History of the Montreal Protocol, FDA regulation of CFCs and Background to Meeting

1. History of the Montreal Protocol, FDA regulation of CFCs and Background to Meeting Robert J. Meyer, MD Director, ODE II / CDER

2. General Background The earth’s ozone layer is a region of relatively higher ozone concentrations in the stratosphere

3. General Background • This “layer” reduces the amount of ultraviolet radiation (UV-B) reaching the surface from sunlight • As a result of ozone loss, the increased UV-B leads to increases in skin cancers (melanoma and non-melanoma), cataracts, impaired immunity • Other deleterious effects on the environment also result, as do effects on man-made substances (like plastics)

4. General Background • Development of US law, FDA regulations, and the Montreal Protocol have proceeded in overlapping timeframes, so this talk will overlap the discussions

5. History of the Montreal Protocol and 21 CFR 2.125 • 1974- Work by Molina and Rowland published tying ozone depletion to stratospheric chlorine from degraded CFCs1 • At that time, use of CFCs was widespread in the US • Refrigerators, A/C, foams, and in many consumer and medical aerosol products 1 – Nature, 1974; vol 249:810-812

6. History of the Montreal Protocol and 21 CFR 2.125 • 1978 – In response to growing evidence of CFCs harming the ozone layer, CFCs were generally banned in spray can/aerosols by U.S. Govt (EPA) – e.g. hairsprays, spray paint… • FDA published 21 CFR 2.125 banning use of CFCs in FDA regulated products (with essential exemptions)

7. History of the Montreal Protocol and 21 CFR 2.125 • 1987 - 27 nations (including U.S.) initiate a global ozone treaty in Montreal, known as the “Montreal Protocol on Substances that Deplete the Ozone Layer” • hereafter referred to as the “MP” • The original protocol now has over 180 signatory Parties (countries) and is regarded as the model for successful, global environmental treaties

8. History of the Montreal Protocol and 21 CFR 2.125 • Original phase-out of CFCs slated for 2000 (London - 1990) • Phase-out of CFCs is moved up to end of 1995 (Copenhagen - 1992) due to evidence of increasing ozone depletion, especially over the Antarctic (ozone “hole”) • While depletion is most prominent over southern hemisphere, the depletion is global • MP controls many ozone depleting substances (ODS): CFCs, Halons, HCFCs, methyl bromide, carbon tetrachloride,…

9. History of the Montreal Protocol and 21 CFR 2.125 • As of January 1st, 1996, all use of CFCs banned in industrial countries; rest of the world in 2010 • MDIs for asthma and COPD currently exempted under essential use process • Nominations for essential uses reviewed annually (e.g., in Dakar in 2005, the Parties reviewed 2007 nominations and re-reviewed 2006 nominations)

10. History of the Montreal Protocol and 21 CFR 2.125 Montreal Protocol has stipulated the following: • Decision IV/25 - All essential uses of CFCs based on products necessary for public health without adequate alternatives (technically & economically) - ‘macroscopic’ determination of essentiality (i.e., use of CFCs in MDIs for asthma and COPD)

11. History of the Montreal Protocol and 21 CFR 2.125 Montreal Protocol has stipulated the following: • Decision XII/2 - Any product approved after Dec. 2000 must individually meet IV/25 • Product-centered determination of essentiality that essentially precludes new CFC generics or other new CFC products unless the new product individually exceeds the high hurdle of IV/25

12. History of the Montreal Protocol and 21 CFR 2.125 Montreal Protocol has stipulated the following: • Decision XV/5: • Essential use nominations are now use specific (e.g., XX tonnes for albuterol) • No quantity of essential use CFCs will be authorized for albuterol beginning with this year’s MOP if a “plan” for albuterol phase-out has not been submitted by the OEWG the summer of 2005 • FDA final rule published in March 2005 on phase-out of albuterol meets this stipulation for US

13. History of the Montreal Protocol and 21 CFR 2.125 • CAA amendments of 1990, in part, codified MP into US law • Implementing EPA regulations refer to HHS/ FDA through 21 CFR 2.125 for definition of medical essentiality • Again, 2.125 was originally published in as a final rule in 1978

14. History of the Montreal Protocol and 21 CFR 2.125 • 1978 Federal Regulation (21 CFR 2.125) was promulgated stating that CFC containing regulated products were misbranded/adulterated unless deemed essential • “Essential” based on: • No technically feasible alternatives • Provides substantial (health, public, or environmental) benefit • Release of CFC small, or justified given benefit

