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DISCUSSION DRAFTS CONCERNING PRESCRIPTION

DRUG USER FEE ACT REAUTHORIZATION,

MEDICAL DEVICE USER FEE AND

MODERNIZATION ACT REAUTHORIZATION,

DRUG SAFETY, AND CERTAIN PEDIATRIC

PHARMACEUTICAL AND DEVICE LEGISLATION

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON ENERGY AND

COMMERCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

JUNE 12, 2007

Serial No. 110–55

(

Printed for the use of the Committee on Energy and Commerce

energycommerce.house.gov

COMMITTEE ON ENERGY AND COMMERCE

JOHN D. DINGELL, Michigan, Chairman

HENRY A. WAXMAN, California

EDWARD J. MARKEY, Massachusetts

RICK BOUCHER, Virginia

EDOLPHUS TOWNS, New York

FRANK PALLONE, JR., New Jersey

BART GORDON, Tennessee

BOBBY L. RUSH, Illinois

ANNA G. ESHOO, California

BART STUPAK, Michigan

ELIOT L. ENGEL, New York

ALBERT R. WYNN, Maryland

GENE GREEN, Texas

DIANA DEGETTE, Colorado

Vice Chairman

LOIS CAPPS, California

MIKE DOYLE, Pennsylvania

JANE HARMAN, California

TOM ALLEN, Maine

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

CHARLES A. GONZALEZ, Texas

JAY INSLEE, Washington

TAMMY BALDWIN, Wisconsin

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

G.K. BUTTERFIELD, North Carolina

CHARLIE MELANCON, Louisiana

JOHN BARROW, Georgia

BARON P. HILL, Indiana

JOE BARTON, Texas

Ranking Member

RALPH M. HALL, Texas

J. DENNIS HASTERT, Illinois

FRED UPTON, Michigan

CLIFF STEARNS, Florida

NATHAN DEAL, Georgia

ED WHITFIELD, Kentucky

BARBARA CUBIN, Wyoming

JOHN SHIMKUS, Illinois

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

CHARLES W. ‘‘CHIP’’ PICKERING,

Mississippi

VITO FOSSELLA, New York

STEVE BUYER, Indiana

GEORGE RADANOVICH, California

JOSEPH R. PITTS, Pennsylvania

MARY BONO, California

GREG WALDEN, Oregon

LEE TERRY, Nebraska

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

PROFESSIONAL STAFF

DENNIS B. FITZGIBBONS, Chief of Staff

GREGG A. ROTHSCHILD, Chief Counsel

SHARON E. DAVIS, Chief Clerk

BUD ALBRIGHT, Minority Staff Director

(II)

(III)

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman

HENRY A. WAXMAN, California

EDOLPHUS TOWNS, New York

BART GORDON, Tennessee

ANNA G. ESHOO, California

GENE GREEN, Texas

Vice Chairman

DIANA DEGETTE, Colorado

LOIS CAPPS, California

TOM ALLEN, Maine

TAMMY BALDWIN, Wisconsin

ELIOT L. ENGEL, New York

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

JOHN D. DINGELL, Michigan (ex officio)

NATHAN DEAL, Georgia,

Ranking Member

RALPH M. HALL, Texas

BARBARA CUBIN, Wyoming

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

STEVE BUYER, Indiana

JOSEPH R. PITTS, Pennsylvania

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

JOE BARTON, Texas (ex officio)

(V)

C O N T E N T S

Page

Hon. Frank Pallone, Jr., a Representative in Congress from the State of

New Jersey, opening statement .......................................................................... 1

Hon. Nathan Deal, a Representative in Congress from the State of Georgia,

opening statement ................................................................................................ 3

Hon. Lois Capps, a Representative in Congress from the State of California,

opening statement ................................................................................................ 4

Hon. Mike Rogers, a Representative in Congress from the State of Michigan,

opening statement ................................................................................................ 5

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, opening statement ........................................................................................ 6

Hon. Michael C. Burgess, a Representative in Congress from the State of

Texas, opening statement .................................................................................... 7

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, opening statement ....................................................................................... 8

Prepared statement .......................................................................................... 8

Hon. Darlene Hooley, a Representative in Congress from the State of Oregon,

opening statement ................................................................................................ 9

Hon. Jim Matheson, a Representative in Congress from the State of Utah,

opening statement ................................................................................................ 10

Hon. Jan Schakowsky, a Representative in Congress from the State of Illinois, opening statement ....................................................................................... 11

Hon. Gene Green, a Representative in Congress from the State of Texas,

opening statement ................................................................................................ 12

WITNESSES

Randall Lutter, Deputy Commissioner, Policy, Food and Drug Administration,

Department of Health and Human Services ...................................................... 13

Prepared statement .......................................................................................... 16

Answers to submitted questions ...................................................................... 282

Caroline Loew, senior vice president, scientific and regulatory affairs, Pharmaceutical Research and Manufacturers of America ........................................ 65

Prepared statement .......................................................................................... 67

Answers to submitted questions ...................................................................... 278

Jim Guest, president, Consumers Union ............................................................... 105

Prepared statement .......................................................................................... 107

Answers to submitted questions ...................................................................... 296

Steven Ubl, president and chief executive officer, Advanced Medical Technology Association ................................................................................................ 120

Prepared statement .......................................................................................... 121

Diana Zuckerman, president, National Research Center for Women & Families ......................................................................................................................... 127

Prepared statement .......................................................................................... 130

Steven Walker, Abigail Alliance for Better Access to Developmental Drugs ..... 139

Prepared statement .......................................................................................... 142

Richard L. Gorman, M.D., on behalf of the American Academy of Pediatrics ... 207

Prepared statement .......................................................................................... 209

SUBMITTED MATERIAL

‘‘FDA Advisory Committees. Does Approval Mean Safety?’’ National Research

Center for Women & Families ............................................................................ 228

Submitted by Ms. Eshoo:

Jay E. Berkelhammer, M.D., president, American Academy of Pediatrics,

letter of June 7, 2007 .................................................................................... 306

Page

VI

Submitted by Ms. Eshoo—Continued

Pamela W. Barnes, president and chief executive officer, Elizabeth Glaser

Pediatric AIDS Foundation, letter of June 12, 2007 .................................. 307

‘‘Potentially Incompatible Goals at FDA,’’ Gardnier Harris, the New York

Times, June 11, 2007 .................................................................................... 308

(1)

DISCUSSION DRAFTS CONCERNING PRESCRIPTION DRUG USER FEE ACT REAUTHORIZATION, MEDICAL DEVICE USER FEE

AND MODERNIZATION ACT REAUTHORIZATION, DRUG SAFETY, AND CERTAIN PEDIATRIC PHARMACEUTICAL AND DEVICE LEGISLATION

TUESDAY, JUNE 12, 2007

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC.

The subcommittee met, pursuant to call, at 10:00 a.m., in room

2123 of the Rayburn House Office Building, Hon. Frank Pallone,

Jr. (chairman) presiding.

Members present: Representatives Green, Eshoo, DeGette,

Capps, Schakowsky, Hooley, Matheson, Dingell, Deal, Buyer, Wilson, Pitts, Rogers, Sullivan, Murphy, Burgess, Blackburn, Myrick,

and Hall.

Also present: Representative Markey.

Staff present: Jack Maniko, John Ford, Virgil Miller, Ryan Long,

Nandan Kenkeremath, Katherine Martin, Brin Frazier, Robert

Clark, Chad Grant, and Melissa Sidman.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY

Mr. PALLONE. I call the meeting of the subcommittee to order.

Good morning, everyone. Today the subcommittee is meeting to

hear testimony about discussion drafts concerning the Prescription

Drug User Fee Authorization, Medical Device User Fee and Modernization Act Reauthorization, Drug Safety, and several proposals

to encourage more research into the appropriate use of drugs and

devices in pediatric populations. I will note, as a matter of process,

that each of these issues has had its own hearing in the subcommittee over the course of the past 6 weeks. We have worked

very hard to cover a lot of ground and I want to thank all the subcommittee members for their participation in these hearings and I

welcome comments and suggestions on these discussion drafts as

we continue to move forward.

I will also note that while we did have a hearing regarding follow-up on biologics, I did not include a proposal in last week’s

2

drafts that would address this issue. I want to stress that this

issue is of vital importance and its lack of inclusion should not be

viewed as a signal to anyone that the door is closed on this very

important topic. I am still very interested in developing a consensus on this issue and I hope to do so in the near future.

Let me just say a few words about each of the discussion drafts

that we circulated last week, and I think you all know they were

on the Web site. The proposal to reauthorize the Prescription Drug

User Fee Act or PDUFA, is largely based on the agreement between the FDA and the industry with a few changes. First and

foremost, an additional $225 million in user fees is authorized in

the discussion draft. These new fees would be dedicated to postmarket safety activities and would build upon the $29 million in

additional fees already included in the administration’s proposal for

post-market safety activities. We also include a provision that

would require more transparency in the next PDUFA process by allowing a consumer or patient group to participate in the negotiations between the FDA and the pharmaceutical industry.

Now, like the PDUFA proposal, the discussion draft to reauthorize MDUFMA is also largely based on the proposed agreement between the FDA and the medical device industry, with some modifications. Undoubtedly, the most controversial change is to eliminate the changes to the third party inspection program. I realize

that the medical device industry has deep concerns about this provision. Over the last week they have come to see us about it. However, I have not been convinced that these changes are necessary

in order to improve participation in the program. No one has been

able to show me how or why the policies we are changing act as

significant barriers to participation.

And finally, I have a philosophical problem with the idea of liberalizing a program that is designed to privatize the core function of

a Government regulatory agency. Other key changes to the

MDUFMA proposal include a study of the 510(k) process and an

authorization of appropriations for post-market activities.

Now, we have also circulated two draft proposals to reauthorize

the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act, which are designed to provide necessary research on the appropriate use of prescription drugs in pediatric

populations. While these drafts make a number of changes to the

program, the two largest changes are eliminating the sunset provision associated with PREA and including an exclusivity adjustment

under BPCA. Also included amongst these drafts are proposals supported by Representatives Markey and Rogers to encourage the development of devices to be used in pediatric populations.

And finally, we included a number of proposals that would improve our drug safety system. I realize that the drug safety provisions will be the most contentious. We saw how contested this debate was in the Senate and it is my hope that we can avoid having

a repeat performance in this subcommittee. However, it is very

clear that there are gaping holes in the current system and the

public has lost a great amount of confidence in FDA’s ability to protect them from potentially harmful drugs. We must work diligently

to strengthen our Nation’s drug safety system and restore the

public’s trust in FDA.

3

At the heart of our drug safety proposal is the requirement that

all new drugs include a risk evaluation and mitigation strategy,

which outline the conditions that need to be put in place to ensure

that FDA has the tools necessary to protect consumers from unknown risks associated with a new drug. I realize that not everyone is going to agree with the REM strategy or how we are proposing to implement it. The direct-to-consumer advertising provisions

included in the REMS have already caused great anxiety among

stakeholders and members and I am certainly open to hearing any

concerns you have.

Other provisions included in the drug safety drafts are a new

clinical trials registry and results database, which are designed to

give patients and providers greater access to the information they

need to determine the most appropriate and safest course of treatment. There are also new conflict of interest standards that are designed to ensure that FDA’s advisory committees remain impartial

and provide the best possible advice when it comes to critical issues

that impact public health.

These are the major provisions of the draft we circulated last

week in which we will hear more about today. Again, I thank all

the subcommittee members for their participation in the hearings

we had and I am looking forward to getting your feedback today.

I would like to also welcome our witnesses here today. We are

eager to hear from you and hear your opinions and whatever suggestions you may have.

And now I would recognize my friend, Mr. Deal from Georgia, for

5 minutes for an opening statement.

OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA

Mr. DEAL. Thank you, Mr. Chairman. Many of the pieces of legislation before us today play an important role in ensuring that patients have timely access to approved, safe and effective medications and medical devices. Moreover, some of these drafts encourage the study of medications to meet the special needs of our pediatric population. Historically, these have been bipartisan pieces of

legislation and recent action in the Senate on a similar package of

proposals demonstrated that the two sides can work together to

reach a consensus and preserve patients’ access to lifesaving medications.

Unfortunately, as I see the schedule, there is little time for the

two sides to work together to move a more largely bipartisan package. I am sure today’s hearing will highlight certain aspects of the

legislation which could be offered in a way acceptable to both sides.

This is especially true on certain reauthorization measures like

PDUFA and MDUFMA, which must be passed in order to prevent

possible personnel disruptions at the FDA.

It originally was my hope that the chairman would provide the

staff enough time to work through these issues prior to our markup. However, with a markup little more than a day from now, I am

not sure that is possible. I do look forward to the testimony of our

witnesses regarding certain provisions of these drafts. I certainly

sympathize with the goal of providing the FDA adequate resources

to ensure the safety of the Nation’s drug supply. However, making

4

the agency even more dependent on the industry through an even

greater increase in the user fees to achieve this goal may not be

the wisest course of action.

I am also concerned that these drafts do not include the suggestions in the original MDUFMA agreement to improve the third

party inspection program. Certain changes to the pediatric programs also deserve attention during this hearing. Pediatric device

legislation ought to be carefully crafted so that there are not any

unnecessary regulatory hurdles which thwart the purpose of the

bill. The Pediatric Research Equity Act and the Best Pharmaceuticals for Children Act had been an effective combination to foster the study of medications in children. I have reservations about

any attempt to de-link these programs which have successfully promoted the health of the Nation’s children.

The drug safety proposals before us deserve important attention

during this hearing. I look forward to our witnesses’ opinions on

these matters in addition to get whatever guidance they can provide on the troubling preemption clause included at the end of

some of these drafts. Ultimately, I believe there is room for compromise on these bills. We just need time to allow the negotiation

process to work to reach a bipartisan agreement. Holding a subcommittee markup a day from now and a full committee markup

a week later, seriously jeopardizes that effort. It takes time for the

committee to report good bipartisan legislation, but I am afraid the

timeframe we are working in make that virtually impossible.

Thank you, Mr. Chairman.

Mr. PALLONE. Thank you, Mr. Deal. Mrs. Capps.

OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Mrs. CAPPS. Thank you, Chairman Pallone, and thank you to our

witnesses, both panels. I want to commend you, Mr. Chairman, and

the committee staff for working so diligently on drafting these proposals and taking into consideration our concerns. As you noted,

this has been no easy task. One of the hardest things for me, from

the beginning, has been the fact that the administration did not

bring patients and consumers to their table for negotiations. I, like

many of my colleagues, have always prided myself in protecting

consumers. It has been quite a journey to draft a proposal that

takes in account consumer protections and concerns. But I am confident that the draft we have before us today is an excellent start

and I hope that today we can discuss ways in which to protect both

consumers and innovations simultaneously. That remains my goal

and I believe it is a possibility.

Some of the concerns I still have and which I know many of my

colleagues share include these: reducing conflicts of interest, ensuring the integrity of direct-to-consumer advertising, ensuring proper

recourse in the event of patient injury. The issue of conflicts of interest is most glaring because I think there is a misconception

about what is and what isn’t necessary. It is hard for me to hear

that the pool of experts is so small that it is near impossible to

have a committee free of financial interest of the company whose

product is under review.

5

Because in reality, I have been told that there is another pool of

equally competent experts in academia with no financial ties to industry who have not been solicited and who would be willing to

serve on advisory committees. Mr. Chairman, I sincerely hope that

as we consider the final language to be marked up on Thursday,

we are sure to protect the newly crafted language regarding conflicts of interest and reject any attempts to weaken it.

I would even go so far as to say that we should strengthen it further, that is my goal. And I hope some of our witnesses today, I

believe they will, do agree with this. I am eager, also, to hear today

from our witnesses regarding the integrity of direct-to-consumer

advertising. I think there is more progress to be made in the way

of crafting a compromise that protects free speech while also ensuring consumer safety. So thanks again for listening to our concerns

and I look forward to hearing from our witnesses today. And I yield

back.

Mr. PALLONE. Mrs. Wilson was next. I don’t know if she is in the

back. If not, we will go to Mr. Ferguson. Mr. Ferguson.

Mr. FERGUSON. I will waive, then.

Mr. PALLONE. Ms. DeGette.

Ms. DEGETTE. Thank you, Mr. Chairman. I have many views on

these issues, but I think I will save them for the questioning time

and waive my opening statement.

Mr. PALLONE. Mr. Burgess was next, but I don’t know if he is

back, yet. We will go to Mr. Rogers.

OPENING STATEMENT OF HON. MIKE ROGERS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN

Mr. ROGERS. Thank you, Mr. Chairman. I hope we can come to

some better working relationships by next week and before I do

that, I want to thank Mr. Markey for working with us on the pediatric devices portion of the bill. He and his staff have been excellent. But in all of the drafts that were circulated, something that

didn’t come over in the Senate bill, was this notion of preemption

of the States and what concerns me most is all the good work that

we have done was taken away in kind of a last minute addition

that was not in any of the drafts and was not worked with the minority side, something that I think absolutely renders these bills

awful and we have made so much progress.

That book of regulations to get a device or a drug to market, you

can comply, according to these new additions in this law, you can

comply with every single one of these rules and regulations and we

are going to get ready to add new ones in addition, and you can

comply with all of it and the last minute addition language that

was put into these bills last week would mean that I can sue for

any reason in a State court. So I have gone through all the compliance costs, I have used up all my intellectual capital investing in

the compliance with this—as a matter of fact, the FDA could tell

me certain things aren’t eligible to be put on labels and you should

not do it because I complied with this and I could still get sued in

State court for what the FDA told me not to do.

I hope that we can sit down and talk about it. This makes all

of this work, all of the good work of so many people absolutely useless. It absolutely will destroy any hope of innovation in moving the

6

industry forward so that we get some accountability, we get new

innovation, we get new devices and we get new drugs to market.

I mean, I feel pretty strongly about this, Mr. Chairman, and I hope

that in the spirit of openness and working together in a bipartisan

way we can have those kind of discussions before these things kind

of get dropped in the bowl like this, because if you leave this language, it puts in jeopardy everything that this committee has done

over the last few months and I look forward to hopefully we can

work through this, take a look at the language. I am sure it was

a mistake that it was dropped in, Mr. Chairman and we can work

on it and get this language taken out and we will work through

it for the markup coming up. Thank you, Mr. Chairman. I yield

back.

Mr. PALLONE. Thank you. Ms. Eshoo.

OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Ms. ESHOO. Thank you, Mr. Chairman, for holding this legislative hearing on the nine bills that are before us today. All of them

are important for ensuring the safety and the efficacy of pharmaceuticals and medical devices available to the American people.

Thank you also for including the legislation that will reauthorize

two important programs that have helped to increase the number

of drugs and biologics tested labeled for use in children, the Best

Pharmaceuticals for Children Act, which I have a great source of

pride in, and the Pediatric Research Equity Act.

Last week I introduced H.R. 2589, the Improving Pharmaceuticals for Children Act, to reauthorize both of these successful

programs. By making a number of improvements to current law,

my bill increases the availability of pediatric information to doctors, parents and researchers. It improves transparency and accountability at FDA and of drug sponsors and it enhances postmarket surveillance of pediatric drugs. It also makes permanent

the FDA’s authority to require pediatric studies. This adjustment

is consistent with FDA’s permanent authority to require studies of

adult formulations.

I have also included many of the recommendations of the GAO,

the American Academy of Pediatrics, the Elizabeth Glaser Pediatric AIDS Foundation, and the FDA, in developing the bills. I

would like to ask unanimous consent to insert in the record the letters of support.

Mr. PALLONE. Without objection, so ordered.

Ms. ESHOO. Thank you.

Ms. ESHOO. I am also pleased that the committee print includes

many of the provisions in this bill and I look forward to working

with it to resolve some of the differences.

In the interest of time, I just want to highlight a couple of points

with respect to the other bills before us. The funding for FDA’s IT

system, I think is woefully inadequate. The committee print allocates $4 million specifically the goal, but I think additional funding

should be allocated for IT and I want to work with you to provide

these resources.

7

With respect to third party inspections under MDUFMA, I recognize that FDA is not able to conduct all of the inspections it needs

to and that the device and the imaging industries are frustrated by

this. I think we need to take another look at the user fee and appropriated funds available under MDUFMA and see if we can come

up with a better way of enabling direct FDA oversight of the device

and the imaging industries. There is a real tension, a push and a

pull between the two, a company being able to do it; consumers

saying well, this serves them and the whole issue of post-market

surveillance in this, I think we can do better at it, so I want to

work with you on that.

Finally, I have serious concerns about the risks to public safety

presented by direct-to-consumer advertising. I think that the chairman has done a good job for including provisions in both the

PDUFA and the REMS committee print that seek to increase funds

at FDA for the voluntary review of DTC ads, but most frankly, I

think the voluntary review doesn’t really add up to very much. I

mean, there just isn’t any teeth in it, so we make ourselves feel

good by saying we don’t like it, but it is not going to do anything

about it, so I think that we have to take a harder look at that. So

I look forward to this hearing. Thank you for the work that has

been put into it. I think we still have some more work to do to ferret out some of the points that have already been made by members and I thank the witnesses in advance for their being here and

being instructive to us.

Mr. PALLONE. Thank you. You guys are coming in and out on the

other side, so I am getting confused. Mr. Buyer is next, but then

I guess we will go back to Mr. Burgess. You waive? OK, Mr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. BURGESS. Thank you, Mr. Chairman, and I will be brief. I

am glad we are taking up these bills and starting to legislate on

these important issues. The process, so far, my opinion is somewhat strained. I am concerned that the bills have fallen victim to,

in some cases, what might even be described as unnecessary partisanship, barring minority staff involvement from the drafting of

even the least controversial of these bills is highly concerning, but

whatever concerns we have about the process, there is also concerns about the policies in the draft bills we have seen.

First would be the Federal preemption issue. The bills, as drafted, seem to upset the delicate legal balance set up by the FDA rule

and would seem to open up the State courts to a situation that

might be labeled litigation for all. Secondly, pediatric exclusivity. I

am concerned about the revenue triggers set forth in the draft bill

and how the FDA would comply with its requirements. Thirdly, the

issue surrounding post-market surveillance. I am interested in

working with members of the majority to modify the Risk Evaluation Mitigation Strategy. I believe this committee could adopt a

more eloquent approach to this important issue.

Finally, the conflict of interest issue. While I believe we should

do all we can to limit conflicts of interest in regulatory agencies,

I am concerned that the proposal on conflicts perhaps goes too far

8

the other direction and would limit important technical institutional expertise that is currently available to the FDA. But Mr.

Chairman, there are good provisions in the package, as well, and

there is work to be done. I hope we can improve on some of the

areas and I hope the witnesses here today will help us begin that

process. And I will yield back the balance of my time.

Mr. PALLONE. Thank you. The gentleman from Michigan, the

chairman of our full committee, Mr. Dingell.

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN

Mr. DINGELL. Mr. Chairman, thank you for your recognition. Mr.

Chairman, first, commendations to you and congratulations on the

outstanding leadership that you are providing on this matter and

other matters. The staff draft is an excellent one and I commend

you for your vigor and the diligence with which you have moved

this forward. Mr. Chairman, I have an excellent statement which

I am sure everybody is going to want to read, so I ask unanimous

consent to put it in the record at this time.

I do have a few comments to make to my Republican colleagues.

The committee is under considerable pressure to move a lot of legislation and as a result, we are not able to proceed in the way that

I would ordinarily like to do it. I will tell my Republican colleagues

and I want them to hear this because it is a statement made with

good will. I intend, first of all, to see to it, on this matter, that

every possible procedural fairness and opportunity is given to

them. I intend to try to work with them. I know you, Mr. Chairman, intend to do the same thing and we will try and come up

with, first of all, substance to which the committee may agree.

Second of all, procedures and processes which will enable our Republican colleagues to not only have fair treatment, but to feel assured that they are having fair treatment and also to see to it that

when we have completed the legislation, which we will try to do expeditiously, that we have completed legislation which meets with

the high standards that this committee has always had and that

we will try to see to it that we do so in a way which is marked

by good humor and cooperation amongst the two parties. I will tell

my Republican colleagues that I intend, myself, and I know you do,

to see to it that this process is not only fair, but results in a good

piece of legislation. I thank you, Mr. Chairman.

PREPARED STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF MICHIGAN

Mr. Chairman, thank you for your leadership on these issues and for the opportunity to begin consideration of the staff discussion drafts released by your subcommittee last week. This hearing is an important step in crafting legislation that

will affect millions of Americans, young and old, who need a medical device or take

a prescription medication.

