Understanding MedDRA and Its Importance in Clinical Trials

Introduction to MedDRA

The Medical Dictionary for Regulatory Activities (MedDRA) is an internationally standardized medical terminology developed under the auspices of the International Council for Harmonisation (ICH). It is the global standard for coding adverse events, medical histories, indications, and procedures across clinical trials and post-marketing surveillance. Regulators such as the FDA, EMA, MHRA, PMDA, and CDSCO require the use of MedDRA for consistent reporting of adverse events.

MedDRA provides a common language that allows harmonized reporting of clinical and safety data across companies, regions, and regulatory submissions. This prevents misinterpretations that could arise if sponsors used different medical terminologies. For example, one sponsor might describe an event as “heart attack,” while another uses “myocardial infarction.” MedDRA coding ensures both are standardized under the same Preferred Term (PT) for regulatory analysis.

The dictionary is used throughout the product lifecycle: from early phase clinical trials to post-marketing pharmacovigilance. In safety reporting databases such as the FDA FAERS and the EMA EudraVigilance, MedDRA ensures that safety signals are consistently captured and analyzed across millions of case reports.

Why MedDRA Is Used in Clinical Trials

MedDRA is not just a vocabulary; it is a regulatory requirement and an analytical tool. Its use offers several key benefits:

• Regulatory compliance: All IND, NDA, BLA, and CTA submissions must use MedDRA coding for adverse events.
• Consistency: Ensures uniform representation of medical concepts across trials, preventing duplication or misclassification.
• Signal detection: Facilitates statistical analyses to identify potential safety issues across large datasets.
• Global harmonization: Enables cross-regional reporting under FDA, EMA, and WHO guidelines.
• Audit readiness: Provides clear documentation and coding traceability during GCP and pharmacovigilance inspections.

For example, in oncology trials, adverse events such as “low white blood cell count” are coded under the MedDRA PT “Neutropenia.” This standardization enables consistent analysis of hematological toxicity across multiple compounds and studies.

Structure of MedDRA and Its Application

MedDRA is hierarchical, consisting of five levels:

1. Lowest Level Terms (LLTs): Lay or specific terms entered by investigators (e.g., “heart attack”).
2. Preferred Terms (PTs): Standardized terms for analysis (e.g., “Myocardial infarction”).
3. High Level Terms (HLTs): Group of related PTs (e.g., “Ischemic coronary artery disorders”).
4. High Level Group Terms (HLGTs): Broader groupings (e.g., “Coronary artery disorders”).
5. System Organ Class (SOC): Highest level, grouping by organ system (e.g., “Cardiac disorders”).

By applying this structure, sponsors ensure that adverse events can be reviewed both in detail (PT-level) and broadly (SOC-level). Regulatory reviewers use SOC-level summaries to evaluate system-wide toxicities, while safety physicians use PT-level data for case-level assessments.

A sample MedDRA coding workflow might look like this:

This process demonstrates how MedDRA transforms site-reported terms into standardized codes for regulatory use.

Challenges and Limitations of MedDRA Use

While MedDRA brings enormous benefits, it is not without challenges:

• Ambiguous terms: Investigators may use vague language like “unwell,” which requires careful coding to avoid misclassification.
• Version updates: MedDRA is updated biannually (March and September). Sponsors must reconcile coding across versions, which can affect ongoing trials.
• Training needs: CRAs, coders, and safety teams must be trained regularly on MedDRA use and version changes.
• Auto-coding risks: Automated systems can misclassify terms if not reviewed by trained coders, especially for complex events.
• Consistency across teams: Large sponsors with multiple coding teams must maintain coding conventions to avoid discrepancies.

For example, if one coder selects the PT “Headache” for the term “Migraine” while another selects “Migraine,” analyses of central nervous system toxicity could be distorted. SOPs and coding guidelines are critical to mitigate such risks.

Regulatory Expectations and Inspections

Regulatory authorities expect sponsors to demonstrate traceability in MedDRA coding. During inspections, common findings include:

• Incorrect coding of investigator-reported terms.
• Lack of documentation explaining coding choices.
• Failure to update coding after MedDRA version upgrades.
• Inconsistent coding across related studies.

To prepare, sponsors should maintain coding conventions documents, perform regular coding reviews, and reconcile data after each MedDRA update. Training logs for CRAs and coders are often reviewed by inspectors as proof of competency.

Best Practices for MedDRA Implementation

To maximize the benefits of MedDRA and ensure regulatory compliance, clinical teams should adopt these best practices:

• Establish clear SOPs for coding workflows and version updates.
• Use hybrid coding: auto-coding for straightforward terms, manual coding for complex/ambiguous cases.
• Conduct regular coding consistency checks and audits.
• Train CRAs, coders, and pharmacovigilance staff on MedDRA fundamentals and updates.
• Reconcile coded data across studies and ensure alignment in DSURs and PSURs.

For example, a sponsor may implement quarterly coding review boards to evaluate difficult terms and ensure consistent PT selection across all trials.

External resources such as the WHO International Clinical Trials Registry provide references to safety reporting standards, reinforcing the need for harmonized MedDRA use worldwide.

