The news that GSK is not pursuing a phase III study for skipping exon 51 here in the US has certainly come as a blow. It seems that the FDA would like to see longer term toxicology data before approving the 48 week human study. Meanwhile, almost every European family with DMD will have access to the phase III study. It seems obvious that the FDA is being blindly obstructionist and GSK is showing its true stripes as money-sucking big pharma company that is going to choose the path of least resistance for drug approval after leading parents in the US on a merry-go-round of broken promises and shattered expectations. Or is it?
In the 1950’s and 1960’s between 10,000 and 20,000 babies around the world were born with severe birth defects and many didn’t survive due to the use of the drug thalidomide for morning sickness. The drug has been called one of the “biggest medical tragedies of modern times.” In the US the drug had minimal impact because a pharmacologist at the FDA refused to approve it for marketing because she felt that the drug needed “further tests.”
And then there are the FDA regulators who made the decision to leave on the market Vioxx—a prescription anti-inflammatory drug for arthritis—despite some indications that it might be linked to an increased risk of heart attack and stroke. It’s now estimated that the drug may have been responsible for between 88,000 and 139,000 heart attacks worldwide. The drug has been withdrawn, FDA officials have been hauled in front of congress, jobs have been lost, lives have been lost and millions of dollars of law suits are still progressing through the system. Although the general consensus is that Merck’s advertising team was responsible for some misleading information about the drug, congress still pointed fingers at the FDA and Merck jointly in public hearings.
Now imagine that you are an FDA official reviewing an application for a phase III study of exon-skipping in the US that will involve weekly subcutaneous injections of little chemically modified pieces of DNA into children for close to a year. This is a new class of drug with no approved applications anywhere in the world. On the one hand, if there is some cumulative toxic effect of this drug that can only be seen after it’s given over a longer period of time you might be responsible for another great and preventable “modern medical tragedy.” On the other hand, by not approving the studies, you may be delaying access in the US to this drug that could potentially slow the progression of a fatal disease and buy these boys many years—also a great modern medical tragedy (keeping in mind that the drug is experimental because we don’t know if it will work or not). The rock and the hard place.
I guess the point is that most of the FDA staff I’ve met over the years take their jobs extremely seriously—they feel a crushing weight of responsibility knowing that their decisions can impact so many lives for better or worse. Of course there is always some CYA (“Cover Your Rear”) behavior and bureaucratic nonsense going on because a certain amount of that happens everywhere, and we should fight that behavior vigorously when it’s clear that that’s the case. But I think we don’t really know what’s going on behind the scenes at the FDA on exon-skipping. Is the FDA reacting to the unknown with an overabundance of caution despite the EMEA’s approval in Europe of the same data? Have they asked GSK for data that GSK decided not to provide because of the expense? Or have they asked for new data that GSK doesn’t yet have and so can’t provide immediately? Because of the confidential nature of these discussions, we really can’t know the cause of the latest delay.
And what about the profit-motivated companies involved? Those of you who were able to attend the PPMD conference got to meet at a breakfast session Dr. John Kraus, who is a senior Medical Science Director at GSK and Dr. Steve Shrewsbury, who is AVI’s Chief Medical Officer. Companies, like any other organization, are actually groups of people who have come together in some sort of formal way to achieve an end. In the case of a for-profit organization, the goal is to make money (it’s the American way—all you Republicans out there give a big “head nod”). But a for-profit goal doesn’t make the people who work for a company bad people. In fact, like John and Steve, many of them seem to be quite caring—many are medical doctors who went into the field with a desire to help people. I’ve gotten to spend some time with Steve Shrewsbury, both at AVI headquarters in Bothell and in Tucson, and he shared with me how upset he used to get when he volunteered at camps for children with asthma and saw so many whose symptoms hadn’t been treated properly. These are the people behind those black-box facades. Now to be fair, there are people behind those people, and even more people who have invested in the company to make money—the further removed the investors are from the company’s mission the more likely they are to make decisions based purely on profit motives. But it’s not fair to tar the whole company with the same brush or perhaps even to complain in the first place about their reason for being.
