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61-457: It introduced a requirement for drug manufacturers to provide proof of the effectiveness and safety of their drugs before approval, required drug advertising to disclose accurate information about side effects, and stopped cheap generic drugs being marketed as expensive drugs under new trade names as new "breakthrough" medications. The amendment was a response to the thalidomide tragedy, in which thousands of children were born with birth defects as

122-411: A 31% yield of S -thalidomide, whereas the two-step synthesis yields 85–93% product that is 99% pure. In 2023, it is reported that phthalic anhydride and L -glutamine under suitable conditions can react directly to form thalidomide. In the procedure, phthalic anhydride and L -glutamine are grounded and added into toluene solvent. The solution, along with triethylamine and acetic anhydride ,

183-501: A challenge for these people, and women in particular have experienced difficulty in locating healthcare professionals who can understand and embrace their needs. Brand names include Contergan, Thalomid, Talidex, Talizer, Neurosedyn, Distaval and many others. Research efforts have been focused on determining how thalidomide causes birth defects and its other activities in the human body, efforts to develop safer analogs, and efforts to find further uses for thalidomide. The exploration of

244-408: A consequence of thalidomide use. The severity and location of the deformities depended on how many days into the pregnancy the mother was before beginning treatment, with the time-sensitive window occurring approximately between day 20 and day 36 post-fertilisation. Thalidomide taken on the 20th day of pregnancy caused central brain damage, day 21 would damage the eyes, day 22 the ears and face, day 24

305-539: A new drug was both safe and effective. Previously the 1938 Food, Drug and Cosmetic Act was the main law that regulated drug safety. Informed consent was required of patients participating in clinical trials, and adverse drug reactions were required to be reported to the FDA. The Drug Efficacy Study Implementation was begun to classify all pre-1962 drugs that were already on the market as either effective, ineffective, or needing further study. Estes Kefauver considered

366-473: A patient critically ill with leprosy . The patient exhibited erythema nodosum leprosum (ENL), a painful skin condition, one of the complications of leprosy. The treatment was attempted despite the ban on thalidomide's use, and results were favourable: the patient slept for hours and was able to get out of bed without aid upon awakening. A clinical trial studying the use of thalidomide in leprosy soon followed. Thalidomide has been used by Brazilian physicians as

427-433: A pregnant woman could pass across the placental barrier and harm the developing fetus. There soon appeared reports of abnormalities in children being born to mothers using thalidomide. In late 1959, it was noticed that peripheral neuritis developed in patients who took the drug over a period of time, and it was only after this point that thalidomide ceased to be provided over the counter. While initially considered safe,

488-587: A regimen to fight two conditions. Interest turned to pomalidomide , a derivative of thalidomide marketed by Celgene . It is a very active anti-angiogenic agent and also acts as an immunomodulator . Pomalidomide was approved in February 2013 by the FDA as a treatment for relapsed and refractory multiple myeloma . It received a similar approval from the European Commission in August 2013, and

549-441: A result of their mothers taking thalidomide for morning sickness during pregnancy. The bill by U.S. Senator Estes Kefauver , of Tennessee , and U.S. Representative Oren Harris , of Arkansas , required drug manufacturers to provide proof of the effectiveness and safety of their drugs before approval. The majority of the tragic birth defects that occurred were in other countries because Thalidomide had not been approved for use in

610-770: A sense of unwellness. There are no expected pharmacokinetic interactions between thalidomide and other medicines due to its neutral effects on P-glycoprotein and the cytochrome P450 family. It may interact with sedatives due to its sedative action and bradycardic agents, like beta-blockers, due to its bradycardia-inducing effects. Risk of peripheral neuropathy may be increased by concomitant treatment of thalidomide with other agents known to cause peripheral neuropathy. The risk of venous thromboembolisms with thalidomide seems to be increased when patients are treated with oral contraceptives or other cytotoxic agents (including doxorubicin and melphalan ) concurrently. Thalidomide may interfere with various contraceptives, and hence it

