Presentation: Spotlight on complementary medicines MMDR reforms
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The document discusses reforms to the regulation of complementary medicines in Australia resulting from a 2015 review. It focuses on 5 streams of work: 1) enhancing the listing framework; 2) improving transparency for consumers; 3) increased flexibility for sponsors and improving the evidence base; 4) increased flexibility and predictability for industry; and 5) enhanced post-market monitoring and compliance actions. Key reforms discussed include establishing a permitted indications list, new pathways for assessing medicines, incentives for innovation, and enhanced post-market monitoring.
Presentation: Spotlight on complementary medicines MMDR reforms
- 1. Spotlight on Complementary Medicines MMDR Reforms Michael Shum Director, Complementary Medicines Reforms Complementary and OTC Medicines Branch, Medicines Regulation Division, TGA
- 2. Review of Medicines and Medical Devices Regulation (MMDR) • July 2015: the Expert Panel released their recommendations arising from the review – 19 recommendations to improve the regulation of complementary medicines • September 2016: Government response released – accepted the majority of the review’s recommendations in full or in-principle – identified the need for consultation with stakeholders in progressing the reforms Spotlight on Complementary Medicines MMDR Reforms 1
- 3. 5 streams of work Enhancing the listing frameworkStream 1 Improving transparency for consumersStream 2 Increased flexibility for sponsors and improving the evidence baseStream 3 Increased flexibility and predictability for industryStream 4 Enhanced post-market monitoring and compliance actionsStream 5 Spotlight on Complementary Medicines MMDR Reforms 2
- 4. Stream 1: Enhancing the listing framework Recommendation Government Response Recommendation 34: Capacity to refuse to list Supports the intent of the recommendation Recommendation 37: Online searchable catalogue of permissible ingredients Accepts the recommendation Recommendation 38: Establishing a list of permitted indications Accepts the recommendation Spotlight on Complementary Medicines MMDR Reforms 3
- 5. Recommendation 38: Permitted indications Recommendation 38 The Panel recommends that the TGA establishes the list of permitted indications, from which sponsors must exclusively draw, for listed medicinal products in the ARTG. Government response The Commonwealth accepts Recommendation 38, noting that implementation of the list of Permitted Indications will require legislative change and will be subject to consultation with consumers, sponsors and health professionals. Spotlight on Complementary Medicines MMDR Reforms 4
- 6. What does Permitted Indications mean for sponsors? • Sponsors listing a medicine on the ARTG will only be able to use indications from a permitted indications list • The “free text” field will no longer be available • TGA will also have the ability to create a non-permitted indications list e.g. smoking cessation • 3 year transition period proposed Spotlight on Complementary Medicines MMDR Reforms 5
- 7. Permitted indications on product labels Indications will not have to be ‘word for word’ on the label or advertising material: the intent and meaning of the indication must not change this will give flexibility to sponsors and contain the size of the list For example: ARTG indication: ‘Maintain/support bowel regularity’ Label indication - same meaning: ‘X helps maintain regular bowel movements’ Label indication - different meaning: ‘X relieves constipation’ Spotlight on Complementary Medicines MMDR Reforms 6
- 8. Development of the permitted indications list • A draft list of permitted indications has been published on the TGA website • Stakeholders have the opportunity to review, comment and propose new indications • Supporting materials have been published to help stakeholders understand how regulatory requirements for listed medicines will change • The list is open for comments and suggestions until 31 October 2017 • New indications proposed after this time will incur a fee Spotlight on Complementary Medicines MMDR Reforms 7
- 9. Criteria for permitted indications • Must only refer to: – health enhancement – health maintenance – prevention or alleviation of dietary deficiency; and/or – a health benefit for a non-serious forms of a disease, ailment, defect or injury • Permitted indications can only refer to conditions that are: – self-diagnosable – self-manageable • A delay in medical treatment would not be detrimental to the consumer Spotlight on Complementary Medicines MMDR Reforms 8
- 10. Low Level Indications What this means Examples Health enhancement Beneficial effects of substances on the physiological and /or psychological state of the body; • above and beyond normal growth, development and functions of the body Helps improve immune system May increase energy / reduce fatigue Helps stimulate digestive function Health maintenance Normal physiological effects of substances in; growth, development and normal functions of the body Helps maintain healthy hair, skin and nails Assists with normal liver function Helps support healthy connective tissue / joints Prevention or alleviation of a dietary deficiency Prevention of mild dietary deficiency (not prevention of diseases resulting from severe deficiency) When taken regularly, may prevent vitamin D/ calcium deficiency Helps reduce the risk of iodine deficiency Helps prevent dietary vitamin B12 deficiency Spotlight on Complementary Medicines MMDR Reforms 9