Many of these programs will expire at the end of the fiscal year, less than 4

months from now. It is this committee’s responsibility to ensure that these programs

are reauthorized in a timely manner to avoid any personnel disruptions at the Food

and Drug Administration. Hardworking, skilled employees at FDA are looking to us

to do our job, so they can continue to do theirs.

As we begin this process of reauthorization, we must work towards strengthening

the safety and effectiveness of the Nation’s supply of drug and device therapies. We

must strike the correct balance between allowing patients timely access to new

9

therapies, while ensuring that those therapies that enter the marketplace are monitored for safety. We must enhance the post-market surveillance of both devices and

pharmaceuticals so that if another Vioxx situation should occur, it is caught quickly.

Another important issue that the discussion drafts focus upon is the need for

greater resources at FDA. We have heard about this need from a wide range of

stakeholders. I agree. This legislation should provide FDA the necessary user fees

to provide timely review of new drug applications, biologic license applications, and

premarket approvals for devices. Equally important, we must work to ensure that

Congress appropriates the funds authorized for FDA.

This subcommittee has held a number of hearings this year on many of the issues

contained in the discussion drafts. Those hearings have been very helpful in preparing us to work on these legislative matters. Again, I thank the chairman for holding

this hearing on the discussion drafts, and look forward to the testimony of the witnesses.

Mr. PALLONE. Thank you, Mr. Chairman. Mr. Sullivan of Oklahoma. Are you waiving? The gentlewoman from Oregon, Ms.

Hooley.

OPENING STATEMENT OF HON. DARLENE HOOLEY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON

Ms. HOOLEY. Thank you, Mr. Chairman. The bills before the subcommittee take critical steps to promote the safe and rapid approval of prescription drugs and medical devices. I am pleased to

support the enhanced post-market surveillance provisions throughout the bills. I think these bills improve the Food and Drug Administration’s capacity to safely approve drugs and devices and then

monitor them for continued safety after they reach consumers.

I would now like to turn to a medical device issue that I believe

has significant impact with consumers of implanted medical devices. As a patient, I have had bilateral knee replacement. Dozens

of my friends and family and thousands of constituents have similarly had surgeries where medical devices were implanted in their

bodies. In many cases, those devices provided lifesaving or prolonged benefits. In other instances such as my own, people’s quality

of life has been greatly improved as a result of implanted medical

devices.

However, when a medical device is recalled, too often a patient

may never find out there is a problem. Our current system of notifying patients in cases where a device is recalled, is simply deficient. I am particularly concerned about class 1 recalls that the

FDA characterizes as having a reasonable chance the product will

cause serious health problems or death. Device manufacturers

work very hard to ensure their products are safe. Despite the most

diligent efforts, products sometimes fail. In cases where a product

has a reasonable chance of causing serious health problems or

death, I believe that, as a patient, you or I should be informed.

That is not too much to ask. If someone could die or suffer serious

harm, those patients should be notified.

As we move toward markup, I hope this committee will be able

to take sensible and prudent steps to improve patient notification.

A first step in that process is to allow the FDA to conclude its work

on a unique device identification or UDI. It has been working hard

with stakeholder groups for years as it considers how best to implement a UDI system. Such a system would greatly assist in the recall process and also improve supply chain efficiency.

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I believe it is critical to encourage the FDA to continue its rulemaking process while not tying their hands as to the manner or

system the agency believes will best serve the public interest. With

the unique device identification system as a foundation, I believe

we can further empower the FDA to engage in a thoughtful rulemaking process to better ensure patients are notified in those instances where the implanted medical devices may malfunction. The

key to any such system is to enable those at the FDA with expertise and recalls and notifications to guide the process of strengthening the system. The public health will benefit from patients having

more information.

I believe the FDA can develop a prudent and workable system

to notify our parents, grandparents, friends and loved ones when

their implanted medical devices present a reasonable chance of

death or serious health problems. They deserve no less. Thank you,

Mr. Chairman.

Mr. PALLONE. Thank you. The gentlewoman from Tennessee,

Mrs. Blackburn.

Mrs. BLACKBURN. Thank you, Mr. Chairman. In the interest of

time, I will do as many have done and waive my opening statement. I do just want to register my concern with the delay in getting the legislation and the information to us last night, those of

us that have healthcare industry and of course, we all have consumers in our districts and I think that the lack of orderly process

is something that has been a disappointment to me and I hope that

we will see a more timely process as we move forward with consideration and I yield back.

Mr. PALLONE. Thank you. Mr. Matheson.

OPENING STATEMENT OF HON. JIM MATHESON, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF UTAH

Mr. MATHESON. Thank you, Mr. Chairman. I certainly appreciate

the opportunity to hear from the witnesses today regarding the discussion drafts. I hope the witnesses will provide some insight regarding the impact the draft legislation will have to improve drug

safety, support FDA in its mission and improve access for children

to appropriate drugs and devices.

In light of recent adverse examples brought before Congress, I

look forward to hearing recommendations from the panel on how

best to achieve a balance between innovation and public safety. I

am concerned about one item missing from the discussion drafts.

Currently, there are no provisions to address antimicrobial resistance, a true issue of drug safety. I appreciate the rich history this

committee has regarding concern about this issue.

Mr. Chairman, as you know, I have been working on this issue

and look forward to working with you and others of the committee

to pass legislation in this area. I plan on introducing to reauthorize

and build on a program my colleague, Mr. Stupak, authored with

our former colleague, Mr. Burr, section 319(e) of the Public Health

Service Act, combating antimicrobial resistance. I hope my colleagues will work with me to include these provisions as we consider FDA legislation. It would be a shame to miss this opportunity

to put in place provisions that will help protect us against many

11

resistant infections that are out there and are placing people in

danger.

Antibiotics present unique challenges for drug safety. As we

know, they are researched and developed to respond to infectious

organisms that continue to mutate and build resistance to the

product even after approval. Even if we all demonstrate good judgment and use antibiotics wisely, eventually the bad bugs become

resistant. It will take a coordinated effort and a partnership between manufacturers, Federal agencies, providers and patients to

truly make a difference in slowing the trend of antimicrobial resistance.

It is my hope that this committee will include provisions to protect antibiotic safety and effectiveness, as well as improve access

to new antibiotics. I do think we should make every effort to ensure

that people have access to effective new medicines as quickly as

possible and with thorough safety guidelines. Mr. Chairman, I will

yield back.

Mr. PALLONE. Thank you. The gentlewoman from Illinois, Ms.

Schakowsky.

OPENING STATEMENT OF HON. JAN SCHAKOWSKY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. I do just have a

brief statement. I want to thank you for your leadership, Mr.

Chairman, on these critical issues. The legislation we have before

us today has the potential to significantly improve the way patients

make decisions about the drugs or medical devices they use in a

variety of ways. I appreciate the witnesses being here today, I look

forward to hearing their insight on the proposals. A lot of work remains here as we work to pass these significant and critical pieces

of legislation, but I am confident that the subcommittee has the

ability to come to a consensus that is in the best interest of patient

safety and scientific integrity.

Clearly, a balance is being sought here, but it is crucial to protecting consumers of drugs and medical devices. We need an efficient process that brings us medicines and devices that are both

safe and effective and we need to work to ensure that the agency

responsible for overseeing much of this process maintains its integrity and reliability. Without a doubt, within this debate lies the difference between sickness and health and life and death for so many

of our constituents. As we move forward, I remain concerned that

patients continue to be first and foremost throughout any debate.

I look forward to passing legislation that will truly enhance the

way information comes out of the FDA, is made available to the

public and is used by all parties involved to improve the health of

those who must take prescription drugs or use medical devices.

This of course, includes our children and I appreciate the chairman’s efforts in making safer pediatric therapies more readily

available to this population. I also commend the chairman’s work

to increase the resources available to the FDA’s drug review program and to make significant improvements to both the pre- and

post-market safety programs.

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Again, I look forward to the work we have ahead of us and anticipate that we will bring positive change and essential improvements to the legislation before us. I yield back.

Mr. PALLONE. Thank you. And I recognize our vice chair, Mr.

Green from Texas.

OPENING STATEMENT OF HON. GENE GREEN, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. GREEN. Thank you, Mr. Chairman, for holding our legislative

hearing on this legislation that would reauthorize expiring user

fees or approval of both prescription drugs and medical devices at

the FDA, as well as several bills that we are going to enact some

much needed reforms at FDA. This committee, particularly the

Oversight and Investigation Subcommittee, has spent a wealth of

time investigating lapses in drug safety at the FDA, specifically

with regard to Vioxx, Ketek and antidepressants. These investigations uncovered significant structural and cultural problems at the

FDA that these bills should seek to remedy to better ensure the

safety of our Nation’s drug supply.

I am particularly supportive of the legislation to enact a Risk

and Evaluation Mitigation Strategy at the FDA whereby each new

drug the FDA approves would be analyzed and a safety profile

would be established for that specific drug so that risk and benefits

continue to be monitored throughout the life cycle of that drug.

This draft includes an important step forward for safety by granting the FDA much needed authority to require post-market studies.

The FDA’s post-market authority has been sorely lacking. I think

a majority of us would agree that this additional authority and a

dedicated funding source through the user fee program is a good

step forward.

The Risk Evaluation Mitigation Strategy proposal is not without

controversy. There is no question that a point of contention remains over the direct-to-market, direct-to-consumer advertising. I,

for one, support the language in the discussion drafts that provide

the Secretary with the authority to impose a temporary waiting period for the mass advertising of a drug. I understand there may be

Constitutional concerns with the language, however I support our

chairman in his efforts to have the strongest language possible out

of the committee.

There is no question that sales of Vioxx skyrocketed during the

direct-to-consumer advertising despite the fact that the drug was

indicated for a small subset of individuals who couldn’t tolerate

other drugs. This temporary advertising waiting period would help

us on this post-market side to identify and monitor any adverse

events in larger sets of people before a drug is mass marketed for

the entire country.

All along we said that additional authority must be met with a

cultural change at the FDA and I am glad to see that the subcommittee will take up legislation that addresses the conflicts of interest of the FDA advisory panels. While many of us that prefer

that the advisory committee meetings be entirely free of conflicts

of interest, I can understand the need to conclude a waiver process

to ensure that the panel can gain the appropriate expertise as long

as the one waiver and the nature of the panel members financial

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interest is made public. I would, however, like to see additional

safeguards put into place for FDA scientists to ensure that their

scientific opinions are heard and not suppressed for financial or political purposes.

We have heard too many times the FDA scientists consider the

drug companies to be clients. Let there be no mistake. The American people are the clients of the FDA and the publicity around supervisors who are telling people not to do it because we need to

move these drugs is just wrong and I hope this bill corrects that.

The American people are the ones the FDA is supposed to represent, not the people paying those bills. If they don’t have the authority to do that, to over see that, they pay it to get the speediest

approval possible, but the American people are the ones that the

FDA represents and I hope they remember that.

I hope we can work together on these bills and move the process

to include strong language to protect the FDA scientists and allow

them to do their jobs on behalf of the American people. There are

many specific issues in the bill that need to be analyzed and I say

these are questions for later and I thank the FDA representatives

and the stakeholder groups for appearing today. And also, I would

like to thank the chair for your work in moving these bills through

the committee, particularly ensuring that each of the issues have

benefited from the public hearing process and I will yield back my

time.

Mr. PALLONE. Thank you. Mrs. Wilson, did you want to make an

opening statement? No? I think that concludes our opening statements, then, so I will now turn to our witness, our first panel. We

have with us Mr. Randall Lutter, who is Deputy Commissioner for

Policy at the FDA. Welcome you. Thank you for being with us

today. I always say that you may, in the discretion of the committee, submit some written responses later or additional material if

you can’t answer the questions that we pose today, but if you

would, I would like you to begin and thank you again for being

here.

STATEMENT OF RANDALL LUTTER, DEPUTY COMMISSIONER

FOR POLICY, FOOD AND DRUG ADMINISTRATION

Mr. LUTTER. Thank you, Mr. Chairman, and members of the subcommittee. I am Randy Lutter, Deputy Commissioner for Policy at

the Food and Drug Administration. I am pleased to be here today

to talk about discussion drafts to reauthorize several statutes of

vital importance. In my oral remarks, I will highlight only a few

areas of concern. Our broader comments and concerns are outlined

in written testimony that was also submitted to the committee.

The Prescription Drug User Fee Act has produced significant

benefits for public health, including providing the public access to

over 1,200 new drugs and biologics since its enactment in 1992. We

believe that the administration’s proposal places PDUFA on sound

financial footing, enhances pre-market review and creates a modern post-market drug safety system that would follow products

throughout their full life cycle. We are pleased that the discussion

draft is generally consistent with the administration’s proposal.

One significant concern to us is the lack of clarity about funding

new drug safety activities. In our view, the amount that could be

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raised through user fees may be inadequate to support the new activities.

Similarly the user fees provided by the Medical Device User Fee

and Modernization Act and annual appropriations have allowed us

to make significant improvements in the device review program.

Since MDUFMA was enacted, FDA has approved more than 150

original pre-market approvals. We believe our proposal would ensure sound financial footing for the device review program and

would enhance the process for pre-market review of device applications. We have technical concerns about the discussion draft.

The administration also supports reauthorization of the Best

Pharmaceuticals for Children Act and the Pediatric Research Equity Act. Together, these statutes have transformed information

about safety and efficacy for children of important therapeutics and

promoted safety and innovation in pediatric drug development. We

are concerned, however, that the discussion drafts contain provisions that could have an unintended and negative impact on these

successful programs.

The draft bill’s creation of an internal review committee for both

BPCA and the PREA functions are of concern. A legislative requirement for what are primarily staff functions is in direct conflict

with our expertise, flexibility and efficiency needed to ensure rapid

review of pediatric product development. For this reason and for related reductions and incentives to provide appropriate pediatric

drug trials, the administration would favor straight reauthorization

over the enactment of these provisions. The PREA discussion draft

would require FDA to give priority review status for all supplements to new drug and biologics applications submitted as a result

of PREA. This would remove the flexibility FDA currently has in

determining the appropriateness of the priority designation in relation to other priorities.

With respect to safe and effective pediatric medical devices, FDA

is committed to supporting their development and availability. The

discussion draft raises several concerns, however. The draft would

require FDA to track separately the adverse events associated with

for-profit sales versus not for profit sales of pediatric devices. The

public health benefit of such a requirement is unclear to us. The

draft also would require annual review of for-profit pediatric devices by the Pediatric Advisory Committee. This duplicative review

imposes significant burden without a clear public health benefit.

We have a number of concerns with the discussion draft on drug

safety. Some changes prescribe a specific agency action without

clear public health benefit, such as the requirement to present all

new molecular entities to advisory committees for review. We are

also concerned about the breadth of the proposed requirements for

Risk and Evaluation Mitigation Strategies outlined in the bill. We

believe it is unnecessarily burdensome to require REMS and periodic assessments or reassessments for all drugs.

We support the addition of provisions for an active drug safety

surveillance system that would be established through a public/private partnership and we want to work with you on this provision

to ensure the most effective implementation. We are concerned

about new language on preemption in the discussion drafts which

state that nothing in the Act may be construed as having any legal

15

effect on actions for damages under State law, including statutes,

regulations and common law. We believe that State law actions

that can conflict with agency conclusions and frustrate the agency’s

implementation of its public health mandate should not be endorsed in Federal laws.

In conclusion, PDUFA III and MDUFMA expire on September

30, 2007. I want to reemphasize the importance of timely reauthorization of these laws in order to avoid disrupting key ongoing and

effective programs. FDA is ready to work with you to accomplish

this goal. We welcome the opportunity to work with Congress to

ensure the benefits of these acts will be enjoyed as Congress considers reauthorization of the BPCA and the PREA programs, as

well. Thank you very much, Mr. Chairman.

[The prepared statement of Mr. Lutter follows:]

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Mr. PALLONE. Thank you. We are going to start with questions

and I recognize myself for 5 minutes, Mr. Lutter.

I understand that the administration is in favor of changing the

requirement included in our discussion draft that requires all new

drugs include a REMS. You would prefer—and again, I am putting

words in your mouth, so if you disagree with me at the end here,

tell me. But my understanding is that you would prefer that the

FDA be granted the discretion to apply REMS when a problem

arises with particular drugs as you currently do with RiskMAPs.

First let me say, is that correct?

Mr. LUTTER. We are concerned that a broad requirement of

REMS being applied to all products may be unnecessary and, in

particular, to the allocation of resources to areas where there is no

clear public health benefit.

Mr. PALLONE. OK, but then the whole point of the REMS is to

mitigate certain unknown risks, but what you seem to be suggesting is that FDA wouldn’t react until a risk for a particular drug

becomes known, is that correct?

Mr. LUTTER. Well, the purpose of REMS is to mitigate risks, but

the concern is that for many products, the need for a particular action beyond what is already in place is not obvious to us and may

be unnecessary. That is why we think with the breadth of the requirement on REMS is excessive.

Mr. PALLONE. But why do you think that it is more appropriate

to act only when a risk becomes apparent instead of having safeguards in place prior to a risk being revealed? That is what I don’t

understand.

Mr. LUTTER. Well, the REMS requirement would apply to all

products and it may be lifted from all products only if a waiver is

granted under circumstances that we think would be very rare if

there was a finding of no risk to any sub-populations resulting from

use of the waiver. And the real question is whether this process of

having REMS applied to all products is one that is efficient and a

good use of resources to promote drug safety relative to an alternative one that is more narrowly targeted.

Mr. PALLONE. But how burdensome would this really be on the

FDA? Opponents argue that FDA is going to be overwhelmed by

REMS requirements, but isn’t it true, for most drugs, that the

REMS requirements will only consist of labeling and adverse event

reporting requirements? Don’t new drugs already have to comply

with those minimum requirements?

Mr. LUTTER. New drugs do have to comply with those requirements, but we believe that the post-marketing commitments that

we are currently to get from industry are generally satisfactory in

providing a lot of information to us. We reported, in January 2007,

the results of post-marketing studies and in that case, only 3 percent of open post-marketing commitments had been delayed, so in

that sense we think our track record is relatively successful in that

regard.

Mr. PALLONE. Well, let me get to the post-market safety with regard to medical devices. There is some concern about the lack of

attention paid to post-market activities for medical devices. We

heard that at the hearing. Specifically, FDA has testified before the

subcommittee before that the agency does not feel that a specific

35

earmark of user fees is necessary because the agency already has

the discretion to use the fees that are collected on whatever functions it deems appropriate, whether that be pre-market or postmarket. But can you tell me, what kinds of post-market activities

are currently being conducted as they relate to medical devices and

to what extent those activities are funded by user fees? And how

about if you would comment on the idea of annual appropriations,

too.

Mr. LUTTER. First, with respect to the amount of user fee money

spent on post-marketing safety for devices, I am not aware of that.

We can get back to you on that. Overall, the program of medical

devices, user fees provides approximately 17 or 18 percent of the

medical device program. Our broad point with respect to an earmark is that we believe that the agency management and leadership would benefit from discretion about how to use funds in a

most effective way to promote and protect public health pursuant

to its mission.

Mr. PALLONE. What about the annual appropriations?

Mr. LUTTER. The specific question there, sir?

Mr. PALLONE. About annual appropriations. We have a provision

in the draft to provide for annual appropriations for this purpose.

Do you have any comment on that?

Mr. LUTTER. We could always do more with respect to additional

appropriations.

Mr. PALLONE. OK. And then lastly, can you tell me, under the

authority granted to FDA under section 522 of the Federal Food,

Drug and Cosmetic Act, how often does the agency require a manufacturer to conduct post-market studies?

Mr. LUTTER. For drugs or devices, sir?

Mr. PALLONE. For devices. I am only talking about devices now.

Mr. LUTTER. I don’t know that. I will have to get back.

Mr. PALLONE. All right, if you could get back to me, I would appreciate it. Thank you. Mr. Deal.

Mr. DEAL. Thank you for being here. Let me ask you about the

third party inspection provisions in the draft. First of all, would

you explain to us how these third party inspection programs, the

changes that are proposed would lead to greater utilization of these

inspections?

Mr. LUTTER. The third party inspection program that is in

MDUFMA now has not been very extensively used by industry and

the key idea in coming up with proposals to improve its use is that

it could be used particularly for surveillance, which is essentially

routine surveillance. The idea is to what extent should FDA delegate entirely to third parties responsibility for a third party review.

With respect to this, the modifications in the third party inspection

program for medical devices, those would be intended to promote

third party inspections and routine surveillance where we think

that is an appropriate use of third party inspection and also, is one

that allows our resources to be better allocated for areas of key risk

and concern to us.

Mr. DEAL. And my understanding is the proposed changes don’t

do anything to get rid of safety requirements or conflict of interest

provisions.

Mr. LUTTER. That is correct.

36

Mr. DEAL. And you, as the FDA, could have an inspection on

your own at any time you chose?

Mr. LUTTER. We could surely have an inspection on our own in

addition to any third party inspection.

Mr. DEAL. Obviously, one of the areas of concern in the proposed

preemption provisions that are included in most of these drafts. It

is my understanding that there has been a Federal preemption

from medical devices since 1976. Is that correct and if so, can you

tell us what the purpose of that was?

Mr. LUTTER. My understanding is that there has been exclusive

Federal preemption on medical devices for some years. The key

purpose of that is, I believe, to ensure consistency in risk communications with respect to devices. One concern that we have with

preemption broadly, is that when we make determinations of safety

and the effectiveness of products, medical products that we regulate, we would like to be sure that these are communicated in a

manner that is clear and understandable to stakeholders, not only

patients but also the medical community and the industry, as a

whole.

A key concern is that if there are other views, other authoritative

views or other dissent of the regulatory requirements, there may

instead be a multiplicity of statements about risk, and multiplicity

of statements about efficacy which serve, indirectly, to undermine

our effectiveness in communicating to the American public about

the risks and benefits of medical products that we regulate.

Mr. DEAL. Let me ask you about pediatric drugs. Is the 180 days

that is provided from the date of enactment a realistic timeframe

for a final rule to be issued on how the tiering of exclusivity would

be decided?

Mr. LUTTER. We have a variety of concerns associated with the

180-day deadline and also with that rule, in particular. Issuing

that rule within 180 days would be very difficult for us, but the key

concern is really the effect of that rule and consideration by FDA,

subsequently, of sales relative to the cost of the study on incentives

for the industry to develop trials to provide information to patients

and healthcare professionals about the benefits and risks to children. We believe that the value of information about the health of

kids is so high that it is inappropriate to reduce incentives for

these trials and that is why we are concerned about the effect of

this rulemaking and its implications for incentives for pediatric

trials.

Mr. DEAL. I would like to ask you about the advisory panels and

the provisions in the advisory panels that are proposed. First of all,

is it difficult to obtain qualified people to serve on advisory panels

and as I understand this, the current draft would allow only one

waiver per advisory panel for potential conflicts, and what effect

would this change have on obtaining the necessary advisory panels

and would this have the potential of delaying the effective drugs

being put on the market?

Mr. LUTTER. Thank you. We are very concerned about ensuring

that the advisory committees that FDA manages operate in a manner that is transparent and clear and enjoys the full trust of the

American public. We have taken a variety of steps to strengthen

the management of our advisory committees, including in April

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2007 we issued a new guidance for public comment that would not

only ensure greater transparency and consistency, our use of waivers of conflicts of interest, but also establish new, more stringent

criteria for granting waivers of conflicts of interest than are currently required by regulations of the Office of Government Ethics

or by existing statute.

That guidance that we issued is now being examined internally.

We have received 77 comments from the public about that and we

are taking steps to implement it. Broadly, with respect to your

question, the concern that we have is that there are so many recognized established scientific experts in the biomedical innovation

community who have had financial ties to some sort with affected

industry, that it is very difficult to find experts with the authority

and the broad recognition of expertise that we want on these committees.

Evidence to this effect is in waivers that I have signed. I sign

these waivers for the Food and Drug Administration. They are

posted on our Web site and in a collection of recent ones, you will

see this waiver is signed after we have looked for a collection of experts at the National Institute of Health and within FDA. We are

signing these after deliberate efforts to search for appropriate expertise from unconflicted individuals and then found that we were

unable to find the expertise that we needed.

Mr. DEAL. Thank you.

Mr. PALLONE. Thank you. Mrs. Capps.

Mrs. CAPPS. Thank you, Mr. Chairman. Dr. Lutter, Avandia was

a wildly successful drug when it came onto the market. Since being

introduced in 1999 it has blossomed into a $3.2 billion per year

drug. However, with this success, information of its shortcomings

has come to surface. Specifically, its association with increased risk

of heart attacks among people with diabetes, a population already

at higher risk for heart disease. I applaud the FDA for convening

an advisory committee hearing scheduled now for July 30 on

Avandia.