671-418: Is racemic ; while S -thalidomide is the bioactive form of the molecule, the individual enantiomers can racemize to each other due to the acidic hydrogen at the chiral centre , which is the carbon of the glutarimide ring bonded to the phthalimide substituent . The racemization process can occur in vivo . The process of conversion of one enantiomer to its mirror-image version with no other change in

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732-401: Is a known human teratogen and carries an extremely high risk of severe, life-threatening birth defects if administered or taken during pregnancy. It causes skeletal deformities such as amelia (absence of legs and/or arms), absence of bones, and phocomelia (malformation of the limbs). A single dose of thalidomide, regardless of dosage, is enough to cause teratogenic effects. Thalidomide

793-419: Is advised that women of reproductive age use at least two different means of contraception to ensure that no child will be conceived while they are taking thalidomide. As of 2013, eighteen cases of overdoses had been reported with doses of up to 14.4 grams, none of them fatal. No specific antidote for overdose exists and treatment is purely supportive . The precise mechanism of action for thalidomide

854-459: Is estimated at over 10,000, possibly 20,000, of whom about 40% died around the time of birth. Those who survived had limb, eye, urinary tract, and heart problems. Its initial entry into the US market was prevented by Frances Kelsey , a reviewer at the FDA. The birth defects caused by thalidomide led to the development of greater drug regulation and monitoring in many countries. It was approved in

915-544: Is expected to be marketed in Europe under the brand name Imnovid . Rash A rash is a change of the skin that affects its color, appearance, or texture. A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch , become warm, bumpy, chapped , dry, cracked or blistered , swell, and may be painful. The causes, and therefore treatments for rashes, vary widely. Diagnosis must take into account such things as

976-491: Is refluxed at ~110°C for 9 hours; after that the solution goes though a simple vacuum filtration procedure to obtain the product. In 1952, thalidomide was synthesised by Chemical Industry Basel , but was found "to have no effect on animals" and was discarded on that basis. In 1957, it was acquired by Chemie Grünenthal in Germany. The German company had been established as a soap maker after World War II ended, to address

1037-410: Is related to leprosy . Thalidomide may be helpful in some cases where standard TB drugs and corticosteroids are not sufficient to resolve severe inflammation in the brain. It is used as a second-line treatment to manage graft-versus-host disease and aphthous stomatitis in children and has been prescribed for other conditions in children, including actinic prurigo and epidermolysis bullosa ;

1098-764: The Medicines Act 1968 (UK). In the United States, the new regulations strengthened the FDA, among other ways, by requiring applicants to prove efficacy and to disclose all side effects encountered in testing. The FDA subsequently initiated the Drug Efficacy Study Implementation to reclassify drugs already on the market. In 1977 the US Federal Drug Administration published a clinical trial guideline that excluded women of "childbearing potential" from

1159-455: The androgen receptor and hence is a nonsteroidal antiandrogen of some capacity. In accordance, it can produce gynecomastia and sexual dysfunction as side effects in men. Thalidomide is provided as a racemic mixture of two enantiomers ; while there are reports that only one of the enantiomers may cause birth defects, the body converts each enantiomer into the other through mechanisms that are not well understood. The (R)-enantiomer has

1220-415: The antiangiogenic and immunomodulatory activities of thalidomide has led to the study and creation of thalidomide analogs . Celgene has sponsored numerous clinical trials with analogues to thalidomide, such as lenalidomide , that are substantially more powerful and have fewer side effects — except for greater myelosuppression . In 2005, Celgene received FDA approval for lenalidomide (Revlimid) as

1281-660: The 1960s had thalidomide embryopathy (TE). Of these babies born with TE, "about 40% of them died before their first birthday". The surviving individuals are now middle-aged and they report experiencing challenges (physical, psychological, and socioeconomic) related to TE. Individuals born with TE frequently experience a wide variety of health problems secondary to their TE. These health conditions include both physical and psychological conditions. When compared to individuals of similar demographic profiles, those born with TE report less satisfaction with their quality of life and their overall health. Access to health care services can also be

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1342-418: The 1990s. Judah Folkman pioneered studies into the role of angiogenesis (the proliferation and growth of blood vessels) in the development of cancer, and in the early 1970s had shown that solid tumors could not expand without it. In 1993 he surprised the scientific world by hypothesizing the same was true of blood cancers , and the next year he published work showing that a biomarker of angiogenesis

