FDA Drug Approval Process
The U.S. Food and Drug Administration (FDA) has the responsibility to determine if newly developed medical products are safe and effective. Whether it is a prescription medication, a medication sold over the counter, a medical device, a vaccine, or another type of biologic, the product can be marketed for general sale in the United States only if it has FDA approval.
FDA advisory committees are the most visible part of the FDA approval process. They meet in public to review the most controversial and cutting-edge medical products, examining applications for FDA approval. Committee members discuss the strengths and weaknesses of the studies and their enthusiasm or concerns about the medical product under review. At recent FDA advisory committee meetings on controversial drugs and medical devices such as Vioxx®, silicone implants, and antidepressants, the media have provided the Congress and the general public with a glimpse of the approval process.
FDA schedules meetings for several of its advisory committees, the outcome is almost certainly going to be FDA approval for the products under review. In most cases the advisory committee will recommend approval, but even products that are not recommended for approval are frequently approved by the FDA. Even lopsided votes against approval apparently do not have much weight, since the FDA subsequently approved many of those products.
Although FDA officials describe the advisory committees as providing diverse perspectives and expertise, the large number of unanimous or nearly unanimous votes suggests that either the data are exceptionally convincing or that the committee members are reluctant to disagree with their colleagues or believe that the FDA wants the advisory committee members to come to consensus.
By combining information from the NRC study with studies of conflicts of interest on FDA advisory committees, it is possible to understand how a few committee members with conflicts of interest can have a disproportionate impact on approval recommendations. NRC’s analysis of meeting transcripts indicates that many committee members’ votes seem inconsistent with their concerns about the safety or efficacy of the drug or medical device under review. These transcripts clearly illustrate the pressures that committee members describe to conform to their colleagues or to be able to vote ‘yes’ even if it means changing the wording of the question so that they can do so in good conscience. The report includes examples of committee members directly trying to influence the views or votes of other committee members.
If the FDA is relying on advisory committees to help determine the conditions of approval, one would expect that FDA officials would provide explicit oral instructions about the types of conditions that the FDA is willing to impose, and that the FDA would impose most of the conditions and then enforce them. That is not the case, however.
Committee members frequently recommended unenforceable or vaguely worded conditions of approval and expressed their intention to recommend approval for products that they did not believe were proven safe or effective. Their candor suggests that they would welcome guidance from the FDA officials present, to make sure their recommendations were appropriate. Nevertheless, during committee discussions FDA officials showed remarkably little interest in providing oral guidance regarding the criteria for approval, or the realities of approval conditions to advisory committee members during the eight years of the study. Conditions of approval imposed by the FDA often did not reflect the conditions recommended by the advisory committees. Conditions that were imposed were rarely enforced.
Overall, the findings indicate that committee members, intentionally or unintentionally, move toward a consensus that often seems inconsistent with their differing views or perspectives in making decisions that may have life-or-death consequences for millions of Americans. Voting for approval contingent upon conditions is a popular compromise, but the FDA does not impose most of the specified conditions on the companies when it grants approval. The Committees’ tendency toward approval seems to reflect the FDA’s goals; in fact, the FDA appears to be even more geared toward approval than the advisory committees. The FDA approved almost all the prescription drugs and devices recommended by the advisory committee, and also frequently approved products that were opposed by the committee members.
Whatever the reasons, many of today’s FDA drug and device advisory committees are rubber stamps for approval almost every time they meet. Moreover, even when an overwhelming majority recommend “nonapproval,” there is a good chance that FDA officials will approve the product anyway. Approval is even more likely for medical devices than it is for drugs.