J K Aronson – The Hitchhiker’s Guide to Clinical Pharmacology Part 2

Jeff Aronson, Honorary Consultant Physician and Clinical Pharmacologist

 

 

 

How Drugs are Discovered and Developed

Jeffrey K Aronson

 

 

 

                                                                                                                          

Contents
1. Costs of drug discovery
2. Methods of drug discovery
     2.1.    Serendipity
     2.2.    Herbal remedies
     2.3     Studies of endogenous agents in animals and micro-organisms
     2.4.    Metabolites of existing drugs
     2.5.    Prodrugs
     2.6.    Applied pharmacology and empirical chemistry
     2.7.    Rational design based on knowledge of pathophysiology
     2.8.    Rational design based on the human genom
3. Drug development
     3.1.    Preclinical pharmacology and toxicology
     3.2.    Clinical testing
     3.3.    Phase 0 studies
     3.4.    Phase 1 studies
     3.5.    Phase 2 studies
     3.6.    Phase 3 studies
     3.7.    Marketing authorization
     3.8.    Phase 4 studies and post-marketing surveillance
                                                                                                                                                    

Most drug discovery nowadays is carried out by pharmaceutical companies. However, they rely heavily on findings from research carried out in academic institutions.

1. Costs of drug discovery

The ten largest multinational drug companies together employ about 900,000 people. They spend an estimated £33 billion each year on research and development, and about twice that on marketing; total expenditure is in excess of £110,000 per employee. In contrast, the NHS, one of the biggest employers in the world, has more than 1.7 million employees and an annual budget of about £116 billion, about £68,000 per employee; the drugs budget is about £14 billion. There are about 240 million patient consultations per year, of which 80% occur in general practice, at about £25 each, and 20% in secondary care, at about £2300 each. UK universities employ about 383,000 people, of whom 186,000 are academics. Total annual expenditure is about £28 billion, about £73,000 per employee.

Current estimates of the costs to a company of developing a new drug range from $500 million to $1500 million or more. Misleading accounting techniques may explain some of the higher estimates. However, profits from the sales of drugs after marketing can be very large. Table 1 shows the reported global incomes of the top ten selling products in 2014; five of them are monoclonal antibodies.

Table 1. Reported global sales of the top ten selling pharmaceutical products in 2014

Rank Product INN (Brand name(s)) Sales ($b)
1 Adalimumab (Humira) 13.0
2 Sofosbuvir (Sovaldi/Harvoni) 12.4
3 Infliximab (Remicade) 10.2
4 Etanercept (Enbrel) 9.1
5 Insulin glargine (Lantus) 8.2
6 Rituximab (MabThera/Rituxan) 7.4
7 Bevacizumab (Avastin) 6.8
8 Fluticasone propionate + salmeterol (Seretide/Advair) 6.7
9 Trastuzumab (Herceptin) 6.7
10 Rosuvastatin (Crestor) 6.6

 

The top 50 products in this list all earned sales of more than $2 billion in 2014. Nine were for cancers of some sort, including two for multiple myeloma, six were for diabetes mellitus, of which four were formulations of insulins, five were for multiple sclerosis, four were for inflammatory arthropathies, including one non-steroidal anti-inflammatory drug, three were lipid-modifying agents, three were for asthma, two were for hepatitis C, two were angiotensin receptor antagonists, two were anticoagulants, and two were combination products for HIV/AIDS.

2. Methods of drug discovery

Drugs can be discovered in several ways.

2.1. Serendipity

The discovery that sildenafil caused penile erection was made when it was being tested for its potential as a vasodilator to treat coronary artery disease. The discovery that isoniazid alleviated depression while it was being used to treat tuberculosis led to the development of iproniazid and other monoamine oxidase inhibitors. Clonidine was originally tested as a nasal decongestant and was then found to lower the blood pressure. The hypoglycaemic effects of sulfonamides in patients being treated for typhoid fever led to the development of the structurally related sulfonylureas as oral hypoglycaemic drugs.

Sometimes faulty reasoning leads to a lucky discovery. In the early 1940s Nana Svartz in Sweden reasoned that rheumatoid arthritis, which was thought to be an infective disease, would respond to a molecule containing a sulfonamide to combat the infection and a salicylate as an anti-inflammatory agent. She therefore synthesized a new molecule, sulfasalazine (salicylazosulfapyridine), from sulfapyridine and 5-aminosalicylic acid (now called mesalazine), but found that it had no effect in rheumatoid arthritis. However, a rheumatoid type of arthropathy sometimes occurs in patients with ulcerative colitis, and the therapeutic efficacy of sulfasalazine in ulcerative colitis was noted when those patients were given the drug, later leading to the development of other aminosalicylates. The wheel later came full circle with the use of sulfasalazine in the treatment of rheumatoid arthritis.

The discovery of lithium in the treatment of affective disorder was also serendipitous. In the 1940s Jonathan Cade in Australia was looking in the urine of patients with mania for substances that might be responsible for their illness. He extracted the urine, tested the extracts in guinea-pigs, and observed that urates seemed to be toxic. Cade used the lithium salt to make the urate soluble for injection into the animals. He noted that they were sedated and wondered whether lithium salts might sedate manic patients.

2.2. From herbal remedies

Examples are given in Table 2. Some of these medicines are derivatives of substances in the plants with which they are associated; for example the bisbiguanides, such as metformin, are derivatives of guanidine, which is present in Galega officinalis, and which was known for many years to have hypoglycaemic properties.

