FDA

Med Device Monday: The Monarch external Trigeminal Nerve Stimulation (eTNS) System: The first non-drug treatment for ADHD

Photo from prnewswire.com

Photo from prnewswire.com

A recent press release from the U.S. Food and Drug Administration (FDA) certainly caught our attention! In April, FDA permitted marketing of the first medical device to treat attention deficit hyperactivity disorder (ADHD). The device, known as the Monarch external Trigeminal Nerve Stimulation (eTNS) System, is for prescription use only and intended to be used in patients ages 7 to12 years old who are not currently taking prescription ADHD medication. The device was developed by NeuroSigma, and is the first non-drug treatment for ADHD granted marketing authorization by the FDA.

ADHD is a common disorder that often begins in childhood, with symptoms including inattentiveness, impulsiveness, and very high levels of activity. A diagnosis of ADHD requires a comprehensive evaluation by a health care professional, and for a person to receive an ADHD diagnosis the symptoms must impair the their functioning and cause them to fall behind normal development for his or her age.

The Monarch eTNS System is intended to be used at home under the supervision of a caregiver. The cell-phone sized device generates a low-level electrical pulse and connects via a wire to a small patch that adheres to a patient's forehead, just above the eyebrows. The stimulation should feel like a tingling sensation on the skin, and is administered by the caregiver when the child is asleep. The device is purported to stimulate the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD. While the exact mechanism of eTNS is not yet known, neuroimaging studies have shown that eTNS increases activity in the brain regions that are known to be important in regulating attention, emotion and behavior.

“This new device offers a safe, non-drug option for treatment of ADHD in pediatric patients through the use of mild nerve stimulation, a first of its kind,” said Carlos Peña, Ph.D., director of the Division of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health. “Today’s action reflects our deep commitment to working with device manufacturers to advance the development of pediatric medical devices so that children have access to innovative, safe and effective medical devices that meet their unique needs.”

The FDA reviewed the Monarch eTNS System via the de novo premarket review pathway (previously blogged about HERE and HERE), a regulatory pathway for low- to moderate-risk devices of a new type. This action creates a new regulatory classification, which means that subsequent devices of the same type with the same intended use may go through the FDA’s 510(k) premarket process, whereby devices can obtain marketing authorization by demonstrating substantial equivalence to a predicate device. The main mitigation measures included biocompatibility evaluation, software validation, shelf life testing, electromagnetic compatibility and electrical safety testing. While the Classification Order has been released by FDA, we look forward to posting more info about the details of the testing that NeuroSigma provided in their de novo once the Decision Summary is made public.

Additional Reading:

1.       FDA Press Release

2.       FDA Classification Order

3.       NeuroSigma

4.       About ADHD

5.       ADHD Support Organizations

FDA Friday - Robert Allen, PhD

This #FDAFriday series consists of mini-interviews with former FDA regulators. Our goals are twofold: (1) help students and professionals interested in Regulatory Affairs see what career paths are possible, and (2) talk about some of the various roles at FDA to demonstrate the diversity of responsibilities at the Agency. If you are a former FDA employee and would like to participate, please email us at info@acknowledge-rs.com.


I really enjoyed working with FDA reviewers and managers. You might think that FDA employees are focused on just rules and red tape, however, people there are very passionate about public health, and creative in getting things done that benefit patients within the framework of rules and regulations.
— Robert Allen, PhD
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Dr. Allen received his bachelor’s and doctorate degrees in Bioengineering from the University of Pittsburgh, Swanson School of Engineering. As a Ph.D. candidate, his research focus was in cellular and medical product engineering. In 2015, he began work at FDA as an American Institute for Medical and Biological Engineering (AIMBE) Scholar. After completing his tenure as an AIMBE fellow, Dr. Allen joined the FDA’s Center for Devices and Radiological Health (CDRH) as a biomedical engineer and staff fellow. Robert acted as a lead reviewer in the former Division of Cardiovascular Devices, coordinating the review of premarket regulatory submissions such as 510(k)s, Pre-Submissions, and various supplements for Investigational Device Exemption (IDE) and Pre-Market Application (PMA) submissions. He also worked as a biocompatibility consulting reviewer, evaluating the potential biological response patients could have to a medical device.


Start off by giving us some more detail about your time at FDA.

I spent three years at FDA. For the first nine months, I was an American Institute for Medical and Biological Engineering (AIMBE) Scholar, working on strategic projects for the Center for Devices and Radiological Health (CDRH). Afterward, I became a premarket device reviewer for CDRH. My titles included “Biomedical Engineer” and “Staff Fellow”, and my roles included Lead Reviewer and Biocompatibility Consulting Reviewer for the Division of Cardiovascular Devices (now referred to as DHT2B), Vascular Surgery Devices Branch (now known as the Vascular and Endovascular Devices Team).

