pharmacovigilance practice in
DESCRIPTION
TRANSCRIPT
![Page 1: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/1.jpg)
Virgilio Vintildeas MD MPH PhD
Ceara LLC
Known side effects
Unavoidable
Avoidable
Medication Errors
Product Quality Defects
Preventable Adverse Events
Injury or Death
Remaining Uncertainties
Unexpected Side Effects
Unstudied UsesUnstudied Populations
Main Business Objectives
bullMinimize Risks for Patients
bullMinimize Risks for Company
bullMeet Global Regulatory Requirements 1048782Full compliance
bullProlong Life-Cycle of Products
bullProvide Competitive Advantage
bullSpontaneous reports (SRs)
ndashHealth Care Professionals (HCPs)
ndashNon Health Care Professionals (non-HCPs)
bullLiterature cases
bullThe internet
bullSolicited reportsndashClinical trials phases I-IVndashObservational Post-Marketing Surveillance (PMS) studies
bullStimulated reportsndashPatient support programsndashDisease managementndashMarketing surveysndashRegistriesndashPharmacoeconomicsndashClass action lawsuitsndashQuality of life questionnaires
bullSpontaneously reported from any source physicians pharmacists consumers lawyers etc
bullEvery attempt to obtain medical verification of consumer reports
bullEmphasize report quality over source type triage appropriately
bullReport consumer cases to HA if required even if they can not be medically confirmed (only mandatory in US and Canada)
bullInclude consumer reports in Periodic Safety Update Reports (PSURs)
bullInclude consumer reports in signal detectionanalysis
bullProtect patient privacy
bullCompanies should screen at least two major databases at least once a month
bullLiterature screening should cover cases in local journals
bullDo not monitor broadcast and lay media but do not ignore potential cases from these sources
bullTreat unspecified generics as your own brand
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 2: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/2.jpg)
Known side effects
Unavoidable
Avoidable
Medication Errors
Product Quality Defects
Preventable Adverse Events
Injury or Death
Remaining Uncertainties
Unexpected Side Effects
Unstudied UsesUnstudied Populations
Main Business Objectives
bullMinimize Risks for Patients
bullMinimize Risks for Company
bullMeet Global Regulatory Requirements 1048782Full compliance
bullProlong Life-Cycle of Products
bullProvide Competitive Advantage
bullSpontaneous reports (SRs)
ndashHealth Care Professionals (HCPs)
ndashNon Health Care Professionals (non-HCPs)
bullLiterature cases
bullThe internet
bullSolicited reportsndashClinical trials phases I-IVndashObservational Post-Marketing Surveillance (PMS) studies
bullStimulated reportsndashPatient support programsndashDisease managementndashMarketing surveysndashRegistriesndashPharmacoeconomicsndashClass action lawsuitsndashQuality of life questionnaires
bullSpontaneously reported from any source physicians pharmacists consumers lawyers etc
bullEvery attempt to obtain medical verification of consumer reports
bullEmphasize report quality over source type triage appropriately
bullReport consumer cases to HA if required even if they can not be medically confirmed (only mandatory in US and Canada)
bullInclude consumer reports in Periodic Safety Update Reports (PSURs)
bullInclude consumer reports in signal detectionanalysis
bullProtect patient privacy
bullCompanies should screen at least two major databases at least once a month
bullLiterature screening should cover cases in local journals
bullDo not monitor broadcast and lay media but do not ignore potential cases from these sources
bullTreat unspecified generics as your own brand
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 3: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/3.jpg)
Main Business Objectives
bullMinimize Risks for Patients
bullMinimize Risks for Company
bullMeet Global Regulatory Requirements 1048782Full compliance
bullProlong Life-Cycle of Products
bullProvide Competitive Advantage
bullSpontaneous reports (SRs)
ndashHealth Care Professionals (HCPs)
ndashNon Health Care Professionals (non-HCPs)
bullLiterature cases
bullThe internet
bullSolicited reportsndashClinical trials phases I-IVndashObservational Post-Marketing Surveillance (PMS) studies
bullStimulated reportsndashPatient support programsndashDisease managementndashMarketing surveysndashRegistriesndashPharmacoeconomicsndashClass action lawsuitsndashQuality of life questionnaires
bullSpontaneously reported from any source physicians pharmacists consumers lawyers etc
bullEvery attempt to obtain medical verification of consumer reports
bullEmphasize report quality over source type triage appropriately
bullReport consumer cases to HA if required even if they can not be medically confirmed (only mandatory in US and Canada)
bullInclude consumer reports in Periodic Safety Update Reports (PSURs)
bullInclude consumer reports in signal detectionanalysis
bullProtect patient privacy
bullCompanies should screen at least two major databases at least once a month
bullLiterature screening should cover cases in local journals
bullDo not monitor broadcast and lay media but do not ignore potential cases from these sources
bullTreat unspecified generics as your own brand
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 4: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/4.jpg)
