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4/18/2013 Disclosure What Is Wrong With Peter A. Schneider Current Regulation of Potential conflicts of interest to report: Vascular Devices By the FDA? Consultant to start-ups: Silk Road, Altura, Revascular, Intact Vascular, Pro-med Peter


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What Is Wrong With Current Regulation of Vascular Devices By the FDA?

Peter A. Schneider, MD Hawaii Permanente Medical Group and Kaiser Foundation Hospital Honolulu, Hawaii

UCSF Vascular Symposium April, 2013

Disclosure

Peter A. Schneider Potential conflicts of interest to report: Consultant to start-ups: Silk Road, Altura, Revascular, Intact Vascular, Pro-med Enter patients in studies: Abbott, Gore, Medtronic, Cordis Modest royalty from Cook

Current Regulation of Vascular Devices

Perspective

  • Vascular is a device-dependent endeavor
  • Safety-”do no harm”, safety concerns are

ingrained into modern medical practice, risk aversion

  • Innovation-at some point, innovation

forces us to change how we do things, how will we know if that is safe enough?

Endovascular Today March, 2013

Current Regulation of Vascular Devices

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What Does the FDA Regulate?

Foods safety of all food products, labeling, bottled water, food additives, infant formulas Dietary Supplements Human Drugs product approvals, OTC and prescription drug labeling, drug manufacturing standards Vaccines, Blood Products, and Other Biologics product and manufacturing establishment licensing, safety of the nation's blood supply research to establish product standards and develop improved testing methods Medical Devices from simple items like tongue depressors, to complex technologies such as heart pacemakers premarket approval of new devices, manufacturing and performance standards tracking reports of device malfunctioning and serious adverse reactions Electronic Products products that give off radiation, such as microwave ovens and X-ray equipment radiation safety performance standards for microwave ovens, television receivers, diagnostic x-ray equipment, cabinet x-ray systems (such as baggage x-rays at airports), laser products, ultrasonic therapy equipment, mercury vapor lamps, and sunlamps accrediting and inspecting mammography facilities Cosmetics Safety, labeling Veterinary Products livestock feeds, pet foods, veterinary drugs and devices Tobacco Products

25% of the US economy

Forbes, 2012

FDA

  • 14,648 Employees

– Margaret Hamburg, MD FDA Commissioner

  • 2013 budget-$4.4B

– FDA Justification of Estimates for Appropriations Committees, 670 pg – Budget for 2000 was $1.3B

  • 8 Divisions
  • Center for Devices and Radiological Health

– Jeffery Shuren, MD – 1,413 Employees

Get safe and effective medical devices to market as quickly as possible… … while ensuring that medical devices currently

  • n the market

remain safe and effective. Help the public get science-based accurate information about medical devices and radiological products needed to improve health.

CDRH Mission

Get safe and effective medical devices to market as quickly as possible… … while ensuring that medical devices currently

  • n the market

remain safe and effective. Help the public get science-based accurate information about medical devices and radiological products needed to improve health.

Bill Sutton: Overview of Regulatory Requirements for Medical Devices

Current Regulation of Vascular Devices

What Is Right With the System?

  • Significant resources have been devoted
  • Recent efforts to clarify pathways
  • Innovation approval pathway
  • New teaching materials
  • Entrepreneur in residence program
  • Safety is being achieved

– 99.6% of 510(k) and PMA devices did not experience a recall in last 5 years

– Hall R. Using recall data to assess the effectiveness of the FDA clearance process. Institute of Medicine, Washington DC, July, 2010.

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Current Regulation of Vascular Devices

Device Classifications

Type I- Low Risk Type II- Medium Risk Type III- High Risk

Bandages Exam gloves Wheel chairs Usually exempt: Must register device with FDA Angioplasty balloon Blood pressure kit Fixation screw Catheter Infusion pump Typically through 510(k) premarket notification submission Stent Pacemaker Heart valve Dental laser Total joint Typically through premarket approval process (PMA) <10% of cases

Define Terms

  • 510(K): Statute provides for approval of a device that is

substantially equivalent to already approved device.

  • IDE: Granted to study unapproved significant risk device in

human subjects. Typically involves first-in-man data from OUS and preclinical data. Must obtain prior to PMA.

  • PMA: Premarket approval of device (513(k)), requires

clinical trial.

  • MDUFA: Medical Device User Fee Amendments (2007)
  • GLP and GCP: Good Laboratory Practices, governs

preclinical studies, Good Clinical Practices: clinical trials.

  • FDA panel: Convened to review clinical study data.
  • Post-approval Study: Mandated for selected Class III

devices.

