Draft Guidance For Industry Research Articles

Decision taking in corneal refractive surgery.

A 27-year-old woman who wants to get rid of contact lenses and spectacles was seen at our clinic. She had strabismus surgery as a child and was patched for the right eye but now shows mild nondisturbing exophoria. Infrequently, she likes to box in the sports school. Her corrected distance visual acuity at presentation in the right eye was 20/16 with -3.75 -0.75 × 50 and in the left eye 20/16 with -3.75 -1.25 × 142. Her cycloplegic refraction in the right eye was -3.75 -0.75 × 44 and in the left eye was -3.25 -1.25 × 147. The left eye is the dominant eye. The tear break-up time was 8 seconds in both eyes, and the Schirmer tear test was 7 to 10 mm in right and left eyes, respectively. Pupil sizes under mesopic conditions were 6.62 mm and 6.68 mm. The anterior chamber depth (ACD) (measured from the epithelium) in the right eye was 3.89 mm and in the left eye was 3.87 mm. The corneal thickness was 503 μm and 493 μm of the right and left eye, respectively. Corneal endothelial cell density was on average 2700 cells/mm2 for both eyes. Slitlamp biomicroscopy showed clear corneas and a normal flat iris configuration. Supplemental Figures 1 to 4 (available at http://links.lww.com/JRS/A818, http://links.lww.com/JRS/A819, http://links.lww.com/JRS/A820, and http://links.lww.com/JRS/A821) show the corneal topography and Belin-Ambrósio deviation (BAD) maps at presentation of the right eye and left eye, respectively. Would you consider this patient a candidate for corneal refractive surgery (eg, laser-assisted subepithelial keratectomy, laser in situ keratomileusis [LASIK], or small-incision lenticule extraction [SMILE] procedure)? Has your opinion changed given the recent opinion of the U.S. Food and Drug Administration (FDA) regarding LASIK?1 The patient herself is slightly favoring an implantation of a phakic intraocular lens (pIOL), as she prefers something reversible. Would you implant a pIOL, and which type of IOL, for this level of myopia? What is your diagnosis or are additional diagnostic methodologies needed to establish a diagnosis? What is your treatment advice for this patient? REFERENCES 1. U.S. Food and Drug Administration, HHS. Laser-assisted in situ keratomileusis (LASIK) lasers-patient labeling recommendations; draft guidance for industry and food and drug administration staff; availability. July 28, 2022, Federal Register; 87 FR 45334. Available at: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/laser-assisted-situ-keratomileusis-lasik-lasers-patient-labeling-recommendations Accessed January 25, 2023.

Using the Bayesian detection of potential risk using inference on blinded safety data (BDRIBS) method to support the decision to refer an event for unblinded evaluation.

In the Sponsor Responsibilities-Safety Reporting Requirements and Safety Assessment for IND and Bioavailability/Bioequivalence Studies: Draft Guidance for Industry (June 2021) the Food and Drug Administration recommends that sponsors develop a Safety Surveillance Plan as a key element of a systematic approach to safety surveillance and describes two possible approaches to assess the aggregate safety data. One approach regularly analyzes unblinded serious adverse events (SAEs) by treatment group. The alternative approach prespecifies estimated background rates for anticipated SAEs in the study population (e.g., myocardial infarctions in an older adult population). If the event rate in the blinded data from the study population exceeds a "trigger rate," then an unblinded analysis by treatment group is conducted. The Bayesian detection of potential risk using inference on blinded safety data (BDRIBS) method has been previously described and offers a quantitative approach for assessing blinded events. In this article we provide a procedural workflow for blinded review of safety data that is consistent with the unblinding "trigger approach" for aggregate safety review. In addition, this publication contextualizes the use of BDRIBS within the broader safety surveillance framework, extends the method to allow for multiple studies, and offers examples of its use in various settings via an R-Shiny application that allows for dynamic visualization and assessment.