bullSpontaneous reports (SRs)
ndashHealth Care Professionals (HCPs)
ndashNon Health Care Professionals (non-HCPs)
bullLiterature cases
bullThe internet
bullSolicited reportsndashClinical trials phases I-IVndashObservational Post-Marketing Surveillance (PMS) studies
bullStimulated reportsndashPatient support programsndashDisease managementndashMarketing surveysndashRegistriesndashPharmacoeconomicsndashClass action lawsuitsndashQuality of life questionnaires
bullSpontaneously reported from any source physicians pharmacists consumers lawyers etc
bullEvery attempt to obtain medical verification of consumer reports
bullEmphasize report quality over source type triage appropriately
bullReport consumer cases to HA if required even if they can not be medically confirmed (only mandatory in US and Canada)
bullInclude consumer reports in Periodic Safety Update Reports (PSURs)
bullInclude consumer reports in signal detectionanalysis
bullProtect patient privacy
bullCompanies should screen at least two major databases at least once a month
bullLiterature screening should cover cases in local journals
bullDo not monitor broadcast and lay media but do not ignore potential cases from these sources
bullTreat unspecified generics as your own brand
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 5: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/5.jpg)
bullSolicited reportsndashClinical trials phases I-IVndashObservational Post-Marketing Surveillance (PMS) studies
bullStimulated reportsndashPatient support programsndashDisease managementndashMarketing surveysndashRegistriesndashPharmacoeconomicsndashClass action lawsuitsndashQuality of life questionnaires
bullSpontaneously reported from any source physicians pharmacists consumers lawyers etc
bullEvery attempt to obtain medical verification of consumer reports
bullEmphasize report quality over source type triage appropriately
bullReport consumer cases to HA if required even if they can not be medically confirmed (only mandatory in US and Canada)
bullInclude consumer reports in Periodic Safety Update Reports (PSURs)
bullInclude consumer reports in signal detectionanalysis
bullProtect patient privacy
bullCompanies should screen at least two major databases at least once a month
bullLiterature screening should cover cases in local journals
bullDo not monitor broadcast and lay media but do not ignore potential cases from these sources
bullTreat unspecified generics as your own brand
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 6: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/6.jpg)
bullSpontaneously reported from any source physicians pharmacists consumers lawyers etc
bullEvery attempt to obtain medical verification of consumer reports
bullEmphasize report quality over source type triage appropriately
bullReport consumer cases to HA if required even if they can not be medically confirmed (only mandatory in US and Canada)
bullInclude consumer reports in Periodic Safety Update Reports (PSURs)
bullInclude consumer reports in signal detectionanalysis
bullProtect patient privacy
bullCompanies should screen at least two major databases at least once a month
bullLiterature screening should cover cases in local journals
bullDo not monitor broadcast and lay media but do not ignore potential cases from these sources
bullTreat unspecified generics as your own brand
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 7: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/7.jpg)
bullCompanies should screen at least two major databases at least once a month
bullLiterature screening should cover cases in local journals
bullDo not monitor broadcast and lay media but do not ignore potential cases from these sources
bullTreat unspecified generics as your own brand
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 8: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/8.jpg)
bullNew challenge
bullldquoIdentifiable patient refers to a real person that can be validated
bullSurfing non-company web sites is unnecessary but should be done selectively to manage specific safety issues
bullScreen all company web sites for AEs daily
bullMaintain global consistency in approach
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 9: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/9.jpg)
bullClinical Studies Phase I-IV
bullObservational Post marketing Surveillance studies
bullInvestigator and sponsor causality required for reporting purpose
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 10: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/10.jpg)
bullImportant to distinguish from ldquosolicitedrdquo reports
bullUsually originate in the course of interaction with patients
bullHandle as study reports -causality is needed even if difficult to assess
bullReport under guidelines for post-marketing studies
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 11: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/11.jpg)
bullPrioritize by the value of the case
bullHighest priority for seriousunlabeled followed by seriouslabeled then non-seriousunlabeled
bullNon-seriouslabeled should not be followed up if the 4 criteria are met
bullTreat special issues and events that might lead to label changes as high priority
