Several panelists voted "yes" for approval not because of a compelling risk/benefit profile, but because they believe physicians and patients should have the "option" to choose the therapy. This reveals a philosophy where regulatory approval is seen as a gateway to choice, deferring the final, nuanced risk-benefit decision to the clinic.

While political drama at the top of the FDA captures headlines, the agency's rank-and-file reviewers are largely maintaining operational continuity. Many drug programs are still receiving necessary feedback within expected timeframes, suggesting the core machinery of the FDA is resilient.

The FDA issued a Complete Response Letter for Syndaxus's pediatric myopia drug, which met its endpoint and was approved in Europe. This decision, made without an advisory committee meeting, points to shifting regulatory standards, a lack of transparency, and a reversal of the FDA's historical tendency to be more permissive than its European counterparts.

Internal power shifts at the FDA, such as Vinay Prasad's rising influence, create a chilling effect on review teams. Even without direct orders, reviewers feel less emboldened to be flexible when leadership's public stance favors greater rigor. This 'tone from leadership' can shift regulatory outcomes more than explicit policy changes.

By using big data for continuous, real-time post-market surveillance, the FDA can identify safety signals almost instantly. This robust safety net after a drug is launched paradoxically allows the agency to lower the evidence threshold required for initial approval, accelerating access to new cures.

The FDA commissioner found that scientific reviewers only share groundbreaking ideas for process improvement when guaranteed anonymity, fearing repercussions from their supervisors. This highlights a stifling bureaucratic culture where true innovation happens in one-on-one meetings, not formal briefings.

The replacement of CEDAR Director Richard Pazder with Tracy Beth Hoeg, who is viewed as an ideologue lacking regulatory experience, signals a shift toward politically driven decisions at the FDA. This move creates significant uncertainty and raises concerns that ideology, not science, will influence drug approvals.

The FDA is shifting policy to no longer allow reliance on immunogenicity data (immunobridging) for approving new or updated vaccines. This move toward requiring full clinical efficacy trials will make it harder to combat evolving pathogens and would have prevented past approvals of key vaccines like those for HPV and Ebola.

The current disconnect between the FDA leadership's public calls for flexibility and its divisions' strict actions is not new. For decades, the agency's hierarchy has acted as a promotional arm to encourage industry, while the review divisions have maintained a more conservative, old-school approach to rigor. This historical pattern is often overlooked.