1403-711: The Amendment his "finest achievement" in consumer protection . Louis Lasagna , then a prominent clinical pharmacologist at the Johns Hopkins School of Medicine , advised Congress about the proper conduct of clinical research during the 1962 hearings leading up to passage of the Amendment. The law also exempted from the " Delaney clause " (a 1958 amendment to the Food, Drugs, and Cosmetic Act of 1938) certain animal drugs and animal feed additives shown to induce cancer, but which left no detectable levels of residue in

1464-492: The National Institute of Health policy that women should, when beneficial, be included in clinical trials. In the 1960s, thalidomide was successfully marketed as a safer alternative to barbiturates . Due to a successful marketing campaign, thalidomide was widely used by pregnant women during the first trimester of pregnancy. However, thalidomide is a teratogenic substance, and a proportion of children born during

1525-470: The UK, Australia and New Zealand, under the brand name Distaval, as a remedy for morning sickness . Their advertisement claimed that "Distaval can be given with complete safety to pregnant women and nursing mothers without adverse effect on mother or child ... Outstandingly safe Distaval has been prescribed for nearly three years in this country." Globally, more pharmaceutical companies started to produce and market

1586-563: The US. The US FDA refused to approve thalidomide for marketing and distribution. However, the drug was distributed in large quantities for testing purposes, after the American distributor and manufacturer Richardson-Merrell had applied for its approval in September 1960. The official in charge of the FDA review, Frances Oldham Kelsey , did not rely on information from the company, which did not include any test results. Richardson-Merrell

1647-637: The US. She was also inducted into the National Women's Hall of Fame in 2000. Canada's Food and Drug Directorate approved the sale of thalidomide by prescription in November, 1960. There were many different forms sold: Kevadon, produced by the William S. Merrell Company seeking approval for its thalidomide product, was released on the market in April 1961, and the most common variant (Horner's Talimol)

1708-543: The United States in 1998 for use as a treatment for cancer. It is on the World Health Organization's List of Essential Medicines . It is available as a generic medication . Thalidomide is used as a first-line treatment for multiple myeloma in combination with dexamethasone or with melphalan and prednisone to treat acute episodes of erythema nodosum leprosum , as well as for maintenance therapy. The bacterium that causes tuberculosis (TB)

1769-560: The United States. However, samples were distributed to physicians in the US and 17 birth defects were attributed to its use. Frances Oldham Kelsey was the FDA reviewer who refused to approve Thalidomide for use. It introduced a "proof-of-efficacy" requirement for the first time. In addition, the Amendment required drug advertising to disclose accurate information about side effects and efficacy of treatments. Finally, cheap generic drugs could no longer be marketed as expensive drugs under new trade names as new "breakthrough" medications. The law

1830-415: The appearance of the rash, other symptoms, what the patient may have been exposed to, occupation, and occurrence in family members. The diagnosis may confirm any number of conditions. The presence of a rash may aid diagnosis; associated signs and symptoms are diagnostic of certain diseases. For example, the rash in measles is an erythematous , morbilliform , maculopapular rash that begins a few days after

1891-489: The archives of the FDA, shows that in 1956–57, as part of its in-licensing approach, Smith, Kline and French conducted animal tests and ran a clinical trial of the drug in the US involving 875 people, including pregnant women. In 1956, researchers involved in clinical trials at SKF noted that, even when used in very high doses, thalidomide could not induce sleep in mice. When administered at doses 50 to 650 times larger than that claimed by Chemie Grünenthal to be "sleep inducing",

Kefauver–Harris Amendment - Misplaced Pages Continue

1952-526: The arms, and leg damage would occur if taken up to day 28. It is not known exactly how many worldwide victims of the drug there have been, although estimates range from 10,000 to 20,000. Despite the side effects, thalidomide was sold in pharmacies in Canada until 1962. The disaster prompted many countries to introduce tougher rules for the testing and licensing of drugs, such as the 1962 Kefauver Harris Amendment (US), 1965 Directive 65/65/EEC1 (EU), and

