title: Regulatory approval of pharmaceuticals without a randomised controlled study: analysis of EMA and FDA approvals 1999-2014.
abstract: The efficacy of pharmaceuticals is most often demonstrated by randomised controlled trials (RCTs); however, in some cases, regulatory applications lack RCT evidence.
  
  
  
  To investigate the number and type of these approvals over the past 15 years by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA).
  
  
  
  Drug approval data were downloaded from the EMA website and the 'Drugs@FDA' database for all decisions on pharmaceuticals published from 1 January 1999 to 8 May 2014. The details of eligible applications were extracted, including the therapeutic area, type of approval and review period.
  
  
  
  Over the period of the study, 76 unique indications were granted without RCT results (44 by the EMA and 60 by the FDA), demonstrating that a substantial number of treatments reach the market without undergoing an RCT. The majority was for haematological malignancies (34), with the next most common areas being oncology (15) and metabolic conditions (15). Of the applications made to both agencies with a comparable data package, the FDA granted more approvals (43/44 vs 35/44) and took less time to review products (8.7 vs 15.5 months). Products reached the market first in the USA in 30 of 34 cases (mean 13.1 months) due to companies making FDA submission before EMA submissions and faster FDA review time.
  
  
  
  Despite the frequency with which approvals are granted without RCT results, there is no systematic monitoring of such treatments to confirm their effectiveness or consistency regarding when this form of evidence is appropriate. We recommend a more open debate on the role of marketing authorisations granted without RCT results, and the development of guidelines on what constitutes an acceptable data package for regulators.
authors.affiliation: Department of Statistical Science, University College London, London, UK.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Hatswell
authors.affiliation: Department of Statistical Science, University College London, London, UK.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Baio
authors.affiliation: Johnson & Johnson, Titusville, New Jersey, USA.
authors.forename: Jesse A
authors.initials: JA
authors.lastname: Berlin
authors.affiliation: Department of Pharmacology, University of Tartu, Tartu, Estonia.
authors.forename: Alar
authors.initials: A
authors.lastname: Irs
authors.affiliation: Department of Primary Care & Population Health, University College London, London, UK.
authors.forename: Nick
authors.initials: N
authors.lastname: Freemantle
mesh_terms: D000970:Antineoplastic Agents; D017277:Drug Approval / Q000379:methods / Q000706:statistics & numerical data*; D005060:Europe; D006077:Government Agencies; D006801:Humans; D011358:Product Surveillance, Postmarketing; D016032:Randomized Controlled Trials as Topic; D014481:United States; D014486:United States Food and Drug Administration
chemical_list: D000970:Antineoplastic Agents
keywords: CLINICAL PHARMACOLOGY; Regulatory