Scientific and Regulatory Considerations for the Approval of the First Generic Glucagon

Glucagon for Injection (NDA 020928) is a polypeptide hormone identical to human glucagon approved 20 years ago for severe hypoglycemia in patients with diabetes mellitus. On Dec 28, 2020, the U.S. FDA approved the first generic version of glucagon for injection USP, 1 mg/vial packaged in an emergency kit. The generic and the reference listed drug (RLD) version, i.e., the innovator version, of glucagon were each produced through different manufacturing processes. The RLD version of glucagon is produced via recombinant DNA in yeast while the generic version of glucagon is produced by peptide synthesis. The FDA published its current thinking on how to ensure sameness between the generic and innovator peptide products prepared with different manufacturing processes in a Draft Guidance for Industry: Submission of Abbreviated New Drug Applications for Certain Highly Purified Synthetic Peptide Drug Products, which applies to five peptide drug products, including glucagon. In this presentation, we aim to provide an overview of the regulatory recommendations for submitting generic glucagon drug products for approval, as outlined in the aforementioned draft guidance. Although glucagon may be produced using different manufacturing processes, the sameness in glucagon can be adequately demonstrated using analytical methods, which involve demonstrating physicochemical properties, as well as primary and secondary structures, oligomers and aggregation states. Biological assays may also be used as part of the demonstration of active pharmaceutical ingredient sameness. Synthetic glucagon may have different impurity profiles when compared to the RLD recombinant product. As part of the ANDA review, impurities in the synthetic drugs are analyzed and controlled, in addition, the potential immunogenicity of new impurities, which are not in the RLD products, are assessed and compared using non-clinical assays. In this work, we will discuss non-clinical assays for assessing the immunogenicity risk of these impurities, for both adaptive and innate immune responses. In conclusion, the sameness of an approved generic synthetic glucagon to an RLD can be adequately established through various analytical methods and biological assays.

Continuous twin screw granulation: Impact of microcrystalline cellulose batch-to-batch variability during granulation and drying – A QbD approach

Despite significant advances in the research domain of continuous twin screw granulation, limited information is currently available on the impact of raw material properties, especially considering batch-to-batch variability. The importance of raw material variability and subsequent mitigation of the impact of this variability on the manufacturing process and drug product was recently stressed in the Draft Guidance for Industry on Quality Considerations for Continuous Manufacturing by the U.S. Food and Drug Administration (FDA). Therefore, this study assessed the impact of microcrystalline cellulose (MCC) batch-to-batch variability and process settings in a continuous twin screw wet granulation and semi-continuous drying line. Based on extensive raw material characterization and subsequent principal component analysis, raw material variability was quantitatively introduced in the design of experiments approach by means of t1 and t2 scores. L/S ratio had a larger effect on critical granule attributes and processability than screw speed and drying time. A large impact of the t1 and t2 scores was found, indicating the importance of raw material attributes. For the studied formulation, it was concluded that MCC batches with a low water binding capacity, low moisture content and high bulk density generated granules with the most desirable quality attributes. Additionally, an innovative and quantitative approach towards mitigating batch-to-batch variability of raw materials was proposed, which is also applicable for additional excipients and APIs.

Statistical Considerations in Assessing In Vivo Adhesion with Transdermal and Topical Delivery Systems for New Drug Applications.

Proper adhesion plays a critical role in maintaining a consistent, efficacious, and safe drug delivery profile for transdermal and topical delivery systems (TDS). As such, in vivo skin adhesion studies are recommended by regulatory agencies to support the approval of TDS in new drug applications (NDAs). A draft guidance for industry by the US Food and Drug Administration outlines a non-inferiority comparison between a test product and its reference product for generic TDS in abbreviated new drug applications (ANDAs). However, the statistical method is not applicable for evaluating adhesion of TDS for NDAs, because no reference product exists. In this article, we explore an alternative primary endpoint and a one-sided binomial test to evaluate in vivo adhesion of TDS in NDAs. Statistical considerations related to the proposed approach are discussed. To understand its potential use, the proposed approach is applied to data sets of in vivo adhesion studies from selected NDAs and ANDAs.

Advancing regulatory science and assessment of FDA REMS programs: A mixed-methods evaluation examining physician survey response.