The compound originally called taxol, later renamed paclitaxel, was discovered during a multimillion dollar search by the US Department of Agriculture and the National Cancer Institute, looking for anticancer drugs in plants. Over a period of 20 years they screened an estimated 6% of the world’s plants and discovered one effective compound.

Artemisinin was found by a Chinese pharmacologist, Youyou-Tu, who investigated a recipe in a fourth century therapeutics text by the Chinese physician Ge Hong (284–363); her discovery won her the 2015 Nobel Prize.

2.3. From studies of endogenous agents in animals and micro-organisms

For example, the anticoagulant hirudin from the medicinal leech (Hirudo medicinalis). Examples are given in Table 3. Some such endogenous agents are toxins that are used to study physiological systems; these include apamin (from bee venom), charybdotoxin (from Leiurus quinquestriatus, the Israeli scorpion), dendrotoxin (from the green mamba, Dendroaspis angusticeps), and iberiotoxin (from Buthus tamulus, the Eastern Indian red scorpion), all of which are inhibitors of potassium channels, and tetrodotoxin from the puffer fish (fugu), which is an inhibitor of sodium channels.

Table 2. Some commonly used therapeutic agents that were originally derived from plants or from compounds that plants contain

Drug Example of medical use Plant of origin
Artemisinin derivatives Malaria Artemisia annua (qinghao)
Atropine Anticholinergic Atropa belladonna (deadly nightshade)
Cannabinoids Palliative care Cannabis sativa (cannabis)
Capsaicin Painful neuropathies Capsicum spp. (peppers)
Cephaeline [Emetogenic] Cephaëlis ipecacuanha (ipecacuanha)
Cocaine Local anaesthetic Erythroxylon coca (coca)
Colchicine Gout Colchicum autumnale (autumn crocus)
Curare Anaesthesia Chondrodendron tomentosum (pareira)
Digoxin/ digitoxin Atrial fibrillation and heart failure Digitalis lanata/purpurea (foxgloves)
Emetine [Emetogenic] Cephaëlis ipecacuanha (ipecacuanha)
Ephedrine Sympathomimetic Ephedra sinica (sea-grapes)
Gamolenic acid Mastodynia Oenothera biennis (evening primrose)
Hyoscine (scopolamine) Anticholinergic Datura stramonium (thorn apple)
Ispaghula Laxative Plantago ovata (ispaghula)
Metformin Hypoglycaemic Galega officinalis (goat’s rue)
Opioid alkaloids Analgesia Papaver somniferum (poppies)
Physostigmine Myasthenia gravis Physostigma venenosum (Calabar bean)
Pilocarpine Glaucoma Pilocarpus jaborandi (jaborandi)
Quinine Malaria Cinchona pubescens (cinchona)
Salicylates
Analgesics
Spiraea ulmaria (meadowsweet)
Salix alba (willow)
Gaultheria procumbens (wintergeen)
Sennosides Purgative Cassia acutifolia (senna)
Taxanes Cytotoxic Taxus spp. (yew trees)
Theophylline Asthma Camellia sinensis (tea plant)
Topoisomerase inhibitors Cancers Camptotheca acuminata (cancer tree)
Vinca alkaloids Cytotoxic Catharanthus rosea (Madagascar periwinkle)

 

Table 3. Examples of drugs derived from animals and micro-organisms

Natural source Compounds of proven efficacy (indication) Compounds of unproven or doubtful efficacy, or an unfavourable benefit/harm balance, or not used because of toxicity
 

Mammals: Tissues

 

Insulin (diabetes mellitus); growth hormone (growth impairment); melatonin (jet lag) Melatonin (aid to sleep); bear bile; gangliosides; glycosaminoglycans
Mammals: Dairy products Milk hydrolysates; ghee
Fish, shellfish Calcitonin Omega-3 fatty acids; tetrodotoxin; carp bile; green tipped mussel; imedeen; oyster extract; shark cartilage; squalene
Arachnids Iberiotoxin
Reptiles Ancrod (anticoagulant) Dendrotoxin; rattlesnake meat; toad venom
Worms Hirudin (anticoagulant)
Insects Apamin; cantharides; charybdotoxin; propolis; royal jelly
Micro-organisms: Fungi

 

Penicillin (infections)

Antibiotics from Actinomycetes, e.g. chloramphenicol (Streptomyces venezuelae), streptomycin (Streptomyces griseus), chlortetracycline (Streptomyces aureofaciens) and oxytetracycline (Streptomyces rimosus), numerous macrolides (including erythromycin, nystatin, and amphotericin)

Psilocybin; mycotoxins

 

Micro-organisms: Algae Laminaria
Micro-organisms: Bacteria Probiotics (e.g. bifidobacteria, Escherichia coli Nissle 1917, lactobacilli); Kombucha “mushroom”

 

2.4. Metabolites of existing drugs

Examples of drugs that were discovered because they are active metabolites of pre-existing compounds are given in Figure 1 and Table 4.

