COVID breaks the chain

COVID breaks the chain

“A wise human would have an understanding of the supply chain and how the pieces fit together. But it’s against our nature to think about it. (Paolo Bacigalupi)

There is no denying that the COVID-19 pandemic has ravaged the globe, leaving in its wake death and severely ill patients. The novelty of this virus and the speed of its spread have meant there is no specialised cure. Instead, health professionals and pharma companies alike have struggled to repurpose existing drugs in an attempt to treat those that have contracted the disease.

This has resulted in many countries having to break from the authorised prescribing practices in their efforts to find a drug or combination of drugs to defeat the virus or treat its varied symptoms.

From a pharmacovigilance perspective, this unique situation presents many opportunities that could result in a reduction in patient safety. To ensure this does not happen, major regulatory authorities including the FDA, the UK MRHA and the EMA have revised guidelines, set up special reporting websites and pleaded for all and any, valid or suspect, adverse events to be reported, particularly related to COVID-19 treatments.

So – while the regulatory authorities are encouraging patients and healthcare practitioners to be vigilant with safety related to COVID-19, there is also a growing concern for safety issues relating to continuity of treatments for conditions not related to COVID-19. These concerns stem from:

  • the interruption in the supply chain for Active Pharmaceutical Ingredients (APIs) and manufactured novel and generic drugs
  • the unfounded fear that certain medications for cardiovascular and rheumatic diseases could increase the chances of contracting COVID-19.

There is a strong possibility that the financial burden forced on healthcare systems caused by the COVID-19 pandemic will increase prescription of generic rather than branded drugs in an attempt to cut costs and contain budgets.

The irony is that the enforced boarder closures and the prolonged lockdowns first in China and then in India has had a huge impact on the ability of these two dominant countries to produce and distribute both generic agents and the APIs they are manufactured from. China and India are responsible for more than 80% of the APIs used to make drugs sold in Europe; together they host 31% of the world’s FDA-registered API-manufacturing plants. Furthermore, India supplies 40% of the World’s generic drugs, and before it was affected by the pandemic, was making strides to increase its API-manufacturing capacity to become less reliant on China for its chemical supplies.

The reality that the world is majorly reliant on two countries for its ability to provide pharmaceuticals is a concern, especially when we see how quickly the supply chains were impacted by enforced lockdowns.

Interestingly, even before the outbreak of COVID-19, Europe was keen to bring back drug manufacturing to its home lands so not to rely so heavily on imported materials. In the US, however, the concept of drugs made in America is being met with some resistance. Perhaps the huge disruption COVID-19 has had in terms of being able to heal and protect ourselves, maybe the catalyst required to rethink the concept of putting all our drugs in one basket.

With respect to generics, there is a misconception that they do not “work the same way” as branded medicines. Small molecule generics need only demonstrate bioequivalence to a reference product within an accepted 80%-125% margin of difference; generic agents do not have to demonstrate bioequivalence with each other. There is a concern two generic agents can legitimately have a 45% difference in their bioavailabilities. However, the FDA has stated over a 12-year period the average difference in drug absorption between branded and generic agents was 3.5%.

Adverse events occurring in patients switching to, or between generic agents is not unheard of, and in some cases it is the excipients and bulking agents that are the culprits. In an attempt to avoid drug shortages, some countries have changed to prescribing practices permitting only one instead of three months’ supply. This could result in more frequent “generic swapping”, particularly as the duration of the pandemic extends. If this happens, we must rely on patients and healthcare practitioners to report their experiences. And for generic manufacturers extra vigilance regarding literature monitoring is prudent since generic products may be more frequently prescribed than before.

It is not only generic drugs per se that may be cause for concern. The FDA recently highlighted the importance of drug packaging in terms of safe use. In response to a shortage of a neuromuscular blocking agent, required for intubation of COVID-19 patients, the temporary production of a similar drug was permitted without the usual warnings on the bottles. Although the two contain the same active ingredient, Propoven 2% (the drug under EUA) is double the concentration of the FDA-authorised Diprivan; the lack of warnings could lead to accidental overdose if practitioners are not aware of the temporary replacement.

I believe that, especially in the wake of the COVID-19 pandemic, “pharmaco-extra-vigilance” practices are necessary regarding literature monitoring to ensure all safety events, particularly those categorised as special situations, are captured. Not only for drugs directly involved in the treatment of the virus and its pathological symptoms, but also for branded and generic drugs that will have been impacted by the global disruptions in the supply chains resulting from the waves of lockdown that have swept the globe.

Image by Shaojie on Unsplash.

COVID causes chaos and special situations

COVID causes chaos and special situations

“Order brings sameness. Chaos brings newness every moment. The problem is first overcoming our fear of chaos, and then mining for the great ideas and bringing them back home.” (anon.)

