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Expanded access

Expanded access, also known as compassionate use, is a pathway regulated by the United States Food and Drug Administration (FDA) that enables patients facing serious or immediately life-threatening conditions to obtain investigational drugs, biologics, or medical devices outside of clinical trials when no comparable or satisfactory alternative treatments exist and potential benefits justify the risks.^[1]^[2] The program operates under FDA regulations (21 CFR 312.300 et seq.), requiring a licensed physician to submit an Investigational New Drug (IND) application or protocol, secure manufacturer consent to provide the product, and often obtain institutional review board oversight to ensure ethical treatment use.^[3]^[4] The framework includes individual patient access for single cases, including emergency use without prior IRB review if immediate threats exist; intermediate-size access for small groups not feasible in trials; and treatment INDs or protocols for larger populations facing similar unmet needs during extended development periods.^[2]^[5] This mechanism prioritizes early availability of promising therapies while mandating adverse event reporting and prohibiting manufacturers from profiting beyond direct costs, aiming to balance humanitarian access with evidentiary safeguards against unproven interventions.^[2] The FDA approves nearly all qualified requests, often within days via expanded access coordinators, countering claims of undue bureaucracy, though it generates data that can inform future approvals or reveal risks in non-trial settings.^[6]^[7] Notable applications have included antivirals during outbreaks and oncology agents for refractory cancers, underscoring its role in addressing gaps in standard care, yet it has sparked debates over risks like false hope, diversion of limited drug supplies from trials, and incomplete safety profiles for sicker patients, prompting alternatives such as the 2018 Right to Try Act that circumvents some FDA protocols but yields fewer documented uses due to manufacturer reluctance and liability concerns.^[8]^[9]^[10] Critics argue expanded access may undermine randomized trial recruitment or inflate perceived efficacy without controls, while proponents highlight its empirical foundation in case-level risk-benefit assessments over blanket denials.^[6]^[11]

Definition and Principles

Core Definition

Expanded access, commonly referred to as compassionate use, constitutes a regulatory pathway enabling patients with serious or immediately life-threatening conditions to obtain investigational medical products—including drugs, biologics, or medical devices—for treatment purposes outside formal clinical trials, provided no comparable or satisfactory alternative therapies are available.^[1]^[2] This mechanism operates under the premise that the potential direct benefit to the patient justifies the risks associated with unapproved products, while mandating safeguards such as physician oversight, informed consent, and adverse event reporting to mitigate harms.^[3]^[4] In practice, expanded access applies to products in various stages of development, from early investigational phases to those nearing approval, but excludes routine commercial distribution. Eligibility hinges on the condition's severity, the investigational product's promise based on available data, and the treating physician's determination that participation in a clinical trial is not feasible.^[5] Programs distinguish between individual patient access, intermediate-sized groups, and larger treatment protocols, with the latter resembling expanded treatment investigational new drug (IND) applications.^[12] The framework prioritizes patient autonomy and urgency in unmet needs, yet imposes manufacturer consent and regulatory review to prevent diversion from trial enrollment or resource strain on development pipelines.^[13] Empirical data indicate rare approvals relative to trial participants, underscoring its exceptional rather than standard role in drug access.^[4]

Underlying Rationale

Expanded access programs exist primarily to enable patients facing serious or immediately life-threatening conditions—who lack satisfactory alternative therapies and cannot participate in clinical trials—to obtain investigational medical products under controlled conditions.^[1] This mechanism addresses the gap between ongoing drug development and urgent patient needs, allowing treatment when the potential benefits outweigh known risks, as determined by regulatory review.^[14] The U.S. Food and Drug Administration (FDA), which oversees such access, emphasizes that it serves as a humanitarian pathway rather than a substitute for rigorous clinical evaluation, ensuring that access does not compromise broader public safety or divert resources from pivotal trials.^[15] Ethically, the rationale draws on principles of beneficence and autonomy, permitting informed patients to pursue potentially efficacious therapies absent approved options, while justice considerations support equitable distribution to those with no other recourse.^[16] Proponents argue that denying access equates to withholding hope from individuals with progressive diseases, where delays in approval—often spanning years—can prove fatal; for instance, programs have facilitated use of drugs like those for rare cancers when trial enrollment is infeasible due to geographic or eligibility barriers.^[17] However, ethical frameworks require robust preliminary evidence of safety and efficacy to avoid undue harm, distinguishing expanded access from unproven experimentation.^[18] From a practical standpoint, expanded access can yield real-world data on investigational products in diverse patient populations, informing future approvals without supplanting randomized controlled trials, which remain the gold standard for establishing causal efficacy.^[19] Regulatory bodies like the FDA have approved over 10,000 individual patient expanded access requests since 2005, demonstrating its role in bridging innovation gaps for conditions such as amyotrophic lateral sclerosis or pediatric leukemias, where standard treatments fail.^[1] This approach aligns with causal realism by prioritizing direct intervention for verifiable unmet needs over indefinite postponement, tempered by mandatory adverse event reporting to safeguard against unanticipated risks.^[20]