Figure 1. Metabolic relations of several benzodiazepines
Fig1

 

 

 

 

 

 

 

Table 4. Examples of compounds that were first identified as active metabolites of other compounds

Parent compound Active metabolite
Benzodiazepines See figure 1
Carbamazepine Oxcarbazepine (metabolized to licarbazepine)
Loratadine Desloratadine
Morphine Morphine-6-glucuronide
Procainamide Acecainide
Spironolactone Canrenone
Sulfasalazine Mesalazine
Terfenadine Fexofenadine

Other drugs that were discovered independently and that are metabolized to active compounds include codeine, diamorphine, and tramadol (all metabolized to morphine), tamoxifen (metabolized to 4-hydroxytamoxifen), and aspirin (metabolized to salicylate). In some cases active metabolites cause adverse effects; these include the metabolites of lidocaine (the glycine xylidides) and pethidine (norpethidine).

2.5. Prodrugs

Some drugs turn out to be inactive precursors of an active compound; for example, prednisone is converted to prednisolone, methimazole is converted to carbimazole, and the first sulfonamide, sulfanilamide, was discovered as a metabolite of the dyestuff Prontosil (sulfonamidochrysoidine). In other cases inactive precursors (prodrugs) are specifically synthesized as inactive compounds that are converted after administration to the active compound; in some cases the prodrug is better absorbed after oral administration (e.g. talampicillin and pivampicillin compared with ampicillin), but in some cases intracellular conversion is necessary for activation, as in the case of nucleoside analogues (e.g. cytosine arabinoside), which are activated by intracellular phosphorylation.

2.6. Applied pharmacology and empirical chemistry

The understanding of drug/receptor interactions has led to the synthesis of specific receptor agonists and antagonists, based on modifications of the structures of known agonists. Computer technology also allows the design of new compounds by an examination of the three-dimensional structures of existing compounds.

Beta-blockers were developed with the intention of finding compounds that would be antagonists of the actions of the agonist isoprenaline and the partial agonist dichloroisoprenaline, on whose structure the first compounds (e.g. pronethalol) were based; subsequent beta-blockers, with different types of actions, were developed by structural modifications (Table 5 and Figure 2). The folllowing list of 17 beta-blockers that are included in the current issue of the British National Formulary shows the chronological progression of their development; each of the intervening asterisks represents a beta-blocker that is not listed in the formulary:

*propranolol, sotalol ** oxprenolol, pindolol, acebutolol, atenolol **** timolol, metoprolol, levobunolol ** labetalol,
nadolol, carteolol ********* celiprolol ************* esmolol ***** bisoprolol, carvedilol *** nebivolol

Table 5. Examples of beta-blockers and features that made them innovative compared with their predecessors

Beta-blocker Year of earliest publication*  

Innovative feature(s)

Pronethalol 1963 Novel pharmacological target (first in class)†
Propranolol 1964 First therapeutically useful beta-blocker
Sotalol 1967 Beta-blocker and class III antiarrhythmic drug
Practolol 1969 Beta1 selective†
Oxprenolol 1970 Partial agonist
Atenolol 1972 Hydrophilic and beta1 selective
Metoprolol 1974 Short-acting and beta1 selective
Labetalol 1975 Alpha-blocker and beta-blocker
Nadolol 1975 Very long-acting
Celiprolol 1978 Vasodilatory
Esmolol 1982 Very short-acting
Bisoprolol 1984 Highly beta1 selective and vasodilatory

*From Pubmed
†Failed or withdrawn owing to adverse reactions

Similarly, the first histamine H2 receptor antagonists (e.g. burimamide and metiamide, which were never used clinically, and cimetidine and ranitidine) were based on the structure of histamine (Figure 3).

Both of these groups of drugs were developed by Sir James Black, who consequently won the Nobel prize in 1988.

Figure 2. Isoprenaline and a selection of beta-adrenoceptor antagonists (beta-blockers), showing structural similarities

Fig 2

 

 

 

 

 

 

 

 

 

 

 

Figure 3. Histamine and a selection of histamine H2 receptor antagonists, showing structural similarities

Fig 3

 

 

 

 

 

 

 

 

 

2.7. Rational design based on knowledge of pathophysiology

Levodopa in the treatment of Parkinson’s disease is a good example. The sequence was as follows:

TNF alfa blocking agents were introduced for the treatment of rheumatoid arthritis, based on the finding of increased TNFα concentrations in the joints of affected patients. Antiviral drugs used in the treatment of hepatitis C have been synthesized to have specific inhibitory actions on viral RNA polymerase (sofosbuvir) and serine kinase (boceprevir, simeprevir, and telaprevir). Many other compounds are inhibitors of tyrosine kinases of different types of receptors and of other types of kinases; examples are listed in Table 6. Many monoclonal antibodies have been synthesized expressly to have actions on specific targets thought to be involved in diseases; examples are listed in Table 7.

