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> Definition and content

Therapeutic patient education (TPE) can be defined in several ways.

The World Health Organization (WHO) gave the following definition in 1996: “Therapeutic patient education aims to help patients acquire or maintain the skills they need to manage their lives with a chronic disease”.

In 2007, the French National Authority for Health (HAS) clarified the specific aims of therapeutic education:

– The acquisition and maintenance by the patient of self-care skills;

– The mobilization or acquisition of coping skills”.

Under the French law no. 2009-879 of July 21, 2009 on hospital reform and patients, health and territories (known as the HPST law), TPE is defined as being “[…] part of the patient’s care pathway. Its aim is to make patients more autonomous by facilitating their compliance with prescribed treatments and improving their quality of life. It is not enforceable against the patient and cannot condition the rate of reimbursement for his or her treatment or for drugs related to his or her illness”.

ETP, as provided for in the French Public Health Code, is divided into three distinct actions:

– Therapeutic patient education programs, which comply with national specifications, are implemented at local level after registration with regional health agencies (ARS). They are proposed to the patient by a healthcare professional and lead to the development of a personalized program;

– Accompaniment programs, which comply with national specifications, are designed to provide assistance and support to patients and their families in managing their disease;

– Learning programs are designed to help patients acquire the technical skills they need to use a medicine/Auto-administration. These programs are implemented by healthcare professionals working on behalf of an operator who may be financed by the company exploiting the medicine. The learning program is proposed by the prescribing physician to the patient. In this case, the ANSM authorizes their implementation, after consulting an approved patient association To this end, the manufacturer submits a training application, justifying the expected benefits for the patient.

> ETP objectives

ETP is based on an individualized approach, considering the specific characteristics of each patient. It involves close collaboration between the patient, healthcare professionals and often the patient’s family and friends. The aim is to foster an in-depth understanding of the disease, its implications and associated treatments. This approach encompasses not only the medical aspects, but also the psychological, social and environmental aspects of health.

– Understanding the disease: ETP enables patients to understand the mechanisms of their disease, their symptoms, treatments and effects. Better knowledge helps patients adhere to treatment and prevent complications.

– Skills acquisition: Patients learn to manage their treatment, recognize the early signs of complications and adopt healthy lifestyle habits.

– Autonomy and decision-making: ETP aims to reinforce patients’ autonomy by giving them the tools they need to actively participate in decisions concerning their health.

> Who can set up this type of program?

> Manufacturers and their medicines, at the heart of TVE… but with less room for manoeuvre:

– Ever more innovative medicines

– Pathologies requiring increasingly advanced patient knowledge/technical gestures

– Image and communication issues, as well as the promotion of public health, may lead the laboratory to wish to support an ETP program especially when self-administering drugs.

In order to remain compliant, it is essential for manufacturers wishing to leverage the benefits of ETP to be aware of the roles and levels of involvement they are allowed to play.

Finally, implementing a TVE program without being authorized to do so is punishable by a fine of up to 30,000 euros.

> Conclusion

Therapeutic patient education represents a major evolution in the way we approach health and illness. In a world where it is becoming commonplace for patients to become experts in their own disease, they are a tool for them to understand, actively participate in their treatment and adopt health-promoting behaviors, while contributing to comprehensive, personalized care.

However, the role of the operator of a medicine is regulated and requires a case-by-case analysis of each project.

In such a context, manufacturers have a role to play, while considering the regulatory complexity imposed by the system and the need to steer clear of the multiple risks associated with their highly regulated field of activity (promotional requalification, contact with patients, granting benefits to patients or healthcare professionals).

Article written by Zarine RAMJAUNY, Legal Advisor

Following the “Médiator” case and inspired by the Sunshine Act in the United States, the law of December 29, 2011, concerning the strengthening of health safety, known as the “Bertrand Law,” was passed.

This law establishes systematic transparency of links between health industries on one hand, and other actors in the health field on the other. This primarily includes healthcare professionals, but also students, learned societies, associations, media, etc.

The “transparency of links” system, which provides the general public with information on the relationships between health industries and members of the health system, is in line with the “regulation of benefits” system, which aims at the ethics of healthcare professionals. These two legislations interact with each other, with some subtle specificities that distinguish them.