Regulatory Frameworks

United States

In the United States, expanded access to investigational drugs, biologics, and devices is regulated by the Food and Drug Administration (FDA) under 21 CFR Part 312 Subpart I, which permits treatment use outside clinical trials for patients with serious or immediately life-threatening conditions when no comparable or satisfactory alternative therapies exist.^[21] The program requires that the potential benefits justify the risks and that access does not interfere with or delay the drug's development or marketing approval process.^[22] Physicians must submit an Investigational New Drug (IND) application or protocol to the FDA, obtain manufacturer consent to provide the product, and secure Institutional Review Board (IRB) oversight where applicable, with the FDA typically reviewing individual patient requests within 30 days.^[2] The framework originated in the 1970s as an informal compassionate use mechanism for terminal cancer patients, evolving into formalized regulations in 1987 to standardize access while ensuring safety monitoring and data collection.^[4] By the 2010s, the FDA approved over 99% of expanded access requests, reflecting a low denial rate based on clinical need rather than stringent barriers.^[23] Three main categories exist: individual patient access (for single patients, including emergency use without prior IRB approval if documented appropriately); intermediate-size access (for groups of up to several hundred patients when evidence suggests clinical benefit); and treatment protocols or INDs for larger populations exceeding clinical trial needs.^[24] Emergency individual access bypasses prospective IRB review but requires retrospective reporting, while non-emergency cases demand full IRB approval.^[25] The 21st Century Cures Act of 2016 expanded eligibility by clarifying that expanded access applies to serious conditions (not solely life-threatening ones) and mandated manufacturers of drugs in phase 2 or 3 trials to publicly post their expanded access policies on company websites.^[22] This provision aimed to enhance transparency without altering core safety criteria. In contrast, the federal Right to Try Act, enacted in 2018, provides an alternative pathway for patients with life-threatening diseases who have exhausted approved options and cannot enroll in trials, allowing access to investigational drugs after phase 1 testing with manufacturer agreement but without mandatory FDA or IRB review.^[26] Unlike expanded access, Right to Try prohibits the FDA from using treatment outcomes in approval decisions and has resulted in fewer than 10 documented uses annually since implementation, as manufacturers often prefer the FDA-monitored route for liability and data reasons.^[27] Sponsors must report adverse events to the FDA under both mechanisms, though expanded access facilitates broader safety surveillance.^[25]

Europe

In the European Union, expanded access to investigational medicinal products is primarily regulated through compassionate use programs under Article 83 of Regulation (EC) No 726/2004, which allows unauthorized medicines to be made available to patients with unmet medical needs when no satisfactory authorized alternatives exist.^[28] These programs apply to products in advanced clinical development stages, typically Phase II or III, where preliminary data suggest potential efficacy against serious or life-threatening conditions.^[29] The European Medicines Agency (EMA) coordinates recommendations via its Committee for Medicinal Products for Human Use (CHMP), focusing on uniform application across member states, including protocol design, patient selection criteria, and safety monitoring requirements.^[29] National competent authorities retain primary responsibility for approvals, authorizing distribution only under strict conditions to ensure patient safety and ethical standards.^[28] Compassionate use differs from individual named-patient access, which permits one-off treatments for specific patients without a formal program, often handled at the national level without EMA involvement.^[30] Eligibility criteria emphasize patients facing chronically or seriously debilitating diseases with no comparable therapies, where the investigational product demonstrates plausible therapeutic benefits outweighing foreseeable risks, supported by non-clinical and clinical data.^[29] Programs target groups of patients rather than isolated cases, requiring manufacturers to submit detailed protocols outlining dosing, monitoring, and pharmacovigilance plans; for multi-member state programs, manufacturers notify the EMA, which may issue coordinated CHMP advice.^[29] Treatments occur outside clinical trials, with costs typically borne by patients, national health systems, or manufacturers, though reimbursement varies by country.^[28] Implementation varies across EU member states due to decentralized authority. In Germany, the Paul-Ehrlich-Institut oversees compassionate use via a confirmed notification procedure under the Medicines Act, emphasizing rapid access for orphan drugs and requiring post-use reporting.^[31] France's Temporary Authorisation for Use (ATU) program, managed by the Agence Nationale de Sécurité du Médicament, allows both individual and cohort access, with over 200 ATUs granted annually as of recent data, prioritizing oncology and rare diseases.^[32] Italy's Agenzia Italiana del Farmaco facilitates named-patient imports and compassionate use for up to 600 patients per program, mandating ethical committee review.^[30] Spain and the Netherlands employ similar frameworks, with Spain's compassionate use under Royal Decree 109/2010 requiring regional health service coordination, while the Netherlands focuses on investigator-initiated requests through the Medicines Evaluation Board.^[32] These national processes ensure alignment with EU pharmacovigilance rules, including mandatory adverse event reporting to EudraVigilance.^[28] Manufacturer responsibilities include supplying the product free or at cost, developing risk management plans, and collaborating with authorities on data collection, which may inform future marketing authorizations.^[29] As of 2021, compassionate use has facilitated access to therapies like those for amyotrophic lateral sclerosis and rare cancers, though uptake remains limited by evidentiary thresholds and resource constraints in smaller member states.^[30] The framework prioritizes evidence-based access over expediency, reflecting causal links between rigorous preclinical data and reduced post-access risks, without compromising ongoing trial integrity.^[28]

