Professional Documents
Culture Documents
Compiled by the Medicines and Healthcare products Regulatory Agency, the Association of the British Pharmaceutical Industry, the Proprietary Association of Great Britain, the British Association of Research Quality Assurance and the British Generic Manufacturers Association as part of a BROMI initiative
February 2011
MedDRA is a registered trademark of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) Crown Copyright 2011 Published by the Medicines and Healthcare products Regulatory Agency Guidance on reproducing and re-using MHRA Crown copyright material can be found on our website at: http://www.mhra.gov.uk/CrownCopyright/index.htm An application for permission to reproduce MHRA material, available from our website, should be sent to the MHRA at the address below: Medicines and Healthcare products Regulatory Agency Information Services 4th Floor 151 Buckingham Palace Road London SW1W 9SZ E-mail: info@mhra.gsi.gov.uk
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CONTENTS
1. CHAPTER 1 - INTRODUCTION .................................................................................................... 5 1.1 1.2 1.3 1.4 2. INTRODUCTION ........................................................................................................................ 5 BACKGROUND .......................................................................................................................... 5 REFERENCES........................................................................................................................... 6 FEEDBACK ............................................................................................................................... 6
CHAPTER 2 - VALID ADVERSE DRUG REACTION................................................................... 7 2.1 INFORMATION TO VALIDATE A CASE FOR EXPEDITED REPORTING ................................................. 7
3.
CHAPTER 3 - REPORTING REQUIREMENTS ............................................................................ 8 3.1 3.2 3.3 3.4 3.5 EXPEDITED REPORTING REQUIREMENTS .................................................................................... 8 REPORTING OVERDOSE, ABUSE AND MISUSE ............................................................................. 8 REPORTING OF MEDICATION ERRORS ........................................................................................ 9 REPORTS OF LACK OF EFFICACY ............................................................................................... 9 PRODUCT COMPLAINTS .......................................................................................................... 10
4.
CHAPTER 4 - ICSR SUBMISSIONS BASED ON MHRA ASPRS ............................................. 11 4.1 ICSR SUBMISSIONS BASED ON MHRA ASPRS ....................................................................... 11
5.
CHAPTER 5 - GENERAL DATA ENTRY GUIDANCE ............................................................... 13 5.1 GENERAL DATA ENTRY GUIDANCE ........................................................................................... 13
6.
7.
CHAPTER 7 - DRUG INFORMATION......................................................................................... 15 7.1 DRUG INFORMATION ............................................................................................................... 15 7.2 ADDITIONAL DRUG INFORMATION............................................................................................. 16 7.2.1 Drug dosage.................................................................................................................... 17 7.2.2 Pharmaceutical form ....................................................................................................... 17 7.2.3 Route of administration ................................................................................................... 18 7.2.4 Indication ......................................................................................................................... 18 7.2.5 Dates ............................................................................................................................... 18 7.2.6 Action taken with drug ..................................................................................................... 18
8.
CHAPTER 8 - REACTION INFORMATION ................................................................................ 20 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 8.12 MEDDRA .............................................................................................................................. 20 REACTION OUTCOMES ............................................................................................................ 23 ADVERSE DRUG REACTIONS VERSUS ADVERSE EVENTS ............................................................ 23 WITHDRAWAL REACTION CLASSIFICATION ................................................................................ 25 REACTION OCCURRING AT MULTIPLE BODY SITES ..................................................................... 25 DUPLICATION OF REACTION TERMS ......................................................................................... 26 DRUG INTERACTION ............................................................................................................... 26 DEFINITIVE AND PROVISIONAL DIAGNOSES WITH SIGNS AND SYMPTOMS ..................................... 26 OTHER PATIENT OUTCOMES.................................................................................................... 27 NO ADVERSE EFFECT ............................................................................................................. 27 PRODUCT SUBSTITUTION ........................................................................................................ 27 UNEXPECTED BENEFIT............................................................................................................ 27
9.
CHAPTER 9 - CASE NARRATIVE.............................................................................................. 28 9.1 CASE NARRATIVE ................................................................................................................... 28 CHAPTER 10 TEST RESULTS ........................................................................................... 29 TEST RESULTS ....................................................................................................................... 29
10. 10.1
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11. 11.1 11.2 12. 12.1 12.2 12.3 13. 13.1 14. 14.1 15. 15.1 15.2 15.3 15.4 15.5 15.6 15.7 16.
