This
guidance represents the Food and Drug Administration's (FDA's)
current thinking on this topic. It does not create or confer
any rights for or on any person and does not operate to bind FDA
or the public. You can use an alternative approach if that
approach satisfies the requirements of the applicable statutes
and regulations. If you want to discuss an alternative
approach, contact the FDA staff responsible for implementing
this guidance. If you cannot identify the appropriate FDA
staff, call the appropriate number listed on the title page of
this guidance.
This question and answers (Q&As)
guidance is intended to assist applicants in evaluating the impact
of ethnic factors in the acceptability of foreign clinical data.
This guidance provides answers to questions that have arisen since
the implementation of the E5 guidance in June 1998.
The
questions and answers provided here reflect the consensus of the
ICH parties. This guidance will be revised to include additional
Q&As as new questions arise.
FDA's guidance documents, including this
guidance, do not establish legally enforceable responsibilities.
Instead, guidances describe the Agency's current thinking on a
topic and should be viewed only as recommendations, unless
specific regulatory or statutory requirements are cited. The use
of the word should in Agency guidances means that something
is suggested or recommended, but not required.
The ICH guidance E5 Ethnic Factors in the
Acceptability of Foreign Clinical Data was endorsed by the
International Conference on Harmonisation in
February 1998 and issued by the FDA in June 1998. ICH
E5 is intended to facilitate the registration of drugs and
biologics among ICH regions by recommending a framework for
evaluating the impact of ethnic factors on a drug’s effect, i.e.,
its efficacy and safety at a particular dosage and dose regimen.
Q1: I am planning to develop my new drug globally.
Does E5 provide guidance for this approach?
A1: E5 does provide some guidance in this situation. E5
addresses primarily how development programs in one or two regions
might support approval in another region. E5 says, in general,
that if the data developed in one region satisfy the requirements
for evidence in a new region, but there is a concern about
possible intrinsic or extrinsic ethnic differences between the two
regions, then it should be possible to extrapolate the data to the
new region with a single bridging study. The bridging study could
be a pharmacodynamic study or a full clinical trial, possibly a
dose-response study.
The bridging study
would allow extrapolation of an adequate database to the new
region. It would seem possible, and efficient, to assess
potential regional differences as part of a global development
program, i.e., for development of data to occur simultaneously in
various regions, rather than sequentially. For example, if
multi-regional trials had a sufficient number of trial subjects
from the new region, it might be possible to analyze the impact of
ethnic differences in those studied, to determine whether the
entire database is pertinent to the new region.
The basic issues
to be considered in a global study design that could affect a
region's willingness to rely on these data are: (a) definition and
diagnoses of disease condition and patient, (b) choice of control
group, (c) regional target or objective of treatment with choice
of efficacy variables, (d) methods of assessment of safety, (e)
medical practice, (f) duration of the trial, (g) regional
concomitant medications, (h) severity distribution of eligible
subjects, and (i) similarity of dose and dose regimens.
To determine
whether your proposed global program will address the requirements
of a specific region, it is recommended that early consultation
and discussions be held with regulatory authorities in that
region.
Q2: I have developed my drug in one region, addressing
safety, efficacy, dosing, etc., as well as use in special
populations such as patients with renal/hepatic impairment, the
elderly, children, and pregnant and lactating women.
If I can successfully demonstrate (e.g.,
through a bridging study) that my safety, efficacy, and dosing
information in the general population are relevant to the new
region, will I also need to further address the extrapolatability
of the special population data?
A2: In general, if the studies of special populations are
sufficient in design (e.g. include an appropriate range of
severity of impairment) to address regulatory requirements of the
new region, but are conducted in a foreign region, and if evidence
supports the extrapolation of the data in the general population
to the new region, you will probably not need to address the issue
of special populations again in the new region. Note, however,
that for a new indication in a special population (e.g., pediatric
depression), a region might require a separate bridging study.
Q3: I believe that my drug is sensitive to ethnic
factors and that the medical settings in which it is used may vary
among regions. Does this mean that my efficacy study in one
region is of no value in support of my application in another?
A3: No. Assuming the new region finds the studies in the
first region pertinent, the regulatory authority of the new region
will likely require a controlled study in its own region to
establish efficacy (and/or to address other issues). E5
indicates, however, that the second region would be likely to
consider a single such study adequate if the data from the foreign
region otherwise meet all the requirements of the new region. If
the new study supports the same conclusions as the
study(ies) in the original region, no
further confirmation should be needed, as the data from the
original region would likely be considered to confirm the finding
in the new region. In that case, the study in the new region need
not necessarily have the identical dose and treatment effect size
to confirm the findings from the initial region. There might also
be situations in which the region would consider further safety
data necessary. For example, if the new region considered a
higher dose or more frequent dosing necessary and if this finding
were not a pharmacokinetic effect, sponsors might need to provide
additional safety data.
Q4: I believe that my drug is insensitive to ethnic
factors and that there are no significant relevant differences in
extrinsic factors, including the practice of medicine, among the
regions. The pharmacokinetics of the drug are
insensitive to intrinsic and extrinsic factors. The diagnosis and
therapy of the conditions in the indication do not significantly
vary among regions. Nonetheless, the regulatory authority of the
new region is requiring an additional study of safety and efficacy
for bridging. Is this requirement inconsistent with E5?