I have two questions to ask you about this, briefly, if you would

answer. One, how did your agency advertise for positions on this

advisory committee?

Mr. LUTTER. The advisory committee is comprised with requirements under the Federal Advisory Committees Act as a collection

of standing members who serve 4-year terms and are appointed for

a 4-year term in anticipation of whatever events may arise during

those 4 years. So in that sense, those standing members who will

serve on that panel have been appointed in the past. We have

greatly improved our process for recruiting members of all advisory

committees. In February of this year we posted on our Web site a

centralized listing of all vacancies so that an expert in

rheumatology or pediatric rheumatology or cardiology with interest

in serving on different committees or one committee at FDA doesn’t

need to track down which of our 47 panels might have a vacancy,

but instead can submit his or her resume or nomination to a single

source and thereby we can review that application in an integrated

manner.

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Mrs. CAPPS. Let me try it this way. Do you anticipate any members of this advisory committee having any conflicts of interest

with this particular hearing that you have scheduled?

Mr. LUTTER. At this point? It is too early to say. We have a process which involves extensive review of all the financial holdings of

all members of the advisory committees. That process takes approximately 45 to 60 days, even when it is done on a very accelerated basis.

Mrs. CAPPS. Is that ongoing now?

Mr. LUTTER. Yes, it is ongoing.

Mrs. CAPPS. Will you complete it by the time of the hearing?

Mr. LUTTER. Absolutely.

Mrs. CAPPS. So you will know how many people, but you can’t

say it now?

Mr. LUTTER. It is not completed.

Mrs. CAPPS. And they will serve whether or not they have a conflict of interest?

Mr. LUTTER. We will review their qualifications. We will review

their qualifications with respect to the statutory requirement,

which is if the need for their expertise outweigh the potential conflicts of interest, we will grant waivers accordingly and in a manner consistent with the statute and also the guidance that we have

currently in place.

Mrs. CAPPS. So you might not allow some of the advisory members to serve on this panel?

Mr. LUTTER. As a routine matter, we occasionally decide that different candidates who may be considered for panels are not appropriate because of conflicts of interest.

Mrs. CAPPS. And then they don’t serve?

Mr. LUTTER. They recuse themselves, we recuse them or we may

limit their participation based on the findings.

Mrs. CAPPS. And this is a matter of public record, those that

have been asked on different panels so that when your hearing is

scheduled the public will know which members have been asked

not to serve——

Mr. LUTTER. For reasons of privacy, we do not reveal the different reasons that they have not——

Mrs. CAPPS. But you do acknowledge which ones are not serving

who are regularly on the committee?

Mr. LUTTER. Well, the names of everybody on the committee is

a matter of public record and the participants in the meeting is

also a matter of public record.

Mrs. CAPPS. Thank you. I want to ask you another question,

though I am not particularly satisfied there. Maybe there will be

a way to communicate in writing with some additional questions

about this process.

Mr. PALLONE. The members may ask additional questions in

writing, certainly.

Mrs. CAPPS. Thank you. Let me get one more topic on this particular drug out and you may not have time to answer me now, but

I would like that answer in writing, too. A New York Times article

published yesterday the story of Dr. Johann-Liang. She joined the

FDA in 2000 and eventually rose to deputy division director in the

agency’s Office of Surveillance and Epidemiology. However, soon

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after she recommended a black box warning for Avandia over a

year ago, things changed. She became increasingly excluded from

important reviews and meetings and eventually, she left your agency. That is what the article in the New York Times reported. My

question is: after she made her conclusion regarding Avandia’s

heart risk, was she increasingly supervised by her FDA supervisors? Please answer yes or no.

Mr. LUTTER. I am sorry, I don’t have enough information to answer.

Mrs. CAPPS. Is there a way you can find out?

Mr. LUTTER. We can back to you on that.

Mrs. CAPPS. I would like that in writing, then, since you don’t

know today. I do think this case illustrates a larger problem at

FDA of employee morale and political interference in scientific decision making. I think it is hard for us, in this case, not to draw

some kind of connection between industry influence and an incident like this. I yield back my time.

Mr. PALLONE. Thank you. Mr. Ferguson.

Mr. FERGUSON. Thank you, Mr. Chairman. Thank you, Dr.

Lutter, for being here, as well. I just want to begin by echoing some

of the concerns that Mr. Deal and Mr. Rogers had raised before.

I know, from being on the other side in this committee and subcommittee, the best work that we do is work that is thorough and

frankly, takes into account lots of different viewpoints and the

work that we have done over the years in a bipartisan fashion, that

has always been the spirit of this committee and I think that has

largely been the case with regard to the legislation that we are considering today.

It has perhaps not been as much the case the last several days.

And I am hopeful that in the next several days and in weeks

ahead, as we work through this legislation, that we really will be

able to take more viewpoints into account. I have a particular concern, I have several concerns about the legislation that we are looking at.

One in particular is preemption language that Mr. Deal had

raised before. I think Mr. Rogers made a very eloquent, brief case

for an alternative point of view than is reflected in the draft, the

drafts that we are looking at and I think, my sense is that having

something dropped into a draft mysteriously at the last second, I

know from it happening some time when I was in the majority. It

never serves the civility and a solid end product very well on this

committee and I am hopeful that we can address that in the next

several days.

Dr. Lutter, as you know, the FDA is currently holding a public

meeting on medication guides today and tomorrow. Just a couple

of hours ago I actually testified at that hearing and at that public

meeting. I presented, just this morning, the findings of a year-long

investigation that we had been conducting in my office about the

distribution of medication guides and I want to register my thanks

to you and to the FDA and the agency for holding the public hearing and focusing on the issue. As I said, at the public meeting this

morning, and I repeated at the committee hearings here, the current regulation of medication guides represents a potentially

alarming situation in which young patients and their parents may

40

not be receiving the information they need to make fully informed

decisions about certain prescription medications.

It is clearly all of our shared goal to ensure that patients, including children, have the access to the safest and most effective therapies. But taking that into consideration, the FDA has rightly implemented strict requirements on the prescribing of some drugs, including antidepressants used by children and adolescents by

issuing black box warnings and requiring medication guides. Those

and other requirements are necessary to ensure that people to

whom certain medications are prescribed, including parents and

adolescents, parents of children and adolescents have the information they need to make fully formed decisions.

If these needed requirements are not being implemented, the

public can’t make fully informed decisions and therefore may be

placed at risk and that may well be that in many cases, the children and adolescents who are being prescribed these particular

drugs may be receiving the medication guides, but it can’t be said

with certainty at a hundred percent of the time these parents are

receiving this information. There has been a breakdown in the communication between the FDA and State boards of pharmacy. The

FDA issues the regulations on med guides. State boards of pharmacy are charged with enforcing the regulations on the distribution

of medication guides.

And I have been in correspondence back and forth with our New

Jersey State Board of Pharmacy and with the FDA and others. I

believe that one component to a solution to this problem that we

face is communication, consistent dialog between the FDA and the

National Association of Boards of Pharmacy. I think that can be a

very helpful part of this process.

Dr. Lutter, does the FDA currently have the ability and the authority to work with groups like these to keep them fully updated

on the ever-changing duties regarding the distribution of medication guides?

Mr. LUTTER. We work very closely with the National Association

of Boards of Pharmacy and with State boards of pharmacy in different States and I appreciate very much your interest in our public meeting on medication guides this morning. As you know, several members of the senior leaders of the team spoke there and I

was looking forward, myself, to the opportunity but decided I would

better spend my time preparing here.

With respect to the broad question, though, we are very concerned about ensuring that information about the risks of pharmaceutical products is conveyed as effectively as possible to patients,

to their families and to their healthcare providers. In that sense,

this public meeting that we are holding today is an open, transparent, visible and we are grateful for our participation. We are

thankful for the different participation of the various stakeholders

and we will work expeditiously to ensure that medication guides

provide as effective communication of risk as possible in the future.

Mr. FERGUSON. Thank you for that. I know the FDA has been engaged with pharmacist organizations and others about the distribution chain of medication guides. But it is my understanding, my

sense, really, that the FDA has dragged its feet a little bit on enabling pharmacists to provide and produce medication guides elecVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00046 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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tronically. Don’t you think it makes sense to give pharmacists the

ability to electronically print out med guides to alleviate the problems that may be currently in the med guide chain? I mean, one

concern we hear from pharmacists all the time is they simply don’t

have the shelf space to store boxes and boxes and boxes of paper

medication guides. We allow them to distribute other things electronically, just print them out at the pharmacy. Is it your sense

that it would also make sense to allow them to do this?

Mr. LUTTER. I think that is one potentially very intriguing option

that we will explore in the course of looking at all public comments

received in the course of the public meeting on medication guides

today.

Mr. FERGUSON. As you might guess, I am a strong supporter of

electronic distribution of med guides. I just think it doesn’t sacrifice

the quality of information, but enhances the quantity of information that is available, particularly to parents, as they are trying

to—and the great thing about medication guides, as you well know,

is it is in English. A non-doctor, non-pharmacist can actually read

it, understand it and therefore make a more informed better decision about the healthcare of their child. I would ask my colleagues

on the committee to consider changes, as we work through this legislation and reauthorization, that would encourage or mandate the

FDA to engage in these measures, to use some of these measures

to streamline or enhance the distribution of medication guides. I

think it would do a great deal to help the cause of public health

and in addition to some of the other concerns and issues that I

raise, Mr. Chairman, that would help to get to work through as we

mark up and move this legislation, I hope that this might be something that we could consider, as well, and I yield back.

Mr. PALLONE. Thank you. Ms. DeGette.

Ms. DEGETTE. Thank you, Mr. Chairman. Dr. Lutter, recently

Dr. Shuren, who is here, I see, testified before this subcommittee

and I had a whole series of questions for him about medical devices

in pediatric populations which we forwarded to the FDA but which

we have not received written responses back to yet, so I thought

I would ask you these questions. The first one is that the Institute

of Medicine conducted a study to determine whether the FDA’s system for post-market surveillance of medical devices provides adequate safeguards for their use in pediatric populations. The study

included a number of recommendations for the FDA and I will enumerate them quickly.

Number 1, collaboration with the National Institutes of Health

and the Agency for Healthcare Research and Quality to define a research agenda and priorities for the evaluation of short and longterm safety and effectiveness of medical device use with growing

and developing children.

Number 2, promotion of the development and use of standards

and approaches for capturing and linking use and outcomes data

for medical devices.

Number 3, collaboration with industry, healthcare professionals

and organizations and parent and patient advocates to improve adverse event reporting.

Number 4, oversight of the management of high profile medical

device safety issues similar to the independent drug safety overVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00047 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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sight board within the FDA and finally, establishment of a central

point of responsibility where pediatric issues within the Center for

Devices and Radiological Health to evaluate the adequacy of the

center’s use of pediatric expertise and its attention to pediatric

issues in all aspects of its work. That is a long list, but I want to

have it in the record because I want to ask you whether the FDA

has adopted any of those recommendations.

Mr. LUTTER. We are in the process of reviewing both your letter

and the recommendations and I am not prepared to give you a

more explicit answer on that. I don’t know.

Ms. DEGETTE. So you don’t know whether they have adopted

those recommendations?

Mr. LUTTER. I understand you sent this letter and we owe you

a reply and I look forward——

Ms. DEGETTE. Well, but the recommendations were made before

I sent the letter and now you guys have had over a month to review the letter and the previously made recommendations, so have

you all implemented any of them?

Mr. LUTTER. I am not informed about the status of this. We will

have to get back to——

Ms. DEGETTE. Did you know about my letter before today’s hearing?

Mr. LUTTER. No, I didn’t.

Ms. DEGETTE. When did you find out about it?

Mr. LUTTER. This letter and the specific contents I am learning

about now.

Ms. DEGETTE. You didn’t know about my letter until I asked you

the question just now?

Mr. LUTTER. I didn’t know about the contents until you asked me

the questions.

Ms. DEGETTE. OK. Mr. Chairman, I would ask unanimous consent for a written response to my letter, which was made after the

last hearing within 2 weeks of today’s date.

Mr. PALLONE. Without objection, so ordered.

Ms. DEGETTE. Thank you.

Mr. PALLONE. I would hope that you would be able to do that.

Ms. DEGETTE. And especially since your staff is sitting right here

in this room who were at the hearing last week. Now, there were

also a number of recommendations in this report; you probably

don’t know about these, either, but I will put them on the record.

They cited recommendations for Congress, including, No. 1, requiring the FDA to establish a system for monitoring and publicly reporting the status of post-market study commitments involving

medical devices.

Number 2, permitting the FDA to order post-market studies as

a condition of clearance for the categories of devices for which section 522 post-market surveillance studies are now allowed, and No.

3, allowing the FDA to extend those studies for devices with expected high pediatric use beyond the current 3-year limit.

Do you think that Congress should follow these recommendations

and make those necessary statutory changes?

Mr. LUTTER. Could I ask you to repeat the question?

Ms. DEGETTE. You bet. The same report I just referred to cited

a number of recommendations for Congress requiring the FDA esVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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tablish a system for monitoring and publicly reporting the status

of post-market study commitments involving medical devices, permitting the FDA to order post-market studies as a condition for

clearance for the categories of devices for which section 522 postmarket surveillance studies are now allowed and No. 3, allowing

the FDA to extend those studies for devices with expected high pediatric use beyond the 3-year limit. Do you think those are good

ideas?

Mr. LUTTER. Now, with respect to the first one on the monitoring

and reporting of post-marketing studies, we think we already have

some ongoing programs in that regard, but ma’am, these are really

areas where I need to express my apologies and say that I am not

in a position to respond about the specific program and I will have

to get back to you on this.

Ms. DEGETTE. OK. This was a study that was conducted by the

Institute of Medicine. Oh, it came out in 2005, so I would appreciate it if you would have your staff review those recommendations

and also get back to me in writing.

In April, Dr. Theresa Mullin, who is also here in this room, testified before this committee. I asked her, given the public’s loss of

faith in the FDA’s ability to regulate the drug industry whether it

would be possible to hold the next round of PDUFA negotiations in

public and I also asked whether commercial, confidential or trade

secret material of individual companies was discussed at those

meetings. Dr. Mullin said to me there is no confidential, commercial, trade secret, anything of that type discussed in such meetings.

So I would just like to confirm, does the FDA have any concern

over opening up the PDUFA negotiation process to the public since

none of these confidential things are discussed in the meetings?

Mr. LUTTER. Let me offer a brief comment on background before

I offer the specific answer to your question. We think that the process would run with respect to developing our PDUFA recommendations has already complied with not only the statutory requirements for involving all stakeholders, but is exemplary in that it

had a public meeting a year ago last fall; it had another public

meeting more recently and it had a series of approximately a half

dozen meeting with public interest groups, stakeholders like patient representatives and consumer representatives, as well as the

healthcare provider community.

In that sense, there has already been, we believe, ample input

from non-industry participants in this process. If these participants, these stakeholders wanted to sit in on the meetings, this is

something that may raise challenges from the viewpoint of efficient

use of time and the detailed nature of these discussions, but it is

not something that we have any particular objections to.

Ms. DEGETTE. OK. There are a number of provisions included in

these bills that address direct-to-consumer advertising from drug

companies. In the PDUFA legislation we are talking about, drug

companies may pay a user fee to submit to direct-to-consumer television advertisements for advisory review. So given that it is a voluntary program, I am wondering how beneficial it will be and

quickly, could you answer for me what percentage of direct-to-consumer television advertisements are reviewed by the FDA?

44

Mr. LUTTER. I don’t know that answer, but I do know that in developing that proposal, we paid a lot of attention to how much work

would be involved and the specific answer was that we expected

approximately 150 television ads to come in for review and this

suggests that it is a large number that would offer significant benefits to the American public in terms of ensuring that a large set

of TV advertisements meet appropriate standards are truthful and

not misleading.

Ms. DEGETTE. Again, Mr. Chairman, I guess in the same answer

that I am going to get in 2 weeks, if you could provide the information I have asked for, what percentage of these television advertisements are reviewed. I would appreciate it. Thank you.

Mr. PALLONE. Thank you. You heard our requests. If we can get

this back in writing within 2 weeks, we would appreciate it.

Mr. LUTTER. We understand, thank you.

Mr. PALLONE. Thank you. Mrs. Wilson.

Mrs. WILSON. Thank you, Mr. Chairman, and thank you very

much for being here. I think there is a generalized agreement that

we need to do more with respect to post-market surveillance of

drugs and side effects and so forth. Can you explain how that

might be achieved and what your views are on how we can modernize our drug safety system with respect to post-market surveillance. The draft of the legislation, I think, is fairly general, but

what do we need to do to strengthen post-market surveillance and

how might you implement that?

Mr. LUTTER. The draft and language in Senate proposals emphasized, at one point, or mentioned at one point, something that we

think would be fair to emphasize and that is a public/private partnership on surveillance. And the idea is that FDA and perhaps the

Reagan-Udall Institute, which was outlined in some detail in the

Senate provision, could work with a very broad collection of private

parties to ensure that appropriate expertise is brought to bear

about statistical data mining, signal detection, signal characterization and through the interlinking of different databases using electronic medical records and other new information technology systems.

This is not something that may be done successfully overnight,

but it is a vision of what would be the future of drug safety. It is

something that we announced in a public meeting earlier this year,

called the Sentinel Network. I think we held that in February and

we are working with a variety of stakeholders inside and outside

the Government to try and cooperate in the interlinking of electronic databases. We believe that further language in the discussion draft characterizing this public/private partnership, linking it,

in particular, to the Reagan-Udall Foundation might be beneficial.

Mrs. WILSON. How would it really work? And I am quite familiar

with linking databases and doing statistical analysis and so forth,

but as a regulator, how would this work and change either the information that is available to consumers or families, or change your

regulatory approach to now how are you going to decide that a

drug should be taken off the market or a special warning needs to

be put on a drug?

Mr. LUTTER. Such a partnership and the system of interlinked

databases would not change our regulatory standards, the standVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00050 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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ards for making regulatory decisions would be independent of that.

But what it would do is give us substantially new, more and better,

more timely information about risks and in particular, if these

databases existed and could be analyzed more quickly than we now

are able to do with the post-market surveillance system currently

in place, we would be better able to detect signals about adverse

events like heart attacks or heart failure and we would thereby

have an ability to inform families, patients and doctors earlier

about these risks through label changes, through black box warnings. It might be implemented earlier than would otherwise be the

case and that is the way in which it would matter to families.

Mrs. WILSON. Let me ask you something about device recalls.

When a medical device recall is issued, to whom is it issued and

can the FDA currently direct a company to notify patients about

a recall or do you need more specific legislative language in order

to direct them to do so?

Mr. LUTTER. Device recalls fall into several categories, depending

on their class and depending on the level of information about the

health risks and we do not, at this point, my understanding is that

we do not have information to notify individual patients. We are

working expeditiously on the development of a unique device identifier that may provide more information and a better way of communicating concerns to families.

Mrs. WILSON. But do you have the authority that you need to direct a company to inform patients currently or is greater authority

required?

Mr. LUTTER. Yes, we currently have authority to notify patients.

Mrs. WILSON. To notify patients or direct that companies notify

patients?

Mr. LUTTER. We have authority to do both.

Mrs. WILSON. OK. Thank you. That is all I have, Mr. Chairman.

Mr. PALLONE. Thank you. The gentlewoman from Oregon.

Ms. HOOLEY. Thank you, Mr. Chairman. Dr. Lutter, I have been

working with Mr. Engel and Mrs. Capps with pharmaceutical

groups to help address the concerns about pharmacy compounding.

I believe that traditional pharmacy compounding provides an extremely valuable service to consumers. It enables patients to get

the medicines they need that would otherwise have been unavailable. However, I have been concerned about a couple of recent

events that have happened in my State where two people in Portland and one in Washington State died because of a pharmacy

compounding mistake.

I believe we need to ensure patients know they are taking a compounded drug, but we must do so without unduly burdening pharmacists. Do you believe the FDA and the State Board of Pharmacy

have all the tools they need to ensure pharmacy compounding is

done safely? Or what do you need?

Mr. LUTTER. Currently we are concerned about the safety of patients and of compounded drugs. We have taken a variety of enforcement actions against pharmacy compounders who may be

making products that are unsafe through a very large industrial

level, organizations and manufacture of products and we have

taken enforcement action against those. As you know, there is

pending litigation on compounding and we look forward to the outVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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come of that. But with respect to our efforts currently to ensure

that safety of the American public and of patients from

compounding drugs, we are currently taking enforcement action

and since this is where we believe that compounders are violating

the law.

Ms. HOOLEY. You have small pharmacists that make a few compounds because that is what the patients need and then you have

large companies doing compounding. Do you distinguish between

the two? Do you need further authority to make a difference here?

Mr. LUTTER. The distinction is nuance. It depends on whether or

not the products are being made by the pharmacist in response to

a prescription written by an authorized healthcare provider for an

individual patient and in that instance, it is an area which falls

into traditional compounding and does not merit further new authorities on our part. We have authorities to take action against

compounders who are essentially producing unapproved drugs because they are working on an industrial type of operation, and in

instances where we find that there are products that are unsafe for

the American public being sold by such compounders, we do take

such action.

Mr. PALLONE. The gentlewoman is done. Mr. Burgess.

Mr. BURGESS. Yes. Doctor, let me just follow up on that briefly

about the compounding issue. How do those compounding issues

come to your attention if there is a small pharmacy that is

compounding a particular medication, how does that come to the

FDA’s attention? Why type of surveillance do you have over the

small pharmacy that is providing that service for patients?

Mr. LUTTER. Well, we have a very large collection of ways of getting information. It may be other pharmacists, it may be drug companies, it may be healthcare providers, it may be patients, it may

be the State Boards of Pharmacy, sort of a variety it may come

from and it would really depend on the individual circumstance.

Mr. BURGESS. But there is not a structured surveillance system

at the FDA that oversees that?

Mr. LUTTER. We have an adverse event reporting for all drugs

and I am not familiar with whether or not it has any information

organized in it about compounded products as opposed to non-compounded products.

Mr. BURGESS. OK, thank you. Under the negotiation process for

PDUFA IV, you said in your testimony you met with the various

stakeholders. Were you meeting with patient groups during that

time, as well?

Mr. LUTTER. Absolutely. The stakeholders included patient representatives, consumer representatives and representatives of medical organizations such as pharmacists.

Mr. BURGESS. Now, in the brief time that I have had, that my

staff has had the ability to have the bill, there are some technical

problems with the drafts. Has the other side, the majority, afforded

you the opportunity to provide technical comments on the drafts as

they have been submitted?

Mr. LUTTER. We met with staff last week. We received the bill

last Thursday. We look forward very much to further opportunities

to meet with staff over the next few days and weeks.

47

Mr. BURGESS. And are those discussions, are those generally

available to the staff on both sides of the dais?

Mr. LUTTER. Absolutely.

Mr. BURGESS. OK. I also want to ask a question about the New

York Times article yesterday. We have already heard that referenced at one point. Now, prior to PDUFA—I am a physician and

practiced in the 1980s. I do remember the slow pace of new drug

approvals and it was painful and I think it was a group of, actually, AIDS activists who said look, we are being denied significant

medication that could help us because of the length of time it takes

the FDA to approve medication, so the need for speed was certainly

underlined in the early 1990’s when a Democratic Congress passed

the first version of PDUFA. Now we are in discussions that perhaps we are approving things too quickly, that safety needs to balance the speed. How good a job are we doing at balancing safety

and speed under our present system?

Mr. LUTTER. A key point to recognize is that PDUFA gives FDA

more resources and in that sense, the dichotomy that has often

been described, that is between access and safety is false. It suggests that without additional resources and without the additional

staff and information technology support that PDUFA fees can provide, we are unable to do things better in the same amount of time.

In fact, we can. And the whole thesis behind the success of reauthorizations of PDUFA ever since 1992 is that with the additional

resources we are able to review, not approve, but to review product

applications faster, in a manner that preserves our ability to ensure that they meet exactly the same standards that existed prior

to PDUFA.

And in that sense, the strength of the statute has really been

through additional resources. We have an ability to make review

decisions which tend to be associated with approval decisions and

therefore access, but from our perspective, they are review decisions, be they approval or non-approval, faster. As a result, we are

able to lead to faster access of drugs to market in a way that promotes the access that was driving the AIDS activists about 20

years ago in a manner that benefits the American public and does

not sacrifice, in our judgment, drug safety at all.

