combating the drug shortage crisis
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Combating the Drug Shortage Crisis. Moderator Ron Hartmann, PharmD , Senior Vice President, Pharmacy, MedAssets Panelists Valerie Jensen, RPh , Cpatain , USPHS, Associate Director, Drug Shortages Program, FDA - PowerPoint PPT PresentationTRANSCRIPT
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Combating the Drug Shortage Crisis
ModeratorRon Hartmann, PharmD, Senior Vice President, Pharmacy, MedAssets
PanelistsValerie Jensen, RPh, Cpatain, USPHS, Associate Director, Drug Shortages Program, FDA
Erin Fox, PharmD, FASHP, Director, Drug Information Service, University of Utah
Bona Benjamin, Director, Medication Use Quality Improvement, American Society of Health System Pharmacists
Mark Hendrickson, Director of Sciences and Regulatory Affairs, Generic Pharmaceutical Association (GPhA)
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Combating the Drug Shortage CrisisErin R. Fox, PharmDDirector, Drug Information ServiceUniversity of Utah Hospitals and Clinicshttps://hscintranet.med.utah.edu/document_center/Documents/DIS-Newsletter-Influenza-Vaccines-2013-2014-Season.pdf
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Disclosure
This presentation represents my own opinions, not those of the University of Utah.
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Current Trends
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National Drug Shortages New Shortages by YearJanuary 2001 to September 30, 2013
01 02 03 04 05 06 07 08 09 10 11 12 130
50
100
150
200
250
300
12088
73 58 74 70
129149 166
211
267
204
109 Shortage
Note: Each column represents the # of new shortages identified during that year
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National Drug Shortages – Active Shortages by Quarter
Q1-10
Q2-10
Q3-10
Q4-10
Q1-11
Q2-11
Q3-11
Q4-11
Q1-12
Q2-12
Q3-12
Q4-12
Q1-13
Q2-13
Q3-13
0
50
100
150
200
250
300
350
152167 176 188
239 246 256 273 260
211
282 299295 299 294
Active Shortages
Shortages
Note: Each column represents the # of active shortages at the end of each quarter. University of Utah Drug Information Service
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Active Shortages Top 5 Drug Classes
Antimicrobial
s
Chemotherapy
Cardiova
scular CNS
E-Lytes, N
utrition
0102030405060
3931 26
50
37
Active Shortages 9/30/13
Active Shortages
University of Utah Drug Information Service
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What do these numbers mean?
• Decreasing rate of new shortages• Ongoing shortages are not resolving• Continued daily impact for patients,
clinicians, health systems, health care
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Why is this happening?
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Med Watch Trends – Reports Related to Safety, Medication Quality, and Compounding Quality
2009 2010 2011 2012 2013*0
10
20
30
40
50
60
70
80
90
6954 54
3621
10
21 19
32
16
1
7
22 CompoundingQualitySafety
http://www.fda.gov/Safety/MedWatch/default.htm*2013 are data through August
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Fragile Supply Chain - Generic Injectables
• Concentrated market • Few products with > 3 suppliers
• Manufacturing capacity– At capacity, no resiliency– Multiple products made on single line
• Complex manufacturing process– No simple fixes for quality problems– Problems typically affect multiple products– ISPE survey identifies “Quality systems of
manufacturing” as key cause of shortages
http://aspe.hhs.gov/sp/reports/2011/DrugShortages/ib.shtmlhttp://www.ispe.org/drug-shortages-initiative
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Economic Drivers
Quality
Not Transparent
No Incentive
Clin Pharmacol Ther. 2013;93:170-176Clin Pharmacol Ther. 2013; 93:145-147
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Example – Fragile Supply ChainElectrolyte / Nutrition ShortageKey supplierWarning letter 2011Closed in 2012Trace elements*Zinc, Selenium*Sodium phosphatePotassium phosphateCalcium gluconateCalcium chlorideSodium bicarbonate
Zinc shortage results in dermatitis at Children’s National
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a5.htm
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Where does FDA fit?