CHAPTER 11 FATAL REACTIONS .................................................................................... 31 REPORTS OF DEATH ............................................................................................................... 31 PATIENT DEATH DETAILS ......................................................................................................... 32 CHAPTER 12 - REPORTS OF DRUG EXPOSURE DURING PREGNANCY........................ 33 REPORTS OF DRUG EXPOSURE DURING PREGNANCY ................................................................ 33 PARENT - CHILD REPORTS ...................................................................................................... 33 PREGNANCY WITH CONTRACEPTIVE MEDICINES ....................................................................... 35 CHAPTER 13 - LITERATURE REPORTS .............................................................................. 36 LITERATURE REPORTS ............................................................................................................ 36 CHAPTER 14 - REPORTER DETAILS................................................................................... 38 REPORTER DETAILS ............................................................................................................... 38 CHAPTER 15 - ADMINISTRATIVE INFORMATION .............................................................. 39 WORLDWIDE UNIQUE CASE IDENTIFICATION NUMBER AND SAFETY REPORT ID............................ 39 REPORT TYPE ........................................................................................................................ 39 SERIOUSNESS CRITERIA AND MEDICALLY CONFIRMED SELECTION ............................................. 41 DUPLICATES AND NULLIFICATIONS ........................................................................................... 41 DATES ................................................................................................................................... 45 FOLLOW-UP REPORTS ............................................................................................................ 45 SENDER AND RECEIVER DETAILS ............................................................................................. 45 APPENDIX 1 ABBREVIATIONS.......................................................................................... 47
17. APPENDIX 2 ELECTRONIC TRANSMISSION OF INDIVIDUAL CASE SAFETY REPORTS MESSAGE SPECIFICATION (ICH ICSR DTD VERSION 2.1) ............................................................ 48 18. 19. 20. 21. 22. APPENDIX 3 MHRA VALIDATION RULES ........................................................................ 49 APPENDIX 4 PHARMACEUTICAL FORMS ....................................................................... 50 APPENDIX 5 ROUTE OF ADMINISTRATION..................................................................... 51 APPENDIX 6 USEFUL WEBSITES ..................................................................................... 52 APPENDIX 7 GLOSSARY ................................................................................................... 53
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1.
1.1
Chapter 1 - Introduction
Introduction
Spontaneous adverse drug reaction (ADR) reporting is fundamental in the post-marketing surveillance of medicines. It is therefore important to capture information on ADRs in a structured manner and to the highest possible quality standards to support accurate detection and analysis of drug safety signals. With the recent move to electronic reporting, maintaining quality for electronic reports received from industry is a major challenge as reports are no longer subject to the regulators internal review or manual intervention. It is therefore essential that a common understanding and methodology for best practice in coding and data classification is implemented. Through rigorous internal monitoring the MHRA has identified a need to develop a Best Practice guide in reporting of Individual Case Safety Reports (ICSRs) using the E2B standard. This guide aims to remove the various differences that occur in reporting through differing classification and coding practices across companies, a key problem highlighted through the MHRA audit process. The audit process involves reviewing a random sample of 50 UK E2B reports for four Marketing Authorisation Holders (MAHs) each month. The selection for audit may be based upon concerns raised through review of reports at signal assessment, compliance data or intelligence gathered from pharmacovigilance inspections. This guide combines ideas from both industry trade associations and the MHRA as part of a Better Regulation of Medicines Initiative (BROMI). It is hoped the guide will contribute to delivering high standards in classification by highlighting common findings from audits of ICSRs and providing specific examples of good practice.
1.2
Background
Electronic exchange of information on suspected adverse reaction reports between regulators and industry allows the data to be made immediately available for qualitative signal detection and evaluation. The E2B standard ensures that this information is easily transferred and therefore facilitates uniformity and high quality with regard to the content and format of ICSRs. At the MHRA the procedure for paper reports involves internal coding and quality review in the workflow to ensure data are correctly coded before they are committed to the database and made available in outputs such as ICSRs, Drug Analysis Prints (DAPs), Anonymised Single Patient Reports (ASPRs) and signal detection outputs. However, usually electronic reports received from industry are automatically committed to the database without manual intervention. This means that E2B reports are available in the public domain as initially coded by the MAH. Validation rules have been built to ensure basic quality standards are met. The full list of these rules can be found in Appendix 3. Nevertheless, the MHRAs audit of reports submitted from industry demonstrates a significant difference in classification and coding practices across companies. 5/55
Errors in the database could have serious consequences such as missing signals or creating false signals where ADRs are duplicated. Furthermore, such errors also generate a large volume of enquiries. This results in further work to update the case and/or contact the originator company to request an update to their case. Each enquiry that requires a case update will generate an updated version of the ASPR which is a significant administrative burden for both industry and the MHRA. The MHRA and industry trade associations have agreed to issue guidance on best practice to support consistent coding practices to satisfy all stakeholders.