Who is Affected by the System?

The following actors are concerned:

Types of Declaration and Publication

It is appropriate to publicly disclose retrospectively:

• Agreements: publication of all contracts made between laboratories and a health actor (for example: agreements with coverage of hospitality expenses (catering, transport, accommodation, registration fees at a congress));

• Service provision contracts (for example: remuneration for clinical expert work);

• Benefits exceeding 10 euros including taxes (for example, the granting of health product samples);

• Remunerations awarded (for example: remuneration of a healthcare professional for speaking at an event).
  
  
  

Commercial contracts are excluded.

The typology of benefits and agreements responds to precise definitions that have been clarified by the authorities.

The system requires that pharmaceutical companies, in particular, are obliged to publish information on the public database https://www.transparence.sante.gouv.fr, according to the following frequency:

• Publication twice a year:

• First calendar semester, i.e. from January 1st of year N to June 30th of year N: submission on the “transparency-health” website by September 1st of year N.

• Second half of the calendar year, i.e. from 1 July of year N to 31 December of year N: submission on the “transparency in health” website no later than 1 March of year N+1.

Thus, the general public can access the work links and professional relationships maintained between health industries and actors in the French healthcare system.

In parallel, the European Federation of Pharmaceutical Industries and Associations (EFPIA) has also adopted the “EFPIA code of practice” to frame collaboration with Healthcare Professionals or their Organizations when conflicts of interest exist. This text is applicable to member companies.

ATESSIA supports its clients on all these questions.

Article written by Zarine RAMJAUNY, Junior Legal Consultant

Atessia supports its clients daily in the practical modalities of implementing the French early and compassionate access system, whose subtleties require some explanations. 

On July 1, 2021, the new early and compassionate access system was introduced through 2 decrees, supplemented by 4 orders, with immediate effect. This new system is based on 2 mechanisms for access and coverage by health insurance: 

• Early Access (AAP)  

Firstly, early access, which targets medicinal products that meet an unmet therapeutic need and may be innovative. The laboratory submits a request for early access authorization (AAP) to the High Authority for Health (HAS) and, for medicinal products not yet authorized under a Marketing Authorization (AMM), to the National Agency for the Safety of Medicines and Health Products (ANSM).  

These authorizations can apply to: 

• A medicinal product prior to obtaining the AMM in the considered indication (Pre-AMM AAP = AP1), 
• A medicinal product that already has an AMM in the considered indication, prior to common law coverage by health insurance (Post-AMM AAP = AP2) Interestingly, the product may or may not have an AMM for another indication. As per HAS doctrine, granting early access authorization is reserved for certain specialties meeting the following 5 cumulative eligibility criteria: 

1. Strongly presumed efficacy and safety in the considered indication. 

2. The disease to be treated is severe, rare, or disabling. 

3. There is no “appropriate treatment.” 

4. The implementation of treatment cannot be delayed. 

5. The medicinal product is presumed to be innovative.  

The authorities examine each of these criteria separately, in a relatively strict manner. 

This system also requires concrete commitments from laboratories, which should not be underestimated and need to be weighed with the parent company. 

• From a REGULATORY standpoint: the laboratory must commit to filing an AMM request within 2 years for an AAP1 or a request for registration within the month following the AMM’s approval for an AAP2. Thus, the timing of the filing is crucial in the project. 
• From a LOGISTICAL standpoint: the laboratory makes the product available within 2 months following the granting of the AAP (PUI) and ensures it can supply the product to allow continuity of treatments initiated during the entire AAP, for a minimum period of one year (including 3 months of coverage). 
• From a FINANCIAL standpoint: the laboratory implements a PUT-RD, for data collection and transmission of periodic summary reports. The laboratory finances this data collection (cf. agreement to be signed with health establishments). 
• The pharmaceutical laboratory is also required to assist prescribers in entering and monitoring the collection of real-life follow-up data of the medicinal product, providing them with the necessary means. 

