pv.pptx pharmacovigilance, its need, aspects, brief overview,outline

1.INTRODUCTION
2.AIMS
3.RESPONSIBILITIES
4.NEED OF PHARMACOVIGILANCE
5.GOVERNING BODIES
6.METHODS OF PHARMACOVIGILANCE
7. PHARMACOVIGILANCE INSPECTION
8.ADVERSE DRUG REACTION
9.APPLICATION OF PHARMACOVIGILANCE
10.TERMINOLOGY
11.POST MARKETING SURVEILLANCE
12. PHARMACOVIGILANCE PROGRAMME IN INDIA
13.WHO PROGRAMME FOR INTERNATIONAL DRUG
MONITORING
14.PHARMACOVIGILANCE OF MEDICAL DEVICES
15.PHARMACOVIGILANCE OF HERBAL MEDICINES

Pharmacovigilance(PV) also called as drug safety
Pharmakon-------in greek----drug
Vigilare -----------in latin------to keep watch
def: Pharmacovigilance is the science &activities
relating to the detection , assessment,
understanding and prevention of adverse effects
(WHO collaborating centre for international drug
monitoring)

AIMS
 To improve patient care and safety
 To improve public health and safety
 To contribute to the assessment of benefit,
harm ,effectiveness and risk of medicines
 To promote education and clinical training
 To promote rational and safe use of
medicines

RESPONSIBILITIES
 Timely collection of data ,recording and
notification
 Appropriate assessments
(data completeness , seriousness)
 Expedited and periodic reporting
 Creates appropriate structures for
communication

1.HUMANITARIAN CONCERN
-Animal toxicology is often not a good
predictor for human effects .
-Evidence of safety from clinical trials is
insufficient due to some limitations
 LIMITATIONS (phase 1-3): limited size ,
narrow population (age &sex specific),
narrow indications (only specific disease),
short duration

2. SAFE USE OF MEDICINES
it has been suggested that ADRs may
cause 5700 deaths per year in UK
3.ADRs ARE EXPENSIVE
4.PROMOTING RATIONAL USE OF MEDICINES
5.ENSURING PUBLIC CONFIDENCE
6.ETHICAL CONCERN
not reporting is serious reaction is unethical

 The pharmaceutical industry
 Regulatory authorities
 WHO collaborating centre for international
drug monitoring
 CIOMS(Council for International
Organization of Medical Sciences )

METHODS 0F PHARMACOVIGILANCE
1. Individual case safety reports
2. Clinical review of case reports
3. Cohort event monitoring
4. Longitudinal electronic patient records
5. Spontaneous reporting
6. Periodic Safety Update Reports (PSUR)
7. Expedited report
8. Record linkage

1.INDIVIDUAL CASE SAFETY REPORTS:
-Like yellow card system of the
Pharmacovigilance section of the U.K.
-Their strength in signaling causal associations
depend on the skill and experience of the
reporter and the documentation and
characteristics of the event.

2.CLINICAL REVIEW OF CASE REPORTS:
-The quality of reports is variable , large national
and international organizations collect
hundreds of thousands of reports each year ,
every one of which can’t possibly be reviewed
by the available experts.
-Even if each report could be reviewed ,
important reporting patterns would be missed.
-Computational have therefore been developed
to help highlight the most urgent problems .

3.COHORT EVENT MONITORING:
-Cohort Event Monitoring (CEM) systems for
intensified follow up of selected medicinal products.
-The main limitations are its restriction to small
subset of medicinal products , the relatively small
fraction of the population covered .

4.LONGITUDINAL ELECTRONIC PATIENT
RECORDS:
-It is extremely valuable but underused.
-They cover large populations, provide detailed
information on both exposed and unexposed
patients.
-Information is extracted directly from the
computer systems in which physicians store
patient’s data.
-Privacy protection for patients and physicians is
of the utmost importance.

5.SPONTANEOUS REPORTING:
-The reporting might be directly to the
company , or it could be to the regulatory
authority.
-Main limitation is under reporting.
-However , their main purpose is not the
quantification of the frequency, but
identification of signals.

-When becoming aware of a serious adverse drug
reaction , health care providers, pharmacies,
pharmaceutical companies shall report to the health
authority.
-Time frame of reporting , report within a specific
time frame(ex:7days) upon knowing of any serious
ADR.

-REPORTING METHODS AND TEMPLATE : shall
submit reports by post, fax or internet .
-A verbal report is acceptable in urgent situations, but
written submission should be completed before the
deadline.
-Additional information on a serious ADR report, not
available at the time of the initial report , should be
provided in follow up reports.

