Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X

Review Article

Detection, Assessment, Understanding and Prevention of Adverse Effects: Pharmacovigilance: A Review

Rahul Dogra*, Rajeev Garg, Vinay Kumar, Vivek Verma, Vikas Tripathi Amar Shaheed Baba Ajit Singh Jujhar Singh Memorial College of Pharmacy, Bela, Ropar, Punjab, India. *Corresponding author’s E-mail: [email protected]

Accepted on: 03-03-2013; Finalized on: 30-04-2013. ABSTRACT Pharmacovigilance is an important and integral part of clinical research. Despite its 40 years history, pharmacovigilance remains a dynamic clinical and scientific discipline. It continues to play a crucial role in meeting the challenges posed by the ever increasing range and potency of medicines. When adverse effects and toxicity do appear especially, when previously unknown, it is essential that these are reported, analysed and their significance communicated effectively to an audience that has the knowledge to interpret the information, which carry an inevitable and some for all medicines there is a trade-off between the benefits and the potential for harm. The harm can be minimized by ensuring that medicines of good quality, safety and efficacy are used rationally and that the expectations and concerns of the patient are taken into account when therapeutic decisions are made. Taking medicines and prescribing them are among the commonest of activities of people who are unwell and of those who care for them. It makes sense that those medicines should be monitored to equally demanding standards as those evident in the development and evaluation of drugs and that prescribing habits and the extent of rational and cost-effective use should be reviewed. Responsibility for the holistic approach to drug safety that is encompassed in the science and practice of pharmacovigilance as reflected in this article has to be shared if ideal practice is to be achieved. The scientists, clinicians, pharmaceutical manufacturers, drug developers, regulators, public policy makers, patients and the general public all have their own complementary roles in achieving what is envisaged. Keywords: Pharmacovigilance, National Pharmacovigilance Programme, Role of Pharmacovigilance, Risk Management, Good Pharmacovigilance Practice, Pharmacoepidemiologic Studies.

INTRODUCTION marketing (that is clinical phase) and post-marketing. The process of collection of such information about a drug harmacovigilance (abbreviated as PV or PhV) also begins in phase I of clinical trial, before approval of the known as drug safety, is the pharmacological drug, and continues even after approval, several post- science relating to the detection, assessment, P market safety studies are conducted, with many made understanding and prevention of adverse effects, mandatory by drug regulatory agencies around the world. particularly long term and short term side effects of medicines. Generally speaking, pharmacovigilance is The etymological roots are: pharmakon (Greek Word) the science of collecting, monitoring, researching, means “drug” and vigilare (Latin Word) means “to keep assessing and evaluating information from healthcare awake or alert, to keep watch.” Pharmacovigilance is providers and patients on the adverse effects gaining importance for doctors and scientists as the of medications, biological, herbalism and traditional number of stories in the mass media of drug recalls medicines with a view to1: increases.  Preventing harm from adverse reactions in humans Because clinical trials involve several thousand patients at arising from the use of authorised medicinal products most, less- common side effects and ADRs are often within or outside the terms of marketing unknown when a drug enters the market. Even very authorisation or from occupational exposure and severe ADRs such as liver damage are often undetected because study populations are small. Post marketing  Promoting the safe and effective use of medicinal surveillance uses tools such as data mining of products, in particular through providing timely spontaneous reporting systems and patient registries, and information about the safety of medicinal products investigation of case reports to identify the relationships to patients, healthcare professionals and the public. between drugs and adverse events.  Identifying new information about hazards TERMINOLOGY2 associated with medicines Pharmacovigilance is particularly concerned with Adverse Pharmacovigilance is therefore an activity contributing to Drug Reactions (ADRs). the protection of patients and public health. Adverse Drug Reactions are officially described as a Pharmacovigilance starts from the clinical stage and response to a drug which is noxious and unintended continues throughout the product life cycle of the drug, including lack of efficacy of drug and which occurs at mainly divided as pharmacovigilance during pre-

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X doses normally used for the prophylaxis, diagnosis or interpretation. A single definition of a Signal is very therapy of disease, or for the modification of challenging, because of the different types of information physiological function. It also includes overdose, misuse that might constitute a signal in different contexts. A and abuse of drug. basic difficulty is, what is new and to whom? Adverse Effect Aronson and Hauben considered all definitions they could find and then produced a new one: An appreciably harmful or unpleasant reaction resulting from an intervention related to the use of a medicinal “Information that arises from one or multiple sources product, which predicts hazard from future (including observations and experiments), which suggests administration and warrants prevention or specific a new potentially causal association, or a new aspect of a treatment or alteration of the dosage regimen or known association, between an intervention and an event withdrawal of the product. or set of related events, either adverse or beneficial, which would command regulatory, societal or clinical This definition can include medication error which is a attention and is judged to be of sufficient likelihood to major cause of adverse effects due to drugs, it includes justify verifiable and when necessary, remedial actions.” harm from counterfeit drugs, it includes accidental overdose, it includes all medicinal products (so it includes Serious Adverse Event or Reaction delivery systems such as inhalers) and it includes quality A serious adverse event or reaction is any untoward problems and excipients. This definition therefore medical occurrence that at any dose: includes adverse effects from a much broader range of causes. On the other hand the latter part of the definition  Results in death or focuses on the value of knowing about adverse effects:  Requires inpatient hospitalisation or prolongation of we want to know about those we can do something existing hospitalisation or about in terms of prevention, diagnosis or treatment. ‘Adverse reaction’ and ‘adverse effect’ are  Results in persistent or significant disability/ interchangeable but adverse effect is more patient- incapacity or centred and adverse reaction is more drug-centred.  Is life- threatening Unexpected Adverse Reaction To ensure no confusion or misunderstanding of the An adverse reaction, the nature or severity of which is not difference between the terms "serious" and "severe", the consistent with domestic labelling or market following note of clarification is provided: authorization, or expected from characteristics of the drug. The term "severe" is not synonymous with serious. In the English language, "severe" is used to describe the Adverse Event/ Adverse Experience intensity (severity) of a specific event (as in mild, Any untoward medical occurrence that may present moderate or severe), the event itself, however, may be of during treatment with a pharmaceutical product but relatively minor medical significance (such as severe which does not necessarily have a causal relationship with headache). Seriousness (not severity) which is based on this treatment patient/ event outcome or action criteria serves as guide for defining regulatory reporting obligation4. Side Effect This definition is used almost globally. One comment is Any unintended effect of a pharmaceutical product important: the terms ‘life threatening’ and ‘requires occurring at doses normally used in man which is related inpatient hospitalisation’ are value judgement and to the pharmacological properties of the drug. context dependent, respectively. It is particularly Signal important to reflect that whether or not a patient is admitted to hospital or not will vary from situation to Reported information on a possible causal relationship situation. between an adverse event and a drug, the relationship 5 being unknown or incompletely documented previously, IMPORTANCE OF PHARMACOVIGILENCE Usually more than a single report is required to generate Pharmacovigilance is an important and integral part of a signal, depending upon the seriousness of the event and clinical research. Both clinical trials safety and post 3 the quality of the information . marketing pharmacovigilance are critical throughout the This is considerably outmoded as a general definition. It product lifecycle. Pharmacovigilance is still in its infancy in retains some value in respect of signals from India and there exists very limited knowledge about the ‘spontaneous reports’, but it fails to include signals from discipline. published series or from examination of health care While major advancements of discipline of records, laboratory experiments, or from clinical trials or pharmacovigilance have taken place in the western epidemiological studies. ‘Incompletely documented countries not much has been achieved in India. There is previously’ is also a statement which requires an immense need to understand the importance of

