Latin America as Part of Rare Disease and Oncology Drug Development

Contributors: Sara Tylosky, CEO/Farmacon Global; Luis Squiquera, MD, CMO/Farmacon Global; Gerald L. Klein, MD, Principal at MedSurgPI, LLC and Roger E. Morgan, MD, Vice President, Medical Affairs at MedSurgPI, LLC

Introduction

Rare disease and oncology research represent some of the most challenging yet rewarding areas in clinical development. With over 700 rare disease therapies in development and thousands of oncology trials underway globally, the race to bring innovative treatments to patients is intensifying. Despite these advances, drug and treatment development in these fields face significant obstacles, ranging from protocol design to patient recruitment. This paper examines these challenges and offers strategic solutions for investors and biotech companies aiming to accelerate clinical trial success and reduce development costs.

Challenges in Rare Disease and Oncology Drug Development

Developing Practical Protocols with Robust Statistical Support

Protocols for rare disease and oncology trials must balance scientific rigor with real-world feasibility. Rare disease trials, in particular, face the challenge of small patient populations, complicating statistical power and endpoint selection. These constraints necessitate advanced statistical methodologies, such as linkage analysis, transmission disequilibrium tests, and rare-variant association studies, supported by cost-effective sequencing and genotyping platforms. Additionally, national-scale electronic health records (EHRs) provide invaluable data for estimating prevalence and clinical characteristics (Abdala, 2023). 

Streamlining Inclusion and Exclusion Criteria

Overly complex or restrictive eligibility criteria can hinder patient recruitment and trial efficiency. Pragmatic, well-defined inclusion and exclusion steps are essential for maintaining regulatory compliance while ensuring a broad patient participation.

Engaging Key Opinion Leaders (KOLs)

Involving experienced KOLs enhances protocol design and ensures clinical applicability. We have identified and engaged key Latin American KOLs so that we save significant time and resources in selecting clinical sites. 

Selecting Optimal Trial Sites

Choosing trial sites with limited patient pools or inadequate infrastructure can lead to costly delays. Our unique expertise and strong relationships enable strategic site selection, guided by demographic and epidemiological data, to drive trial success.

Partnering with Patient Advocacy Groups (PAGs)

PAGs play a critical role in connecting researchers with patient communities, enhancing recruitment and retention. Building effective partnerships requires significant time and effort to establish culturally sensitive relationships and these dedicated resources.

Ensuring Quality and Compliance Among Principal Investigators (PIs)

Quality regulatory compliance is vital for trial integrity. PIs must be well-versed in Good Clinical Practice (GCP) guidelines to mitigate risks and enhance data reliability. This necessitates a collaborative partnership and ongoing quality improvement with trial sites to uphold data integrity and ensure the highest standards of excellence.

Comprehensive Training for Trial Staff

We ensure comprehensive training to decrease the potential of protocol deviations and data integrity concerns, including audit preparation for sites. Standardized training programs ensure consistency and adherence to best practices.

Solutions for Success in Rare Disease and Oncology Trials

Strategic Regulatory Support

Engaging experienced regulatory teams facilitates navigation through complex global frameworks, ensuring adherence to stringent approval processes.

Expanding Trials into Emerging Markets

Latin America has become a key destination for clinical trials due to multiple advantages:

●        Large Treatment-Naïve Population:  With a population of 664 million, the region offers a substantial pool of treatment-naïve patients who may meet eligibility requirements for oncology and rare disease studies.

●        Cost Advantage:  Clinical trials in Latin American can be 30-40% less expensive than those conducted in the U.S. or Europe, making it a financially viable option.

●        Availability of Experienced Investigators and High-Quality Research Sites: Rather than focusing solely on real-world data, Latin America benefits from a strong network of experienced principal investigators and high-quality research sites capable of efficiently conducting trials.

●        Lower Competition for Clinical Trials: Unlike North America and Europe, Latin America has fewer competitive trials, allowing for faster patient recruitment and higher enrollment rates.

●        Diverse Representation:  The region’s diverse ethnic mix has a significant Latino/Hispanic population, and in places like Brazil and Colombia also includes African descent, which enhances inclusivity and representativeness in clinical trials.

●        Regulatory Expertise: Regulatory timelines have significantly improved in Brazil, Mexico, and Argentina. With our expert guidance, we ensure a seamless and efficient regulatory approval and drug importation process, helping you stay on track and accelerate your clinical trial progress.