Table 6. Examples of kinase inhibitors and their targets

Compound Principal target(s)
Afatinib epidermal growth factor receptor (EGFR) and erbB-2 (HER2) tyrosine kinases
Axitinib BCR-abl tyrosine kinase
Boceprevir hepatitis C serine kinase
Bosutinib BCR-abl/src tyrosine kinase
Ceritinib anaplastic lymphoma kinase
Crizotinib anaplastic lymphoma kinase
Dabrafenib B-raf kinase
Dasatinib BCR-abl/src tyrosine kinase
Erlotinib epidermal growth factor receptor (EGFR) tyrosine kinase
Gefitinib epidermal growth factor receptor (EGFR) tyrosine kinase
Ibrutinib Bruton’s tyrosine kinase
Imatinib BCR-abl and c-KIT receptor tyrosine kinases
Lapatinib human epidermal growth factor receptor II (HER2) tyrosine kinase
Nilotinib BCR-abl tyrosine kinase
Nintedanib platelet-derived growth factor receptor (PDGFR), fibroblast growth factor receptor (FGFR), and vascular endothelial growth factor receptor (VEGFR) tyrosine kinases
Pazopanib c-KIT, FGFR, PDGFR, and VEGFR receptor tyrosine kinases
Ponatinib BCR-abl tyrosine kinase
Regorafenib VEGFR2 and angiopoietin TIE2 tyrosine kinases
Ruxolitinib Janus-associated tyrosine kinases, JAK1 and JAK2
Simeprevir hepatitis C serine kinase
Sorafenib VEGFR, PDGFR, and Raf family tyrosine kinases
Sunitinib platelet-derived growth factor (PDGF-R) and vascular endothelial growth factor receptor (VEGFR) tyrosine kinases
Telaprevir hepatitis C serine kinase
Trametinib Mitogen-activated protein kinase (MAP kinase)
Vandetanib vascular endothelial growth factor receptor (VEGFR), epidermal growth factor receptor (EGFR), and the RET proto-oncogene tyrosine kinases
Vemurafenib B-raf kinase

 

Table 7. Examples of monoclonal antibodies and their targets

Monoclonal antibody Target
Abciximab platelet glycoprotein IIb/IIIa receptors
Alemtuzumab lymphocyte CD52
Apolizumab lymphocyte HLA-DR
Basiliximab CD-25 antigen of interleukin receptors on T lymphocytes
Bevacizumab vascular endothelial growth factor, VEGF
Biciromab fibrin
Certolizumab TNF alfa
Daclizumab CD-25 antigen of interleukin receptors on T lymphocytes
Epitumomab human episialin
Fontolizumab interferon gamma
Ibritumomab CD-20 receptors on tumour cells
Imciromab myosin
Infliximab TNF alfa
Lambrolizumab programmed cell death protein 1, PD-1
Mepolizumab interleukin-5, IL5
Nebacumab bacterial endotoxin
Nivolumab programmed cell death protein 1, PD-1
Ofatumumab CD20 cell surface antigen on B lymphocytes
Omalizumab Ig E
Palivizumab respiratory syncytial virus
Pembrolizumab programmed cell death protein 1, PD-1
Pertuzumab human epidermal growth factor receptor II, HER2
Pexelizumab CD-5 complement
Ranibizumab Vascular endothelial growth factor, VEGF
Rituximab CD-20 receptors on tumour cells
Satumomab colonic and ovarian tumour-associated antigens
Secukinumab interleukin-17A, IL17A
Tacatuzumab alfa-fetoprotein
Talizumab human immunoglobulin E Fc region
Trastuzumab human epidermal growth factor receptor II, HER2
Votumumab colorectal tumour-associated antigens

 

2.8. Rational design based on the human genome

Cathepsin K inhibitors were developed as bone resorption inhibitors, based on the observation that mutations of cathepsin K result in increased bone mass with reduced bone resorption.

3. Drug development

When a new drug has been discovered it goes through a prescribed development process, after which it is licensed for use and marketed.

3.1. Preclinical pharmacology and toxicology

Preclinical studies of a new chemical entity include extensive pharmacological testing in vitro and in animals, including pharmacokinetic studies and short-term and long-term toxicity testing, so that its toxicological properties can be defined in a rough dose-response fashion. The duration of this toxicological testing is geared to the likely duration of therapeutic use. At this stage other special studies may be necessary, such as tests of the effects of the compound on fertility and reproduction, teratogenicity testing, and tests for mutagenicity and carcinogenicity.

 

3.2. Clinical testing

Next the pharmacokinetics of the drug are studied after single and multiple doses in healthy people. If it has measurable effects, its pharmacology is studied and clinical, biochemical, and haematological adverse effects and reactions are assessed. In some cases (for example, drugs for AIDS or cancer) healthy volunteer studies are not possible and the drug is tried immediately in patients.

 

3.3. Phase 0 studies

Phase 0 studies are first-in-human studies. They involve the administration of tiny doses (microdoses) of the drug in a few subjects, in order to collect preliminary pharmacokinetic and pharmacodynamic information. They do not cover safety or efficacy.

There are guidelines governing the introduction of new chemical entities into humans, which were formulated in the wake of the disastrous first use of TGN1412, an agonistic anti-CD28 monoclonal antibody, which was first given to six healthy volunteers in a research unit on 13 March 2006. Within hours all six were in intensive care with severe inflammatory reactions that progressed to multiorgan failure. They had developed headache within 50–90 minutes, lumbar myalgia, rigors within 58–120 minutes, and a fever over 38°C within 2.5–6.5 hours. They subsequently developed hypotension, tachycardia, dyspnea and tachypnea, respiratory failure, radiological pulmonary infiltrates, and evidence of disseminated intravascular coagulation; two had peripheral limb ischemia; one developed dry gangrene of the fingers and toes. All developed lymphopenia, with significant falls in CD3, CD4+, and CD8+ counts. All recovered, but had prolonged memory problems, headaches, and inability to concentrate. This syndrome was due to a massive cytokine storm. Serum concentrations of TNFα rose markedly within 1 hour, and TNFγ, IL2, IL4, IL6, and IL10 all increased over days 1 and 2; there were very large increases in interferon gamma at 4 hours and on day 2. In vitro experiments had not predicted this effect.