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X pharmacovigilance and how it impacts the life cycle of the the quality of drugs, detection and preventing of any product. This will enable integration of good adverse effects of drugs. Pharmacovigilance involves pharmacovigilance practice in the process and procedures evaluating information provided by health care providers, to help ensure regulatory compliance and enhance pharmaceutical companies and patients in order to clinical trials safety and post marketing surveillance. understand the risk and benefits involved with a particular drug. Pharmaceutical companies spend millions Pharmacovigilance is not new to India and has in fact of dollars and a considerably long time in developing new been going on from 1998, when India decided to join the drugs. Uppasla centre for adverse event monitoring. The importance of pharmacovigilance is withdrawals the They again spend a lot of money in conducting clinical regulatory agencies, media; consumers have become trials before the drugs are approved and launched in the more aware about the benefit and risks of medicines. market. It is recognized that information technology (IT) Spontaneous reporting of adverse drug reaction and has entered and transformed the world of health care adverse events is an important tool for gathering the and clinical medicine in which the work of doctors and safety information for early detection. In recent years the care of patients proceed with higher quality, many Indian companies are increasing the investment in efficiency and lower costs. It is also no secret that IT has research and development and are enhancing their merged in to clinical safety practice and sparks the capacity to develop and market new drugs with their own creation of worldwide pharmacovigilance systems for research efforts. safety signal detection. Further India is becoming a hub for clinical research The IT transformative force and health it, adoption have activities due to its large population, high enrolment rate fundamentally changed the conduct of clinical research, and low cost. Moreover, the lag period when a drug is practice of medicines and medicinal safety monitoring. In placed for the first time on the market in USA, Europe, today’s world pharmacovigilance pushes new boundaries and Japan or somewhere in the world and its subsequent and it is no longer sufficient to simply report adverse availability in India has decreased considerably. As a events along with efficacy and quality requirements. result, for such drugs the long term safety data is not Regulators are demanding proactive surveillance available and the time of their marketing in India. This is programs that include comprehensive risk management clear by the fact that all the high profile drugs that have plans and signal detection/ analysis throughout a clinical been recently withdrawn were available in Indian market. products life cycle. In such cases, the Indian regulatory agencies cannot count on the experience of other market to assess benefit  This addresses what exactly is pharmacovigilance? risk balance of a drug6.  What do we know of its benefits and risks? There by stressing the importance of developing their  own adequately designed pharmacovigilance system in What challenges are out there preventing its wide India. For an effective pharmacovigilance system to be spread usage? functional and efficient, all the stake holders need to be  And what does the future hold for pharmacovigilance alert and attentive throughout the life cycle of a in worldwide medicine? medicinal product in the market. The office of the Drugs Controller General of India (DCGI) has been making It is now generally accepted that part of the process of sincere attempts for the implementation the National evaluating drug safety needs to happen in the post Pharmacovigilance Programme (NPP) in India. To full fill marketing phases through judgment as to whether and the pharmacovigilance obligations for its marketed how this might happen lies with the regulators. The products, as per regulations, a generic company in India is stronger the national systems of pharmacovigilance and mainly to carry out the following activities. Collection adverse drug reaction (ADR) reporting, the more likely monitoring and reporting of spontaneous adverse reasonable regulatory decisions will be made for the early reactions, including expedited reporting of serious release of new drugs with the promise of therapeutic unexpected adverse reactions and preparations. advances. Careful safety monitoring is not restricted, Pharmacovigilance help to prevent adverse drug effects: however to new drugs or to significant therapeutic Medical science has grown in leaps and bounds since the advances. It has a critical role to play in the introduction days of Hippocrates. Modern day pharmaceutical drugs of generic medicines, and in review of the safety profile of are really life saves. They have increased life expectancy older medicines already available as well, where new and improved the quality of life for millions of people. But safety issues may have arises. While spontaneous there is the other side of the coin as well; these drugs reporting remains a corner stone of pharmacovigilance in sometimes have very adverse effects that can even be life the regulatory environment, and is indispensable for threatening7. signal detection, the need for more active surveillance has also become increasingly clear. Without information There is a need to monitor the effects of drugs before and on utilization and on the extent of consumption, after it’s successfully tested and launched in the market. spontaneous reports are unable to determine the Pharmacovigilance involves the monitoring and assessing

