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BMC Medicine: a decade of open access medical research

Sabina alam.

1 BioMed Central Ltd, 236 Gray’s Inn Road, London WC1X 8HB, UK

Jigisha Patel

On 24 November 2003, BMC Medicine published its first article. Ten years and over 900 articles later we look back at some of the most notable milestones for the journal and discuss advances and innovations in medicine over the last decade. Our editorial board members, Leslie Biesecker, Thomas Powles, Chris Del Mar, Robert Snow and David Moher, also comment on the changes they expect to see in their fields over the coming years.

Just a few months after the Human Genome Project was declared complete [ 1 ] BMC Medicine was launched as an open access [ 2 , 3 ], open peer review journal (i.e. where signed peer review reports are published with the article) [ 4 , 5 ], with the aim of making high impact clinical peer-reviewed research of general interest, accessible to everyone from the basic scientist to the practicing clinician. The journal, initially under the direction of Pritpal Tamber and then Melissa Norton as Editor-in-Chief, was launched amidst a raging debate about the viability of open access publishing [ 6 ]. But open access survived and evolved [ 7 , 8 ], and BMC Medicine now ranks 8 th out of 155 journals in the 2012 general and internal medical journals category of the Journal Citation Reports [ 9 ].

While mainly focused on primary research in its early days, the journal responded to the needs and demands of its readers and contributors by providing, for example, a platform for discussing controversies in medical practice [ 10 - 15 ] and embracing social networking technology to promote open scientific discussion and debate [ 16 - 19 ]. Although proud of its Impact Factor (IF) of 6.68, BMC Medicine recognizes that the IF is a restrictive metric that does not fully reflect the influence of individual articles post-publication. The journal therefore provides informative article metrics which are immediately available on published articles - a feature which has proven to be popular with many of our authors [ 20 ].

Of course, innovations in publishing and technical advances notwithstanding, BMC Medicine owes its success to the scientific contributions made by its authors, reviewers and expert editorial board members. To celebrate its 10 th anniversary, we recently reviewed some of our most successful articles in terms of accesses [ 21 ], citations [ 22 ] and ‘impact’ in news and social media [ 23 ], and also summarized author and reviewer experiences [ 24 ] and explored our author demographics [ 25 ]. As a general medical journal with a very broad scope, it is not possible for us to cover all the main advances in medicine featured in the journal over the last decade, but in this editorial we present a selection of our favorite recent content, together with predictions by our editorial board members on possible future directions for their respective fields of research.

Translational medicine: how far have we come with stem cells, biomarkers and ‘Omics’ research?

Stem cell research and therapy has advanced rapidly in the last decade, and clinical trials for a wide range of diseases are already underway [ 26 , 27 ]. In 2012, the journal published an intriguing study by Zhao and colleagues, who used Stem Cell Educator therapy to safely reverse Type 1 diabetes. The researchers used stem cells from cord blood to ‘re-educate’ T cells in patients with Type 1 diabetes, thereby restoring pancreatic function and reducing the need for insulin [ 28 ]. These compelling results highlight how stem cell therapies may become part of mainstream treatment for many diseases.

Within the last 10 years, major advances have also been made in biomarker research and ‘Omics’ studies in a preclinical setting. Advances in whole genome sequencing have allowed the identification of genes involved in a large number of diseases, and biomarkers that indicate disease severity or susceptibility to treatment are increasingly being characterized [ 29 - 32 ]. As Leslie Biesecker points out (Box 1), clinical exome and genome sequencing are already being used in the clinic for diagnostic and prognostic purposes. However, Biesecker also indicates that these new technologies are not without problems and alludes to the role the journal plays in ensuring the latest research is appropriately validated and disseminated.

Despite the discovery of many biomarkers for cancer in particular, so far very few have been used within the clinical setting [ 33 ], which is partly due to a lack of consistency and clarity in the reporting of prognostic tumor markers. This prompted the development of the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK) checklist [ 34 ], which was updated in 2012 by Altman and colleagues [ 35 ] and more recently, the development of criteria to address the lack of scientific rigor when evaluating preclinical evidence to support translation of omics-based predictors to clinical trials [ 36 , 37 ].