1.3
References
It is intended that this guide will complement current EU legislation and guidance and provide practical advice to key stakeholders on the classification of ICSRs. It is important to note that the guide is not intended to replace the existing legislation and guidance. A list of the abbreviations referred to within the guide is provided in Appendix 1. This guide has been based on the current pharmacovigilance framework. New legislation for pharmacovigilance in the EU will have an impact on the guidance provided. References for this guide include: Electronic Transmission of Individual Case Safety Reports Message Specification (ICH ICSR DTD version 2.1). This document provides information on the E2B fields (see Appendix 2). Volume 9A of The Rules Governing Medicinal Products in the European Union Guidelines on Pharmacovigilance for Medicinal Products for Human Use (available from the European Commission website) http://ec.europa.eu/health/documents/eudralex/vol-9/index_en.htm Volume 10 ENTR/CT3 Detailed guidance on the collection, verification and presentation of adverse reaction reports arising from clinical trials on medicinal products for human use Volume 10 ENTR/CT4 Detailed guidance on the European database of Suspected Unexpected Serious Adverse Reactions (Eudravigilance - Clinical Trial Module) MedDRA Term Selection: Points to Consider (MTS: PTC) Note for guidance EudraVigilance Human Processing of safety messages and individual case safety reports (ICSRs)
The MHRA has also published a Good Pharmacovigilance Practice Guide which gives guidance on developing effective pharmacovigilance systems.
1.4
Feedback
For general enquiries about pharmacovigilance, the MHRAs Pharmacovigilance Service Desk can be contacted by e-mail at: pharmacovigilanceservice@mhra.gsi.gov.uk.
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2.
2.1
The minimum criteria for a valid case with regards to expedited reporting are: an identifiable patient (anonymised) a suspect drug a suspect reaction an identifiable healthcare professional reporter (should be anonymised to avoid data protection issues but reporter qualification must be available).
Further guidance on the four minimum criteria can be found in the relevant chapters (chapters 6, 7, 8 and 14). When one or more of these criteria are missing, it is expected that the MAH should follow up the case in order to validate the report. For consumer reports, it is expected that the MAH should seek the consumers consent to contact their healthcare professional to obtain medical confirmation. Medical notes relating to the reaction and the specific patient can be accepted as healthcare professional confirmation of a report from a consumer. Volume 9A states that if ICSRs, which do not qualify for expedited reporting provide information that may lead to a change in the known risk-benefit balance for the product, this possible change should be notified to the Competent Authorities without delay. If reports are received that provide details of a drug and a reaction term but not an identifiable patient and/or reporter, MAHs should enter these cases on their safety database and expedite if validating information is received. Invalid reports should be regularly reviewed to consider how these reports might provide information on the known risk-benefit balance for the product. MAHs should also take appropriate action to investigate the possibility of an emerging pattern e.g. reports from the same source or a cluster of similar adverse events. There is a need for further guidance to be developed on how to handle invalid reports and for reports identified through social networking websites, web blogs and other such sources of data. A valid ADR for expedited reporting must include an identifiable patient, a suspect drug, a suspect reaction, an identifiable healthcare professional reporter.
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3.
3.1
European expedited reporting requirements are covered in Volume 9A, with additional details of specific requirements for Member States provided in Annex 6. The following cases should be expedited to the MHRA: a) Spontaneous All UK serious. (The MHRA forwards all serious UK reports to the EMA and therefore companies must not expedite these cases to the EMA). All serious EU cases for centralised and MR products where the UK is the RMS or Rapporteur (including EU competent authority cases where applicable) All serious worldwide cases * All serious Black Triangle EU cases. **
It is important to note that reports derived from post-marketing studies are subject to the same reporting requirements as spontaneous reports. b) Clinical Trials reporting requirements for trial sponsors All UK SUSARs Any non-UK SUSAR that is related to an IMP under investigation by the sponsor in the UK.
It should be noted that although some reports may not meet the expedited reporting requirements, they should be recorded in the MAHs pharmacovigilance system as they may provide useful information on the overall risk-benefit balance of the medicinal product. These reports should be included for risk-benefit evaluation during signal detection and PSUR preparation e.g. reports of overdose, abuse and misuse that are not associated with a serious adverse drug reaction (see section 3.2).
3.2
In line with Volume 9A the MAH should continuously monitor and evaluate the potential impact of overdose, abuse and misuse on the overall risk-benefit balance of the medicinal product.
*
In addition to the legal requirement for reporting unexpected serious cases, MAHs are also encouraged to report electronically all expected serious adverse reactions occurring outside the EU on an expedited basis, regardless of the authorisation procedure.
