As the FDA Stakeholder Meeting approaches, we explore the various ways that patients can get involved – and offer some suggestions on how to make the most of this unprecedented opportunity.
On April 25-26, 2013, the United States Food and Drug Administration (FDA) is holding a workshop in Bethesda, MD to discuss how best to facilitate and expedite the development of safe and effective drug therapies to treat signs and symptoms related to CFS and ME. This meeting is expected to attract not only patients and ME/CFS expert clinicians, but also other groups including pharmaceutical companies and the FDA. This is an unprecedented opportunity for us to get the attention and interest of the pharmaceutical industry and to bring a patient perspective to the development and review of drugs for ME/CFS.
Day 1: April 25th
Day 1 of the workshop will give patients the opportunity to share the symptoms and signs that they experience, their experience with treatments and how this disease affects their quality of life. This is being conducted as part of the Patient-Focused Drug Development Initiative, an FDA effort to incorporate the patient experience into the drug approval process by better understanding the patients’ perspective on the severity of their disease and the effectiveness of available treatments. ME/CFS has been chosen as one of the 20 diseases for which such a workshop will be conducted and will be the first of the 20 to go! For a disease like ME/CFS, whose impact is poorly understood by those outside the community, this first day will provide the critical insights needed for discussions on the second day of the FDA workshop, but just as importantly it will also ensure that the drug approval process better incorporates the patient perspective going forward.
Day 2: April 26th
Day 2 will include a scientific workshop on how to best facilitate and expedite the development of safe and effective drug therapies for the signs and symptoms related to ME/CFS. Presentations will include:
- Lessons learned from previous studies
- The role of drug repurposing
- Pathways to expediting drug therapies
- Appropriate clinical trial design in CFS and ME
- Outcome measures to assess efficacy
- Potential valid endpoint measurements of symptom improvement.
The Importance of both Symptoms and Biological Abnormalities
Obviously it is critical that FDA and the pharmaceutical companies understand the symptoms you experience and the impact of those symptoms on your quality of life. But it is just as essential that they also understand the biological abnormalities that are associated with ME/CFS – biological abnormalities that are already being measured through lab tests and other testing. Some examples include:
- Neurological impairment, seen in symptoms like sleep dysfunction, headaches and sensory disturbances, that can be measured in lab tests like SPECT scans or MRI.
- Cognitive dysfunction, seen in symptoms like impaired memory and processing speed, that can be measured through various cognitive performance tests.
- Immunological dysfunction, seen in cytokine abnormalities, high viral titers, RNASE-L abnormality and low natural killer cells.
- Autonomic dysfunction and orthostatic intolerance, causing symptoms like dizziness, racing heart and feeling sick when standing for long periods, that can be measured by tests like tilt table tests, heart rate and blood pressure monitoring and blood volume.
- Post exertional malaise and low anaerobic threshold, causing a relapse after mental or physical exertion, documented by cardiopulmonary exercise testing.
By understanding both the symptoms and the related biological pathologies and associated abnormalities, pharmaceutical companies will be in a better position to identify opportunities to subgroup patients and potentially re-purpose existing drugs that might treat ME/CFS. This is especially critical in a disease like ME/CFS – which is too often described simply in terms of “fatigue not improved by rest”, assumed to be due to depression and deconditioning, or thought to be simply another name for chronic fatigue.
Joint Letter to the FDA
To ensure that the pharmaceutical companies understand this biology, a group of ME/CFS organizations and advocates (including Phoenix Rising) submitted a joint letter to the FDA to ask for assurance that a brief overview of the biology and abnormalities of ME/CFS will be summarized right at the beginning of the meeting. The letter that was sent can be found at:
Information and suggestions for those providing comments
For those who wish to provide comments, either in person at the meeting as part of the panel or ‘open discussion’, or directly to the FDA, the following information will be useful:
- The suggested topics include:
- Topic 1: Disease Symptoms and Daily Impacts That Matter Most to Patients
- Topic 2: Patients’ Perspectives on Current Approaches To Treating CFS and ME
The questions that the FDA is asking on each of these topics are listed at the bottom of this article. You are also given the option to suggest a topic when you register.
- In addition to the questions that the FDA asked, please provide comments about your lab/test abnormalities – linked to symptoms and dysfunction where possible – and indicate how those abnormalities changed as a result of treatment if known. Examples include:
- Abnormal VO2Max as a result of PENE/PEM
- Abnormal tilt test as indicative of orthostatic intolerance
- High inflammatory cytokines indicative of immunological issues
- Cognitive issues seen in impaired working memory and slow processing speed tested by cognitive performance testing
- Other suggestions:
- Comments should be concise and to the point. Avoid jargon. Speak about your personal experience and how this disease has affected you.
- For some people, the term “biomarker” may imply that the biomarker has been “validated”. It is better to use the term “abnormalities” or “test abnormalities” to avoid this confusion.
- If you’re planning on speaking at the meeting, then given that the time for comments may need to be shortened, it would be good for you to have both a 1-2 minute version and a 3-4 minute version.
