Abstract
After US Food and Drug Administration (FDA) approval of a new drug, sponsors can submit additional clinical data to obtain supplemental approval for use for new indications. To characterize pivotal trials supporting recent supplemental new indication approvals of drugs and biologics by the FDA and to compare them with pivotal trials that supported these therapeutics' original indication approvals. This is a cross-sectional study characterizing pivotal trials supporting supplemental indication approvals by the FDA between 2017 and 2019 and pivotal trials that supported these therapeutics' original indication approvals. Data analysis was performed from August to October 2020. Number and design of pivotal trials supporting both supplemental and original indication approvals. From 2017 to 2019, the FDA approved 146 supplemental indications for 107 therapeutics on the basis of 181 pivotal efficacy trials. The median (interquartile range) number of trials per supplemental indication was 1 (1-1). Most trials used either placebo (77 trials [42.5%; 95% CI, 35.6%-49.8%]) or active comparators (65 trials [35.9%; 95% CI, 29.3%-43.1%]), and most of these multigroup trials were randomized (141 trials [99.3%; 95% CI, 96.0%-100.0%]) and double-blinded (106 trials [74.5%; 95% CI, 66.6%-81.0%]); 80 trials (44.2%; 95 CI, 37.2%-51.5%) used clinical outcomes as the primary efficacy end point. There was no difference between oncology therapies and those approved for other therapeutic areas to have supplemental indication approvals be based on at least 2 pivotal trials (11.5% vs 20.6%; difference, 9.1%; 95% CI, 2.9%-21.0%; P = .10). Similarly, there was no difference in use of randomization (98.3% vs 100.0%; difference, 1.7%; 95% CI, 1.6%-5.0%; P = .43) among multigroup trials, although these trials were less likely to be double-blinded (50.8% vs 92.3%; difference, 41.5%; 95% CI, 27.4%-55.5%; P < .001); overall, these trials were less likely to use either placebo or active comparators (64.9% vs 86.7%; difference, 21.8% 95% CI, 9.8%-33.9%; P < .001) or to use clinical outcomes as their primary efficacy end point (27.5% vs 61.1%; difference, 33.6%; 95% CI, 14.1%-40.9%; P < .001) and were longer (median [interquartile range], 17 [6-48] weeks vs 95 [39-146] weeks). Original approvals were more likely than supplemental indication approvals to be based on at least 2 pivotal trials (44.0% [95% CI, 33.7%-42.6%] vs 15.8% [95% CI, 10.7%-22.5%]; difference, 28.2%; 95% CI, 17.6%-39.6%; P < .001) and less likely to be supported by at least 1 trial of 12 months' duration (27.6% [95% CI, 17.9%-35.0%] vs 54.8% [95% CI, 46.7%-62.6%]; difference, 27.2%; 95% CI, 14.5%-37.8%; P < .001). Pivotal trial designs were otherwise not significantly different. These findings suggest that the number and design of the pivotal trials supporting supplemental indication approvals by the FDA varied across therapeutic areas, with the strength of evidence for cancer indications weaker than that for other indications. There was little difference in the design characteristics of the pivotal trials supporting supplemental indication and original approvals.
Highlights
To receive US Food and Drug Administration (FDA) approval for a new small-molecule or biologic drug, sponsors must submit “adequate and well controlled investigations”1 to demonstrate the drug’s efficacy and safety
There was no difference between oncology therapies and those approved for other therapeutic areas to have supplemental indication approvals be based on at least 2 pivotal trials (11.5% vs 20.6%; difference, 9.1%; 95% CI, 2.9%-21.0%; P = .10)
Pivotal trial designs were otherwise not significantly different. These findings suggest that the number and design of the pivotal trials supporting supplemental indication approvals by the FDA varied across therapeutic areas, with
Summary
To receive US Food and Drug Administration (FDA) approval for a new small-molecule or biologic drug, sponsors must submit “adequate and well controlled investigations” to demonstrate the drug’s efficacy and safety. Approximately one-third of new approvals are based on a single pivotal trial, whereas nearly one-half are based on trials solely focused on surrogate markers of disease, as opposed to clinical outcomes.. Approximately one-third of new approvals are based on a single pivotal trial, whereas nearly one-half are based on trials solely focused on surrogate markers of disease, as opposed to clinical outcomes.2 This flexibility highlights the FDA’s ability to adapt its standards to the clinical context and use of the drug or biologic under consideration.. Less is known about the clinical trial evidence that supports supplemental indication approvals by the FDA, which are required when sponsors intend to add use of the originally approved drug for new clinical indications or in specific subpopulations to the labeling. In 2014, the FDA approved 40 new supplemental indications compared with 44 new drug approvals. Supplemental new indication approvals are common among oncology therapies, such as the anti-programmed death–1 biologic pembrolizumab (Keytruda), which was originally approved for the treatment of advanced melanoma in 2014 and has since been approved for 19 additional clinical indications. it is critical that both new and supplemental indication approvals are based on strong evidence, because certain therapeutics may be prescribed more often for their supplemental indications than for their initially approved indication. Supplemental indication approval by the FDA is critical for ensuring insurance coverage, especially for more expensive biological therapies and those used for oncology, where effective treatment options may be more limited.
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