2013-453: The controls. In 1998, the FDA approved the drug's use in the treatment of ENL. Because of thalidomide's potential for causing birth defects, the drug may be distributed only under tightly controlled conditions. The FDA required that Celgene Corporation , which planned to market thalidomide under the brand name Thalomid , establish a system for thalidomide education and prescribing safety (STEPS) oversight program. The conditions required under

2074-466: The desired sedative effect while the (S)-enantiomer harbors embryo-toxic and teratogenic effect. Attempting to extract solely R -thalidomide does not remove the risk of birth defects, as it was demonstrated that the "safe" R -thalidomide undergoes an in vivo chiral inversion to the "teratogenic" S -thalidomide.  Under biological conditions, the enantiomers interconvert ( bidirectional chiral inversion – (R)- to (S)- and vice versa). Thalidomide

2135-438: The difficulty of adequately controlling its use, and due to the availability of clofazimine . Shortly after the teratogenic properties of thalidomide were recognized in the mid-1960s, its anti-cancer potential was explored and two clinical trials were conducted in people with advanced cancer, including some people with multiple myeloma; the trials were inconclusive. Little further work was done with thalidomide in cancer until

2196-1460: The drug can be transmitted in semen . There is a high risk that thalidomide can cause excessive blood clots . There is also a high risk that thalidomide can interfere with production of several types of new blood cells, creating a risk of infection via neutropenia , leukopenia , and lymphopenia , and risks that blood will not clot via thrombocytopenia . There is also a risk of anemia via lack of red blood cells. The drug can also damage nerves, causing potentially irreversible peripheral neuropathy . Thalidomide has several adverse cardiovascular effects, including risk of heart attacks , pulmonary hypertension , and changes in heart rhythm, such as syncope , bradycardia , and atrioventricular block . Thalidomide can cause liver damage and severe skin reactions like Stevens–Johnson syndrome . It tends to make people sleepy, which creates risk when driving and operating other machinery. As it kills cancer cells, it can cause tumor lysis syndrome . Thalidomide can prevent menstruation . In addition, very common (reported in more than 10% of people) adverse effects include tremor , dizziness, tingling, numbness, constipation, and peripheral edema . Common adverse effects (reported by 1–10% of people) include confusion, depressed mood, reduced coordination, heart failure, difficulty breathing, interstitial lung disease, lung inflammation, vomiting, dry mouth, rashes, dry skin, fever, weakness, and

2257-739: The drug of choice for the treatment of severe ENL since 1965, and by 1996, at least 33 cases of thalidomide embryopathy were recorded in people born in Brazil after 1965. Since 1994, the production, dispensing, and prescription of thalidomide have been strictly controlled, requiring women to use two forms of birth control and submit to regular pregnancy tests. Despite this, cases of thalidomide embryopathy continue, with at least 100 cases identified in Brazil between 2005 and 2010. 5.8 million thalidomide pills were distributed throughout Brazil in this time period, largely to poor Brazilians in areas with little access to healthcare, and these cases have occurred despite

2318-465: The drug under license from Chemie Grünenthal. By the mid-1950s, 14 pharmaceutical companies were marketing thalidomide in 46 countries under at least 37 different trade names. In the US, representatives from Chemie Grünenthal approached Smith, Kline & French (SKF), now GlaxoSmithKline , with a request to market and distribute the drug in North America. A memorandum, rediscovered in 2010 in

2379-646: The drug was responsible for teratogenic deformities in children born after their mothers used it during pregnancies, prior to the third trimester. In November 1961, thalidomide was taken off the market due to massive pressure from the press and public. Experts estimate that thalidomide led to the death of approximately 2,000 children and serious birth defects in more than 10,000 children, with over half of them in West Germany. The regulatory authorities in East Germany never approved thalidomide. One reason for

2440-487: The early phases of most clinical trials, which in practice led to their exclusion from later trial phases as well. This 1977 FDA guideline was implemented in response to a protectionist climate caused by the thalidomide tragedy. In the 1980s, a US task force on women's health concluded that a lack of women's health research (in part due to the FDA guideline) had compromised the amount and quality of information available about diseases and treatments affecting women. This led to