Food and Drug Administration's (FDA) Draft Guidance for Industry on pharmaceutical REMS (Risk Evaluation and Mitigation Strategies) assessment and survey methodology highlights physician knowledge-attitudes-behaviors (KAB) surveys as regulatory science tools. This mixed-methods evaluation advances regulatory science and the assessment of FDA REMS programs when using physician surveys. We: (1) reviewed published physician survey response rates; and (2) assessed response bias in a simulation study of secondary survey data using different accrual cut-off strategies. A systematic literature review was conducted of US physician surveys (2000-2014) on pharmaceutical use (n = 75). Kruskal-Wallis tests were used to examine the relationships between response rates and survey design characteristics. The simulation was conducted using secondary data from a population-based physician KAB survey on diabetes risk management with antipsychotic use in Missouri Medicaid (n = 973 accrued over 30 weeks). Survey item responses were compared using Pearson's chi-square tests for two faster completion simulations: Fixed Sample (n = 300) and Fixed Time (8 weeks). Survey response rates ranged from 7% to 100% (median = 48%, IQR = 34%-68%). Surveys of targeted populations and surveys using member lists were associated with higher response rates (p = 0.02). In the simulation, 9 of 20 (45%) KAB items, including diabetes screening advocacy, differed significantly using the smaller Fixed Sample strategy (achieved in 12 days) versus full accrual. Fewer response differences were found using the Fixed Time strategy (2 of 20 [10%] items). Published data on physician surveys report low response rates with most associated with the sample source selected. FDA REMS assessments should include formal evaluation of survey accrual and response bias.

An Assessment of Concerns Regarding New Regulatory Guidance for Combination Products: A Review of the Submissions Made to the FDA Regarding Their Proposed Draft New Guidance on Human Factors Studies for a Combination Product in an Abbreviated New Drug Application.

The US Food and Drug Administration (FDA) put out a call for comments on new draft guidance for industry "Comparative Analyses and Related Comparative Use Human Factors Studies for a Drug-Device Combination Product Submitted in an ANDA." This call for comments elicited 7 submissions from various organizations in the field of health care products. This article reports on a review conducted on these 7 submissions. The purpose of this review was to identify any commonalities across the different submissions and determine if there was consensus on any point or aspect of the draft guidance. To identify any commonalities, a heat map plotting the lines of the draft guidance that had raised a comment/suggestion was produced. Also, a thematic analysis was conducted on the comments/suggestions. In total the 7 submissions produced 137 suggestions. The heat map revealed that these suggestions did not focus on any single part of the guidance but were spread throughout the guidance. The thematic analysis conducted on the suggestions found a number of distinct trends. These trends were grouped into 10 primary themes, each with a number of subthemes. It was concluded that guidance from the FDA on this matter is warranted and would be appreciated. However, it was also concluded that based on the distinct trends identified in the suggestions, there are issues that the FDA may wish to consider before publishing their final guidance.

Comparisons of false negative rates from a trend test alone and from a trend test jointly with a control-high groups pairwise test in the determination of the carcinogenicity of new drugs

ABSTRACTInterest has been expressed in using a joint test procedure that requires that the results of both a trend test and a pairwise comparison test between the control and the high groups be statistically significant simultaneously at the levels of significance recommended in the FDA 2001 draft guidance for industry document for the separate tests in order for the drug effect on the development of an individual tumor type to be considered as statistically significant. Results of our simulation studies show that there is a serious consequence of large inflations of the false negative rate through large decreases of false positive rate in the use of the above joint test procedure in the final interpretation of the carcinogenicity potential of a new drug if the levels of significance recommended for separate tests are used. The inflation can be as high as 204.5% of the false negative rate when the trend test alone is required to test if the effect is statistically significant. To correct the problem, new sets of levels of significance have also been developed for those who want to use the joint test in reviews of carcinogenicity studies.

Developing drugs for treatment of atopic dermatitis in children (≥3 months to <18 years of age): Draft guidance for industry

Atopic dermatitis is the most common chronic skin disease, and it primarily affects children. Although atopic dermatitis (AD) has the highest effect on burden of skin disease, no high-level studies have defined optimal therapy for severe disease. Corticosteroids have been used to treat AD since the 1950s and remain the only systemic medication with Food and Drug Administration approval for this indication in children, despite published guidelines of care that recommend against this option. Several clinical trials with level 1 evidence have supported the use of topical treatments for mild to moderate atopic dermatitis in adults and children, but these trials have had little consistency in protocol design. Consensus recommendations will help standardize clinical development and trial design for children. The Food and Drug Administration issues guidance documents for industry as a source for "the Agency's current thinking on a particular subject." Although they are nonbinding, industry considers these documents to be the standard for clinical development and trial design. Our consensus group is the first to specifically address clinical trial design in this population. We developed a draft guidance document for industry, Developing Drugs for Treatment of Atopic Dermatitis in Children (≥3 months to <18 years of age). This draft guidance has been submitted to the Food and Drug Administration based on a provision in the Federal Register (Good Guidance Practices).