The continued identification of new genes and biomarkers specific to disease subtypes and individual patients is essential for translation into personalized medicine, in terms of estimating both disease risk and response to therapy. As highlighted above, the field which has seen the most progress in this area is clinical oncology, and Thomas Powles explains what further changes are required to achieve effective personalized cancer therapies (Box 2).

Leslie G. Biesecker National Human Genome Research Institute, USA

Genomics has provided new modes of discovery in the basic sciences and is now doing the same for clinical research. It has already started to change medical practice with clinical exome and genome sequencing. These two assays are now being used in thousands of patients, for example, to provide a genome-wide diagnostic assay for uncharacterized disorders of birth defects or neurologic disorders and in tumor sequencing to identify targets for cancer therapeutics. BMC Medicine has a critical role to fulfil in this process by providing a forum for critical evaluation of these new technologies. The objective could not be more important - to preserve what works well in medicine and remake what does not. It is hard to imagine a more exciting time for our field.

Thomas Powles St Bartholomew's Hospital, London, UK

The field of medical oncology is moving at a breathtaking speed. A plethora of new agents are now available based on the molecular biology of specific tumors. The next step is to identify subsets of patients who benefit from therapy and move away from ‘one size fits all’ strategies. Therefore, biomarkers predicting response to these therapies are required. The application of whole genome sequencing, novel tracers within the context of functional imaging and circulating biomarkers, such as free circulating tumor DNA will be important pieces in this complex puzzle. There is also a need to develop therapies which focus on inducing longer remission rather than temporary disease controls. A collaborative international approach is required to achieve these goals.

Evidence-based medicine: education, communication and collaboration

There has been increasing international focus on public health initiatives, development of healthcare policies and evidence-based guidelines to improve medical practice [ 38 , 39 ]. This is embedded in effective education strategies, which is evident from a continuing medical education intervention aimed at strengthening links between evidence-based and values-based medicine in healthcare personnel [ 40 ]. Researchers found this intervention led to improved values, such as openness to change, which are essential for improving medical care. Chris Del Mar (Box 3) recommends that going forward a more collaborative approach to decision-making between clinicians, patients and policy makers needs to be developed, and highlights the importance of transparency and communication.

There is also increasing focus on involving researchers based in low-to-middle income countries as principal investigators in local research projects. This is especially important as local knowledge helps to ask the ‘right’ questions in health research, ensures the best available evidence is accumulated and that all ethical aspects have been considered [ 41 - 43 ]. This is vital to guide healthcare policies and identify new tools and strategies; the consequences of not doing so is evident from a recent bibliometric analysis of childhood immunization research output from Africa. Since the onset of the Expanded Program on Immunization in 1974, vaccine research productivity in Africa has skewed toward those funded privately, with minimal research input from African authors, suggesting a need for better communication among all stakeholders [ 44 ]. Robert Snow points out (Box 4), conditions for research are now improving in Africa, and it is important that local researchers and governments work closely to drive the research output from these regions forward.

Chris Del Mar Bond University Gold Coast, Australia

Medicine will enter a new phase of concern about decreasing gains for increasing harms - including not just cost but also over-diagnosis and over-treatment. The medical profession has not been able hitherto to demonstrate an ability to make such cost-benefit decisions sensibly alone, and therefore there will be increasing input from society; increased demand for shared decision-making with the patient; and more directives from government. One important element of quality will soon be considered to be the extent to which the clinician has explicitly, clearly and carefully communicated the evidence in such a way that every patient is in a position to express a preference for the range of management options available. Evidence-based medicine will no longer be some hidden activity that clinicians may (or may not) engage in: it will become the currency expected for patient-clinician communication.

Robert William Snow Kenya Medical Research Institute, Kenya

Since I started work in Africa 30 years ago the landscape of science and research capacity has changed enormously. It is no longer legitimate to make excuses that model-based computing, laboratory science or gene sequencing can only be done in the north. The infrastructure and human capacity now exists in Africa to provide the best possible science for public health problems that face the continent. A fundamental requirement for any form of development is that countries have to take ownership of their problems. The next decade requires an active promotion by governments in Africa, and international partners that support regional development, of the expanding cohorts of African scientists who champion the very highest standards of medical and public health science within the region. Generating new research from within Africa holds untold promise. Unlike external research agendas and funding 30 years ago, this new research will have a much greater and much faster impact on the health of communities in Africa over the next decade.

