, legal, and ethical issues in expanded access to investigational drugs. N Engl J Med 2015;372:279-86. DOI: https://doi.org/10.1056/NEJMhle1409465
Wendler D, Johnson R. When clinical care is like research: The need for review and consent. Theor Med Bioethics 2016;37:193-209. DOI: https://doi.org/10.1007/s11017-016-9364-x
Mathur R. Ethics preparedness for infectious disease outbreaks research in India: A case for novel coronavirus disease 2019. Ind J Med Res 2020;151:124. DOI: https://doi.org/10.4103/ijmr.IJMR_463_20
Terpos E, Engelhardt M, Cook G, Gay F, Mateos MV, Ntanasis- Stathopoulos I, et al. Management of patients with multiple myeloma in the era of COVID-19 pandemic: A consensus paper from the European Myeloma Network (EMN). Leukemia 2020;34:2000-11. DOI: https://doi.org/10.1038/s41375-020-0876-z
Geffen N. Anything to stay alive: The challenges of a campaign for an experimental drug. Dev World Bioethics 2016;16:45-54. DOI: https://doi.org/10.1111/dewb.12084
Caplan AL, Bateman-House A, Waldstreicher J. Compassionate use: A modest proposal. Am Soc Clin Oncol Educ Book 2016;36:e2-4. DOI: https://doi.org/10.1200/EDBK_156130
Puthumana J, Miller JE, Kim J, Ross JS. Availability of investigational medicines through the US Food and Drug Administration’s expanded access and compassionate use programs. JAMA Net Open 2018;1:e180283. DOI: https://doi.org/10.1001/jamanetworkopen.2018.0283
Caplan AL, Teagarden JR, Kearns L, Bateman-House AS, Mitchell E, Arawi T, et al. Fair, just and compassionate: A pilot for making allocation decisions for patients requesting experimental drugs outside of clinical trials. J Med Ethics 2018;44:761-7. DOI: https://doi.org/10.1136/medethics-2016-103917
Caplan AL, Bateman-House A. Should patients in need be given access to experimental drugs? Exp Opin Pharmacother 2015;6:1275-9. DOI: https://doi.org/10.1517/14656566.2015.1046837
Nardini C. The ethics of clinical trials. Ecancermedicalscience 2014;8:387.
Lorigan P, Ascierto PA, Dummer R, Eggermont AM, Flaherty KT, Garbe C, et al. Expanded access programmes: Patient interests versus clinical trial integrity. Lancet Oncol 2015;16:15-7. DOI: https://doi.org/10.1016/S1470-2045(14)71161-1
Hajibabaee F, Joolaee S, Cheraghi MA, Salari P, Rodney P. Hospital/ clinical ethics committees’ notion: An overview. J. Med Ethics History Med 2016;9:17.
Brierley J, Larcher V. Compassionate and innovative treatments in children: A proposal for an ethical framework. Arch Dis Childhood 2009;94:651-4. DOI: https://doi.org/10.1136/adc.2008.155317
Borysowski J, Ehni HJ, Górski A. Ethics codes and use of new and innovative drugs. Br J Clin Pharmacol 2019;85:501-7. DOI: https://doi.org/10.1111/bcp.13833
Jarow JP, Lemery S, Bugin K, Khozin S, Moscicki R. Expanded access to investigational drugs: The experience of the center of drug evaluation and research over a 10-year period. Ther Innov Regul Sci 2016;50:705-9. DOI: https://doi.org/10.1177/2168479016656030
Mack GS. Expanded access rules pose quandary for drug developers. Nat Biotechnol 2009;27:871-2. DOI: https://doi.org/10.1038/nbt1009-871
Vale J. Expanding expanded access: How the Food and Drug Administration can achieve better access to experimental drugs for seriously ill patients. Georgetown Law J 2007;96:2143.
Weiss R. Roundtable for the Development of Drugs and Vaccines against Acquired Immuno Deficiency Syndrome (AIDS). Washington, DC; National Academy of Sciences; 1991. DOI: https://doi.org/10.21236/ADA260145
Furin J, Brigden G, Lessem E, Rich M, Vaughan L, Lynch S. Global progress and challenges in implementing new medications for treating multi drug-resistant tuberculosis. Emerg Infect Dis 2016;22:e151430. DOI: https://doi.org/10.3201/eid2203.151430
US Food and Drug Administration. Food and drug administration amendments act of 2007. Public Law 2007;110:85.
Content EG. Available from: http://www.ema.europa.eu/ema/index. jsp?curl=pages/about_us/general/general_content_000091.jsp and mid=WC0b01ac0580028a42. [Last accessed on 2017 Jan 19].
Bedell E. Global access to medicinal products: Compassionate use procedures. Regul Focus 2010:9-12.
Kinsinger LS, Anderson C, Kim J, Larson M, Chan SH, King HA, et al. Implementation of lung cancer screening in the veterans health administration. JAMA Int Med 2017;177:399-406. DOI: https://doi.org/10.1001/jamainternmed.2016.9022
Nightingale SL. FDA expanded access programs for experimental medicines. JAMA 2015;314:1296. DOI: https://doi.org/10.1001/jama.2015.9725
Miller JE, Wilenzick M, Ritcey N, Ross JS, Mello MM. Measuring clinical trial transparency: An empirical analysis of newly approved drugs and large pharmaceutical companies. BMJ Open 2017;7:e017917. DOI: https://doi.org/10.1136/bmjopen-2017-017917
Published
How to Cite
Issue
Section
Copyright (c) 2021 Sumel Ashique, Tahamina Khatun
This work is licensed under a Creative Commons Attribution 4.0 International License.
The publication is licensed under CC By and is open access. Copyright is with author and allowed to retain publishing rights without restrictions.