“The safety of sodium reduction in the food supply: A cross-discipline balancing act”—Workshop proceedings

ABSTRACTThis workshop, jointly presented by the ILSI North America Technical Committees on Food Microbiology and Sodium, aimed to provide greater knowledge and appreciation of the opportunities and challenges facing the food industry in answering the public health community's call to reduce sodium levels in the food supply. One major challenge is finding effective substitutes for the various antimicrobial and functional roles that sodium plays across different food categories. Sodium plays a critical role in retarding the growth of pathogens and food spoilage bacteria. Moreover, taste is an important factor for consumers when they choose food products, and the flavor changes that occur when salt is reduced or replaced must be considered and ingredients and processes adjusted accordingly. The workshop provided a platform for a multidisciplinary discussion among the microbiology, food science, nutrition, and public health communities to share progress and propose solutions, including the formation of public-private partnerships, to develop coordinated and comprehensive strategies. This paper provides an overview of the issues raised, rather than a specific summary of workshop discussions. The Food and Drug Administration's Draft Guidance for Industry on voluntary sodium reduction and the 2015 US Dietary Guidelines for Americans were released subsequent to the workshop and are also discussed.

Biomarker measurements: how far have we come and where are we heading?

Biomarker measurements: how far have we come and where are we heading?

Acrylamide in Food – EU versus FDA Approaches

Acrylamide is a versatile organic compound that finds its way into many products in our everyday life. The presence of acrylamide in foods dates from 2002, when a series of studies published in Sweden, confirmed its presence in high temperatures processed foods. At EU level, first adopted measure was Commission Recommendation on the monitoring of acrylamide levels in food , on May 2007, extended then by Commission Recommendation 2010/307/EU . European Food Safety Authority (EFSA) then, collected and compiled data, each year (2007-2010), and published an annual report. On January 2011 was adopted the Recommendation on the investigations into the levels of acrylamide in food and then, on November 2013 was adopted Commission Recommendation 2013/647/EU on investigation into levels of acrylamide in food . Based on these, EFSA had published, in June 2015 a comprehensive risk assessment on acrylamide in food. The FDA first published a draft regarding Detection and Quantitation of Acrylamide in Foods , in 2003 followed in 2004 by the Action Plan for Acrylamide in Food . In 2006 FDA published Survey Data on Acrylamide in food then in 2009, in August (updated in November) a Federal Register Notice entitled: Acrylamide in food: Request for comments and for scientific data and information . Their findings have been materialized, in November 2013, into a powerful tool for industry: Draft Guidance for industry: Acrylamide in Foods . Despite research implications that exposure to acrylamide from food is safe, some consumers may choose to take measures to further reduce their acrylamide exposure.

Sample Size Re-estimation Designs In Confirmatory Clinical Trials—Current State, Statistical Considerations, and Practical Guidance

A sample size re-estimation (SSR) design is a flexible, adaptive design with the primary purpose of allowing sample size of a study to be reassessed in the mid-course of the study to ensure adequate power. In real world drug product, biologic, and device development, there may be large uncertainty in key factors that drive the sample size estimation for a confirmatory clinical trial. For example, early phase studies may have encouraging results but could be of shorter duration, or use a different endpoint than what is required for confirmatory phase clinical trials. The negative impact of high uncertainty at design stage for a confirmatory trial can be mitigated by an SSR design. Recent surveys have reported an encouraging upward trend in the use of SSR designs in clinical trials since the release of the draft guidance for adaptive design clinical trials for drugs and biologics by the U.S. Food and Drug Administration in 2010 (U.S. Food and Drug Administration (FDA) (February, 2010), Draft Guidance for Industry: Adaptive Design Clinical Trials for Drugs and Biologics). To support broad understanding and acceptance of SSR designs in confirmatory settings, especially unblinded SSR designs, we summarize statistical methods pertaining to SSR designs, including recent development in this field, and discuss design alternatives among blinded SSR, unblinded SSR, and conventional group sequential designs. To support appropriate implementation of SSR designs, we make recommendations on operational logistics for trial conduct based on accumulated experience in recent years, and provide points to consider for final data analysis and reporting for studies where the sample size has been increased following either a blinded or an unblinded SSR algorithm.