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X frequency of an ADR attribution to a product or its safety limited number of carefully selected individuals. In some in relation to a comparator. cases as few as 500 subjects, and rarely more than 5000, will have received the product prior to its release10. More systematic and robust epidemiological methods that take in to account the limitations of spontaneous For good reason, therefore it is essential that new and reporting or post marketing studies are required to medically still evolving treatments are monitored for their address these key safety questions. They need to be effectiveness and safety under real-life conditions post incorporated in to post marketing surveillance programs. release. This includes the use of pharmacoepidemiologic studies8. More information is generally needed about use in These activities are under taken with the goal of specific population groups, notably children, pregnant identifying adverse events and understanding to the women and the elderly and about the efficacy and safety extent possible, their nature, frequency and potential risk of chronic use, especially in combination with other factor. Pharmacovigilance in principle involves the medicines. Experience has shown that many adverse identification and evaluation of safety signals. Safety effects, interactions (i.e. with foods or other medicines) signal refer to a concern about an excess of adverse and risk factors come to light only during the years after events compared to what would be expected to be the release of a medicine associated with products use. KEY PLAYERS OF PHARMACOVIGILENCE Signals can arise from post marketing data and other Key players of pharmacovigilance in national drug policy sources, such as pre clinical data and events associated are: Government, Industry, Hospitals and Academia, with other products in the same pharmacological class. Medical and Pharmaceutical Associations, Poisons and Pharmacovigilance is particularly concerned with adverse medicines information centres, Health professionals, drug reactions. Many other issues are also relevant to Patients, Consumers, Media and World Health pharmacovigilance science are substandard medicines, Organization. Key elements of pharmacovigilance in medication errors, lack of efficacy reports, use of national drug policy are: medicines for indications that are not approved and for which there is inadequate scientific basis, case reports of  Establishment of national pharmacovigilance systems acute and chronic poisoning, assessment of drug related for the reporting of adverse events, including mortality, abuse and misuse of medicines, adverse national and, if appropriate, regional interactions of medicines with chemicals, other medicines pharmacovigilance centres. and food.  Development of legislation/ regulation for medicine 9 AIM OF PHARMACOVIGILENCE monitoring.  Improve patient care and safety in relation to the use  National policy development (to include costing, of medicines, all medical and Para medical budgeting and financing). interventions.  Continuing education of health-care providers on  Research the efficacy of drug and by monitoring the safe and effective pharmacotherapy. adverse effects of drugs right from the lab to the  pharmacy and then on for many years. Provision of up-to-date information on adverse reactions to professionals and consumers.  Pharmacovigilance keeps track of any drastic effects  of drugs. Monitoring the impact of pharmacovigilance through process indicators and outcome.  Improve public health and safety in relation to the The purpose of the programme is to collate data, analyse use of medicines. it and use the inferences to recommend informed  Contribute to the assessment of benefit, harm, regulatory interventions, besides communicating risks to effectiveness and risk of medicines, encouraging their healthcare professionals and the public9. safe, rational and more effective (including cost- The management of the risks associated with the use of effective) use. medicines demands close and effective collaboration  Promote understanding, education, clinical training in between the key players in the pharmacovigilance. pharmacovigilance and its effective communication Sustained commitment to such collaboration is vital if the to the public. future challenges in pharmacovigilance are to be met and if the discipline is to continue to develop and flourish. These processes involved in the clinical development of medicines. Once put onto the market, a medicine leaves Those responsible must jointly anticipate, describe and the secure and protected scientific environment of clinical respond to the continually increasing demands and trials and is legally set free for consumption by the expectations of the public, health administrator policy general population. At this point most medicines will only officials, politicians and health professionals However have been tested for short-term safety and efficacy on a there is little prospect of this happening in the absence of

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X sound and comprehensive systems which make such Multidisciplinary collaboration is of great importance; in collaboration possible. The constraints typically include particular, links need to be forged between various lack of training, resources, political support, and most departments of the ministry of health and also with other especially scientific infrastructure. Understanding and stakeholders, such as the pharmaceutical industry, tackling these are an essential prerequisite for future universities, nongovernmental organizations (NGOs) and development of the science and practice of those professional associations having responsibility for pharmacovigilance. The provision of good quality, safe education on rational use of medicines and and effective medicines and their appropriate use is the pharmacotherapy monitoring. responsibility of national governments. The establishment MILESTONES OF THE PROGRAMME of a national medicine regulatory agency and a designated centre for the study of adverse reactions are  Short-Term Objectives: To foster a culture of central to the achievement of these functions. notification. Multidisciplinary collaboration is of great importance, in  Medium-Term Objectives: To engage several particular, links need to be forged between various healthcare professionals and NGOs in the drug. departments of the ministry of health and also with other stakeholders, such as the pharmaceutical industry,  Monitoring and information dissemination processes. universities, nongovernmental organizations (NGOs) and  Long-Term Objectives: To achieve such operational those professional associations having responsibility for efficiencies that would make Indian. education on rational use of medicines and pharmacotherapy monitoring.  National Pharmacovigilance Programme a benchmark for global drug monitoring. NATIONAL PROGRAMME OF PHARMACOVIGILANCE  Endeavours Before a product is marketed, experience of its safety and OUTLINE OF THE NATIONAL PHARMACOVIGILANCE efficacy is limited to its use in clinical trials, which are not 11, 12 reflective of practice conditions as they are limited by the PROGRAMME patient numbers and duration of trial as well as by the The National Pharmacovigilance Programme aims to highly controlled conditions in which Clinical Trials are provide adverse drug reaction data related to various conducted. The conditions under which patients are drugs available in the country to the central drugs studied during the pre-marketing phase do not regulatory authority i.e. Central Drugs Standard Control necessarily reflect the way the medicine will be used in Organisation (CDSCO). The programme will be 11 the hospital or in general practice once it is marketed . coordinated by the National Pharmacovigilance Advisory Information about rare but serious adverse drug Committee (NPAC) constituted by the Ministry of Health reactions, chronic toxicity, use in special groups (e.g. & Family Welfare. The Programme would comprise of the pregnant women, children, elderly) and drug interactions following steps: is often incomplete or not available. Certain adverse drug Step 1- Identifying various centres across the country for reactions may not be detected until a very large number capturing ADR related data of people have received the medicine. 1) Set up 2 Zonal Pharmacovigilance Centres (ZPC) to Pharmacovigilance is therefore one of the important post- coordinate the nationwide programme (AIIMS for marketing tools in ensuring the safety of pharmaceutical North and East, KEM- Mumbai for South and West) and related health products. Zonal Centres shall provide a room and other  Assessing the risks and benefits of medicines in order requisite infrastructure, e.g. a PC with internet to determine what action, if any, is necessary to facility, access to fax, telecom etc. improve their safe use. 2) Identify 5 Regional Pharmacovigilance Centres (RPC)  Providing information to users to optimise safe and across the country. effective use of medicines.  Ideally medical colleges with interested and initiated  Monitoring the impact of any action taken. pharmacologists. PHARMACOVIGILANCE IN NATIONAL DRUG POLICY  Can provide a small area (approx. 100 sq. feet). The provision of good quality, safe and effective  Can deploy a pharmacologist for the Programme. medicines and their appropriate use is the responsibility 3) Identify Peripheral Pharmacovigilance Centres of national governments. The establishment of a national (PPC): At least one teaching hospital in each state medicine regulatory agency and a designated centre for and union- territory and some other leading medical the study of adverse reactions are central to the institutions, clinics or pharmacies in the area under 12 achievement of these functions . each RPC.  Ideally centres that have internet facility

