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International Clinical Trials

Making a Difference

Once largely considered too costly to produce – given the limited number of patients affected by a particular disease – new technology and breakthroughs in biopharma have changed the orphan drug landscape, allowing more of these drugs to be produced than ever before, and thus saving countless lives that would otherwise be lost.

Bringing an orphan drug to market, however, has its own unique set of obstacles and considerations that must be overcome, many due to the narrow scope of use for which the medicine is intended. Meeting these challenges, while endeavouring to produce a needed drug as quickly as possible, requires the cooperation of clinical trial investigators, drug manufacturers, local and national governments and more.

Where to Start?

“Typically, the demand for an orphan drug is recognised by a doctor needing a specific drug in order to treat a rare disease,” says Robert Smith, former Global Head of Quality for the Clinical Pharmacy Research Service at Genzyme. “At this point, the doctor may apply for a research grant through one of many funding services, including the National Institute for Health, various philanthropic concerns or private industry. Alternatively, the need may be raised by a disease advocacy group, spotlighting a certain ailment that needs attention.” This was the case, for example, with the Muscular Dystrophy Association (MDA), who began advocating for cures for various neuromuscular diseases in 1950. Since its founding, MDA has funded research and clinical trials for a number of rare diseases, including Emery-Dreifuss muscular dystrophy, Zaspopathy-related myopathy and Walker-Warburg syndrome.

“The next step in the process is finding a drug manufacturer interested in producing the needed drug,” claims Smith. “Due to their limited audience and small production runs, orphan drugs can be very expensive to produce, and there is a very real possibility that the manufacturer may never break even on their investment. In the case of life-saving drugs, it is not uncommon for manufacturers to provide the approved medications through charitable access, or patient assistance programmes, often at no charge for those that need it. On the other hand, the cost of clinical trials can be significantly lower than those investigating better-known diseases, as the study samples are necessarily smaller and there is a lack of competing medications.”

Smith continues: “The health versus economic benefits must be weighed when one contemplates taking on a treatment for a rare disease. These treatments can be very expensive, and the ramifications of such an investment must be considered. Someone, somewhere has to make an objective decision about whether or not to move forward. Sadly, we live in a world in which there are very real restrictions. Consequently, we may have the ability, but not the resources, to cure everyone.”

Second Life

Of course, there is always the possibility that a drug intended to treat a rare disease may be found to have a secondary, more profitable use, as in the case of botox. Derived from botulinium toxin, it was originally developed to treat spasms and dystonias due to its ability to weaken muscle function. More recently, it has been used in cosmetic treatments by paralysing muscles and preventing the development of wrinkles.

In 2012, more than six million botox injections were administered in the US at an average cost of $570 each, with a total cost of more than $3.42 billion. Naturally, when a drug is found to have a second purpose, it must still go through trials for efficacy, even though safety has already been proven.

Trials and Tribulations

The next step in the process is the execution of clinical trials. “Like all clinical trials, the main purpose here is to prove the safety and efficacy of the drug in question,” Smith states, “although, due to the small patient sample size, some compromises must be made. While clinical trials for a drug to treat diabetes, for example, might require a sample size of several hundred, or even several thousand patients, the required sample size for a drug to treat a rare disease might, by necessity, number fewer than 20. In some instances, historical consults – case histories of patients suffering from the disease – are used to supplement the actual live patient sample.”

“I was involved with a clinical trial for a rare disease that included 17 patients in the study sample,” Smith recalls. “The question that we asked to prove the drug’s efficacy was, simply, whether or not our sample population made it to their first birthday.”

“Being such a particular niche market,” Smith says, “with such a small number of patients in the study population, there is much more personal interaction with doctors, nurses, researchers and subjects. This means that the researchers really get to know the people in their study, and losing one through failure to come up with an effective treatment can be devastating.”

Ethical and Practical Considerations

“Another consideration unique to studies of rare, lifethreatening diseases,” Smith continues, “is whether or not it is ethical to give certain patients a placebo, as is regularly done in ordinary drug trials. That is a hard question to answer when you are trying to determine how much good a drug actually does. By providing certain patients with a placebo, are you sentencing them to death? And do you, as a researcher, have a right to do that in service of a greater good? That is a terrible question to answer.”

In cases like these, lower safety standards may actually apply. “Again, due to the small sample sizes, studies may accept a higher degree of toxicity in the study drug,” Smith claims, “as doctors are better able to treat the results of the toxicity, than they are able to treat the effects of the underlying disease. One has to consider the risk/benefit ratio, especially in the case of life-threatening diseases.”

“Another difference between trials of orphan and non-orphan drugs,” Smith adds, “is the amount of follow-up that is done. In a typical non-orphan situation, follow-ups are usually part of the trial, examining the effects of the drug after a certain period of time. With orphan drugs, or with drugs that need to be moved to market quickly, additional surveillance of patients is allowed to be done after the trial, to facilitate getting the drugs out there in a timely fashion.”

Cold, Hard Facts

Aside from the challenges that occur due to the small number of patients suffering from a rare disease, logistics can also be an issue. “Particularly in the early stages of development,” Smith states, “many rare disease or orphan drugs tend to require cold chain logistics of one form or another, especially when going through regions in which temperature control can be a challenge. When dealing with drugs produced in such small quantities, any degree of damage or spoilage can be a major issue. In the case of life-saving drugs, the consequences may be severe. These days, some researchers might choose to have a quantity of study medications stored at the patient’s home, to reduce the risk of damage in transit and to make administering the drugs easier. Practical solutions are available, for example a radio frequency identification refrigerator solution like MyCubixx from ASD Healthcare, which monitors when the unit is open, what drugs are removed or replaced, and even keeps track of expiration dates. Even with all that, however, it’s critically important to have a shipper that intimately understands cold chain and temperature-controlled logistics – otherwise all your efforts may be for naught.”

“There is enormous pressure to get everything right in doing this kind of work,” Smith continues. “The difference between 95% right, which may be the case in non-orphan trials, and 99.5% right, in the case of rare disease trials, is enormous. This is why having good systems in place, as well as solid contingency plans, is absolutely critical.”

In many cases, paperwork can take up a huge amount of time as, after the trial is over, the licensing process starts. “Although orphan and non-orphan drugs go through the same licensing process,” Smith explains, “those in the pipeline clearly recognise the need for life-saving drugs and go the extra mile to make things happen quickly and efficiently. This greatly streamlines the process wherever possible, meaning that the drug can be released faster than it would otherwise.”

Once the licensing portion of the journey is complete, the drug is taken to market. It is common in the case of rare diseases for key opinion leaders and patient advocacy groups to spread the word about a new treatment, supplementing the manufacturer’s own marketing plan. At that point, the drug is out in the world, working to both improve and save lives. While many of these drugs are expensive, it is not unknown for drug companies to have charitable programmes in place, where the drug can be made available to patients without charge or at a substantially reduced cost.

A Matter of Time

For those suffering from a rare disease, for which there is no current treatment, Smith offers these words of encouragement: “Never give up hope,” he says. “There are people all over the world looking for the next great cure, and someone, somewhere is probably looking into your disease right now. It may just be a matter of time.”

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Sue Lee, Technical Portfolio Manager, has worked for World Courier for 25 years. During this time, she has experienced a variety of customer service and operational functions, including the setting up of numerous multinational clinical sites for the transportation of biological samples. Sue has orchestrated thousands of shipments with very specific temperature requirements to a host of challenging locations, each presenting their own obstacles and dilemmas.
Sue Lee
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