Enhancing research with reporting guidelines

Without clear guidelines for conducting and analyzing medical research, there is a limit to how far medicine can progress, and the last few years have seen many important improvements in reporting standards. In 2010, BMC Medicine co-published the updated CONSORT (CONsolidated Standards of Reporting Trials) statement by Schulz and colleagues [ 45 ]. This statement guides authors on the reporting of two-parallel design randomized controlled trials by using a checklist and flow diagram based on the latest methodological evidence. More recently, in response to the particular challenges in reporting economic evaluations of health interventions, the Consolidated Health Economic Evaluation Reporting Standards ( CHEERS ) was published [ 46 ]. This statement consolidates existing guidelines with the aim of providing more ‘user-friendly’ guidance for researchers and editors.

As research methods become more sophisticated, so too do the methods via which literature analysis can be conducted. The ‘RAMESES’ (Realist and Meta-review Evidence Synthesis: Evolving Standards) statement [ 47 , 48 ] was published to provide researchers, institutes and journals with guidance on how to conduct these new forms of literature analysis, and adherence to the guidelines will lead to quality assurance and uniform reporting of studies.

Ensuring consistency is a challenging task, and David Moher explains (Box 5) that journals and editors play a key role in providing peer reviewers and authors with the tools and guidance to ensure that medical research is appropriately reported.

We hope you have enjoyed our selection of just some of the most exciting content from BMC Medicine, and hope this has prompted you to seek out favorites of your own.

As an open access general medical journal, we aim to promote better informed clinical decisions and improved therapies. We will continue to publish content that has the potential to improve clinical practice, research and reporting. We especially encourage debate on health related issues not just within the clinical community, but also for the general public who should be, after all, the primary beneficiaries of the research.

David Moher Ottawa Hospital Research Institute, Canada

To reduce the considerable waste of inadequately published research, medical journals will need to develop long-term innovative strategies, such as developing core competencies for editors and peer reviewers, as well as accreditation programs for journals. More immediately, they can help foster greater implementation of reporting guidelines by facilitating the development of applications that can take manuscript content and automatically populate reporting guideline checklists. Such information can provide immediate feedback about the completeness of reporting of manuscripts to authors, editors and peer reviewers.

Competing interests

Both authors are employees of BioMed Central, the publisher of BMC Medicine .

Authors’ information

Sabina Alam is the Editor of BMC Medicine . Jigisha Patel is the Medical Editor at BioMed Central.

Acknowledgements

We thank our academic editorial board and our reviewers for the contribution they have made to the success of BMC Medicine and our authors and readers for their ongoing support.

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Volume 24, issue 1, December 2024

82 articles in this issue

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Bioequivalence trials for the approval of generic drugs in Saudi Arabia: a descriptive analysis of design aspects

• Turki A. Althunian   ORCID: orcid.org/0000-0002-8030-7963 1 , 2 ,
• Bader R. Alzenaidy 3 ,
• Raseel A. Alroba 1 ,
• Ohoud A. Almadani 1 ,
• Fahad A. Alqahtani 3 ,
• Albatool A. Binajlan 3 ,
• Amal I. Almousa 3 ,
• Deema K. Alamr 3 ,
• Malak S. Al-Mofada 3 ,
• Nora Y. Alsaqer 3 ,
• Hessa A. Alarfaj 3 ,
• Abdulmohsen A. Bahlewa 3 ,
• Mohammed A. Alharbi 3 ,
• Ali M. Alhomaidan 4 ,
• Abdulaziz A. Alsuwyeh 3 &
• Abdulmohsen A. Alsaleh 3  

BMC Medical Research Methodology volume  24 , Article number:  82 ( 2024 ) Cite this article

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This retrospective analysis aimed to comprehensively review the design and regulatory aspects of bioequivalence trials submitted to the Saudi Food and Drug Authority (SFDA) since 2017.

This was a retrospective, comprehensive analysis study. The Data extracted from the SFDA bioequivalence assessment reports were analyzed for reviewing the overall design and regulatory aspects of the successful bioequivalence trials, exploring the impact of the coefficient of variation of within-subject variability (CVw) on some design aspects, and providing an in-depth assessment of bioequivalence trial submissions that were deemed insufficient in demonstrating bioequivalence.