How You Can Take Action
So what can you do to make sure the FDA and the pharmaceutical companies understand how ME/CFS has affected you and what you have experienced with treatments? There are a number of opportunities for you to participate and to provide comments.
1. Register to attend the meeting and optionally provide comments, or provide comments by proxy
To attend in person, register first-come, first-served at https://mecfsmeeting.eventbrite.com by April 8. You will be asked to provide your name and business, organization, or personal affiliation as applies (e.g. industry, government, patient). When you register, you will need to indicate whether you wish to provide comments. There are three opportunities to present comments at the meeting:
- You can request to be part of an initial panel discussion on the topics listed below. If you wish to be considered to present comments part of initial panel discussions, you will need to indicate the topic that you wish to address when you register. Then, you will need to send a brief summary of your response to the topic(s) you selected to ME-CFS-Meeting@fda.hhs.gov. The deadline to send the summary of your comments is April 8. You will be notified before the meeting if you will be on a panel.
- You can participate in open moderated discussion following the panel discussions on the topics listed below. You do not need to register to provide comments or have prepared testimony for this part of the discussion. A moderator will recognize participants to comment when they raise their hands.
- You can request to provide comments on other topics as part of the open comment period at the end of the day. If you want to do this, you will need to register as above. In addition, you will need to send a brief summary of your comments for the open public comment session to ME-CFS-Meeting@fda.hhs.gov. The deadline to submit the summary of your comments is April 8.
You can also provide comments by proxy. If you cannot attend but wish to provide comments, you can have a proxy provide them for you. You will need to register to do this.
2. Participate in the FDA meeting remotely
The meeting will also be webcast at https://mecfsmeeting.eventbrite.com.
See https://www.fda.gov/Drugs/NewsEvents/ucm319188.htm for additional information about joining the meeting.
3. Respond to two different surveys that are collecting information for the meeting.
- Both surveys are collecting information about a) disease symptoms and daily impacts that matter most to patients and b) patient perspectives on current approaches to treating ME/CFS.
- Dr. Leonard Jason and his team and Dr. Lily Chu have created an online survey that uses checkboxes to collect information on symptoms, impact on daily life, treatments being used and the effect of treatments. For those who live outside the U.S., ignore questions about the U.S. region. The link to Dr. Jason’s and Dr. Chu’s survey is here.
- The CFIDS Association of America (CAA) has taken the questions from the FDA workshop agenda and turned them into an online questionnaire where you can type answers into text boxes. The link to the survey is here.
- Both surveys are open to everyone no matter where you live. Your responses will be anonymous and confidential.
- Please try to complete both surveys.
- Although the surveys may not ask for it specifically, don’t forget to also include comments as above about your lab abnormalities – linked to symptoms and disease dysfunction where possible – and indicate how those abnormalities changed as a result of treatment if known.
4. Provide comments directly to the FDA now
- Go here and submit comments now by clicking on the ‘Comment Now!” box in the upper right corner of the page.
- You can also submit written comments to Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, rm. 1061, Rockville, MD 20852. Include the docket number, which is “FDA-2012-N-0962-0004”.
- The Docket is open until August 2, 2013.
- The FDA is encouraging patients to provide answers to the questions asked in the Federal Register. But again, don’t forget to also include information about the biological abnormalities – linked to symptoms where possible – and indicate how those abnormalities changed as a result of treatment if known. Examples are given above.
Details on the questions that the FDA would like asked on the two topics
Remember to also provide information on the biological abnormalities associated with these symptoms and the known neurological, immunological and energy production dysfunction and how treatments have affected these biological abnormalities. Examples are given above.
Topic 1: Disease Symptoms and Daily Impacts That Matter Most to Patients
- What are the most significant symptoms that you experience resulting from your condition? (Examples may include prolonged exhaustion, confusion, muscle pain, heat or cold intolerance.)
- What are the most negative impacts on your daily life that result from your condition and its symptoms? (Examples may include difficulty with specific activities, such as sleeping through the night.)
- How does the condition affect your daily life on the best days and worst days?
- What changes have you had to make in your life because of your condition?
Topic 2: Patients’ Perspectives on Current Approaches To Treating CFS and ME
- What treatments are you currently using to help treat your condition or its symptoms? (Examples may include FDA-approved medicines, over-the- counter products, and other therapies, including non-drug therapies such as activity limitations.)
- What specific symptoms do your treatments address?
- How has your treatment regimen changed over time and why?
- How well does your current treatment regimen treat the most significant symptoms of your disease?
- Have these treatments improved your daily life (for example, improving your ability to do specific activities)? Please explain.
- How well have these treatments worked for you as your condition has changed over time?
- What are the most significant downsides of these treatments (for example, specific side effects)?
You can get additional information from the following sources:
- The FDA maintains this webpage that lists information on its efforts regarding ME/CFS.
- The Federal Register Notice for the April 25-26 FDA workshop can be found here.
- The FDA has also provided a set of FAQs here about the meeting, which provide additional information.
- A description of the Patient-Focused Drug Development Initiative can be found here.