Other Regions

In Canada, Health Canada authorizes expanded access to investigational drugs through expanded access clinical trials, defined as trials providing potential therapeutic benefit to patients with serious or life-threatening conditions who cannot enroll in conventional trials due to ineligibility, disease progression, or geographic barriers.^[33] Sponsors must submit a Clinical Trial Application under Part C, Division 5 of the Food and Drug Regulations, demonstrating that anticipated benefits outweigh risks based on prior data, with reviews typically completed in 30 days.^[33] These programs adhere to good clinical practices, prioritize patient safety, and avoid interfering with standard drug development timelines. Complementing this, the Special Access Programme permits case-by-case access to unmarketed drugs for compassionate use when no authorized alternatives exist, subject to physician requests and Health Canada assessment.^[34] Australia's Therapeutic Goods Administration (TGA) oversees the Special Access Scheme (SAS), which allows registered health practitioners to supply unapproved therapeutic goods, including investigational drugs, to individual patients lacking suitable options on the Australian Register of Therapeutic Goods.^[35] The scheme categorizes requests by urgency and risk: Category A for patients with serious illnesses where death is likely without treatment, requiring post-supply notification within 28 days; Category B for other cases needing prior TGA approval and clinical justification, processed in 2-3 days; and Category C for products with established safe use histories, also via notification.^[35] Sponsors bear responsibilities for legal importation, adverse event reporting within 15 days, and ensuring supply chain integrity, while practitioners must document patient suitability and monitor outcomes.^[35] In Japan, the Pharmaceuticals and Medical Devices Agency (PMDA) supports compassionate use via the Japanese Compassionate Use (J-CU) program, established in January 2016, enabling access to investigational drugs for patients with life-threatening diseases ineligible for clinical trials.^[36] Unlike U.S. or European systems, J-CU requests bypass PMDA approval, relying on sponsor and institutional review, yielding approval rates approaching 100% for eligible cases when safety data supports use.^[36] Prior to 2016, access occurred under physician discretion or Advanced Medical Care B, which covers basic costs via public insurance but limits broader implementation; the program emphasizes ethical conduct without formal pharmacovigilance mandates equivalent to trials.^[37] Brazil's National Health Surveillance Agency (ANVISA) regulates expanded access and compassionate use programs for unregistered drugs targeting serious unmet needs, requiring sponsor-initiated requests with commitments to pursue full marketing authorization.^[38] These mechanisms, formalized around 2013, ensure patient safety through ethics committee oversight and adverse event reporting, though supply obligations extend post-access if trials conclude without approval.^[39] In other Latin American countries, similar named-patient or import pathways exist but vary, often lacking centralized frameworks and relying on local health authorities for case-by-case approvals.^[40] Across Asia-Pacific regions beyond Japan, programs emphasize named-patient access for imported unapproved drugs, with countries like India permitting imports via Form 11 licenses for personal use under physician certification, prioritizing rapid response over extensive data collection.^[41]

Application and Implementation

Eligibility and Criteria

Eligibility for expanded access, also known as compassionate use, typically requires patients to have a serious, life-threatening, or debilitating condition without satisfactory approved alternatives, and where enrollment in clinical trials is not feasible.^[1]^[29] Physicians must assess that the investigational product's potential benefits outweigh its risks based on available data, and provision must not compromise the product's development or ongoing trials.^[22] In the United States, the Food and Drug Administration (FDA) specifies three core criteria under 21 CFR 312.305 for treatment use expanded access: the patient must have a serious or immediately life-threatening disease or condition with no comparable or satisfactory alternative therapy; the prospective benefit justifies the potential risks, which are reasonable given the condition; and access will not interfere with clinical investigations supporting marketing approval or the drug's development.^[1]^[21] These apply to individual patient, intermediate-size patient populations (typically fewer than 100 subjects), and larger treatment protocols.^[22] For single-patient access, the requesting physician submits Form FDA 3926, certifying the criteria are met and that adequate preclinical and clinical data exist on the drug's pharmacology and risks.^[42] Institutional review board (IRB) approval or concurrence is required for non-emergency individual access, while emergency use bypasses prior IRB review but mandates retrospective notification.^[2] In the European Union, compassionate use eligibility is determined at the member state level, with the European Medicines Agency (EMA) offering optional scientific opinions via its Committee for Medicinal Products for Human Use (CHMP) on quality, safety, and efficacy for specific programs.^[29] Patients generally qualify if they have life-threatening, chronically or seriously debilitating diseases without authorized therapies and cannot participate in clinical trials; the investigational medicine must be in active clinical trials (typically phase III) or the marketing authorization process, with sufficient early evidence of safety and potential benefit.^[29]^[43] National authorities set distribution, patient targeting, and monitoring conditions, prioritizing trial-eligible patients first.^[29] Internationally, criteria align closely with U.S. and EU standards but vary by jurisdiction; for instance, programs in countries like Australia or Canada emphasize unmet need and ethical review, often requiring sponsor agreement and regulatory notification without unified global protocols.^[44]