A total of 590 bioequivalence trials were included of which 521 demonstrated bioequivalence (440 single active pharmaceutical ingredients [APIs] and 81 fixed combinations). Most of the successful trials were for cardiovascular drugs (84 out of 521 [16.1%]), and the 2 × 2 crossover design was used in 455 (87.3%) trials. The sample size tended to increase with the increase in the CVw in trials of single APIs. Biopharmaceutics Classification System Class II and IV drugs accounted for the majority of highly variable drugs (58 out of 82 [70.7%]) in the study. Most of the 51 rejected trials were rejected due to concerns related to the study center ( n  = 21 [41.2%]).

This comprehensive analysis provides valuable insights into the regulatory and design aspects of bioequivalence trials and can inform future research and assist in identifying opportunities for improvement in conducting bioequivalence trials in Saudi Arabia.

Peer Review reports

The development of generic drugs has played a pivotal role in increasing patient access to affordable medications (90% of the prescribed drugs in the United States [U.S.] are dispensed as generics with $2.4 trillion dollars cost savings in the past decade), and has been associated with improved patient adherence and clinical outcomes [ 1 , 2 , 3 , 4 , 5 , 6 ]. These impacts were anticipated given the abbreviated nature of developing and approving generic drugs (i.e. generic drug manufacturers are precluded from replicating pre-clinical and clinical development programs of the corresponding brand-name drugs) [ 7 , 8 , 9 , 10 ]. From a clinical perspective, generic drugs are only anticipated to achieve equivalence to their corresponding brand-name drugs in terms of the rate and extent of absorption (i.e. bioequivalence) [ 7 , 8 , 9 , 10 ]. The in vivo assessment of bioequivalence is performed in the context of bioequivalence trials that are conducted mostly in a small sample of at least 24 healthy volunteers ( n  = 12 per group), and designed in a crossover fashion to demonstrate equivalence in several pharmacokinetic parameters using pre-defined bioequivalence margins [ 7 , 8 , 9 , 10 ]. However, alternative design aspects/settings might be acceptable by regulators in certain conditions (e.g. drugs with a long plasma elimination half-life, drugs with highly variable pharmacokinetic parameters, or when recruiting healthy volunteers is considered unethical for safety reasons) [ 7 , 8 , 9 , 10 ]. Notwithstanding the submission of thousands of bioequivalence trials to regulatory agencies, little is known about their designs, the extent of alternative design choices were used, and to what extent bioequivalence was demonstrated as judged by regulators both internationally and in Saudi Arabia.

Most reviews on published bioequivalence trials (or those assessed by regulators) were directed towards re-analyzing their original findings (e.g. pharmacokinetic parameter estimation, bioequivalence testing) [ 11 , 12 , 13 ]. A comprehensive design characterization was only provided by one study which covered bioequivalence trials that were assessed by the Ministry of Food and Drug Safety in South Korea [ 14 ]. However, the latter study excluded trials that did not demonstrate bioequivalence and those conducted for fixed-combination products. Additionally, the study did not provide data on some important bioequivalence design aspects (e.g. country of the trial center, patient ages, body measurements, number of patients who completed the study, details about the nature of replicated trials). None of the published reviews was conducted using data on bioequivalence trials from the Middle East in general and in Saudi Arabia in particular. In Saudi Arabia, there is a lack of knowledge about bioequivalence data of the approved generic drugs in the Saudi health market [ 15 , 16 ]. Studies have shown that medical representatives have been the major source of clinical information about generic drugs for physicians, and only small proportion relies on published bioequivalence trials [ 17 , 18 ]. A panel of Saudi experts also recommended providing more data about bioequivalence trials for the approved generic drugs in the Saudi Arabia [ 15 , 18 ].

Since the establishment of the new electronic recording system of bioequivalence trials at the Saudi Food and Drug Authority (SFDA) in 2017, hundreds of bioequivalence trials have been reviewed by the SFDA’s evaluators for the approval of generic drugs in Saudi Arabia. The review process has been based on the SFDA Guidelines for Bioequivalence and on the SFDA’s Product Specific Bioequivalence Guidance [ 7 , 8 ]. This study was aimed to provide comprehensive review of all bioequivalence trials that were assessed by the SFDA since 2017 from a design and regulatory perspective.