Drugs and Diseases Interacting with Cigarette Smoking in US Prescription Drug Labelling.

The US Food and Drug Administration (FDA) draft guidance for industry on drug interaction studies recommends, but does not mandate, that both cigarette smokers and non-smokers can be used to study drug metabolism in clinical trials, and that important results related to smoking should be included in drug labelling to guide medication usage. This study aimed to provide a comprehensive review of drugs or diseases interacting with smoking, as presented in all US drug labelling. The 62,857 drug labels deposited in the FDA Online Label Repository were searched using the keywords 'smoke', 'smoker(s)', 'smoking', 'tobacco' and 'cigarette(s)' on 19 June 2014. The resultant records were refined to include only human prescription drug labelling, for manual examination. For 188 single-active-ingredient drugs and 36 multiple-active-ingredient drugs, the labelling was found to contain smoking-related information. The pharmacokinetics of 29 and 21 single-active-ingredient drugs were affected and unaffected, respectively, by smoking. For the remaining drugs, the provided information related to smoking affecting efficacy, safety or diseases but not pharmacokinetics. Depending on the nature of specific drugs, the perturbation in pharmacokinetic parameters in smokers ranged from 13 to 500%, in comparison with non-smokers. Dosage modifications in smokers are necessary for four drugs and may be necessary for six drugs, but are unnecessary for seven drugs although the pharmacokinetic parameters of four of them are affected by smoking. Cigarette smoking is a risk factor for 16 types of diseases or adverse drug reactions. For one single-active-ingredient contraceptive drug and 10 multiple-active-ingredient contraceptive drugs, a black box warning (the FDA's strongest safety warning) is included in the labelling for increased risks of heart attacks and strokes in female smokers, and "women are strongly advised not to smoke" when using these drugs. This study presents the first comprehensive overview of cigarette smoking interacting with drugs and/or diseases, as presented in US drug labelling.

A Note on Breast Cancer Trials With pCR-Based Accelerated Approval

Accelerated approval by the Food and Drug Administration (FDA), under the agency’s Fast Track review designation, allows early approval of drugs to treat serious diseases and fill an unmet medical need based on a surrogate endpoint. In May 2012, FDA issued a draft Guidance for Industry on the accelerated approval of breast cancer drugs based on the surrogate endpoint “pathologic complete response” (pCR). The research reported in this article investigates potential issues in designing clinical studies for pCR-based accelerated approval. The correlation between pCR and long-term survival was investigated. Two sample comparisons based on a conditional survival model under different assumptions were performed and are discussed along with simulation results. The findings from this research may shed some light on the implementation of the FDA draft guidance.

Compliance Within Medical Information and the Emergence of a Medical Information-Dedicated Compliance Person: A Benchmarking Survey.

In light of the increasing scrutiny by governing authorities, compliance requirements for medical information (MI) departments have increased over the past few years. In response to the Food and Drug Administration (FDA) draft guidance for industry, entitled Responding to Unsolicited Requests for Off-label Information About Prescription Drugs and Medical Devices, MI groups may be changing their policies and procedures to further ensure compliance. The primary objective of this study was to benchmark industry-specific practices related to maintaining compliance in MI, particularly whether there is an emergence of a dedicated compliance person working within the MI department, whom we refer to as the MI-dedicated compliance person hereafter. A secondary objective was to identify changes to MI interactions with internal and external stakeholders that occurred in the last 2 years in response to an evolving regulatory climate. A web-based survey was disseminated to MI professionals from 49 companies between December 2012 and February 2013. Practices that were assessed include MI team training, monitoring, audits, and creation of letter responses. The results may be useful for MI groups interested in changing or comparing their compliance practices to those currently utilized by their peers.

Key Considerations in the Transition to Risk-Based Monitoring.

In the 2 years since publication of the European Medicines Agency's "Reflection Paper on Risk Based Quality Management in Clinical Trials" and US Food and Drug Administration's "Draft Guidance for Industry: Oversight of Clinical Investigations-A Risk-Based Approach to Monitoring," the methodologies, products, and services for risk-based monitoring have proliferated and diversified. The biopharmaceutical industry can choose from a variety of general approaches and specific practices. This article provides a framework to assist biopharmaceutical companies in selecting and implementing a risk-based monitoring approach or selecting a service provider. The framework includes discussion of different approaches to source data verification but also discusses other important dimensions of risk-based monitoring: individualization of the monitoring approach for each study; error detection and correction, including but not limited to source data verification; real-time quality management; error prediction and prevention; and adoption and implementation.