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FDA’s Role• FDA CAN require:
Notification– FDASIA (Supply
disruptions, discontinuations)
– Manufacturing changes
– No penalties
• FDA CANNOT require manufacturers to:– Make a drug– Make more– Distribute in a
particular way • FDA CANNOT fix a
manufacturing problem
Patient care is top concernFDA works to prevent and mitigate shortages
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FDA’s Approach
• Prioritize based on medical necessity• Review risks / benefits of medication• Minimize risk to patients while maintaining
availability• Work with manufacturers to address problems• Toolkit
• Regulatory discretion• Request increased production• Expedite reviews• Temporary importation
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FDA Efforts
• Prevention doesn’t work for every shortage
• Unforeseen breakdowns, API shortage
• Longstanding quality problems• Fixes can take a long time
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Summary
• Drug shortages impact patients daily and are not resolving.
• New suppliers are needed to manufacture generic drugs with both high quality and high reliability.
• Hospitals need unit of use products – may be an opportunity for suppliers to enter the generic injectables market.
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Drug Shortages Summit 2013
Seeking long-range solutions for drug shortagesPresented to : Healthcare Supply Chain Expo 2013By: Bona Benjamin, Director, Medication-Use Quality ImprovementAmerican Society of Health-System PharmacistsOctober 22, 2013
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The “difficult problem” of shortages
Apr 19, 2013 Drug Shortages 2.0: Long range solutions
Jul 12, 2002
Nov 5, 2010
Provisional Observations on Drug Product Shortages. Am J Health-Syst Pharm—Vol 59 Nov 15, 2002
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Summit Agenda
• Update on FDASIA and FDA’s strategic plan
• GPhA update on ARI• Analysis of economic factors• Group discussion of quality,
economic, and contributory factors
* Woodcock, J, Wosinska, M. Economic and Technological Drivers of Generic Sterile Injectable Drug Shortages. Clinical Pharmacology and Therapeutics. 93-2: 170-176 http://www.nature.com/clpt/journal/v93/n2/pdf/clpt2012220a.pdf
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Economic factors
• Inverse relationship between tolerance for shortage risk and price of drug
• Buyers in the dark
• Price remains fixed – market fails to correct shortage
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Discussion themes
• Ongoing shortages persistent• Traceability issues
• Inequitable distribution • Hoarding/stockpiling• “Leaking” supply chain• Paper pedigree
• Low bid trumps guarantee of availability
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Areas to explore Legislative/Regulatory
1. Accelerate/streamline DEA quota
procedures
2. Continue to enhance FDA
communication to providers
3. Traceability
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Areas to explore Legislative/Regulatory
4. Consider the BARDA model
5. Give FDA sufficient resources to
manage shortages
6. Require data that extends
expiration dating, if needed.
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Areas to explore Economic incentives
7. Get payers involved
8. Offer multiple contract awards
9. Use FDA quality metrics in buying
decisions
10.Explore corporate tax credits for
firms that invest in quality
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Areas to explore - Other
11.Better methods for demand
forecasting
12.Unit of use presentations
13.Essential Drug List
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Some good news
• Increased collaboration between
industry and FDA DSP
• “Workable pathway”
• Increased interest from new firms
• End users: “Guaranteed availability
worth the price.”
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Questions
http://www.ashp.org/menu/DrugShortages.aspx
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Drug Shortages: Industry Prospective
Mark HendricksonDirector for Sciences and Regulatory Affairs
Generic Pharmaceutical Association
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Introduction • The drug shortage problem has hit crisis
proportions and is of extreme concern for patients, clinicians, the pharmaceutical industry and policymakers.
• Drug shortages represent a complex, multi-faceted issue.
• The generic pharmaceutical industry is devoted to working with all stakeholders to minimize current shortages and mitigate factors that could contribute to future shortages.
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Why Are Shortages Occurring?Causal factors of drug shortages are numerous and do not apply in every case. They include everything from:
• An insufficient supply of available raw materials to meet demand.