Study design and data source

This was a retrospective, comprehensive analysis study. The SFDA generates assessment reports for bioequivalence trials if they were included in generic drug registration applications (one report for all bioequivalence trials per drug application). In each assessment report, all details per trial about the design, technical, and logistic aspects are added, with feedback on each aspect from the SFDA’s scientific evaluators. Each report ends with a decision on whether bioequivalence was demonstrated, was not demonstrated, or whether a decision could not be reached due to concerns related to the design or conduct of the trial. Data for trials since 2017 were extracted by the study team members using several data collection sheets. Approval from the SFDA Institutional Review Board was granted (the data are confidential and not available in the public domain of the SFDA).

SFDA requirements for bioequivalence testing

Based on the SFDA guidelines [ 7 ], the successful demonstration of bioequivalence is conditional mainly on the following:

Achieving statistical equivalence in the targeted pharmacokinetic parameters : The 90% confidence interval (CI) for the ratio of the test generic drug vs. reference brand-name drug must be contained within 80.0 to 125.0% equivalence margins in the targeted pharmacokinetic parameters, mainly the area under the plasma concentration curve from administration to last observed concentration at time t (AUC 0-t ) and the maximum plasma concentration (C max ). Stricter equivalence margins are required for drugs with a narrow therapeutic index. However, more lenient margins (up to a maximum of 69.84 to 143.19 in C max ) might be acceptable with highly variable drugs, i.e., CVw > 30%.

Choosing the right design aspects : The typical 2-sequence, 2-period, crossover design (i.e., 2 × 2) under fasting conditions is generally requested for immediate-release oral formulations, unless the brand-name drug is administered under fed conditions. Two 2 × 2 bioequivalence trials (one under fasting and one under fed conditions) are required for specific dosage forms (e.g., modified-release dosage forms, microemulsions, and solid dispersions). Alternative designs (e.g., replicate and parallel trial designs) could be considered in highly variable drugs or in drugs with a long elimination half-life (t 1/2 ). Other considerations about alternative design aspects are provided in the SFDA Guidelines for Bioequivalence and by the SFDA Product Specific Guidelines.

Compliance with quality and other regulatory standards : Assessing bioequivalence findings cannot be completed without meeting certain quality and regulatory standards. Examples of these standards are the selection of the production batch, specifications of critical quality attributes, whether the trial was conducted in a center accredited by the SFDA, and the choice of bioanalytical methodology.

Study outcomes and statistical analysis

Our review of bioequivalence trials that were assessed by the SFDA was conducted for three outcomes: reviewing the overall design and regulatory aspects of bioequivalence trials that were deemed successful by the SFDA in demonstrating bioequivalence, exploring the nature of within-subject variability in these trials and its relevance to other design aspects (e.g. the trial sample size), and providing an in-depth assessment of bioequivalence trial submissions that were deemed insufficient in demonstrating bioequivalence.

The overall review of the successful bioequivalence trials covered the following: the biopharmaceutics classification system (BCS), the therapeutic class of the active pharmaceutical ingredient (API) which was determined according to the World Health Organization Anatomical Therapeutic Chemical codes (ATC), the dosage form, the safety index (wide vs. narrow therapeutic index), the trial center, the trial design (2 × 2 crossover, replicate or parallel designs), the study condition (fasting vs. fed), masking study participants (blinding vs. open-label designs), the washout period, the sample size, the choice of equivalence margins, the coefficient of variation of within-subject variability (CVw), age, sex, and body mass index. The review was conducted at the single-API and fixed-combination levels.

The extracted CVws from the accepted trials (for both single APIs and fixed combinations) were assessed in relation to the trial sample size , trial design, and the different BCS classes (the recent Korean review found that highly variable drugs are mostly BCS Class II or IV [i.e. drugs with poor solubility]) [ 14 ]. Reasons for rejecting the submission of bioequivalence trials or for rejecting their results were explored in addition to the success rate of study centers per country. All study outcomes were analyzed descriptively using RStudio Version 2022.12.0.

