The January 2025 edition of Orange County Lawyer magazine features an article written by Metaverse Law’s Lily Li. Read “AI and Machine Learning in Drug Development and Clinical Trials” below or in Orange County Lawyer magazine.

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[Originally published as a Feature Article: AI and Machine Learning in Drug Development and Clinical Trials, by Lily Li, in Orange County Lawyer Magazine, January 2025, Vol. 67 No.1, page 28.]   AI and Machine Learning in Drug Development and Clinical Trials by Lily Li   In 2013, sleep medication zolpidem (Ambien, Ambien CR, and Edluar) swept headlines. Marie Claire reported on an alarming and suspicious rise in users experiencing irrational eating, gambling, and even “sleep-driving” while in a hypnotic trance—waking with no memories of their actions.[1] In several cases, women arrested and convicted for driving under the influence contested their convictions, arguing that they were not liable for these undisclosed drug-related side effects. At the same time, several clinical studies suggested that women metabolized zolpidem differently from men. By reviewing existing literature, Japanese researchers out of Shimane University identified 40% higher concentrations of zolpidem in women than men following use, and higher rates of visual hallucinations and sensory distortions.[2] The FDA released a safety advisory, warning users of the risks of “next-morning impairment” for the use of Ambien and related drugs.[3] In addition, the FDA took the unusual step of recommending a 50% cut in the dosage for women. When asked about the change, an FDA director told ABCNews.com: “The changes are different in women and men . . .We don’t understand why yet, but women are more susceptible to next-morning impairment.”[4] Yet, a decade later, the evidence supporting different zolpidem dosages for women and men is unclear.[5] In part, this is due to the lack of research surrounding sex differences in drug impact and drug treatment, as well as substantial gaps in the inclusion of women in clinical studies. From 1977 to 1993, FDA policy recommended excluding women of childbearing potential from Phase 1 and early Phase II drug trials.[6] Even after this policy was removed in 1993, industry fears remained with respect to drug interactions with pregnancy. This episode with zolpidem raised several concerns in the drug development and clinical trial process:

• How do we recruit representative candidates for drug trials?
• How do we ensure the quality and availability of datasets for clinical research?
• How do we measure potential impacts of drug dosing on different populations?
• What are the legal implications for failing to address appropriate drug doses?

  AI and ML to the Rescue? Now that artificial intelligence is being used in research and development, one wonders: Can artificial intelligence (AI) and machine learning (ML) reduce bias and risks during drug development? Or will it create new legal risks due to bias, privacy intrusions, and lack of transparency? The FDA released a discussion paper on AI, Using Artificial Intelligence and Machine Learning in the Development of Drug and Biological Products, to discuss potential regulatory frameworks to address the use of AI and ML.[7] In this discussion paper, the FDA released a set of fascinating case studies into existing research and uses of AI in the clinical trial process. Several of these case studies are discussed below, as well as an analysis of their potential impact on the zolpidem example.