2501-405: The evidence for these uses is weak. It is recommended only as a third line treatment in graft-versus-host-disease in adults because of lack of efficacy and side effects observed in clinical trials. Prescriptions of thalidomide are accompanied by strict measures to avoid any possibility of use during pregnancy, and thalidomide should be avoided in women wanting to conceive. In the United States,

Kefauver–Harris Amendment - Misplaced Pages Continue

2562-426: The examination include: A patch test may be ordered, for diagnostic purposes. Treatment differs according to which rash a patient has been diagnosed with. Common rashes can be easily remedied using steroid topical creams (such as hydrocortisone ) or non-steroidal treatments. Many of the medications are available over the counter in the United States. The problem with steroid topical creams i.e. hydrocortisone;

2623-476: The fever starts. It classically starts at the head, and spreads downwards. Common causes of rashes include: Uncommon causes: The causes of a rash are numerous, which may make the evaluation of a rash extremely difficult. An accurate evaluation by a provider may only be made in the context of a thorough history, i.e. medications the patient is taking, the patient's occupation, where the patient has been and complete physical examination. Points typically noted in

2684-487: The first commercially useful derivative. Revlimid is available only in a restricted distribution setting to avoid its use during pregnancy. Further studies are being conducted to find safer compounds with useful qualities. Another more potent analog, pomalidomide , is now FDA approved. Additionally, apremilast was approved by the FDA in March 2014. These thalidomide analogs can be used to treat different diseases, or used in

2745-784: The human food supply. Sources Thalidomide Thalidomide , sold under the brand names Contergan and Thalomid among others, is an oral medication used to treat a number of cancers (e.g., multiple myeloma ), graft-versus-host disease , and many skin disorders (e.g., complications of leprosy such as skin lesions ). Thalidomide has been used to treat conditions associated with HIV : aphthous ulcers , HIV-associated wasting syndrome , diarrhea, and Kaposi's sarcoma , but increases in HIV viral load have been reported. Common side effects include sleepiness , rash , and dizziness . Severe side effects include tumor lysis syndrome , blood clots , and peripheral neuropathy . Thalidomide

2806-489: The initially unobserved side effects of the drug and the subsequent approval in West Germany was that at that time drugs did not have to be tested for teratogenic effects. They were tested for toxicity on rodents only, as was usual at the time. In the UK, the British pharmaceutical company The Distillers Company (Biochemicals) Ltd, a subsidiary of Distillers Co. Ltd (now part of Diageo plc ), marketed thalidomide throughout

2867-443: The lead compound into a suitable drug: the result was thalidomide. The toxicity was examined in several animals, and the drug was introduced in 1956 as a sedative, but it was never tested on pregnant women. Researchers at Chemie Grünenthal found that thalidomide was a particularly effective antiemetic that had an inhibitory effect on morning sickness . On 1 October 1957, the company launched thalidomide and began marketing it under

2928-543: The molecule is called chiral inversion. Celgene Corporation originally synthesized thalidomide using a three-step sequence starting with L -glutamic acid treatment, but this has since been reformed by the use of L -glutamine . As shown in the image below, N -carbethoxyphthalimide (1) can react with L -glutamine to yield N -phthaloyl- L -glutamine (2). Cyclization of N -phthaloyl- L -glutamine occurs using carbonyldiimidazole , which then yields thalidomide (3). Celgene Corporation's original method resulted in

2989-602: The patient's doctor to try thalidomide, and that doctor conducted a clinical trial of thalidomide for people with multiple myeloma in which about a third of the subjects responded to the treatment. The results of that trial were published in the New England Journal of Medicine in 1999. After further work was done by Celgene and others, in 2006 the US ;Food and Drug Administration granted accelerated approval for thalidomide in combination with dexamethasone for

3050-468: The prescribing doctor is required to ensure that contraception is being used, and that regular pregnancy tests are taken. Thalidomide causes birth defects . The U.S. Food and Drug Administration (FDA) and other regulatory agencies have approved marketing of the drug only with an auditable risk evaluation and mitigation strategy that ensures that people using the drug are aware of the risks and avoid pregnancy; this applies to both men and women, as