Collaborating with Leading Experts

Engaging KOLs in rare diseases and oncology helps refine protocol design and improve recruitment strategies. Early expert involvement ensures trials align with real-world patient needs and regulatory expectations.

Comprehensive Training Initiatives

Providing targeted training for PIs, site staff, and monitors enhances protocol adherence and regulatory compliance, reducing risks and optimizing efficiency.

Optimized Site Selection

Leveraging local expertise and networks in Latin America allows sponsors to identify sites with strong infrastructure and access to large patient populations.

Strengthening Partnerships with PAGs

Collaborating with PAGs ensures patient-centric trials, boosting recruitment and retention while refining research methodologies based on patient experiences.

Conclusion

Rare disease and oncology clinical trials are essential for advancing medical innovation. However, these trials require tailored strategies to overcome challenges related to protocol design, patient recruitment, and regulatory compliance. By leveraging emerging markets, engaging key experts, and fostering strong patient advocacy partnerships, biotechs and investors can reduce costs, accelerate timelines, and enhance trial outcomes.

MedSurgPI, LLC offers expert fractional Chief Medical Officers worldwide, providing strategic medical consulting in development, safety, and medical monitoring. www.medsurgpi.com.

Farmacon Global provides integrated solutions to navigate these complexities. From optimizing site selection and regulatory strategies to engaging stakeholders and advocacy groups, our expertise empowers clinical research teams to advance breakthrough treatments efficiently.

References

bioaccess®. Why Latin America demographics benefit clinical trials. Retrieved from https://www.bioaccessla.com/blog/why-latam-demographics-benefit-clinical-trials.

Abdala, M. July 2023. Strategies to achieve greater competitiveness for clinical trials in Latin America. DIA Global Forum. Retrieved fromhttps://globalforum.diaglobal.org/issue/july-2023/strategies-to-achieve-greater-competitiveness-for-clinical-trials-in-latin-america/

Practical Pointers for February 2025: Asymmetric Weight Distribution: Using the Carematix Scale in Clinical Practice

Authors: Michael Fath, PhD; Gerald L. Klein, MD; Roger E. Morgan, MD

WHAT IS ASYMMETRIC WEIGHT DISTRIBUTION?

When patients favor one side of their body over the other while standing or walking, they're exhibiting asymmetric weight distribution (AWD). This common finding accompanies numerous neurological conditions and can significantly impact mobility, balance, and fall risk.

While we've traditionally relied on expensive force platforms or pressure mats to quantify AWD, a new patented weight scale by Carematix offers a practical alternative that doesn't require a trip to the gait lab.  MedSurgPI is partnering with Carematix to bring this innovation to clinicians across the US.

The Carematix Advantage

The Carematix scale measures weight-bearing through each limb in real-time, providing immediate feedback on asymmetry. Unlike bulky force platforms, it’s portable, affordable, and interfaces with most Electronic Medical Record (EMR) systems.[1]


Condition-Specific Applications

Stroke:

  • What we See: Post-stroke patients typically bear 60-80% of their weight on the unaffected side.[2]

  • Why it Matters: Persistent AWD correlates with slower walking speeds, reduced community mobility, and increased fall risk.[3]

  • How We Use It:

    • Baseline AWD measurements help quantify impairment severity

    • Weekly measurements track improvement during rehab

    • Patients use visual feedback during weight-shifting exercises

      • Remote monitoring between visits catches regression early[4]


Clinical Nugget: A 10% improvement in weight symmetry often translates to significant functional gains in stair navigation.[6]

Parkinson’s Disease

  • What We See: Subtle AWD often appears years before clinical diagnosis.[6]

  • Why It Matters: Worsening asymmetry may signal medication wearing off or disease progression.

  • How We Use It:

    • Track responses to levodopa throughout the day

    • Guide DBS programming by measuring immediate effects on symmetry

    • Identify fall risk before clinical observation catches it[7]

Clinical Nugget: We’ve found that AWD measurements better predict freezing of gait than standard clinical scales.[8]

Cerebral Palsy

  • What We See: Children with CP often develop compensatory patterns that create longstanding AWD.