1. Recruitment. According to the FDA, “AI/ML is being used to mine vast amounts of data, such as data from clinical trial databases, trial announcements, social media, medical literature, registries, and structured and unstructured data in EHRs [electronic health records], which can be used to match individuals to trials (Harrer, 219 Shah, Antony, & Hu, 2019).” In this manner, researchers can combine huge quantities of publicly available data and individual health data from prior research to identify participants with certain medical conditions (or lack of adverse conditions) for investigational treatments. For zolpidem, the use of AI/ML may have been able to identify a much broader list of participants for initial clinical testing, making it easier to assess and identify adverse reactions.
2. Selection and Stratification of Trial Participants. In addition to initial recruitment, AI/ ML has the capability improve intake, selection, and classification of clinical trial participants. Based on baseline characteristics selected by the researchers, such as prior clinical data, and vitals/labs taken during intake, predictive algorithms can help identify high-risk participants.[8] These groups can then be randomized and then subject to more strict monitoring protocols. In the case of zolpidem, alcohol use is associated with sometimes severe adverse effects from the drug, and so it would be beneficial to screen out candidates with a history of alcoholism or, on the flip side, assess drug interactions for this high-risk group with additional support, monitoring, or counseling.
3. Dose/Dosing Regimen Optimization. AI/ML can be used to predict drug exposure for different populations based on factors such as weight, height, sex, and other characteristics that might impact drug metabolism. Based on prior drug exposure and response profiles for similar drugs and similar populations, AI/ML can help to narrow the dose/dosing regimen selected for a study. As noted by the FDA’s discussion paper, this can help optimize drug dosing “in special populations where there may be limited data (e.g., rare disease studies, pediatric and pregnant populations).” Based on this research, we can imagine future scenarios where AI/ML could have avoided zolpidem dosing concerns, where graduated and limited dosing was tested and applied to different sex, age, and metabolism categories to determine ideal dosing.
4. Data Analysis. On a more intriguing level, the FDA AI discussion paper discussed the concept of creating “digital twins” of patients for clinical trials. Essentially, an AI version of the clinical participant is created, using the existing candidate’s electronic health records, vital signs, labs and other records. Researchers can assess how the digital twin would react under normal conditions using AI/ML modeling based on data gathered from similar individuals. This digital twin would then act as a substitute for a placebo candidate in a clinical trial, and act as a benchmark against the actual patient undergoing investigational treatment. For zolpidem, this could be used to assess candidates that already have underlying medical conditions such as anxiety, depression, or other confounding factors, to see whether an adverse effect from a trial is due to the investigational treatment or something that is likely to occur to the same individual from anxiety alone.
5. Postmarketing Safety Surveillance. Finally, AI/ML can help detect and assess adverse events once the drug enters the market. This is not just limited to individual case safety reports (ICSR), required by regulators, but can include adverse events reported publicly on social media and the wider internet. This type of postmarketing safety surveillance could assist researchers and drug companies in identifying potential drug risks, prior to landing on primetime news.

