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U.S. Department of Health and Human Services

Inspections, Compliance, Enforcement, and Criminal Investigations

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Enforcement Actions

Bruce Branitz, M.D.

   

Department of Health and Human Services logoDepartment of Health and Human Services

Public Health Service
Food and Drug Administration
  Rockville, MD 20857

WARNING LETTER

CERTIFIED MAIL
RETURN RECEIPT REQUESTED

Ref. No. 09-HFD-45-03-03

Bruce Branitz, M.D.
2121 Fountain Drive, Suite D
Snellville, GA 30078

Dear Dr. Branitz:

Between September 14 and November 6, 2007, Ms. Stephanie Hubbard, representing the Food and Drug Administration (FDA), conducted an investigation and met with you, to review your conduct of the following clinical investigations:

Protocol [(b)(4)], entitled "A Phase 2, Randomized, Multicenter, Placebo-Controlled, Double-Blind, Dose-Ranging Clinical Trial To Study The Efficacy And Safety of [(b)(4)] For The Treatment of [(b)(4)] of the investigational drug [(b)(4)] sponsored by [(b)(4)]., and Protocol [(b)(4)], entitled "A [(b)(4)].

This inspection is a part of the FDA's Bioresearch Monitoring Program, which includes inspections designed to evaluate the conduct of research and to ensure that the rights, safety, and welfare of the human subjects of those studies have been protected.

From our review of the establishment inspection report, the documents submitted with that report, and your November 23, 2007, written response, we conclude that you did not adhere to the applicable statutory requirements and FDA regulations governing the conduct of clinical investigations and the protection of human subjects. We are aware that at the conclusion of the inspection, Ms. Hubbard presented and discussed with you Form FDA 483, Inspectional Observations. We wish to emphasize the following:

1. You failed to conduct the studies in accordance with the investigational plan [21 CFR 312.60].

Protocol [(b)(4)]

a. The following subjects were enrolled inappropriately as they had conditions or laboratory values which were exclusionary according to the protocol:

i. A Screening Case Report Form (CRF) for subject 8201 noted the presence of right lower lobe lung cancer and an LDH level of 242 U/L.

ii. The laboratory report dated June 21, 2006, for the screening sample collected on June 15, 2006, for subject 8202 indicated values for BUN and creatinine of 41 mg/dL and 1.8 mg/dL, respectively.

iii. The laboratory report dated June 20, 2006, for the screening sample collected on June 15, 2006, for subject 8204 indicated a value for BUN of 36 mg/dL.

iv. Subject 8205 had lung cancer on the date of enrollment in the study.

v. The laboratory report dated June 24, 2006, for the screening sample collected on June 15, 2006, for subject 8208 indicates values for BUN and creatinine of 33 mg/dL and 1.6 mg/dL, respectively.

vi. The laboratory report dated June 30, 2006, for the screening sample collected on June 20, 2006, for subject 8209 indicates a value for creatinine of 1.8 mg/dL.

b. The protocol required that randomization be done in sequential order as the patients qualified for entry into the study. Study subjects were not randomized sequentially; for example, subject 8201, the first subject enrolled in the study, was assigned randomization number 10007 which was not the first randomization number. The majority of the remaining subjects were also randomized out of sequence.

The above examples of protocol violations are not intended to he a comprehensive listing of all exclusionary criteria met by subjects in protocol [(b)(4)]. Similar violations were found in the conduct of protocol [(b)(4)]. For example, the following subjects were enrolled in violation of the protocol:

c. The medical histories for subjects 0003 and 0014 note that the subjects had [(b)(4)] adenocarcinoma. The protocol excluded subjects with any history of carcinoma of the [(b)(4)].

d. Subject 0002 did not meet the inclusion criterion of eight or more [(b)(4)] on average every 24 hours for the five day study diary period leading up to Visit 3 but was randomized to treatment and dispensed medication at Visit 3 on July 24, 2006.

e. For subjects 0002 and 0013, Visit 3 diaries documented that they did not meet the inclusion criterion of an average of eight or more [(b)(4)] per day.

f. For subject 0005, based upon an EKG performed during visit 3, the visit during which subjects were enrolled in the study, you noted that the subject had an abnormal EKG and that its significance would require referral to a cardiologist. The protocol excluded those individuals with "significant medical problems" including cardiac problems. This subject was enrolled in the study without documentation of an assessment of the significance of the subject's abnormal EKG findings.

g. For subject 0010 the progress notes indicated that the subject had a history of [(b)(4)] adenocarcinoma, external beam radiation therapy for [(b)(4)], and brachytherapy implants. Exclusion criteria specified that subjects with any history of carcinoma of the [(b)(4)] or [(b)(4)] radiation would not be allowed in the study.

h. For subjects 0010 and 0012 progress notes indicated that the subjects had been treated previously with darifenacin; therefore, these subjects did not meet the inclusion criterion which stated that subjects must be naive to darifenacin treatment.

i. For subject 0013, a blood sample taken on June 27, 2007, revealed a blood glucose level of 219 mg/dL. The protocol defined glucose levels greater than 200 mg/dL as clinically significant and to be followed to resolution. A laboratory report faxed to the Investigator at the time of referral noted a "degree of uncontrolled diabetes indicated". In violation of the protocol, there is no documentation that the diabetic condition of this subject was followed up.