Tell us a little more about being an American Institute for Medical and Biological Engineering (AIMBE) Scholar. Can you briefly describe the program and talk about your responsibilities in that role?

The AIMBE Scholars program is an opportunity for early career PhDs in biomedical engineering or related fields to serve as expert advisors to policy makers at CDRH. The first cohort of AIMBE Scholars started at FDA in 2014. To date, AIMBE Scholars have worked on a wide range of projects aimed at improving the review process, providing tools to support regulatory decision-making, and developing policies to promote innovation and public safety. More information on the program can be found at https://aimbe.org/scholars-program/.

My AIMBE Scholar appointment was with the Office of Device Evaluation (now known as the Office of Product Evaluation and Quality, or OPEQ), where I assisted with efforts to reclassify a large number of medical devices. Reclassification is a process that impacts the regulatory requirements for each reclassified device. It is a complex process involving multiple teams across CDRH. To coordinate this process, I needed to learn the details of the process, then guide each team through it. This involved project management and lots of internal written and verbal communication. Throughout the process I worked with upper management, middle management, and individual premarket reviewers.

In addition to our FDA projects, AIMBE Scholars also attended site visits to current and potential industry sponsors. We also presented our projects at the AIMBE Annual Meeting to academic and industry members of AIMBE. These were great opportunities to network and hone our regulatory communication skills.

What about your experience as an AIMBE scholar made it clear to you that you wanted to spend more time at FDA?

Two things: the public health impact of FDA’s work, and the people at FDA. Regarding public health impact, it was fulfilling to work on projects where the immediate goal was to benefit public health. Prior to this work, I was a graduate student developing early-stage technologies that might one day help patients. While such research could be important in the long-term, it takes many years to prove a new technology, and many more years to develop a medical product and obtain regulatory approval/clearance. In contrast, the work I did at FDA changed the regulatory requirements for each reclassified device, which directly impacts the speed and cost to develop and market new products in that device category. It was thrilling to be able to see how my work could have a positive impact on patients in the short term.

Regarding people, I really enjoyed working with FDA reviewers and managers. You might think that FDA employees are focused on just rules and red tape, however, people there are very passionate about public health, and creative in getting things done that benefit patients within the framework of rules and regulations.

You worked as a lead reviewer in the Vascular Surgery Devices Branch. Before your time at FDA, what was your experience with blood-contacting cardiovascular devices?

Prior to FDA, I helped develop a resorbable vascular graft, which is a blood-contacting permanent implant. This was part of my dissertation work as a graduate student at the University of Pittsburgh, under the mentorship of Dr. Yadong Wang. That work helped me to understand how device materials interact with blood. I also learned about the design requirements for implants that need to withstand and maintain blood pressure, and the various failure modes to watch for.

While this experience was certainly helpful to my work as a lead reviewer, it was not a prerequisite for the job. After starting as a reviewer, I learned that FDA considers a wide range of backgrounds for lead reviewers, though they are most commonly engineers or scientists. Additionally, most of what I needed to know I learned on the job. FDA review teams have a wealth of collective experience and scientific knowledge about their devices. Coming in as a fresh Ph.D., I certainly did not know even 10% of what it takes to review a device. But the review team did and they got me up to speed quickly.

What was your favorite thing about working with a review team on a premarket notification (510(k)) or premarket approval (PMA) submission?

I enjoyed “standing on the shoulders of giants”, so to speak. I had the privilege of working with seasoned scientists, engineers, medical officers, and veterinary officers. I learned so much from these FDA veterans over the course of my premarket reviews. Much of their insight comes uniquely from experience reviewing devices, so it felt like I was learning things I couldn’t learn anywhere else.

What does it mean to be a biocompatibility reviewer?

Here is my personal take on what a biocompatibility reviewer does: Biocompatibility reviewers focus on reviewing the potential biological response that a patient can have to a medical device. Practically speaking, this means that biocompatibility reviewers review a combination of in vitro and in vivo testing, risk assessments, and rationales for why testing is not needed. These tests, risk assessments, and rationales focus on the impact of the device, or chemicals that can leach out of the device; on the patient’s cells/tissues, blood, and organ systems.

Biocompatibility review is just one of many roles that a premarket device reviewer can play at FDA. For example, I served as both a lead reviewer and a biocompatibility reviewer for premarket device submissions.

What past experience or trait do you think helped you be a successful reviewer during your tenure at FDA?

