We’ve been waiting quite a while for the FDA to modernize its positions on the truthful off-label communications by regulated manufacturers. Under current First Amendment practice, the FDA’s positions are quite likely unconstitutional as both speaker- and topic-based restrictions on the truthful communication of scientific information. However, the best we’ve seen from the Agency to date was a “statement,” issued last June, that truthful off-label communications to third-party payers (or “payors,” if you’d rather) would henceforth be OK. Further details were available in an FDA guidance issued at the same time. We blogged about that statement here.
The June 2018 guidance, however, did not go beyond TPPs. Id. at 22. We editorialized at the time:
We fail to see how any constitutionally valid distinction can exist between providing the identical information, with identical disclaimers and limitations, to one “sophisticated” audience (third-party payors) while prohibiting that information’s distribution to another “sophisticated” audience – that being medical doctors that directly prescribe these drugs and devices. . . . Thus, we believe that, as a practical matter, the OLP Guidance effectively dooms any First Amendment defensibility of an FDA ban on the same truthful information being distributed, in the same fashion, to the rest of the medical community. . . . After all, just as third-party payers are sophisticated professionals . . ., so are the doctors directly involved in treating [their] patients.
Then, nothing. Over the last eight months we’ve seen no detectable movement through either FDA guidance documents or, the pending process – a reassessment of which was announced two years ago (see our post here) – to amend the FDA’s archaic “intended use” regulations.
We’re not surprised that a lot of other people are tired of the FDA’s foot-dragging. Among other things, the FDA stated in that guidance we mentioned above that it would be deferring to “existing current good research practices for substantiation developed by authoritative bodies.” Guidance at 10.
One of those “authoritative bodies” is the Advanced Medical Technology Association (“AdvaMed,” for short), which describes itself as “a trade association that leads the effort to advance medical technology in order to achieve healthier lives and healthier economies around the world. AdvaMed’s membership has reached over 400 members and more than 80 employees with a global presence.” One of the things AdvaMed has done is to create a code of ethics for medical device manufacturers. The last AdvaMed code was issued about a decade ago and was in need of updating. So AdvaMed has prepared a new ethics code that’s due to become effective on January, 1, 2020. The entire code is methodically discussed in a Reed Smith client alert, but for present purposes we’re interested section 10, entitled “Communicating for the Safe & Effective Use of Medical Technology.”
Full disclosure, as stated in the client alert: “Reed Smith was honored to serve as outside counsel to AdvaMed in connection with drafting the original, current, and revised versions of the AdvaMed Code.”
Section X of the new AdvaMed Code starts with a specific description of off-label use, so it’s obvious to all what the code is discussing:
Health Care Professionals may use a product for any use that they determine is in the best medical interests of their patients. This includes uses that are contained in the Medical Technology’s labeling or otherwise consistent with such labeling, but it could also include uses that are not approved or cleared (i.e. “off-label” uses). As recognized under U.S. law and by the FDA, off-label use of these Medical Technologies can be an important part of medical practice and may even constitute a medically recognized standard of care.
2020 AdvaMed Code at 29 (emphasis added). One “key concept” that this section of the new AdvaMed code emphasizes is that “[a]ccess to truthful and non-misleading information relating to Medical Technologies is critical to a Health Care Professional’s ability to exercise his or her medical judgment, to provide high-quality care, and to safely use available Medical Technology.” Id. (emphasis added).
Thus, AdvaMed has stopped waiting for the FDA and is taking the position that direct off-label communications between medical device manufacturers and the physicians (and other health care professionals) that use their products is 100% ethical if done in a truthful, transparent, and non-misleading fashion:
Industry appropriate communications of such information can include, among other activities:
Proper dissemination of peer-reviewed scientific and medical journal articles, reference texts, and clinical practice guidelines;
Presentations at educational and medical meetings regarding clinical trial results or research and development data for an investigational use (taking care that no claims are made regarding safety and effectiveness); and
Discussions with consultants and Health Care Professionals to obtain advice or feedback relating to topics such as unmet patient needs, product research and development, and the like.
Id. AdvaMed’s ethical guidelines for such communications (which the FDA would call “promotion”) are about what one would expect a company with good marketing practices to employ generally – authorization, truth, and disclaimers:
Company responses that contain information regarding unapproved or uncleared uses should be provided by authorized personnel.
Company communications must be truthful and nonmisleading.
Information related to unapproved or uncleared uses should be identified as such.
Id. at 30.
Thus AdvaMed – one of the “authoritative bodies” to which the FDA has stated it would be deferring – has stepped up to the plate and declared that truthful manufacturer communication of off-label information to physicians and other health care practitioners is both ethical and desirable. “Companies are encouraged to develop policies and controls that apply the principles above.” Id.
FDA, the ball is in your court. Either take command or lose control. Industry is not going to wait forever for the Agency to bring its regulation of truthful commercial speech into the Twenty-First Century.
Moreover, from a litigation standpoint, the AdvaMed Code is what we call an “industry standard” (at least when it goes into effect in 2020), and in almost every jurisdiction in the country, compliance with industry standards is admissible evidence in product liability cases. “[I]ndustry standards promulgated by trade associations” are “acceptable” as evidence in strict product liability cases. Kim v. Toyota Motor Corp., 424 P.3d 290, 299 (Cal. 2018). “[T]rade associations consist of manufacturers and other businesses whose conduct comprises the industry custom and practice.” Id. Accord, e.g., Adams v. Genie Industries, Inc., 929 N.E.2d 380, 385 (N.Y. 2010) (“weight” of an “industry standard for” the product “was up to the jury”); Mikolajczyk v. Ford Motor Co., 901 N.E.2d 329, 335 (Ill. 2008) (“conform[ance] with . . . guidelines provided by an authoritative voluntary association” held relevant to proving a “unreasonably dangerous” defect); Wash. Rev. Code §7.72.050(1) (“[e]vidence of custom in the product seller’s industry . . . may be considered by the trier of fact”). So now, when plaintiffs start bleating about “off-label promotion” being such a horrible thing, we have evidence to point to that – provided it’s done correctly and in compliance with a company’s internal guidelines – such activity is recognized as proper and ethical.
Oh, yes, and Happy Valentine’s Day to everyone at the FDA. Among other things, they keep the nation’s chocolate supply safe.