Process and Procedures

The process for expanded access typically begins with the treating physician evaluating the patient's eligibility, confirming a serious or immediately life-threatening condition with no comparable alternative therapy available, and determining that the potential benefits of the investigational product justify its risks.^[2] The physician must then obtain the manufacturer's agreement to provide the product, as sponsors are not obligated but often cooperate under FDA encouragement.^[25] For individual patient access, which constitutes the majority of requests, the physician submits Form FDA 3926 to the FDA's Center for Drug Evaluation and Research or Center for Biologics Evaluation and Research; in emergencies, verbal or electronic communication suffices initially, followed by the form within 15 working days.^[42] FDA review occurs within 30 days for non-emergency individual requests, though approvals are frequent—over 99% since 2005—due to the program's low denial threshold focused on risk-benefit imbalance rather than efficacy proof.^[4] Prior to administration, the physician secures informed consent from the patient or guardian, detailing the experimental nature, uncertainties, and risks.^[2] For single-patient emergency use, institutional review board (IRB) oversight may be retrospective or waived if immediate treatment is needed, but non-emergency cases require prospective IRB review or a determination of minimal risk.^[42] Intermediate-size expanded access, for groups of patients up to several hundred, follows similar steps but involves an expanded access IND or protocol submission, with FDA review ensuring no interference with pivotal trials.^[1] Treatment protocols or INDs for larger populations demand manufacturer initiation, including safety monitoring plans and annual reports to FDA.^[25] Throughout, physicians report serious adverse events to FDA and the sponsor within 15 days, while manufacturers handle manufacturing, labeling, and distribution compliant with current good manufacturing practices.^[2] Costs may be recovered by the sponsor for direct production and distribution but not for research or profit.^[1]

Manufacturer Responsibilities

Manufacturers, also referred to as sponsors in regulatory contexts, are not obligated to provide investigational drugs through expanded access programs, as participation remains voluntary; the U.S. Food and Drug Administration (FDA) lacks authority to compel supply to patients or physicians.^[25] If a manufacturer elects to participate, it must supply the investigational product—typically a drug or biologic—while ensuring compliance with current good manufacturing practices (cGMP) to maintain product quality and integrity during distribution outside clinical trials.^[45] This decision often weighs potential impacts on ongoing clinical development, such as resource diversion or data integrity risks, against patient needs, with policies required to be publicly disclosed under the 21st Century Cures Act.^[25] Upon agreement to provide access, manufacturers hold primary responsibility for submitting or facilitating an Investigational New Drug (IND) application under 21 CFR Part 312 Subpart I, which may amend an existing IND or initiate a new one, including protocols for individual patient, intermediate-size, or treatment IND categories.^[45] Safety monitoring constitutes a core obligation, requiring expedited reporting of serious unexpected suspected adverse reactions per 21 CFR 312.32, along with annual IND reports if access extends beyond one year, and summaries of treatment outcomes including adverse effects at protocol conclusion.^[25]^[45] Manufacturers must also designate qualified investigators, such as physicians, to oversee administration and ensure patients receive risk-benefit information, while prohibiting any promotional claims of safety or efficacy for the unapproved product under 21 CFR 312.^[25] Charging patients or third parties for the drug is permissible only to recover direct costs—such as manufacturing, packaging, and shipping—provided the manufacturer demonstrates to the FDA that such recovery does not interfere with clinical trial enrollment and that sufficient supply exists for development needs, as outlined in 21 CFR 312.8 and related guidance.^[25] In intermediate or treatment use scenarios involving larger patient groups, manufacturers bear additional burdens to track usage and report aggregated safety data to inform potential labeling updates or risk assessments.^[45] Internationally, analogous responsibilities apply under frameworks like the European Medicines Agency's (EMA) compassionate use procedures, where manufacturers must supply unauthorized medicines to national competent authorities upon request, ensure ongoing safety monitoring in line with good pharmacovigilance practices, and collaborate on reporting without direct EMA authorization but with notification to member states.^[29] Variations exist by jurisdiction, such as in Canada or other regions, emphasizing voluntary provision, GMP adherence, and pharmacovigilance to mitigate risks while facilitating access.^[33]