When I started review work, I thought that my technical expertise would be my most valuable asset for day-to-day work. While it certainly came in handy, the skills that helped me most were actually my communication and consensus building skills. Review teams often include multiple experts with a range of technical backgrounds and communication styles. To complete a review efficiently, we all needed to find common ground regarding priorities, action items, and ultimately, the safety and effectiveness of the device.

What were your favorite FDA submissions to work on and why?

I enjoyed reviewing 30-Day Notices for manufacturing changes. In reviewing these submissions I got to see some of the manufacturing steps for the device, then evaluate and/or question the thought process behind each manufacturing change. This was fun because I got to see how devices are made; there are a wide range of manufacturing techniques out there, and some of them are fascinating. For the techniques that I already knew well from graduate school, it felt satisfying to leverage my existing knowledge to expedite a review.

What are you up to now and how does your current role incorporate your regulatory experience?

I currently work as a Senior Associate within the Regulatory Affairs team at MCRA. MCRA is a leading advisory firm and Contract Research Organization (CRO) for the medical device industry, with a range of services including regulatory, reimbursement, clinical research, healthcare compliance, and quality assurance. As a Regulatory Affairs Senior Associate at MCRA, I help our US and international clients to write and submit regulatory submissions to achieve and maintain market approval/clearance. These submissions include US FDA submissions, such as 510(k)s, Investigation Device Exemptions (IDE), and Premarket Approvals (PMA). They also include international submissions such as Clinical Evaluation Reports (CER). We also help our clients to develop and execute long-term regulatory strategies.

My FDA experience translates well to my work as a regulatory consultant. I am constantly using my firsthand knowledge of FDA’s regulatory expectations when I write premarket submissions for MCRA’s industry clients. The translation is direct for cardiovascular devices and biocompatibility evaluations, since I worked on those two specific things at FDA. For other device types and different types of testing, I can extrapolate from what I know, while also leveraging the experience of other MCRA employees. One of the great things about working at MCRA is the depth of experience that MCRA has in a range of product areas. For example, if I’m working on an orthopedic device submission, I can ask any of our 5 former FDA orthopedic device reviewers for their firsthand knowledge. I can also borrow the experience of MCRA’s other seasoned regulatory consultants who have a long track record of developing successful orthopedic device submissions.

How is working in industry similar and/or different than working at FDA?

As a regulatory consultant, I’m writing rather than reviewing device submissions. However, the process of writing submissions is very similar to that of FDA review. For example, as a consultant I still think about things like technological characteristics, benefit/risk, and the appropriateness of predicate devices. I also frequently reference FDA Guidances and regulations, just as I did at FDA. In addition, I often change hats and “review” my draft submissions from the perspective of an FDA reviewer; this helps me to anticipate FDA questions and thereby strengthen the overall submission. So overall, writing a submission doesn’t feel too different from reviewing one.

Of course, there are some differences in consulting vs. FDA review. As a consultant at MCRA, I work on a larger range of project types than I did as an FDA reviewer. This includes both the types of devices and the types of work products. For example, at FDA, I worked only on cardiovascular devices without electrical components, also known as the “plumbing” devices. As a consultant with six months experience at MCRA, I have already worked on a larger range of technologies than I did at FDA, including cardiovascular, orthopedic, and wound care devices. Similarly, at FDA I mainly worked on US premarket reviews. As a consultant at MCRA, I do write US premarket submissions, but I also work on international submissions as well as developing overall regulatory strategy recommendations for clients, which consider not just the technology but also the regulatory time and costs of each potential pathway. I like the variety that comes with working as a consultant!


More about Robert Allen, PhD

For more information about Robert, please visit his LinkedIn page; and to learn more about MCRA, LLC, please visit their website.

Med Device Monday – De Novo Clearance of The Miris Human Milk Analyzer

Breast milk is often considered a “superfood” for babies; it contains the appropriate vitamins, minerals, and nutrients to support a baby’s growth and development (not to mention hormones and enzymes that promote maturation and digestion, and antibodies that help the baby resist infection!). It’s no wonder why breast milk is often referred to as “nature’s first health plan.”

Yet for infants born preterm (before 37 weeks gestation), or with certain health conditions, breast milk may not contain sufficient protein or provide enough energy. For these infants with increased nutritional needs, knowing the macronutrient content of the breast milk being provided could give vital information to the health care team and parents, allowing them to make informed decisions on how to fortify the breast milk based on the individual needs of the infant.