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 12: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/12.jpg)
bullFor priority cases obtain as much information as possible during the initial contact
bullThe extent of follow-up detail solicited should be driven by the seriousness and expectedness (use CIOMS triage algorithm)
bullFor serious unlabeled cases follow up until the long-term outcome is known
bullIf reporter does not cooperate with telephone follow-up send written reminders
bullAcknowledgment letters should be sent to suppliers of follow-up
bullDo not encourage rechallenge
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 13: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/13.jpg)
bullLimited Size
bullShort Duration
bullNarrow Population
bullNarrow Set of Indications
bullConcomitant Medications
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 14: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/14.jpg)
No of Patients
2000
Threshold for ADR
1 500 (Lymphoma from Azathioprine)
1 1000 (Eye Damage from Practolol)
1 5000 (MI in Older Women from OCP)
1 10000 (Anaphylaxis from Penicillin)
1 50000 (Aplastic Anemia from Chloramphenicol)
Probability
098
086
033
018
004
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 15: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/15.jpg)
bullVolume of use
bullDuration on Market
bullSeverity of Reaction
bullLabelled Status
bullNew Molecular Entities
bullManufacturer
bullPublicity
bullCalendar Year
bullAwareness of Reporting
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 16: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/16.jpg)
bullAdverse Event Recognition
bullUnder Reporting
bullEstimated Exposure Data
bullQuality of Reports
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 17: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/17.jpg)
bullBroad Exposure
bullCost Effective
bullSignal Generation
bullRepresents Every Day Use
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 18: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/18.jpg)
bullInternational standard in general
ndashSerious unexpected suspected adverse reaction
ndashUnblind reportable Clinical Trial (CT) cases
ndashSuspected fatallife-treatening CT cases 7 calendars days
ndashAll other reportable serious suspected SRs and CTs 15 calendars days
ndashUpdate of labeling reference document as appropriate
ndashNotification to all investigators amp ethics committeesIRBs
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 19: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/19.jpg)
bullNational requirements beyond accepted international standards Example of
ndashFrance all study-related serious adverse reactions
ndashIreland all serious adverse reactions irrespective of labelingunblinded occurring in domestic centers
ndashUSA all fatal amp life-treatening SAEs irrespective of causality within 7 days for very specific drugs genetically engineered
ndashFinland India Norway Slovakia Switzerland all domestic SAEs irrespective of causality
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 20: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/20.jpg)
bullProtocol review -to ensure proper collection SAEsAEs
bullAdverse event coding glossary review
bullClinical trial report -safety sections
bullInvestigatorrsquos Brochure -safety sections update
bullIntegrated Safety Summary (ISS)
bullPreparation Periodic Safety Update reports
bullIND and EU Annual Safety Reports
bullCore Data Sheet ndashSafety Sections Update
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 21: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/21.jpg)
Fully Validated System
Part 11 Compliance-Audit Trail-Electronic Signature
Global workflowconfiguration
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 22: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/22.jpg)
Pharmacovigilance component
Global Safety System
Global Safety System
StandardQueries
Signal detectio
n
Clinical Database
Quality Complaints Database
Sales Databas
e
FlexibleQuery
Database
Power Analysis Graphic
PresentationsTool
External Database
Data warehouse
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 23: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/23.jpg)
What is a signal
ldquoReported information on a possible causal relationship between an adverse event and a drug the relationship being unknown or incompletely documented previously Usually more than one reports required to generate a signal depending on the seriousness of the event and the quality of the informationrdquo
T Delamothe(1992) -WHO definition
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 24: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/24.jpg)
Purpose
ndashAssess benefitrisk ratio
ndashIdentification of potential issuessignal identification
ndashProvision of relevant information on potential side-effects to investigators and agencies
ndashProposetake action
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 25: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/25.jpg)
Prerequisites
ndashAccuracy and completeness of data
ndashProper collection and follow-up of AE reports including proper source data verification
ndashStandardized coding and assessments
ndashPowerful analysis tool
ndashSignal identification tool ndashAdequate MethodologyTreshold