Since the start of 2020, and the dawning realisation that something was “not quite right” with the world, chaos has indeed reigned. Bringing with it fear, not only of the chaos, but also of the cause….the novel coronavirus SARS-CoV-2 (COVID)

The COVID-19 pandemic has necessitated the unprecedented use of a number of pharmaceutical agents not only in an attempt to find an effective treatment for the viral infection itself, but also to manage the severe and varied nature of the symptoms associated with this deadly virus.

This has resulted in an increase in the number of (often emergency) situations where drugs have been used off-label and/or resulted in cases of pregnancy exposure or lack of efficacy. From a pharmacovigilance perspective, these “special situations” must be closely monitored to ensure the emerging safety information relating to the use of drugs in such cases, is appropriately recorded and analysed so that subsequent interventions can happen to ultimately guarantee patient safety.

From our experience, the proportion of special situations identified in the literature is approximately 15% of Individual Case Safety studies (ICSRs) reported. During the first half of 2020, the proportion of special situations associated with COVID-19-related drug use has increased by a further 10%…. and this is only the beginning.

Unfortunately, while the virus has increased the number of drug safety events worldwide, it has simultaneously reduced the resource and potential to record what will become an important phase in the history of global drug safety.

This was recognised by the US FDA when it recently updated its guideline related to post-marketing adverse event reporting during a pandemic.

To ensure that safety data related to medicinal use during the COVID-19 pandemic are captured, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) has set up a designated website, and the EMA has taken a similar approach with its call to action for all patients with COVID-19 to report any adverse events relating to the use of medicinal products they may receive, since it is important to understand the potential drug interactions that patients may experience.

These data-capturing processes are essential in the current “trial and error” situation we find ourselves in. The need for close monitoring of off-label use of drugs is imperative, now more than usual, if industry is to ensure patient safety in the search for the most effective treatment in the absence of a purpose built cure.

This agile approach has been demonstrated by the FDA when it issued two Emergency Use Authorisations (EUAs) for off label use of Remdesvir and also for chloroquine phosphate and hydroxychloroquine sulfate; then, just 11 weeks later, the EUA for chloroquine and hydroxychloroquine was revoked, based on on-going gathering of evidence that indicated these agents may not be effective for the treatment of COVID-19.

Use of azithromycin to protect healthcare workers from the virus was fleetingly entertained in the UK; this glimmer of hope was short lived as evidence emerged to indicate azithromycin was not effective and may have an unfavourable risk-benefit profile especially when given in combination with hydroxychloroquine. This was supported by National Institutes of Health that issued guidelines strongly recommending against the combined use of hydroxychloroquine plus azithromycin, citing potential toxicities, and also against the use of HIV protease inhibitors without evidence of clinical benefit against the disease. Although disappointing, this information is important for patient safety, and in terms of pharmacovogliance the lack of efficacy observed with these and other repurposed drugs will contribute to the growing volume of valuable safety literature.

At the beginning of 2020 an increase in special situation literature safety reports began to emerge as the pandemic swept the globe and the world looked for an effective treatment for this disease. A search of the AdisInsight Safety database confirms that off-label use of lopinavir and ritonavir, alone and combination was associated with adverse events in patients located in China, Japan, Poland France Iran and the US. And pregnancy exposure, to a variety of drugs, was evident particularly in China and the US.

With the unfortunate possibility that we will experience a second wave of COVID-19 infections in countries that seem to have already conquered the disease, hopefully we can learn from the safety information generated during the initial wave and can put it to good use.

The global impact this disease has had on the use of pharmaceutical products is yet to be fully realised. I believe that the volume of safety-related literature is set to soar over the next few years as the information regarding this unique situation is processed and published.

Image: Morning Brew on Unsplash.

Reactions Weekly: Introducing New Features for 2020

Reactions Weekly: Introducing New Features for 2020

From January 2020, Reactions Weekly ( – an Adis newsletter – will have a new focus and features.

Reactions Weekly provides readers with the latest and most important news and research relating to drug safety. It has published drug safety news for almost 40 years, producing over 1700 issues. It offers readers a significant saving in the time and effort required to research and keep up to date with the thousands of information sources reporting drug safety information. This information is provided in a concise and convenient weekly update.

Over time, it has become increasingly challenging to find relevant drug safety information in Reactions Weekly because of our focus on providing extensive coverage of the large volume of articles published in the biomedical literature. Therefore, we are introducing changes to the content of Reactions Weekly from 2020 to streamline the product and improve the reader experience.

The changes we are introducing will focus the content on the most clinically important adverse reaction news of significance to healthcare practitioners, researchers and regulators. The new features will increase our coverage of drug safety research, simplify the presentation of case report articles, and improve the ability to identify key data at a glance.

