Once again, off-label use of medical products has become a hot topic on the front page of many newspapers. The rumored $1
billion Zyprexa settlement by Eli Lilly (Indianapolis) is drawing attention because of the size of potential recovery but
is only one of a number of similar cases that have been addressed in the media. As the atmosphere becomes increasingly charged
with ongoing scrutiny of off-label use by the media, Congress, the US Food and Drug Administration, and federal prosecutors,
it is difficult to take a step back and consider whether all of the activity is leading to better science, better medicine,
or greater consumer protection.
Janice M. Hogan
Congress and FDA have made several attempts to grapple with off-label use over the years but none of these attempts as yet
have been successful. The most recent Congressional attempt, Section 401 of the 1997 Food and Drug Administration Modernization
Act (FDAMA), amended previous law to allow pharmaceutical manufacturers to distribute limited information about off-label
use to physicians and healthcare providers (1). FDA issued a regulation, known as Part 99, to implement the law. Under Part
99, a manufacturer could seek FDA "pre-review" of off-label information before distribution to ensure that the agency did
not find the material objectionable (2).
As enacted, the off-label use provision of FDAMA imposed so many restrictions on the type of information that could be distributed
that it was cumbersome at best, and therefore of limited practical use in guiding or controlling off-label information. Other
restrictions in Part 99 were considered reasonable and noncontroversial (e.g., distributed information had to be truthful
and could not bemisleading or pose a public health risk). The requirement that the material be labeled prominently to show
it was related to off-label use was also unobjectionable.
A slow but significant sunset
Among the many restrictions, however, Part 99 coupled a manufacturer's ability to distribute information on off-label uses
with a near-term intent to pursue FDA approval for the off-label use, with only a very narrow exception allowing the manufacturer
to apply for an exemption from this requirement. This limitation essentially sidestepped the heart of the off-label use problem:
What should pharmaceutical companies do with information on off-label indications for which they do not plan to seek approval,
but that may be of considerable interest to physicians?
In addition to the practical limitations of Part 99, the provision was subject to a number of high-profile court cases that
challenged whether the rule was consistent with the First Amendment. Several of these challenges achieved at least partial
success in court, and FDA questioned continued enforcement of Part 99.
As planned in the original legislation, Section 401 "sunset" in September 2006, and Part 99 became obsolete. Although FDA
officials continued to articulate similar principles to Part 99 in public speeches, the expiration of this provision took
away the mechanism for FDA to pre-review off-label information. As a result, if a manufacturer wishes to seek input from FDA
on whether off-label information is suitable for distribution, there is no available means for doing so.
Fast forward to early 2007 when a group of lawyers representing multiple drug companies met privately with high-level FDA
officials, including the Commissioner, to discuss the problems created by the sunsetting of Part 99. At the meeting, the lawyers
discussed the effect of the sunset provision and the problems it presented for regulated companies. The minutes of the meeting
also cited "concerns about federal prosecutors pursuing distributors of this [off-label] information for criminal misconduct,"
concluding that "[t]here is confusion about the rules, possibly an FDA guidance could clarify the rules" (3).
In late 2007, FDA circulated internally a draft guidance document on Good Reprint Practices regarding the policy on distribution of journal article reprints on off-label use. The guidance document attempts to go beyond
Part 99 in certain respects, allowing dissemination of some off-label information even if the manufacturer did not plan to
seek FDA approval. The guidance does, however, retain limitations on the content of the information to ensure it was fair
and balanced, and to limit the information to unabridged versions of published, peer-reviewed material.
US Representative Henry Waxman (D-CA) sent two letters to FDA inquiring about the motivation for the draft guidance and questioning
its content. The first letter, sent from Rep. Waxman to FDA Commissioner Dr. Andrew von Eschenbach in November 2007, begins
"I have obtained a copy of an October 2007 internal draft of new FDA guidance that would allow drug companies to use journal
articles to promote potentially dangerous uses of drugs and medical devices without prior FDA review and approval. It is my
understanding that the FDA intends to issue this guidance without significant changes in the very near future. I urge you
to refrain from going forward with this ill-advised guidance." (4)
Rep. Waxman further cautioned that the draft guidance could "reduce the incentive for drug and device companies to conduct
the rigorous studies needed to win full FDA review and approval."
In a December 2007 response to Rep. Waxman, Dr. von Eschenbach noted that the draft guidance was solely for internal purposes
and that it had not yet reached a final stage. Rep. Waxman responded in January 2008, asking further questions about the lawyers'
meeting and the guidance. He asked FDA to provide information about the history of development of the draft guidance, all
communications with non-agency personnel about the guidance, and how the agency planned to enforce the guidance. The letter
asked for FDA's response by Feb. 5. On Feb. 15, FDA formally issued the draft guidance, despite the ongoing Congressional