• Inadequate and delayed communications about shortages. • Unpredictable changes in product demand • Problems associated with the manufacturing and release of
products.• Quality compliance • Limited number of production lines • Complexity of manufacturing sterile injectables
• Most drugs are supplied by only one or two companies.*• Seven manufactures supply most of the market
• Suppliers cite production-related issues and increased demand as top reasons for shortages.*
• Hoarding of drugs in short supply can exacerbate shortage
*Source: “Drug Shortages: A Closer Look At Products, Suppliers And Volume Volatility” IMS InstituteFor Healthcare Informatics, Nov. 2011
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Drug Shortage by The Numbers The drug shortage problem is highly concentrated.
• 58% of the drugs on the shortage list are produced by at least one facility undergoing remediation as a result of FDA action.*
• Generic Injectables*• Make up over 80% of drugs in shortage.
• Of the total generic injectable market, half are on the shortage list.
• Oncology drugs make up the highest share of the shortages list at 16 %.
*Source: “Drug Shortages: A Closer Look At Products, Suppliers And Volume Volatility” IMS InstituteFor Healthcare Informatics, Nov. 2011
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Primary Difficulties Reported by Patients and Providers
• No advanced warning and suggested alternatives
• No information about cause of shortage• No information about duration of shortage• Difficulty obtaining suitable alternatives• Substantial resources necessary to educate
practitioners on the use of alternatives• Possible loss of prior safety safeguards put in
place
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Inspections & Drug Shortages:
Is There a Correlation?
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Inspections & Drug Shortages: Is There a Correlation?
In recent years, four trends have increased:• Registered manufacturing sites• Foreign inspections• Warning letters• Drugs in shortage
Between 2000 and 2007, the number of warning letters issued to the generic injectable companies, who represent a significant portion of the generic injectable products currently listed on the FDA Drug Shortage website, was one (1)*
Between 2008 and YTD 2013, the number of warning letters issued to these same generic injectable companies, was seven (7), a 7-fold increase*
As a result of FDA actions, generic injectable companies have made the decision to take approximately 30% of the total capacity off-line for remediation efforts.
*Source: FDA Website – FDA.gov/ICECI
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Accelerating the Recovery
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Accelerated Recovery Initiative • An unprecedented multi-stakeholder initiative
designed to provide FDA with additional scope of vision into manufacturing production planning schedules.
• Represents private-public sector partnership.
• Predicted on voluntary, confidential communication between manufacturers, an independent third party (IMS Health), and the FDA.• Information made available through ARI is designed to
increase visibility and improve decisions related to manufacturing capabilities and production of priority products.
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Accelerated Recovery Initiative The Premise:
• ARI is designed to expand FDA’s “scope of vision”
ARI uses real-time supply, distribution, and demand forecast information to determine current supply gaps compared to historical market requirements.
This data could give the FDA a better understanding of current conditions internal to manufacturing company production planning and provide for real-time decisions. It could also provide the potential to expand the supply of critical medications, or avert future shortages.
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Accelerated Recovery Initiative The Process
• GPhA will identify a subset of products on the Drug Shortage List based on inclusion criteria, and provide this list of drugs to IMS
• GPhA will contact all of the manufacturers of the products on the list in an effort to sign them up to participate in ARI
• Participating manufacturers are expected to:• Provide IMS with their respective 90 day supply schedules/forecasts covering
those products • Update monthly the supply schedules• Provide IMS with immediate notice of unanticipated changes to the existing
supply schedule
• IMS will prepare a “gap analysis” and send to the FDA• FDA could then utilize all available information to assist it’s remediation efforts
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Accelerated Recovery Initiative
The goal of the ARI is to:
• Put in place industry practices that provide a more accurate, timely and comprehensive view of the current drug shortage situation.
• Provide greater visibility to potential shortages solutions.
• Establish processes that allow for potential, voluntary production adjustments to lessen or eliminate the impact of a current shortage.
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Thank you!