15. History of the Montreal Protocol and 21 CFR 2.125 • 1978 FDA rule had no mechanism to determine when uses are no longer essential and to delist them (only mechanims to add new classes/drugs to the list) • Many important drugs not listed separately, but in broad classes • e.g., “Adrenergic bronchodilators for human use….” • 1996, FDA publishes an Advanced Notice of Proposed Rulemaking (ANPR) proposing revisions to 2.125

16. History of the Montreal Protocol and 21 CFR 2.125 • Close to 10,000 comments received, many sparked by lobbying efforts • NPR published in 1999 with fewer resulting substantive comments and little controversy • FR amending 2.125 published on July 24, 2002 • FR went into effect January 2003

17. History of the Montreal Protocol and 21 CFR 2.125 2002 revisions to 2.125: • Listed individual moieties as essential uses of ozone depleting substances (ODS) in 2.125 (e) rather than classes (e.g., albuterol is listed, rather than all adrenergic bronchodilators) • Added a higher hurdle for IND use of ODSs and to raise the bar for new listings of essential uses • Lists criteria for determining individual uses are no longer essential

18. History of the Montreal Protocol and 21 CFR 2.125 Non-essentiality Criteria: • At least one non-ODS product with the same active moiety* , the same indication, route of administration, about the same level of convenience • At least 1 year of post-marketing data is available for the non-ODS product • Production capabilities and supplies are adequate • Patients who require the CFC product are adequately served * For products with only one marketed brand or strength

19. History of the Montreal Protocol and 21 CFR 2.125 Non-essentiality Criteria (continued): • For Moieties with more than one available product/strength: • At least two non-ODS product with the same active moiety , the same indication, route of administration, about the same level of convenience • Other criteria the same

20. History of the Montreal Protocol and 21 CFR 2.125 • Since a moiety-by-moiety approach does not effectively address drugs not being reformulated, rewrite of 2.125 stated that: [FDA] has therefore revised § 2.125(g)(2) to permit the agency to undertake an evaluation of all ODS products after January 1, 2005, not just those products without a non-ODS replacement.

21. History of the Montreal Protocol and 21 CFR 2.125 • Beginning in 2005, FDA may convene public meetings (i.e., PADAC meetings, in the case of epi – NDAC/PADAC) to discuss those products still listed as essential to determine if changes in the medical practice and availability of alternatives render these products as no longer essential • “Essential” based on: • No technically feasible alternatives • Provides substantial (health, public, or environmental) benefit • Release of CFC small, or justified given benefit

22. CFC essential Use - then and now • Beta-agonists: isoethrane, isoprot., albuterol, epineph, metaprot., pirbuterol, bitoterol, salmeterol • ICS: fluticasone, flunisolide, TAA, BDP, Dexamethsone • Nasal Steroids • Cromones: Cromolyn, Nedocromil • Anticholinergics:Ipratropium, atropine • Albuterol/Ipratropium , Talc, Contraceptive Foams, Rectal CS foams, Ergotamine MDIs, Polymyxin, anesthetic drugs, NTG No longer essential; Delisting possible soon

23. Moieties currently listed as essential for which no current reformulated or direct alternative product exists: 1. Beta-agonists* • Epinephrine • metaproterenol (Alupent) • pirbuterol (Maxair) 2. Inhaled Corticosteroids • flunisolide (Aerobid), • triamcinolone (Azmacort) 3. Cromones • Cromolyn (Intal) • Nedocromil (Tilade) 4. Beta agonist/Anticholinergic combination • Albuterol/Ipratropium (Combivent)

24. History of the Montreal Protocol and 21 CFR 2.125 • On July 14th, 2005, the PADAC met to discuss all remaining uses of CFCs in MDIs with the exception of epinephrine • Due to the need to get joint input from the NDAC as well as the PADAC

25. Trends in Global CFC essential uses: TEAP Report 2004

26. Conclusions • US Govt. moved proactively to address issue of ozone depletion and has had a key role in the Montreal Protocol • MP is a successful treaty, leading to important reductions in CFCs and other ODS • MP is increasingly moving towards control in specific essential uses, notably albuterol

27. Source: NOAA

28. Conclusions • US is progressing in CFC transition, with many non-CFC products available, many CFC products no longer marketed • Epinephrine MDIs arguably are unique in their therapeutic niche, as the sole OTC bronchodilator MDI • Do these OTC epinephrine MDI products remain an essential use of CFCs in 2006?

29. Charge to the NDAC / PADAC • As per the revisions to 2.125, FDA is convening the NDAC/PADAC meeting to discuss the use of CFCs in OTC epinephrine MDIs to determine if changes in the medical practice and availability of other non-OTC medications render these products as no longer essential • “Essential” based on: • No technically feasible alternatives • Provides substantial (health, public, or environmental) benefit • Release of CFC small, or justified given benefit