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X

 Manned by doctors/ pharmacists who are  Appropriate communication skills to elicit ADR enthusiastic about carrying out research activities related information. e.g. monitoring ADRs  For recording ADR information through hands on  Visited by not less than a total of 50 patients daily in training. any/ all of the following departments: Medicine,  For meticulous collation and completeness of data. Gynaecology, Paediatrics, Orthopaedics, Cardiology and Oncology  For fostering notification culture. Step 2- Training and Coordination These training programs and interaction meetings shall be held every 6 months after the initial training. Besides, To ensure harmonized implementation of the Programme continuous communication through emails, carrying efforts shall be made to arrive at a uniform understanding relevant information related to ADR monitoring methods of the operational systems along with standardized shall be maintained among the participating centres. formats to document and analyse ADRs. An induction training programme shall be arranged for healthcare BROAD OBJECTIVES OF THE PROGRAMME professionals participating in the NPP13.  To foster the culture of AE notification and reporting Intensive interaction/ training sessions will be organized to establish a viable and broad-based ADR for all participants to: monitoring program in India14. 1) Clearly define their individual and team roles and  Specific objectives of the Programme. responsibilities.  To create an ADR database for the Indian population 2) Set operational benchmarks e.g. Each PPC to record to create awareness of ADR monitoring among at least 30 AEs (Adverse Events) each month people to ensure optimum safety of drug products in (statistically speaking 30 AEs in about 1500 patients Indian market to create infrastructure for ongoing who visit each month would be quite easy to record). regulatory review of PSURs. Completed AE forms shall be forwarded to the concerned RPC at the end of each month. COORDINATOR’S ELIGIBILITY AT DIFFERENT TIERS OF NPP Each RPC  PPC- Any physician (primary- care or specialist),  To collate and scrutinize the data received. pharmacist.  To perform the causality analysis of all 120 to 150  RPC- A pharmacologist, preferably not below the forms received every month. rank of an assistant professor, attached to a medical  To submit a monthly report- Prepared in a specific college. form to be forwarded to National Pharmacovigilance  ZPC- A pharmacologist, not below the rank of a Centre (NPC) every month. professor, attached to a medical college  To report any alarming or critical ADRs to NPC along NATIONAL PHARMACOVIGILANCE CENTRES ARE with supporting evidence. RESPONSIBLE FOR: Each ZPC  Promoting the reporting of adverse reactions.  To collate the data (approx. 1000- 1200 forms)  Collecting case reports of adverse reactions. received from RPCs.  Clinically evaluating case reports.  To verify/ validate the causality analysis.  Collating, analyzing and evaluating patterns of  To prepare MIS reports for NPC in a specified format. adverse reactions.  To pass on the final data to WHO Uppsala Centre for  Distinguishing signals of adverse reactions from their global data pool. “noise”.  To publish a periodic newsletter.  Recommending or taking regulatory action in 3) Evolve SOPs for generating and forwarding ADR data response to findings supported by good evidence. and for general conduct of the Programme (Zonal  Initiating studies to investigate significant suspect centres to prepare SOPs which must ensure that the reactions. Programme is conducted in compliance with this Protocol).  Alerting prescribers, manufacturers and the public to new risks of adverse reactions; and 4) Impart relevant skills for carrying out ADR data capture namely  Sharing their reports with the WHO Programme for International Drug Monitoring.

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National centres have played a significant role in Regional Centre is expected to carry out the following increasing public awareness of issues relevant to the tasks: To maintain a log of all ADE notification forms safety of medicines. As a result, in some countries, received and forwarded To receive blank ADE forms and pharmacovigilance is increasingly being seen as much acknowledge receipt To fill or get filled the ADE forms more than a regulatory activity as it also has a major part Collect & collate Adverse Drug notifications from to play in clinical practice and the development of public Peripheral as well as own centres Receive Adverse Drug health policy15. This development is partly attributable to Events (ADE) forms and maintain log of all ADE forms the fact that many national and regional centres are received and forwarded. housed within hospitals, medical schools or poison and  Correspond with Peripheral Centres, provide them medicine information centres and is in collaboration with with general technical support, coordinate and a Medicines Regulatory Authority (MRA). The scope of monitor their functioning. activities of national centres has expanded to include communication of information about the benefits, harm  Identify and delegate a pharmacologist for and effectiveness of medicines to practitioners, patients management of pharmacovigilance tasks. and the public.  Carry out (and/ or review) data causality analysis of The Central Drugs Standard Control Organization (CDSCO) all ADEs. is initiating a country-wide pharmacovigilance programme under the aegis of DGHS, Ministry of Health  To forward all duly-filled ADE forms [those generated & Family Welfare, and Government of India. The at the same centre and those received from programme shall be coordinated by the National immediate lower-level centre] as per pre-determined Pharmacovigilance Centre at CDSCO. The National Centre time line. will operate under the supervision of the National  Liaise with health care professionals in order to Pharmacovigilance Advisory Committee to recommend inculcate/ foster the culture of ADE reporting/ procedures and guidelines for regulatory interventions. notification by acknowledging the cooperation by the The overall objective as per the National notifier and share with the notifier relevant feedback Pharmacovigilance Programme will be: from higher centre.  To monitor safety of the drugs and provide  Organize and attend training programmes/ structured inputs for appropriate regulatory interactive meetings for all peripheral centres falling interventions. under the respective regional pharmacovigilance centres.  To create awareness about ADR monitoring in India.  To provide updates, reports and such other Regional centres will be the secondary pharmacovigilance information as may be required by the National centres under the National Pharmacovigilance Pharmacovigilance Advisory Committee and to Programme. attend their meetings. To carry out the functions as envisaged in the “Protocol  To conduct special pharmacovigilance projects on for the National Pharmacovigilance Programme” a various drugs which may be of special concern or Coordinator will have to be designated who will be in- interest to CDSCO/ Government of India. charge of the pharmacovigilance activities at the designated regional centre18.  To maintain account of the funds provided under this program as per your institution’s systems; to review By accepting to participate in the National the account statement received from peripheral Pharmacovigilance Programme all centres explicitly agree centres, and provide a consolidated statement to the that all pharmacovigilance activities at their institutions zonal centre. Carryout audits to ensure compliance shall be performed in strict consonance with the National with the program, enlist non-compliance, establish Pharmacovigilance Programme appended here corrective measures and implement them at regional (Coordinators of the centres and heads of the institutions centres and oversee their implications at peripheral are advised to carefully go through the Protocol prior to centres joining the programme). In line with the size & patient intake of the institutions Outline of tasks to be carried out: The National where it is based, the regional centre shall ensure a Pharmacovigilance Programme encourages the reporting minimum 50 adverse event reporting’s every month and of all suspected adverse reaction to drugs and other this number must be increased periodically. This number medicinal substances including herbal, traditional or will be in addition to the number of reports generated by alternative remedies. The reporting of seemingly the peripheral centres falling under respective regional insignificant or common adverse reactions would be centres. important since it may highlight a wide spread prescribing problem.