Following an enquiry by an independent expert scientific group, the following 22 recommendations were made about first-in-human studies:

  1. The strategy for preclinical development of a new medicine and the experimental approaches used to assemble information relevant to the safety of phase I trials must be regarded as science-based decisions, made and justified case by case by investigators with appropriate training.
  2. Developers of medicines, research funding bodies, and regulatory authorities should expedite the collection of information on unpublished preclinical studies and phase I trials, and explore the feasibility of open access to this database.
  3. Regulatory authorities should consider ways to expedite the sharing between regulators world wide of information on Suspected Unexpected Serious Adverse Reactions (SUSARs) in phase I trials, and explore the feasibility of open access to these data.
  4. A broader approach to dose calculation, beyond reliance on the “No Effect Level” or “No Adverse Effect Level” in animal studies, should be taken. The calculation of starting dose should use all relevant information. Factors to be taken into account include the novelty of the agent and its mechanism of action, the degree of species specificity of the agent, the dose-response curves of biological effects in human and animal cells, dose-response data from in vivo animal studies where relevance to human has been validated, the calculation of receptor occupancy versus concentration, and the calculated exposure of targets or target cells in humans in vivo. The “MABEL” (minimum anticipated biological effect level) approach is a good option for achieving this.
  5. If different methods give different estimates of a safe dose in humans, the lowest value should be taken as the starting point in first-in-human trials and a margin of safety should be introduced.
  6. When it is likely that preclinical information, for any reason, may be a poor guide to human responses in vivo, the starting dose in first-in-human trials should be calculated to err on the side of caution.
  7. Careful consideration should be given to the route and the rate of administration of the first dose in first-in-human trials, with careful monitoring for an exaggerated response.
  8. Decisions on the starting dose and dose escalation should be made on a case-by-case basis, and should be scientifically justifiable, taking account of all relevant information.
  9. The decision whether to conduct a first-in-human trial in healthy volunteers or in volunteer patients should be carefully considered and fully justified, taking into account all factors relevant to the safety of the subjects and the value of the scientific information that is likely to be obtained.
  10. Principal Investigators in first-in-human trials should always be appropriately qualified and satisfy themselves that they know enough about the agent, its target, and its mechanism of action to be in a position to make informed clinical judgements.
  11. In first-in-human studies in which there is a predictable risk of certain types of severe adverse reaction, a treatment strategy should be considered beforehand. This should include the availability of specific antidotes, when they exist, and a clear plan of supportive treatment, including the pre-arranged contingency availability of ITU facilities.
  12. First-in-human studies of higher-risk medicines should always be conducted in an appropriate clinical environment, supervised by staff with appropriate levels of training and expertise, with immediate access to facilities for the treatment and stabilization of individuals in an acute emergency and with pre-arranged contingency availability of ITU facilities.
  13. New agents in first-in-human trials should be administered sequentially to subjects with an appropriate period of observation between dosing.
  14. The interval of observation between sequential dosing of the subjects should be related to the kind of adverse reactions that might be anticipated based on the nature of the agent, its target, and the recipient.
  15. A similar period of monitoring should occur between sequential doses during dose escalation.
  16. More communication should be encouraged between developers and the regulator at an earlier stage before an application is filed, especially for higher-risk agents, to ensure that there is time for appropriate consideration of any safety concerns, without introducing undue delay in product development. Ways to increase communication between the regulator and research ethics committees should also be considered.
  17. For appraisal of applications for trials of higher-risk agents, as defined by the nature of the agent, its degree of novelty, its intended pharmacological target, and its intended recipient, the regulator should have access to additional opinions from independent, specialist experts with research knowledge of their fields.
  18. An Expert Advisory Group (EAG) of the Commission on Human Medicines, or a similar body, might undertake this role, with a core membership of appropriate experts and the ability to co-opt additional experts as the need dictates.
  19. Consideration should be given to introducing some flexibility in the time-scale of clinical trial appraisal in exceptional cases of unusual complexity.
  20. The availability of “hands-on” experience in the planning and conduct of clinical trials should be widened, for example by secondment periods to commercial organizations within postgraduate training programmes, or the development of specialist centres within the [UK’s] NHS and Universities (see next recommendation).
  21. The feasibility of developing specialist centres for phase I clinical trials of higher-risk agents and advanced medicinal products should be explored.
  22. The regulatory process for first-in-human trials of higher-risk agents and advanced medicinal products based on innovative technologies should be subject to frequent review.

3.4. Phase 1 studies

Phase 1 studies in patients or healthy volunteers concentrate on the clinical pharmacology of the drug, short-term safety, efficacy, pharmacological effects, and pharmacokinetics. These early studies also provide information about the likely dose range to be used in phase 2 studies.

Adverse reactions can occur in phase 1 studies, despite apparent safety during first-in-human studies. BIA 10-2474 was an inhibitor of fatty acid amide hydrolase (FAAH), an enzyme involved in the metabolism of anandamide and other endocannabinoid neurotransmitters. Single doses up to 100 mg, fed and fasting, and doses of up to 20 mg/day on 10 consecutive days produced no serious adverse events. However, when 8 volunteers were given 50 mg/day for 10 days in a phase 1 study in France, in January 2016, adverse events started to appear after 5 days. Haemorrhagic and necrotic lesions were seen on MRI scans in the hippocampus and pons and one volunteer died. Complete inhibition of FAAH had been observed at a single dose of 1.25 mg.