2. You failed to maintain adequate and accurate case histories that record all observations and other data pertinent to the investigation on each individual [21 CFR 312.62(b)].

Protocol [(b)(4)]

a. Regarding Subject [(b)(4)]:

i. There was no documentation of the interpretation of the Visit 1 EKG. The requisition and EKG tracing for Visit 6 were available; however, the Cardiac History portion of the requisition was not completed nor was there any documentation of the review of the Visit 6 EKG tracing.

ii. The Medical History source document dated June 7, 2006, indicated a normal cardiovascular system; however, this notation was revised on November 6, 2006 to indicate two instances of cardiac bypass surgery. A Protocol Deviation form dated August 24, 2006, noted an inferior infarct and possible lateral ischemia.

iii. Two diaries were present which recorded the number and severity of [(b)(4)] between the periods of June 14 and June 21, 2006. It is unclear why the subject completed two diaries for this period of time. Furthermore, these two diaries are not in agreement with each other in terms of number and severity of [(b)(4)]. Two CRFs were completed to report these [(b)(4)]. These CRFs were not in agreement with each other, and one of the CRFs did not agree with the data reported in either diary. In addition, a handwritten log of [(b)(4)] that did not agree with either CRF in number or severity was observed in the subject's records. These multiple discrepancies make it impossible to determine the actual number/severity of [(b)(4)] experienced by this subject.

b. For subjects 8202, 8203, and 8205, the dates next to the subjects' signatures on the consent forms were initially dated 6/8/06 and then changed to 6/15/06. For subject 8202, the date was then revised back to 6/8/06 and multiple date changes were made to most of the pages in the Screening Visit Source Documents for these subjects. No documentation was provided to explain these changes.

c. For subject 8203, 8204, 8205, 8207 and 8208, Karnofsky performance scores were revised by the study coordinator at various times for various study visits without documentation explaining the changes.

d. The "Medical History" source document dated June 8, 2006 (later revised to June 15, 2006), for subject 8205 indicated normal cardiovascular and respiratory systems; however, the subject's medical history included source documents indicating the presence of coronary artery disease, chronic obstructive pulmonary disease (COPD), and lung cancer.

e. The Medical History Screening CRF for subject 8206 originally indicated normal respiratory, cardiovascular, gastrointestinal, and endocrine systems. The screening visit occurred on June 15, 2006. On May 10, 2007, the screening CRF was revised to indicate that the subject had emphysema, coronary artery disease, gastroesophageal reflux disease, diverticulitis, and diabetes.

f. The Medical History Screening CRF for subject 8208 noted "cough, sinus drainage" for the respiratory system and "congested w/ cough" for the cardiovascular system. All other systems were indicated to be normal. The subject had a history of hypertension, coronary artery disease, adult onset diabetes, emphysema, kidney stones and abnormal EKG and laboratory results. These conditions were not noted on the Medical History Screening CRF. Numerous clinical laboratory parameters were noted as being clinically significant for the blood sample collected at screening on June 15, 2006; however, the Lab Assessments Screening CRF indicated that there were no clinically significant laboratory values. This subject was enrolled and treated in the study.

g. The Medical History Screening CRF of June 20, 2006, for subject 8209 originally indicated all body systems to be normal. On June 20, 2007, the CRF was revised to indicate the presence of COPD, urinary stents, kidney stones, erectile dysfunction, overactive bladder, bladder cancer, and osseous degeneration. There is no documentation that these medical problems were assessed to determine the subject's eligibility for study participation. In addition, numerous clinical laboratory parameters were noted as being clinically significant for the blood sample collected at screening on June 20, 2006; however, the Lab Assessments Screening CRF indicated that there were no clinically significant laboratory values. This subject was enrolled and treated in the study.

h. For subject 8210, the Visit 5 Source Worksheets were lined through and noted as "Not Done"; however, a progress note in your clinical chart dated September 6, 2006, indicates that the subject was present for Visit 5, that study-related procedures were performed, and that the subject returned his Visit 5 diary.

Protocol [(b)(4)]

i. The Medical History CRF for subject 0003 noted all body systems, including the urologic system, to be normal except for sinus drainage during cold weather; however, the subject's history included prostate cancer (including a trans-urethral resection of the prostate), hypertension, asthma, kidney stones, and arthritis.

j. The Medical History CRF for subject 0010 noted all body systems to be normal despite the subject's medical history from another provider which indicated that the subject had prostatic adenocarcinoma, rheumatoid arthritis, hypertension, gastritis, and high cholesterol.

k. For subject 0011 the [(b)(4)] Registration Confirmation form dated May 16, 2007, and the [(b)(4)] Reference Sheet indicated that the subject's last overactive bladder (OAB) treatment consisted of oxybutynin extended release; however, a note dated October 15, 2007, on the Registration Confirmation form indicated that the subject's last treatment for OAB was Detrol LA.