6.PERIODIC SAFETY UPDATE
REPORTS(PSUR):
-Pre marketing clinical trials may not be
sufficient to reflect the product safety profile.
-Therefore medically advanced countries impose
the “post marketing drug safety monitoring period
” on new drugs.
-license holders shall proactively collect post
marketing safety data, prepare PSUR and submit
them to the health authority.

-According to the “regulation of medical products
under safety monitoring” ,if pharmaceutical
companies fail to submit PSUR as required , then
the health authority may reassess the safety of
the concerned product.
-The last PSUR should be submitted before the
expiration of the drug safety monitoring period.
-The “summary bridging report” provides
summarized information of the PSURs.

7.EXPEDITED REPORT:
-If there has been spontaneous reporting of a
suspected ADR to a pharmaceutical company , there
are legal obligations on the company to report
serious reactions within a specified time frame to the
regulatory authority.
-based on the results of drug safety assessment ,
license holders shall report to the health authorities
in an expedited manner

8.RECORD LINKAGE:
- Bring together a variety of patient records
.
-A specific example is prescription event
monitoring scheme.
-It is less expensive but time consuming
method.

PHARMACOVIGILANCE INSPECTION
two types -
1.routine inspection
2.targeted inspection
1.Routine inspections
- To make sure that pharmaceutical companies
have the ability in performing Pharmacovigilance
activities

2.targeted inspections
a) inspections irrelevant to drug safety
-companies that have not yet been inspected
-companies that launch their first product
-companies which are newly merged
b) inspections relevant to drug safety
-companies that delay or fail to take their obligations on
safety monitoring
-companies that delay to submit or submit incomplete
periodic safety update reports
-companies that failed to report drug safety related
issues (like drug withdrawal with out reporting )

ADVERSE DRUG REACTIONS
Adverse event reporting –comprises 4
elements
1.an identifiable patient
2.an identifiable reporter
3.a suspect drug
4.a suspected adverse event

TYPES OF ADR
 non immunological
a) TYPE A (or) predictable
b) TYPE B (or) unpredictable
 immunological a) TYPE -I (Ig E mediated)
b) TYPE -II (cytotoxic)
c) TYPE -III (immune
complex)
d) TYPE -IV (cell mediated)
 miscellaneous a) jarisch - herxheimer reaction
b) infectious mononucleosis

NON IMMUNOLOGICAL
TYPE A (or) predictable
1.side effects
2.secondary effects
3.toxic effects
4.mutagenicity&carcinogenicity
5.drug interactions
6.teratogenicity
7.nonimmunological activation of effector
pathways
8.exacerbation of disease
9.Metabolic alterations
10.drug induced chromosomal damage
11.effect on spermatogenesis

TYPE B (or) unpredictable
1. intolerance
2. idiosyncrasy

Type A
1.Side effects :
- undesirable and unavoidable effects of
drugs due to their pharmacological property at
recommended doses.
Ex-dry mouth from atropine therapy
2.Secondary effect:
-Indirect effects of drug due to its principal
action.
Ex-occurrence of TB in corticosteroid therapy.

3.toxic effect:
-It is a pharmacological action due to over
dosage or prolonged usage.
Ex-coma with barbiturates
4.mutagenicity & carcinogenicity:
-metabolites from drugs can cause structural
changes in chromosomes to produce mutations.
Ex-anti cancer drugs

5.drug interactions:
-Can occur before its absorption into systemic
circulation .
Ex- phenobarbitone inhibits griseofulvin
absorption from intestine
6.teratogenicity:
-Fetal abnormalities produced due to drug
intake by the pregnant woman
Ex-androgens cause virilization of fetus

7.non immunological activation of effector
pathways:
-Some drugs cause release of mediators from
mast cells resulting in urticaria.
Ex-radio contrast media
8.exacerbation of disease :
-Barbiturates precipitate symptoms of
porphyria

9.metabolic alterations :
Ex- isotretinoin interferes with VLDL
metabolism and causes xanthoma
10.drug induced chromosomal damage:
-Also called clastogens
Ex-antibiotics, anticonvulsants
11.effect on spermatogenesis:
-Cytotoxic drugs causes oligospermia.

