John Talbot, Senior Lecturer, University of Hertfordshire, UK. Formerly Director, Global Drug Safety, AstraZeneca R&D Charnwood, Loughborough, Leicestershire, UK

Jeffrey Aronson, Reader in Clinical Pharmacology, University of Oxford, Oxford, UK and President Emeritus of the British Pharmacological Society

The detection and evaluation of adverse drug reactions is crucial for understanding the safety of medicines and for preventing harm in patients. Not only is it necessary to detect new adverse drug reactions, but the principles and practice of pharmacovigilance apply to the surveillance of a wide range of medicinal products.
Stephens' Detection and Evaluation of Adverse Drug Reactions provides a comprehensive review of all aspects of adverse drug reactions throughout the life cycle of a medicine, from toxicology and clinical trials through to pharmacovigilance, risk management, and legal and regulatory requirements. It also covers the safety of biotherapeutics and vaccines and includes new chapters on pharmacogenetics, proactive risk management, societal considerations, and the safety of drugs used in oncology and herbal medicines.
This sixth edition of the classic text on drug safety is an authoritative reference text for all those who work in pharmacovigilance or have an interest in adverse drug reactions, whether in regulatory authorities, pharmaceutical companies, or academia.
Praise for previous editions
"This book presents a comprehensive and wide-ranging overview of the science of pharmacovigilance. For those entering or already experienced in the pharmaceutical sciences, this is an essential work." - from a review in E-STREAMS
"...a key text in the area of pharmacovigilance...extensively referenced and well-written...a valuable resource..." - from a review in The Pharmaceutical Journal