A total of 590 bioequivalence trials were included in the study (Fig. 1 ). Bioequivalence was demonstrated in 521 trials (440 and 81 trials for single-API and fixed combination drugs; respectively), which were used to evaluate bioequivalence for 184 unique APIs and 36 unique fixed combinations. The remaining 69 of 590 were rejected either due to failed submissions of marketing authorization applications or due to the failure of a trial to demonstrate bioequivalence. Of the included trials, 240 (40.7%) were conducted ≥ 2017 (the trial date was not available for one trial). Almost two-third of 590 trial were conducted using Jordanian and Indian populations (237 and 203 trial centers; respectively), and 98 trials (16.6%) were conducted in European centers (only one study was conducted in Saudi Arabia).

The process of selecting the included bioequivalence trials

The design of the successful bioequivalence trials

Most of the 521 successful trials were conducted for single APIs/fixed-combinations of the cardiovascular system (84 of 521 [16.1%]), antineoplastic and immunomodulating drugs (75 [14.4%]), drugs for alimentary tract and metabolism (73 [14.0%]), and drugs for the nervous system (65 [12.5%]), Fig. 2 . More than half of single-API trials were BCS Class I drugs, and most BCS combinations in the fixed-combinations were BCS Class I and II combination and Class I and III combination (15 combinations each). Almost two-third and all of single-API and fixed-combination trials were conducted for tablet and capsule dosage forms; respectively (Table 1 ). A large proportion (79.0%) was conducted under fasting conditions (85.5% of these trials were conducted for immediate-release dosage oral dosage forms), and all trials. except for six, were conducted for drugs with a wide therapeutic index.

The most common therapeutic classes of successful trials

The typical 2 × 2 crossover design was used in 455 (87.3%) trials. The replicate design was used in 58 trials (wider C max equivalence margins were used in 25 of 58 replicate trials). Nine trials were designed as randomized, parallel design trials (four trials for generic forms of fingolimod hydrochloride, and five for enzalutamide, toremifene, entecavir, and terifunormide). The range of t 1/2 for drugs in these nine parallel trials was 4 to 20 days. The range of the sample size was 12 to 216. The median sample size for the single APIs was 36, and per trial design, the parallel-design trials had the highest median number of study participants ( n  = 71), followed by the replicate and 2 × 2 crossover trials (40 and 35; respectively). Similarly, the fixed-combination trials had a median of the sample size ( n  = 36), and almost comparable medians per trial design ( n  = 39 and 36 for the replicate and 2 × 2 crossover trials).

CVw, sample size, trial design and BCS classification

Figure 3 shows that the sample size tended to increase with the increase in CVw in bioequivalence trials of single APIs. The median sample size in trials of highly variable, single APIs was higher vs. the median in trials of drugs with CVw of ≤30%. This trend was not observed in trials of the fixed-combinations (Fig. 3 ); however, the median sample size in trials of fixed-combinations with a highly variable API was slightly higher vs. those low-CVw APIs (40 vs. 36; respectively).

Trials with replicate design had the highest median CVw for both the single APIs (33.5% vs. 18.9% vs. 16.3% compared with the 2 × 2 crossover and parallel trials; respectively) and the fixed combinations (31.1% vs. 19.8% compared with the 2 × 2 crossover trials). BCS Class II and IV drugs accounted for most of the highly variable drugs (58 of 82 [70.7%] of the highly variable drugs in the successful trials were BCS Class II and IV drugs). Figure 4 shows the distribution of CVw at the BCS class level in the single-API trials.

The distribution of CVws per BCS class. Class I: Trials with BCS Class I active pharmaceutical ingredients. Class II: Trials with BCS Class II active pharmaceutical ingredients. Class III: Trials with BCS Class III active pharmaceutical ingredients. Class IV: Trials with Class IV active pharmaceutical ingredients

The rejected bioequivalence trials

Justifications for the SFDA rejection was available for 51 of 69 (73.9%) rejected trials (Table 2 ). Most of these 51 trials ( n  = 21 [41.2%]) were rejected due to concerns related to the study centers (e.g. the center was not accredited by the SFDA; the center was suspended by the SFDA or a reference regulatory authority [e.g. US FDA or EMA]). Ten trials (19.6%) failed do demonstrate bioequivalence, and 17 had major regulatory or design concerns or concerns related to the quality of the APIs (Table 2 ).