In the UK, additional voluntary requirements are in place for products that are subject to intensive monitoring, also known as black triangle products to report all serious reactions that originate from within the EU to the MHRA.
As of Feb 2011 / Ver: 1.0
**
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Only cases of overdose, abuse and misuse that lead to serious adverse reactions should be expedited to the MHRA. Reports should be routinely followed up to ensure that information is as complete as possible with regard to early symptoms, treatment and outcome. This includes cases of intended suicide. Reports of overdose, abuse and misuse that are not associated with a serious adverse drug reaction should be recorded in the MAHs pharmacovigilance system as they provide useful information on the overall risk-benefit balance of the medicinal product and should be included for risk-benefit evaluation during signal detection and PSUR preparation. If an overdose is reported and it was specifically stated that there were no clinical consequences, it is acceptable to code the LLT Overdose and the additional LLT No adverse effect on the MAHs database in line with the guidance in the MedDRA Term Selection: Points to Consider (MTS: PTC) document, however these reports should not be expedited as ICSRs to the MHRA. The most appropriate MedDRA term to describe the overdose should be selected e.g. whether the overdose is accidental or intentional or involves a multiple drug overdose. Reports that indicate that the taking of the suspect drug led to a suicidal intention and subsequent overdose of the suspect drug or other medication should also be expedited. Example 1: In the following example the patient was hospitalised following an overdose, however this case should not be expedited as there was no reaction associated with the overdose. The MAH should consider whether or not the drug may have contributed to the overdose and the report should be followed up for further information. <narrativeincludeclinical>Spontaneous report, reported by a nurse, received on 06OCT2009. A 21 year old female patient has taken an overdose of XXXXXX of 40 mg on 24SEP2009 at 11am. She also took an overdose of 20 mg XXXXXXX. The patient rang the hospital at 6pm and discharged herself at 3 am. No side effects were experienced by the patient. The reporting nurse did not provide a causality assessment and outcome.</narrativeincludeclinical>
3.3
Reports of medication errors such as wrong route of administration or wrong drug administered - should only be expedited to the MHRA if they are accompanied by a serious ADR.
3.4
Volume 9A states that reports of lack of efficacy should not normally be reported on an expedited basis, but should be recorded in the MAHs pharmacovigilance system and discussed in the relevant PSUR. However, in certain circumstances reports of lack of efficacy should be treated as expedited cases for reporting purpose. Medicinal products used for the treatment of life-threatening diseases, vaccines and contraceptives are examples of classes of medicinal products where lack of efficacy should be considered as cases requiring expedited reporting. It is important to provide batch numbers for vaccines.
As of Feb 2011 / Ver: 1.0
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Judgement should be used in reporting, considering if other cases qualify for reporting. For example, antibiotics used in life-threatening situations where the medicinal product was not in fact appropriate for the infective agent should not be reported. However, a life-threatening infection where the lack of efficacy seems to be due to the development of a newly resistant strain of a bacterium previously regarded as susceptible should be reported on an expedited basis. Companies should apply judgment on a case by case basis to decide if the reports raise a concern about lack of efficacy. If in doubt, please contact us through the Pharmacovigilance Service Desk (pharmacovigilanceservice@mhra.gsi.gov.uk).
3.5
Product complaints
Product complaints should be reviewed for efficacy-related issues or problems with the manufacturing process in accordance with good manufacturing practice requirements. Reports of product technical complaints should also be reviewed on an ongoing basis to ensure that any reports associated with an ADR are recorded on the MAHs database so that they are included for risk-benefit evaluation during signal detection and PSUR preparation. Any reports that fulfil the requirements for expedited reporting should be submitted within the regulatory timeframes.