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What to Report? ROLES AND RESPONSIBILITIES16, 17 The National Pharmacovigilance Programme (NPP) shall Where established, the national pharmacovigilance encourage reporting of all suspected drug related adverse centre will be responsible for the development of events, including those suspected to have been caused by pharmacovigilance in the public health system will herbal, traditional or alternative remedies. The reporting promote pharmacovigilance in the PHPs and sensitize of seemingly insignificant or common adverse reactions professionals and public health staff to the reporting of would be important since it may highlight a widespread adverse reactions and irrational use of medicines. prescribing problem. Role of Pharmacist The programme particularly solicits reports of:  Participate in spontaneous Reporting of Adverse  All adverse events suspected to have been caused by Events, Also report (even if no adverse event). new drugs and ‘Drugs of current interest’ (List to be  Medication errors. published by CDSCO from time to time).  Exposure during pregnancy.  All suspected drug interactions.  Monitor clinical status of patients.  Reactions to any other drugs which are suspected of significantly affecting a patient's  Identify the correct ADRs not side effects. management, including reactions suspected of causing: Death, Life- threatening (real risk of dying),  Get more information. Hospitalisation (initial or prolonged), Disability  Investigate at hospital level. (significant, persistent or permanent), Congenital anomaly and required intervention to prevent  Help doctors to fill-up the forms. permanent impairment or damage.  Keep patient’s record if more information needed. What can Report? Patients and the Public Any health care professionals (Doctors including Dentists, Public awareness about adverse reactions, early reporting Nurses and Pharmacists) may report suspected adverse and management are essential for ensuring patient drug events. The Programme shall not accept reports confidence, in and adherence to, pharmacotherapy. In from lay members of the public or anyone else who is not some countries patient reporting is accepted and can add a health care professional. value, but this needs to be separate from involvement of Where to Report? patient interest groups can be sought while formulating the programme and should be part of the feedback- After completion the form shall be returned/ forwarded communication link. to the same pharmacovigilance Centre from where it was received. Reporting can be done to any one of the Primary Health-Care Workers country vide pharmacovigilance Centres nearest to the It is the responsibility of the primary health-care provider reporter (Complete list of pharmacovigilance Centres is to detect, investigate, manage and report ADRs. These available at www.cdsco.nic.in). In case of doubt the form staff will need training on the importance of adverse may be sent to the national pharmacovigilance centre at: reactions, diagnosis, basic principles of causality Central Drugs Standard Control Organisation, New Delhi. assessment and the important elements of the adverse What happens to the information submitted? reactions reporting form. The information in the form shall be handled in strict Patient education is an important role of the primary confidence. Peripheral Pharmacovigilance Centres shall health-care provider. Educating the public on ADRs is forward the form to the respective Regional important for promoting adherence. Counselling and Pharmacovigilance Centres who will carry out the explanation about adverse reactions will promote causality analysis. This information shall be forwarded to patients’ confidence and adherence. the Zonal Pharmacovigilance Centres. The data will be The reporting of adverse reactions needs continuous statistically analysed and forwarded to the global stimulation. It is important to achieve a positive attitude Pharmacovigilance Database managed by WHO Uppsala towards pharmacovigilance. To encourage reporting, the Monitoring Centre in Sweden. The final report based on following steps should be of help: the analysed data will be periodically reviewed by the National Pharmacovigilance Advisory Committee  Easy access to reporting forms and Training. constituted by the Ministry of Health and Family Welfare.  Acknowledgement of receipt of a report and The Committee is entrusted with the responsibility to provision of feedback to the reporter. review data and suggest any regulatory interventions that may be required with respect to the drug/ drugs or class  Participation of reporting staff in pharmacovigilance of drugs. meetings, and of pharmacovigilance staff in professional meetings and

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 Collaboration with the national pharmacovigilance  Reports considered to be a signal of a new adverse centre. reaction and Other Health-Care Workers  All other reports, which may be presented in summary format, so that an overall reaction profile Health-care workers outside the government system of the medicine can be obtained. should also report adverse reactions. These would include among others, nongovernmental organizations and National Medicines Regulatory Authority charitable health facilities. The regulatory authority will receive reports and District Investigation Team recommendations from the ESRP. It will perform risk assessment and consider options for regulatory action The district investigation team plays a central role in which may involve requiring the manufacturers to make monitoring adverse reactions. The team should comprise changes in the labelling of their product or may be a a clinician in the district hospital, head nurse, pharmacist restriction in the use of the product, a temporary and district health officer or programme manager. The suspension or complete withdrawal. The regulatory team is responsible for following up adverse reactions authority may liaise with other national MRAs and it reported from all the health facilities within their district. should always pass on the information on any action (In the case of vertical programmes the specific taken to WHO (Wold Health Organisation). programme manager will be responsible for medicines Pharmaceutical Industry and Marketing Authorization pertaining to that programme.) The team will play an Holders important role in collaboration with and encouragement of reporting by primary health centre staff and hospital Pharmaceutical manufacturers are legally responsible for staff. Their detailed follow-up of suspected ADRs will be the safety and effectiveness of medicines while the used to assess causality. product is available in the marketplace. They should provide medicines of good quality and have stewardship When dealing with reports of ADRs, the district of their products. As essential players in the provision of investigation team should: medicines, they should be kept informed of the results of  Seriousness (including all deaths). monitoring and relevant decisions. They also have a duty towards assessing the effectiveness and safety of a PHP  Severity; exposure to medicine during pregnancy. and the benefits to patients. They should report adverse  Apparent signals of new reactions and reactions both to the national pharmacovigilance centre (and in the absence of such to the MRA) or PHP and in  Patterns of suspected reactions which although not countries with no MRA they should also report to WHO serious, may affect adherence and the success of the through the disease control PHP. programme. Media Refer all reports to the national pharmacovigilance It is important that the media are involved from the start coordinator for processing and review by the Expert of a PHP and that the need for the programme is Safety Review Panel (ESRP). publicized together with the need for pharmacovigilance. National Pharmacovigilance Coordinator The pharmacovigilance programme should be explained and good lines of communication should be set up The coordinator, who should be on the staff of the between the media and the ESRP or the designated national pharmacovigilance centre, should function as the liaison person, to ensure the availability of authoritative focal point for the national pharmacovigilance system in information. The need for good information should be the PHP. anticipated so that potential crises can be dealt with Ideally this should be a full-time position. The quickly and effectively, and public confidence responsibilities of the national coordinator would include maintained19. coordination, communication, integration, training and When communicating with the media, the following supervision of the pharmacovigilance-related activities of information should be available: the district investigation teams. This person would also serve as member or secretary of the national ESRP.  A complete account of any event of concern and its appropriate context (in terms that will be understood The coordinator should ensure that the ADR reports are by the lay public), e.g. a clear statement that an processed appropriately for assessment by the ESRP. event is an isolated occurrence, to prevent concern These would generally fall into one of three categories: that it may be widespread.  Reports selected for investigation by the district  The likelihood that there will be new cases linked to investigation team, which should be considered in therapy with the medicine. detail.

