The FDA responded to
my follow-up, but they did not answer my questions. They referred me to the pre-IND consult process, and I initiated it to find out exactly what the requirements will be. It appears that they are sticking to their guns of keeping FMT regulated as an unapproved drug and requiring GMP standards, so we will have to run clinical trials to get it approved. We will likely need 1 physician, a few thousand patients with the same condition, and funding to pay the physician and donor(s). A trivial amount of money compared to what's being spent on other research, but it's not money I have.
I think the FDA needs to drop the GMP requirement no matter what. Then, if they're unwilling to create FMT-specific regulation that allows this project to continue, we will need funding for a clinical trial.
https://www.sciencedirect.com/science/article/pii/S2452302X1600036X
New drug and device approval in the United States take an average of 12 and 7 years, respectively, from pre-clinical testing to approval. Costs for development of medical devices run into millions of dollars, and a recent study suggests that the entire cost for a new drug is in excess of $1 billion. For investigators seeking approval for new drugs and devices, FDA processes can be formidable.
The incompetence of the research system:
Elaborating on the points above with supporting evidence.
On my personal blog, there are also multiple posts about this.
- They act like robots that have been programmed to perform a very narrow set of tasks. There is a complete lack of innovative thinking, initiative, and ability to think outside the box.
- They continue to do the same thing over and over despite extremely poor results. I don't think they're expecting to get different results from doing the same thing. I think they're happy to just keep doing the bare minimum to get paid, and there appears to be no incentive for them to actually solve the problem.
- Lack of motivation. Anyone can do FMT outside of clinical trials. So if someone was motivated to learn about FMT and run an effective clinical trial they would look for information outside clinical trials. Not only have they not done that, but they've ignored answers that I went out of my way to discover and hand deliver to them.
In support of my statements, here's an example of the "best of the best" FMT study currently being done:
Fecal microbiota transplantation influences microbiota without connection to symptom relief in irritable bowel syndrome patients (Aug 2024, n=49)
No reasonably intelligent person would do a study like that if they were genuinely trying to find a cure. You could say "They're ignorant", but a sufficiently motivated person would strive harder to become well-informed before running a trial like that.
Here's another one that even failed for C. diff:
VA trial using the University of Minnesota's donors finds no reduction in C. diff recurrence after FMT (Sep 2024, n=153, UMN)
And another halted for futility:
Rigorous Donor Selection for Fecal Microbiota Transplantation in Active Ulcerative Colitis: Key Lessons From a Randomized Controlled Trial Halted for Futility (May 2024, n=72)
You couldn't blame anyone for thinking it's being done on purpose to ensure that a cure is never available, and billions of dollars continue to get made from selling drugs to sick people. But as the saying goes,
never attribute to malice what can be explained by incompetence.
A single disabled patient with zero funding should not be out-performing the entire world's research system.
Regardless of what happens with this situation, there needs to be massive changes to our research systems. It seems clear that there is a lack of performance-based incentives. Patients should not have to obtain and develop their own treatments and run their own clinical trials.
Here's an example of the high costs and deficient nature of using blood & stool testing as a primary screening tool:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0276323 - more than 61% of their applicants failed the tests.
None of Human Microbes' donors have failed a blood or stool test because those tests are not our main screening tool, they are simply the cherry on top. Those tests are not an appropriate "primary tool" for screening donors, as the links above demonstrate.
Virtually all other sources of FMT use these tests as a primary screening tool because they do not have better tools, and haven't bothered to acquire or test better tools. I developed a better set of tools. So our donor applicants who make it to the blood & stool testing portion are extremely unlikely to fail those tests.
I recently tested a very good donor, and while they were very helpful in many ways, they were not "a cure", so I think it's time to focus on Step #3:
https://maximiliankohler.blogspot.com/2019/12/fmt-roadmap-proposal.html. That requires funding and partnerships with research groups.
Expounding further for federal legislators:
There seems to be a severe deficiency in competence, motivation, and even being well-informed.
It appears to be due to a lack of market and competition-based incentives. The distribution of funds does not seem to be merit-based or based on their performance and accomplishments.
If the right incentives were in place, all the major universities would have been rushing to screen
their student-athletes to find the most effective stool donors and demonstrate a panacea.
A group of some of the most well-known microbiome researchers
wrote a paper about how catastrophic the loss of microbiome diversity is.
Yet they did nothing about it despite being in a fantastic position to do so.
Many research groups do not have the ability to take on a project like this and screen huge amounts of donors, but most of the university research teams are in an excellent position to recruit from their student-athletes. These groups are the source of the vast majority of top professional athletes.
Dr. Anthony Fauci is a good example of someone who is extremely healthy and who was a college athlete but didn't go on to be a pro. He likely would have made a good stool donor in his youth.
Some of it may have to do with universities giving tenured positions, which is basically researchers being set for life with a good job and automatic respect, as long as they don't f**k up really badly.
Whatever the cause, politicians can't keep blindly pouring billions of dollars into this extremely flawed research system.
The experimental nature of FMT:
Let's say FMT, or one source of FMT, gets approved after a clinical trial. I think it's still erroneous to regulate FMT as a drug at that point. Each donor and recipient are so unique; there's an inherent level of unpredictability. And that should be ok as long as recipients are informed about this, able to review donor-specific results from other patients, and have adequate information to judge donor quality, risks, etc. FMT is experimental and will likely remain experimental for many decades. Regulation should account for that instead of prohibiting FMT due to it.
The most recent donor I used is a perfect example of this. I've done countless FMTs from 16+ donors. I arguably have the most practical knowledge and experience with FMT out of anyone in the world, yet this donor had unique, unusual, and unpredictable impacts. I have little idea what would happen if other people used this donor. The only valid approach is to publicly track the results of this donor to see how other people fare, and then let people decide for themselves if the risk-to-reward ratio is worth it for them.
Let's say that for the clinical trial I pick the donor that I think is the #1 rank. That donor may not be the best for everyone/every condition. Some people may benefit more from another donor. The best donors are also going to be a limited supply. People should have the option to choose other donors, and there needs to be informed consent (public tracking of results).
I think a decent comparison is food/diet
https://humanmicrobiome.info/diet/. Watermelon and avocados are good, but you shouldn't force everyone to only eat watermelon and avocados.
I think the main goal of any clinical trial should be to verify that my donor criteria are valid for safety, and my top donors are effective enough to be worth any risks.