Mr. BURGESS. And then, just in the brief time I have left, would

you address again for me, if you would, the issue of conflict of interests, the need for having the technical expertise to have the experts in the room. When you were answering the question earlier,

I guess I was left with a question in my mind, who sort of oversees

that process? Who oversees the overseer in that regard? How can

we know that you did have the right experts in the room, that they

weren’t excluded because of a perceived conflict of interest, or on

the other hand, how do we know that a conflict of interest was not

allowed to have access to the decision making process where it

really would have been inappropriate?

Mr. LUTTER. Well, with respect to who oversees the overseer

within FDA, I do. I sign the waivers of conflicts of interest and

under my jurisdiction is the Advisory Committee Oversight and

Management Staff. More broadly, the public and you. We post on

our Web site all of the waivers that we are permitted to under law.

We post, also, information disclosures signed by the advisory comVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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mittees, themselves. We reveal to the public, during the advisory

committee meetings, the conflicts of interest that may be present

by the advisory committee members or consultants that we bring

to the advisory committee meetings. All of this is available to the

public and in that sense, we operate under a regime of full disclosure to the extent that any conflicts are revealed that are material.

We disclose them to the public through the advisory committee

meetings, themselves, and on the Web site.

Mr. BURGESS. But if I could just interrupt and how do we ensure

that the balance doesn’t go too far the other way? Maybe I will submit that to you in writing because that is a concern of mine. Thank

you for your time.

Mr. PALLONE. Thank you. Ms. Eshoo.

Ms. ESHOO. Thank you for recognizing me, Mr. Chairman. Thank

you, Doctor, for your testimony. First, I just want to make a comment about this direct-to-consumer advertising. I don’t like any advertising of pharmaceutical companies. I just don’t find it to be appropriate and the idea that this is really in-depth information to

consumers, I think is a joke. I mean, it is on par with political advertising. I mean, how much do you know about a candidate in 30

seconds or less? So I just don’t like it and I think that the way it

is set up, that the program is almost designed to fail because companies don’t have to submit their DTC ads for review and they

don’t have to pay fees to support the program. I don’t know. At any

rate, every time I hear about advertising, it really pushes a button

with me. Here are my questions.

On third party inspections, when we authorized MDUFMA in

2002, we actually, with reluctance, established a third party inspection program. It was controversial and the legislation was not

easy to get done. In fact, I think most bets were that it would fail.

But I think that we have taken some very large important steps

forward and I am proud of it, I am pleased about it. Now, the purpose of the program was to allow the agency to have some resources, obviously, to utilize outside accredited inspectors to conduct the inspections and provide reports back to the FDA. Now, the

GAO report published earlier this year found that manufacturers

have been reluctant to participate in the program because of the

number of statutory obstacles. First, what has FDA done to increase the participation in the third party program and has the

agency done anything since its inception to increase the number of

inspections actually conducted by FDA? And do you agree with the

GAO findings?

I don’t have a lot of time. I have some other questions.

Mr. LUTTER. We will have to get back to you on that.

Ms. ESHOO. That is interesting. Good, I will look forward to hearing back from you. I have serious concerns about liberalizing the

third party program. The reliance on third party has always had,

as I said earlier in my opening statement, a real push and pull to

it. While I think it has worked, I think the public has raised legitimate questions about it and it can be likened to the fox being in

charge of the chicken coop, although I think that that diminishes

some of the things that happen, there is that kind of take on it.

Now, I understand that the industry is frustrated by the lack of

direct oversight conducted by the FDA and so the third party proVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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gram ends up being a good alternative for them. Do you think that

this is set up so that it lessens the FDA’s inspection authority

under the law? It relates back to what I was asking before and you

said you have to get back to me, but I want to probe in this area

to see how far we have come since the 2002 legislation became law.

Mr. LUTTER. We believe that with the recommendations for

change in our MDUFMA proposal, it would not lessen at all the

FDA’s authority. The key question is efficient use of resources that

we have and an ability to allocate them with respect to risks that

we believe are important. What we have is a proposal for a third

party——

Ms. ESHOO. But the participation, historically, has been low, so

I am asking you what you think has worked, that the proposed legislation really enhances, the best of what we made law in 2002.

There is something not working right because the participation is

low.

Mr. LUTTER. We agree that the program currently has not

worked. We agree with you.

Ms. ESHOO. Now, why? Why do you think so, FDA? GAO has

leaned in on it. Why do you think it hasn’t?

Mr. LUTTER. We think it is partly for the lack of the changes that

we are making with respect to the particular——

Ms. ESHOO. Did you ever come up and ask for additional authorities or changes in this?

Mr. LUTTER. Well, the changes are ones that we are now asking

for with respect to part of the MDUFMA proposal. The key concern

that we have is the use of resources internally. We have spent, I

think it is like $3 million over the years as part of MDUFMA, implementing the proposal. It is very little money for third party inspection and, that is, the use of our resources that aren’t well spent

relative to alternative ways of improving device safety.

Ms. ESHOO. Can I just get a real quick one in here regarding the

sunset of PREA and the exclusivity incentive under the BPCA?

Does the FDA prefer any of the provisions that are being cast

about, the blockbuster provision included in the Committee Print

or an extension of the 6-month exclusivity?

Mr. LUTTER. We would prefer the existing statute for its simplicity and for the high incentives that it gives for pediatric trials that

provide information that benefit the children.

Ms. ESHOO. Thank you. Thank you, Mr. Chairman.

Mr. PALLONE. Thank you. I didn’t know what your intention was

there with the other gentleman and if you wanted to have one of

them answer a question, that is fine. I didn’t know if that is what

you were trying to do there.

Mr. LUTTER. Thank you, sir. We will figure it out.

Mr. PALLONE. All right. Mr. Pitts.

Mr. PITTS. Thank you, Mr. Chairman. To follow up, just briefly

on Congresswoman Wilson’s question about, Dr. Lutter, has the

agency done anything to date related to establishing a unique device identifier system for medical devices?

Mr. LUTTER. We are currently involved in a rulemaking process

that would allow for the development of unique device identifiers

and we are pursuing that expeditiously.

50

Mr. PITTS. Now, some claim it is not as easy to establish a UDI

system for devices as it is for drugs. Can you please explain what

issues make UDI for devices more complicated along with the steps

that you are proposing to address those concerns?

Mr. LUTTER. I am not in a position at this time to talk about the

rulemaking that is ongoing. I think with respect to the difficulties,

the first question is that unlike with the drugs, there is a threshold

issue of scope. Is it all medical devices or is it only a subset and

what is the subset of special concern; is it implantable or does it

go more broadly than that. And second, there is also a question of

how the unique device identifiers should be linked to the device,

itself; is it on the labeling or should it be implanted in some way

on the device so that it can’t be separated, even after the device

is separated from its labeling. Those are questions that we will consider in the rulemaking.

Mr. PITTS. Regarding preemption, some proponents of the labeling or language, claimed that the language only has to do with provisions in the current bills before us. Would it not be counterproductive to public health for States to impose different REMS requirements than those imposed by the FDA?

Mr. LUTTER. Confusion about REMS requirements or confusion

about risks of FDA-regulated products is broadly of concern to us

because it undermines both the trust that we need to have with the

public to communicate the risk with them in a manner that lets

them take appropriate action to control and to mitigate those risks

and we think that preemption language would essentially have the

effect of formalizing, in Federal statute, a collection of State actions

that may be contradictory to or inconsistent with FDA actions on

the safety and effectiveness of FDA-regulated products.

Mr. PITTS. That is all I have. Thank you, Mr. Chairman.

Mr. PALLONE. The gentleman from Utah.

Mr. MATHESON. Mr. Chairman, I have a series of questions I am

going to submit in writing. I am not, after discussion with the

agency, I am pretty sure they are not ready to answer today, so I

will just submit them for written response. I yield back.

Mr. PALLONE. Thank you. Mr. Rogers. He is not there? Mr.

Buyer.

Mr. BUYER. Thank you. I would like to follow-up on Mr. Pitts’

questions. If all this legislation is intended to strengthen your ability to give assurances to the public about the products that are in

the marketplace, how is it that the provisions that are in the bill

regarding preemption actually allow you to do that? If we are going

to allow these State class action lawsuits to even make jurisprudence more complex, how does that help you do your job?

Mr. LUTTER. We are concerned with the preemption provision in

the discussion draft, because it may actually complicate our efforts

to communicate risks in a manner that people understand. And the

key question is, if we have additional resources through PDUFA

and an additional set of information about risk, do we also have a

system that we can convey to the public the risks of and the benefits of use in FDA-regulated products? We think that the preemption position may undermine our ability to do that effectively by allowing for multiplicity of views in State jurisdictions that may be

51

seen as contrary to or inconsistent with the FDA statements about

risks and effectiveness.

Mr. BUYER. Mr. Pitts asked you about unique device identifiers.

Let us talk about your present authority as opposed to what authority you may not have that you may need for us to put in a bill.

Right now you have authority to require tracking for class II and

class III devices, correct?

Mr. LUTTER. Yes.

Mr. BUYER. Now, in the bill, it appears that there is a broad expansion, which would require unique device identifiers on about

anything imaginable that we are going to put into the body. Now,

you said you don’t want to talk about your present rulemaking on

the development of a present system, but it would be shocking to

me that the FDA would like to create a system in a rulemaking

whereby you would have—well, let me take another step back. I

would think that you need to create a rule that would have tracking orders that would be issued based on risk, would it not?

Mr. LUTTER. Our focus, in general, in managing the agency is on

risk and we try to be——

Mr. BUYER. So earlier, when you talked about scope and subsets

of scope, you are talking about tracking devices that are going to

go into the body based on the risk and the impact that failure could

have, right?

Mr. LUTTER. That is correct.

Mr. BUYER. So when we want you to have that focus in that

scope, how does broadening the expansion to apply to about every

device imaginable going into the body help you do your job if tracking is not going to be based on assessment of the risk?

Mr. LUTTER. In general, our effort and our policy with respect to

protecting and promoting public health is to emphasize the risks of

greatest concern and in that sense we would be concerned about

excess breadth in the design of a program to focus unique identifiers. With respect to the particular language, this is something that

because we received this only last Thursday, we should probably

welcome that opportunity to talk separately with your staff about

the unique identifier language, because this is not an area that we

have studied in this legislation in detail.

Mr. BUYER. As you are developing your regulations for your own

type of tracking system, what is your timeline to complete such

system?

Mr. LUTTER. We are committed to doing it expeditiously, but we

do not have a timeline for completion of a final rulemaking.

Mr. BUYER. Would your counsel to us be for you to complete your

work and for us to then provide the oversight with regard to your

system? And then, if we have questions or have our own ideas or

want to broaden its scope, it would be more prudent to modify

FDA’s system rather than Congress just mandating a broad expansion with no regard to the system you are presently developing?

Mr. LUTTER. Well, the present program is one that we are developing without any concern about limitations of authorities in regard. So in that sense it is one that we think is worth pursuing

with existing authorities, yes.

Mr. BUYER. Yes. In other hearings FDA had witnesses come before us, and not only myself but some other members of the comVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
52

mittee have been concerned about counterfeit drugs and their prevalence in the marketplace. So we have seen this growth of adverse

events reports over the last 3 years, and I have been trying to figure out what has been the impact of the growing prevalence of

counterfeit drugs on the marketplace on this increase in adverse

reports. What I am learning is that it is very difficult to determine

this impact, and that, really, the system itself is not set in such a

manner whereby we can have such retrospective analysis of that

data. So I have a couple of recommendations that you can do on

your own that we don’t have to put into law, so I want you to

please take these back to the FDA, and I think we can be helpful

to each other.

What I am learning also, from the current MedWatch adverse

events reporting, on the reporting form itself—is anybody going to

write this down? Alright, because I don’t want to waste my breath

here, otherwise I will put it in the law. It includes a line that calls

for name, strength and then manufacturer, and that information is

all in that one line. My recommendation would be that the manufacturer be given a separate space on the form so whenever the

healthcare provider completes the MedWatch form, we get the correct name of the manufacturer, because what I am also—and I

know you are saying, Steve, that is up to the clinicians—but what

is happening out there is that the clinicians are putting the name

of the manufacturer, and sometimes it is a generic product and

they mistakingly put the name of the original manufacturer. So if

we give it a separate line, we are actually saying that we hope the

clinician stops and gives it some good thought and actually pulls

the manufacturer that is from the drug label itself.

Number 2 is you would also have a separate line that would have

the addition of the purchase location of the medication. Now, earlier at one of the other hearings I had said, are we going to have

to require doctors to start asking their patients where are they obtaining their drugs, because many of them are either running off

to Canada or they run off to an Internet or they go to an Internet

site and they are pulling them down from many different sources.

So we have docs out there that are struggling. We have internists and they give their script to their patient, but then we have

no idea where the patient then is obtaining the drug and they come

back and the doc thinks that the drug which they are prescribing

is supposed to get the effect but they are not. He is puzzled. He

then switches drugs. So I am trying to figure out how we get to

that next follow-on step as we are trying to deal with these counterfeit drugs. These are actions that you can take on your own and

I wish you would consider them.

Mr. LUTTER. Thank you very much for sharing them.

Mr. BUYER. Right.

Mr. LUTTER. I made careful note and we will discuss them internally.

Mr. BUYER. All right. Thank you very much. I yield back.

Mr. PALLONE. Thank you. Ms. Schakowsky.

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. Dr. Lutter, I wanted to go back to the subject that Congresswoman Capps raised and

that was the New York Times article yesterday. You did not see

it?

53

Mr. LUTTER. I had an opportunity to glance at it only.

Ms. SCHAKOWSKY. OK. Mr. Chairman, I would like to have it included in the record, if I could.

Mr. PALLONE. Without objection, so ordered.

Ms. SCHAKOWSKY. Well, let us talk about the substance of it

rather than maybe the specific issue. I will just quote. ‘‘The increasing number of FDA drug safety officers who say they have

been punished or ignored after uncovering dangerous popular medicines.’’ They talk about this one particular woman and the drug

Avandia, but they give a number of other examples. Dr. Andrew

Mossholder, in 2003, who discovered antidepressants led some children to become suicidal and the findings—Dr. Mossholder was prevented from speaking to an advisory committee about his analysis.

Then Dr. David Ross, in 2006, very concerned about serious illness

and death from patients taking the antibiotic Ketek. Is that Ketek?

And Dr. Ross met with agency officials and pleaded with them to

take action and nothing happened. It ends with a quote from someone still at the FDA, saying that people in this former office of Dr.

Johann-Liang were very demoralized. There is a feeling of fear.

Obviously, that is of concern, I think, to us as representing the

interests of consumers, if people who do report problems that they

have found are being suppressed or even feel the need to leave the

agency. This particular issue, this culture that seems to be at the

FDA, I think, shows the need for transparency, and there was the

inclusion in the Senate version of this bill an action package that

would provide the public with documents related to a drug’s approval, including a scientific explanation of the risk-to-benefit ratio

and a summary review of any disputes and how they were resolved

during the approval.

So what I am asking you is, in your experience, is there a culture

of, let us say, bullying and intimidation and do you agree that allowing FDA scientists to give voice to their concerns and decisions

is an integral piece of the scientific process?

Mr. LUTTER. In my experience, I am unaware of bullying at FDA

and I think it would be appalling to me personally and to the FDA

leadership, including the leadership of the Center for Drugs and

the Center for Biologics and the Center for Medical Devices. We

take these concerns expressed in the public very, very seriously.

Ms. SCHAKOWSKY. Well, are you saying, then, that the individuals that are cited in this article are misrepresenting the situation

at the agency?

Mr. LUTTER. I am unfamiliar with the specifics of their cases. I

do not know the facts about their cases.

Ms. SCHAKOWSKY. Well, what happens when something like this

comes to light?

Mr. LUTTER. Let me tell you the commitments that have been

made by the FDA leadership to address culture. The Institute of

Medicine last fall issued a report that we had asked for, which was

openly critical of the agency’s ability to address scientific dissent.

We responded in a report of our own, the future of drug safety that

we issued in late January 2007. At that press conference, Dr.

Gaulson and Dr. von Eschenbach made open personal commitments to welcome a diversity of scientific views as well as diversity

54

of individuals throughout the agency and to a personal responsibility for ensuring that dissent would not be punished.

Ms. SCHAKOWSKY. Well, let me just ask you this. There is a 2006

survey of FDA scientists done by the Union of Concerned Scientists, which found that 40 percent of scientists said they could

not publicly express ‘‘concerns about public health without fear of

retaliation.’’ Are you saying that Dr. von Eschenbach’s response is

something new that is being done in response to the criticism or

that that has always been the policy and that what you are saying

is there never was this culture of retaliation?

Mr. LUTTER. I don’t know whether there was a culture of retaliation. There is surely a culture of controversy and we acknowledge

that, and that has had adverse effects on morale and effectiveness

and we are concerned about that. But the key question is, A, we

recognize that, and then B, we have laid out, in our response to the

IOM report, a whole collection of actions, including personal commitments by the FDA leadership and the leadership of the relevant

centers for medical products to ensure that the diversity is not in

any way suppressed, is surely not punished, and does not result in

any bullying or suppression of scientific views.

Mr. PALLONE. We have to move on. Thank you. Mr. Sullivan.

Mr. SULLIVAN. Thank you, Mr. Chairman. And thank you for

being here. A lot of the questions I was going to ask have already

been asked and there were other members that were talking about

preemption, and you talked about that as well. One thing I would

like to talk about is wouldn’t you think that conflicting State labeling requirements for drugs, wouldn’t that be confusing to consumers and potentially adversely affect public health? For example, if

a grandmother was living in Nebraska and visiting her children in

Oklahoma and had to get her prescription filled there and had a

different notice on the labeling couldn’t that be detrimental?

Mr. LUTTER. Conflicting, inconsistent and even contradictory

statements about the benefits and the effectiveness and the risk of

medical products is surely of concern. How can people figure out

what they should be doing if there is not a single voice? The best

approach to ensuring safety of medical products is to ensure that

there is a single authoritative voice which, through a process of developing the best available scientific information, and evaluating

that in a timely and effective manner, can be conveyed to everybody as an authoritative statement, and we believe that is our job.

We believe that is our job as a regulatory agency. We have responsibility for regulating the safety and effectiveness of medical products, devices and drugs and biologics. We have been asked to do

that by Congress and the American public and we think that if

those messages that we convey to the pubic are seen as inconsistent with other authoritative sources, then confusing may result to

the detriment of public health.

Mr. SULLIVAN. So you would say that different State labeling

would be very confusing and bad to public health?

Mr. LUTTER. If it is seen as inconsistent and incompatible with

ours. If we say something and a different statement is made by a

State authority, then surely consumers may be confused.

Mr. SULLIVAN. Wouldn’t you agree that different labeling would

be detrimental to public health?

55

Mr. LUTTER. Yes.

Mr. SULLIVAN. Thank you.

Mr. PALLONE. Finished? Ms. Solis.

Ms. SOLIS. Thank you, Mr. Chairman. My question is for the director.

Has the FDA ever evaluated whether any of its mechanisms for

warning the public, for instance, changes in labeling, are effective

in terms of raising awareness for safety issues with products? And

are there any plans to evaluate how FDA communicates with the

pubic and how effective such measures are and if you have ever

looked at that? And then lastly, what kinds of evaluation tools do

you have for, say, consumers that don’t speak English, whose primary language is something other than English?

Mr. LUTTER. We take very seriously our responsibilities to communicate the information about risks and effectiveness. We recently instituted, in this regard, a new committee on risk communication. Its function is to advise FDA about how to communicate

the risks and the benefits of medical products and other FDA-regulated products as well. This committee was first initiated in response to the recommendations of the Institute of Medicine that I

alluded to earlier. We anticipate that it will be up and running to

have public meetings in the early part of next year. And we are

currently soliciting, publicly, nominations from interested experts

and people with responsibilities for communication to serve on that

advisory committee. One of its functions will be to look at the effectiveness of our efforts generally. This is, we think, an area that is

important and could be greatly strengthened by work of this committee.

Ms. SOLIS. And what about reaching out to groups that its primary language is not English? How do you communicate with

them?

Mr. LUTTER. We do have a plain English program at FDA. We

have a variety of outreach efforts that run through the Office of External Relations to representatives of minority groups and people

for whom English is not the primary language.

Ms. SOLIS. Has that been evaluated?

Mr. LUTTER. The effectiveness of that has not been separately

independently evaluated.

Ms. SOLIS. That probably should be looked at, because of course

there are degrees of education with different groups from different

backgrounds and I would even say English, in terms of just the

type of individuals that may have no more than an eighth grade

education and may not—labeling obviously has to be simplified in

some format; but to find also different groups, Asian as well as Hispanic, that may not be fluent in English to have appropriate culturally competently appropriate language that is made available to

them, because that could even be misconstrued and obviously lead

to abuses.

Mr. LUTTER. We would be very happy to take that suggestion

into advisement as a topic for the advisory committee when it has

its first meetings next year.

Mr. SOLIS. And I would hope, just as a follow-up, too, I know that

sometimes we often talk about the Internet and put posting information to the public. But by and large, the Hispanic community

56

and African-American community and in rural areas are not privy

to access to the Internet. So I would encourage more outreach either through form of radio, newspapers and things of that nature

that can actually be a lot more helpful in terms of providing better

consumer information, and obviously testing focus groups, I think,

could be helpful as well. And that is a comment.

Lastly, I wanted to ask you, what has the FDA done to decipitate

what I see as tensions between some of the staff that you have

doing oversight, monitoring, those that are evaluating and those

that are actually helping to approve some of the drugs and devices

that are coming forward? I understand that there has been occasion where morale has not been one of the highlights of the agency.

Mr. LUTTER. Before turning to that, thank you, let me first add

a comment that I should have made earlier about the evaluation

of risk communication. There is a reevaluation of risk management

tools, broadly, as part of our PDUFA IV reauthorization. We look

forward to using PDUFA IV resources to do that reevaluation.

With respect to the culture issue, we recognize this is important.

There is a variety of essentially management efforts in the individual centers to identify, if you will, best management practices and

communicating, communications between supervisors and staff and

surely to support diversity, not only of people according to their demographic backgrounds, but also of scientific views and scientific

thought. We have a very diverse agency with respect to the multiplicity of scientific backgrounds and expertise that is represented.

Many people bring different views and perspectives to the table because of their training. The determination of safety and efficacy for

drugs is something that requires many, many different types of experts, not just MDs.

Ms. SOLIS. What kind of concrete things will you be instituting,

because my understanding, if I could just reiterate, the tension is

between the pre-approval review staff and the post-marketing safety staff.

Mr. LUTTER. There are ongoing regular workshops and new

meetings internal to CDER, to ensure that communication and respect among those different staffs is enhanced as much as possible.

Mr. PALLONE. We have to move on.

Ms. SOLIS. Thank you, Mr. Chairman.

Mr. PALLONE. Thanks. Mrs. Blackburn.

Mrs. BLACKBURN. Thank you, Mr. Chairman. Thank you for your

patience. I want to be certain that I am understanding your remarks, since we didn’t have your testimony in advance and it

seems you have five major problems with the legislation. And just

to recap with you, one would be that it is too focused on process

and structural changes; No. 2 would be the breadth of proposed requirements for risk evaluation; No. 3 would be the existing FDC

Act labeling requirements dealing with the med guides, et cetera;

No. 4 would be the risk map provisions; and then fifth would be

the DSOB oversight and review for disputes. So it seems as if that

pretty much encapsulates the problems that you have with the legislation.

Then you go on, on page 14, and you talk about a better overall

strategy is to be sure you have appropriate resources. And Dr.

Lutter, I would just like to highlight with you, going back to some

57

of our other hearings that we have done, sometimes the public has

a real problem with giving more resources to an agency that seems

to have difficulty in fulfilling their mission or understanding their

mission, maybe, and there seems to be a frustration when there is

a lack of best practices in place with a certain agency and when

there seems to be a communications problem between different divisions not knowing what another division is doing, and then

maybe even one division telling another one don’t take action there,

we don’t want you to do that, when a person feels as if they are

doing their job.

So I would highlight with you that those are concerns. We still

are looking for that list of best practices. We still want to be certain that you all are putting the needed transparency in place

when you are dealing with adverse reactions. And going through

the process of quantifying these, you mention at the bottom of page

14 your analytical tools and approaches that you use with turning

that raw data into appropriate questions and practical information.

Some transparency through that process would be very helpful, I

think, not only for you all, but for us.

I have got a couple of specific questions before my time runs out.

The REMS process. In the discussion draft, the way the changes

are written there, would all safety labeling on drugs have to be approved by the FDA, if you were to take the action from the discussion draft?