3111-425: The program include limiting prescription and dispensing rights to authorized prescribers and pharmacies only, keeping a registry of all patients prescribed thalidomide, providing extensive patient education about the risks associated with the drug, and providing periodic pregnancy tests for women who take the drug. In 2010, the World Health Organization stated that it did not recommend thalidomide for leprosy due to

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3172-474: The researchers could still not achieve the hypnotic effect in animals that it had on humans. After completion of the trial, and based on reasons kept hidden for decades, SKF declined to commercialize the drug. In 1958, Chemie Grünenthal reached an agreement with the William S. Merrell Company in Cincinnati, Ohio ( later Richardson-Merrell , now part of Sanofi ), to market and distribute thalidomide throughout

3233-424: The trade name Contergan. It was proclaimed a "wonder drug" for insomnia , coughs, colds and headaches. During that period, the use of medications during pregnancy was not strictly controlled, and drugs were not thoroughly tested for potential harm to the fetus . Thousands of pregnant women took the drug to relieve their symptoms. At the time of the drug's development, scientists did not believe any drug taken by

3294-405: The treatment of newly diagnosed multiple myeloma patients. It was also evaluated whether thalidomide can be combined with melphalan and prednisone for patients with multiple myeloma. This combination of drugs probably results in an increase of the overall survival. In the late 1950s and early 1960s, more than 10,000 children in 46 countries were born with deformities, such as phocomelia , as

3355-477: The urgent market need for antibiotics. Heinrich Mückter was appointed to head the discovery program based on his experience working with the German army's antiviral research. While preparing reagents for the work, Mueckter's assistant Wilhelm Kunz isolated a by-product that was recognized by pharmacologist Herbert Keller as an analog of glutethimide , a sedative . The medicinal chemistry work turned to improving

3416-466: Was called on to perform tests and report the results. The company demanded approval six times, and was refused each time. The distribution for "testing" resulted in 17 children born in the US with thalidomide-induced malformations. Oldham Kelsey was awarded the President's Award for Distinguished Federal Civilian Service by President Kennedy in 1962 for not allowing thalidomide to be approved for sale in

3477-446: Was first marketed in 1957 in West Germany, where it was available over-the-counter . When first released, thalidomide was promoted for anxiety , trouble sleeping , "tension", and morning sickness . While it was initially thought to be safe in pregnancy, concerns regarding birth defects arose, resulting in its removal from the market in Europe in 1961. The total number of infants severely harmed by thalidomide use during pregnancy

3538-531: Was higher in all people with cancer, but especially high in people with blood cancers, and other evidence emerged as well. Meanwhile, a member of his lab, Robert D'Amato, who was looking for angiogenesis inhibitors , discovered in 1994 that thalidomide inhibited angiogenesis and was effective in suppressing tumor growth in rabbits. Around that time, the wife of a man who was dying of multiple myeloma and whom standard treatments had failed, called Folkman asking him about his anti-angiogenesis ideas. Folkman persuaded

3599-445: Was not known until the twenty-first century, although efforts to identify thalidomide's teratogenic action generated more than 2,000 research papers and the proposal of 15 or 16 plausible mechanisms by 2000. The primary mechanism of action of thalidomide and its analogs in both their anti-cancer and teratogenic effects is now known to be as cereblon E3 ligase modulators. Thalidomide also binds to and acts as an antagonist of

3660-484: Was put on the market on October 23 of the same year. Two months after Talimol went on sale, pharmaceutical companies sent physicians letters warning about the risk of birth defects. It was not until March 1962 that both drugs were banned from the Canadian market by the directorate, and soon afterward physicians were warned to destroy their supplies. In 1964, Israeli physician Jacob Sheskin administered thalidomide to

3721-525: Was signed by President John F. Kennedy on October 10, 1962. The Kefauver–Harris Amendment strengthened the U.S. Food and Drug Administration 's control of experimentation on humans and changed the way new drugs are approved and regulated. Before the Thalidomide scandal in Europe, and Canada, U.S. drug companies only had to show their new products were safe. After the passage of the Amendment, an FDA New Drug Application (NDA) would have to show that

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