  • How We Use It

    • Guide orthotic adjustments in real-time

    • Measure immediate effects of spasticity interventions

    • Track post-surgical weight-bearing patterns[9]

    • Provide objective feedback during therapy sessions


Clinical Nugget: For pediatric patients, turning AWD measurement into a game (“balance the scale!”) significantly improves engagement.

Neuromuscular Disorders

  • What We See: Progressive conditions like ALS and MS show evolving patterns of asymmetry.

  • Why It Matters: Changes in AWD often precede functional decline.

  • How We Use It:

    • Track disease progression between clinic visits

    • Guide assistive device selection and adjustment

    • Inform home modification recommendations[10]

    Clinical Nugget: Weekly AWD tracking has helped us identify MS exacerbations an average of 10 days earlier than patient self-report.[11]


Incorporating Into Your Practice

Getting Started

  1. Establish your patient’s baseline AWD during initial evaluation

  2. Document the percentage of weight bornre on each side

  3. Set symmetry targets based on diagnosis and functional goals

  4. Re-measure at each visit to track progress

Reimbursement Tips

  • AWD measurement is billable under CPT97750 (Physical Performance Test)

  • Remote monitoring qualifies for RPM codes 99453, 99454, and 99457

  • Document medical necessity by connecting AWD to fall risk or functional limitation


Practical Case Example:

Patient: 68-year-old male, 4 weeks post-stroke

Initial AWD: 75% on right (unaffected side)

Intervention: Twice-weekly PT with Carematix feedback during standing exercises + home program with portable scale

8-Week Result: Improved to 57% weight on right side; 10-meter walk speed increased from 0.5 to 0.8 m/s.[12]


Bottom Line: The Carematix scale turns the abstract concept of “weight-bearing symmetry” into an objective, measurable target for both clinicians and patients. It’s a practical tool that delivers relevant data without breaking your budget or workflow.

Have you incorporated AWD measurement into your practice? Share your experience with us at info@medsurgpi.com


References

[1] Winter DA, et al. (2005). Biomechanics and Motor Control of Human Movement. Wiley.

[2] Patterson KK, et al. (2010). "Gait asymmetry in stroke: Determinants and implications for rehabilitation." Neurorehabilitation and Neural Repair, 24(8), 728-735.

[3] Mancini M, et al. (2018). “Mobility and balance in Parkinson’s disease: A review. “Movement Disorders, 33(5), 24-38.

[4] Wang J, et al. (2015). “Remote monitoring in stroke rehabilitation.” Stroke Rehabilitation and Recovery, 10(4), 247-253.

[5] Laufer Y, et al. (2003). “The effects of balance training on gait symmetry in stroke patients.” Clinical Rehabilitation, 17(5), 478-489.

[6] Palmisano C, et al. (2020). “Gait asymmetry in Parkinson’s disease.” Frontiers in Neurology, 11, 585.

[7] Ashburn A, et al. (2001). “Postural instability and fall risk in Parkinson’s disease.” Movement Disorders, 16(5), 946-952.

[8] Mancini M, et al. (2012). “Longitudinal assessment of balance and gait in Parkinson’s disease.” Journal of Neurology, 259(7), 1337-1346.

[9] Tedroff K, et al. (2011) “Surgical outcomes and balance in children with cerebral palsy.” Journal of Pediatric Orthopedics 31(8), 853-859.

[10] DiFabio RP. (1995). “Balance measurement in the elderly and in individuals with neuromuscular deficits.” Physical Therapy, 75(6), 475-491.

[11] Sosnoff JJ, et al. (2011) “Mobility in multiple sclerosis: Relationship between AWD and fall risk.” Neurorehabilitation and Neural Repair, 25(8), 735-742.

[12] Lee MJ, et al. (215). “Asymmetrical weight bearing as a marker of functional recovery following stroke.” Journal of Rehabilitation Medicine, 47(4), 373-389.

Practical Pointers for Product Development and Medical Affairs / May 2023

Written by: Gerald L. Klein, MD; Roger E. Morgan, MD; Shabnam Vaezzadeh, MD; Burak Pakkal, MD and Michael Fath, PhD

Product Development

  • Academic Innovation Centers can serve as pivotal hubs in the context of product development. These hubs can be a focal point in the development of entrepreneurial centers. The ideal center combines diverse university schools of science, nursing, engineering, dental, pharmacology, and dentistry medicine along with a business school. If they can break down the myriad of academic political walls and combine forces with regional governments, state governments, and industry, they can develop a scientific and economic powerhouse. Tremendous centers of innovation and entrepreneurship have been established in the Boston, San Francisco, San Diego, NJ/NY Corridor, and in Research Triangle Park, North Carolina. Academic leadership should proactively enhance the effectiveness of their innovation centers in order to be more effective.