Key Takeaways

MedDRA is the global standard for adverse event coding and is indispensable for regulatory compliance, data integrity, and safety signal detection. Clinical teams must:

• Understand the hierarchical structure of MedDRA (LLT → PT → HLT → HLGT → SOC).
• Apply consistent coding practices to avoid misclassification.
• Ensure timely updates with each new MedDRA version release.
• Train staff regularly to maintain competency in coding practices.
• Maintain audit-ready documentation and coding conventions.

By implementing robust MedDRA processes, sponsors and CROs ensure that safety data is reliable, regulators receive accurate submissions, and patient safety remains at the core of clinical research.

Understanding the Hierarchy of MedDRA Terms from LLT to SOC

Introduction to the MedDRA Hierarchical System

The Medical Dictionary for Regulatory Activities (MedDRA) is a standardized terminology used globally to code adverse events in clinical trials and post-marketing surveillance. One of its most powerful features is its hierarchical structure, which allows for flexible analysis of safety data. The hierarchy ranges from very specific patient-reported terms (Lowest Level Terms, LLTs) to broad categories used in regulatory summaries (System Organ Class, SOC).

This structure ensures that data can be reviewed at varying levels of detail. For example, a regulatory reviewer may focus on SOC-level summaries such as “Nervous system disorders,” while a safety physician may need PT-level data on “Convulsions” to understand case-level safety implications. Without this hierarchy, harmonized signal detection and cross-study comparisons would be impossible.

MedDRA’s hierarchy is applied across regulatory submissions, including FDA IND safety reports, EMA EudraVigilance submissions, and DSURs. Its standardized nature ensures global consistency in how adverse events are categorized and reported.

The Five Levels of MedDRA Terms

MedDRA’s structure is comprised of five interconnected levels. Each level rolls up into a broader category, enabling flexibility in data analysis.

1. Lowest Level Term (LLT): The most specific level, often the exact wording used by investigators. Example: “Heart attack.”
2. Preferred Term (PT): A distinct descriptor representing a single medical concept. Example: “Myocardial infarction.”
3. High Level Term (HLT): Groups of related PTs that share a common medical concept. Example: “Ischaemic coronary artery disorders.”
4. High Level Group Term (HLGT): Broader groups of related HLTs. Example: “Coronary artery disorders.”
5. System Organ Class (SOC): The highest level, grouping terms by organ system or etiology. Example: “Cardiac disorders.”

This structured roll-up allows sponsors and regulators to analyze adverse events at different levels of granularity. Investigators may use patient language (“chest pain”), but regulators require consistency across submissions, which MedDRA provides by coding these terms into PTs and SOCs.

Example of Hierarchical Mapping

Below is an illustrative example showing how terms map through the MedDRA hierarchy:

This example demonstrates how LLTs used by investigators are standardized into PTs and then progressively grouped into SOCs for high-level regulatory analysis.

Application of the Hierarchy in Clinical Trials

The MedDRA hierarchy is critical for both operational and regulatory purposes:

• Case-level analysis: Coders assign PTs to investigator terms for precise classification.
• Aggregate analysis: Regulators and safety teams review SOC-level data to detect system-wide toxicity patterns.
• Signal detection: Aggregated PTs under HLTs and HLGTs allow statistical analysis for safety signal identification.
• Regulatory submissions: IND safety reports, DSURs, and PSURs require tabulations at SOC and PT levels.

For example, in oncology trials, individual reports of “low platelets” coded as “Thrombocytopenia” (PT) roll up to the SOC “Blood and lymphatic system disorders,” enabling regulators to quickly assess hematologic toxicity across trials.

Challenges in Using the MedDRA Hierarchy

Despite its strengths, applying MedDRA’s hierarchy presents challenges:

• Ambiguity at LLT level: Investigator terms like “felt unwell” require careful coding to avoid misclassification.
• Overlapping SOCs: Certain PTs may link to multiple SOCs (primary and secondary linkages), complicating analysis.
• Version updates: Twice-yearly MedDRA updates may alter mappings, requiring database reconciliation.
• Consistency issues: Different coders may choose different LLTs for similar investigator terms.

These issues highlight the need for SOPs, coding conventions, and periodic coding reviews. Training coders on version updates and providing case-based examples reduces inconsistency and ensures compliance.

Regulatory Expectations and Audit Readiness

Regulatory agencies such as the FDA, EMA, and CDSCO expect sponsors to demonstrate traceability in their coding practices. During inspections, common findings include:

• Incorrect LLT or PT assignment for investigator terms.
• Failure to reconcile coding after MedDRA version updates.
• Inconsistent mapping of similar events across different studies.
• Lack of coding conventions documentation.

To avoid findings, sponsors must maintain coding guidelines, training logs, and reconciliation records. Regular audits and mock inspections can strengthen inspection readiness. Reference resources such as the EU Clinical Trials Register demonstrate regulatory emphasis on standardized coding practices.

