title: Number of patients studied prior to approval of new medicines: a database analysis.
abstract: BACKGROUND
  At the time of approval of a new medicine, there are few long-term data on the medicine's benefit-risk balance. Clinical trials are designed to demonstrate efficacy, but have major limitations with regard to safety in terms of patient exposure and length of follow-up. This study of the number of patients who had been administered medicines at the time of medicine approval by the European Medicines Agency aimed to determine the total number of patients studied, as well as the number of patients studied long term for chronic medication use, compared with the International Conference on Harmonisation's E1 guideline recommendations.
  
  
  RESULTS
  All medicines containing new molecular entities approved between 2000 and 2010 were included in the study, including orphan medicines as a separate category. The total number of patients studied before approval was extracted (main outcome). In addition, the number of patients with long-term use (6 or 12 mo) was determined for chronic medication. 200 unique new medicines were identified: 161 standard and 39 orphan medicines. The median total number of patients studied before approval was 1,708 (interquartile range [IQR] 968-3,195) for standard medicines and 438 (IQR 132-915) for orphan medicines. On average, chronic medication was studied in a larger number of patients (median 2,338, IQR 1,462-4,135) than medication for intermediate (878, IQR 513-1,559) or short-term use (1,315, IQR 609-2,420). Safety and efficacy of chronic use was studied in fewer than 1,000 patients for at least 6 and 12 mo in 46.4% and 58.3% of new medicines, respectively. Among the 84 medicines intended for chronic use, 68 (82.1%) met the guideline recommendations for 6-mo use (at least 300 participants studied for 6 mo and at least 1,000 participants studied for any length of time), whereas 67 (79.8%) of the medicines met the criteria for 12-mo patient exposure (at least 100 participants studied for 12 mo).
  
  
  CONCLUSIONS
  For medicines intended for chronic use, the number of patients studied before marketing is insufficient to evaluate safety and long-term efficacy. Both safety and efficacy require continued study after approval. New epidemiologic tools and legislative actions necessitate a review of the requirements for the number of patients studied prior to approval, particularly for chronic use, and adequate use of post-marketing studies. Please see later in the article for the Editors' Summary.
authors.affiliation: Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.
authors.forename: Ruben G
authors.initials: RG
authors.lastname: Duijnhoven
authors.forename: Sabine M J M
authors.initials: SM
authors.lastname: Straus
authors.forename: June M
authors.initials: JM
authors.lastname: Raine
authors.forename: Anthonius
authors.initials: A
authors.lastname: de Boer
authors.forename: Arno W
authors.initials: AW
authors.lastname: Hoes
authors.forename: Marie L
authors.initials: ML
authors.lastname: De Bruin
mesh_terms: D002908:Chronic Disease; D016208:Databases, Factual; D017277:Drug Approval / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D040541:Marketing / Q000191:economics; D010358:Patient Participation / Q000191:economics / Q000706:statistics & numerical data*; D018401:Sample Size; D013997:Time Factors