by Giuliana Miglierini
The first version of the Union list of critical medicines was published on 12 December 2023 by the European Commission, the European Medicines Agency (EMA) and the Heads of medicines Agencies (HMA).
The initiative is part of the actions planned according to the Pharmaceutical Strategy and the Communication on addressing medicine shortages in the EU. A Q&As documentwas also published to illustrate the main features of the list, together with the methodology to identify critical medicinesto be included in the list (see the dedicated webpage of EMA’s website). The first version of the Union list of critical medicines is comprehensive of approx. 200 active substances, selected starting from a pool of more than 600 referred to in the national lists of critical medicines of Finland, France, Germany, Portugal, Spain, and Sweden. These six countries were chosen as their lists were based on criteria aligned with those agreed for the Union list. The process also comprised consultations of key stakeholders, including patients and healthcare professionals’ organisations and industry associations.
The list will be updated annually, and further references will be added in 2024. The final list will also include the separate assessment of the vulnerability of the supply chains to be run by the European Commission.
The Union list will not replace existing national lists of critical medicines, that will continue to support national policy decisions. EU member states may also use the Union list to create their own national lists, if not yet available.
“Ensuring an uninterrupted supply of critical medicines is essential for a strong European Health Union. With the publication of the first Union list of critical medicines today, we are delivering on our promise to accelerate work in this area and to take every possible measure to avert the risk of shortages for our citizens”, said Stella Kyriakides, Commissioner for Health and Food Safety.
A list to prevent shortages
The Union list of critical medicines represents a warning about the importance of avoiding shortages for specific medicines, as they would highly impact both patients and healthcare systems. No immediate effect is expected on shortages, but the risk might decrease in the longer term.
The Union list specifies human medicines (both innovators and generics, vaccines, and medicines for rare diseases) those continued supply is considered a priority in the EU. It will be used by the EU Commission, EMA and HMA for the definition of proactive measures to strengthen the supply chain and minimise the risk of supply disruptions (see more on EMA’s webpage on Availability of critical medicines).
The Union list of critical medicines will also serve as the basis for the Commission to run the analysis of vulnerabilities, followed by recommendation of suitable measures in consultation with the Critical Medicines Alliance (we wrote about this part 1 and part 2). The Commission may issue recommendations for companies to diversify suppliers or increase production within the EU. Incentives to invest may also be used to favour the resilience of European manufacturing. As for procurement, strong contractual obligations for delivery may apply.
Medicines included in the Union list will also be prioritised for actions by the European medicines regulatory network, in charge of monitoring their availability and implementing measures to minimise the risk of supply disruptions. To this instance, existing processes and structures will be used as defined in the mandate of EMA’s Medicine Shortages Single Point of Contact (SPOC) Working Party and EMA’s Executive Steering Group on Shortages and Safety of Medicinal Products (MSSG).
No additional obligations have been introduced by now for marketing authorisation holders and national competent authorities. This will be a topic of discussions during the final phase of negotiations on the proposed revision of the EU pharmaceutical legislation.
The methodology to select critical medicines
The therapeutic indication and the availability of alternative medicines are the two main criteria for the insertion of a certain medicinal product in the Union list of critical medicines. Additionally, it has to be classified as critical in at least one-third (33%) of EU/EEA (European Eco-nomic Area) member states.
National lists of critical medicines may differ from one another, reflecting differences of the internal evaluation criteria used to assess criticality. For example, some products are marketed just in some countries, or alternatives are available in some countries and not in others. Furthermore, the Union list is still incomplete, as some important medicines have not yet been assessed at the central level. The Union list does not include as well products mentioned in the WHO list of essential medicines. Orphan medicines are included in the Union list if they meet the above-mentioned assessment criteria.
The document on methodology further clarifies the governance of the process and the matrix for identifying medicines to be included in the Union list of critical medicines. The methodology was created starting in 2021 (European Commission Structured Dialogue initiative), finalised by the HMA/EMA Task Force on the availability of authorised medicines for human and veterinary use (HMA/EMA TF-AAM), and finally adopted in June 2023.
The medicinal product criticality is evaluated on the basis of a risk assessment. As for therapeutic indications (criterion 1), all authorised medicines in a member state should be classified, irrespective of their marketing status. Criterion 2 refers to the availability of alternatives, and only authorised medicines marketed in the respective member state should be classified.
A low, medium or high-risk level is assigned for each of the two above-mentioned criteria, thus resulting in a risk matrix. The exercise allows to assign the medicine in one of the following categories: critical medicines, medicines at risk, other medicines.
Medicines considered at high risk with respect to their therapeutic indication refers to products those use may have very serious implications for the health of individual patients or public health (general life-threatening acute conditions, specific life-threatening acute conditions, or irreversibly progressive conditions). Evaluation parameters include the fact the disease is potentially fatal, irreversibly progressive or, if left untreated, will pose an immediate threat to the patients. Furthermore, the treatment must be administered immediately or within regular dosing intervals, and the product has to be part of a national disease control program.
Appropriate alternatives are identified according to the fact they are authorised for the same therapeutic indication and are available on the market in the respective member state. Furthermore, alternative treatment has to be clinically possible, without negative impact on the patient’s health and providing the same quality of care standard. As for criterion 2, high risk cri-tical medicines refer to products for which no appropriate alternative is available, or only one appropriate alternative (product) on ATC level 4 or 5 (same active substance or alternative is within the same ATC level 4 group or in another ATC level 4 group) is available.
Public consultation for the review of HERA
We inform all interested EIPG’s members that the public consultation for the review of the Health Emergency Preparedness and Response Authority (HERA) is open until 19 February 2024 and it can be accessed through the dedicated webpage of the EU Commission website.
The consultations aim to assess how HERA’s mandate and tools contributed to achieve EU’s political objectives, and how the Authority complements the work of other EU bodies and responds to the current health challenges.