  • Efficient clinical trial enrollment is a critical factor in successful product development. Poor patient enrollment into clinical trials is one of the main reasons for study failure. This is an expensive, time-consuming process. One way that may aid this process is to use Artificial Intelligence (AI) to help with enrollment. There are many AI systems available to achieve this critical goal. Some examples include:

    • IBM Watson Health: Uses machine learning and Natural Language Processing (NLP) to analyze medical records and identify eligible patients for clinical trials. Provides predictive analytics for patient recruitment and engagement.

    • Deep 6 AI: Leverages AI to match patients to clinical trials by analyzing structured and unstructured data from electronic health records. Focuses on speed and accuracy in patient identification.

    • TriNetX: A global health research network that uses real-time access to HER data to identify eligible patients for clinical trials. Offers analytics and patient recruitment solutions.

    • Antidote: Utilizes AI to connect patients with relevant clinical trials. Uses advanced search algorithms to match patient profiles with trial eligibility criteria.

    • CureMetrix: Employs AI to enhance patient identification and engagement through medical imaging analysis and predictive analytics. Helps improve the accuracy of patient matching and recruitment.

    • Clinical AI: Uses AI to streamline the clinical trial process, from patient recruitment to data analysis. Focuses on automating trial management and enhancing patient engagement through AI-driven insights.

  • Include clinical research training for students in health care related programs. Providing proper training for students in medical, nursing, PA, PharmD, and other health care related programs can contribute significantly to product development. We believe that it is important to teach the basic elements of clinical research to all health care students in order to instill the following virtues:

    • Increase their scientific curiosity

    • Enhance their ability to understand the scientific literature

      • Increase their capability to analyze pharmaceutical product effectiveness and adverse effects.

    • Improve their interpretation of clinical trials

    • Be able to apply scientific literature to clinical pracctice

    • Increase the likelihood that students will engage in conducting clinical research and publication

Medical Affairs

  • Webinars serve as a powerful way to get your message out. In order for this to be successful, the target audience must be persuaded to watch this event in either real time or at a later date. This can be enhanced by the following:

    • Selecting appropriate speakers

    • Timing of the event

    • Cutting edge or important subject matter

    • Promotional campaign to attract an audience

  • Strategy: One key strategy in product promotion is to identify a medical need. This could be:

    • Specific populations: consider unique patient groups (e.g., pediatric, geriatric or rare diseases) that require tailored solutions.

    • Intolerant patients: highlight cases where patients cannot tolerate existing therapies. Position your product as an alternative.

    • Niche Situations: Explore scenarios where your product fills a gap. Initiate communication with key opinion leaders (KOLs) and other healthcare providers.

  • Cost-effective data generation using surveys and small studies: The use of surveys and small studies are a cost-effective way to produce data for poster sessions at scientific conferences. This data can be published in a brief publication, and then followed up with subsequent studies and publications. It may be a way to initiate a marketing campaign when you are faced with a low budget.

The AI Revolution in Pharma: Remaking Medical Affairs, One Insight at a Time

MedSurgPI, LLC is pleased to introduce the AI Revolution in Pharma: Remaking Medical Affairs, One Insight at a Time.  This document highlights the role of AI, not just as an automation tool but as a game-changer for medical affairs and stakeholder engagement.  Join us as we explore the evolving landscape of AI, promising a new era of innovation and strategic partnership.

By Michael Fath, PhD1,2; Gerald L. Klein, MD2; L. Allen Kindman, MD2; Larry Florin, MBA2; Victoria Manax, MD2; Shabnam Vaezzadeh, MD2

1Cavabio Consulting, LLC, 2MedSurgPI, LLC


Practical Pointers

Practical Pointers: Product Development and Medical Affairs

Written by: Gerald L. Klein, MD; Burak Pakkal, MD, Roger E. Morgan, MD; Renu Jain, PhD; Shabnam Vaezzadeh, MD; Pavle Vukojevic, MD; Larry Florin, MBA; Victoria Manax, MD

Product Development

  1. Data Monitoring Committees in Clinical Trials: The new FDA Guidance on “Use of Data Monitoring Committees in Clinical Trials” (DMC) just came out in February 2024. [1] The FDA strongly recommends using a DMC if there is a risk of a serious mortality or morbidity due to the participant’s medical condition or if the investigation may cause serious unexpected adverse events during the trial. The agency further states that the use of such a committee is practical.