Benefits and Empirical Outcomes

Successful Case Studies

In 2014, during the West African Ebola outbreak, two American healthcare workers, Kent Brantly and Nancy Writebol, received the investigational monoclonal antibody cocktail ZMapp under FDA expanded access protocols after contracting the virus in Liberia. Both patients, treated at Emory University Hospital in Atlanta starting in August 2014, showed clinical recovery, with Brantly discharged on August 21 and Writebol on August 19; their survival was attributed in part to the experimental therapy alongside supportive care, though causality remains observational given limited supplies and concurrent cases without ZMapp who succumbed.^[46]^[47] Another prominent case involved Josh Hardy, a seven-year-old boy with a history of recurrent Wilms' tumor who developed disseminated adenovirus infection following bone marrow transplantation in early 2014. After initial denial by manufacturer Chimerix, public advocacy led to FDA-facilitated access to brincidofovir via an open-label trial on March 12, 2014; Hardy's viral load became undetectable within weeks, he was removed from ICU shortly thereafter, and discharged home from St. Jude Children's Research Hospital in July 2014, marking a reversal from near-fatal progression.^[48]^[49] A scoping review of compassionate use for rare diseases, covering 46 studies and 2,079 patients from 1991 to 2022, documented favorable efficacy in 84.8% of cases, including symptom improvement in 76.1% and disease resolution in 8.7%. One specific instance involved defibrotide administered to an infant with hepatic veno-occlusive disease, resulting in complete cure where standard therapies failed.^[50] Such outcomes underscore expanded access's role in addressing unmet needs, though individual successes do not imply generalizability without controlled data.

Data on Patient Access and Survival

In the United States, the Food and Drug Administration (FDA) receives thousands of expanded access submissions annually, primarily for single-patient use, enabling patients with serious or life-threatening conditions to access investigational drugs outside clinical trials. From 2019 to 2023, the FDA processed 17,349 single-patient investigational new drug (IND) submissions (5,614 non-emergency and 11,735 emergency), approving 17,271 (99.7% approval rate), corresponding roughly to the number of individual patients treated under these protocols. Intermediate-size and treatment INDs, which serve small groups or larger populations, accounted for fewer submissions (154 and 37 received, respectively), with approval rates of 87% and 78%. These figures reflect a surge during the COVID-19 pandemic, where expanded access facilitated broad distribution of investigational therapies, but non-pandemic access remains in the low thousands of patients yearly, limited by eligibility for those exhausted of approved options.^[51] Empirical data on survival outcomes from expanded access remains sparse and heterogeneous, as programs target terminal or refractory patients without randomized controls, complicating causal attribution of benefits to the investigational agent. A 2019 analysis of 266 oncology patients receiving single-patient expanded access to targeted therapies reported median progression-free survival of 4.0 months, with 38.9% surviving progression-free at 6 months and 24.5% at 1 year; overall response rates were approximately 20% across similar compassionate use cohorts for various cancers, though overall survival data were not uniformly tracked. Broader reviews of peer-reviewed expanded access publications from 2000 to 2022 indicate variable efficacy by disease—e.g., positive signals in rare genetic disorders or oncology subsets—but highlight selection bias toward advanced cases, where placebo-like outcomes predominate absent the drug. Serious adverse events, including fatalities possibly linked to treatment, occurred in under 0.2% of cases across 1,033 drugs in one FDA-reviewed dataset, underscoring safety but not efficacy.^[52]^[19]^[53] Limitations in outcome reporting stem from the program's ad hoc nature; FDA mandates safety reporting but not systematic survival tracking, leading to reliance on voluntary publications that may overrepresent successful cases from academic centers. Real-world evidence from expanded access has informed post-approval labeling in some instances, but aggregate survival gains are not quantifiable due to confounding factors like concurrent standard care and patient frailty. Critics note that while access expands hope for the ~1% of pediatric cancer patients or similar refractory cohorts annually utilizing the program, survival extensions are often modest or unproven, prioritizing individual access over population-level trial data generation.^[54]^[55]

Risks and Criticisms

Safety and Adverse Events

Expanded access programs incorporate safety monitoring protocols comparable to those in clinical trials, requiring sponsors to report serious adverse events (SAEs) to the FDA within 15 calendar days of awareness, including any unexpected events potentially related to the investigational drug.^[25] For single-patient expanded access, immediate reporting of SAEs is mandatory, followed by annual summaries if treatment exceeds one year and a final report detailing outcomes, ensuring continuous risk evaluation without compromising patient access.^[56] Empirical data reveal that adverse events arising from expanded access infrequently alter drug development trajectories or contribute to restrictive labeling. A review of FDA regulatory actions from 2005 to 2015 identified only one case where expanded access safety data alone prompted adverse product labeling—a drug-drug interaction—amid thousands of requests, underscoring the rarity of such impacts.^[57] Similarly, serious adverse events sufficient to affect overall program progression occur exceedingly rarely, with FDA analyses confirming negligible influence on investigational drug approvals or holds.^[58] In compassionate use contexts, particularly for rare diseases, adverse events have been documented in approximately 67% of reviewed studies spanning 1991–2022, though causality attribution is complicated by patients' advanced disease states and comorbidities; no events were reported in 28% of cases, and outcomes often aligned with expected risks in uncontrolled settings.^[59] The FDA integrates expanded access data into broader safety assessments via systems like the Adverse Event Reporting System (FAERS), but isolated incidents from these programs seldom trigger clinical hold or withdrawal decisions.^[25] Critics of less-regulated variants, such as Right to Try provisions bypassing certain FDA pre-approvals, highlight inherent safety risks including unmonitored toxicities or interactions, potentially exacerbating harm in terminal patients without trial safeguards.^[60] Nonetheless, post-enactment utilization data through 2024 shows minimal reported SAEs leading to program-wide changes, attributed to manufacturer discretion and voluntary reporting, though comprehensive outcomes remain understudied due to limited mandatory disclosures.^[61] Overall, while adverse events occur at rates reflective of high-risk populations, structured reporting mitigates systemic threats to drug safety profiles.