Mr. LUTTER. Yes, that is our understanding.

Mrs. BLACKBURN. It would all have to be approved by the FDA.

OK. And then another place in the discussion draft they talk about

a non-promotional summary of the results, as they are talking

about the clinical trial registry and the results database. I don’t see

non-promotional summary defined anywhere. So do you all have a

definition of that? And then the flipside of that question would be,

is writing a factual summary then considered to be a promotional?

If something has favorable results and you are writing, would that

be considered to be a promotional summary? And if you need to

come to that one in writing to us later, that is fine, but insight on

that would be helpful.

Mr. LUTTER. If I could try and take it orally here, I will do what

I can do. One thing I have not had an opportunity to talk about

because part of the complexity of the legislation is the clinical trials

registry and particularly the requirement for this results database

that I think you are referring to. And a key question is what we

would mean by an appropriate summary of the results, and the difficulty with that is that the studies are essentially designed to answer specific questions. But later on, when they find that the results of the study designed to answer question A may be very, very

interesting or helpful with respect to other questions, and in that

sense this non-promotional summary is something that may be actually quite problematic to implement from an operational perspective. So we have——

Mrs. BLACKBURN. So the non-promotional would be problematic?

Mr. LUTTER. Yes, but we have concerns generally about this results database and the key question is what would constitute an

appropriate summary of results in this results database. We think

58

that may be a very difficult requirement actually to implement in

practice.

Mrs. BLACKBURN. And do you have any guidance going on forward on that as you look at the legislation to make it workable and

practicable?

Mr. LUTTER. Our understanding is that there is currently a pilot

project underway, in cooperation with NIH, to look at how one

might summarize this information in an effective way and we think

that might provide a way to identify, first in practice using this

pilot project, appropriate information before implementing on a

much broader scale.

Mrs. BLACKBURN. Well, with the pilot project at NIH, I would

just highlight with you, one of our concerns many times is the lack

of communication that seems to exist between the FDA and NIH,

and probably a bit more transparency there would be helpful as

you would look at how NIH would go about trying to figure this

out and make it workable. I have got two more questions. What I

will do is submit those and then yield back my time so that everyone gets their questions in before votes. Thank you.

Mr. PALLONE. Are you completed? OK. Thanks. Mr. Green.

Mr. GREEN. Thank you, Mr. Chairman. During the negotiations

on the medical device fee, Dr. Lutter, the FDA and the device industry agreed on changes to the Third-Party Inspection Program

that were not adopted in the discussion draft that is before today.

If the program were utilized to increase the rate of inspections, I

would like to see us enact improvements in the program. However,

concerns remain about the potential for conflict of interest increasing with increased reliance on these third-party inspections. If we

were to adopt the changes you negotiated, what safeguards are included in your proposal to address these conflicts of interest? And

would that proposal limit in any way the FDA’s ability to directly

inspect a facility? And the next to the final one was, how much

money would the FDA need to conduct its own inspections? Is it

a question of resources?

Mr. LUTTER. Let me try to answer them in reverse order. I don’t

know the answer to how much money it would take. It is a question of resources, but more than just in the sense that we could do

more with more. It is really a question of is it wise to be doing it

and using our resources in this way, when we think that there is

higher risk that could be better addressed with use of the same resources? In that sense it is really an efficiency concern rather than

the concern with the amount of resources overall. I am sorry.

Mr. GREEN. On the issue of if we use outside or third-party inspection programs, I am concerned about the third-party conflict of

interest. Obviously, we have the problem within the FDA, but

would we see it even worse with third-party inspections?

Mr. LUTTER. We believe that it would surely not be worse with

respect to third-party inspections. We would reserve the right to be

able to inspect any facility on our own and we would be verifying

that the skills, the appropriateness of the third-party inspectors,

before they go out to do their third-party inspections. So in essence,

you can see it in a way as double protection. We are certifying the

inspectors and then we reserve the right to do inspections on our

own.

59

Mr. GREEN. OK. Another question. The discussion draft—language that would require the GAO to study the 510(k) process for

the approval of medical devices. We know that a large majority of

devices are approved using the 510(k) process. However, one of our

witnesses on the second panel suggests that we prohibit the use of

the 510(k) process for implantable devices and mandate that each

implantable device go through the PMA process. Your understanding is that the 510(k) process is utilized primarily for class I and

class II devices. Can you quantify for us how many class III

implantable devices utilize the 510(k) process for approval?

Mr. LUTTER. I will have to get back to you on that. I don’t know.

Mr. GREEN. OK, I appreciate it. And that last question. I continue to be concerned about structural issues at FDA that weigh

the agency too heavily towards drug approval. While your statement suggests that the drug safety draft focuses unnecessarily on

structural changes, it doesn’t contain some of the structural

changes such as a separate, independent Office of Drug Safety that

some on our committee have advocated for. Under the REMS

framework, would you support language giving the Office of Drug

Safety the ability to request a REMS change such as an additional

post-market study to help level the bureaucratic playing field for

the Office of New Drugs?

Mr. LUTTER. Well, we think that a lot of the conversations within

CDER about risk, require also a consideration of benefits, because

the real question is, in addressing drug safety questions, is that the

safety issue is very difficult to evaluate on its own, independently,

without asking or evaluating how effective is this drug at providing

the benefits to the patients who need it. And in that sense, we

think that the best way to proceed is with improved communications that we are working on with the consideration by the relevant

parties within the Center for Drugs and that is what we are planning on doing.

Mr. GREEN. OK. Would you support language giving the Office

of Drug Safety the ability to request an REMS change such as an

additional post-market study? Could we give that authority to the

Office of Drug Safety?

Mr. LUTTER. We would prefer that that authority not be prescribed through statute. That is a particular change within a small

office within FDA. We think that the responsibility should reside

with the management of the Center for Drugs and with the Commissioner.

Mr. GREEN. OK. Thank you.

Mr. PALLONE. Thank you. Mr. Murphy.

Mr. MURPHY. Thank you, Mr. Chairman. Welcome here. A couple

questions regarding the issue of allowing exclusivity for a limited

number of months after some new treatments have been found. In

particular, I am concerned about pediatric drugs for orphan diseases. As you know, there is a separate act that controls some of

the aspects of dealing with orphan drugs, whereby the timeframe

may be—we provide Federal grants and contracts for clinical trials.

There is tax credits, up to 50 percent for clinical testing costs and

exclusive marketing rights for 7 years. This, of course, is important

because some of the orphan drugs have such a small number of

children or patients that they may influence. I am concerned that

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if we are too broad in our approach of saying that there is 3 or 4

or 5 or 6 months exclusivity, that is hardly enough time to recover

the cost of research for some of these things and we know that the

expenses, however, can be extremely high because there are so few

people that take these medications, in some cases, where the costs

of development, even if it is an adaptation of an adult to pediatric

drug.

What I would like to know is, should Congress act in legislation,

such as PDUFA or others, to make sure we protect the exclusivity

rights of orphan drugs in these cases, so that companies are more

willing to make some investments into research on those drugs?

Mr. LUTTER. Could I ask for clarification?

Mr. MURPHY. Yes.

Mr. LUTTER. The question is, so you are not asking about the exclusivity period for BPCA and with respect to pediatrics?

Mr. MURPHY. Yes. I want to make sure that we are not stepping

on the toes of the orphan drugs, so that we still are providing

enough incentives for companies to research treatments for some of

these diseases where there is a smaller number.

Mr. LUTTER. Our understanding is that, currently, the sponsors

can get exclusivity of 6 months under BPCA and they also have orphan exclusivity under 7 years, and that provides incentives that

are fairly robust with respect to the need to protect children.

Mr. MURPHY. I just want to make sure, in your review, as we

look at this legislation, if you could review it carefully in making

sure that we maintain those issues there.

It is very important. Let me go to a second area here and that

has to do with us looking at some of the adequacies of medication

to see if this is the right bill to do that. I am concerned about antibiotic-resistant strains for infections that are forming. And I am

concerned that there a number of strains have developed, which

one medication is no longer able to treat them. And if there are

some things that we should be doing with this, also, that as drugs

are reviewed in terms of their effectiveness, we are not only looking

at side effects in terms of harmful things that may come as side

effects of taking medication, but also reviewing side effects that

may come from overuse or inappropriate hospital or healthcare

practices that may also contribute to the spread of infections that

whereby we are creating drug-resistant strains. And I don’t expect

you to answer this now, but it is one that I consider pretty important, because so often we name a specific drug and we say it has

this association with heart problems or diabetes problems, et

cetera.

But there are also practices, I think, in the practice of medicine,

that contribute to problems, iatrogenic effects and nosocomial infections that occur, which in turn can make some medications useless.

So I am hoping that one of the things you could look at with us,

also, is provide suggestions of how when reports are made on medications, that we are looking to see if it is the practice that is also

leading to some problems with that as well, not just the medication

itself.

And a third point has to do with something that is more of using

medical devices. Now, with the medical devices, as you know, some

of these are being reused, sterilized and reused, and that may work

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in some cases, in other ones I have some concerns. For example,

do you think that patients have the right to know and to choose

when a medical device designed for single use has already been

used on another patient before it is used on them?

Mr. LUTTER. Our broad concern is that the labeling should be related to risks. And if the reuse or the manipulation of the product

to ensure reuse is one that is well enough managed that there is

no appreciable risks or concern to the patient, then the need for labeling is not clear.

Mr. MURPHY. Well, that is something, I guess, when one says appreciable risks, does that include giving at least that information

to the patient, that we have determined that there is no appreciable risk from reusing this equipment?

Mr. LUTTER. It is also a question that a patient could ask a doctor about whether or not the particular——

Mr. MURPHY. What if a patient doesn’t know to ask?

Mr. LUTTER. Well, then there is a variety of opportunities for

doctors to provide information to patients that may be of interest

to the patients.

Mr. MURPHY. Well, this is another one those areas, Mr. Chairman, where I hope we can get some more clarification to make sure

that in these cases where there may be some increased risk for infection control, to find ways we can adequately address that and

I appreciate that. Thank you, Mr. Chairman, and thank you.

Mr. PALLONE. Thank you. Mrs. Myrick.

Mrs. MYRICK. Thank you. Thank you for being here. I had a

question relative to the medical devices and the approval procedures. The 510(k) process, I understand, basically has been in use

for a long, long time and that 98 percent of the devices are approved under that procedure. But basically, if a device is just an

improvement over something that maybe failed or whatnot, it is

OKed or allowed to be on the market? My question is because I had

myself a jaw joint replacement, which is not real common, and

there was very little information available about what was available to me to use, because it is not an area where there has been

a lot of research, et cetera. And I am trying to find out on everything, you all had on your Web site and every place else I could

go to see just what was being done.

My question is: where do you get your feedback for knowing

whether something is really working or not? And does this come

from doctors, because this particular surgery is fairly rare and a

very small percentage of doctors who do it correctly, so there is not

a lot of background testing. It hasn’t been done for that long. And

I am just curious as to how this process really works, because what

do you know ahead of time and how, in this particular case, I guess

I am referring to, how much background information is available

before you approve something. And then what kind of feedback do

you get as you are going through the process?

Mr. LUTTER. Well, with respect to 510(k), the key issue is one of

equivalence. Is it really similar to something that is already on the

market?

Mrs. MYRICK. Right.

Mr. LUTTER. And I think, with respect to the information that we

receive, it is useful to draw a distinction between the risk of use

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of the product and other measures of effectiveness or just outcomes

very broadly. And in particular, one can imagine it with an

implantable device. What matters is also the quality of the surgery

as well as simply the device and then there may be measures of

the effectiveness of the device that vary over time, if it is

implantable, that are also harder to measure. We do track the adverse events. We get information from the manufacturers on that.

They are obliged to give us information about——

Mrs. MYRICK. So they are required to do that?

Mr. LUTTER. Yes, to pass on to us information that they have

from any source, about the adverse events associated with products

that they produce. So in that sense, yes, we do have that information. But I think that, from a patient perspective, it is probably

useful to know that there is a collection of information about just

the—think of it as the effectiveness or the success, if you will, of

the surgery. That is not necessarily in FDA jurisdiction, because it

is not really the product that we are regulating. It is the service

that is associated with that product.

Mrs. MYRICK. Yes. And there are a lot of surgeons who are not

being effective in the way they do it, I know that. You feel that the

process, the way you are doing it currently, is an acceptable, effective process?

Mr. LUTTER. We collect information and we collect information

from the manufacturers, who are obliged to pass on all of the information that they have to us about the adverse events. And in that

sense, we have information about the adverse events associated

with the product that we regulate. That part of it is satisfactory.

I think a real question is where one would wish to go in the future

if one were designing a better program and we have a couple of

ideas in that regard that I talk about here.

Mrs. MYRICK. That was going to be my next question.

Mr. LUTTER. One is with respect to unique device identifiers,

where we might be able to better notify patients in the event that

there is some evidence of unexpected adverse events or harm or recall or something like that, more broadly outside the area of devices, but also with respect to drugs. I talked earlier today about

a public/private partnership with vigilance. That is something that

is mentioned, at least, in the Senate draft and in the discussion

draft here. We think that tying that with respect to the ReaganUdall Foundation would be an effective way to manage it. That sort

of partnership offers several great strengths. One is probably a perception of neutrality and respect. It would be FDA along with many

other partners. And it, in principle, would allow for a very timely

expedited access to this sort of information through interlinked

databases that would permit and facilitate faster identification of

safety signals that would let us develop the subsequent studies in

a timely way, as to better inform patients and their doctors.

Mrs. MYRICK. But if all of that is implemented, et cetera, what

kind of timeline are you looking at for implementing the process?

Mr. LUTTER. Well, it is difficult to say. This sort of thing has not

been done previously, so it is really difficult to say we could do it

within X months. But in terms of a vision of what the future might

look like in a world where only 5 years ago, people weren’t walking

around with BlackBerries and cell phones as they are today. So

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what would one envision the world of the future to look like, and

that is the vision that we have.

Mrs. MYRICK. Thank you. My time is up.

Mr. PALLONE. Thank you. Mr. Hall.

Mr. HALL. Mr. Chairman, thank you. We have been in and out

here. Each of us have two or three committee hearings going on

right now and if I ask a question that has already been asked and

you have fear that you won’t answer it the same way you did earlier, why I won’t press it. But Mrs. Blackburn asked you and set

out to you, I think, five of your concerns here. I didn’t hear any

concern about any constitutionality of that, Dr. Lutter, that you are

dealing with. The draft bill contains a provision that would require

the pre-clearance of DTC ads and places a moratorium on these ads

for new products. Does that give you any constitutional concern?

Mr. LUTTER. Thank you for asking the question. It is not something I have had a chance to talk about earlier today. FDA has a

repository of expertise in drugs, devices and food and their safety

and efficacy and not in constitutional law. We are told, however,

that this raises concerns from a constitutional perspective and we

caution about progress in implementing a provision that may, because of constitutionality questions, be difficult to implement and

enforce in an effective and timely way.

Mr. HALL. Well, the reason I asked this is for a different reason

than that and I didn’t make a very good grade on constitutional

law when I was at SMU. And I want to know the nature of these

provisions that seem like they could expose the agency to some

lawsuits, and I think that you all would have had some discussion

on that.

Mr. LUTTER. We are concerned about litigation risk, generally,

litigation ties up agency resources in a really dramatic way and it

provides uncertainty about how we can implement our programs.

And a real question, ensuring that the programs are implemented

in an effective and timely way, would involve consideration of litigation risks and yes, we have had these conversations. But the advice on constitutional law is probably one that would best be given

by parties other than FDA.

Mr. HALL. Are you an attorney?

Mr. LUTTER. No, I am not, sir.

Mr. HALL. The ladies behind you that are advising you, have

they been into this?

Mr. LUTTER. Some of them have talked about this, but I think

what you will hear is that there are experts in constitutional law

that are best equipped to address this from outside of FDA.

Mr. HALL. Given the Western States case, do you think that preclearance might withstand judicial scrutiny? Do you have an opinion on that? Come on, give me an answer.

Mr. LUTTER. I am not equipped to answer that. I don’t have——

Mr. HALL. Well, if I answer it for you, then if so, would this requirement take away resources from other drug safety activities?

It would, wouldn’t it?

Mr. LUTTER. Tying FDA up in litigation will take resources away

from our other activities.

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Mr. HALL. Let me shift my gear here just a little bit. Would a

mandatory REMS system improve drug safety, or could a mandatory REMS, for every drug, actually divert FDA resources?

Mr. LUTTER. Well, the mandatory REMS for all, if applied to all

drugs, is going to divert it, because we think there is a class of

drugs where that sort of attention is not needed. The best procedure that we have as an analog to the REMS is the RiskMAPs,

which currently applies to a fraction of the products that we approve.

Mr. HALL. It makes sense. Under one of the drafts, to shift

again—well, not really a total shift, but on one of the drafts, a company could face a fine of up to 10 percent of U.S. sales for violating

a REMS. One component of a REMS is for the manufacturers to

ensure that a physician or a pharmacy is not violating the REMS

and if they are to restrict access to the product to that entity. So

my question then would be, does a manufacturer have direct control of the products it moves to the pharmacies? Does the manufacturer have a direct control of the products it moves to the pharmacies? Or do manufacturers most often sell to wholesalers?

Mr. LUTTER. They most often sell wholesale, so any control is at

best indirect.

Mr. HALL. Then, I guess my follow-up question and my final

question, is it fair for a company to be subject to such a fine for

which they have no direct control?

Mr. LUTTER. Well, only to the extent that they have control,

would it be fair?

Mr. HALL. If they had no direct control.

Mr. LUTTER. I guess, if they have no direct control, there is a real

question about the appropriateness of the fine.

Mr. HALL. Well, that is a pretty good answer and I thank you

and I yield back my time.

Mr. PALLONE. Thank you. I think you have stayed here long

enough to clear the podium and we appreciate it. Or clear the dais,

I should say. But I appreciate your bearing with us. It has been

pretty difficult, I think, to answer all of these questions and you

have done so, for the most part. So thank you for being with us.

I know a lot of Members asked you questions for which you said

you would get back to us in writing, so please do so as quickly as

you can and we appreciate you being here today.

Mr. LUTTER. Thank you for the questions and diversity of views

and we look forward to working with you on implementing and

passing this legislation in a timely way.

Mr. PALLONE. And we hope to do so in an expeditious way and

I know that makes it difficult sometimes, but I agree that we have

no choice, given the time constraints. Thanks again.

Can I ask the second panel to come forward? I guess I should

mention, while you are getting seated, that we do expect some

votes that might interrupt the second panel or the questions, but

right now the House is in recess, so we are going to proceed until

there is a vote. So we may just get right through it. I don’t know.

OK, if everyone is seated, I want to welcome our second panel

and let me mention who is here. I will go from my left to right.

First, on our left is Dr. Caroline Loew, who is the senior vice

president for science and regulatory affairs for PhRMA. And then

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we have Mr. James Guest, who is president and CEO of the Consumers Union. Then we have Mr. Steven Ubl, president and CEO

of Advanced Medical Technology Association. And then we have Dr.

Diana Zuckerman, who is president of the National Research Center for Women and Families. And then we have Mr. Steve Walker,

who is co-founder and chief advisor for Abigail Alliance for Better

Access to Developmental Drugs. And last is Dr. Richard L.

Gorman, who is chair of the AAP Section on Clinical Pharmacology

and Therapeutics for the American Academy of Pediatrics.

Let me again say that you may get some questions from the subcommittee members that you would have to answer and follow up

in writing. With the discretion of the chair, we will certainly do

that. And we will start for 5 minutes with Dr. Loew.

STATEMENT OF CAROLINE LOEW, SENIOR VICE PRESIDENT,

SCIENCE AND REGULATORY AFFAIRS, PhRMA

Ms. LOEW. Mr. Chairman, Ranking Member Deal and members

of the subcommittee, I want to than you for inviting me back to testify today about our shared commitment to strengthen the safety

of America’s drug supply. My name is Dr. Caroline Loew and I am

the senior vice president for scientific and regulatory affairs for the

Pharmaceutical Research and Manufacturers of America, or

PhRMA.

I return today to this subcommittee to reiterate the commitment

on the part of PhRMA, and its member companies, to work with

the FDA and other stakeholders to improve our drug safety system

in a way that preserves innovation and patient access. No other

issue carries more importance to our industry than patient safety.

PhRMA believes that the FDA’s proposal to reauthorize the Prescription Drug User Fee Act, or PDUFA, will provide the agency

with the tools and resources necessary to make a good system even

better, ensuring that FDA’s drug review and monitoring systems

keep pace with 21st century science.

Since 1992, PDUFA has been a crucial program for FDA and the

pharmaceutical industry, but most importantly for patients. The increased funding provided through user fees has enabled the agency

to review new drug applications in a thorough and timely manner,

without compromising its exacting standards for evaluating safety

and efficacy.

The reauthorization proposal under consideration that has been

forwarded by the FDA includes new resources that would enhance

and modernize FDA’s Drug Safety Program, specifically providing

nearly $150 million over the next 5 years, including 82 additional

staff for post-market safety activities. These additional resources

would also allow the agency to increase its use of modernized techniques and tools for the assessment of drug risks. PhRMA also supports the inclusion of funding to advance FDA’s Critical Path Initiative, as well as legislation establishing the Reagan-Udall Institute to conduct related research.

Just as drug safety fundamentally involves a balance between

benefit and risk, so should the process of reforming an already successful and effective system.

The proposed Risk Evaluation and Mitigation Strategy, or REMS

process, creates a complicated and bureaucratic safety oversight

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system that may not be workable in practice, and which if applied

to all drugs would be overly burdensome for the FDA. At the very

least, use of REMS should be limited to and focused on higher risk

products that warrant more rigorous post-marketing monitoring.

The anti-preemption language in the REMS and other discussion

drafts is also a significant concern. This provision would undermine

the intent of the REMS bill to reinforce FDA’s control over drug

warnings, because it would enable each State to require warnings

the FDA specifically rejected based on its scientific review. Such

conflicting warnings could cause considerable confusion for patients

and their physicians.

Further, the civil money penalties for REMS violations that will

be allowed under the discussion draft are unreasonable. Punitive

fines as high as 10 percent of U.S. sales are excessive and may be

a particular issue for small to midsized companies.

Limitations on direct-to-consumer, or DTC, advertising imposed

under the discussion draft would not be in the best interest of patients. Restrictions on advertisements would deny patient access to

important information, which repeated studies have shown to be

valuable in educating patients and fostering patient/physician dialogue.

Additionally, FDA’s PDUFA proposal already provides the agency

with enhanced resources to pre-review DTC advertising through a

new dedicated user fee, further helping to ensure that benefits and

risks are clearly and accurately communicated in DTC advertisements.

Instead of the broad reforms proposed, PhRMA would favor targeted drug safety enhancements to address key issues. For example, we support the creation of a robust post-marketing labeling

program that would give FDA greater authority to require a labeling change and to complete the process in an expedited manner

when warranted.

The current Pediatric Exclusivity Incentive Program has been a

tremendous success and PhRMA supports continuing it as currently authorized.

According to the FDA, the Best Pharmaceuticals for Children

Act, or BPCA, has done more to spur research and generate information about the use of medicines in pediatric patients than any

other Government program. Changes in the current program, particularly the proposed exclusivity adjustment, or tiering of exclusivity, could reduce the incentive to conduct pediatric studies.

Ultimately, it is important to recognize that FDA’s current drug

safety system is robust and effective; however, there is always

room for improvement. FDA needs more resources to enhance and

modernize its already strong drug safety monitoring system, and

the PDUFA IV proposal submitted by the FDA achieves this. As

such, we urge Congress to quickly reauthorize it.

Thank you for this opportunity to inform the subcommittee about

PhRMA’s perspectives in this critical public health arena. Thank

you.

[The prepared statement of Ms. Loew follows:]

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Mr. PALLONE. Thank you. Mr. Guest.

STATEMENT OF JAMES GUEST, PRESIDENT AND CEO,

CONSUMERS UNION

Mr. GUEST. Mr. Chairman and members of the committee, thank

you for the opportunity to testify on what is crucial legislation to

improve the safety of our Nation’s prescription drugs. Consumers

Union is the independent, nonprofit publisher of Consumer Reports, with 8 million online and print subscribers and we have been

working for a long time to strengthen our drug safety system at the

State and national level on behalf of the consumer interest.

Drug safety is not a dry and abstract issue. It is a matter of life

and death. In the room today behind me are families and individuals who suffered from what we believe are adverse drug events

that could have been avoided, Mr. Chairman, with stronger laws.