1. For subject 0012 the Patient's Previous Treatment Assessment questionnaire indicated that Detrol was the last OAB drug taken; however, both the [(b)(4)] Reference Sheet and the [(b)(4)] Registration Confirmation form indicated that the subject was last treated with oxybutynin extended release.

The medical history for subject 0012 indicated the presence of a neurogenic bladder as the result of a gunshot wound to the spinal cord. Exclusion criteria number 6 specifically excluded those subjects with neurological diseases affecting urinary bladder function (including spinal cord injury). This subject was enrolled and treated in the study. You stated during the inspection that the subject did not have a neurogenic bladder; however, there was no documentation in the subject's study records to that effect.

The laboratory reports for subject 0012 for Visit 1 were completed on May 17, 2007; however, you initialed and dated these records as having reviewed them on May 15, 2007.

m. The Medical History CRF for subject 0013 indicated all body systems to be normal despite the subject's self-reported history of diabetes, glaucoma, heart trouble, vein trouble, kidney disease, and bypass surgery.

n. The FDA investigator's review of the electronic CRFs (eCRFs) for the Novartis study revealed discrepancies. When the FDA investigator requested hard copies of the eCRFs, you were unable to provide copies of the eCRFs. Your study coordinator informed our investigator that the eCRFs were maintained by another firm and that you had no access to that eCRF database. Accordingly, you could not show that you prepared and maintained adequate and accurate case histories.

3. You failed to obtain informed consent in accordance with the provisions of 21 CFR Part 50 [21 CFR 312.60 and 21 CFR 50].

Subject 8210was randomized to protocol [(b)(4)] on June 12, 2006. You did not obtain informed consent from this subject until June 26, 2006.

4. You failed to maintain adequate records of the disposition of the drug including dates, quantity, and use by subjects [21 CFR 312.62(a)].

Protocol [(b)(4)]

a. You did not maintain adequate records of the disposition of the drug. For example, the Master Drug Dispensation Log (MDDL) contained no drug accountability documentation for any subject in the study at Visit 5 or later.

b. For subject 8202, the randomization number was 10002 according to the source worksheet and the MDDL. The bottle/kit numbers identified on the shipment form for randomization number 10002 were 248752, 343193, and 218605. Bottle labels with numbers 248752, 343193, and 899686 were attached to the Label CRF for subject 8202 indicating that those bottles had been dispensed to the subject. The shipment form identified 899686 as a bottle number for the subject with randomization number 10003 and the Investigational Product Return Form indicated that reference number 899686 was not returned. According to the same form, bottle number 343193 was also not returned and the Patient No. was "UNK". The patient number and initials on the label of 248752 were obliterated in black. Nonetheless, the CRF documented 100% compliance for Subject 8202. The result of these discrepancies in drug dispensation and documentation is that there is no assurance that subject [(b)(6)] was dispensed the study drug as allocated nor is there any assurance that the subject was compliant with the drug regimen.

c. For subject 8204, the randomization number was 10001. The bottle/kit numbers identified on the shipment form for randomization number 10001 were 864628, 104632, and 591691. Labels for the first two numbers were placed on the label CRF but not the label for bottle 591691; however, the Product Return Form indicates that this bottle was used since 14 tablets were returned.

d. For subject 8208, the Drug Label CRF indicates that this subject was dispensed bottle number 168130; however, the Product Return Form indicates that Patient No. was "UNK" and that the bottle was not returned.

Protocol [(b)(4)]

e. According to statements made by the current study coordinator to the FDA investigator, drug accountability logs for those subjects she enrolled were prepared in advance of study visits with projected visit dates and projected amounts of remaining drug, and that these pre-filled forms were then revised as necessary to reflect actual visit dates and amounts of drug returned.

Inadequate records of the disposition of the drug including dates, quantity, and use by subjects, are not limited to the examples listed above. The drug records for both protocols are inadequate to document study drug accountability.

This letter is not intended to be an all-inclusive list of deficiencies with your clinical study of an investigational drug. It is your responsibility to ensure adherence to each requirement of the law and relevant FDA regulations. You should address these deficiencies and establish procedures to ensure that any on-going or future studies will be in compliance with FDA regulations.

Within fifteen (15) working days of your receipt of this letter, you should notify this office in writing of the actions you have taken or will be taking to prevent similar violations in the future. Failure to adequately and promptly explain the violations noted above may result in regulatory action without further notice.

If you have any questions, please contact Constance Lewin, M.D., M.P.H., at (301) 796-3397; FAX (301) 847-8748. Your written response and any pertinent documentation should be addressed to:

Constance Lewin, M.D., M.P.H.
Branch Chief
Good Clinical Practice Branch I
Division of Scientific Investigations
Office of Compliance
Center for Drug Evaluation and Research
Food and Drug Administration
Building 51, Room 5354
10903 New Hampshire Avenue
Silver Spring, MD 20993

Sincerely yours,

{See appended electronic signature page}

Leslie K. Ball, M.D.
Director
Division of Scientific Investigations
Office of Compliance
Center for Drug Evaluation and Research

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This is a representation of an electronic record that was signed electronically and this page is the manifestation of the electronic signature.
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/s/

LESLIE K BALL
04/09/2009