- 11. Low Level Indications What this means Examples A non-serious disease, ailment, defect or injury (other than prevention or alleviation) Those low risk conditions that are non-serious and self manageable. May be related to: • reduction in risk/frequency/duration • relief • management or improvement in quality of life …without resolution of the underlying non-serious disease, ailment, defect, condition or injury. May relieve symptoms of mild osteoarthritis Helps reduce the severity of common cold symptoms For the management mild dermatitis symptoms May relieve post-menopausal/PMS symptoms Helps reduce the frequency of common cold sore outbreaks Spotlight on Complementary Medicines MMDR Reforms 10
- 12. Implementation: Proposed approach • Sponsors will be required to certify that indications for their medicine are from the permitted indications list and they hold supporting evidence • Consistent with current Evidence Guidelines, qualifying terms can be used by sponsors to align indications with the evidence they hold • Indications will have a consistent structure and terminology to describe therapeutic uses appropriate for listed medicines • Sponsors will select ‘core permitted indications’ (action and target only) with optional qualifiers Spotlight on Complementary Medicines MMDR Reforms 11
- 13. Selecting permitted indications when listing a medicine 1. Select tradition of use (Optional) Indications that do not specify a tradition of use are by default scientific 2. Select core permitted indication (Mandatory) At least one core indication is selected in ELF using drop down lists or key word search 3. Select specifying qualifiers (Optional) Sponsors can choose to apply one or more pre-approved qualifiers to each core permitted indication by selecting from a drop down list Healthy target population Effectiveness Time of use Tradition of use N/A Core permitted indication Relieves muscle aches and pains Specifying qualifiers Healthy target population: ‘in healthy individuals’ Effectiveness: 'Temporarily’ Time of use: ‘after exercise’ Final permitted indication on product label E.g. Temporarily relieve muscle aches and pains after exercise in healthy individuals Spotlight on Complementary Medicines MMDR Reforms 12
- 14. Transition arrangements • From 1 January 2018, all new listed medicines must select permitted indications (free text will be turned-off) • Sponsors of existing listed medicines will be required to transition their existing indications to ‘permitted indications’ by 31 December 2020: AUST L numbers will not change Fee waiver/reduction if indications changed by 31 June 2019 • Listed medicines that do not transition to permitted indications will be cancelled from the ARTG from 1 January 2021 Spotlight on Complementary Medicines MMDR Reforms 13
- 15. Stream 2: Improving transparency for consumers Recommendation Government Response Recommendation 43: Requirement to publish efficacy evidence Supports the intent of the recommendation Recommendation 44: Publication of disclaimers on promotional material where product has not had efficacy assessed Supports the intent of the recommendation and will conduct further consultation on ways to better educate consumers however the Government will not require sponsors to place a disclaimer on product labels Recommendation 45: Publication of a ‘claimer’ where product has had efficacy assessed by TGA Accept in principle Recommendation 46: Adopt or develop evidence monographs Accepts the recommendation Spotlight on Complementary Medicines MMDR Reforms 14
- 16. Recommendation 45: Claimers for assessment of efficacy Recommendation 45 Where a medicinal product is listed in the ARTG following an assessment by the TGA of an application under Option Two (refer to Recommendation 39), the sponsor is able to indicate on all promotional materials and on the product label, that the efficacy of the product has been independently assessed for the approved indications. Government response Accepts-in-principle Recommendation 45, noting that the design and use of the promotional statements will require careful consideration by the TGA and further consultation with stakeholders. Spotlight on Complementary Medicines MMDR Reforms 15
- 17. Label ‘claimer’: Key features • A claimer can be used by medicines that have had TGA pre-market assessment: – medicines assessed via the assessed listed medicines pathway (refer to Recommendation 39) – Registered complementary medicines • A claimer cannot be used by medicines that have not had a pre-market assessment: – Listed medicines, including those that have been subject to a post market compliance review – “Grandfathered” medicines Spotlight on Complementary Medicines MMDR Reforms 16
- 18. Label ‘claimer’: Key features • Must be supported by the appropriate scientific evidence for all indications made for the medicine • Must not imply superiority of the product over other medicines that have been pre-market assessed (e.g. prescription medicines) • Must not be more prominent or detract from the label information mandatorily required by the current Labelling Order Spotlight on Complementary Medicines MMDR Reforms 17