It is critical that Congress close the gap between the time when

drug makers first learn of drug safety problems and when consumers learn this information. These individuals behind me face a lifetime of heartbreak and grief because Congress has not closed that

gap and done enough to promote drug safety.

One of those persons behind me is Patricia Slingo, who is described in an ad that Consumer Reports has taken out today, a

full-page ad in USA Today, describing her situation, where she was

prescribed Vioxx, never told about the heart safety risks that it

could have. She ended up in angioplasty stints placed in her heart

and bypass surgery. As she puts it, ‘‘I can’t say for certain Vioxx

caused my heart problems, but I wish I would have known what

the drug maker knew.’’ And that statement really goes to the crux

of the matter before us. The public is not being given the full story

about all the potential risks of medications and therefore they can’t

make informed decisions about their healthcare. We need you, as

the committee and the Congress, to significantly strengthen drug

safety laws and adequately fund drug safety efforts at the FDA.

My written statement, Mr. Chairman, explains how these measures will help prevent future Vioxx disasters, the uncertainty we

are seeing now with the diabetes drug Avandia, and other threats

to patient safety. But let me concentrate my comments here on four

key points.

First, we strongly endorse your proposal that all phase II

through IV clinical trial results be honestly and accurately made

public in a timely manner. If there is concern about the integrity

of the trial data that would be made public by drug companies, as

we have heard from some, you can study and recommend regulations on ways to achieve unbiased, honest reporting. In the interim,

though, whether perfect or not, make all results and data public so

that the world’s researchers can help detect serious problem areas

and detect them early rather than well after the fact.

Second, there is great concern that the drug safety division in

the FDA has been overshadowed and in some cases ignored by the

division that approves new drugs to the detriment of public safety.

Again, we urge you to raise the drug safety office’s profile, independence, and influence in critical decisions. To help achieve that,

you could include the Kennedy-Enzi section 210, which makes public the FDA drug action letter, including a public statement of any

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dissents and disagreements about a drug safety. We hope you will

also include language on the right of staff to publish in scientific

journals, and that you include whistleblower protection for FDA

staff who raise safety concerns. We have also long supported legislation by Representatives Tierney and Stupak that would create a

separate Office of Drug Safety within the FDA, a focus point within

the agency where safety issues can be raised, vetted and acted on.

Now, I understand if there is a concern that a completely separate

office would slow but, as you have heard, we recommend at the

least Senator Grassley’s amendment that failed by only one vote on

the Senate floor vote. It would give the Office of Drug Safety the

power to ask for a safety change on a medication. If the director

of the Office of New Drugs disagreed, the commissioner would be

required to quickly settle the dispute. This would not slow actions

down, but would clearly make someone responsible for safety and

resolving these issues.

Third, given the long history of abuses in direct-to-consumer advertising, we recommend that consumers get the most accurate, upto-date clear information about a drug’s benefits and risks. Currently under the voluntary DTC User Fee Program, there is no incentive for a drug company to pay the user fee to have their ad

cleared. Consumers deserve the right to have the full information.

They should be given the truth, the full truth, and nothing but the

truth, and that is what we recommend for this legislation. In the

rare cases of drugs with serious potential health dangers, we also

support including up to a 3-year temporary delay period on DTC

ads as part of the REMS safety tool chest, but that would be a very

rare occurrence, but it should be available to the FDA. It is a commonsense consumer protection tool.

Finally, on conflicts of interest, we would urge you to prohibit

any conflicts of interest on drug advisory committees. It is critical

that the public have faith in the integrity of our prescription drug

safety system. They don’t today. A survey a few months ago by the

Consumer Reports National Research Center found that six out of

10 consumers feel that Congress and the FDA is not doing enough

to protect them. The conflict of interest undermines public confidence, so again, we would say let us have a strong requirement

here. Have the FDA go out and find the right people and take some

time to find them if they need to.

So those are some of our concerns, Mr. Chairman. Again, thank

you for your leadership on this and congratulations on the proposals. We look forward to working for their enactment. Thank you,

sir.

[The prepared statement of Mr. Guest follows:]

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Mr. PALLONE. Thank you. Mr. Ubl.

STATEMENT OF STEVEN UBL, PRESIDENT AND CEO,

ADVANCED MEDICAL TECHNOLOGY ASSOCIATION

Mr. UBL. Good afternoon. I am Steve Ubl, president and CEO of

AdvaMed, which is the Advanced Medical Technology Association.

I would like to thank you, Mr. Chairman, Ranking Member Deal

and other members of this subcommittee for the opportunity to provide our views on MDUFMA.

Reauthorization of MDUFMA is critically important to public

health and safety and ensuring FDA is on sound financial footing.

I would like to commend you and the subcommittee for including

the FDA industry agreement in the discussion draft, and for its

critical role in developing the original proposal back in 2002, and

for the restructuring of the program that occurred in 2005. The

program has made an immense difference to FDA, to industry and

to patients. And without your support, we would not be where we

are today. However, we do have concerns with the discussion draft,

which, in our view, if not address would jeopardize our support for

the underlying measure.

First, as we read the preemption language contained in the initial draft and in the chairman’s mark, we are concerned to the degree that it would threaten our ability to support the overall bill,

the reason being the existing statutory preemption provided for

medical devices is absolutely critical to ensuring that FDA’s expert

and uniform regulatory regime will not be undermined by divergent State requirements. This uniform and predictable regime is

critical for innovation for developing the most novel treatments for

the most dangerous diseases and for maintaining the flow of venture capital to small firms. And those concerns are reflected in my

written testimony.

Essentially, what the draft would do is allow for State courts,

State agencies and State legislators to substitute their views or second guess FDA’s determinations around safety and effectiveness. I

should point out that we very much appreciate that, in the most

recent draft, we think you are trying to narrow the scope of this

provision. But I would just like to point out by just referencing the

clinical trials section of the bill. You are implicating the underlying

statute relative to devices. So we view any insertion of ambiguity

in this area as highly problematic.

With regard to third-party inspections, we are disappointed that

the program was essentially dropped in the discussion draft. In our

view, the Third-Party Program should be a win/win for FDA, for

the public and for industry. It benefits industry because it reduces

the number of duplicative and costly inspections by numerous foreign governments and the FDA. And as Dr. Lutter testified, it benefits the FDA because the agency currently inspects facilities once

every 5 years, so it enables the agency to get inspection reports it

otherwise would not get to get target resources where problems are

most likely. There are many misunderstandings about Third-Party

Program and I would like to emphasize a few key protections that

are included in the agreement as adopted by the Senate.

None of the FDA inspectional authorities are reduced in any

way. FDA can inspect a facility at any time and continue to receive

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third-party inspection reports whether FDA inspects the facility or

not. FDA credits the third-party inspectors and also inspects the

inspectors on a regular basis. FDA can disqualify an inspector at

any time, and a company can continue to participate in the program only if it maintains a clean inspection record. In our sense,

if the committee leaves the program in its current unworkable

form, FDA will be deprived of valuable information that it would

otherwise have to make decisions for the public health.

With regard to pediatric medical devices, we support the goal of

increasing access to pediatric devices, and I want to commend Congressman Markey and Congressman Rogers for their leadership in

this area. However, in order for a pediatric bill to truly be successful in increasing the number of studies, we believe there should be

a careful balance of carrots and sticks. Unfortunately, the current

draft is virtually all stick and no carrot. The bill lacks any significant financial incentives to provide device companies incentives to

conduct pediatric trials. Similar incentives on the drug side have

been estimated by HHS to be worth billions of dollars. And they

have worked. Those incentives have produced numerous additional

trials.

In terms of the stick side of the equation, the bill gives FDA the

authority to prohibit access to a device that was developed for an

adult or general use, if the agency foresees a potential pediatric

use, until such time as the sponsor agrees to conduct a pediatric

study. It could take months to negotiate such a study and during

that time, patient access to the device in question would be denied.

The bill could be improved in our view by providing an expedited

waiver process to resolve such disagreements between a product

sponsor and the FDA, when in the view of the sponsor, it would

be impossible to conduct a trial due to lack of information about

the target population or difficulty enrolling patients.

We are also concerned with one aspect of the clinical trial registry provision, the requirement to disclose information on a clinical trial before the device is approved. Unlike drug companies, patents provide only limited protection for device companies, because

it is often easy to engineer around a patent for a device. Clinical

trial design is critical intellectual property for device companies. If

a company’s trial design is known to competitors before the device

is approved, a competitor can drastically shorten the period of market exclusivity or even beat the originator company to market. We

recommend the approach taken in the Senate to require device

trial registry, but to delay public disclosure data until the device

is cleared or approved by FDA.

In summary, AdvaMed strongly supports reauthorization of

MDUFMA. We have had a number of concerns which we have outlined. We ask that you consider these changes going forward, and

I appreciate the opportunity to provide my views.

[The prepared statement of Mr. Ubl follows:]

STATEMENT OF STEPHEN J. UBL

AdvaMed, the Advanced Medical Technology Association, represents more than

1,600 medical technology companies, affiliates, and subsidiaries. Our members develop and manufacture medical devices, diagnostic products and medical information systems that represent nearly 90 percent of the health care technology products

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purchased annually in the United States, and nearly 50 percent of those purchased

around the world. AdvaMed members range from the largest to the smallest medical

technology innovators and companies. More than 70 percent of AdvaMed’s core

members have less than $30 million in sales annually. AdvaMed is pleased to offer

this written testimony on behalf of our members.

AdvaMed believes that the reauthorization of the Medical Device User Fee and

Modernization Act (MDUFMA) is good for the public health. It will facilitate the

timely and effective review of new medical technologies and bring them to patients

as soon as those products can be shown to meet the necessary rigorous FDA requirements. It also ensures that FDA’s medical device program will be on sound financial

footing. FDA’s device program needs sufficient funding to do its job in a timely way,

and this bill will ensure that the agency has that funding for the next 5 years. However, we have serious concerns that other provisions in the proposed discussion

drafts will not serve the public health and instead will undermine the intended impact of user fees and FDA’s authority to ensure safe and effective devices.

The constructive goals that emerged from FDA and industry discussions to improve medical device regulation are frustrated by the proposed preemption section

that would overturn previous clear Congressional intent and court precedent and

elevate individualized state decisions over FDA’s expert science-based determinations of product safety and effectiveness. On this issue, we have great concern that

the draft not only harms the agency’s ability to fulfill its mission to safeguard public

health, but also disincentivizes research and development of life saving technologies

and diminishes patient access to beneficial technologies. This represents a substantial step back and will cede our nation’s leadership in health care innovation. Inclusion of the proposed preemption section may jeopardize industry support for the legislation.

The following summarizes our concerns with the proposals and identifies areas

that we believe members of the Subcommittee should examine closely in order to

further the public health.

LIMITATION ON FEDERAL PREEMPTION

Section 108 of MDUFMA, which purports to be a ‘‘rule of construction,’’ is (1) unnecessary and (2) damaging to medical device innovation and FDA’s authority. Specifically, section 108 states ‘‘Nothing in this Act or the amendments made by this

Act may be construed as having any legal effect on any cause of action for damages

under the law of any State (including statutes, regulations, and common law).’’ It

is hard to understand the point of the inclusion of this language in the proposed

House bill except as an attempt to create ambiguity regarding the preemptive effect

of fee-based agency actions, including approval of premarket applications (PMAs),

and to deconstruct the clear Congressional expression of preemption included in the

1976 Medical Device Amendments. Consideration of an issue that would so fundamentally change the FDA regulatory structure should not be included in a bill

designed to reauthorize the hiring of additional reviewers at the agency, especially

given the importance of reauthorizing the bill before expert reviewers at FDA are

notified that the funding, and therefore their jobs, may be in jeopardy.

Manufacturers (and their third party sources of capital that fuel further research

and development) require a level of certainty that they will not be subject to state

tort liability after spending the vast amounts of time, money, and other resources

to adhere to stringent FDA requirements for PMA devices and to obtain FDA’s full

safety and effectiveness approval of a PMA device. Whether or not section 108 of

MDUFMA is an attempt to muddy the waters regarding the preemptive effect of

PMAs and device specific reviews, we believe it could have that effect and for that

reason should be struck from the proposed House MDUFMA legislation.

Express preemption for medical devices is governed by section 521 of the Federal

Food, Drug, and Cosmetic Act (or the FDCA), which expressly preempts state requirements that are ‘‘different from or in addition to, any requirement applicable

under . . . [the FDCA] to the device, and which relate ‘‘to the safety or effectiveness

of the device or to any other matter included in a requirement applicable to the device under’’ the FDCA. According to the House Committee Report for the 1976 Medical Device Amendments, section 521 was included in the 1976 Amendments because

consistency in requirements for medical devices was considered necessary to avoid

unduly burdening interstate commerce.

Device specific reviews, such as a PMA, entail a comprehensive review of safety

and effectiveness by FDA’s expert scientists, physicians and other analysts. The

PMA process established by the 1976 amendments required the most exacting review for the riskiest devices, those in class III. Additionally these devices were of

the most concern, and included those which are either for use in supporting or susVerDate 11-SEP-98 09:49 Oct 14, 2008 Jkt 000000 PO 00000 Frm 00128 Fmt 6633 Sfmt 6633 Q:\DOCS\110-55 SCOM1 PsN: SCOM1
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taining human life, or are of substantial importance in preventing impairment of

human health or present an unreasonable risk of illness or injury. The safety and

effectiveness of class III premarket approval devices must be determined with respect to the persons for whom they are intended, with respect to the labeled conditions of use and by weighing any probable benefit to health from the use of the device against any probable risk of injury or illness from such use.

The PMA process is a rigorous, device-specific FDA review as has been recognized

by the courts. To obtain PMA approval, a manufacturer must, among other things,

submit full reports of investigations that provide a reasonable assurance of the safety and effectiveness of the class III, PMA device, typically one or more clinical investigations. Breakthrough PMA devices normally are reviewed by an outside panel of

experts. The amount and type of data necessary to meet the PMA approval standard

of a reasonable assurance of safety and effectiveness requires expert scientific analysis that Congress long ago assigned to FDA and which the agency is uniquely qualified to render. FDA has vigorously advocated preemption in defending its role in determining the safety and effectiveness of devices in recent years.

A substantial majority of courts, including Federal circuit courts, have held that

the PMA process is the type of device specific review entitled to preemptive effect

over state tort claims under section 521 of the FDCA. Nonetheless, there is a small

minority of courts that have reached a different conclusion, including one Federal

circuit court. The Supreme Court has not directly addressed the question, thus some

uncertainty remains despite the majority consensus favoring preemption in the Federal circuit courts.

In sum, elevating individualized state actions and decisions through tort lawsuits

over FDA’s expert determination not only undermines FDA’s authority regarding

product-specific determinations, such as the requirements necessary for PMA approval and adequate device labeling, but also diverts resources from research and

development to litigation and insurance. The PMA process applies to the approval

of the newest, riskiest, most complex, and some of the most transformative and beneficial devices developed. Innovation leads to earlier disease detection, less invasive

procedures, and more effective treatments. The cost of section 108 will be an unnecessary unsettling of the law and resulting additional uncertainty that will likely discourage investment and innovation and delay or deny patients access to devices.

OMISSION OF THIRD PARTY INSPECTION PROGRAM IMPROVEMENTS

The MDUFMA discussion draft fails to address the problems currently plaguing

third party inspections, a statutorily authorized program widely recognized as falling short of its potential to improve the inspection process and free up agency resources. AdvaMed was pleased to work with FDA and others in industry to design

improvements to the FDCA to both encourage more participation and streamline the

currently burdensome third party inspection program. We are extremely disappointed that these much needed improvements were not included in the House

bill.

The reality of the situation is that FDA does not conduct inspections as often as

they would like. In fact, they inspect facilities every 6 years on average rather than

every 2. So to reject a streamlining of this process that allows FDA to better focus

their resources where they are most needed is short-sighted at best. In fact, the

agreement reached by industry and FDA ensures that more, not less, information

about facilities will be made available to FDA. And at any time, FDA can choose

to pursue its own inspection of any facility.

The changes included in the FDA/industry agreement are designed to streamline

the process but do not change in any way the strong conflict of interest prohibitions

for industry and third party inspectors. For example, the agreement contains provisions that would simplify the eligibility criteria and process by which establishments request an inspection by accredited parties. Those changes were included in

the Senate-passed version of the reauthorization. For example, the owner or operator of an establishment is required to submit a notice to FDA that identifies, among

other things, the most recent inspection and its classification. Establishments for

which FDA classified the most recent inspection as ‘‘official action indicated’’ would

be ineligible for a third party inspection and, unlike under current law, could not

submit a petition seeking such an inspection. The Senate bill also eliminated an eligibility requirement that was impractical to satisfy, namely that the owner or operator submit to FDA a statement that the government in a foreign country where the

device is, or is intended to be, marketed recognizes an FDA or third party inspection.

Another important change to the program is the elimination on the number of

times a company can use a third party inspection. Currently, a company is limited

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on the number of times it may use a third party inspector to two times. After two

third party inspections, FDA must conduct an inspection. The Senate bill eliminates

this limitation and allows a company to continue to use third party inspectors as

long as the company maintains a good inspection record. Although this limitation

is removed in S. 1082, the statute would require that an establishment must continue to have its inspection reports classified as compliant to continue participating

in the program. Under current law, if a manufacturer received a noncompliant inspection from an accredited third party, the company could appeal to the Secretary

to remain in the program. This provision is removed from S. 1082.

The authority to conduct inspections at any time remains at the discretion of the

FDA. The MDUFMA agreement and the Senate bill allow FDA to consider the goals

of international harmonization of quality systems standards thus streamlining overlapping international inspection requirements. Specifically, it would allow FDA to

accept international standards reports of certifications, thus providing the Agency

the opportunity to receive additional information on a facility so they can focus their

resources where they see the most risk. This is another provision that was omitted

from the House discussion draft.

The failure to include these process improvements threatens the tenuous existence of the current third party inspection program.

REQUIREMENTS FOR UNIQUE DEVICE IDENTIFIERS FOR ALL IMPLANTS

The proposed amendment that would require FDA to establish a medical device

registry and unique identification system for medical device implants represents a

broad expansion of current law without delineating any criteria to govern which implants would be subject to the unique identifier requirements, i.e., it is not riskbased and encompasses all implants regardless of their risk. Under the existing authority of §510(e) and 502(o) of the FDCA, FDA is currently developing regulations

for a system of unique device identification for all medical devices. Also, FDA currently has authority to require tracking for the useful life of any class II or class

III device the failure of which would be reasonably likely to have serious adverse

health consequences, which is intended to be implanted in the body for more than

1 year, or which is life sustaining or life supporting and is used outside a user facility. FDA considers the following factors in determining whether a tracking order

will be issued: likelihood of sudden, catastrophic failure; likelihood of significant adverse clinical outcome; and the need for prompt professional intervention. The agency has issued tracking orders for a number of devices including abdominal aortic aneurysm stent grafts, cardiovascular permanent pacemakers and electrodes, mechanical replacement heart valves, and silicone gel-filled breast implants.

The proposed identification and registry system would be a wholesale and unnecessary expansion of the present system. It could include devices not likely to have

catastrophic failures or that are only implanted short term. For example, under the

proposed language, sutures and dental implants would be covered. In sum, the proposed new UDI and registry requirements are duplicative and an unnecessary and

unduly burdensome expansion of the current system without real public health benefit.

AVAILABILITY OF PEDIATRIC MEDICAL DEVICES

The device industry is committed to the goal of providing children access to lifesaving, life-enhancing medical devices, and we commend Representatives Edward

Markey and Mike Rogers for their work on the Pediatric Medical Device Safety and

Improvement Act of 2007. AdvaMed has engaged in discussions with the offices of

Representatives Markey and Rogers about the device industry’s concerns (outlined

below) and we are hopeful we can reach an acceptable agreement.

Because FDA has indicated it already has authority to require postmarket surveillance for any device at any time, including at the time of approval or clearance, we

believe the language giving FDA authority to require postmarket surveillance as a

condition of approval or condition of clearance is unnecessary. Importantly, the language as currently drafted has the unintended consequence of adversely impacting

the availability of safe and effective medical devices for the broader population.

We are also concerned that the postmarket surveillance database duplicates an

effort that FDA has already undertaken—to create a database of all postmarket surveillance device studies. There is no need to legislate the creation and maintenance

of a new database—a costly and expensive proposition.

In addition, as we attack the problem of limited availability of pediatric devices

for children, we need to address the root causes—lack of knowledge of pediatric

needs and lack of incentives. The market for pediatric uses is often very limited,

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parable to the adult market. Unlike drugs, the kinds of incentives that exist in the

Best Pharmaceuticals for Children Act are not available to the device industry. Creating incentives such as improvement in the pediatric HDE program, establishing

a new compassionate use pediatric device provision, using existing regulatory mechanisms to facilitate device clearance and approval without reduced safety and efficacy standards for children, or creating tax credits or grant programs for companies

developing pediatric devices could improve pediatric device access.

We thank Congressmen Markey and Rogers for their leadership on pediatric

issues and look forward to working with them and members of the Subcommittee

and the Full Committee to resolve the important, outstanding issues on this legislation.

CLINICAL TRIAL REGISTRY AND RESULTS DATABASES

AdvaMed supports patient and doctor access to important information about the

health benefits and risks of medical devices. The current language, however, would

harm device innovation without any benefit to patients. We support the Senate language which requires disclosure of all clinical trial information once a device is actually available to patients.

In the competitive device environment, protecting proprietary technology is especially important because patents provide little protection for devices. Engineering or

design changes can readily negate device patents whereas for drugs, entire molecules are patented, frequently before the first trial begins. As a result, disclosure

of the existence of an Investigational Device Exemption (IDE) or related data in a

registry could unfairly reveal important proprietary information to competitors who

could speed competing devices into trials, obtain FDA clearance or approval and

take advantage of the significant benefits associated with being first-to-market.

When there is no FDA-approved product, information related to the device design

and to the design of the trial and its endpoints is the only intellectual property a

company may have.

Such disclosures could have the unintended consequence of eliminating many

small device companies from the marketplace. Small companies account for the vast

majority of device innovation and contribute greatly to maintaining strong price

competitiveness across the industry.

DIFFERENCES BETWEEN DRUGS AND DEVICES

We encourage the House to consider including a recognition of the differences between drug and device trials in their database requirements. The Senate bill, for

example, requires early registration of device clinical trials but protects sensitive intellectual property and trade secrets until the device is cleared or approved. In addition, S. 1082 recognizes that the vast majority of device companies are small and

allows a link to the FDA-required PMA Summary of Safety and Effectiveness (SSE)

or the 510(k) Summary to satisfy the bill’s results requirements. More than 70 percent of AdvaMed’s members have less than 50 employees and fewer than $30 million in sales annually. They will be unable to manage the extremely burdensome

requirements of this legislation. The SSE and 510(k) Summary include a detailed

summary of information on the clinical trials that supported the PMA or 510(k) application including information on any adverse events during the trial.

Finally, the discussion draft includes a requirement that any agreement that prohibits an investigator from discussing or publishing the results of a trial must be

included in the clinical trials registry and results databases. The provision indicates

a fundamental misunderstanding of the current nature of most device clinical trials

which are multi-center trials (multiple sites and investigators conduct the trial).

While device trials are much smaller than drug trials, they typically require multiple sites to assist with recruitment. FDA may also require multi-center trials in

order to see experience over several sites. It is standard procedure to require investigators to withhold discussing or publishing the results of a trial at their particular

site until the data from all of the sites has been aggregated. Discussion or publication of information from one site could provide false or misleading information about

the trial and could introduce bias (positive or negative) into the study that could

jeopardize the integrity of the trial. Further, premature discussion or publication of

one site’s trial information could jeopardize publication of the aggregate data later

in a peer-reviewed journal. Most medical journals refuse to publish information that

has previously been released. Thus, there is a legitimate need for restrictions on discussion or publication until the data has been aggregated. Although there are rational and legitimate reasons to restrict individual investigators from premature release of information, the legislative requirement to reveal these restrictions will unfairly paint sponsors as bad actors.

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To ensure continued medical device innovation for patients, AdvaMed recommends that the House legislation:

• Delay disclosure of device clinical trial registration information until the device

is cleared or approved. • Allow device companies to satisfy results requirements via a link to the PMA

SSE or 510(k) Summary. • Eliminate the faulty provision requiring disclosure of agreements that prohibit

investigators from prematurely discussing or publishing clinical trial results.