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 An outline of actions taken or planned (depending on Programme has achieved much in improving the the stage, this will range from a plan of action to a activities, support and recognition of individual national completed investigation). pharmacovigilance centres21.  The cause of the event (when identified with It plays a key role as a communication and training centre reasonable certainty). and clearing-house for information on the safety of medicines. The WHO Collaborating Centre for  The corrective action that has been or will be taken. International Drug Monitoring in Uppsala, Sweden  Guidance to the public on how to respond to manages the international database of adverse reaction concerns over the medicine including contact reports received from national centres. In 2005 this information for reporting further adverse events. database held over 3.5 million case reports. The majority of contributing national centres has ready electronic It is useful to assess the impact of media communications access to these. The Centre has established standardized on public awareness and attitudes as this will assist the reporting by all national centres and has facilitated development of future communication strategies. communication between countries to promote the rapid The roles of WHO and the International Advisory identification of signals. The terminologies developed Committee: within the WHO programme for coding adverse reactions to medicines have been widely adopted by national At an international level WHO will play a key role. While centres, manufacturers and medicine regulators. supporting countries to conduct PHPs, WHO and its regional offices have a responsibility to promote the GOOD PHARMACOVIGILANCE PRACTICES establishment and building of sustainable safety The Premarketing Guidance and the Pharmacovigilance monitoring systems. WHO will take a lead role in Guidance focus on premarketing and post marketing risk supporting Member States in the safe use of medicinal assessment respectively. The Risk MAP Guidance focuses products, WHO will serve as a repository for information on risk minimization22. Together risk assessment and risk from both pharmacovigilance programmes and PHPs, and 19 minimization form what FDA calls risk management. will disseminate this information appropriately . Specifically risk management is an iterative process of WHO will identify areas requiring research and encourage 1) Assessing a product’s benefit-risk balance. and support initiatives to conduct operational research. It will assist countries to define and develop policy on 2) Developing and implementing tools to minimize its monitoring the safe use of medicinal products and it will risks while preserving its benefits. respond to controversial issues on the safety of medicines 3) Evaluating tool effectiveness and reassessing the that threaten the use of medicines in a national or benefit-risk balance and international PHP. It will promote and encourage uniformity of terminology and will promote and develop 4) Making adjustments as appropriate to the risk resource materials and provide leadership in training and minimization tools to further improve the benefit-risk capacity development. balance. Advisory Committee on Safety of Medicinal Products This four part process should be continuous throughout a (ACSMP): product’s lifecycle with the results of risk assessment informing the sponsor’s decisions regarding risk An Advisory Committee has been established by WHO to minimization. advise on issues that: Industry already performs risk assessment and risk  Are important to national or international minimization activities for products during development programmes and have the potential to affect them and marketing. The Federal Food Drug and Cosmetic Act adversely if not resolved. (FDCA) and FDA implementing regulations establish  Cannot be met by structures and/or institutions requirements for routine risk assessment and risk and/or systems that are already available. minimization (e.g., FDA requirements for professional labelling and adverse event monitoring and reporting).  Respond to identified needs of a country that may be THE ROLE OF PHARMACOVIGILANCE AND beyond the capability of the country or countries 23 themselves; such responses should be made within PHARMACOEPIDEMIOLOGY IN RISK MANAGEMENT an appropriate period of time, taking into account Risk assessment during product development should be any existing information and the urgency of the conducted in a thorough and rigorous manner; however, 20 issue . it is impossible to identify all safety concerns during WHO Programme for International Drug Monitoring clinical trials. Once a product is marketed there is generally a large increase in the number of patients National pharmacovigilance centres are functioning as an exposed, including those with co-morbid conditions and international network coordinated by the WHO those being treated with concomitant medical products. Programme for International Drug Monitoring. The Therefore post marketing safety data collection and risk

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X assessment based on observational data are critical for 2) Characteristics of a Good Case Report evaluating and characterizing a product's risk profile and Good case reports include the following elements: for making informed decisions on risk minimization.  Description of the adverse events or disease Pharmacovigilance principally involves the identification experience, including time to onset of signs or and evaluation of safety signals. Here safety signal refers symptoms. to a concern about an excess of adverse events compared to what would be expected to be associated with a  Suspected and concomitant product therapy details product's use. Signals can arise from post marketing data (i.e., dose, lot number, schedule, dates, duration) and other sources, such as preclinical data and events including over- the- counter medications, dietary associated with other products in the same supplements, and recently discontinued medications. pharmacologic class. It is possible that even a single well documented case report can be viewed as a signal,  Patient characteristics including demographic particularly if the report describes a positive re challenge information (e.g., age, race, sex), baseline medical or if the event is extremely rare in the absence of drug condition prior to product therapy co- morbid use. Signals generally indicate the need for further conditions, use of concomitant medications, relevant family history of disease and presence of other risk investigation, which may or may not lead to the 25 conclusion that the product caused the event. After a factors . signal is identified, it should be further assessed to  Documentation of the diagnosis of the events determine whether it represents a potential safety risk including methods used to make the diagnosis. and whether other action should be taken.  Clinical course of the event and patient outcomes IDENTIFYING AND DESCRIBING SAFETY SIGNALS: FROM (e.g., hospitalization or death). CASE REPORTS TO CASE SERIES  Relevant therapeutic measures and laboratory data Good pharmacovigilance practice is generally based on at baseline, during therapy, and subsequent to acquiring complete data from spontaneous adverse event therapy including blood levels as appropriate. reports also known as case reports. The reports are used to develop case series for interpretation.  Information about response to de challenge and re challenge and 1) Good Reporting Practice  Any other relevant information (e.g., other details Spontaneous case reports of adverse events submitted to relating to the event or information on benefits the sponsor and FDA, and reports from other sources received by the patient, if important to the such as the medical literature or clinical studies may assessment of the event). generate signals of adverse effects of drugs. The quality of the reports is critical for appropriate evaluation of the For reports of medication errors good, good case reports relationship between the product and adverse events. also include full descriptions of the following, when such FDA recommends that sponsors make a reasonable information is available: attempt to obtain complete information for case  Products involved (including the trade (proprietary) assessment during initial contacts and subsequent follow- and established (proper) name, manufacturer, up, especially for serious events and encourages sponsors dosage form, strength, concentration, and type and to use trained health care practitioners to query size of container). reporters. Computer- assisted interview technology, targeted questionnaires, or other methods developed to  Sequence of events leading up to the error. target specific events can help focus the line of  Work environment in which the error occurred and questioning. When the report is from a consumer it is often important to obtain permission to contact the  Types of personnel involved with the error, types of health care practitioner familiar with the patient’s error, and contributing factors. adverse event to obtain further medical information and 3) Developing a Case Series to retrieve relevant medical records as needed24. FDA suggests that sponsors initially evaluate a signal FDA suggests that the intensity and method of case generated from post marketing spontaneous reports follow- up be driven by the seriousness of the event through a careful review of the cases and a search for reported, the report's origin (e.g., health care additional cases. Additional cases could be identified from practitioner, patient, literature), and other factors. FDA the sponsor’s global adverse event databases, the recommends that the most aggressive follow-up efforts published literature and other available databases such as be directed towards serious adverse event reports, FDA’s Adverse Event Reporting System (AERS) or Vaccine especially of adverse events not known to occur with the Adverse Events Reporting System (VAERS) using thorough drug. database search strategies based on updated coding terminology (e.g., the Medical Dictionary for Regulatory Activities). When available FDA recommends that