  Quality and Reliability Risks While AI/ML can help to address the costs and efficiency of clinical trials, this relies substantially on the underlying data used to train AI. The quality and reliability of any AI/ML model requires similar quality controls for underlying training data. Given the safety risks of inappropriate drug dosing, or recruiting candidates with severe medical conditions, AI developers cannot rely solely on self-reported healthcare data with no external medical testing or validation. Developers should be equally wary of training on third-party data sets that do not provide documentation on the collection of data and data validation. Within an existing healthcare organization, if the organization is big enough, aggregate and de-identified data may be obtained from existing electronic health care records and prior clinical trials. Yet, even within these large datasets, errors may surface during training. Medical providers may code the same procedure, and similar symptoms, a dozen different ways. Even drug names can be misspelled and coded incorrectly within existing records. While many of these errors may end up being statistically insignificant with enough data, there is the risk of missing one or two major adverse events, or “black swan” events, that would otherwise change the entire risk profile of a drug. In addition to quality and reliability, the underlying dataset needs to be representative of the population that will be studied for the clinical trial. If the underlying dataset is only trained on a handful of individuals with a certain medical predisposition, age, sex, weight, etc., it will be difficult for the AI model to make predictions for that group. As an example, if the training data only contains the medical information for two individuals over the age of sixty, and shows no adverse effects from a particular drug dose, this information is not enough to generalize that the drug at that dosage is appropriate for all individuals over the age of sixty. For all we know, these two candidates could be a former Olympic diver and a nutrition coach, two outliers that completely skew the data. Consequently, the underlying training data for any AI model should also be assessed for bias and representativeness as it applies to the proposed clinical trial.   Data Privacy, Cybersecurity, and AI Risks The data privacy and cybersecurity risks associated with the foregoing uses of AI/ML cannot be underestimated. The quality and representativeness of any AI system in this field will rely heavily on large swathes of healthcare data, fine-tuned and, at times, personalized in the case of digital twins. This is sensitive or special category data at its finest, triggering heightened scrutiny under the EU’s data privacy law, the GDPR, and U.S. data privacy and data breach laws. To date, most healthcare organizations have sidestepped data privacy concerns by relying on HIPAA’s de-identification standard to remove personal information and other identifiers from healthcare data, making it difficult to associate with an individual. While the FDA requires Institutional Review Board (IRB) review of most biomedical research involving human subjects, this generally does not apply to de-identified personal information that cannot be linked to an individual. Simply de-identifying data and then running with it is not enough, however. Under the California Consumer Privacy Act and similar state laws, for example, recipients of de-identified data need to affirm that they will not attempt to reidentify the data (except to test their de-identification methods). The GDPR has a much higher “anonymization” standard, which looks at the re-identifiability of personal information, given all the different datasets that an organization may have access to. AI/ML itself is making the de-identification process harder. As it is capable of slicing and dicing data by age, race, sex, and medical condition, and combining multiple large datasets, it is easy to run the risk of re-identifying data. While several thousand people might have the same configuration of eye color, age, gender, and weight, only one or two may have participated in a clinical trial at a particular location, or have specific allergies or side effects to certain types of medication. As a result, in circumstances where healthcare data is not de-identified, or the risk of reidentification is heightened, then it behooves clinical organizations and their AI developers to implement written information security programs and associated privacy and security controls.   Legal Liability and Drug Dosing In several notable cases, defendants on zolpidem were able to contest or overturn DWI or even vehicular manslaughter cases. Essentially, these defendants argued that they were not aware of the potential dangers of zolpidem, and so could not be liable for their actions while “sleep driving.” This raises the question: If AI gets good enough, and can tell you exactly the right dose to take of a drug, will you (or your doctor) be liable if you deviate from the AI’s recommendations? Will the AI’s recommendations be discoverable in court (and surfaced via AI-enhanced search)? Only time will tell what this brave new world will bring.   ENDNOTES [1] Kai Falkenberg, While You Were Sleeping (September 27, 2012), Marie Claire, https://www.marieclaire.com/culture/news/a7302/while-you-were-sleeping/.   [2] Takuji Inagaki, Tsuyoshi Miyaoka, Seiichi Tsuji, Yasushi Inami, Akira Nishida, and Jun Horiguchi, Adverse Reactions to Zolpidem: Case Reports and a Review of the Literature, 12 Prim Care Companion J Clin Psychiatry 6 (2010), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3067983/.   [3] U.S. FDA, Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR (May 14, 2013), https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-approves-new-label-changes-and-dosing-zolpidem-products-and.   [4] FDA: Cut Ambien Dosage for Women, ABC News (January 10, 2013, 6:03AM), https://abcnews.go.com/Health/fda-recommends-slashing-sleeping-pill-dosage-half-women/story?id=18182165.   [5] David J Greenblatt, Jerold S Harmatz, & Thomas Roth, Zolpidem and Gender: Are Women Really At Risk?, 39(3) J. Clinical Psychopharmacol. 189 (May/Jun 2019), https://pubmed.ncbi.nlm.nih.gov/30939589/.   [6] NIH Inclusion Outreach Toolkit: How to Engage, Recruit, and Retain Women in Clinical Research, last accessed September 16, 2024: https://orwh.od.nih.gov/toolkit/recruitment/history.   [7] FDA, Using Artificial Intelligence and Machine Learning in the Development of Drug and Biological Products (May 10, 2023), https://www.fda.gov/media/167973/download; see also Using Artificial Intelligence and Machine Learning in the Development of Drug and Biological Products; Availability, 88 FR 30313 (May 11, 2023), https://www.federalregister.gov/documents/2023/05/11/2023-09985/using-artificial-intelligence-and-machine-learning-in-the-development-of-drug-and-biological.   [8] Thi Tuyet Van Tran, Hilal Tayara, and Kil To Chong, Artificial Intelligence in Drug Metabolism and Excretion Prediction: Recent Advances, Challenges, and Future Perspectives, 15 Pharmaceutics. 1260 (Apr 17, 2023), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10143484/.   Lily Li is an AI, data privacy, and cybersecurity lawyer and founder of Metaverse Law. She is a certified information privacy professional for the United States and Europe and is a GIAC Certified Forensic Analyst for advanced incident response and computer forensics. She can be reached at info@metaverselaw.com.