Drugs, QT interval prolongation and ICH E14: the need to get it right

Regulatory concerns on the ability of an ever-increasing number of non-cardiovascular drugs to prolong the corrected QT (QTc) interval and induce potentially fatal ventricular tachyarrhythmias have culminated in initiatives to harmonise internationally the regulatory guidance on strategies by which to evaluate new drugs for this liability. The International Conference on Harmonisation (ICH) has released consensus texts for clinical (ICH topic E14) and non-clinical (ICH topic S7B) strategies as regulatory drafts for wider consultation. Draft ICH E14 calls for a clinical 'thorough QT/QTc study' (typically in healthy volunteers) for new drugs with systemic bioavailability, regardless of the non-clinical data. This indifference to non-clinical data has sparked off a major debate, even among the regulators. The 'thorough QT/QTc study' is intended to determine whether a drug has a threshold pharmacological effect on cardiac repolarisation, as detected by QT/QTc prolongation, and proposes the use of a positive control to validate the study. The guideline recommends exploration of the effect of concentrations that are higher than those achieved following the anticipated therapeutic doses and, consequently, a negative 'thorough QT/QTc study', even in the presence of non-clinical data of concern, will almost always allow standard collection of on-therapy ECGs. The proposed threshold of a 5 ms increase in mean placebo-corrected QTc interval for designating a study as positive for an effect, with all its implications for subsequent development of the drug and its regulatory assessment and labelling, has also generated a controversy. This paper provides an overview commentary on some contentious or ambiguous aspects of draft ICH E14 with a view to stimulating a debate and inviting scientifically supported comments from stakeholders in order to ensure that the application of the ICH E14 strategy, when finalised and adopted, does not result in either restriction in the use (or even rejection) of a potentially beneficial drug or approval of an otherwise hazardous drug without the restrictions required to promote its safe use.