Specifically, the changes include:

  • To increase our coverage of drug safety research, there will be a table of additional drug safety news articles relevant to our readers (see example 1).
  • To streamline the presentation of case report articles, author comments and reporter country will be removed to focus on the most relevant information for our target readers.
  • To make it easy to identify the key data at a glance, non-serious case reports will be presented in a table rather than as individual articles (see example 2).

We look forward to presenting the new features to you in 2020. If you have any questions, please contact

Photo credit: Photo by pina messina on Unsplash



Brexanolone (Zulresso™): First Global Approval – First approved therapy for postpartum depression

Brexanolone (Zulresso™): First Global Approval – First approved therapy for postpartum depression

In March 2019, the small molecule brexanolone was approved by the United States Food and Drug Administration (FDA) for the treatment of postpartum depression (PPD) in adult women.[1] Brexanolone, developed by Sage Therapeutics under a license from the University of California, was granted priority review status and breakthrough therapy designation by the FDA.[2][3] Continue reading “Brexanolone (Zulresso™): First Global Approval – First approved therapy for postpartum depression”

Is the Search for a Cure for Alzheimer’s Disease Hopeless?

Is the Search for a Cure for Alzheimer’s Disease Hopeless?

It is likely that in one’s lifetime a friend or family member will be diagnosed with Alzheimer’s disease. As of 2018, approximately 50 million people worldwide are living with dementia and this number is expected to triple to 152 million by 2050.[1]

Despite the increasing prevalence of the disease, no new drugs have been approved for the treatment of Alzheimer’s since 2003.[2] An article recently published on PharmaTimes proclaims, “The search for a cure for Alzheimer’s is far from over.”[3]

Continue reading “Is the Search for a Cure for Alzheimer’s Disease Hopeless?”

Roxadustat (Ai Rui Zhuo® in China): First Global Approval – First-in-class small molecule for anaemia in patients with DD-CKD

Roxadustat (Ai Rui Zhuo® in China): First Global Approval – First-in-class small molecule for anaemia in patients with DD-CKD

In December 2018, roxadustat, developed by FibroGen, in collaboration with Astellas and AstraZeneca, received its first global approval in China for the treatment of anaemia in patients with dialysis-dependent chronic kidney disease (DD-CKD).[1] Roxadustat is expected to launch in China in the second half of 2019.[2]

Continue reading “Roxadustat (Ai Rui Zhuo® in China): First Global Approval – First-in-class small molecule for anaemia in patients with DD-CKD”

Tagraxofusp (Elzonris™): First Global Approval – Breakthrough therapy for BPDCN and novel CD123-targeted therapy

Tagraxofusp (Elzonris™): First Global Approval – Breakthrough therapy for BPDCN and novel CD123-targeted therapy

The recent first global approval of tagraxofusp (Elzonris™) has been reviewed in detail in the First Global Approval report in Adis’ journal Drugs[1], based on the development milestones tracked in AdisInsight[2].

In December 2018, tagraxofusp, developed by Stemline Therapeutics, was approved by the United States Food and Drug Administration (FDA) for the treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adults and children 2 years and older.[1][3] Continue reading “Tagraxofusp (Elzonris™): First Global Approval – Breakthrough therapy for BPDCN and novel CD123-targeted therapy”

Planning and strategizing in the face of evolving regulatory guidelines: Report from the DIA Pharmacovigilance and Risk Management Strategies Conference (PVRMS19)

Planning and strategizing in the face of evolving regulatory guidelines: Report from the DIA Pharmacovigilance and Risk Management Strategies Conference (PVRMS19)

The PVRMS19 was presented at the Omni Shoreham Hotel, Washington DC, January 2019. During the packed three-day event, we learned that many aspect governing the development and subsequent safe and effective use of medicines are in a state of flux… and so they should be. As we learn by our actions (triumphs and failures) we make adjustments to enhance the future investigations and create medicinal agents that are effective and safe, or more precisely, have a benefit that outweighs the risks. Continue reading “Planning and strategizing in the face of evolving regulatory guidelines: Report from the DIA Pharmacovigilance and Risk Management Strategies Conference (PVRMS19)”

The World Drug Safety Congress in Amsterdam addresses key challenges

The World Drug Safety Congress in Amsterdam addresses key challenges

Adis Pharmacovigilance attended the World Drug Safety Congress in Amsterdam on Sept 10th and 11th.

The event has been running for over a decade and is world renowned for its ability to connect key stakeholders in the drug safety field, as well as for leading the way in moving the sector forward.

Senior level drug safety professionals, as well as representatives from sponsors and service providers, met to discuss key topics and showcase solutions.

This year’s theme, Addressing Key Challenges for Safety Professionals, had us prepared for a series of interesting presentations and discussions on the ever growing importance of pharmacovigilance and the challenges connected with ensuring patient safety. Continue reading “The World Drug Safety Congress in Amsterdam addresses key challenges”