Effects on Drug Development and Trials

Expanded access programs are regulated to minimize interference with clinical trials and overall drug development, with the U.S. Food and Drug Administration (FDA) requiring under 21 CFR 312.305(a)(3) that such access does not compromise the initiation, conduct, or completion of trials needed for marketing approval.^[45] This determination involves assessing patient eligibility—typically limited to those unable to enroll in ongoing trials due to factors like geography or disease stage—and evaluating larger-scale programs (e.g., treatment INDs) for higher risks of recruitment overlap.^[45] FDA may impose clinical holds if interference is evident and often requires sponsors to detail accrual plans to ensure trial viability.^[45] Critics argue that expanded access can divert limited resources, including drug supply and personnel, from pivotal trials, potentially delaying approvals and broader patient access to validated therapies.^[17] It may also deter trial enrollment by offering patients an alternative pathway to investigational drugs without randomization or placebo risks, prolonging the time to accrue sufficient participants for robust efficacy data.^[6] ^[17] Sponsors face additional burdens, as drugs are typically provided free, imposing financial and logistical costs that compete with development priorities and may discourage participation in such programs.^[17] Empirical analyses, however, indicate limited adverse effects on regulatory outcomes. A review of 321 FDA decisions from 2010–2016 found drugs with prior expanded access had an 84% approval rate versus 76% without (P=0.001), with no refusals or complete responses attributed to expanded access safety data; in one case, approval relied solely on such data.^[57] Labeling changes from expanded access events were rare (two instances of warnings for interactions or liver issues), often tied to patient comorbidities rather than inherent drug risks, suggesting concerns over undermining innovation or approval are overstated.^[57] Real-world data from these programs can supplement trial evidence, potentially accelerating development for rare diseases where trials are challenging.^[57]

Ethical and Philosophical Debates

Individual Rights vs. Collective Safety

The ethical debate surrounding expanded access programs centers on the tension between a patient's autonomy to pursue potentially beneficial investigational therapies and the broader imperative to safeguard public health through rigorous evidence generation. Proponents of prioritizing individual rights argue that terminally ill or severely afflicted patients, facing imminent death or irreversible harm, possess a moral claim to access unapproved drugs when clinical trials are unavailable, grounded in principles of self-determination and the alleviation of extreme suffering.^[19] This perspective gained legislative traction with the federal Right to Try Act of 2017, which enables eligible patients with life-threatening conditions to obtain investigational drugs directly from manufacturers after phase 1 trials, bypassing certain FDA oversight to affirm personal liberty over bureaucratic delays.^[27] Critics contend that such access undermines collective safety by exposing vulnerable individuals to therapies lacking robust efficacy and safety data, potentially yielding harms without verifiable benefits due to the absence of controlled comparisons. Adverse events in expanded access cohorts, often comprising sicker patients than trial participants, can complicate regulatory approval and erode confidence in the drug development pipeline, as unmonitored outcomes may obscure risks that would otherwise inform randomized controlled trials (RCTs)—the gold standard for establishing causal efficacy and minimizing population-level harms.^[6] The Right to Try Act exacerbates these concerns by prohibiting the FDA from accessing safety data generated under its provisions, insulating manufacturers from liability while depriving regulators of critical pharmacovigilance insights that protect future patients.^[62] From a utilitarian standpoint, the collective benefits of mandatory RCTs—evidenced by their role in averting widespread adoption of ineffective or dangerous treatments, as seen in historical rejections of agents like laetrile—outweigh isolated individual gains, particularly given the low probability of benefit in pre-approval settings where selection bias inflates anecdotal successes.^[63] Manufacturers frequently decline expanded access requests to avoid jeopardizing trial enrollment or generating noisy data that could derail approval, highlighting how individual pursuits can inadvertently stall innovations benefiting millions.^[9] Empirical data from FDA programs show high approval rates for requests (over 99% since 2009), yet sparse long-term tracking reveals persistent risks of overpromising without evidence, underscoring the need for informed consent that candidly weighs personal hope against societal evidentiary standards.^[64]