There were four unsuccessful attempts to obtain waivers for demonstrating bioequivalence through in-vivo testing, commonly known as biowaivers. The first was denied because the request to register a 20 mg generic form of rosuvastatin relied on previous in-vivo bioequivalence data from the unregistered higher strength of 40 mg (i.e., additional strength waiver requests for generic drugs might be acceptable if the maximum strength is approved by the SFDA). Additionally, two other requests for biowaivers were made for generic forms of two drugs, ibuprofen and mirtazapine, which are not classified as BCS Class I (the SFDA only accepts biowaiver requests for BCS Class I drugs). The fourth and final rejected request was for a generic form of dabigatran etexilate mesylate, which failed in the in-vitro comparative dissolution testing—a requirement by the SFDA for biowaiver applications.

Figure 5 illustrates the risk of rejecting a bioequivalence trial per country. There were five countries with a number of conducted bioequivalence trials of higher than 10: Jordan ( n  = 237), India (203), Canada ( n  = 47), Egypt ( n  = 41), and Romania ( n  = 15). The highest risk of rejection among these five countries was in Egypt (48.8%), followed by Canada (12.8%), and Jordan (8.4%). The SFDA rejection decision in the Egyptian trials was driven by one of the three trial centers, which led to its suspension by the SFDA.

The risk of rejecting bioequivalence trials per country

For the support of the marketing authorization of generic drugs in Saudi Arabia, we found that the majority of submitted bioequivalence trials were accepted by the SFDA. Most were designed in the conventional 2 × 2 crossover format, with a focus on immediate-release dosage forms. These trials were primarily conducted in Jordan and India, with most drugs exhibiting low CVw. Additionally, a significant proportion of the trials involved BCS Class II drugs, and the therapeutic categories most frequently tested were drugs for the cardiovascular system, and antineoplastic agents and immunomodulatory drugs. Studies involving single APIs with high CVw tended to require larger sample sizes, with BCS Class II and IV drugs accounting for the majority of high CVw drugs. Finally, our findings indicate that conducting trials at centers not accredited by the SFDA or suspended by other stringent authorities is likely to result in trial rejection.

Several design aspects of the accepted bioequivalence trials in our study share similarities with those submitted to other regulators [ 13 , 14 , 19 ]. This similarity can be attributed to the common adoption of a 2 × 2 crossover design, immediate-release oral dosage forms, and drugs for the cardiovascular system as the most commonly targeted therapeutic class. Our study identified six parallel trials, which typically had a larger sample size than other designs (median sample sizes were 70, 40, and 35 for parallel, replicate, and crossover trials; respectively). The range of sample sizes in our study was wider compared to those reported in published reviews (12 to 216 versus 12 to 170) [ 13 , 14 ]. Our study also revealed that an increase in sample size was necessary to accommodate an increase in CVw for trials with single APIs. Notably, we observed that the replicate design had the highest median CVw, as expected. Consistent with previous research, which found that CVw was influenced by solubility-limited absorption and/or low permeability, our results indicated that BCS Class II and IV drugs accounted for the highest variability [ 14 , 20 ].

The age range of trial participants in our study was wider (18 to 87 years) than those reported in previous reviews (18 to 60 years) [ 13 , 19 ]. The SFDA might accept an age limit higher than 60 years if adequately justified by the marketing authorization holder. Almost two-third of the trials in our study were conducted under fasting conditions, similar to trials conducted in South Korea [ 19 ]. Only six trials were conducted for narrow-therapeutic index drugs, and no data from published reviews were available for these drugs. Only one study was conducted in Saudi Arabia, with the majority of trials conducted in Jordanian and Indian populations. Further studies are needed to explore opportunities and to identify gaps in conducting bioequivalence in Saudi Arabia, and to determine the extent to which bioequivalence results can be extrapolated directly to the Saudi population as a previous study found differences in fed-between-population pharmacokinetic parameters [ 21 ].

