In the Federal Register of March 18, 2008 (73 FR 14471), FDA published a 60day notice requesting public comment on the information collection provisions. We received the following comments:
(Comment 1) The comments said that FDA's estimate of the hourly burden for pharmacists to comply with the Medication Guide requirements is inaccurate, and that pharmacists spend significantly more time determining whether a Medication Guide is required, tracking appropriate Medication Guides from manufacturers or distributors, explaining to the patient what the Medication Guide is, in addition to patient counseling. The comments noted that FDA's estimate that a pharmacist spends 0.0014 hours (5 seconds) to distribute each Medication Guide remains unchanged since the December 1, 1998, final rule entitled ``Prescription Drug Product Labeling; Medication Guide Requirements,'' even though the Medication Guide program has continued to expand (63 FR 66378). The comments said that FDA's estimates are inadequate and fail to consider the operational realities pharmacists now face in complying with the program. The comments said that pharmacy personnel spend tens of thousands of hours obtaining and distributing Medication Guides for each new prescription and all refills for Medication Guide medications.

Response: FDA agrees with the comments. However, the comments did not suggest an alternative burden estimate for Medication Guide distribution by pharmacists. We are increasing the burden estimate for Sec. 208.24(e) to 3 minutes for each Medication Guide distributed by pharmacists. If the commenters believe that this estimate is insufficient, we request comments on why an alternative estimate would be more accurate. We are also increasing to 25 the number of Medication Guides that FDA receives per year under Sec. 208.20.
(Comment 2) The comments also said that there are distributor costs to comply with the Medication Guide requirements, and table 1 in the March 18, 2008, Federal Register notice omitted Sec. 208.24(c), which provides that ``Each distributor or packer that receives Medication Guides * * * shall provide those Medication Guides * * * to each authorized dispenser to whom it ships a container of drug product.'' The comments said that the burden to distributors and packers to distribute Medication Guidesthe process of tracking, sorting, matching, and shipping multiple versions of Medication Guides for multiple productsshould be included in the analysis.

Response: FDA agrees with the comments and is willing to include a burden estimate for Sec. 208.24(c). We are requesting comments on specific estimates for this requirement.
(Comment 3) The remaining issues raised by the comments in response to the March 18, 2008, Federal Register notice are generally the same as the issues raised during FDA's public hearing on the use of Medication Guides to distribute drug risk information to patients (announced in the Federal Register of April 9, 2007 (72 FR 17559)) and the same as the comments submitted to that docket. (One commenter also referenced comments previously submitted to FDA in the ``June 2006 White Paper on Patient Safety Implications on Implementation of the Current FDAMandated Medication Guide Program''). On July 2, 2007, FDA posted a ``Summary of Public Hearing on FDA's Use of Medication Guides to Distribute Drug Risk Information to Patients'' at http:// www.fda.gov/cder/meeting/SummaryPublicHearingMedicationGuides.htm. The issues raised in conjunction with the public hearing, as well as the comments summarized below, are still under consideration at FDA, and we have not yet decided what actions we will take in response to suggestions to modify the Medication Guide program.