Are all of the agencies, companies and organizations out there doing everything perfectly? Of course not. There is always room for improvement until we have an effective therapy and more in some cases than in others—at PPMD we are constantly evaluating what we are doing and whether or not it’s having the impact we’d like. But anger can be a very blunt weapon—today I demonstrated this perfectly when I took a hammer to the latch on the back gate because it tends to stick. Now it doesn’t open at all (and in fact my husband is going to be most displeased). Not to make this analogy too drawn out and painful, but what I should have done was figured out which part of the mechanism was sticking and put some WD-40 on it. To advocate for your child effectively it’s important to direct your energy toward the real bottlenecks in the process and these aren’t always the obvious culprits.
In other words, after the announcement on Monday from GSK that phase III studies will not go forward in the US (at this point in time) it may look obvious that the FDA is being obstructionist and/or that GSK just doesn’t care about the kids in the US and is moving on…but neither is necessarily true. I guarantee you that at the FDA there are officials who have agonized over this decision because they don’t want to be responsible for the preventable deaths of children taking part in a clinical study—children that may have a disease that reduces lifespan, but who are right now regular kids who just walk a bit slower. And GSK has some internal strategy for getting these drugs approved as widely as possible, including in the US, because that’s the best way to maximize the market size. It may mean stepping back now to do the extra studies that the FDA wants, but they are going to jump through all the hoops they need to test the drug in the US if they are ever going to see profits. The true breakthrough is that a big pharma like GSK is involved in developing a small-market drug in the first place.
Here’s where I think the true bottlenecks are – where we need to add a little lubricant:
1. Lack of harmonization between the FDA and the EMEA. We shouldn’t have to do clinical trials in multiple countries to get drugs approved in multiple countries unless there is some demonstrable difference or reason to think there would be a difference in the way the populations in those countries react to the drug (which is rarely the case). The EMEA is not always faster than the FDA, it’s just different. The FDA is not always “safer” than the EMEA, it’s just different. We need to push for harmonization of regulatory requirements between these two agencies—this was on the PPMD advocacy agenda this year and it’s going to be one of our major priorities going forward. The barriers to FDA/EMEA harmonization are largely political and therefore something we can and should take on as a community.
2. Splintering of resources. The DMD community is too small to build clinical infrastructure—registries, clinical networks, databases—over and over again. In the US we need a single, far-reaching clinical research network with a single patient registry so that every child diagnosed with DMD can participate in a clinical study. Read about the Children’s Oncology Network if you want to see the system I think we should emulate: http://www.curesearch.org/resources/cog.aspx .
3. The requirement that every institution participating in a clinical study reviews and approves the study protocol through its own Institutional Review Board (IRB). This means that a multi-center study with 12 participating sites must have 12 different IRB approvals and every change that’s made to the protocol must go through an IRB approval—a process that can take weeks, and more commonly months. The institutions themselves have put these IRBs in place to protect patients from dangerous or unethical studies, but it’s not clear to me that reviewing the same protocol 12 different times makes it any safer. So called “centralized” IRBs exist, but most institutions won’t use them because they are in CYA (“Cover Your Rear”) mode. The use of a single centralized IRB could dramatically reduce the time and therefore the cost of the multi-center phase II and III trials that are required to get a new drug on the market. This is another issue that I think this community can help tackle (along with all the other disease associations out there) that would have an immediate and beneficial effect in how quickly we can test and approve new drugs.
4. Lack of a “voice” at government agencies. Both the FDA and the National Institutes of Health provide numerous opportunities for people from the general public to get involved in the development of policy, but this community hasn’t taken advantage of these opportunities as thoroughly as it should. Although Pat and I between us are on committees for almost every government agency that touches DMD, it’s important that you out there who are not professional advocates also be represented directly, either through sitting on committees, attending congressional hearings, or submitting comments to the FDA and NIH when they are requested. The FDA Office of Orphan Products is currently looking for families from the DMD community in the Washington DC area to participate in a committee—please let me know if you are interested and I can pass on your name. We will post other opportunities for commenting or participating as they are available, starting with the planned FDA meeting on exon-skipping this Fall (info should be available soon—it will be posted simultaneously by multiple organizations when it is).
None of this is black and white and none of this is easy, but beating on the FDA and/or GSK with a hammer probably won’t help (although it might feel good at the time). We need to pull together and focus on changing the things that we know for sure are a problem.