3.5. Phase 2 studies

In phase 2 studies further evidence of safety and efficacy is obtained in larger numbers of patients, often with a surrogate clinical endpoint, with further attention to dose-ranging and adverse effects. Currently, a large number of drugs in development fail during phase 2. It has been estimated that success rates during phase 2 in large pharmaceutical companies fell from 28% in 2006/7 to 18% in 2008/9. In one survey of 108 compounds, 51% failed because of lack of efficacy, 29% because of “strategic reasons”, and 19% because of harms.

3.6. Phase 3 studies

Phase 3 studies are full-scale clinical trials, in which the effects of the drug are studied in relation to an important clinical endpoint. These may be placebo-controlled studies or comparisons with other active compounds. In comparative studies the intention is usually to demonstrate superiority or, at the very least, non-inferiority. So-called “real-life” trials involve a comparison of the new agent with standard therapy; such trials often include a pharmacoeconomic assessment of the added value that a new treatment brings in relation to its cost. Of drugs that reach phase 3, about 50% can be expected to go on to be marketed.

3.7. Market authorization

After success in phase 3 a manufacturer will apply to the regulatory authority for authorization to market the drug as a medicinal product, presenting a dossier of evidence to support the application. If the regulatory authority is convinced about the quality of the pharmaceutical product, the efficacy of the medicine in the conditions for which the licence is to be issued, and the benefit to harm balance, the medicinal product will receive a marketing authorization (commonly called the product licence). Marketing authorizations are issued by regulatory authorities in different countries (e.g. the Medicines and Healthcare products Regulatory Agency in the UK and the Food and Drug Administration in the USA) or by a supranational organization, such as the European Medicines Evaluation Agency (EMA).

(a) The marketing authorization

The 1968 Medicines Act introduced the UK system whereby applicants are granted Marketing Authorizations, permitting them to market medicinal products for specified indications under specified conditions. Matters relating to prescribing were later covered by The Prescription Only Medicines (Human Use) Order 1997, which partially repealed the 1968 Act. That Order was later mostly revoked by the Human Medicines Regulations 2012, which consolidated the law contained in previous instruments.

Those who hold Marketing Authorizations in the UK are known as Marketing Authorization Holders (MAHs). Separate licences are issued to manufacturers of medicinal products (who are usually the MAHs) and wholesale dealers.

Because a product licence is granted to the MAH, not the product, terms such as “licensed drug”, “licensed medicine”, and “licensed product”, commonly used colloquially, are inaccurate. Neither the drug itself nor the medicinal product in which it is formulated is licensed. It is the MAH who is licensed, i.e. given permission, to market the product.

The World Health Organization (WHO) has defined a marketing authorization as “an official document issued by the competent drug regulatory authority for the purpose of marketing or free distribution of a product after evaluation for safety, efficacy and quality”. UK legislation has not explicitly defined the terms “product licence” and “marketing authorization”, but definitions are implied by Section 7 of the 1968 Medicines Act, which stipulates that, except in accordance with a product licence, “no person shall, in the course of a business carried on by him …

(a)    sell, supply or export any medicinal product, or
(b)    procure the sale, supply or exportation of any medicinal product, or
(c)     procure the manufacture or assembly of any medicinal product for sale, supply or exportation.”
This implies that a Marketing Authorization can be defined as “permission granted to a Marketing Authorization Holder to sell, supply, or export, procure the sale, supply or exportation, or procure the manufacture or assembly for sale, supply or exportation of a medicinal product”.
An “unlicensed product” can be defined, based on the definition in the Unlicensed Medicinal Products for Human Use (Transmissible Spongiform Encephalopathies) (Safety) Regulations 2003, as “a medicinal product for human use [with some exceptions, such as herbal products], in respect of which no marketing authorization has been granted by the [national] licensing authority or by the European Medicines Agency”.
A medicinal product is defined as:
(a)  any substance or combination of substances presented as having properties of preventing or treating disease in human beings; or
(b)  any substance or combination of substances that may be used by or administered to human beings with a view to
(i)   restoring, correcting or modifying a physiological function by exerting a pharmacological, immunological or metabolic action, or
(ii)  making a medical diagnosis.
A medicinal product is authorized if there is in force for the product
(a)  a marketing authorization;
(b)  a certificate of registration as a homoeopathic medicinal product;(c)  a traditional herbal registration; or
(d)  an Article 126a authorization.

An Article 126a authorization is one that can be issued to license a product whose use is justified for public health reasons and that has been imported from another Member State in the European Union.

Any medicinal product for which a UK marketing authorization has not been granted is an unlicensed product in the UK, even though it may be licensed elsewhere. This is made explicit in Section 7 of the 1968 Act, which stipulates that “[n]o person shall import any medicinal product except in accordance with a product licence”. Importation from non-EU states is covered in the 2012 Human Medicines Regulations.

Manipulation of a licensed product can result in one that is unlicensed. For example, using a solution of bevacizumab for intravitreous injection from a vial marketed for treating metastatic colorectal cancer according to the licence would be using it off-label (see below). On the other hand, if an undiluted solution was, say, diluted before use or divided into several aliquots, the secondary formulations would be regarded as being unlicensed. How much manipulation results in an unlicensed product is debatable.