In December 2018, the U.S. Food and Drug Administration permitted marketing of the Miris Human Milk Analyzer (HMA) to Miris AB of Sweden. The Miris HMA uses an infrared spectroscopy system to analyze samples of human milk, and provides a quantitative measurement of fat, protein and total carbohydrate content, as well as calculations of the total solids and energy content contained in the milk. The prescription device is intended for use by trained health care personnel at clinical laboratories, providing healthcare professionals with a new tool to aid in the nutritional management of newborns and young infants at risk for growth failure due to prematurity or other medical conditions.

FDA reviewed the Miris HMA test through the De Novo premarket review pathway, a regulatory pathway for low-to-moderate-risk devices of a new type. Along with its granting, FDA established a list of special controls to provide for the accuracy and reliability of tests intended to measure the nutritional content of human milk to aid in the nutritional management of certain infants. These special controls, when met along with general controls, provide a reasonable assurance of safety and effectiveness for tests of this type. As discussed in our previous blogs about the De Novo pathway, this action also creates a new regulatory classification; meaning subsequent devices of the same type and intended use may go through FDA’s 510(k) process.

Already on sale in over 25 countries worldwide, the Miris HMA is now available to analyze breast milk and guide the individual nutrition of preterm babies in the U.S. The new device supports Miris’ mission, “to make individual nutrition, based on human milk, available globally to improve neonatal health.” We’re excited to see a new device on the market that has the potential to help one of the most vulnerable patient populations. Go babies!


Additional Reading:

1.      FDA Press Release

2.      De Novo Letter for The Miris Human Milk Analyzer

3.      NIH: Do breastfed infants need other nutrition?

4.      CDC: Breastfeeding

5.      Miris Website

FDA Friday - Dulciana Chan, M.S.E.

This #FDAFriday series consists of mini-interviews with former FDA regulators. Our goals are twofold: (1) help students and professionals interested in Regulatory Affairs see what career paths are possible, and (2) talk about some of the various roles at FDA to demonstrate the diversity of responsibilities at the Agency. If you are a former FDA employee and would like to participate, please email us at info@acknowledge-rs.com.


A common mistake that manufacturers make in their Investigational Device Exemption (IDE) submissions is not having a plan to deal with missing data. It is important to have a plan upfront so that the data from all patients can be used.
— Dulciana Chan, M.S.E.
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Dulciana Chan received her B.S. in Biomedical Engineering from Johns Hopkins University in 2002, and her M.S.E. in Bioengineering from the University of Maryland in 2010. Directly following her undergraduate degree, Dulciana began her FDA career as a research associate in the Center for Devices and Radiological Health (CDRH), Office of Science and Engineering Laboratories (OSEL). A year later, she became a Biomedical Engineer at FDA, and for 14 years operated in various branches of the administration, including as a scientific reviewer and policy analyst in the Office of Device Evaluation (ODE), and as an OSEL principal investigator.

While working at FDA, Dulciana received numerous honors and awards, including the 2014 CDRH Honor Award and the 2014 FDA Scientific Achievement Award for Excellence in Analytical Science. Dulciana has extensive experience in the areas of electromagnetic compatibility (EMC) testing and electrical safety, and is an asset to Acknowledge Regulatory Strategies, where she is a Senior Regulatory Specialist.


Tell us a little bit about your time at FDA.

I started at the FDA as a research associate in the Center for Devices and Radiological Health (CDRH) in the Office of Science and Engineering Laboratories (OSEL). I worked on several research projects and gained skills including computational modeling and electromagnetic compatibility. One of my main projects focused on optical recording of cardiac myocyte monolayers to study cardiac arrhythmias. After my first year at FDA, I also became a scientific lead reviewer in the Office of Device Evaluation (ODE). Fortunately, I was able to continue performing research in OSEL while doing premarket reviews for devices in ODE for the next 14 years.

Can you tell us a little more about your research in the Office of Science and Engineering Laboratories (OSEL)?

The lab I was in began to use pluripotent stem cell derived cardiomyocytes for evaluating drug-induced arrhythmias. It was part of a larger program to predict drug proarrhythmic risk in cells prior to the clinical studies that are required for new drugs. This research was very rewarding in clinical relevance and scope.

You also worked as IDE staff while you were at FDA. What was one of the common mistakes you saw companies make when submitting their clinical study to FDA?

A common mistake that manufacturers make in their Investigational Device Exemption (IDE) submissions is not having a plan to deal with missing data. It is important to have a plan upfront so that the data from all patients can be used. The reality is that there will be missing data, whether from a patient missing a follow-up or a missing test or outcome. However, with preplanning, the data can still be interpreted correctly.

What was your favorite thing about working with a review team on a premarket notification/approval submission?

One of the benefits of working with a review team is being able to access the knowledge of an expert. Often there may be an aspect about a device that you only have high level knowledge about. The review team can quickly explain the technicalities to you in a meaningful way. Their expertise might also help in identifying potential problems.