Foreword xi
Preface to the Sixth Edition xiii
List of Contributors xv
Acknowledgements xvii
1 Adverse Drug Reactions: History, Terminology, Classification, Causality, Frequency, Preventability 1
Jeffrey K. Aronson
1.1 Introduction 1
1.2 Defining pharmacovigilance 1
1.3 The modern history of pharmacovigilance 3
1.4 Terminology and definitions in pharmacovigilance 6
1.5 Medication errors 25
1.6 Pharmacological classification of adverse drug reactions 32
1.7 Drug interactions 53
1.8 Reporting suspected adverse drug reactions 59
1.9 Causality assessment 64
1.10 Frequencies of adverse drug reactions 69
1.11 Risk perception and adverse drug reactions 77
1.12 Class effects of drugs 78
1.13 Unlicensed indications, off-label uses, and orphan drugs 80
1.14 Preventing adverse drug reactions 84
1.15 Publishing accounts of adverse drug reactions 95
References 101
2 Pharmacogenetics of Adverse Drug Reactions 121
Sudeep P. Pushpakom and Munir Pirmohamed
2.1 Introduction 121
2.2 Historical review 121
2.3 Sources of genetic variability 122
2.4 Role of pharmacogenetic factors in drug pharmacokinetics 123
2.5 Role of pharmacogenetic factors in drug pharmacodynamics 133
2.6 The role of pharmacogenetics in pharmaceutical companies 139
2.7 The impact of pharmacogenetics on regulatory agencies 141
2.8 The impact of pharmacogenetics on clinical practice 143
2.9 Conclusions 145
References 145
3 Toxicology and Adverse Drug Reactions 157
D. J. Snodin and A. Suitters
3.1 Introduction 157
3.2 Toxicity testing 157
3.3 Drug discovery and development 168
3.4 Data interpretation and risk assessment 174
3.5 Adverse drug reactions detected after marketing authorization 186
3.6 Examples of toxicological investigation of ADRs 199
3.7 Conclusions 200
Acknowledgements 201
References 201
4 Clinical Trials--Collecting Safety Data and Establishing the Adverse Drug Reactions Profile 215
John Talbot, Marianne Keisu, and Lars St°ahle
4.1 Introduction 215
4.2 Adverse events 216
4.3 Clinical studies and safety 236
4.4 The emerging safety profile 267
4.5 Presentation of safety data 271
4.6 Conclusions 280
References 281
5 Clinical Laboratory Safety Data 291
Alan Craig
5.1 Introduction 291
5.2 Factors that influence the interpretation of clinical laboratory data 294
5.3 Sample collection procedure 300
5.4 Analytical variation 301
5.5 Reference ranges 304
5.6 Intra-individual biological variation 307
5.7 Detecting adverse events during drug development 309
5.8 Test selection 333
5.9 Exclusion criteria and "panic levels" 335
5.10 Harmonization of data from different laboratories 337
5.11 Data analysis and presentation 339
5.12 Conclusions 344
5.13 Appendix 345
References 346
6 Statistics: Analysis and Presentation of Safety Data 349
Stephen J. W. Evans and Dorothea Nitsch
6.1 Introduction and background 349
6.2 Problems with efficacy trials for detecting adverse drug reactions 352
6.3 Analysis and presentation of data from trials 355
6.4 Statistical measures of the occurrence of adverse events 356
6.5 Combining data from several trials--meta-analysis 364
6.6 Use of statistical methods for signal detection from spontaneous reports 365
6.7 Analysis and presentation of data from observational studies 373
6.8 Summary and conclusions 384
Acknowledgements 385
References 386
7 Proactive Pharmacovigilance and Risk Management 389
June Raine, Lesley Wise, John Talbot, and Jeffrey K. Aronson
7.1 Introduction 389
7.2 Risk management--definition and general principles 390
7.3 Defining the knowledge base--the safety specification 391
7.4 Extending the knowledge of safety and characterizing risk--the pharmacovigilance plan 394
7.5 Minimizing risks 395
7.6 Special challenges for risk management 397
7.7 Experience with risk evaluation and mitigation strategies (REMS) in the USA 398
7.8 A possible method for risk management when a new adverse reaction is discovered after marketing 399
7.9 Future challenges for risk management 405
7.10 Conclusions 406
References 407
8 Regulatory Aspects of Pharmacovigilance 411
Kristina Leila Strutt and Barry David Charles Arnold
8.1 Introduction 411
8.2 The standardization and harmonization of safety data collection and reporting: CIOMS and ICH 412
8.3 The European Union 447
8.4 The UK 481
8.5 France 483
8.6 Germany 485
8.7 USA 487
8.8 Japan 500
Acknowledgements 505
References 506
Useful web sites 509
9 Legal Aspects of Pharmacovigilance in the European Union 511
Christine H. Bendall
9.1 Introduction 511
9.2 Application of EU legislation in Member States 511
9.3 Interpretation of EU law 514
9.4 Relationship between law and guidelines 515
9.5 Issues in interpreting EU pharmacovigilance legislation 517
9.6 Legal responsibility for pharmacovigilance activities 519
9.7 Failures to meet pharmacovigilance requirements 522
9.8 Enforcement and sanctions 524
9.9 European powers and procedures in the event of a product safety issue 528
9.10 Civil liability 534
9.11 Personal data privacy 537
9.12 Safety in research products 538
References 541
10 Dictionaries and Coding in Pharmacovigilance 545
E. G. Brown and J. E. Harrison
10.1 Introduction 545
10.2 Scope of this chapter 546
10.3 What is a dictionary? 546
10.4 Drug dictionaries 547
10.5 Disease classifications 554
10.6 Medical Dictionary for Regulatory Activities, MedDRA R557
10.7 Common Terminology Criteria for Adverse Events (CTCAE) 567
10.8 Definition of adverse reaction terms 567
10.9 Dictionaries used in electronic health records 568
10.10 Use of dictionaries in standard product information 570
10.11 Conclusions 571
Acknowledgements 571
References 571
11 Adverse Drug Reactions: Societal Considerations 573
Nicky Britten
11.1 Introduction 573
11.2 Adverse drug reactions at the population level 574
11.3 The social production of ADRs 576
11.4 Trust 579
11.5 Information about ADRs 581
11.6 Conclusions 583
References 583
12 Safety of Biotherapeutics 585
Andrew Erdman, James Nickas, and Benton Brown
12.1 Introduction 585
12.2 Properties of proteins 586
12.3 Classification of biotherapeutics 587
12.4 Monitoring for adverse events due to biotherapeutics 589
12.5 Conclusions 598
References 598
13 Vaccine Safety Surveillance 603
E. Miller and J. Stowe
13.1 Introduction 603
13.2 What is special about vaccine safety compared with other drugs? 604
13.3 Pathogenesis of vaccine reactions 605
13.4 Criteria for establishing causality after vaccine-related adverse events 608
13.5 Pre-licensing evaluation of vaccine safety 610
13.6 Objectives of an ideal post-licensing vaccine safety surveillance system 611
13.7 Conclusions 620
References 620
14 Assessing the Safety of Drugs Used in Oncology 625
Anne Kehely
14.1 Introduction 625
14.2 Factors to consider when assessing the safety of drugs used in oncology 627
14.3 Sources of adverse effect data 632
14.4 Nature of the data 634
14.5 Assessment of adverse effects data in oncology 635
14.6 Conclusions 641
References 642
15 Adverse Drug Reactions and Pharmacovigilance of Herbal Medicines 645
Joanne Barnes
15.1 Introduction 645
15.2 Herbal medicines: definitions and descriptions 646
15.3 Characteristics of herbal medicines 647
15.4 Regulation of herbal medicines and pharmacovigilance requirements 648
15.5 Access to and use of herbal medicines 655
15.6 Adverse reactions associated with herbal medicines 656
15.7 Methods for pharmacovigilance of herbal medicines 666
15.8 Responding to safety concerns associated with herbal medicines 673
15.9 The future for pharmacovigilance of herbal medicines 674
15.10 Conclusions 675
References 676
Appendix 1 Web Sites Relevant to Pharmacovigilance--An Analysis of Contents 685
Charlotte I. S. Barker, John Talbot, and Jeffrey K. Aronson
A1.1 Introduction 685
A1.2 Ten national pharmacovigilance web sites 685
A1.3 Twelve institutional web sites 689
Acknowledgements 697
References 697
Appendix 2 Guidelines and a Checklist for Reporting Suspected Adverse Drug Reactions Anecdotally in Journals 699
Jeffrey K. Aronson
A2.1 Introduction 699
A2.2 Notes on the checklist 700
A2.3 Conclusions 706
Note 706
References 706
Index 709