    MedSurgPI suggests that when the study is short in duration, a Safety Review Committee, (SRC) may be a more practical approach to further ensure safety of the clinical trial. This consists of a medical monitor, the principal investigator, and another medical safety expert.

  2. Overview of Device Regulation: The FDA has just issued the “Quality Management System Regulation (QMSR) Final Rule”, which amends the good manufacturing practices requirements of the Quality System Regulation (21 CFR Part 820).[2]

    Medical device manufacturers of US medical devices must adhere to the following:

    US FDA Registration Guidance | US Medical Device Registration

    Device Registration and Listing

    Premarket Notification 510(k) unless exempt, or Premarket Approval (PMA)

    Investigational Device Exemption (IDE) for clinical studies

    Quality System (QS) regulation

    Labeling Requirements

    Medical Device Reporting (MDR)

  3. Still a Need to Improve More Diverse Populations in Clinical Trials: Clinical Trials need to involve more diverse populations such as racial and ethnic minorities, the elderly, rural populations, women, etc.[3] The FDA has published a new guidance document that explains how this data is to be collected during a clinical trial: “Collection of Race and Ethnicity Data in Clinical Trials, and Clinical Studies for FDA-Regulated Medical Products: Draft Guidance for Industry.”[4] One resource, with tools and other information to help improve this situation, may be found at the National Institute of Minority Health and Health Disparities website.

Medical Affairs

  1. Keeping Current: Presenting yourself as an expert goes beyond just understanding your product; it’s crucial to be deeply knowledgeable about the conditions it treats. This requires a commitment to continuously monitoring and analyzing relevant medical literature, including newsletters, attending conferences, and reviewing clinical trial data. Keeping abreast of advancements in the field ensures that you remain a comprehensive resource for both your product and its application. This ensures that your team can provide accurate and up-to-date information, establishing yourself as a reliable source.

  2. AI Chatbots for Medical Education: Some medical information tasks can be automated by the use of AI chatbots for providing such information to health professionals and patients about medication and device indications, adverse effects, dosages, and drug interactions.

  3. Medical Affairs Microgrants: Our experience suggests that a ‘microgrant’ program can be a useful tool in obtaining greater healthcare professional (HCP) engagement. This entails establishing a very modest grant program that allows HCPs who do not conduct formal clinical trials to defray the cost of such activities as creating an article (case history), small study (observational, history, etc.) of interest to your company.

[1] https://www.fda.gov/media/176107/download.

[2] https:www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/overview-device-regulation#reg.

[3] Kim J and McDaniel D.  From Words to Action: Advancing Efforts to Reduce the Racial Gap in Clinical Research. Applied Clinical Trials. Feb 7, 2024.

[4] https://www.fda.gov/regulatory-information/search-fda-guidance-documents/collection-race-and-ethnicity-data-clinical-trials-and-clinical-studies-fda-regulated-medical.

Practical Pointers Special Edition - Investment Essentials

Written by: Gerald L. Klein, MD; Roger E. Morgan, MD; Shabnam Vaezzadeh, MD; Pavle Vukojevic, MD; Burak Pakkal, MD; Michael Fath, PhD; Renu Jain, PhD; Larry Florin, MBA; Victoria Manax, MD

In light of the recent conclusion of the JP Morgan Healthcare Conference in San Francisco, a pivotal event for global investment, there’s a noticeable shift in focus among companies and investment groups. As they reassess strategies for raising capital and evaluating a wide spectrum of sectors - including biotech, tech, digital, device, pharmaceuticals, and diagnostic technologies - we find it timely and pertinent to dedicate this month’s Practical Pointers to these emerging trends, which are currently at the forefront of investor and founder discussions.