Incentives and Market Realities

Pharmaceutical manufacturers often weigh participation in expanded access programs against substantial disincentives, including heightened liability exposure from adverse events occurring outside controlled clinical trial settings, where causality attribution to the investigational drug may be scrutinized in litigation.^[65] Such risks are amplified for early-stage drugs, as uncontrolled use could generate data conflicting with trial outcomes, potentially jeopardizing regulatory approval or product labeling.^[57] Manufacturing and distributing limited supplies at cost—or for free—imposes financial burdens without offsetting revenue, particularly straining smaller biopharmaceutical firms with limited resources.^[66] Market dynamics further discourage broad expanded access, as it may divert eligible patients from enrolling in pivotal trials essential for demonstrating safety and efficacy under randomized conditions, thereby prolonging development timelines and delaying market entry.^[67] Clinical trials offer manufacturers proprietary data yielding intellectual property protections and exclusivity periods, whereas expanded access yields anecdotal, non-randomized outcomes of limited regulatory value, though occasionally supportive for post-approval expansions.^[68] U.S. Food and Drug Administration data indicate that while 99% of expanded access requests receive agency approval—often within days—manufacturer consent remains discretionary and frequently withheld, especially for single-patient cases in non-orphan indications, reflecting a prioritization of pipeline integrity over ad hoc access.^[7] Positive incentives, such as reputational benefits or real-world evidence aiding label negotiations, exist but are insufficient to override core commercial imperatives for most sponsors, who structure policies favoring trial participation over compassionate use.^[69] Proposals for compensatory mechanisms, including extended market exclusivity or expedited reviews to offset expanded access costs, have been advocated but not enacted, underscoring a regulatory framework misaligned with industry incentives.^[67] In practice, participation rates skew toward later-stage drugs nearing approval, where risks are lower and access aligns with marketing strategies, rather than foundational research phases critical to recouping development investments averaging $1-2 billion per approved therapy.^[57]

Historical Development

Origins and Early Precedents

The origins of expanded access trace to the 1938 Federal Food, Drug, and Cosmetic Act, which included Section 505(i) permitting the shipment of unapproved drugs labeled "for investigational use only" to qualified experts, enabling limited ad hoc access for patients lacking alternatives.^[70] This mechanism operated informally, often through physician requests or telephone approvals from the FDA, without formalized regulations for broader compassionate distribution.^[70] The 1962 Kefauver-Harris Drug Amendments, enacted after the thalidomide tragedy, imposed requirements for adequate safety and efficacy data, informed consent, and institutional review, which constrained but did not eliminate informal investigational access via individual investigator INDs or orphan drug provisions.^[71] By the 1970s, amid growing demand for experimental cancer therapies, the FDA established the Group C Investigational New Drug program in 1976, authorizing distribution of promising anticancer agents to multiple physicians outside clinical trials for patients with refractory diseases.^[71] In 1979, the FDA issued its first explicit policy on expanded access, formalizing pathways for terminal cancer patients to receive unproven drugs under treatment protocols.^[71]^[4] Early precedents highlighted both potential benefits and risks. In the early 1970s, the FDA approved an open-label IND for 5-iododeoxyuridine (IDUR) to treat herpes encephalitis, a condition with no alternatives, allowing over 70 patients to receive the drug; subsequent placebo-controlled studies revealed severe toxicities, including bone marrow suppression linked to 3-5 deaths and persistent viral presence in autopsied cases.^[72] These cases underscored the need for safeguards, yet set the stage for expanded mechanisms amid the 1980s AIDS crisis, where patient activism pressured regulators; by 1987, FDA regulations codified treatment INDs, enabling access to investigational drugs for larger groups with serious conditions when trials were unavailable.^[4]^[70]

Key Legislative and Regulatory Milestones

The U.S. Food and Drug Administration (FDA) initiated informal provisions for compassionate use of investigational drugs in the late 1970s, primarily to provide terminal cancer patients access to unapproved therapies outside clinical trials when no alternatives existed.^[4] This practice evolved in response to advocacy from patient groups and physicians, marking the practical origins of expanded access without formal regulatory codification at the time.^[4] In 1987, amid the AIDS crisis, the FDA established the Treatment Investigational New Drug (IND) application under 21 CFR 312.34, allowing broader access to investigational therapies for patients with serious diseases after sufficient development to support safety data, but before marketing approval.^[4] This regulation formalized "treatment use" for groups of patients unable to participate in trials, reflecting pressure from activists demanding faster access to experimental antiretrovirals.^[4] By 2009, the FDA consolidated and expanded these pathways through a final rule amending IND regulations to create Subpart I of 21 CFR Part 312, which explicitly governed individual patient, intermediate-size, and emergency expanded access, emphasizing criteria like the absence of comparable therapies and minimal risk to drug development.^[67]^[45] The 21st Century Cures Act, enacted on December 13, 2016, introduced Section 3033 requiring applicable drug and device manufacturers and distributors to develop and publicly post policies on evaluating and responding to expanded access requests, aiming to enhance transparency without mandating approval of requests.^[22]^[73] The FDA Reauthorization Act of 2017 further refined access by authorizing expanded intermediate-size populations and streamlining reporting for single-patient INDs.^[22] On May 30, 2018, President Donald Trump signed the Trickett Wendler, Omar Burleson, and Frank M. Buckles Right to Try Act into law, creating a federal pathway for terminally ill patients to access eligible investigational drugs directly from manufacturers after Phase 1 trials, bypassing FDA pre-approval while still requiring sponsor consent and liability protections under certain conditions.^[26] This legislation supplemented rather than replaced FDA expanded access, addressing concerns over bureaucratic delays but drawing criticism for lacking oversight on safety data collection compared to traditional IND processes.^[7]^[27]