Two types of compassionate access: 

This system targets two distinct cases, both involving a medicinal product to treat patients with diseases without appropriate treatment in a given therapeutic indication, without being intended to obtain an AMM in France. The requests are managed only by the National Agency for the Safety of Medicines and Health Products (ANSM). 

1. Either this compassionate access is requested for an unauthorized and unavailable medicinal product in France by a hospital prescriber for a specifically named patient, provided that the ANSM can presume a favorable benefit/risk ratio for a severe, rare, or disabling disease: this is an individual and nominative compassionate access authorization (AAC). 

2. Or it involves the regulation of a practice, initiated by the ANSM, to secure an off-label prescription practice of a medicinal product available in France, with an AMM for other indications, when it is subject to a well-established off-label prescription on French territory: this is a compassionate prescription framework (CPC).  

Exemptions to compassionate access have been foreseen in the following cases: 

• Allowing nominative access to medicinal products in development for the indication: this is a “very early” compassionate access. 

The grant by the ANSM is subject to several eligibility conditions, which brings this system closer to early access and can be the gateway to it: 

• The implementation of the treatment cannot be delayed; 
• The patient cannot participate in any ongoing research; 
• The company marketing the medicinal product must commit to filing an early access request within 12 months following the first “pre-precoce compassionate” authorization (18 months for rare diseases). 

For these mechanisms, the designation of a laboratory operating a medicinal product may be necessary, to ensure, if necessary, the import/distribution, pharmacovigilance, quality complaints, or medical information. 

The laboratories now have several years of experience with these new systems, and the emerging trends show the authorities’ willingness to make innovative medicinal products available to French patients and to respond to the personal situations of patients in therapeutic dead ends. 

Article written by Caroline LECUELLE, Consultant in Regulatory Affairs & Pharmaceuticals 

From a legislative point of view, the mutual recognition procedure is defined by the Directive 2001/83/EC of the European Parliament and of the Council of 6 November 2001 on the Community code relating to medicinal products for human use. 

Directive 2004/27/EC subsequently laid the foundations for the decentralised procedure. 

These two procedures are available for all marketing authorisation applications that do not fall within the mandatory scope of the centralised procedure. They are applicable whenever an applicant wishes to register its medicinal product in more than one Member State.  

1/ The Mutual Recognition Procedure (MRP) 

Article 28.2 of Directive 2001/83/EC, as amended, specifies the scope of this procedure: the principle is to extend a national MA already obtained in one of the EU Member States, to one or more other Member States in which the laboratory wishes to market its product. The referent state (or “RMS”), which granted the existing MA, manages the procedure. 

Once the evaluation procedure has been completed, the MAs are issued by each of the competent authorities of the member states concerned. 

Timetable 

After a possible upgrade of the MA dossier, the RMS sends the MA dossier and its assessment report, including the SPC, package leaflet and labeling, to the CMS 14 days before the start of the procedure.  

The concerned Member States must then recognize the authorization already issued by the RMS within 90 days (without clock-stop).  

The procedure may, however, end on Day 60 if the RMS has no further comments.  

The MA (including the SPC, package leaflet and labeling) is recognized by the CMS. 

This period is followed by a 30-day national closing phase to issue the national MA. 

If a Member State has objections to recognizing the dossier’s assessment report, summary of product characteristics (SPC), package leaflet and labeling, on the grounds of a potentially serious risk to public health (as defined by Article 29(1) of Directive 2001/83/EC), the dossier is referred back to the CMDh for further discussion. This procedure lasts 60 days. If the CMDh is unable to reach a decision within 60 days, the application is sent to the CHMP for arbitration (art. 29(4) of Directive 2001/83/EC). This procedure also lasts 60 days. 

2/ The decentralized procedure (DCP) 

This procedure differs from the MRP in two main points :  

• No marketing must first have been granted in the EU,  
• The dossier is submitted simultaneously in all Member States.  

In this case, the laboratory asks a member state to act as reference state (“RMS”) for the evaluation among the states in which it wishes to authorize its medicinal product. 

Timetable 

The RMS draws up a preliminary assessment report on the dossier submitted and the draft summary of product characteristics (SPC), package leaflet and labeling. 

This report is submitted to the CMS and the applicant for comments on Day 70 of the procedure. 