What past experience or trait do you think helped you be a successful reviewer/during your tenure at FDA?

I think being a lifelong learner helped me be a successful reviewer. Some might see the process of reviewing medical devices as repetitive. However, I found that each product provided a unique learning experience due to the many types of devices, regulation pathways, and emerging public health issues to learn about. There were endless ways to learn new things at the FDA.

What were your favorite FDA submissions to work on and why?

My favorite FDA submissions were IDEs because I learned about the details of a clinical study and about an emerging technology or trend. It was also nice to ensure that all the aspects necessary for a successful clinical study were planned out. Although there was pre-clinical work performed before an IDE submission, it was interesting to see a device at the beginning of its regulatory path.

What's something that you learned from FDA that helped you in your current position?

Working at FDA helped me learn team communication and managing expectations. Everyone’s time is valuable and it is important to make the most of team meetings. When leading a team, I aim to let each member of the team know the goal, their responsibility, and potential outcomes.

How does your current role incorporate or benefit from your regulatory experience?

Many times, companies are not sure what to submit to the FDA so they submit everything (test report and data), which can be overwhelming to an FDA reviewer. I think my regulatory experience can help companies determine what to submit so that they clearly show they meet all FDA requirements.


More about Dulciana Chan, M.S.E.

For more information about Dulciana, please visit her LinkedIn page.

Med Device Monday: Recall of the Raindrop Vision Inlay Device

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In April 2017, we wrote about a new device called the Raindrop Vision Inlay, manufactured at the time by ReVision Optics. Approved in 2016, the device is basically a small implantable contact lens that reshapes the front of the eye and corrects presbyopia, more commonly known as farsightedness. A little over two years later, the Raindrop Vision Inlay was the subject of an FDA Safety Communication recommending patients not receive the device. After post-market research, FDA identified an increased risk of corneal haze, or the development of a cloudy layer within the eye that impairs overall vision. Shortly thereafter, in November 2018, FDA issued a Class I recall - the most serious type of recall - reserved for devices that may cause serious injuries.

So, what happened?

Going back to 2016, the Raindrop Vision Inlay was given FDA approval in large part due to a two-year clinical trial that yielded promising results, including high numbers of patients who could read smaller print at closer distance post-op. At the time of device approval, the clinical study showed that while 16.1% (60 of 373) of patients had central corneal haze of any severity at some point during follow-up, the percentage of patients with two or more lines of loss in vision on the eye chart caused by corneal haze was 1.1% (4 of 373 patients). The number of patients who had the device removed was 24 of 373 patients (6.4%) at the two-year follow-up visit, with 29% of those device removals (7 of 24 patients) being due to corneal haze.

The Raindrop Vision Inlay was marketed under the conditions that the device be restricted to prescription use and specifically labeled to define the training or experience practitioners needed in order to implant the device. Marketing of the device was also conditional on the reporting of results from two post-approval studies (PAS), one that followed patients enrolled in the original clinical study, and a second that tracked newly enrolled patients. Of the 373 patients from the original study, 150 were enrolled in the PAS. The most recent data from the ongoing study, including 5 years of follow-up in some patients, showed that the rate of central corneal haze, at any time during the study, was 42% (63 of 150 patients), and that the presence of haze at any location within the cornea was a whopping 75% (113 of 150 patients). The percentage of patients with two or more lines loss on the eye chart caused by corneal haze remained low at 2.0% (3 of 150 patients), however that was greater than what was observed during the original clinical study. After evaluation of the PAS data, the risks outweighed the benefits of the device and lead the company and FDA to initiate the recall.

It is awful that the Raindrop Vision Inlay caused any patients implanted with the device to suffer, and one might be quick to judge that FDA ‘screwed up’ by allowing an unsafe device to be sold. The whole story is quite a bit more complicated, however, and we feel the Raindrop Vision Inlay situation is an example of FDA working to uphold its mission. In this situation, FDA took responsibility for both helping speed innovation that would potentially improve patient’s lives, and for ensuring the safety and effectiveness of a medical device before and after market approval.

FDA closely monitors reports of adverse events and other problems with medical devices, and alerts health professionals and the public when needed to ensure their proper use. FDA has stated that it is currently working with the owner of the Raindrop Vision Inlay, Optics Medical, on a plan to collect any remaining devices already distributed. FDA will continue to gather and evaluate data related to the recalled device, and communicate new information as warranted.

Further Reading:

1. FDA Safety Communication

2. Raindrop Vision Inlay PMA Approval Letter

3. Summary of Safety and Effectiveness Data

4. Raindrop Vision Inlay Recall Notice