The licensing system in the UK is intended to protect patients from the use of medicines with a poor benefit to harm balance, based on quality, efficacy, and safety.

(b) The label

The Marketing Authorization, or licence, should be distinguished from the label. The 1938 Food, Drug and Cosmetics Act in the USA defined a label as “a display of written, printed, or graphic matter upon the immediate container of any article; and a requirement … that any word, statement, or other information appear[ing] on the label shall not be considered to be complied with unless such word, statement, or other information also appears on the outside container or wrapper, if any there be, of the retail package of such article, or is easily legible through the outside container or wrapper.” “Labelling” was defined in the 1938 Act as “all labels and other written, printed, or graphic matter (1) upon any article or any of its containers or wrappers, or (2) accompanying such article.” Similarly, a drug label is described in The Human Medicines Regulations 2012 as “a notice describing or otherwise relating to the contents”.

The term “label” is now used to mean not merely the “written, printed, or graphic matter” that accompanies the formulation, but the informative content of such matter, as contained in the UK in the Summary of Product Characteristics (SmPC), previously called the Product Data Sheet. The contents of the SmPC (Table 8) are prescribed by EU law.

Table 8. The contents of a Summary of Product Characteristics, listing the headings under which information about the medicinal product must be given by EU law

1.    Name of the medicinal product

2.    Qualitative and quantitative composition

3.    Pharmaceutical form

4.    Clinical particulars

4.1  Therapeutic indications

4.2  Posology and method of administration

4.3  Contraindications

4.4  Special warnings and precautions for use

4.5  Interaction with other medicinal products and other forms of interaction

4.6  Fertility, pregnancy and lactation

4.7  Effects on ability to drive and use machines

4.8  Undesirable effects

4.9  Overdose

5.     Pharmacological properties

5.1   Pharmacodynamic properties

5.2   Pharmacokinetic properties

5.3   Preclinical safety data

6.     Pharmaceutical particulars

6.1   List of excipients

6.2   Incompatibilities

6.3   Shelf life

6.4   Special precautions for storage

6.5   Nature and contents of container

6.6   Special precautions for disposal and other handling

7.     Marketing authorization holder

8.     Marketing authorization number(s)

9.     Date of first authorization/renewal of the authorization

10.   Date of revision of the text

If a drug is prescribed in a way that differs from the approved ways described in the label, it is said to be prescribed “off-label”. In other words, off-label prescribing is the prescribing of a licensed product in an unapproved way, which is any way that differs from the ways specified in the SmPC. This is not the same as prescribing an unlicensed product. Table 9 lists different ways in which off-label prescribing may occur.

Table 9. Types of off-label prescribing

Type of off-label prescribing Example
A. When the medicine is not approved for the intended indication
1. The branded formulation is not approved for the intended indication, but other branded formulations of the same medicine are so approved Inderal–propranolol is not approved for treatment of infantile haemangiomas, but Hemangiol–propranolol is so approved
2. The medicine is not approved in any formulation for the intended indication, but other medicines of the same pharmacological class, which might be expected to be efficacious, are so approved Licensed formulations of bisoprolol and celiprolol do not include the treatment of migraine among their approved indications, but licensed formulations of propranolol and oxprenolol do
3. The medicine is not approved in any formulation for the intended indication, and no other medicine of the same pharmacological class is so approved either Amitriptyline is used to treat neuropathic pain and is effective, although it not licensed in any formulation for this indication, and neither is any other tricyclic antidepressant
4. The medicine is approved for an indication and is used in a case where the indication is assumed but not known. Use of ampicillin, indicated for the treatment of a wide range of bacterial infections caused by ampicillin-sensitive organisms, to treat infections whose cause is not known or when infecting bacteria are not known to be sensitive
B. When the medicine is approved for the intended indication but not in other respects, e.g. population, dose, or frequency of administration
5. For an unapproved age group Many examples of prescribing for children, when the prescribed drug is approved for the relevant indication in adults
6. In an unapproved dosage regimen Use of an oral contraceptive in twice the recommended dose to obviate reduced efficacy due to a drug-drug interaction
7. By an unapproved route of administration Giving bevacizumab intravitreously for age-related macular degeneration (it is approved for use intravenously); this is also an example of an off-label indication, since the approved indications for bevacizumab do not include AMD
8. With omission of therapy with a drug mandated in the SmPC for co-administration Prescribing infliximab without methotrexate in rheumatoid arthritis as a therapeutic trial in a patient who cannot tolerate methotrexate
9. When monitoring that is mandated by the SmPC is omitted Failing to monitor serum sodium concentrations in patients taking low-dose diuretics for hypertension, given evidence that it is of no therapeutic benefit to do so

(c) Prescribing unlicensed and off-label medicines

In the UK, the MHRA has issued guidance on priorities in choosing medicinal products to prescribe when licensed and unlicensed products are available. In each case in the following list it is assumed that the earlier choices are not available:
(a)  use a licensed product within the terms of its licence (i.e. the label);
(b)  use a licensed product off-label;
(c)  use an imported product that has a licence elsewhere;
(d)  use a product that is not licensed anywhere, but which has been manufactured in the UK as a “special”.