Type B
1.intolerance:
-Appearance of toxic effects in a recipient to
therapeutic doses of drug
Ex- trifluperazine single dose causing muscle
dystonia in children
2.idiosyncrasy:
-Uncertain reaction to a drug in a genetically
defect patient
Ex-chloramphenicol causes bone marrow
depression

IMMUNOLOGICAL
1.Type 1 (immediate or anaphylactic):
Ex:-penicillin, lignocaine
Mediators
urticaria
Earlier exposure
AB formed
AG:AB reaction
mast cells
Re exposure to the
same Drug (AG)

2.Type 2 (cytotoxic):
Drug + particular tissue AB
(AG)
AG:AB reaction
complement
cytolysis
Ex: blood transfusion reactions, cephalosporins

3.Type 3 (retarded or arthus ):
Drug (AG) AB
AG : AB complex
Complement
Inflammatory reaction
Ex:- acute interstitial nephritis with NSAIDs

4.Type 4 (delayed hypersensitivity reactions ):
Ex:-contact dermatitis
Prior sensitization T lymphocytes c receptors
(AB)
Re exposure of the drug
(AG)
Release of lymphokines
AG:AB reaction
Attracts granulocytes
Inflammatory response

MISCELLANEOUS
1.jarisch-herxheimer reaction:
-This is seen when an infective disease is
treated with antimicrobials , due to release of
active substances from dead micro organisms
and injured tissue resulting in focal exacerbation
of the lesions.
2.infectious mononucleosis:
-Ampicillin induced morbilliform rash in
patients suffering from infectious mononucleosis.

Steps of ADR monitoring:
1.identifying adverse drug reactions
2.assessing causality
3.documentation of ADR
4.reporting serious ADRs to PV centres/ADR
regulatory authorities

NARANJO algorithm
For assessing the causality-
-definite = 9
-probable = 5-8
-possible = 1-4
-doubtful =  0

Hartwig and Seigels scale
For assessing the severity-
1.mild ADRs-are self limiting and do not
contribute to prolongation of length of hospital
stay.
2.moderate ADRs- require therapeutic
intervention or hospital admission or prolonged
hospital stay by at least one day .
3.severe ADRs- life threatening, requiring
intensive medical care or produce disability or
lead to death.

APPLICATION OF PHARMACOVIGILANCE
1. in national drug policy
2.in the regulation of medicines
3.in clinical practice
4.in disease control public health programmes
(problems are apparent in situations for the
treatment of tropical diseases)

TERMINOLOGY
1.SIGNAL-reported information on a possible
causal relationship which is being unknown or
incompletely documented previously.
-usually more than 1 report is required to
generate a signal
-before signals are published they are first
clinically assessed by PV experts at
UMC(Uppsala monitoring centre ,Sweden)

-there are 3types of signals
1.confirmed signals-causal relationship
between the drug and adverse event
2.refuted(false) signals-no causal
relationship
3.unconfirmed signals-require further
investigation

2.TRIAGE-process of placing a adverse event
report into one of these 3 categories .
a) non serious case
b)serious case
c)no case
3.ADVERSE DRUG REACTION –any noxious
change which is suspected to be due to a drug,
occurs at doses normally used in man , requires
treatment or decrease in dose or indicates
caution in the future use of the same drug.

4.ADVERSE DRUG EVENT-any untoward
medical occurrence that may present during
treatment with a medicine , but which does not
necessarily have a causal relationship with the
treatment.
5.WHOART-WHO Adverse Reaction
Terminology is dictionary for coding adverse
reactions . This system is maintained by the
UMC.
6.COSTART-COding Symbols for a Thesaurus
of Adverse Reaction Terms developed by
USFDA . But recently COSTART was replaced
by MedDRA.

7.MedDRA-Medical Dictionary for Regulatory
Activities
- International medical terminology dictionary
-Originally available in English &Japanese
- MedDRA is organized as System Organ
Class(SOC).which is divided into
a)high level group terms(HLGT)
b)high level terms(HLT)
c)preferred terms(PT)
d)lower level terms(LLT)

-MedDRA is managed by MSSO(Maintenance
and Support Services Organization)
-MSSO releases new version in twice a year
(march& September)
-March release is the main ,contains changes at
the HLT level &above
-September release contains changes at the PT
level
-Latest version(16.1) was updated on sept 2013

8.DATA MINING-extract information from a data
and transform it into an understandable
structure for further use
-it is practical machine learning tools
&techniques with java
-the term data mining appeared around 1990.
-currently data mining and knowledge
discovery are used interchangeably

Six tasks-
a)anomaly detection –identification of unusual
data &data errors that require further
investigations.
b)association rule learning-searching
relationship between variables
c)clustering-discovering groups that are in some
way similar
d)classification-to apply to new data
e)regression-models the data with least error
f)summarization-compact representation of data