The following is a summary of the comments received on the March 18, 2008, notice; these comments do not pertain to the specific burden estimates, but were taken into consideration by FDA.
(Comment 4) The comments said that despite stating in the Medication Guide final rule that FDA will use Medication Guides sparingly, the agency continues to add new Medication Guides for drugs in a manner inconsistent with its
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original intent. The comments said that FDA intended Medication Guides to be used only when a drug posed very serious or significant side effects, and that it anticipated the program to be limited to a small number of products, and not more than 5 to 10 products per year. The comments said that by 2004, about 20 products required Medication Guides, and that starting in 2005, FDA began requiring Medication Guides for entire medication classes, which have grown to include antidepressants, nonsteroidal antiinflammatory drugs, and attention deficit hyperactivity disorder and sleep disorder drugs. The comments said that today almost 300 million prescriptions per year for over 10,000 separate drug products are subject to the Medication Guide requirement, and pharmacists are dispensing Medication Guides for substantially more drugs than originally estimated. The comments said that this has created significant burdens for pharmacists.
(Comment 5) The comments said that there is no evidence that a Medication Guide is a good vehicle for risk communication, and FDA has not provided evidence that the program is valuable to patients or improves the safe and effective use of prescription drugs. The comments said that given the amount of information patients are likely to receive with their prescriptions, they face a tremendous challenge in actually reading each piece of information. As a result, the comments said, many patients are likely to not read any material provided to them. Those patients that desire to gain additional information about their therapy but are unable to read each document are placed in a position of having to decide which document distributed to them is more important than the other. The comments said that FDA should first evaluate whether patients actually read the Medication Guides distributed to them, and then assess whether the information contained in a Medication Guide is easily understood by patients. The comments said that many patients are likely to find the information difficult to understand or confusing, and that many patients, especially older and disabled patients, have cognitive impairments that may pose tremendous challenges in understanding information contained in a Medication Guide. The comments also asked whether the information contained in the Medication Guide is already available to patients. For example, the comments said that pharmacists provide counseling on the safe and effective use of medication to their patients at the time of dispensing, and are able to translate highly complex information about a drug's characteristics, use parameters, sideeffects and abuse potential. The comments said this counseling by pharmacists, coupled with other information already distributed to patients, such as consumer medication information and the patient package insert or the patient information sheet, raises questions about the need for the Medication Guide program. The comments also said that FDA has not made sufficient data available to the public to support the position that the Medication Guide program is important to communicate risk, and FDA should release all data from its surveys and studies for review and comment by health care provider groups. The comments said that this data will help generate a more accurate estimate of the burden imposed on the public as a result of the Medication Guide program.
(Comment 6) The comments said that pharmacists face difficulties in obtaining Medication Guides. The comments said that some Medication Guides are included with the product itself in the package insert, some are provided in tearoff sheets, and some are available electronically. The comments said that the lack of a standardized delivery model complicates efforts to operationally streamline dispenser and distribution systems for duplicating and providing Medication Guides. In addition, pharmacists at times need to call a tollfree number to order hard copies of the Medication Guides for distribution. The comments said that FDA should establish standards for manufacturer distribution of medication guides and establish a single tollfree number or Internet site for pharmacies to use to obtain Medication Guides.
(Comment 7) The comments said that FDA should waive certain Medication Guide formatting requirements to permit pharmacies to print Medication Guides through existing pharmacy computer systems. The comments said that permitting pharmacies to print Medication Guides would enhance their distribution and will free pharmacists' time to use for patient counseling and care. The comments also said FDA should permit pharmacies to email Medication Guides to their patients. (Comment 8) The comments said that a single, uniform Medication Guide should be used for all brand and generic versions of the same drug, or for drugs within the same therapeutic class, with similar risk warnings, and that each brand and generic manufacturer of the same drug or the same class of drug should not have to produce its own Medication Guide. The comments said that for medications that have unique and rare side effects that are not shared with the other drugs in the same class, FDA should consider having a class Medication Guide that specifically lists per paragraph each drug in the class while highlighting risk information that is unique to certain medications within that class.
(Comment 9) The comments said that Medication Guides should only be required the first time a prescription is filled, and thereafter only when requested by a patient for that prescription's refill. (Comment 10) The comments said to eliminate duplication and enhance the usefulness of patient information, a single, manufacturerproduced, patientoriented FDAapproved Medication Information Document should be developed for each drug that currently requires a Medication Guide. This single document could combine consumer medication information and Medication Guide information. The comments said they are willing to work with FDA and other interested stakeholders in designing and implementing such a program. Alternatively, the comments said that FDA should standardize the information that must be included in the Medication Guide and require a consistent format, look, and feel to Medication Guide information.
(Comment 11) The comments said that physicians and other providers should give the Medication Guide directly to the patient at the time the prescription is written. The comments said the physician is in the best position to discuss not only the possible risks associated with the medication but to also discuss alternative therapies if necessary. The comments also said that FDA should consider ways that prescribers could be better informed about medications that require Medication Guides.
(Comment 12) The comments said that the Medication Guide requirements were imposed on distribution and dispensing entities that were neither prepared nor operationally structured (for example, lack of space, staff, and equipment) to prepare and provide for their dissemination.

Based on the comments in ``Comment (1)'' of this document, FDA has revised the estimated annual reporting burden as follows:
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Table 1Estimated Annual Reporting Burden \1\ No. of Annual Frequency Total Annual Hours per 21 CFR Section Respondents per Response Responses Response Total Hours 208.20 25 1 25 320 8,000 208.24(e) 59,000 5,000 295,000,000 0.05 14,750,000 208.26(a) 1 1 1 4 4 314.70 (b)(3)(ii) 5 1 5 72 360 and 601.12(f)
Total 14,758,364 \1\ There are no capital costs or operating and maintenance costs associated with this collection of information.

Dated: November 19, 2008.
Jeffrey Shuren,
Associate Commissioner for Policy and Planning.
[FR Doc. E828064 Filed 112508; 8:45 am]
BILLING CODE 416001S

FOR FURTHER INFORMATION CONTACT

Elizabeth Berbakos, Office of Information Management (HFA710), Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857, 3017963792.