AVAILABILITY OF ADVISORY COMMITTEE MEMBERS WITH APPROPRIATE EXPERTISE

The House bill prohibits an advisory committee member from voting on a matter

if that member, or an immediate family member, has a financial interest that could

be affected by the committee’s advice to FDA. The agency may grant a waiver of

this prohibition if a waiver is necessary to afford the advisory committee essential

expertise; however, only one waiver may be granted per committee meeting.

AdvaMed is extremely concerned that the limitation of one waiver per committee

meeting could prevent FDA from convening a panel of experts with the appropriate

expertise to address the matter at hand. Because the waivers will be publicly disclosed, thus making the committee process transparent, we do not believe there is

any harm in granting more than one waiver to highly qualified experts who bring

unique expertise to the committee meeting. Advisory committees have been challenging to form because of the difficulty in recruiting the persons most expert in a

type of device. We believe the House’s one waiver limitation undermines other elements of this legislation which require FDA to conduct outreach and recruit potential members to advisory committees, including those who have waivable conflicts.

IOM REPORT ON PREMARKET NOTIFICATIONS

The MDUFMA discussion draft requires an Institute of Medicine (IOM) ‘‘study on

the appropriate use’’ of the 510(k) process ‘‘to clear medical devices as safe and effective.’’ Although commonly referred to as a ‘‘clearance’’ system, the premarket notification system actually is a classification system which regulates classes of devices

according to their risk profile. Congress developed the premarket notification process to mirror the incremental innovation process that occurs in medical technology

and where appropriate to help expedite incremental improvements in devices

through the regulatory process. Upon submission of a premarket notification, FDA

determines whether the device is ‘‘substantially equivalent’’ to a predicate device.

To be substantially equivalent, the device must have the same intended use and the

same technological characteristics as the predicate, or if it has different technological characteristics, there must be information submitted to FDA that demonstrates that the device is as safe and effective as a legally marketed device and

does not raise different types of safety or effectiveness questions from the predicate

device. Many 510(k) devices or their predicates have been on the market more than

30 years (i.e., prior to the Medical Device Amendments of 1976) and their benefits

and risks are well-known and well-qualified.

Congress has fine-tuned the 510(k) process over its 30-year history to ensure that

FDA has the necessary tools and can devote appropriate resources to devices as

needed, including those which present a higher risk. Importantly, The Safe Medical

Devices Act of 1990 (SMDA) strengthened the 510(k) premarket notification process

by requiring substantial equivalence decisions to be made to currently marketed

technology—not to technology that is no longer on the market. This has the effect

of ensuring that FDA’s substantial equivalence decisions are made to the most advanced technology available. SMDA also required that premarket notification submissions include detailed information concerning potential adverse health effects.

Finally, SMDA gave FDA authority to impose a wide range of special controls including performance standards, postmarket surveillance, the submission of clinical

data, the development of patient registries, and any other appropriate action needed

to provide a reasonable assurance of the safety and effectiveness of a device.

While AdvaMed supports any independent analysis of the premarket notification

system to ensure the system is operating to its full potential, because of the complexity of device regulation, any such analysis must be fully informed and include

the perspectives of all potentially affected parties. It is important that any IOM review of the 510(k) process include a device representative. AdvaMed would want to

ensure that any review of the 510(k) process thoroughly consider the views of its

members.

In summary, AdvaMed strongly supports the reauthorization of MDUFMA. However, we have serious concerns with the draft legislation as proposed, and we ask

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that you consider the changes we have requested to ensure that the final draft accomplishes the goal of ensuring that Americans have access to safe and effective

medical technology as soon as possible. We thank the Subcommittee again for its

interest in these important regulatory issues. We look forward to working with Congress and the FDA on this legislation.

Mr. PALLONE. Thank you. Dr. Zuckerman.

STATEMENT OF DIANA ZUCKERMAN, PRESIDENT, NATIONAL

RESEARCH CENTER FOR WOMEN AND FAMILIES

Mrs. ZUCKERMAN. Thank you for the opportunity to testify today.

I am Dr. Diana Zuckerman, president of the National Research

Center for Women and Families, an independent think tank that

analyzes and evaluate health programs and policies. I was trained

as an epidemiologist at Yale Medical School and I have worked on

health policy issues for more than 20 years.

Every American relies on medical devices and more than 5,000

medical devices were cleared or approved by the FDA last year.

Ninety-eight percent were cleared through a quick and easy 510(k)

process that usually does not require clinical trials to prove that

the products are safe and effective. So I am going to start by focusing on that 510(k) process and the relevance to your legislation.

We strongly support provisions in your discussion draft that

would address concerns with the 510(k) process. We applaud your

decision to keep the user fees for each 510(k) application at the current level, and your decision not to speed up the already speedy review process for the 510(k). Keeping the status quo will put less

strain on CDRH, since almost all the devices are reviewed that

way. You have asked for an IOM report on the 510(k) process and

we think that is a great idea and I have some slides to show you

why.

[Slide]

Unlike drugs, most medical devices do not need to be proven safe

and effective, and under the 510(k) process, devices are cleared if

they are deemed substantially equivalent to other devices that

were on the market prior to 1976. Originally, the term substantially equivalent was expected to mean that they were very similar,

but that definition has changed over the years and today, as long

as the products are used for the same purpose, they don’t need to

be the same shape, made from the same materials, use the same

mechanism of action, or be equivalent in any other substantial

way. And so if you look at this first slide, steak and milk are more

substantially equivalent than the FDA would require. Both are

food; both are from cows. But let us look at some medical device

examples instead. Next slide.

[Slide]

Here is a jaw implant made by Vitek, the one on the left. It was

cleared as substantially equivalent to silicone sheeting, which you

see on the right. You can see they are completely different. They

look different and they are even made from completely different

materials. The Vitek implants were made with Teflon and clinical

trials were not required and so nobody knew that the Teflon would

flake off inside people’s jaws and that that would cause the jaw

bone to degenerate, to basically disintegrate. Patients ended up unable to speak or to eat and some with holes in their skull with their

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brain no longer protected. Vitek jaw implants were recalled, but

they could not be safely removed from all patients. Next slide,

please.

[Slide]

Last month a contact lens solution was recalled because it causes

serious eye infections that can cause blindness. That is completely

different from the contact lens solution that was recalled a year

ago, a completely different solution which also caused a different

eye infection which could also cause blindness. Both of these contact lens solutions were approved as substantially equivalent to

older, safer contact lens solutions, and you can see that those eye

infections caused by those new solutions are really terribly serious.

Slide 3, please.

[Slide]

Bladder slings are used to treat stress incontinence in women.

The slings made by Boston Scientific called ProteGen were made

from a different material than slings that looked the same. You can

see these are diagrams are identical. The slings look the same but

they are made of a different material. So the ProteGen was made

out of a new synthetic material, whereas the old slings are made

of Gor-Tex or other materials that had been found to be safe. The

ProteGen slings were recalled because they caused more infections,

they caused vaginal erosion and other serious problems. The last

slide, please.

[Slide]

Yes, apples and oranges are both fruit, they are both round and

they are both good for you, but they have different advantages and

they are not substantially equivalent. That is why we have the expression apples and oranges. They are different. And the FDA

needs to define substantially equivalent to make sure that the

products that they are reviewing really are the same. If they are

not, clinical trials are needed.

So for all its faults and despite Vioxx and Avandia and other

lapses, the FDA approval process for prescription drugs is really

much more cautious and rigorous than the device approval process.

And in speaking with physicians, scientists and consumer advocates, we have developed several suggested changes in the 510(k)

process, which is in my written testimony. From a policy point of

view, when new devices are approved through the 510(k) process,

if there are no studies published, they are not going to be covered

by the Center for Medicare and Medicaid Services and they are not

covered by insurance. So all the rush to get them to market doesn’t

really help patients, if they are not reimbursed through health insurance.

So when you ask the IOM or the GAO to examine the 510(k)

process, which is going to take at least a year or two, I urge you

to consider a temporary moratorium on approving implanted medical devices that have not been carefully evaluated with clinical

trials. And I just want to finish by saying that the FDA has made

it clear that post-market analysis is very important and it is especially important for medical devices because so many are cleared

without clinical trials. We think registries with unique identifying

numbers on products are very helpful and important, and we think

the adverse reporting system needs to be improved. So we are very

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pleased that your discussion draft includes additional funding and

we urge you to specify how that funding will be spent.

Finally, I just want to say a couple of words about direct-to-consumer advertising on medical devices.

Mr. PALLONE. OK. Quickly, though, because you are almost at 2

minutes.

Ms. ZUCKERMAN. I promise. Sorry.

Mr. PALLONE. Over, I mean.

Ms. ZUCKERMAN. OK. Medical devices are also advertised

through direct-to-consumer advertising and any restrictions for

DTC ads for drugs should also be considered for devices. And we

also support your decision not to expand the third-party inspections. Since the current program has not worked very well, we

think it would be foolish to expand it before you can figure out why

it isn’t working better and what needs to be done. Thank you very

much.

[The prepared statement of Ms. Zuckerman follows:]

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Mr. PALLONE. Thank you. Mr. Walker.

STATEMENT OF STEVE WALKER, CO-FOUNDER AND CHIEF ADVISOR, ABIGAIL ALLIANCE FOR BETTER ACCESS TO DEVELOPMENTAL DRUGS

Mr. WALKER. Mr. Chairman, Congressman Deal, members of the

committee, we at the Abigail Alliance wish to express our thanks

for this hearing and for inviting us to testify. I am Steven Walker,

co-founder and chief advisor to the Abigail Alliance. I receive no

compensation of my efforts as an advocate and I pay my own expenses.

The Abigail Alliance for Better Access to Developmental Drugs is

a nonprofit, nonpartisan patient advocacy organization dedicated to

serving the needs of people suffering from serious and life-threatening diseases.

Based on our firsthand experience with the harsh regulatory realities faced by patients with life-threatening diseases, we have

proposed a solution called Tier 1 Initial Approval to ease the regulatory barriers our constituents face, while simultaneously protecting the clinical trial system. Tier 1 was submitted to the FDA in

a citizens petition 4 years ago yesterday and we are still waiting

for a response, and I wonder if I could have the 2-week thing that

Congresswoman DeGette got on that?

Last year a bill called Access Act passed based on our tier 1 proposal. It was introduced in both houses of Congress and it is going

to be reintroduced this year and we strongly urge Congress to pass

the bill. Incidentally, legislation to address the needs of our constituents should have been included in the discussion draft today.

In July 2003, we filed a suit against the FDA in Federal court,

claiming that the FDA’s denial of access to promising investigational drugs for patients with no other option but death from their

disease, violates their constitutional rights of due process and privacy. Last year a three-judge panel of the DC Federal Court of Appeals agreed, but the FDA moved for a rehearing by the full appeals court and almost 4 years after filing the suit, we are still

awaiting a trial on the merits of the claim. Over those 4 years, 2.2

million Americans died from cancer alone. This is not just a regulatory policy issue. It is a civil rights issue. Now I am going to turn

to a few of your discussion drafts.

The Abigail Alliance has long sought readily available and more

complete listings of clinical trials and access programs for investigational drugs, and we support the proposed clinical trials registry in the discussion draft. We also support in concept the idea

of making the results of clinical trials public. But we think the clinical trials results database as proposed in the discussion draft has

all the earmarks of a major regulatory misstep. The evidence for

this can be found in the recent flap over Avandia. The publication

of scientifically-weak analysis results in the New England Journal

of Medicine was a statistical drive-by hit on the integrity of our

regulatory system. If the results database is enacted as proposed,

the FDA will become the regular target for poorly-constructed statistical hand grenades and spend far too much of its time trying

to clean up the mess after each one explodes in sensational fashion

in the media. We ask that the committee schedule future hearings

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to receive additional input on how to make trial results public,

while at the same time preserving the integrity of our regulatory

system.

On advisory panel conflicts of interest, we think you are missing

the point. We think you are putting the cart before the horse. The

Federal Advisory Committee Act prohibits inappropriate influence

by the appointing authority of its advisory committees. But FDA

review office directors are empowered to manipulate the ideological

makeup of their advisory committees, and potentially use that

power to pursue the outcome they want regarding policy matters

and votes on specific drugs. We believe that this has, in fact, happened with some cancer drugs. Congress should start by looking at

the FDA’s process for selecting advisory committee members at the

detail level and then take up the conflict of interest measures.

On REMS, we oppose the proposal to require mandatory Risk

Evaluation and Mitigation Strategies, or REMS, because they are

mandatory, making them yet another one-size-fits-all solution that

won’t work. The FDA already has and uses the authority to impose

what they call risk management plans, or RiskMAPs, on drugs at

the time of approval. RiskMAPs has so far been a mixed bag of

safety controls burdened with unnecessary approval delays and

proscribing restrictions, coupled with requirements for highly unethical post-approval clinical trials. Remember, people are put into

these clinical trials. They are not just exercises in data collection.

RiskMAPs also have resulted in major intrusions by the FDA into

the practice of medicine. Mandatory REMS, even though proposed

as being flexible, are likely to evolve quickly into an over-applied

defensive mechanism for FDA, instead of its intended use of being

a rational, sober post-marketing tool. We need post-market monitoring of drugs, but we do not need anymore one-size-fits-all solutions. We suggest that the flexible model for what must be included

in the REMS be used to replace the current RiskMAP model, but

that the need for a REMS be determined on a case-by-case basis.

And believe me, I find it odd that I am in agreement with the FDA.

I am usually not.

The Reagan-Udall Institute for Applied Medical Research is a

very good idea that could be made even better. The goal is regulatory modernization and that can only come through real change

in the way the FDA does its job. Consequently, the institute should

be moved inside the FDA and given line authority to issue new

policies and guidance and to initiate rulemaking on its own.

I have some closing comments. This entire debate regarding FDA

reform has its roots in a decades-old feud raging within the FDA

and the medical research community, between two groups of statisticians: those who believe the forward-looking trials used for preapproval testing, and those who support the backward-looking

trials who try to find drug safety needles in haystacks. Neither statistical camp should win this feud. Patients should win. And for

that to happen, we need to move away from the rigid, often unethical statistical approaches we have now and move toward real

science. We need to remember that the FDA’s mission is not to control and punish the drug companies, but rather to protect and promote the public health, and it is on the promote side where we will

find better treatments and cures for diseases like cancer.

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I would like to close with an important fact. Every investigational drug for which the Abigail Alliance has sought early access

was eventually approved by the FDA. We knew that patients would

be better off if they could get the drug than if they could not, usually years before the FDA enacted to make those drugs available.

If the FDA was less a barrier to progress, millions more would

have gained access to that progress over the last 7 years. Thank

you.

[The prepared statement of Mr. Walker follows:]

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Mr. PALLONE. Thank you. Dr. Gorman.

STATEMENT OF RICHARD GORMAN, M.D., CHAIR, AAP SECTION

ON CLINICAL PHARMACOLOGY AND THERAPEUTICS, AMERICAN ACADEMY OF PEDIATRICS

Dr. GORMAN. Thank you, Mr. Chairman and members of the

committee. I am Dr. Richard Gorman, a practicing pediatrician who

has taken care of infants, children and adolescents for over 25

years. On behalf of the American Academy of Pediatrics, I would

like to thank the subcommittee for holding this legislative hearing

and for considering bills necessary to address the need for safe and

effective drugs and medical devices for children.

The American Academy of Pediatrics urges the committee to reauthorize BPCA and PREA with necessary improvements, and to

pass the new pediatric medical devices legislation to begin to close

the gap between medical devices that children need and the devices

that are available. I would like to thank Representatives Edward

Markey and Mike Rogers for championing the pediatric medical device legislation, and express our continuing gratitude to Representative Anna Eshoo for leading the efforts on BPCA and PREA.

Thank you, Mr. Chairman, as well as Chairman Dingell, for addressing these bills along with the user fees and drug safety legislation.

In previous testimony before this committee, I have credited

BPCA and PREA with giving healthcare providers and families a

great increase in the useful information on medicine for children.

The American Academy of Pediatrics strongly supports the Improving Pharmaceuticals for Children Act of 2007, H.R. 2589, introduced by Representative Eshoo. We thank the committee for including much of H.R. 2589 in draft legislation we are considering

here today. H.R. 2589 not only reauthorizes BPCA and PREA, but

makes several needed changes to ensure their continued success.

The reauthorizing legislation under consideration does four major

things: it increases the dissemination and tracking of pediatric

drug information; it integrates and strengthens BPCA and PREA’s

administrative process by affirming and institutionalizing an internal review committee that has already been created by the FDA to

provide guidance and oversight for the FDA review divisons when

issuing written requests under BPCA and pediatric plans under

PREA. This legislation also expands the study of off-patent drugs

by expanding the role of the NICHD to include studies of gaps in

pediatric therapeutics, and it makes PREA a permanent part of the

Food and Drug Act, and continues to give Congress the opportunity

to regularly reevaluate the BPCA’s incentives.

As I have testified in the past, the AAP evaluates proposed

changes to BPCA’s exclusivity incentive by asking two questions:

would these proposals reduce the number of pediatric studies, and

would these proposals be administratively burdensome to the FDA?

The blockbuster proposal contained in the Committee Print is troubling, in that it does not protect against a potential reduction in

pediatric studies and leaves open the question of whether regulations would be administratively burdensome. The AAP is on record

for supporting the compromise crafted by Senator Chris Dodd in

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Senate bill 1082. We urge the committee to retain this approach to

adjusting the market exclusivity incentive.

The Pediatric Medical Device Safety and Improvement Act of

2007 will help children get the safe medical and surgical devices

they need by strengthening safety requirements and encouraging

research, development and the manufacture of pediatric devices.

This bill, included in the committee print, strikes the right balance

between new incentives and increased post-market surveillance,

and puts forward a comprehensive package that serves as a critical

step forward for children. The pediatric device legislation will help

define the need for pediatric devices by better organizing the Federal response. It will create a device development mechanism of

nonprofit consortia that will facilitate pediatric device development

and manufacture through mentorship from experienced companies.

It improves the humanitarian device exemption by eliminating the

profit restriction for pediatric HDEs, which will increase the incentive for small companies to enter the pediatric device market and

allow others to make a reasonable return. It makes needed improvements in the way the Food and Drug Administration tracks

pediatric devices, and it strengthens post-marketing safety.

As recommended by the Institute of Medicine, this bill grants the

FDA increased authority to ensure that approved medical devices

are safe for children. Under this proposed law, the FDA would be

able to require post-market pediatric studies as a condition of approval or clearance of certain devices. This legislation also allows

the FDA to require a study of greater than 3 years, if necessary,

to ensure that the study is long enough to capture the effect of a

child’s growth on the safety and efficacy of the medical device.

I would like to thank the committee for allowing me the opportunity to share with you the strong support of the American Academy of Pediatrics for the reauthorization of BPCA and PREA, as

well as the new pediatric medical device legislation. We urge swift

passage by this committee for the sake of all children. Thank you.

[The prepared statement of Dr. Gorman follows:]

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Mr. PALLONE. Thank you, Dr. Gorman. We will start with questions and I will begin. I wanted to ask Mr. Guest, first, a couple

of questions. The Consumers Union urges a zero conflict of interest

policy for FDA advisory committee members. I have a couple of

questions about that. How will this affect recruitment of advisory

committee panelists? Will this hurt the level of expertise of the

panels? Will we be setting up advisory committees with second-rate

experts? You mentioned that CU does not believe the FDA has

tried hard enough to find experts that are not conflicted. What

makes you think this? I am just asking a bunch of questions. If you

could try to answer them.

Mr. GUEST. I know that one group did a small survey. They

called the deans of medical schools around the country and said,

have people within your medical schools been asked by the FDA to

be members of panels? And apparently the results were, in many

cases, no. They said that there is not one person. There doesn’t

seem to be a concerted effort within the FDA to really do an extensive search for people that would be without bias, and that is a real

concern at Consumers Union, and I mentioned that our Consumer

Reports National Research Center did a survey; six out of 10 Americans do not believe that the FDA and Congress, in terms of laws,

are doing enough. There is a real lack of confidence right now in

the FDA. We know Consumer Reports is an exceedingly trusted organization, because people know we are absolutely free from bias

of manufacturers. We don’t take free advertising and don’t take

free samples and so forth. We think a similar kind of credibility,

we would hope, a similar kind of creditability could be developed

at the FDA and we think this legislation, the various parts of this

legislation will help restore faith in the organization that we as

consumers ought to depend on to protect us.

Mr. PALLONE. All right, let me go to my second question. This is

about direct consumer advertising. One area of interest since the

discussion drafts were released has been the 3-year waiting period

on direct-to-consumer advertising and I keep stressing to everyone

that this is not a moratorium. This is a case-by-case analysis in

each. To some extent, I think it has been misrepresented as a 3-

year moratorium, but it is actually case-by-case analysis. But the

question keeps coming up about the constitutionality of the proposal in the draft, why do you think such a provision would be constitutional?

Mr. GUEST. Well, again, like the doctor from the FDA, I don’t

purport to be a constitutional expert on it, but I would suggest that

the committee might consider having the Library of Congress, as

a law division, maybe convene a group of constitutional scholars,

who have no connection to special interests in this, to look at that

question further. The reality is that every country but the U.S. and

New Zealand actually prohibit direct-to-consumer advertising, because it is not, as members have said here earlier, it is not out

there to try to educate consumers so they can make informed

choices. It is out there to try to sell a product. And so there is great

danger that direct-to-consumer advertising are not helping consumers. They are having the opposite effect. We actually did a survey,

also, of doctors and said, how often do you feel pressured by consumers who come in, who saw these happy people living forever

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after, and pushing for a drug? Well, the fact is, what you don’t hear

is that a lot of people who push these drugs are not living happily

ever after. We have got some people in this room who can talk

about that.

Mr. PALLONE. I know and you know, I appreciate your comments.

I wanted to ask one more thing of Dr. Gorman before my time is

up, but I just want to stress again that my concern is that if we

just have a voluntary system with this advertising, that you have

a bad actor and that essentially you have a bad actor who, even

if the FDA determines that there are enough questions about a

new drug to suggest that there be no advertising, that they don’t

have the power to stop it, other than the deceptive advertising,

which is a separate issue, because something may not rise to the

level of deceptive advertising, yet we have serious questions about

it. And so I keep stressing this is not a moratorium. It is just a

case-by-case analysis. But there has to be some stick at the end,

otherwise you have a voluntary system and you don’t get at the

bad actor.

I just wanted to ask Dr. Gorman. You expressed concern with the

way we adjust the exclusivity period for blockbuster drugs in our

draft. Does the academy have any recommendations, other than

the Senate proposal, which I know you said you support, that

would achieve the goal of reducing the exclusivity period for blockbuster drugs, based on annual gross sales? We tried to come up

with something that was a little different than the Senate. I know

you don’t like it, but do you have any other ideas other than the

Senate, other than what is in the Senate proposal?

Dr. GORMAN. Before the beginning of this discussion, the academy set up those two criteria that would judge any proposal to

limit exclusivity, which was that it would not reduce the number

of studies, and two, it would be administratively simple for the

FDA. And we didn’t think that the committee markup language

met those tests, so we felt unable to support them. But we would

be willing to entertain other recommendations other than the one

from the Senate bill, although we have supported that in public.

Mr. PALLONE. OK, thank you. Mr. Deal.

Mr. DEAL. I am going to have a question for everybody and I

think maybe it will be a yes or no as you go down the line. Do you

agree that the FDA should be responsible for approving all safetyrelated label changes for drugs? Dr. Loew, I will start with you.

Ms. LOEW. Yes, we do believe that FDA should have that authority.

Mr. GUEST. We are opposed to preemption. We think that the

States ought to continue to have the authority that they have. The

preemption provision that is in the FDA regulation has never been

actually passed by Congress. That was something that the FDA put

into the preamble of——

Mr. DEAL. Your answer is no?

Mr. GUEST. The answer is no.

Mr. DEAL. Mr. Ubl?

Mr. UBL. I will defer to the pharmaceutical side. But if I could

amend your question and presume it applies to devices——

Mr. DEAL. Yes.

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Mr. UBL. Well, we believe that FDA should have that sole authority.

Mr. DEAL. Dr. Zuckerman?

Ms. ZUCKERMAN. No.

Mr. WALKER. No.

Dr. GORMAN. Yes.

Mr. DEAL. Mr. Walker, your answer surprises me.

Mr. WALKER. In all honesty, sir, it is an issue that I don’t have

a full understanding of.

Mr. DEAL. Well, if we are going to allow labels on drug products

to be amended because of safety concerns, who besides the FDA do

you think ought to make that determination, trial lawyers in the

lawsuits, in the States?

Mr. WALKER. Well, sir, it is a loaded question and the——

Mr. DEAL. Well, that is what I am up here for.

