FDA head Califf on tighter accelerated approvals and lower drug prices

Elon Musk himself espoused the benefits of Ozempic and Wegovy to his over 120 million Twitter followers. Multiple celebrities, namely Kim Kardashian, are rumored to use these drugs, and TikTok videos containing the hashtag #ozempic have garnered over 360 million views and the number continues to rise. The social media frenzy and influencer endorsements have provoked a huge increase in demand. 

The rise in weight loss medication also coincides with changing body standards, which are now more akin to those of two decades ago. A New York Times article from November 2022 announced the return of “heroin chic”, the 90s fashion trend of looking extremely thin to the point of illness. However, both the trend toward weight loss drugs and the return of the once-outdated veneration of ultra-thin bodies should be huge concerns for social media influencers and health regulators alike.

In September 2022, Congress succeeded in passing down-to-the-wire user fee reauthorizations for prescription drugs, generics, and biosimilars (PDUFA, GDUFA, and BsUFA, as well as MDUFA for medical devices). This “skinny” bill passed just in time to continue funding the FDA, with few of the planned amendments. But it was followed on December 22 by the Consolidated Appropriations Act, an omnibus bill granting the FDA $3.5 billion in funding, a $226 million increase on the previous year. “When the omnibus came around much to our surprise a large part of what we wanted passed,” commented Califf. The Act specifically reauthorized funding for orphan and rare disease programs, and also reformed the Accelerated Approvals process, moving more power from drug companies to the agency. 

It gives the FDA greater authority to remove an accelerated approval drug from the market based on poor follow-up safety or efficacy data. The agency can also specify the trial design for post-approval studies (such as protocol and enrollment numbers), and it can require those studies to have begun before granting accelerated approval and for drug companies to regularly report interim data.   

“Accelerated approvals are really important to society and patient populations, and industry,” Califf told the JP Morgan Conference. “[But] frankly I’ve felt for a long time we [at the FDA] didn’t hold down the other part of the bargain. If you [a drug company] get accelerated approval, you need to commit to getting answers as to whether it works.” 

Accelerated approvals can be granted based on unvalidated biomarkers, and the reasonable inference from limited data that a drug’s benefits outweigh its risks, he said. But then, “you should have to prove it. Congress has now given us the teeth” to enforce that, he said. From now on, enrollment in a further trial should have started before accelerated approval goes through, “except where there’s a good reason,” he said. 

Califf added, “The biggest change in user fees is a big boost to the biologics area, to hire a bunch more people for cell and gene therapies. It’s much needed. It’s a hot area.” Regenerative medicine regulation is uncharted territory, he said, “because it’s a small population and so you can’t have traditional evidence development.”

Califf was joined on the panel by Renee Wegrzyn, director of the Advanced Research Projects Agency for Health (ARPA-H), an organization created in March 2022 under a different, $1.5 trillion Consolidated Appropriations Act. It sits within the NIH but is independent and aims to "make pivotal investments in break-through technologies… that have the potential to transform important areas of medicine and health for the benefit of all patients and that cannot readily be accomplished through traditional research or commercial activity." It is expected to have several billions of dollars of funding once federal budget requests are passed. 

Wegrzyn told JPM that the agency is seeking “diversity” in the projects it picks and will fund both disease-specific investments but also technology platforms, such as manufacturing scale-up projects. 

ARPA-H will hire 10–20 project managers in its first year, who will then allocate funding to projects by putting out a call for proposals from companies and academic groups that can solve health problems. 

Wegrzyn stressed that ARPA-H operates independently and is exempt from NIH peer review, meaning that it can take big risks in deciding which projects to fund. This risk-taking approach means that the agency is expecting “a little bit of failure,” she said. Califf added that ARPA-H and FDA should interact from a project’s early stages, especially so stakeholders can plan “what to do to get the thing [drug] paid for.”