-Medical data mining-HITECH act(Health Information
Technology for Economic and Clinical Health act)
-by this data mining opportunities are maximized
a)Free open source data mining soft ware & applications-
carrot 2
GATE
Orange
rapid miner
b)Commercial data mining software & application
-clara bridge
-oracle data mining
-statistica data miner

9.VIGI FLOW-it is a web based ICSR(Individual Case Safety
Report) system designed for national centres ,which does not
have ICH-E2B compatible data base.
-ICH-International Conference on Harmonization
-Vigiflow is based on ICH-E2B
-ICH-E1-E2F -----clinical safety
-E3 ----------clinical study reports
-E4 ----------dose response studies
-E5 ----------ethnic factors
-E6 -----------good clinical practice
-E7-E11 -----clinical trials
-E12 ---------clinical evaluation by therapeutic
category
-E14 ---------clinical evaluation
- E15-16 ----pharmacogenomics

a)input-ICSR data can be manually entered
into vigiflow with support from the latest
version of terminologies such WHO-ART
or MedDRA
b)handling of ICSRs-it is easy to communicate
within the vigiflow by adding a digital
note to the ICSR.
- once a report is complete the first version of
the ICSR is considered to be finalized.

c)analysis-search& statistics module is part of
vigiflow .the results can be exported in
different output formats.
d)communication-data can be sent to external
contacts such as companies or other
regulatory agencies.
-Technical information-requirements are web
browser , internet connection.
- information stored in vigiflow is only accessible
by users within the same country.
-There are downloadable pdf information sheets
available here

10.VIGIBASE-a unique collection of international
drug safety data. Vigibase is the name of the
WHO ICSR data base . Its consists of reports of
adverse reactions
common uses-
-signal detection
-updating product safety update reports
-compare the reports
- WHO member countries have access to the
collected data and analyze
- Vigibase comprises 8million reports in which
2 lack new reports are added quarterly

11.VIGI SEARCH- a search service for accessing
ICSRs stored in the vigibase , offered by UMC to
national centres.
12.VIGIMED-share point based conferencing
facility ,exclusive to member countries of the
WHO. For fast communication .
13.VIGIMINE-a statistical tool within vigisearch. It
allows filtering of the results by age , sex ,
country.

14.VIGILYZE- during may & June 2013
vigisearch & vigimine were replaced by this.
Its a search and analysis tool that provide
access to vigibase.
15.DECHALLENGE AND RECHALLENGE-a
drug being stopped &restarted in a patient to
confirm causal relationship.
16.PHARMACOEPIDEMIOLOGY- study of the
incidence of adverse drug reactions in patient
populations.

17.PHARMACOGENETICS-genetic variation that
gives rise to differing responses to drugs
including ADR.
18.PHARMACOGENOMICS-application of
genomic technologies to new drug discovery.
19.PHARMACOENVIRONMENTOLOGY-form of
pharmacovigilance which deals specifically with
those pharmacological agents that have impact
on the environment via elimination through living
organisms subsequent to pharmacotherapy.

Post marketing surveillance(PMS)
-Is the practice of monitoring the safety of a
pharmaceutical drug or medical device often it has been
released on the market and is an important part of the
science of Pharmacovigilance.
-Since drugs are approved on the basis of clinical trials,
which involve relatively small numbers of people & do
not have other medical conditions.
Approaches are –spontaneous reporting database
- prescription event monitoring
-electronic health records
-patient registries

Uses-no fixed duration or patient population
starts immediately after marketing
report all ADRs
helps to detect rare ADRs
PMS-consists of 3 systems
1.ADR collecting and reporting system
2.reexamination system
3.reevaluation system

Sources-focus groups
- customer surveys
- customer complaints& warranty claims
- literature reviews
- media
Benefits-improvement of medical device quality
-verification of risk analysis
-detection of chronic complaints
-performance in different user
population
- customer satisfaction

Needs of PMS-
-to develop information about drug effects
- to find rare adverse events
-assess to more patient data
Methods of surveillance-
-controlled clinical trials
-spontaneous recording
-cohort studies
-case control studies
-All adverse events occurring in a PMS should
be submitted to UMC in the form of fact sheet.

Fact sheet should be-email to
vigibase@whoumc.org
- confirmation will be sent of received cases
within 3 days
-case report format-ICH E2B
-both serious and non serious cases should
be submitted
-reporter qualification should be specified in
the ICSR
-ICSR on veterinary medicines , cosmetics
should not be submitted to UMC
-either of the two ADR terminologies WHOART
(or)MedDRA can be used .