- 19. Claimer: Next steps • Consumer testing – visual claimers – wording options E.g. ‘Efficacy assessed by the TGA’ • Targeted consultation • Education campaign Spotlight on Complementary Medicines MMDR Reforms 18
- 20. Stream 3: Increased flexibility for sponsors and improving the evidence base Recommendation Government Response Recommendations 35/36: Continue to evaluate ingredients on safety, evidence and quality with two new methods for assessment of ingredients Accepts both recommendations Recommendation 39: Three pathways for inclusion of Listed medicines on the ARTG Accepts the recommendation Recommendation 40: Develop two new pathways for Registered complementary medicines Accepts the recommendation Spotlight on Complementary Medicines MMDR Reforms 19
- 21. Recommendation 39: Three assessment pathways for complementary medicines Recommendation 39 The Panel recommends 3 options by which sponsors may seek ARTG entry for complementary medicines: • Option 1: Listing in the ARTG following self-declaration by the sponsor regarding safety, quality and efficacy (current Listing pathway) • Option 2: Listing in the ARTG following self-assessment of the safety and quality but a TGA assessment for efficacy (New pathway) • Option 3: Registration in the ARTG following full TGA assessment of safety, quality and efficacy (current Registered pathway) Spotlight on Complementary Medicines MMDR Reforms 20
- 22. Recommendation 39: Three assessment pathways for complementary medicines Government response The Commonwealth accepts the recommendation, noting that legislative amendments are required to implement Option Two. Implementing this recommendation would increase transparency for consumers, provide additional flexibility for sponsors and support innovation. Spotlight on Complementary Medicines MMDR Reforms 21
- 23. Assessed listed medicines pathway: Key features • A new assessment pathway sitting between the existing listed medicine (low risk) and registered medicine (high risk) pathways • Maintains low risk status based on their ingredients, the way they are presented and the potential harm associated with their use • Can use ‘intermediate claims’ which are not included on the permitted indications list: Low level indication: ‘May help relieve muscle aches and pains’ Intermediate level indication: ‘ May help relieve arthritis’ Spotlight on Complementary Medicines MMDR Reforms 22
- 24. Assessed listed medicines pathway: Key features • Still required to comply with GMP requirements • Claims must be supported by appropriate scientific evidence • TGA evaluates the evidence for efficacy before it is listed • Option to include a claimer on all promotional material stating it has been independently assessed Spotlight on Complementary Medicines MMDR Reforms 23
- 25. Proposed approach: Assessment pathways Listed Medicines New Pathway Registered Medicines Permitted ingredients Permitted ingredients Not limited to selecting from permitted ingredients list Good Manufacturing Practice Good Manufacturing Practice Good Manufacturing Practice Low level permitted indications only At least one ‘intermediate indication’ May have higher level indications No pre-market assessment Pre-market assessment of evidence for efficacy Full pre-market assessment Ability to claim that efficacy has been assessed Spotlight on Complementary Medicines MMDR Reforms 24
- 26. Proposed approach: Indications Listed medicines New pathway Registered medicines Low level indications May refer to: • health enhancement • health maintenance • prevention/alleviation of dietary deficiency • a health benefit for a non- serious disease or condition (symptomatic relief) E.g: maintain/support healthy bones Intermediate level indications May refer to: • a health benefit for a serious disease (i.e. restricted representations) • prevention, alleviation or management of a non-serious disease or condition (of a higher risk to consumers than low level indications) E.g: prevention of osteoporosis High level indications: May refer to the: • prevention • Alleviation, • cure or • management Of a serious form of a disease, ailment, defect or injury (restricted reps) Must not refer to a prohibited representation Spotlight on Complementary Medicines MMDR Reforms 25
- 27. Establishing efficacy • Sponsors will be required to meet minimum evidence requirements • Existing approaches to establish efficacy for listed and registered complementary medicines will be retained • For the new pathway: – There will be flexibility in how the evidence requirements can be met (de novo vs. well established ingredients) – Sponsor will self-assess the safety and quality (permitted ingredients, compliance with quality standards and GMP) Spotlight on Complementary Medicines MMDR Reforms 26
- 28. Next steps • TGA will conduct a pilot of the new pathway prior to implementation in 2019 – Expressions of interest via the TGA website late 2017 • Minimum data requirements for product efficacy will be developed standardise pre-market assessments • Further consultation to develop evidence guidelines Spotlight on Complementary Medicines MMDR Reforms 27