(404) Extraction testing of a novel extended-release, abuse-deterrent formulation of morphine, Morphine ARER, in common household solvents

Abusers of prescription opioids commonly extract the active ingredient from non-abuse deterrent, extended-release formulations to bypass the intended slow release characteristics and increase the opioid’s bioavailability for injection, smoking, or oral administration. Abuse deterrent products are designed to increase the hurdles required to extract the active ingredient with the ultimate goal of decreasing the misuse and abuse of these formulations for all routes of administration dependent on extraction. The FDA’s Draft Guidance for Industry, Abuse-Deterrent Opioids – Evaluation and Labeling (January 2013) recommends that laboratory-based in vitro manipulation and extraction studies be performed to evaluate the physical characteristics of a novel product and to guide the downstream pharmacokinetic (PK) and clinical abuse studies. To assess the abuse deterrent properties of an investigational extended-release formulation of morphine, Morphine ARER, in vitro laboratory testing was performed to assess the extractability of morphine. Five intact and five finely crushed tablets were dissolved in 30 mL of household solvents including water, saline solution, vinegar, coke, pH 2, pH 4, pH 6, pH 10, 5% ethanol, 10% ethanol, 20% ethanol, 40% ethanol, and 90oC water. The percent of morphine released was assessed via liquid chromatography. Morphine ARER did not dose dump morphine under any condition or solution. Water was found to be the best solvent for extraction. Interestingly, the amount of morphine released was largely similar between crushed and intact tablets and reduced in increasing concentrations of ethanol. These data clearly indicate that Morphine ARER was highly resistant to extraction and did not result dose dumping either from intact or ground tablets, even at 30 minutes, which is longer than an abuser would be expected to wait. Funding Provided by Inspirion Delivery Technologies LLC.

Current FDA Guidance on Whole Grain Labeling

This presentation will present the U.S. Food and Drug Administration's (FDA's) current thinking on how to label whole grain foods and what foods are considered whole grain. The presentation will also discuss the agency’s draft guidance and provide examples to assist manufacturers in labeling their products about the presence of whole grain ingredients. The FDA published a draft guidance for industry and FDA staff entitled “Whole Grain Label Statements” on February 17, 2006, which: • Represents the FDA’s current thinking • Doesn’t operate to bind the FDA or the public • Can use alternative approaches if satisfy applicable statutes and regulations

Secret ingredients: who knows what's in your food?

British chef and food activist Jamie Oliver ignited a firestorm in January 2011 when he mentioned on the Late Show with David Letterman that castoreum, a substance used to augment some strawberry and vanilla flavorings, comes from what he described as “rendered beaver anal gland.”1 The next year, vegans were outraged to learn that Starbucks used cochineal extract, a color additive derived from insect shells, to dye their strawberry Frappuccino® drinks2 (eventually, the company decided to transition to lycopene, a pigment found in tomatoes3). Although substances like castoreum and cochineal extract may be long on the “yuck factor,”4 research has shown them to be perfectly safe for most people; strident opposition arose not from safety issues but from the ingredients’ origins. But these examples demonstrate that the public often lacks significant knowledge about the ingredients in foods and where they come from. This is not a new development; the public relationship to food additives has a long history of trust lost, regained, and in some cases lost again. The Federal Food, Drug, and Cosmetic (FD&C) Act of 19385 was passed shortly after the deaths of 100 people who took an untested new form of a popular drug, which contained what turned out to be a deadly additive.6 The new law was consumer oriented and intended to ensure that people knew what was in the products they bought, and that those products were safe. The law has been amended over the years in attempts to streamline and bring order to the sprawling task of assessing and categorizing the thousands of substances used in foods, drugs, and cosmetics. One result of this streamlining is that under current U.S. law, companies can add certain types of ingredients to foods without premarket approval from the thin-stretched Food and Drug Administration (FDA). In other words, there are substances in the food supply that are unknown to the FDA. In 2010 the Government Accountability Office (GAO) concluded that a “growing number of substances … may effectively be excluded from federal oversight.”7 Is this a problem? The answer depends on whom you ask.