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 26: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/26.jpg)
ndashReport(s) of unexpected and serious AEs
ndashExpected AEs
bullincreased frequency
bullgreater severity
bulllong-term sequelas
bullnew risk factors
ndashEvidence from formal studies
ndashChange in efficacy
ndashRisks are greater than with alternative therapies with similar efficacy
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 27: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/27.jpg)
Single Case Report
Cluster of casesAbnormal Lab
findingsPreclinical Tox history
Signal of a possible change in thesafety profile of a development product
Competitor data
Safety Signalclass effect
Literature Report(s)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 28: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/28.jpg)
Number of reported cases poor
bullPre-defined threshold values eg expected morbiditymortality rate in treated population
bullStatistical signal detection system
bullEpidemiological investigation of signals
bullExcruciating review by physicians scientists and epidemiologists
bullReactive Sit and wait Do not trouble troubles until troubles trouble you
bullProactive Prompt action
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 29: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/29.jpg)
bullNotification of ldquofirst ever event with product
bullEnter signalADE term II generate notification when defined threshold exceeded
bullTrend analysis notification of sudden increase in numbers of reports
bullProportional Reporting Ratio
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 30: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/30.jpg)
bullIntegrate with Development Data Warehouse
bullUse AERs and WHO data for PRR method
bullCompare against competitor drugs in same class
bullCompare multiple arms in a trial for incidence rate differences
bullEvaluate integration of IMS sales data
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 31: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/31.jpg)
Limitations
ndashBlinding
ndashSize of treated population rarridentify mainly frequent type A ADRs(wide exposure post-marketing)
ndashSelected population (exclusion criteria) versus misuse Post-Marketing
ndashHigh morbiditymortality population rarrearly judgment difficult
ndashLack of background prevalenceincidence rates
ndashPoor quality of spontaneous reports ndashUnconfirmed diagnosis
ndashSafety culture within the company rarrvery defensive approach rather than fact oriented
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 32: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/32.jpg)
Safety Signal
Safety SignalAnalysis
Safety SignalAnalysis
Conclusion
Controversial
No problem
Safety signal
confirmation
No action
Closemonitoring
Action
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 33: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/33.jpg)
Action to be taken varies according to the seriousness of the issue and the benefitrisk assessment
ndashAmend labelling ndashboxed warning
ndashAmend protocol eg dose exclusion criteria infusion rate etc
ndashKeep on hold a specific trial
ndashKeep on hold the whole project
ndashTerminate the project
ndashProduct recall
ndashSafety alert
ndashPost-marketing or epidemiological studies
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 34: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/34.jpg)
Phase I Phase II
Phase III Phase IV
Safety SurveillanceMonitoring
ICH E2E ProactivePharmacovigilance Plan
Risk Management Program
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 35: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/35.jpg)
bullPharmacovigilance specificationbullDiscussed with regulators pre-approval 1048782focus on early post-marketing periodbullEstablished risk of a drugbullpotential for significant unidentified riskbullpotential at risk populations and situations that have not been studied pre-approvalbullPharmacovigilance planbulldriven by the pharmacovigilance specificationsbullwill be shared and scrutinized by the regulators assessing the licensing application in the different ICH regionsbullPost-approval safety studiesbullfor products with risks or concernsbullat-risk groups which have not been studied
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 36: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/36.jpg)
Patient Population Epidemiology bullIncidence-Prevalence bullNatural history ndashComorbidity bullDrug utilization patterns bullRisk -preventive factors bullEtiological factorsSafety Issues Review
Safety Monitoring bullPreclinical Safety data bullClinical pharmacology bullAEs from clinical trials bullHA ldquohot topicsrdquo bullExpected patient safety bullRisk management planSafety Signal EvaluationCT Design ndashSimulationsDisease awareness
Safety Signal Generation bullInternal and external bullSafety Monitoring Post-Marketing ReportsbullDrug utilizationbullLong term safetybullRisk Management bullAdditional benefits
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug
![Page 37: Pharmacovigilance Practice In](https://reader033.vdocument.in/reader033/viewer/2022061219/54b92a254a7959eb768b45f5/html5/thumbnails/37.jpg)
working towards
bullINTEGRATED
bullPROACTIVE
Development and life-cycle management of the drug