Recent Developments and Global Trends

Post-2020 Innovations and Challenges

The COVID-19 pandemic spurred significant scale-up in expanded access programs, culminating in the largest such initiative in U.S. history with over 100,000 participants accessing investigational convalescent plasma under FDA oversight by late 2020.^[74] This expansion highlighted the potential for expanded access to serve as a bridge during public health emergencies, enabling rapid distribution of unapproved therapies like remdesivir for severely ill patients when clinical trials could not accommodate demand.^[75] Manufacturers reported heightened managed access activity for COVID-19 indications, with programs adapting to facilitate broader compassionate use while collecting real-world safety data to inform future regulatory decisions.^[76] Post-pandemic innovations included FDA's emphasis on master protocols to streamline expanded access in oncology, discussed in a February 2020 Critical Path Innovation Meeting, which aimed to integrate treatment access with efficient data generation across multiple investigational agents.^[77] Project Facilitate, an FDA service launched prior but intensified post-2020, provided oncology providers with expedited regulatory consultations for expanded access requests, processing thousands of inquiries to reduce administrative barriers.^[78] In October 2025, FDA issued updated guidance incorporating post-2017 queries on eligibility, sponsor duties, and intermediate-size access, clarifying pathways without altering core regulations but enhancing practical implementation for rare diseases and serious conditions.^[22] These steps reflected a shift toward leveraging expanded access data as real-world evidence to support approvals, as seen in cases where compassionate use outcomes contributed to post-approval labeling expansions.^[79] Challenges emerged from the pandemic's volume surge, requiring clinical and translational science award programs to rapidly adapt protocols amid evolving FDA guidance on COVID-19 investigational uses, often under compressed timelines that risked incomplete safety monitoring.^[80] Ethical tensions intensified, as expedited access for desperate patients clashed with imperatives to prioritize trial enrollment and rigorous evidence generation, potentially diluting incentives for controlled studies.^[81] Resource constraints strained sponsors and regulators, with manufacturing scale-up for compassionate distribution proving logistically demanding, while gaps between expanded access and emergency use authorizations led to inconsistent patient outcomes and data silos.^[82] By 2023, implementation hurdles persisted in oncology and advanced therapies, including case-by-case variability and the need for better harmonization to avoid diverting drugs from pivotal trials.^[83]

Emerging Variations in Low-Resource Settings

In low-resource settings, expanded access programs face significant barriers, including absent or underdeveloped regulatory frameworks, limited healthcare infrastructure, and low clinical trial activity, resulting in only 3% of global compassionate use requests originating from low- and lower-middle-income countries between 2018 and 2020.^[84] These disparities persist due to economic constraints and insufficient public awareness, often forcing reliance on ad hoc import provisions rather than structured programs.^[84] For instance, in India, compassionate use remains nascent as of 2020, with no formal terminology but allowances for physicians to import unapproved drugs on a named-patient basis under Central Drugs Standard Control Organization guidelines.^[85] Emerging variations adapt to these constraints through international pharmaceutical managed access extensions and public-private partnerships, particularly for rare diseases and oncology. Novartis's Zolgensma gene therapy program, launched globally around 2019, provided free access in select low-resource contexts despite regulatory gaps, highlighting pharma-led models that bridge local deficiencies.^[84] Similarly, Roche's risdiplam compassionate use for spinal muscular atrophy, expanded post-2020, enrolled patients from low- and middle-income countries lacking dedicated regulations by leveraging sponsor oversight and simplified eligibility.^[86] In South America, Brazil's ANVISA formalized compassionate use under RDC 608/2022 for medical devices and drugs, enabling structured access amid regional variations where Argentina has robust rules but Peru and Uruguay lack explicit definitions.^[87]^[88] NGO advocacy drives further adaptations, such as MSF's 2021 push for AbbVie's glecaprevir/pibrentasvir compassionate use in low- and middle-income countries for hepatitis C treatment failures, emphasizing named-patient programs where standard regimens fail.^[89] For anticancer therapies, strategies include compulsory licensing and patent pooling to lower costs, alongside expanded access pilots integrated with financing reforms, as proposed in 2024 analyses of resource-constrained oncology care.^[90] These variations prioritize equity by combining global pharma commitments with local policy evolution, though implementation remains uneven due to persistent resource limitations.^[84]

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