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X standardized case definitions (i.e., formal criteria for potential association between a product and an adverse including or excluding a case) be used to assess potential event27. cases for inclusion in a case series. In general FDA If the safety signal relates to a medication error, FDA suggests that case-level review occur before other recommends that sponsors report all known contributing investigations or analyses. FDA recommends that factors that led to the event. A number of references are emphasis usually be placed on review of serious, available to assist sponsors in capturing a complete unlabeled adverse events, although other events may account of the event. FDA recommends that sponsors warrant further investigation (see section IV.F. for more follow up to the extent possible with reporters to capture details). As part of the case-level review, FDA suggests a complete account of the event, focusing on the that sponsors evaluate individual case reports for clinical medication use systems (e.g., prescribing/order process, content and completeness, and follow up with reporters, dispensing process, administration process). This data as necessary. It is important to remove any duplicate may be informative in developing strategies to minimize reports26. In assessing case reports, FDA recommends future errors28. that sponsors look for features that may suggest a causal relationship between the use of a product and the 4) Summary Descriptive Analysis of a Case Series adverse event, including: In the event that one or more cases suggest a safety  Occurrence of the adverse event in the expected signal warranting additional investigation, FDA time (e.g., type 1 allergic reactions occurring within recommends that a case series be assembled and days of therapy, cancers developing after years of descriptive clinical information be summarized to therapy). characterize the potential safety risk and, if possible, to identify risk factors. A case series commonly includes an  Absence of symptoms related to the event prior to analysis of the following: exposure.  The clinical and laboratory manifestations and course  Evidence of positive de challenge or positive re of the event. challenge.  Demographic characteristics of patients with events  Consistency of the event with the established (e.g., age, gender, race) pharmacological/ toxicological effects of the product, or for vaccines, consistency with established  Time from initiation of product exposure to the infectious or immunologic mechanisms of injury. adverse event.  Consistency of the event with the known effects of  Doses used in cases including labelled doses, greater other products in the class. than labelled doses and overdoses.  Existence of other supporting evidence from  Use of concomitant medications. preclinical studies, clinical trials and/or  The presence of co-morbid conditions, particularly pharmacoepidemiologic studies and those known to cause the adverse event, such as  Absence of alternative explanations for the event underlying hepatic or renal impairment. (e.g., no concomitant medications that could  The route of administration (e.g., oral vs. parenteral). contribute to the event, no co- or pre- morbid medical conditions).  Lot numbers, if available, for products used in patients with events and Confounded cases are common especially among patients with complicated medical conditions. Confounded cases  Changes in event reporting rate over calendar time or (i.e., cases with adverse events that have possible product life cycle. etiologies other than the product of concern) could still 5) Use of Data Mining to Identify Product-Event represent adverse effects of the product under review. Combinations FDA recommends that sponsors carefully evaluate these cases and not routinely exclude them. Separate analyses At various stages of risk identification and assessment, of unconfined cases may be useful. For any individual systematic examination of the reported adverse events by case report, it is rarely possible to know with a high level using statistical or mathematical tools, or so-called data of certainty whether the event was caused by the mining, can provide additional information about the product. To date, there are no internationally agreed existence of an excess of adverse events reported for a upon standards or criteria for assessing causality in product. individual cases, especially for events that often occur By applying data mining techniques to large adverse spontaneously (e.g. stroke, pulmonary embolism). event databases, such as FDA’s AERS or VAERS, it may be Rigorous pharmacoepidemiologic studies, such as case- possible to identify unusual or unexpected product-event control studies and cohort studies with appropriate combinations warranting further investigation. Data follow-up, are usually employed to further examine the mining can be used to augment existing signal detection