A4: No, although you might want to discuss the issue with the
regulatory authorities in the new region. E5 makes it clear that
the need for a bridging study is always a matter of judgment and
does not seek to discourage the new region’s asking for one. E5
specifically notes that familiarity with the other region is
likely to be an important determinant of whether the new region
asks for a bridging study. E5 does indicate the expectation that
the regulatory authorities of new regions would request only those
additional data necessary to assess the ability to extrapolate
foreign data to the new region, but the amount of additional data
called for is a matter of judgement on the part of the regulatory
authority.
Q5: My drug has been approved in two ICH regions
and I am about to meet with regulatory authorities in the third
region to discuss an application for marketing. I believe that
the new regulatory authority should accept the present data, and
that regulatory authority should require little or no additional
data. What information should I
submit to support my case that additional data are not needed?
A5: There are two distinct issues that need to be considered:
(1) the adequacy of the database and (2) the need for a bridging
study. You will need to convince the regulatory authority that
the available data are both adequate to meet the new region's
requirements and that the data are applicable to the population of
the new region. You should therefore indicate how your data
address all the regulatory requirements of the new region. Where
the choice of control groups, primary endpoints, or other key
clinical trial design features are not those known to be
considered acceptable to the new region, you should explain how
and why they should be considered to meet the regulatory
requirements of the new region.
You should also
indicate why the data and conclusions should be considered
relevant to the new population. In doing this, you should
identify the intrinsic factors (e.g., racial distribution) that
differ between the regions and show that those factors do not
substantially affect the drug effect (i.e., demonstrate that the
drug is insensitive to any differences in ethnic factors). Data
indicating that pharmacologically related compounds have similar
effects in the two regions can be quite useful.
You should also
identify the extrinsic factors (e.g., diagnosis or management of
the patient population studied) that you believe are generally
similar to those in the intended population in the new region and
explain why any significant differences would not alter
conclusions to be drawn about the drug effect.
Dose-response
relationships should be evaluated to determine if these are
sensitive to intrinsic or extrinsic factors, and whether the
appropriate doses might vary markedly among individuals or ethnic
groups.
Q6: I believe that my drug is insensitive to ethnic
factors and that drugs in its class have similar activity in all
regions. However, the endpoints I studied and/or the control
group I used were considered acceptable to the regions in which
the studies were conducted but not to the new region. Does E5
indicate that the new region should accept those data as evidence
of efficacy?
A6: No. E5 indicates clearly that it applies only when the
foreign clinical data address all the regulatory requirements of
the new region, but come from a different region. E5 does not
address the regulatory requirements of individual regions. If
your choice of clinical endpoints or control group is not
considered acceptable to the new region, and if you cannot
convince regulators in that region otherwise, then E5 does not
apply to this situation. Early discussion with regulators in
regions where endpoints, control groups, inclusion criteria or
diagnostic criteria might differ should be considered part of
planning clinical studies to meet an individual region’s
requirements. In this situation, the regulatory authority in the
new region may require you to conduct a study using agreed-upon
criteria in the new region.
Q7: I believe my drug is insensitive to ethnic
factors. However, there is a clear difference in medical practice
and the use and perceived need for certain drugs in the targeted
therapeutic area. Does E5 indicate that the new region should
accept those data as evidence of efficacy?
A7: No. As described, the database might not
be acceptable to the new region, apart from concerns about ethnic
differences, because the data do not refer to a disease that the
new region considers pertinent.
Q8: My drug has been shown to be effective in
preventing certain clinical events. However, the rate of these
events is clearly different in the new region, even though the
pathophysiology is the same. Does E5 indicate that the new region
should accept those data as pivotal evidence of efficacy?
A8: No. Certainly, in most cases where there
is a definitive outcome study in another region, a region would
probably not require that the study be repeated locally. There
could, however, be exceptions; for example, if the event rate is
indeed lower in the new region, and the risk reduction is the same
in both regions, the actual number of patients benefited will be
smaller and an adverse effect could become more important,
affecting the benefit‑to‑risk relationship of the drug. A new
region, in some cases, might need a clinical trial to assess the
value of the drug.
Q9: My drug is approved for various indications in one
region and it is shown in a bridging study in the primary
indication that the data can be extrapolated. Does this mean that
the new regions should accept all indications without further
data?
A9: No. Whether or not the new region will
require further data would be decided on a case-by-case basis,
depending on whether the "bridged" indication was thought to
satisfy all concerns about potential ethnic differences. For
example, the additional indications might be extensions of the
primary indication (perhaps not calling for an additional bridging
study) or quite new uses (perhaps calling for bridging). It is
recommended that early consultation and discussions be held with
the authorities in the new region.
Q10: E5 expresses the principle that, as experience with
interregional acceptance of foreign clinical data increases, there
will be a better understanding of situations in which bridging
studies are needed and that it is hoped that, with these
experiences, the need for bridging data will lessen. Is this
principle still valid?
A10: Yes, this is the expectation. The
accumulation of experience by each region with implementation of
the E5 guidance continues to add to our understanding of
situations in which a bridging study would be considered necessary
by a new region. The expectation continues to be that, with this
experience, the need for a bridging study will lessen.