Note added from Pat:

FDA is holding a Webinar? And PPMD/Cure Duchenne are hosting? And the webinar will not be specific to DMD issues? So what?

All of the above is correct, but this is about building a foundation. This is about understanding FDA requirements and have the opportunity to ask important questions. Given the recent news from GSK, there are loads of questions and not many answers (at least not the ones we were hoping for). This webinar becomes even more important to build a solid foundation of information and utilize the opportunity to ask basic questions. Questions such as :

What is the requirement in terms of toxicology studies

Are there instances when the requirement is different – less? Or more?

Under what circumstances could this happen?

What is the time frame for review?

Are there circumstances when a review process is expedited?

Describe and Individual IND. If the company is unwilling to participate, do patients have any

Leverage?

And….

The planned webinar will serve as a basis for information, a primer of sorts about FDA. It will serve as a platform and an opportunity to prepare for the DMD specific workshop on AON planned for Fall, 2010. It will familiarize you with some of the individuals working within FDA. It will help you better understand Advocacy efforts and rationale for the advocacy strategy. It is FDA 101 for sure and may feel a bit frustrating as for some, it may repeat what you already know, but in there, you may find a tidbit of information that you will tuck away for later. (details on front page of PPMD site).

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Comment by Ofelia Marin on July 7, 2010 at 7:04am
Not only that Sharon, look at cancer. If my child would be diagnosed with cancer they will to EVERYTHING to give him a chance, it might not work of course, it has side effects of course, but they will still try EVERYTHING. It is a very sad day indeed when you wish your son has cancer instead, isn't it? DMD is an 100% FATAL disease. Why is it treated differently? And don't even get me started on all the bs about it being chronic. When your son will look into your eyes and will tell you "when I grow up I want to be a pilot or a firefighter" then you come back to me and talk about the "chronic" DMD. This is 2010 things should be different! I am not going to feel bad that my son was born in 2007 (when some DMD boys actually CAN participate in trials) and not in 1997. In fact I wish my son was born in 2015 or whenever a treatment for DMD will be approved in this country.

I am sorry, but instead of wasting my time and energy in meetings and discussion not leading to a treatment for my son I will focus on making sure he can participate in trials in another country when that time comes. Even if I do not succeed, I know I did my best trying to give my son what he needs, a TREATMENT, and not spending time talking to people who do not understand (or do not have any power to do anything about it really) what I am going through every day looking at my beautiful and smart little boy deteriorating due to DMD.
Comment by Sharon Hesterlee on July 6, 2010 at 11:18pm
AONs have been tested in a lot of diseases but I'm not aware they they've been approved to treat anything yet. I will double-check that. And believe me, I'm very aware of what this disease does. I think the most frustrating thing about it is that if your sons were in a car accident they would be rushed to the ER where people would frantically try to save their lives....as it is, DMD is not treated as the emergency situation that it should be. That's something that I think needs to be changed...DMD is an emergency and we need to treat it appropriately.
Comment by cheryl cliff on July 6, 2010 at 10:25pm
Thanks Ofelia. I was under the idea (can't remember from where) that AON's or Oligo's were already being used for a different disease, something other than dmd.

But I agree with what you said...FDA isn't really interested in what a few DMD parents have to say. They are probably very nice people and while they do care, mostly they care about keeping their jobs. It's clear to see where they are coming from. Only until one of their children is diagnosed with DMD will they comprehend us.
Comment by Ofelia Marin on July 6, 2010 at 9:58pm
Cheryl, morpholinos (PMO) were used and they are incredibly non-toxic...they might not be efficient at lower doses (as seen in the UK AVI trial) but they are safe. Keep in mind that even with all that safety profile FDA requested AVI an additional GLP tox package (which was submitted to FDA, DoD, CureDuchenne and FED funded those studies).

Not sure if the AONs used by Prosensa/GSK (2-Methyl) are/were used here?
Comment by Ofelia Marin on July 6, 2010 at 9:47pm
Yes Jenn, some parents did try. My son is too young but I have that email sent by GSK to other parents. I think it's actually posted here: http://duchennecommunity.ning.com/forum/topics/gsk-trial-of-exon-51...

Sharon, I don't even care about blame at this point, just trying to find solutions. You saw what DMD does to our children and how heartbreaking everyting is. Our boys do not have access to exon skipping trials, they do not have access to ACE-031 and if these drugs are not tested in this country they are not approved, we can have thousands of meetings with the FDA, they will not base their decisions on what parents say or want.
Comment by cheryl cliff on July 6, 2010 at 8:21pm
I thought oligo's had been used for other diseases, including here in the USA, for several years now. If I am wrong someone please set me straight.
Comment by Brian Denger on July 6, 2010 at 7:13pm
http://www.parentprojectmd.org/site/PageServer?pagename=ending_spea...

Go to the link above Keith for more information.

Brian
Comment by jenn on July 6, 2010 at 7:10pm
has anyone talked to gsk, trying to get them to allow out of country kids in? if this is such a large trial certainly there is room for US boys
Comment by Sharon Hesterlee on July 6, 2010 at 7:07pm
Comment by Keith Van Houten on July 6, 2010 at 7:01pm
I don't see the webinar info on the PPMD main page - where can I find it?

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