- 29. Stream 4: Increased flexibility and predictability for industry Recommendation Government Response Recommendation 41: Develop legislative timeframes for pre-market assessments Accepts the recommendation Recommendation 42: Management of variations Accepts the recommendation Recommendation 47: Expand review and appeal rights Supports the intent of the recommendation Recommendation 50: Incentives for innovation of complementary medicines Accepts in principle Spotlight on Complementary Medicines MMDR Reforms 28
- 30. Recommendation 50: Incentives for innovation Recommendation 50 The Panel recommends that the Australian Government gives consideration to improving the competitiveness of the Australian complementary medicines industry by providing incentives for innovation Government response The Commonwealth accepts-in-principle Recommendation 50, noting the cross government responsibility for innovation policy Spotlight on Complementary Medicines MMDR Reforms 29
- 31. Incentives for new ingredients: Key features • The current process for new ingredient applications does not protect the resources invested by applicants • Proposal to allow for a 2 year market exclusivity period for new complementary medicine ingredients approved for use in listed medicines. • Implementation will: – Encourage research into emerging areas of complementary medicines. – Provide incentive for industry to innovate and bring new products to market. Spotlight on Complementary Medicines MMDR Reforms 30
- 32. Stream 5: Enhanced post-market monitoring and compliance actions Recommendation Government Response Recommendation 49: Enhanced post market monitoring scheme Accepts the recommendation, noting that the intent of some elements of the recommendation can be achieved within existing mechanisms Spotlight on Complementary Medicines MMDR Reforms 31
- 33. Recommendation 49: Enhanced post-market compliance Recommendation 49 The Panel recommends a more comprehensive post-market monitoring scheme for listed medicinal products, including complementary medicinal products. Such a scheme should include: • an increase in the number of products subject to random/targeted reviews • integration of available datasets, including eHealth and hospital records, to provide a more streamlined and cost effective approach to post-market monitoring • provision for electronic reporting of adverse events • enhanced collaboration with overseas regulators to share information relating to safety or efficacy of comparable products. Spotlight on Complementary Medicines MMDR Reforms 32
- 34. Recommendation 49: Enhanced post-market compliance Government response The Commonwealth accepts Recommendation 49, as the development of a more comprehensive post-market monitoring scheme will enhance consumer protection and complement existing post-market monitoring processes. The Commonwealth notes that the intent of some elements of the recommendation can be achieved within existing mechanisms. Spotlight on Complementary Medicines MMDR Reforms 33
- 35. Enhanced post-market compliance: Key features How are we going to do this? • Greater targeting of sponsors with a significant history of non-compliance • Enforcing sanctions and penalties for repeat non-compliance • Improved guidance for sponsors about their regulatory obligations • Provide more information on the TGA website to encourage higher levels of compliance Spotlight on Complementary Medicines MMDR Reforms 34
- 36. Phased implementation 2017 - 2019 In 2017 – Online searchable catalogue of permitted ingredients – Review and appeal rights for ingredient assessment By 2018 – Permitted Indications – New assessment pathways for registered complementary medicines and new ingredients – Risk-based approach to medicine variations By 2019 – The New Pathway – Label claimer Spotlight on Complementary Medicines MMDR Reforms 35
- 37. MMDR consultations • Targeted stakeholder consultations commenced October 2016. • Public consultations throughout 2017. • The proposed reforms arising from recommendations 38, 39, 45 and 50 are addressed in our first public consultation paper. • Outcomes from this consultation are on the TGA website. Spotlight on Complementary Medicines MMDR Reforms 36
- 38. MMDR consultation – Business process improvements Second public consultation due for release September 2017 – Broadening the range of sources of evidence for new ingredient assessment (Recommendation 35) – Use of evaluation reports from comparable overseas regulators (Recommendations 36 & 40) – Introduction of legislated timeframes for ingredient assessment (Recommendation 41) – Enhancing post-market compliance (Recommendation 49) See the MMDR public consultation forecast on the TGA website for further information Spotlight on Complementary Medicines MMDR Reforms 37
- 39. Next steps • Legislative amendments to the Therapeutic Goods Act 1989 and the Therapeutic Goods Regulations 1990 • Further consultation • Transitional arrangements • Sponsor education • Updated guidelines Spotlight on Complementary Medicines MMDR Reforms 38
- 40. Questions? Spotlight on Complementary Medicines MMDR Reforms 39
- 41. Find out more: www.tga.gov.au/complementary-medicines-reforms Complementary.Medicine.Reforms@health.gov.au Spotlight on Complementary Medicines MMDR Reforms 40