On Day 105 of the procedure, the clock stops to allow the applicant to submit answers to the questions raised by the Member States at the end of phase 1. 

When the answers have been submitted, the clock starts again on Day 106, and on Day 120 of the procedure, the RMS circulates at the same time an update of all documents (assessment report, SPC, package leaflet and labeling) to the applicant and the CMS. 

A second phase of Questions and Answers begins, and the procedure may be closed on Day 150 if all comments have been resolved.  

Otherwise, a new 60-day phase begins to finalize outstanding issues.  

The DCP therefore lasts a maximum of 210 days. This period is followed by a 30-day national closing phase to issue the national MA. 

As with the MRP, if there is no consensus between member states, the dossier is referred back to the CMDh for further discussion. This procedure lasts 60 days. If the CMDh is unable to reach a decision within 60 days, the application is sent to the CHMP for arbitration (art. 29(4) of Directive 2001/83/EC). This procedure also lasts 60 days. 

To sum up: 

ATESSIA supports laboratories throughout the registration process: from the registration strategy to the draft and submission of the marketing authorization applications. 

Article written by Fabien MEDINA, Pharmaceutical and Regulatory Affairs Senior Advisor. 

*ANSM : Agence Nationale de Sécurité du Médicament et des produits de santé (competent authority for medicines and health products) 

Law No. 2023-451 dated June 9, 2023, which aims to regulate commercial influence and combat abuses by influencers on social media platforms, not only defines the concept of an “influencer”, but also introduces the notion of an “influencer’s agent”.

What is an Influencer?

Influencers are any “(…) natural or legal persons who, for a fee, mobilize their reputation among their audience to disseminate content to the public via electronic means. Their goal is to promote either directly or indirectly, goods, services or any cause. They engage in the activity of commercial influence through electronic means” (Article 1).

Examples include a patient, a healthcare professional or a person with a strong reputation.

What is an Influencer Agent?

” I. – An influencer agent’s role is to represent, for a fee, either natural or legal persons engaged int the activity of commercial influence through electronic means as defined in Article 1. This representation involves liaising with other natural or legal persons, and if relevant, their representatives, to promote goods, services or any cause, also for a fee.

II. – Individuals who undertake the activity defined in Section I of this article must take all necessary measures to safeguard f the interests of those they represent, to avoid situations that might lead to conflicts of interest and to ensure their actions align with the stipulation of the current law  (Article 7).

What are the Law’s Obligations?

Supervision of Sponsored Content:

This law creates an obligation for influencers to report any sponsored content. Specifically, any promotion of goods, services or a cause of any kind carried out by an influencer must systematically include the mention “Advertising” or “Commercial collaboration”. This mention must appear clearly, legibly and identifiably on the influencer’s image or video, whatever its format and for the entire duration of its broadcast.

• Supervision of Published Visuals:

Images should be labelled as “Retouched Images” if they undergo processing to slim or thicken a silhouette or modify face appearance.;

Images should be labelled as “Virtual images” if any artificial intelligence process has been used to generate or modify a face or silhouette.

• Supervision of Dropshipping Activities:

Influencers are obliged to provide the buyer with all pre-contractual information related to a distance sales agreement. This includes the identity of the supplier and confirmation of product availability. Failure to provide this information can result in influencers being held accountable.

What is Prohibited?

Direct or indirect promotion of the following products and services is prohibited:

• Aesthetic procedures, processes, techniques, and methods referred to in Article L. 1151-2 of the French Public Health Code, as well as interventions referred to in Article L. 6322-1 of the same code (including aesthetic medical devices (DMs) listed in Annex XVI of Regulation 2017/745 MDR);
• Procedures, processes, techniques, and methods presented as comparable to, preferable over or substitutes for therapeutic procedures, protocols, or prescriptions;
• Products considered as nicotine-based that can be consumed and are made, even partially, of nicotine.
  
  

What are the Penalties?

Violators may face a fine of up to 300,000 euros and a prison sentence of up to 2 years. To ensure consumer protection, a dedicated team has been set up within the DGCCRF (a French authority, Direction Générale de la Concurrence, de la Consommation et de la Répression des Fraudes), and reports can be submitted via the Signal conso website.