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Int. J. Pharm. Sci. Rev. Res., 20(1), May – Jun 2013; nᵒ 13, 71-86 ISSN 0976 – 044X strategies and is especially useful for assessing patterns, investigation and analysis, it is important to put the signal time trends, and events associated with drug-drug into context33. For this reason, calculations of the rate at interactions. Data mining is not a tool for establishing which new cases of adverse events occur in the product- causal attributions between products and adverse events. exposed population (i.e., the incidence rate) are the hallmark of pharmacoepidemiologic risk assessment. The methods of data mining currently in use usually Limitations in national denominator estimates arise generate a score comparing (1) the fraction of all reports because: for a particular event29 (e.g., liver failure) for a specific drug (i.e., the “observed reporting fraction”) with (2) the  Accurate national estimates of the number of fraction of reports for the same particular event for all patients exposed to a medical product and their drugs (i.e., “the expected reporting fraction”). This duration of exposure may not be available. analysis can be refined by adjusting for aspects of  reporting (e.g., the reporting year) or characteristics of It may be difficult to exclude patients who are not at risk for an event, for example, because their the patient (e.g., age or gender) that might influence the exposure is too brief or their dose is too low and amount of reporting. In addition, it may be possible to limit data mining to an analysis for drugs of a specific class  A product may be used in different populations for 30 or for drugs that are used to treat a particular disease . different indications, but use estimates are not 6) Safety Signals That May Warrant Further available for the specific population of interest. Investigation Although we recognize these limitations, we recommend FDA believes that the methods described above will that sponsors calculate crude adverse event reporting permit a sponsor to identify and preliminarily characterize rates as a valuable step in the investigation and a safety signal. The actual risk to patients cannot be assessment of adverse events. known from these data because it is not possible to FDA suggests that sponsors calculate reporting rates by characterize all events definitively and because there is using the total number of spontaneously reported cases invariably under- reporting of some extent and in the United States in the numerator and estimates of incomplete information about duration of therapy, national patient exposure to product in the denominator. numbers treated, etc. Safety signals that may warrant FDA recommends that whenever possible, the number of further investigation may include, but are not limited to, patients or person time exposed to the product 31 the following : nationwide be the estimated denominator for a reporting rate. FDA suggests that other surrogates for exposure,  New unlabeled adverse events especially if serious. such as numbers of prescriptions or kilograms of product  An apparent increase in the severity of a labelled sold, only be used when patient-level estimates are event. unavailable. FDA recommends that sponsors submit a detailed explanation of the rationale for selection of a  Occurrence of serious events thought to be denominator and a method of estimation. extremely rare in the general population. Comparisons of reporting rates and their temporal trends  New product-product, product-device, product-food, can be valuable, particularly across similar products or or product-dietary supplement interactions. across different product classes prescribed for the same  Identification of a previously unrecognized at risk indication. However, such comparisons are subject to population (e.g., populations with specific racial or substantial limitations in interpretation because of the genetic predispositions or co- morbidities). inherent uncertainties in the numerator and denominator used. As a result, FDA suggests that a comparison of two  Confusion about a product's name, labelling, 32 or more reporting rates be viewed with extreme caution packaging or use . and generally considered exploratory or hypothesis-  Concerns arising from the way a product is used (e.g., generating. Reporting rates can by no means be adverse events seen at higher than labelled doses or considered incidence rates, for either absolute or 34 in populations not recommended for treatment). comparative purposes .  Concerns arising from potential inadequacies of a To provide further context for incidence rates or currently implemented risk minimization action plan reporting rates, it is helpful to have an estimate of the (e.g., reports of serious adverse events that appear to background rate of occurrence for the event being reflect failure of a Risk MAP goal) and evaluated in the general population or, ideally, in a subpopulation with characteristics similar to that of the  Other concerns identified by the sponsor or FDA. exposed population (e.g., premenopausal women, 7) Putting the Signal into Context: Calculating Reporting diabetics). These background rates can be derived from: Rates vs. Incidence Rates  National health statistics, If a sponsor determines that a concern about an excess of  Published medical literature, or adverse events or safety signal warrants further

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 Using large automated databases or ongoing made on a case-by-case basis. When an important epidemiologic investigations with primary data adverse event-product association leads to questions on collection. the product’s benefit-risk balance, FDA recommends that sponsors consider whether the particular signal should be FDA suggests that comparisons of incidence rates or addressed with one or more pharmacoepidemiologic reporting rates to background rate estimates take into studies. If a sponsor determines that a account potential differences in the data sources, pharmacoepidemiologic study is the best method for diagnostic criteria and duration of time at risk. evaluating a particular signal, the design and size of the While the extent of under-reporting is unknown, it is proposed study would depend on the objectives of the usually assumed to be substantial and may vary according study and the expected frequency of the events of to the type of product, seriousness of the event, interest. When performing a pharmacoepidemiologic population using the product, and other factors. As a study, FDA suggests that investigators seek to minimize result, a reporting rate higher than the background rate bias and to account for possible confounding. may, in some cases, is a strong indicator that the true A protocol for a pharmacoepidemiologic study generally incidence rate is sufficiently high to be of concern. includes: However, many other factors affect the reporting of product-related adverse events (e.g., publicity, newness 1) Clearly specified study objectives. of product to the market) and these factors should be 2) A critical review of the literature and considered when interpreting a high reporting rate. Also, because of under-reporting, the fact that a reporting rate 3) A detailed description of the research methods is less than the background rate does not necessarily including: show that the product is not associated with an increased  The population to be studied, the case definitions to risk of an adverse event. be used. PHARMACOEPIDEMIOLOGIC STUDIES35  The data sources to be used (including a rationale for Pharmacoepidemiologic studies can be of various designs, data sources if from outside the U.S.). including cohort (prospective or retrospective), case-  The projected study size and statistical power control, nested case-control and case-crossover. The calculations and results of such studies may be used to characterize one or more safety signals associated with a product, or may  The methods for data collection, management and examine the natural history of a disease or drug analysis. utilization patterns. Unlike a case series, a Depending on the type of pharmacoepidemiologic study pharmacoepidemiologic study which is designed to assess planned, there are a variety of data sources that may be the risk attributed to a drug exposure has a protocol and used, ranging from the prospective collection of data to control group and tests prespecified hypotheses. the use of existing data, such as data from previously Pharmacoepidemiologic studies can allow for the conducted clinical trials or large databases. In recent estimation of the relative risk of an outcome associated years, a number of pharmacoepidemiologic studies have with a product, and some (e.g., cohort studies) can also been conducted in automated claims databases (e.g., provide estimates of risk (incidence rate) for an adverse HMO, Medicaid) that allow retrieval of records on event. Sponsors can initiate pharmacoepidemiologic product exposure and patient outcomes. studies at any time. They are sometimes started at the time of initial marketing, based on questions that remain CONCLUSION after review of the premarketing data. More often, So it can be concluded that important role of however, they are initiated when a safety signal has been pharmacovigilance is to: identified after approval. Finally, there may also be occasions when a pharmacoepidemiologic study is  Serve public health and to foster a sense of trust initiated prior to marketing. Because among patients in the medicines they use that would pharmacoepidemiologic studies are observational in extend to confidence in the health service in general. nature, they may be subject to confounding, effect modification, and other bias, which may make results of  Ensure that risks in drug use are anticipated and these types of studies more difficult to interpret than the managed. results of clinical trials. Some of these problems can be  Provide regulators with the necessary information to surmounted when the relative risk to exposed patients is amend the recommendations on the use of the high. Because different products pose different benefit- medicines. risk considerations (e.g., seriousness of the disease being treated, nature and frequency of the safety signal under  Improve communication between the health evaluation), it is impossible to delineate a universal set of professionals and the public. criteria for the point at which a pharmacoepidemiologic  Educate health professionals to understand the study should be initiated, and the decision should be effectiveness/ risk of medicines that they prescribe.

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Experience has shown that for a country to be able to rely of sharing of information and intelligence in line with the on its own pharmacovigilance programme a number of vision and aspirations of the Erice Declaration. elements need to be in place. These are as follows: REFERENCES  A dedicated pharmacovigilance centre, 1. Pipasha B, Arun KB. Setting standards for independently funded (usually by the state), and proactive pharmacovigilance in India: The way forward, staffed by a person or persons with expert Indian J Pharmacol, 39(3), 2007, 124-128. knowledge of drug safety and of the evaluation of

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Source of Support: Nil, Conflict of Interest: None.

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