3.8. Phase 4 studies and post-marketing surveillance

Phase 4 studies are carried out after a drug has been marketed. They are designed to obtain information on the effects of the drug in populations who have not been studied before marketing and to detect adverse drug reactions or interactions, in that case sometimes called phase 5 studies.
Surveillance of the effects of a new drug continues after marketing, both formally and informally. There is a post-marketing event monitoring (PEM) scheme in the UK, for research into adverse drug reactions after marketing, and doctors are also encouraged to report suspected adverse reactions informally to regulatory agencies (for example, the yellow card scheme in the UK and Medwatch in the USA).
Some adverse reactions are discovered only after approval and marketing, when regulators have several possible courses of action, depending on the risk and seriousness of the adverse reaction. They can:

MAHs may take actions themselves without being required to do so by the regulators. The final action would be to suspend or revoke the licence, and the MAH sometimes withdraws a drug voluntarily before being forced to by the regulator. These options are not mutually exclusive and can be undertaken sequentially or in parallel, depending on the case and urgency. If new serious adverse reactions are noted the drug may be withdrawn or its licensed indications may be changed. Examples of medicines that have been withdrawn or have had their labels changed are given in Table 10.

Table 10. Drugs that have been withdrawn or have had their uses restricted after marketing because of adverse reactions

Drug Year Adverse reaction Outcome
Sulfanilamide 1937 Liver damage due to diethylene glycol Solvent changed; US FDA established
Diododiethyl tin 1954 Cerebral oedema Withdrawn
Thalidomide 1961 Congenital malformations Withdrawn; Dunlop Committee (later the CSM) established in the UK
Chloramphenicol 1966 Blood dyscrasias Uses restricted
Clioquinol 1975 Subacute myelo-optic neuropathy Withdrawn
Practolol 1977 Oculomucocutaneous syndrome Uses restricted; later withdrawn
Benoxaprofen 1982 Liver damage Withdrawn
Etomidate 1983 Adrenal suppression Uses restricted
Zimeldine 1983 Hypersensitivity Withdrawn
Zomepirac 1983 Anaphylaxis Withdrawn
Fenclofenac 1984 Lyell’s syndrome Withdrawn
Indoprofen 1984 Gastrointestinal bleeding/perforation Withdrawn
Osmosin® 1984 Gastrointestinal ulceration/perforation Withdrawn
Phenylbutazone 1984 Blood dyscrasias Uses restricted; later withdrawn
Aspirin 1986 Reye’s syndrome (children) Uses restricted
Bupropion 1986 Seizures Withdrawn; later reintroduced
Nomifensine 1986 Haemolytic anaemia Withdrawn
Tocainide 1986 Neutropenia Uses restricted
Suprofen 1987 Renal impairment Withdrawn
Spironolactone 1988 Animal carcinomas Uses restricted
Flecainide 1989 Cardiac arrhythmias Uses restricted
L-tryptophan 1990 Eosinophilia–myalgia syndrome Withdrawn from foodstuffs
Xamoterol 1990 Worse heart failure in some patients Withdrawn
Noscapine 1991 Gene toxicity Withdrawn
Terodiline 1991 Cardiac arrhythmias Withdrawn
Triazolam 1991 Psychiatric disorders Withdrawn
Temafloxacinin 1992 Various serious adverse reactions Withdrawn
Centoxin 1993 Increased mortality Withdrawn
Flosequinan 1993 Increased mortality Withdrawn
Remoxipride 1994 Aplastic anaemia Withdrawn
Co-trimoxazole 1995 Serious allergic reactions Uses restricted
Naftidrofuryl 1995 Cardiac and neurological toxicity Intravenous formulation withdrawn
Sotalol 1996 Cardiac arrhythmias Uses restricted
Troglitazone 1997 Hepatic disorders Withdrawn
Terfenadine 1997 Interactions (e.g. with grapefruit juice) Withdrawn from OTC sale
Dexfenfluramine 1997 Cardiac valve abnormalities Withdrawn
Mibefradil 1998 Too many drug interactions Withdrawn
Tolcapone 1998 Hepatobiliary disorders Withdrawn
Astemizole 1998 Interactions (e.g. with grapefruit juice) Withdrawn from OTC sale
Sertindole 1998 Cardiac arrhythmias Withdrawn
Trovafloxacin 1999 Hepatotoxicity Withdrawn
Cisapride monohydrate 2000 Cardiotoxicity Withdrawn
Cerivastatin 2001 Rhabdomyolysis; renal failure Withdrawn
Nimesulide 2002 Hepatotoxicity Withdrawn
Rofecoxib 2004 Cardiotoxicity Withdrawn
Torcetrapib 2006 Cardiotoxicity Withdrawn
Sibutramine 2010 Cardiotoxicity Withdrawn
Rosiglitazone 2011 Cardiotoxicity Withdrawn

Occasionally a drug may be withdrawn but then reintroduced for specific reasons or with specific monitoring. Examples include:

o  before starting alosetron, a woman should discuss with her doctor how troublesome her symptoms of irritable bowel syndrome are, and the possible benefits and adverse effects of alosetron, to decide if alosetron is right for her;
o  alosetron is only for women who have diarrhoea as their main symptom; women who have constipation as their main symptom should not use alosetron;
o  because alosetron does not cure irritable bowel syndrome or work for everyone, women are advised to stop using it and to tell their doctors if their symptoms do not improve within 4 weeks of starting the drug.