Fundamental Topics Related to the Technology and Pathway

  1. What is the medical or technological need?

  2. What is the background science?

  3. Is there rational data proving the hypothesis?

  4. What is the patent portfolio?

  5. What is the regulatory pathway?

  6. What is the clinical trial strategy/pathway?

  7. What is the expected clinical benefit?

  8. What is the reimbursement strategy?

  9. Is there an experienced product development team running the organization?

  10. What are the competitive products?

  11. What is the exit strategy?

  12. What is the market size?

  13. What are the risks of the project?

What is the Medical Need? This is one of the most quintessential questions that helps determine the value of a scientific product. The more significant the medical need the more it may lead to quicker funding, quicker regulatory review, and more investigator engagement. For example, there is a huge need for better oncology treatments, so these products are highly valued, and a tremendous amount of venture capital is being poured into many of these companies. Meanwhile, cancer prevention is what has led to a recent reduction in cancer mortality in the U.S. Another example of a critical area is the need for vast improvement in cardiovascular disease.

What is the Science? Is the technology based on plausible and good scientific work? Can the results be replicated? What is the level of expertise of the scientists who have conducted the experiments? Is the scientific hypothesis convincing?

Is there Rational Data Proving the Hypothesis? Does the data support the hypothesis? Are there other plausible explanations for the observed effect? Does this stand up to critical scientific review?

What is the Patent Portfolio? What is the status of patent filings? Have provisional patents been filed? Are patents pending? Which countries are covered? How much longer do the patents last? Are the patents adequate to provide protection vis-a-vis current and future competition? Who owns the patents? If it is a university, what are the licensing terms? It is essential to answer the following questions: Are the patents on the composition of matter; formulation/process; methods of use; and is there confirmation of freedom to operate?

What is the Regulatory Strategy? Is the technology going to be regulated by the FDA? Will it require filing an Investigational New Drug (IND) application or an Investigational Device Exemption (IDE)? What regulatory division of FDA/EMA will review this? Is there potential for special designation; orphan drug, expedited review, breakthrough? Have you had preliminary discussions with FDA/EMA regarding regulatory and clinical pathways? Will Phase I be in a healthy normal population? At what stage will you attempt to obtain proof of concept?

What is the Clinical Strategy/Pathway? What kind of clinical data will be required? Do you have information from the FDA/EMA as to their requirements? How are you planning to generate the clinical data? Are there competitive products on the market or in development that will affect your development plan?

Will you utilize a contract research organization (CRO), fractional service providers, or your own team? Do you have the medical, clinical, and scientific expertise to create a clinical strategy to plan clinical development in the most direct, economic, and efficient manner? Will you work with academic institutions, a site management organization, and/or independent investigators? What will be the duration and expense of each clinical phase? What will be the geographic scope of the clinical program?

What is the Expected Clinical Benefit? Will this product significantly modify a disease, prolong life, improve quality of life, or have fewer side effects than current therapy? Will it improve disease diagnosis? In addition, are there pharmacoeconomic benefits of the product?

What is Your Reimbursement Strategy? Is the technology a novel product or a “me too” (one that closely imitates an existing product)? Will it treat a rare disease? If there are competing products on the market, does it have significant medical or economic benefits? Will it extend life or improve quality of life? Are there reimbursement codes or do you need to lobby for them? Are you planning to generate data for Medicare reimbursement if applicable? Who will provide reimbursement pathway advice to your team?

Do You Have an Experienced Product Development Team? How many people are on your team? Do you have full-time dedicated staff? Has your team developed similar products before? Have they attained a New Drug Application (NDA), Biologics License Application (BLA), or clearance? Does your group work in other countries besides the U.S.? What types of companies and roles has your senior leadership team been involved with in terms of their experience?

What are the Competitive Products? What are the competitive products already on the market or in development? What is your competitive advantage over them? How will they affect your clinical development, commercialization, and market potential? What other products are in development and how might they affect your development and/or commercialization strategy?

What is Your Exit Strategy? Are you planning to sell the product (or company) when you have demonstrated proof of concept? Will you try and obtain product approval before an exit? Do you intend to manufacture, and commercialize the technology yourself, seek partnership, hand off, or some combination in different geographies?

What is the Market Size? Have you identified your Total Addressable Market (TAM)? What is the overall market size, and which is your addressable market? Which geographies and populations will you target? What is your order of entry strategy? Would there be opportunities for expanding the market?

What are the Risks of the Project? Have you characterized the project risks across the full range of functional areas? Have these been quantified in a risk register? Do you have mitigations for the relevant risks?