The study findings indicated a potential lack of understanding or insufficient knowledge regarding SFDA requirements and guidelines for the design and conduct of bioequivalence trials. For instance, conducting trials at centers not accredited by the SFDA resulted in a rejection of 23 bioequivalence trials, and two trials were rejected because the approved brand-name drug was not chosen as the reference drug. There might also be insufficient awareness for the conditions of accepting applications for biowaivers. The SFDA published a comprehensive product-specific bioequivalence guideline in 2022 and they have advised marketing authorization holders to seek for an SFDA scientific advice during the design, conduct or submission stages if further clarification is needed [ 8 ]. The number of SFDA bioequivalence scientific advice letters/meetings increased in the first two months of 2024 in comparison with those of 2023 (43 vs. 15; respectively). The SFDA is in the process of updating its guideline for biowaivers to include more details with illustrative examples. These initiatives are expected to facilitate the development of generic drugs and reduce the number of failed or suboptimal applications for demonstrating or waiving bioequivalence [ 22 ].

Our study provides a comprehensive assessment of bioequivalence trials submitted to a regulator for marketing authorizations of generic drugs, making it among the few studies of its kind and the first in the Middle East. We presented a summary of the design, conduct, and regulatory aspects of these trials, investigated the association of CVw with certain design factors, and analyzed trials rejected by the SFDA in an effort to support the implementation of these trials in the region. However, our study had several limitations. Trials submitted for marketing authorization prior to the introduction of the new electronic recording system for bioequivalence trials in 2017 were not included in our analysis. Additionally, we did not evaluate the selection of reference drugs in these trials or explore the submission of marketing authorization applications for biowaivers. Future studies that address these aspects would complement the findings of our study.

Conclusions

In conclusion, this study provides valuable insights into the design, conduct, and regulatory aspects of bioequivalence trials submitted to the SFDA for marketing authorization of generic drugs in Saudi Arabia. The findings of this study highlight the need for further research to explore opportunities and identify gaps in conducting bioequivalence trials in Saudi Arabia.

Availability of data and materials

The datasets generated during and/or analysed during the current study are not publicly available due to confidentiality but are available from the corresponding author on reasonable request.

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Turki A. Althunian, Raseel A. Alroba & Ohoud A. Almadani

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Turki A. Althunian

Department of Pharmacokinetics, Saudi Food and Drug Authority, Riyadh, Saudi Arabia

Bader R. Alzenaidy, Fahad A. Alqahtani, Albatool A. Binajlan, Amal I. Almousa, Deema K. Alamr, Malak S. Al-Mofada, Nora Y. Alsaqer, Hessa A. Alarfaj, Abdulmohsen A. Bahlewa, Mohammed A. Alharbi, Abdulaziz A. Alsuwyeh & Abdulmohsen A. Alsaleh

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Contributions

Turki A. Althunian, Bader R. Alzenaidy, Abdulaziz A. Alsuwyeh, and Abdulmohsen A. Alsaleh designed the study. Turki A. Althunian, Bader R. Alzenaidy, Raseel A. Alroba, Ohoud  A. Almadani, Fahad A. Alqahtani,  Albatool A. Binajlan,  Amal I. Almousa, Deema K. Alamr, Malak S. Al-Mofada, Nora Y. Alsaqer , Hessa A. Alarfaj, Abdulmohsen A. Bahlewa, Mohammed A. Alharbi, Ali M. Alhomaidan, Abdulaziz A. Alsuwyeh, and Abdulmohsen A. Alsaleh involved in the study conduct, data collection and analysis. Turki A. Althunian wrote the manuscript, and the final version of the manuscript was reviewed by all authors and approved by the study supervisors (Turki A. Althunian and Abdulmohsen A. Alsaleh).

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Correspondence to Turki A. Althunian .

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Our study did not involve human participants and consent forms were not required. The study included anonymized human data from anonymized bioequivalence trials. As a result, an assessment by the SFDA’s institutional review board was deemed unnecessary by the board. However, the final draft of the manuscript was approved by the SFDA’s Research Committee for the publication. (approval number: RL-2022-016).

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Althunian, T.A., Alzenaidy, B.R., Alroba, R.A. et al. Bioequivalence trials for the approval of generic drugs in Saudi Arabia: a descriptive analysis of design aspects. BMC Med Res Methodol 24 , 82 (2024). https://doi.org/10.1186/s12874-024-02207-4

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Received : 29 November 2023

Accepted : 22 March 2024

Published : 05 April 2024

DOI : https://doi.org/10.1186/s12874-024-02207-4

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