To stem cell clinics: do your homework & take FDA “current thinking” seriously

FDA draft guidanceOne of the difficult things about the regulatory sphere that covers stem cells in the US is that many aspects are confusing or puzzling both to the public and so-called experts. We’ve been talking through some of the questions that come up in this area in posts and comments on this blog.

  • What does a warning letter really mean? What triggers it?
  • Why do some businesses selling stem cells get inspected and others don’t?
  • What do some entities get warning letters over the years, while others don’t?
  • What weight does a draft guideline have?
  • How about a finalized one?
  • If a business disagrees with an FDA guideline or action, what should it do?
  • If a business operates without FDA approval (maybe because they disagree with the FDA) when it seems that it should need that approval and yet the FDA takes no action, does that mean anything?

The list goes on and on.

It’s kind of like trying to read tealeaves. One of the FDA reforms I advocated for in my book, Stem Cells: An Insider’s Guide, is more clarity and better communication.

Despite the many questions and confusion out there, I would say one thing is clear: Take FDA “current thinking” very seriously.

While current thinking as articulated in guidances (draft or otherwise) is not formally equivalent to a regulation, it would seem to have the power to trigger action based on the historical record.

Therefore, one broader lesson in this arena would seem to be that the FDA can pull the trigger on actions like visits and warning letters based on their current thinking even if that current thinking is not formally crystalized beyond draft guidances or even without any draft guidances. For instance, it seems pretty clear that the FDA right now views SVF as a drug and while it may not have done much about this action wise yet, the odds are that such action will be coming sooner or later. The same goes for non-homologous use of bone marrow and amniotic stem cells such as for neurologic conditions. In other words, what the FDA staff think is going to be their basis for actions. SVF

As a result, it kind of goes both ways in the sense that guidances (draft or otherwise) are not formal regulations and “only” reflect current FDA thinking, but at the same time “FDA current thinking” shouldn’t be underestimated in terms of importance as it clearly can play a big role as the basis for action.

Too often I’ve heard clinics or other advocates say things like, “these are just draft guidelines” or “the FDA hasn’t been clear on that yet”. The reality is that no matter what any of us might like (e.g. increased FDA clarity), it is not the FDA’s responsibility to make sure everything is crystal clear for every stem cell clinic out there. Rather, it is the physicians’ responsibility to do their homework on the FDA and all relevant regulations, current thinking, etc.

If a clinic wants to challenge the FDA I can respect that if it is done responsibly, but it is a very different matter and a risky game to do such a challenge operationally by administering what by all accounts the FDA considers to be unapproved drugs into patients and then waiting to see if anything happens on the regulatory front.

This game of stem cell chicken is particularly risky if you are “treating” medical conditions outside of your specialty and do not have any rigorous training in stem cells as well as having little if any expertise in FDA regulatory affairs. And, no, a weekend resort or other similar quickie “course” on stem cells doesn’t really count.

ARM Asks FDA for Clarification on Draft Guidance on Minimal Manipulation

Alliance for Regenerative MedicineIn the last few months the FDA has taken steps toward crystalizing regulatory oversight of stem cell and more broadly cell and tissue-based therapies.

These steps come in the form of several draft guidances  (see herehere, and here.

The Alliance for Regenerative Medicine (ARM) has responded to the draft guidance on Minimal Manipulation. For example, ARM has requested that the FDA clarify the term “main function” for human cell and tissue products (HCT/Ps). ARM rightly points out that HCT/Ps can have more than one function. For example, adipose tissue in the draft guidances was said to have a structural function, but fat of course also has roles in metabolism.

In the Press Release it says:

“We’re pleased to see the FDA provide additional insight into their regulatory decision-making process on this important topic,” said Michael Werner, executive director of ARM. “We do ask, however, that the FDA provide clarity on a number of important points within the guidance, given the complexity, significance and impact of this issue. We also encourage FDA to hold a public hearing to engage with stakeholders in a full airing of the topic.”

The idea of public meetings is also potentially worthwhile. More clarity and engagement from the FDA is always a good thing.
One of the challenges for the FDA in regulating these products is that both compliant biotechs such as those represented by ARM and unlicensed stem cell clinics fall under a shared regulatory umbrella.