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Expedited reporting of ICSRs also applies to EU Competent Authorities. EU Competent Authorities are required to provide reports within 15 days of receipt of all serious adverse reactions occurring in their country to relevant MAHs and to the EMA. The MHRA provides this information to MAHs in the form of ASPRs (this includes ICSRs generated at the MHRA). The date the ASPR is made available to the MAH should be considered day 0. ICSRs based on MHRA ASPRs should not be reported back to the MHRA as this will generate duplicate cases in the MHRAs database and result in further duplicate ASPRs. It should be noted that EU competent authority cases should be expedited in line with reporting requirements. The Pharmacovigilance Service Desk (pharmacovigilanceservice@mhra.gsi.gov.uk.) should be contacted if an MAH has obtained significant follow-up information for a case received from the MHRA. The MHRA will provide advice on whether the case should be expedited. If it is deemed necessary to expedite an update to an ICSR originating from the MHRA, it is essential to use the correct format of the World Wide Reference Number (WWRN) in order to prevent the generation of duplicates: GB-MHRA-ADR XXXXXXXX
The following are examples which should not have been reported to the MHRA as they are based on ASPRs. Example 1: This report has a case assigned company reference number which is reported as the WWR number. The MHRA reference number has been entered in the duplicate number field and the MHRA is listed as a reporter in the narrative. <reportduplicate> <duplicatesource>GBR-MHRA</duplicatesource> <duplicatenumb>ADR 10910173</duplicatenumb> </reportduplicate> <narrativeincludeclinical>Serious spontaneous case received on 20Jan-2010 from the U.K. Health Authorities MHRA (ADR 10910173)</narrativeincludeclinical>
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Example 2: This is an example where the ICSR maintains the MHRA assigned WWR number. An update case was created on the MHRA database, with no additional information reported. <authoritynumb>GB-MHRA-ADR 20226863</authoritynumb > <narrativeincludeclinical>This literature report was received via authority and originated in the United Kingdom...</narrativeincludeclinical>
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5.
5.1
The guidance in this chapter is based on the most common findings from audits of E2B reports (further information and examples can be found in the following chapters). One of the most common findings from audit of E2B reports is that key information present in the case narrative is often missing from the structured fields. For example some reports may include information on the age or dose of the medicine in the case narrative but not in the structured E2B age or dose fields. This could affect signal analysis processes for example when reviewing ADRs in paediatric or elderly populations or for dose related affects. All information in the narrative should be correctly coded in the relevant structured fields to assess the cases quickly and facilitate consistent data retrieval. It should be noted that including the patient or reporter details in the case narrative may break confidentiality data protection rules. It is important to select the most appropriate MedDRA terms to describe the reaction and to ensure the correct coding of drug names in the suspected medicines field. Only reports of adverse drug reactions should be expedited, not adverse events (see section 8.3 on Adverse drug reaction versus adverse events).
All information in the narrative should be correctly coded in the relevant structured fields.
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6.
6.1
The <patientinitial> tag can be populated with the patients initials, UNKNOWN or PRIVACY. Entries such as XXX, N/A and --- are not acceptable. If the <patientinitial> tag is populated as UNKNOWN, then one of the other criteria for patient characteristics should be populated in order for the report to be considered valid e.g. date of birth. Entries such as Patient 1 should not be entered in the patient initials. Entries such as this should be captured in the patient investigation number field (B.1.1.1d). The following examples are accepted: <patientinitial>PRIVACY</patientinitial> or <patientinitial>KC</patientinitial>
Entries such as XXX, N/A and --- are not accepted: <patientinitial>XXX</patientinitial> or <patientinitial>---</patientinitial>
The information provided should be as complete as possible, taking into account EU legislation on data protection and relevant national legislation. Including patient details in the case narrative may break confidentiality data protection rules.
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7.
7.1
This section covers coding on suspect drugs, vaccines and concomitant medication. It is important to ensure that drug information is correctly coded to ensure that ADR data can be aggregated at substance level. The drug characterisation indicates whether a drug is classified as suspect, concomitant or interacting. Interacting may be used when an interaction LLT is selected e.g. Drug interaction, Food interaction or Alcohol interaction. Suspect drug(s) The drug(s) suspected of causing the reaction should be listed as the suspect drug(s). Concomitant medication Any drug(s) that are not suspected of causing the reaction and that are administered to the patient at the time the case is reported should be listed as concomitant medication. If a drug has been recently discontinued prior to the reaction, the MAH should consider whether the drug should be coded as concomitant medication or medical history and document their working practices. For example the MHRA codes all drugs discontinued within 3 months prior to the reaction as concomitant medication. Patient Past Drug Therapy All drugs that were completed/discontinued before the start of the treatment with the suspect(ed) drugs should be included in the relevant section, Patient Past Drug Therapy (unless it was recently discontinued prior to the reaction and therefore coded as concomitant medication). It is important to note that any medication given as treatment for the ADR should not be classified as concomitant medication. The MHRA requires either the medicinal product or active substance name to be completed. Any information regarding the formulation and route of administration should be captured in the relevant tags (<drugdosageform> (B.4.k.7) and <routeadministration> (B.4.k.8)). It is important to note that the strength and dosage should not be captured in the drug name fields. Example 1: For example paracetamol 20 mg capsules contains drug name (substance or product) dosage and pharmaceutical form; however there are structured fields available in E2B for the dose and pharmaceutical form. The following is an example with correct coding: <drug> <drugcharacterization>1</drugcharacterization> <medicinalproduct>PANADOL</medicinalproduct>