Existing sanctions are reinforced and graduated. The following acts are punishable:

• Failure to indicate the advertising nature of a video or photo posted by an influencer is now considered a misleading commercial practice;
• Promotion of a prohibited or regulated product carries the same penalties as online advertising;

Additionally, the authorities have been granted a new power of injunction with penalties. This allows them to compel an influencer to remove non-compliant content or for platforms to suspend the influencer’s account promptly.

Judges and supervisory authorities will tailor penalties according to the severity of the act.

What About Drugs and Medical Devices?

The promotion of medicines to the general public is regulated by the French Public Health Code. With the exception of class I or IIa medical devices, the promotion of a drug, medical device or IVDD to the general public based on a recommendation from people who, through their reputation, can encourage the consumption of the product in question, such as influencers on social networks, is already prohibited by the Public Health Code.

Need assistance in managing influencer communication under contract with your laboratory? Our expert consultants are available to discuss your concerns.

Article written by Zarine RAMJAUNY, Junior Legal Consultant

Promotional visit for medicinal products in France refers to promotional interactions with healthcare professionals (HCPs) conducted by authorized collaborators from the pharmaceutical industry.

The structural reform of health insurance established by the law of August 13, 2004, resulted in the first Charter of Medical Visit. The objective was to better regulate the commercial and promotional practices of laboratories that could harm the quality of care (creation of Article L.162-17-8 of the Social Security Code).

Since 2008, the scope of the charter has been broadened to include prescribers practicing in health institutions, and not just those from private practices. The latest version of the Charter, dated October 15, 2014, is now titled the “Charter on information provided for the promotion of medicinal products through prospecting or canvassing “

All pharmaceutical companies with an authorization to open as an “Exploitant” and having signed an agreement with the French Economic Committee for Health Products, CEPS, (reimbursable medicinal products), must commit to respecting the Charter, interpreted by a referential established by the High Authority for Health (HAS). The latest version of this reference system came into effect in March 2017. It is the practical application procedure of the Charter, and it is based on this procedure (certification reference system) that certifying bodies, accredited by the French Accreditation Committee (COFRAC), certify companies for their promotional activity. This procedure has two parts: one dedicated to the certification of the activity performed by the “Exploitant” companies themselves, on their own or in co-promotion, as well as the requirements that these companies must meet in the event of outsourcing all or part of their promotional activity. The second part is dedicated to the certification of the promotional activity performed by subcontracting companies.

Companies subject to this system must implement a quality management system that can sustainably meet the requirements of the Charter and its reference system:

• Definition, implementation, and monitoring of the quality policy for this activity.
• Initial/continuous training and knowledge evaluation of promotional collaborator  (7 regulatory themes and 2 scientific themes)
• Respect for ethical rules towards patients, health professionals, competing companies, their own company, and health insurance.
• Co-promotion and recourse to subcontracting (contract, responsibility, organization, and monitoring).

Pharmaceutical laboratories must prepare for annual certification audits (N: certification, N+1 surveillance, N+2 surveillance, N+3 renewal audit), regularly review their quality management system, monitor the activity of all cross-functional roles involved (marketing, regulatory affairs, medical, field staff: Medical Science Liaison (MSL) and promotional collaborators, etc.). Among the challenges, one is to ensure the regulatory compliance of promotional activity, which is one of the strategic pillars for companies.

Medicines are not the only ones concerned: the Quality Charter for professional practices for products and services reimbursable, published in the JO on March 8, 2022, will apply concomitantly to multiproduct companies, implying a double management of these Charters despite sometimes contradictory injunctions (see LunchWork Atessia x LexCase 20/04/22 “Quality Charter for professional practices for products and services reimbursable”).

It is interesting to note that the rules differ according to the product portfolio of the company: reimbursable or non-reimbursable medicinal products, Medical Devices, food supplements, cosmetics, biocides, everyday consumer products. Hospital visits are subject to additional rules.

The question of samples follows precise rules concerning both  the possible certification, the Law on the Regulation of Benefits, the requirement for transparency of links, the Good Manufacturing Practices (GMP).

