FDA Draft Guidance on Protocol Deviations for Clinical Investigations

The FDA has published a draft guidance for “Protocol Deviations for Clinical Investigations of Drugs, Biological Products, and Devices.”

This draft guidance adopts the ICH E3(R1) definitions for protocol deviation and important protocol deviation, providing more standardized terminology, which is a great thing. Avoiding the term “protocol violation”, it primarily uses “protocol deviation” and “important protocol deviation.”

The FDA guidance provides detailed sections on the roles and responsibilities of investigators, sponsors, and IRBs in monitoring, mitigating, and reporting protocol deviations. It as specific recommendations for reporting protocol deviations to sponsors, IRBs, and FDA, including timelines and methods.

It mostly seems a good application of a quality-by-design approach, focusing on critical-to-quality factors and risk-based monitoring for clinical studies. Hopefully it will help clear up confusion in this area.

The Failure Space of Clinical Trials – Protocol Deviations and Events

FDA Speaks About Recent CRLs for Manufacturing

I hasn’t been difficult to notice that a whole lot of biological new drug applications have been rejected in the last few years, many for CMC reasons. Recently CDER Director Patrizia Cavazzoni spoke on the matter at a recent at a Duke University and FDA event at the National Press Club iin the video above.

“Our standards have not changed. We have exactly the same standards as we had in 2018 and 2019,” she said, before going on to talk about how the quality related issues the FDA is seeing: contamination, overall oversight, manufacturing controls or insufficient quality management systems.

Max Van Tassell, a senior pharmaceutical quality assessor in CDER’s Office of Pharmaceutical Quality, provided insights from analyzing 100 complete response letters (CRLs) for Biologics License Applications (BLAs) issued between 2014 and 2024. He noted that facility-related deficiencies in CRLs typically stem from inadequate demonstration that proposed corrective and preventive actions would effectively mitigate risks identified during on-site inspections.

It should be a key takeaway from this presentation that:

We aren’t doing enough risk management in the right ways.
We treat our facility as a secondary consideration, especially in biosimilars.
Companies do a really bad job building trust with health authorities.

FDA Guidance on Delaying, Denying, Limiting, or Refusing Drug or Device Inspection

The FDA guidance “Circumstances that Constitute Delaying, Denying, Limiting, or Refusing a Drug or Device Inspection” published in June 2024 outlines the behaviors and circumstances that the FDA considers to be non-compliant with inspection requirements under section 501(j) of the Federal Food, Drug, and Cosmetic Act (FD&C Act). This guidance is essential for ensuring that drugs and devices are not deemed adulterated due to inspection-related issues.

The guidance aims to make sure transparency and compliance during FDA inspections to protect public health by ensuring that drugs and devices are manufactured by regulatory standards.

Legal Background

The Food and Drug Administration Safety and Innovation Act (FDASIA) of 2012 added section 501(j) to the FD&C Act, which deems a drug adulterated if the owner, operator, or agent of a facility delays, denies, or limits an FDA inspection, or refuses to permit entry or inspection.

The FDA Reauthorization Act of 2017 extended these provisions to include medical devices.

Scope

The guidance applies to all facilities involved in the manufacture, processing, packing, or holding of drugs or devices. It defines what constitutes delaying, denying, limiting, or refusing an inspection, providing specific examples to illustrate these behaviors.

Examples of Non-Compliant Behaviors:

Delaying: Postponing an inspection without a reasonable explanation.
Denying: Explicitly refusing to allow an inspection to take place.
Limiting: Restricting the scope of an inspection, like limiting access to certain areas or records.
- I want to stress that this includes the situation where a facility provides some, but not all, records requested by the FDA investigator that FDA has authority to inspect. Everyone’s favorite delaying tactic.
- This also includes omitting or limiting the data contained in the electronic records when providing electronic copies of the records to FDA. This includes but is not limited to actions like removing data columns in Excel, removing data from the electronic record when providing the record to FDA, exporting data into reports without including all of the data fields (unless otherwise requested by FDA), or locking the electronic worksheet so that the data cannot be searched, sorted, or analyzed by FDA.
- Preventing an authorized representative of FDA from collecting statutorily authorized samples may be considered limiting the inspection. Examples of sample limitations include, but are not limited to, declining to allow or impeding FDA from collecting the following types of samples: environmental samples, finished product samples, raw material samples, in-process material samples, reserve samples in bioequivalence and bioanalytical studies, and labeling.
Refusing: Not allowing the FDA to enter the premises for inspection.

Background on FDA Guidance

The FDA issues guidance documents to communicate its current thinking on regulatory issues. These documents are not legally binding but give insight into how the FDA interprets and enforces laws and regulations. The guidance on delaying, denying, limiting, or refusing inspections was necessitated by the need to clearly define what constitutes non-compliance under section 501(j) of the FD&C Act. This clarity helps facilities understand their obligations and avoid actions that could lead to their products being deemed adulterated.

The guidance was finalized to replace the previous version issued in October 2014 and incorporates feedback and updates to reflect current practices and challenges in the inspection process. It is a critical tool for both the FDA and industry stakeholders to ensure that inspections are conducted smoothly and effectively, thereby safeguarding the quality and safety of drugs and devices available to the public.

Transparency at the FDA

Leveling Up Agency Disclosures

I fully agree with this excellent post and its closing line “The public should therefore not need to request such materials from the agency, but should have easy, online access to them at any time.”

All 483s, complete response letters (CRL), and other FDA decisions should be easily accessible. This would be a net positive gain for our profession. I know I’ve reached out to my congress critters about this as the FDA is going through budgeting (and Congress continues to not fund the agency enough).

ICH Document Structure, a Call for Change

The International Conference for Harmonization (ICH) has guidelines categorized into four main categories:

Quality (Q) Guidelines focus on the chemical, pharmaceutical, and biological quality standards, including stability testing protocols to ensure the longevity and consistency of drug products.
Safety (S) Guidelines address non-clinical and preclinical safety evaluations, guiding the toxicological assessments necessary to protect patients’ health.
Efficacy (E) Guidelines cover the clinical aspects of pharmaceutical development, providing standards for designing, conducting, and analyzing clinical trials to ensure therapeutic benefits.
Multidisciplinary (M) Guidelines encompass guidelines that do not fit neatly into the other categories, dealing with genomics, terminologies, and technical aspects of drug registration.

Any Q document is instantly and rightly viewed as a GMP guideline. This includes the quality trio, which, while they have a good philosophy, are still written specifically for GMP purposes. So, if you write your paper, good practice guide, standard, article, or what-have-you and refer heavily to the Q trio, you are either writing a GMP-centered piece or losing most of your audience.

The frustrating thing is that quality-by-design (Q8), risk management (Q9), and quality system management (Q10) are core concepts that apply across the pharmaceutical lifecycle, and there are best practices across all three that can and should be universal, especially Q9(r1), which can really better define risk management as defined in E6, and Q10, which can really shore up parts of E8.

What I would love to see the ICH do is write a technical reference document on risk management. Then, E6 and Q9 would have specific implementation aspects related to their focus. Put all the shared approaches in one place and build on them. The amusing thing is that they are already doing that. For example, Q13 applies the Q trio to continuous manufacturing, and Q14 applies it to the analytical lifecycle.

But for now, if you are writing and just referring to Q9 and Q10 don’t be surprised when all your clinical and safety colleagues tune you out.