  • Post-market Surveillance-ongoing registry to monitor safety

and effectiveness of Class II and III devices sold in US.

Current Regulation of Vascular Devices

Current Approval Pathways

  • 510(k)

– Requires a predicate: “substantial equivalence” – FDA has 90 days to review – Takes about a year – 510(k) with clinical data – 510(k) de novo

  • PMA

– All Class III devices – FDA has 180 days to review – Develop clinical trial, get approval from FDA, prepare and submit PMA – No usual timeframe, minimum of 36 months Current Regulation of Vascular Devices

Disadvantages of the System

  • Layered and nuanced
  • Not predictable
  • Expensive
  • Time consuming
  • Created an industry
  • Difference between request and reality

– Are the requests rooted in real risk reduction? – Are the requests reasonable?

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Current Regulation of Vascular Devices

US Medical Device Industry

  • 1023 public and privately backed

companies

  • More than half are in CA, MN, MA
  • 98% of companies have <500 employees

Ernst and Young, Pulse of the Industry Medical Technology Report, 2010 PriceWaterhouseCoopers, 2012

2007 2012 Companies 116 $720M Amount raised 55 $200M

Manufactures and importers of certain medical devices will be taxed 2.3% of the price of the

  • product. Devices will not include retail objects

like corrective lenses or hearing aids, but will include products like defibrillators, pacemakers, artificial joints, stents, and those involved in cancer treatments, angioplasty and vascular

  • surgery. More than 800 companies from the

powerful medical device industry have protested the tax, which will raise $1.8 billion next year, and $20 billion over the next seven years. 5 New Obamacare Taxes Coming in 2013 TIME Dec 7, 2012

2.3% excise tax is on total revenues, not profits Lower costs by shifting manufacturing OUS?

Meer and Makower, Nov. 2010 FDA Impact on US Medical Technology Innovation

Current Regulation of Vascular Devices

What Does Device Industry Say?

  • 44% experienced change of key FDA personnel

during approval process (either the review staff

  • r section chief or both).
  • 34% indicated that appropriate FDA personnel

not present at scheduled meetings.

  • >90% believe that FDA has become more risk

averse in last decade.

  • 66% indicated that these issues negatively

impacted the progress of the company.

Meer and Makower, Nov. 2010

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Meer and Makower, Nov. 2010

Chart 5.

Percentage of 510(k)s With Additional Information (AI) Request on 1st FDA Review Cycle

*10 months

FDA Annual Report 2012

Current Regulation of Vascular Devices

Meer and Makower, Nov. 2010 Meer and Makower, Nov. 2010

Companies rated regulatory bodies on basis of: clinical competence, engineering competence, statistical competence, predictability, transparency and reasonableness.

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Meer and Makower, Nov. 2010 Meer and Makower, Nov. 2010

Current Regulation of Vascular Devices

Clinical Trials

  • Trial set up, manufacturing, travel, data

capture, CRO, procedure, core labs, follow-up studies, visits, data analysis. Total Cost: Concept to Approval FDA- dependent costs 510 (k) Pathway $31M $24M PMA Pathway $94 M $75M

Meer and Makower, Nov. 2010

Current Regulation of Vascular Devices

More Layers to Consider

  • Valley of death=lack of funding
  • No IPOs
  • Most VCs are not currently funding

anything requiring a PMA

  • More companies considering an OUS only

strategy

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Tools We Use-Specific Examples

  • No first-in-man studies in US.
  • Minimum of 2-3 year lag between US and EU.
  • Drug coated balloons: In EU since 2007.
  • AAA: 10 years from first report to approval
  • Carotid stent: 10 years to limited approval
  • Percutaneous aortic valve: CE mark 2007,

approval 11/11 with >1000 patient most market study, $2B in development.

What is FDA doing to improve?

  • Early Feasibility Study Guidance

Document: Get an earlier IDE with less clinical data

  • Innovation Pathway: shorten time to

approval of novel devices by requiring less pre-clinical and clinical testing, placing FDA personnel and innovators on same team

  • Entrepreneurs in Residence

What is FDA doing to improve?

  • Stream line Clinical trials
  • Streamline FDA approval to CMS

coverage pathway

  • Balance Premarket and Postmarket

studies

Conclusion

  • The FDA has a huge job on its hands.
  • It takes about 10 years for any significant

development to make it to clinical use.

  • Device regulation is pushing the

development industry OUS.

  • As the reimbursement decreases, many

companies will take an OUS-only approach.

  • The FDA is taking steps to improve the

process.