Practical Pointers for Drug Development and Medical Affairs

Written by: Gerald L. Klein, MD: Burak Pakkal, MD; Roger E. Morgan, MD; Renu Jain, PhD; Shabnam Vaezzadeh, MD; Pavle Vukojevic, MD; Larry Florin, MBA; Victoria Manax, MD

Drug Development

In 2023, the U.S. Food and Drug Administration (FDA) published numerous significant guidance documents. Below is a selection of these key publications.

  1. Numerous types of real-world data can be analyzed in non-clinical trials such as registries, electronic health records, medical claims, and data on products used in clinical practice as part of a package for FDA regulatory product approval.[1]

    • The FDA suggests the following:

      • Early engagement will allow for timely identification of challenges in the design and planning of a non-interventional study and for discussion of how such challenges might be addressed.

      • When submitting a meeting request, sponsors should include adequate information - as outlined in FDA guidance for formal meetings - for FDA to both assess the potential utility of a meeting and to identify relevant FDA subject matter experts who should address the proposed agenda items.

  2. Optimizing the dosage for oncology products now requires a strong rationale for choice of dosage which should be provided before initiating registration trial(s):

    • To support a subsequent indication and usage:

      • Especially for oncologic diseases not adequately represented in completed dose-finding trials or for new combination regimens.

      • If sufficient rationale for choice of dosage cannot be provided, additional dose-finding should be conducted.[2]

    • The FDA further states that different dosages may be needed in different disease settings or oncologic diseases based on potential differences in tumor biology patient population, treatment setting, and concurrent therapies (for combination regimens), among other factors.

      • Applicable nonclinical and clinical data should be considered to support the proposed.

    • Different dosages may be needed in different disease settings or oncologic diseases based on potential differences in tumor biology, patient population, treatment settings, and concurrent therapies (for combination regimens), among other factors.

      • Applicable nonclinical and clinical data should be considered to support the proposed.

    • For additional information, please see FDA’s Project Optimus:

  3. When developing drugs for rare indications, the FDA frequently allows the use of innovative trial designs. These should be discussed with the appropriate division very early on. This may include Bayesian methods, n-of-1 clinical studies, randomized delayed-start designs, crossover designs, and master protocol.[3] These studies require a detailed statistical analysis plan including key features of the clinical investigation design and preplanned analysis discussed with the review team before the study initiatives.

    Canadian Regulatory Pointers

    On December 4, 2023, Health Canada’s Regulatory Operations and Enforcement Branch revised the medical device establishment licence (MDEL) application form. The form is used to:

    • Apply for an MDEL

    • Apply for an MDEL after a cancellation

    • Submit changes to your existing MDEL

    • Cancel your MDEL

    • Apply for a reinstatement of your MDEL after a suspension

      For specific details, visit the following website: https://www.canada.ca/en/health-canada/services/drugs-health-products/compliance-enforcement/establishment-licences/medical-devices-compliance-bulletin/updates-frm0292-instructions.html

      Medical Affairs

      Direct-to-Consumer Prescription Drug Advertisements in television and radio in new guidance document:[4]

    • First Standard: The major statement is presented in consumer-friendly language and terminology is readily understandable.

    • Second Standard: The major statement’s audio information, in terms of the volume, articulation, and pacing used, is at least as understandable as the audio information presented in the rest of the advertisement.

    • Third Standard: In advertisements in television format, the major statement is presented concurrently using both audio and text.

    • Fourth Standard: In advertisements in television format, for the text portion of the major statement, the size and style of font, the contrast with the background, and the placement on the screen allow the information to be read easily.

    • Fifth Standard: During the presentation of the major statement, the advertisement does not include audio or visual elements, alone or in combination, which are likely to interfere with comprehension of the major statement.


    1. Considerations for the use of real-world data and real-world evidence to support regulatory decision-making for drug and biological products. Guidance for Industry. August 2023.

    2. Optimizing the dosage of human prescription drugs and biological products for the treatment of oncologic diseases. Guidance for Industry January 2023.

    3. Rare Diseases: Considerations for the development of drugs and biological products. Guidance for industry. December 2023.

    4. Direct-to-consumer prescription drug advertisements: presentation of the major statement in a clear, conspicuous, and neutral manner in advertisements in television and radio format final rule Q&A. Guidance for Industry December 2023.