Pharmacovigilance programme of India
(PVPI)
Introduction –
-officially started on 23 November 2004 at new
Delhi
-pharmaceutical industry in India is valued at
90,000crore and is growing at the rate of 12-14% per
annum
-total export of pharma products is to the extent of
40,000crore.
- India is now being recognized as the “global
pharmacy of generic drugs”

-India is also emerging rapidly as a hub of global
clinical trials & destination for drug discovery and
development
-In a vast country like India with a population of
over1.2 billion with vast ethnic variability
,different disease prevalence patterns , practice
of different systems of medicines, different SES ,
it is important to have robust Pharmacovigilance
and drug safety monitoring programmes.

PVPI is under control of-
1.CDSCO(Central Drugs Standard Control
Organization)
2.directorate general of health services
3.indian pharmacopeia commission
(Ghaziabad)
-The programme is conducting by
NCC(National Coordinating Centre) .

Goals & objectives-
goal- to ensure that the benefits of use of medicine outweighs the risks
objectives-
1. to monitor ADRs
2. to create awareness among health care professionals about
ADRs
3.to monitor benefit –risk profile of medicines
4. generate independent ,evidence based recommendations
5.support the CDSCO
6.communicate findings with all stake holders
7.create a national centre

PVPI will be administered and monitored by the
following committees
1.steering committee
2.strategic advisory committee
Technical support by –
1.signal review panel
2.core training panel
3.quality review panel

STEERING COMMITTEE
Chairman-drugs controller general (India), New Delhi
Members-
1.scientific director , Indian pharmacopoeia commission ,
Ghaziabad
2.head of dept of pharmacology ,AIIMS
3.Nominee of director general ,ICMR
4.Assisstant director general as representative of directorate
general health services
5.under secretary as representative of the ministry of
health & family welfare
6.nominee of vice chancellor of medical/pharmacy university
7.nominee of the medical council of India
8.nominee of the pharmacy council of India

-PVPI is a 3 layered structure consisting of
1.peripheral
2.regional
3.zonal centres

Collaboration with WHO- UMC
Long term objective of the PVPI is to establish a
centre of excellence- for that
 training of the staff at the PVPI NCC
 Usage of UMC s vigiflow (for medicines),
paniflow (for vaccines)
 Access to vigibase
 Access to early information about safety
hazards

OPERATIONAL ASPECTS
 Roles and responsibilities of different
personnel in PVPI
 Centre management
 Processing and reporting of suspected ADRs
 Quality assurance in the programme
 Regulatory decision making
 Communication among various stake holders

Risk management
 Ensure availability and management of
funds
 Conduct frequent training and awareness
 Detect and respond to under reporting
ADRs
 Quality review of filled ADR forms
 Proper supervision of the centres
 Feed back to the health care professionals

Programme communications
A,B,C,D,E- programme communications
1,2,3,4- ADR reporting

Monitoring and evaluation
1.Process indicators –
-number of ADR monitoring centres
participating
-number of personnel trained in a year
-funds budgeted and spent
2. Out come indicators –
-number of ADR reports received in year
-number of ADR reports processed in year
-number of ADR reports submitted to vigiflow
3. Impact indicators –
-number of signals generated and confirmed
-number of safety related alerts issued by
CDSCO

WHO Pharmacovigilance programme
Introduction : -Started in 1978
- Known as WHO programme for international
drug monitoring, which is located in Uppsala, Sweden.
-As of October 2013, 117 countries have
joined
Functions –
1. identification and analysis of new ADR signals from
national centres & sent to the WHO ICSR database
2. provision of the WHO database as a reference source.
3. information exchange between WHO UMC , national
centres through vigimed

4. Publications, news letters, guidelines and books in
the pharmacovigilance
5. supplying tools like WHO drug dictionary and WHO
adverse reaction terminology
6. training to national centres
7. Maintaining of computer software(vigiflow)
8. annual meetings
9. research on Pharmacovigilance

REPORTING TRENDS:
1. preferred report format is the ICH E2B
2.but some members still use the old WHO
format(INTDIS)
3.ICSRs should be sent once every month but
at least every quarterly

DISTRIBUTION OF ICSR WORLD WIDE

PHARMACOVIGILANCE OF MEDICAL
DEVICES
- medical device reporting(MDR) which is the
reporting of adverse events with medical devices
PHARMACOVIGILANCE OF HERBAL
MEDICINES
- the safety of herbal medicines has become a
major concern to both national health authorities
and public
-however mass media reports of adverse
events with herbal medicines can be incomplete
and therefore misleading regarding the use of
herbal medicines

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