Advocacy and Health Policy |
Understanding the Practical Implications of the FDA’s December 2021 and January 2023 Mifepristone REMS Decisions
This article was originally published on March 28, 2022 and was republished to include updated information from the FDA's January 2023 Mifepristone REMS Decision.
On January 3, 2023, the FDA issued a final decision on its risk evaluation and mitigation strategy (REMS) for mifepristone, which is part of the recommended regimen for medication abortion and miscarriage management. The 2023 REMS permanently removed the in-person dispensing requirement and add a new pharmacy certification process to enable retail pharmacies to dispense mifepristone directly to patients with a prescription from a certified prescriber. All other previous mifepristone REMS requirements remain in effect, pending a United States Supreme Court decision in the case Alliance for Hippocratic Medicine v. FDA.
For more information, read our assessment of mifepristone’s status in the courts, which is updated regularly. Additional information about the provision of mifepristone under the current REMS can be found in ACOG’s Practice Advisory on Updated Mifepristone REMS Requirements.
Questions about mifepristone and its practical use continue to arise. Nisha Verma, MD, FACOG, an obstetrician–gynecologist who subspecializes in complex family planning, and Molly Meegan, ACOG’s chief legal officer and general counsel, shed light on a number of frequently asked questions about what the current FDA regulation of mifepristone means and how it may affect clinical practice.
What are the reproductive health indications for the medication mifepristone?
A combined mifepristone and misoprostol protocol is used in reproductive health settings as...
- A safe and effective regimen for medication abortion. Taking medications to terminate a pregnancy is currently approved by the FDA through 70 days of gestation, but evidence also exists to support safe and effective use with more advanced gestations. i
- Safe and effective management of early pregnancy loss. ii
ACOG supports the use of and expanded access to mifepristone for these indications and opposes restrictions such as the previous on-site dispensing requirements and mandatory in-person exams prior to and following a medication abortion. iii,iv,v
What is a REMS?
A REMS is a set of rules and regulations for distribution and use applied to drugs when the FDA deems it “necessary to ensure that the benefits of the drug outweigh the risks.” The FDA also has the authority to lift a drugs REMS based on an evaluation of safety data.vi
The FDA restricted the distribution of mifepristone upon its approval in 2000, and then established a REMS for mifepristone in 2011. The original 2011 REMS for mifepristone had three elements:
- Mifepristone could only be administered in a clinic, hospital, or under the direct supervision of a certified medical professional. This “in-person dispensing requirement” precluded availability in retail pharmacies and delivery by mail, even though patients were not required to use mifepristone at the time it was dispensed in the clinician’s office and could take it at home.
- A clinician had to obtain certification by submitting a prescriber agreement form to the drug distributor prior to prescribing mifepristone
- The patient had to sign an FDA-approved patient agreement form before a clinician could dispense mifepristone
What is ACOG’s position on the REMS for mifepristone?
ACOG has long opposed the REMS for mifepristone. Decades of evidence, including the lifting of the in-person dispensing requirement during the COVID-19 public health emergency, and the consensus of the medical community underscore that mifepristone is a safe medication; that FDA requirements do not benefit patients; and that the REMS disproportionately burdens communities already facing structural barriers to care, including people of color and those living far from a health care professional.
How did the REMS for mifepristone change during the COVID-19 pandemic?
When the COVID-19 pandemic began, ACOG petitioned the FDA in court for removal of the burdensome and dangerous in-person dispensing requirement. As a result, the FDA halted enforcement of the in-person dispensing requirement for mifepristone for the duration of the COVID-19 public health emergency, which is ongoing. vii Because enforcement of this requirement was halted, clinicians in multiple states have been able to provide mifepristone to patients by telemedicine and mail. viii Of note, state laws regulating medication abortion remain in effect despite these temporary changes to REMS enforcement.
What did the FDA’s December 2021 decision say?
On December 16, 2021, the FDA issued permanent modifications to the REMS. This decision:
- Removed the in-person dispensing requirement.
- Added a requirement that pharmacies which dispense mifepristone must be certified.
- Maintained the prescriber certification and Patient Agreement Form requirements.
How does the 2023 final decision to update the mifepristone REMS affect previous actions by the FDA?
On January 3, 2023, the FDA issued modifications to the REMS. The 2023 REMS permanently removed the in-person dispensing requirement, added a requirement that pharmacies that dispense mifepristone must be certified, and maintained the prescriber certification and patient agreement form requirements. These changes are currently in effect in states where mifepristone is not otherwise restricted by state law.
How will the change to the FDA’s labelling of mifepristone affect clinical practice in my state?
Whether clinicians can dispense mifepristone by mail or direct patients to fill their mifepristone prescription at a retail pharmacy is a state-specific legal question. If your state has a law regulating medication abortion, it remains in effect.
However, in states without laws or regulations requiring in-person dispensing of mifepristone, clinicians who are certified by the provider agreement form can mail mifepristone to patients. The Guttmacher Institute provides resources reviewing state laws and policies related to medication abortion and abortion in general, which may be useful for clinicians seeking more information. Clinicians can also seek legal counsel to clarify state restrictions or laws regarding mifepristone.
If you have questions about state policies affecting access to medication abortion, you can reach out to ACOG’s State Government Affairs team at [email protected]. If you have other questions about the use of mifepristone or medication abortion, you can submit an inquiry through ACOG’s Spontaneous and Induced Abortion Resource Center.
As a reminder, this message is for informational purposes only and should not be construed as legal advice on any subject matter. As a practitioner, neither you nor anyone who reads this message should act or refrain from acting on the basis of any content included in this message or on ACOG’s website without seeking legal or other professional advice.
i Medication abortion up to 70 days of gestation, Practice Bulletin No. 225 (October 2020)
ii Early Pregnancy Loss, Practice Bulletin No. 200 (November 2018)
iii Increasing Access to Abortion, Committee Opinion No. 815 (December 2020)
iv Improving Access to Mifepristone for Reproductive Health Indications, Position Statement (June 2018)
v The FDA’s Decision Lifting the Burdensome Restriction on Mifepristone during the Pandemic: What You Need to Know Advocacy and Health Policy, web-only document (April 2021)
vi An introduction to risk evaluation and mitigation strategies, Contraception VOLUME 104, ISSUE 1, P4-7, JULY 01, 2021.
vii ACOG Suit Petitions Court to Remove FDA's Burdensome Barriers to Reproductive Care During COVID-19 Advocacy and Health Policy web-only document (May 2020)
viii Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic, Contraception (March 2021)
ix Questions and Answers on Mifeprex, US Food and Drug Administration (December 2021)