What can promotional collaborator say? What can they give to doctors, and what must they give them? How to adapt the rules of the reference system with the digitalization of promotion and the advent of remote visits since the health crisis? And most importantly, what messages to deliver about the therapeutic indications of the marketing authorization , early or compassionate access, and off-label use, taking into account the therapeutic strategy established by the HAS? What part of the discourse should be devoted to job safety and side effects? How to talk about the results of clinical trials?

ATESSIA assists its clients in carrying out annual internal audits in preparation for the certification audits of Exploitant and their subcontractors, writing internal procedures, and training field teams.

Leslie Gorge, Regulatory & Pharmaceutical Affairs Consultant.

For more information

🌐 https://www.atessia.fr/fr/accueil/

Get in touch!

👤 Géraldine BAUDOT-VISSER

✉ hello@atessia.fr

📞 +33 764 273 693

The Chief Pharmaceutical Officer also called Responsible Pharmacist (RP) is a key role , essential to the organization of any pharmaceutical laboratory involved in the manufacture, exploitation and distribution of medicinal products for human use in France.

The Chief Pharmaceutical Officer ensures  the quality of the medicine and the safety of the patients. Their position, functions, and assignements are defined by the regulations. Their skills are validated by their peers based on practical experience. Their responsibilities are numerous. They must maintain their freedom of judgment and hold pharmaceutical authority within their structure. They can delegate some activities and must be replaced in case of absence.

Positions, functions and Assignements

The Chief Pharmaceutical Officer has a statutory position within a pharmaceutical establishment (manufacturer, operator, depositary or wholesaler-distributor).

They  organize and supervise all pharmaceutical activities: manufacturing and batch release, advertising, information, pharmacovigilance, follow up and withdrawal of batches, distribution, import and export, storage and transport.

The responsibilities attributed to the RP are broader than those of the qualified person within the European Union (directive 2001/83/EC, article 48). They have a personal responsibility for all pharmaceutical activities, unlike the qualified person who exercises operational responsibility for the activities they are responsible for (batch release, follow up and recall of batches, pharmacovigilance).

Their status as well as their functions and assignements are defined in the Public Health Code (Code de la Santé Publique CSP) in articles R.5124-16 to R.5124-41.

Validation of Skills and Practical Experience

Their skills and practical experience are validated by the National Council of the Order of Pharmacists. Decree No. 2022-324 of March 4, 2022, recently modified the terms of the practical experience required for the RP (CSP Articles R.5124-16 à R.5124-18).

The RP is appointed by the competent corporate body of the company and then declares themselves to the competent authority: the ANSM*.

The Responsibilities of the RP

The responsibilities of the RP are of three types:

• Legal and criminal liability
• They are a member of the management of the company.
• They are the main contact of the Health Authorities.
• They arepersonally responsible for the compliance of the pharmaceutical establishment with the Public Health Code.
• Disciplinary responsibility
• Respect for professional ethics
• Compliance with their deontologic obligations
• Civil liability

The RP shares civil and criminal liability with the manager(s) of the company.

Freedom of Judgment and Pharmaceutical Authority

Like any pharmacist, the RP preserves their freedom of professional judgment in the exercise of theirfunctions (CSP Article R.4235-3).

They have authority over all pharmaceutical staff (CSP Article R.5124-36) and appoints the delegate pharmacist(s).

Delegation and Replacement

The RP can delegate some pharmaceutical activities. The delegate pharmacist is bound, within the limits of their delegation, to the same obligations as the RP (CSP Article R.4235-68).

In the event of absence, the RP is replaced by an interim responsible pharmacist (CSP Article R.4235-70). The IRP then has the same functions, assignements, and responsibilities as the RP during the replacement period.

ATESSIA supports Chief Pharmaceutical Officer in the performance of their duties: regulatory intelligence, CMC support, advertising, pharmacovigilance, activities related to regulatory affairs and quality assurance, and offers Interim Responsible Pharmacists registered at the Pharmacists Council.

Article written by Christelle PETIT, Pharmaceutical Affairs Advisor and Director.

*ANSM : Agence Nationale de Sécurité du Médicament et des produits de santé (competent authority for medicines and health products)