Mr. WALKER. Yes, sir. The reason it is a very loaded question is

because the Abigail Alliance has a very, I guess, a very high lack

of confidence in the FDA’s ability to make good safety decisions.

And the reason for that is that the FDA is an entirely statistical

agency and the statistical tools that are used to determine, to essentially find the safety needle in the haystack, are weak. You are

working with very dirty—now understand, I am a scientist. I am

not a scientist in the medical field. I am a scientist in the environmental field, but I know a great deal about data. We think that the

FDA needs a complete rebuild in the way it does its science. We

think that the idea that we practice our medical science and all

clinical research, limited by the very restrictive rules of statistics,

has caused the FDA to be an institutionally incompetent agency,

in terms of being able to determine and to balance risk versus benefit. It is not that the people are incompetent. It is that the tools

they use aren’t working.

Mr. DEAL. Well, unfortunately, we don’t have within the realm

of any of these pieces of legislation an effort to rebuild a new organization for purposes of determining patient safety.

Mr. WALKER. Actually, sir, you do. It is the Reagan-Udall Institute and it should be pumped up and put on steroids.

Mr. DEAL. Well, it is contained in one of the bills that we have

here. Dr. Loew, your testimony, I believe, states that the legislation

places the responsibility of policing physicians and pharmacists on

drug sponsors. Would you elaborate on what you mean by that?

Ms. LOEW. That is correct. There is a provision under the distribution and use restrictions that FDA can apply in the REMS

which would require sponsors effectively to police how physicians

and pharmacists dispense the drug, and we believe that is well beyond the ability and in fact the authority of pharmaceutical companies, and those are authorities that should rest with existing bodies, such as State boards of pharmacies who regulate pharmacists.

Mr. DEAL. Mr. Ubl, would AdvaMed withdraw its support for the

user fee legislation of the preemption provision that is in the package? And what would this provision ultimately mean for patients

and small device manufacturers?

Mr. UBL. Well, reluctantly, sir, with consultations with our board

and our extended membership, it does rise to a level of putting the

package in overall jeopardy, in our view. And to get your second

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point, particularly for small companies who rely on a more certain

environment, particularly those that are funded by venture capital,

we view the preemption danger as, again, literally hundreds of

State courts, State agencies, State legislators, second guessing the

scientists and physicians at FDA. And it was mentioned earlier on

the statistic side of things, I think it is important to point out,

these cases are going to be decided on an individual basis and the

multiplicity of these individual determinations are going to become

part of a larger case law that will become what is determined as

safe and effective by FDA, and we just think that is a very slippery

slope that would raise serious objections.

Mr. DEAL. Mr. Walker, you mentioned in your testimony the

phrase manipulating the ideological makeup of the advisory committees. Isn’t an ideological conflict of interest just as damaging

and even perhaps potentially more damaging to the credibility and

impartial nature of an advisory panel, as is a financial conflict of

interest?

Mr. WALKER. Absolutely. And if I could expand a bit. In order to

understand what is wrong with the advisory committees, you first

have to understand precisely how the FDA staffs their advisory

committees. The FDA doesn’t ask people to join their advisory committees. People can either be nominated or self-nominated. Then

those nominations come into the agency and they are given to the

office directors in the various offices. That office director goes

through that stack of nominees and decides who he wants.

In the case of the advisory committee we watch most closely,

which is the oncologic drugs advisory committee, the director literally picks the people he wants and those are the ones that get

sent for rubber-stamp approval to the top of the agency. What has

happened with the ODAC is that every member of that advisory

committee has precisely the same background, precisely the same

view of how to conduct clinical trials, and how to make decisions

about risks and benefits of drugs, as the office director. And in addition, the office director decides when to call a meeting. The office

director decides what questions will be asked. The office director

decides what briefing materials they will get. And the office director also decides if he needs consultants who are not current members of the committee, who will sit on the committee. And we have

seen, over the last several years, drugs that should have been approved rejected on more or less majority votes based on a single

point of view. The Federal Advisory Committee Act requires that

these committees be entirely independent of the FDA, in terms of

their advice, and they are not.

The other problem we have is that the office directors, and again,

with ODAC, can assign members of the committee to work on specific drugs behind the scenes and we think this has happened. In

fact, we think we have proof that has happened. And then those

people then sit on the committee and vote without disclosure. So

we have manipulation of advisory committees and an inappropriate

process for putting people on the advisory committees at the FDA.

And in the case of cancer drugs, we call it decelerated approval.

There is an initiative underway that was developed by the director

of the Office of Oncology Drug Products, on his own, about 4 years

ago, to require every single drug, no matter how compelling the

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data coming out of phase II, to go into phase III, and it has resulted in 2-year delays in a large variety of drugs, all of which are

now approved. But during those delays, people died and it wasn’t

a small amount of people. It was a lot of people.

Mr. PALLONE. Ms. Schakowsky.

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. I apologize to the

witnesses that I didn’t hear directly, but I have the testimony.

Dr. Zuckerman, in your written testimony you mentioned recommendations for improving drug safety, including the need to

clarify FDA officers’ rights to publish scientific articles, as well as

the need for strong whistleblower protection provisions. And you

said that the right to publish could have meant earlier warnings

about the risks of Vioxx and Avandia and others, and I wonder if

you could tell us how these additions to FDA law would help us

avoid future disasters?

Ms. ZUCKERMAN. Sure. Thank you for asking. I have seen numerous examples where data are presented in public at FDA advisory

committee meetings, so it is not a trade secret. It is clear what the

data show for a particular product, whether it is Avandia or jaw

implants or whatever it is. And when those data show problems,

they are basically never published. They are data that a company

controls and doesn’t choose to publish. They publish the results

showing the good news about the products, not the bad news. I

don’t think that most FDA scientists have a lot of spare time to be

writing up articles, publishing these data, but at least if they had

that authority to do that and didn’t have to worry about losing

their jobs. They would have the opportunity to take the data that

is already publicly available and publish them in medical journals,

and that could have given us a lot of advance notice on Avandia

specifically, but other products as well.

Ms. SCHAKOWSKY. Are they currently prohibited from doing that?

Ms. ZUCKERMAN. They are not prohibited so much as they are

working in an atmosphere where they are worried about losing

their jobs if they do.

Ms. SCHAKOWSKY. Right.

Ms. ZUCKERMAN. So it is more having whistleblower protection

that is very clear, that people can’t lose their jobs for publishing

data that are already public. The other issue is whether they would

have to do this in their spare time on weekends and at night, or

whether it could be part of their job, which would be great if that

were possible.

Ms. SCHAKOWSKY. Mr. Guest, did you want to comment at all on

that, the right to publish and the whistleblower protection?

Mr. GUEST. Well, I agree with both of those and that is all part

of our notion that there ought to be real transparency about the

full information that is available for drugs. Whether it is all clinical

trials being public or those who looked at the drug at the FDA and

being able to say what they feel about the drug without being in

fear of loss of their job, the goal is to get that information out

there. We are also supporting, as I said in my testimony, that the

action letters that the FDA produces when they approve a drug,

that that information also ought to be public and the fact that

some people may have dissented in their review. So again, it is all

out there so that the public knows, doctors know, and especially

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importantly, that other researchers know so they can work with

that information at an early stage to either identify or dispel the

notion that there may be safety problems. So for all of those reason, we certainly support that notion.

Ms. SCHAKOWSKY. I wanted to ask a bit about the direct-to-consumer advertising. And again, Dr. Zuckerman, I was looking at

this document. You talk about that there is going to be—we are

going to be seeing, or maybe it is already out and I have missed,

campaigns for gastric lap bands, for Botox, for Juvederm, and that

there is also going to be an ad campaign for silicone gel breast implants, and that the individuals who give those testimonials are

then given free treatment. I don’t know. It raises, to me, some ethical questions, but I am wondering—and also, certainly, potential

health concerns. I wondered if you would comment on that.

Ms. ZUCKERMAN. Yes, and I got that information from the company’s own Web site. There is one company that sells all of those

products, Allergan, and it just happens that this one company has

decided that direct-to-consumer ads are the way to go, especially

for aging baby boomers, and so they are putting a lot of money into

really a very attractive ad, an ad campaign. I have seen them on

TV. They have a Web site and it says right on there that at least

some of the patients who are giving testimonials have gotten free

treatment. And as you can imagine, free treatment for some of

these things are thousands of dollars, worth a lot of money for

what is essentially 2 minutes of taped testimonial.

So there is the concern about—primarily about the fact that

these kinds of ads are showing beautiful people very happy and

they don’t have the risk information provided and maybe they will

have, for more information, see our Web site. Or, for more information, see this month’s issue of Ladies Home Journal. But they are

not providing real risk information. It is not really educating consumers. It is selling a product.

Ms. SCHAKOWSKY. And we baby boomers, who are on a neverending quest for the fountain of youth, it seems like they may be

appealing in a way that could be dangerous to our health.

Ms. ZUCKERMAN. Yes, it really does make it look very quick and

easy, whether it is a gastric lap band, which is far from quick and

easy, or Juvederm, which is an injection into the face for wrinkles.

It is like putting on baby cream or something. I mean, it looks very

simple and it doesn’t tell you what the risks are.

Ms. SCHAKOWSKY. Thank you. Thank you, Mr. Chairman.

Mr. PALLONE. Thank you. Mr. Burgess.

Mr. BURGESS. Thank you, Mr. Chairman. Dr. Loew, you heard a

minute ago a comment made that the Reagan-Udall bill on steroids

would be a better way to go with our approach to the FDA. Is that

a statement that you would agree with?

Ms. LOEW. I think it is where you fundamentally think about the

sort of a system of drug development and approval and managing

drugs in the post-marketing setting. There is sort of a big picture

hierarchy that is very informative. Essentially, through the development process and into the post-marketing setting, we are doing

two things that are distinct and we need to think about a little differently. One is that we are in the process of sort of assessing and

managing things that we know about that. Those can be risks.

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Those can also be benefits as well, things that we are trying to determine.

The other thing that we are trying to do is to detect unknown

risks. So we are in a detection mode as well. And the tools to do

those things are quite different, and what FDA has attempted to

do through their Critical Path Initiative, which we strongly support, is to develop a new suite of technologies to support both of

those things. And so the concept of the Reagan-Udall Institute as

a mechanism to further evolve these technologies, and I think particularly relevant to some of the discussions today and also the

drug safety hearing that this committee recently held, the concept

of developing new tools to monitor risks in the post-marketing setting, through public/private partnership involving many stakeholders, I think is something that is very valuable and that we would

very much support.

Mr. BURGESS. Going further into the bill that deals with the risk

evaluation and mitigation, what is your opinion about that? Is it

overly burdensome? Does it hit the mark?

Ms. LOEW. I think it is a question of focus. Certainly, I think we

applaud the committee’s efforts to increase the tools available to

FDA to manage products in the post-marketing setting and particularly to manage product risks. However, I think there are a couple

of things that are important to note. First, focus is important. It

would be, I think, unproductive and in fact counterproductive to

public health to have FDA’s resources thinly spread across all products, when as a matter of practice, they could focus on products

and focus more effort and more focused safety activities on products where there are known risks that they wish to continue to

manage and assess in the marketplace.

In addition, to go back to the principles that I just set forth to

you, we do need to develop new systems to improve the detection

of unknown risks. But I think the current construct for the REMS

is certainly not an appropriate way to do that and would just lead

to unnecessary diversion and dilution of FDA’s resources.

Mr. BURGESS. It almost strikes me as if we might be over-legislating and there might be the possibility to take some of the reasonable approaches in the REMS bill and incorporate that into the

Reagan-Udall Institute as a single package to try to get the results

that we all want.

Ms. LOEW. I think there are a couple of things that I would specifically suggest. There are almost certainly targeted additional authorities that FDA could use productively in the post-marketing

setting to help manage drug risks. Those relate to use of post-marketing studies when there is a serious risk that FDA perceives with

a product that needs to be assessed. The second is the use of an

expedited labeling authority for the FDA to ensure that, in the

presence of risk, they are able to go through a process, in discussion with a company, that will bring about rapidly a change to the

label that physicians then use to inform their prescribing decisions

with patients. And the third is some great focus used in distribution restrictions.

So on the one hand we have, I think, real sort of focused powers

that we could give FDA to help. On the other hand, under the concept of the Reagan-Udall Institute that you described, the idea of

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evolving new technologies and new tools to try and assess risk in

the post-marketing setting is a very valid one and I think one that

we would certainly support augmenting.

Mr. BURGESS. Thank you. And I thank all of you for your testimony today. It really has been very interesting to listen to. Mr.

Walker, I wanted to ask you a question. You heard referenced earlier the articles in the New York Times yesterday.

Mr. WALKER. Yes.

Mr. BURGESS. And your opinion about the conflict of interest

being along the ideological lines, when you read that article, was

that something that concerned you, that there was some of this ideological restriction involved?

Mr. WALKER. It concerned me so much that I immediately wrote

an e-mail to the author. And there is an ideological problem, but

there is also a misperception of what the job of the FDA is and

what the jobs of the various people within the structure of the FDA

are. The FDA is not a democracy. It is an executive branch agency.

They have to make extremely important decisions and they have

to be decisions that the public can rely on. We can’t have 10 FDAs

within the FDA. We can’t have anyone who works there deciding

they are going to the press and make their own judgment about an

FDA decision. I think what happened with Avandia is, again, another great reason why the FDA is far from perfect, but it is our

FDA and we have to figure out a way to make it better and we

have to figure out a way to make it reliable.

Now to expand on that a little bit more. I own a business. I have

been managing scientists for 24 years. Just because someone is a

scientist and just because someone feels strongly about their opinion does not mean their opinion is right and it does not mean that

it is actionable. And there is a person who was Dr. Lang’s boss,

whose job it was to make those decisions and it was his or her responsibility to do that. Now, they have made the wrong one, but

at that time, that decision may not have been actionable. And what

bothered me the most about the article was that there are people

that could have given the author that side of the story and it

wasn’t in the article.

Mr. BURGESS. Well, I would agree with you. I would have never

thought I would have come down on the side of defending the FDA,

but it is funny how things turn out, isn’t it, sir?

Mr. WALKER. And a very strange day for me.

Mr. PALLONE. We have got to move on here, gentlemen. Thank

you. Mrs. Capps.

Mrs. CAPPS. Dr. Zuckerman, I have only 5 minutes, but I can’t

help but offer you a short time, if you wish, to respond to that last

statement. But I did want to ask you about advisory committees.

Ms. ZUCKERMAN. OK. Well, I will respond. Thank you. Metaanalysis is a respected, appropriate statistical analysis and what it

does it combines a lot of small studies that are too small to have

appropriate power for statistical significance and you put them all

together and it is a legitimate way. It so happens that my dad was

taking Avandia, so I am particular interested in that particular

issue because he was swelling up. His whole body was swelling up

and now I know why. But the doctor just kept him on it because

she thought this was a known side effect and that is OK.

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So just to quickly say there are different opinions in science. Yes,

FDA has to make a decision, but if a scientist disagrees and then

they are punished for it, that is a different issue.

Mrs. CAPPS. Thank you. I wanted to also follow up with you, if

I could, on the questioning I gave to Dr. Lutter this morning and

maybe it was my way I did it, but I wasn’t particularly satisfied

with that answer. In your testimony, I was pleased to see that you

mention the need for members of the FDA advisory panels who

have the need to have members who have no conflicts of interest,

and I understand that your organization, the National Research

Center for Women and Families, has done some research on advisory committee meetings and patterns in participation among

members. So I would like to give you the chance to explain briefly,

again, there is not much time, the results of the study that you

conducted, why it illustrates the importance of prohibiting scientists with conflict of interest from not only voting but also being

part of the discussion because of that persuasive ability? And also,

could you touch on the inadequacies of posting vacancies? Again,

I wasn’t satisfied with the response. The inadequacies of posting

vacancies without outreach or some kind of—particular to academia.

Ms. ZUCKERMAN. Yes. Most people in academia do not even know

that there are advisory committees at the FDA and that they could

participate in them. So if there is no outreach, a whole lot of people

will never volunteer, will never self-select. The study that we did

looked at about a third of all the advisory committee meetings held

between 1998 and 2005, so it was 89 meetings at that time. And

we looked at randomly-selected committees and we found that the

vast majority of advisory committees were recommending approval,

usually unanimously. And when they weren’t unanimous decisions,

they were usually very lopsided. There were very few where you

had a sense that there was a lot of dissention and discussion going

on.

So what we found was that one or two people could really control

the outcome of any of the votes, because the first people to talk and

the people who talked the most were frequently people who had a

lot of direct knowledge from financial ties that they had to the company because they had been paid to speak about a product, had received honoraria and so on.

So it was clear that it doesn’t matter if the minority of people

on a committee have conflicts of interest. Even just one or two people have a lot of sway. And it is a consensus-driven experience. You

don’t have a lot of argument. It is a very collegial consensus-driven

process and very frequently does end up with everyone agreeing to

something.

The other thing that I wanted to mention and I do have copies

of the report, it is filled with direct quotes that we got from the

FDA transcripts, where you have scientists and doctors saying

things like I am really not persuaded that this product works, but

I am going to recommend approval anyway. Or they will say, gee,

I am not sure if this is going to work out, but I hope that it will

and I hope that post-market studies will show that it will. And so

you have people recommending approval who don’t actually think

the product is proven safe or effective, and the FDA is sitting there

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and not saying a word. They are not saying, ‘‘well, but you should

judge it on whether you think it is safe or whether you think it is

effective.’’

So for whatever reason, there is a lot of decisionmaking going on

at the advisory committee meetings that don’t seem in the best interest of patients, because it is not based on whether a product is

proven safe or effective, and a lot of people being persuaded by

other people on the panel to vote a particular way.

Mrs. CAPPS. Thank you very much. I want to make sure, Mr.

Chairman, that we have that report entered into the record, and

I just want to get on the record, also, I don’t have time, Mr. Guest,

and I don’t know if we will do another round, but I wanted to express my support for the clinical trial database in the discussion

drafts and I wanted you, in writing, if you can, to present a rebuttal to an argument that even the publishing of the presence of a

clinical trial is proprietary information. I would like to have more

information like that in our records. And can you also write about

why it is important for the public health to have a clinical trials

database? I am particular interested in how all results, positive

and negative, will boost public health. And I think we need to have

on the record, even if a drug or a device isn’t approved, can’t the

results of clinical trials perhaps be useful for future innovation and

research? And I know there is not time.

Mr. GUEST. I would be happy to supply a prompt and full response to your questions.

Mrs. CAPPS. Thank you very much.

Mr. PALLONE. I just have to ask, Mrs. Capps, that the report that

you are asking to be put in the record is which one?

Mrs. CAPPS. The one just now that Dr. Zuckerman mentioned.

Maybe it is already in the record.

Mr. PALLONE. Is it something that we have in front of us, Dr.

Zuckerman, or not?

Ms. ZUCKERMAN. I didn’t include it as part of my testimony, but

I am happy to provide it for the record. I have copies here.

Mrs. CAPPS. It is the report of the National Research Center for

Women and Families on the advisory, on the study that they did

with all of the advisory committees that they reviewed.

Mr. PALLONE. OK. Without objection, we will include that.

Mrs. CAPPS. I would hope so, too. I think that would be an advantage as well.

Mr. PALLONE. Yes, we will get it and we will include it and we

will certainly make it available. Thank you. Thank you. Mr. Markey is here.

Mr. MARKEY. Thank you, Mr. Chairman, very much. Dr. Loew,

at the time of approval, did the FDA know that Vioxx was going

to cause heart attacks and hurt the many patients and families

that it did?

Ms. LOEW. I am not able to comment on a product-specific question. I am afraid I have no knowledge to answer that.

Mr. MARKEY. Dr. Loew, at the time of approval, did FDA know

that Paxil would actually increase the risk of suicide in kids and

result in many parents losing their children to suicide?

Ms. LOEW. I am not able to answer any product-specific questions.

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Mr. MARKEY. Dr. Loew, how about fen-phen, did the FDA know

about the problems there at the time of approval?

Ms. LOEW. Again, I am not in a position to answer any productspecific questions.

Mr. MARKEY. Dr. Loew, Avandia. Did the FDA know the harm

that Avandia was going to do to families in America at the time

that the FDA approved it?

Ms. LOEW. I am not in a position to answer any product-specific

questions.

Mr. MARKEY. Dr. Loew, I will inform you, then, Dr. Loew, that

at the time of approval, neither the companies, I don’t think the

companies, I hope the companies didn’t know, but the FDA did not

know about all of the risks of those drugs. Do you agree with that?

Ms. LOEW. I am not in a position to answer that question.

Mr. MARKEY. Yes, I am afraid that is the problem, that

PhRMA—I understand why PhRMA doesn’t want to have lifecycle

monitoring to continue to check in on these drugs to see their impact, and I understand PhRMA’s position. It is a legitimate position, but that is not the position which families in America want

for these drugs. They want ongoing monitoring of the drugs, after

they have been approved, to make sure that new and dangerous information hasn’t been developed. So your view is, is that correct,

Dr. Loew, if you could, that PhRMA wants to limit the REMS to

only those drugs with known serious risks at the time of approval,

is that correct?

Ms. LOEW. That is our position and there are currently a number

of processes that are in the post-marketing setting to continue to

monitor products to try and assess whether there are unknown

risks, to detect those risks and then to manage to deal with those.

So we actually do support ongoing monitoring, because that exists

today and companies do it in a very thorough and rigorous fashion.

In addition, we do support and companies do undertake substantial

post-marketing commitments. In fact, a recent study by the Tufts

Center showed that 73 percent of drug conducting post-marketing

studies, those involved in excess of 900 patients. Those are substantial clinical studies. That is in addition to very rigorous postmarketing monitoring, ongoing continuous assessments of adverse

event reporting from the passive systems.

In addition, we support, as I discussed earlier, development of

new technologies to assess risks. I think that it is widely acknowledged that there are limitations with the current passive adverse

event reporting system and we would certainly support, and particularly if we can in a public/private partnership involving all key

stakeholders, the evaluation and development of new technologies

to assess risk in the post-marketing setting.

Mr. MARKEY. So you object to the language which Mr. Waxman

and I have that is recommended by the Institute of Medicine, that

would require that the risks are put into a system to regularly review the drugs for the first couple of years that they are on the

market?

Ms. LOEW. I think there are a number of things. Firstly, there

is already, as I said, in place a system which requires regular assessments of events that are reported.

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Mr. MARKEY. No. Why do you object to our language? What is

the problem with our language?

Ms. LOEW. Specifically, with regard to the REMS, we believe that

the additional authority should be targeted on products where the

risks have previously been detected——

Mr. MARKEY. How can you know that, Doctor? You just told me

you don’t know anything about Vioxx, about Paxil, about fen-phen,

about Avandia. You just said you don’t know anything, even today,

after the fact, you don’t know anything.

Ms. LOEW. With the checks.

Mr. MARKEY. So how can you possibly identify the drugs that are

going to have the high risks? Don’t you need to put in place a system which is going to be able to monitor this risk to families? How

can you possibly determine which drugs are going to have these

high risks and which aren’t?

Ms. LOEW. With respect, I do not have specific knowledge about

specific products.

Mr. MARKEY. Precisely why you need a system.

Ms. LOEW. That is because I am not in a position to——

Mr. MARKEY. You are testifying on behalf of the industry. You

are here on the last hearing before we begin to mark up.

Ms. LOEW. Thank you. Right.

Mr. MARKEY. If you can’t testify on this issue, then no one in

your industry knows, because that is what we are debating.

Ms. LOEW. I can’t testify about policies. I cannot testify about

specific drug examples. What I can testify is that there is actual

pre-market testing of drugs provides indication of issues that

should be assessed in a post-marketing setting——

Mr. MARKEY. In order to have successful testimony, Doctor, you

are——

Ms. LOEW. In order to have legitimacy for supporting a new authority for post-marketing——

Mr. PALLONE. All right, we are over the time here, so I am going

to end it, although it was an exciting ending, I must say. Thank

you, Mr. Markey. Let me just say in closing, I want to remind all

of the members that you can submit additional questions for the

record to be answered by the witnesses. I will say to our witnesses,

you may get additional questions within the next 10 days and the

clerk will notify your offices if that is the case. I do want to thank

all of you for being here today. I thought this was a really good,

this panel as well as the FDA representative, this was a really

good analysis of our drafts and I appreciate the in-depth analysis

that you did give them. So thank you very much. And without objection, this meeting of the subcommittee is adjourned.

[Whereupon, at 2:00 p.m., the subcommittee was adjourned.]

[Material submitted for inclusion in the record follows:]

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