Key Takeaways

The MedDRA hierarchy provides a structured approach to adverse event coding, ensuring accuracy, consistency, and global harmonization. Clinical teams must:

• Understand the five levels of MedDRA: LLT → PT → HLT → HLGT → SOC.
• Apply coding conventions consistently to avoid misclassification.
• Maintain updated databases aligned with new MedDRA versions.
• Document coding decisions for inspection readiness.
• Train coders and CRAs to navigate the hierarchy effectively.

By mastering the MedDRA hierarchy, sponsors and CROs can ensure high-quality safety data, meet regulatory expectations, and protect patients through accurate pharmacovigilance practices.

How to Choose the Right Preferred Term (PT) in MedDRA Coding

Why Preferred Term Selection Matters

The Preferred Term (PT) is the cornerstone of MedDRA coding in clinical trials and pharmacovigilance. Each PT represents a unique medical concept that enables harmonized reporting of adverse events across studies and regions. The correct choice of PT ensures regulatory compliance, supports accurate signal detection, and allows for meaningful safety analysis. Conversely, misclassification at the PT level can lead to erroneous safety conclusions, missed signals, or regulatory findings during inspections.

For example, if an investigator records “fits,” coders must map this to the PT “Convulsion.” Selecting “Epilepsy” instead would be inappropriate because epilepsy implies a chronic condition, not an acute event. Regulators such as the FDA, EMA, and CDSCO expect sponsors to have robust processes and SOPs to ensure accuracy in PT selection.

Since PTs are used in aggregate safety reports such as DSURs, PSURs, and IND safety reports, the reliability of these submissions depends on consistent and accurate PT coding. Training coders and establishing coding conventions are therefore essential.

Process of Selecting a Preferred Term

Coders usually begin with the investigator-reported term, which is mapped to the Lowest Level Term (LLT). From there, MedDRA automatically links the LLT to a PT. The coder’s role is to ensure that the chosen PT truly reflects the intended meaning of the original investigator term.

The selection process typically involves:

1. Reviewing the verbatim term: Understand context and clinical meaning.
2. Identifying LLT matches: Search MedDRA for possible LLTs that fit.
3. Evaluating PT linkage: Ensure the LLT maps to the most accurate PT.
4. Applying coding conventions: Follow sponsor or CRO guidelines for standardization.
5. Quality check: Verify accuracy through peer review or safety database controls.

For example, the investigator term “stomach upset” could map to LLTs such as “Abdominal discomfort” or “Dyspepsia.” The coder must select the PT that best reflects the clinical description, likely “Dyspepsia.”

Examples of Correct PT Selection

Below is a table illustrating how PTs should be chosen for different investigator terms:

These examples show that careful PT selection maintains the clinical intent of the original term while ensuring regulatory-standard consistency.

Challenges in Choosing the Right PT

Despite clear rules, coders often face challenges in selecting PTs:

• Ambiguity: Investigator terms may be vague, such as “feeling unwell,” which lacks clinical specificity.
• Multiple options: Several LLTs may map to different PTs, requiring coder judgment.
• Updates in MedDRA: New PTs are introduced in biannual updates, requiring re-coding or reconciliation.
• Inter-coder variability: Different coders may select different PTs for the same verbatim term.
• System errors: Automated coding tools may misclassify terms without proper review.

For example, “fainting” could map to PTs such as “Syncope” or “Loss of consciousness.” Choosing the right PT depends on clinical context. Without clear conventions, inconsistencies may arise across studies.

Regulatory Expectations and Inspection Findings

Regulators expect traceability and consistency in PT selection. Common inspection findings include:

• Incorrect mapping of investigator terms to PTs.
• Lack of documentation for coding decisions.
• Failure to update PT assignments after MedDRA version upgrades.
• Inconsistent PT use across trials, leading to skewed safety analyses.

For example, an inspection may reveal that the same investigator term “blood clot” was coded as “Thrombosis” in one study and “Embolism” in another. Regulators view this as a major compliance gap. Sponsors are expected to have coding conventions and regular audits to prevent such inconsistencies.

Best Practices for PT Selection

To ensure accuracy in MedDRA coding, clinical teams should adopt these best practices:

• Develop detailed coding conventions with examples for common terms.
• Train coders and CRAs regularly on MedDRA updates and PT selection principles.
• Use hybrid auto/manual coding to balance efficiency with accuracy.
• Perform peer reviews and audits of coded terms to identify errors.
• Reconcile coding across studies to maintain consistency in aggregate reporting.

External resources such as the ClinicalTrials.gov database provide examples of standardized safety reporting, reinforcing the importance of accurate coding practices.

Key Takeaways

Choosing the right PT in MedDRA coding is critical for regulatory compliance, safety analysis, and inspection readiness. Clinical teams must:

• Understand the MedDRA hierarchy and its linkages from LLT to PT.
• Apply clear conventions to reduce ambiguity in coding.
• Ensure PT selection reflects the true clinical meaning of investigator terms.
• Document and audit coding decisions for consistency across trials.
• Stay updated with MedDRA version changes and retrain staff accordingly.

By applying these principles, sponsors and CROs can ensure that safety data is accurate, consistent, and aligned with global regulatory expectations.

Balancing Auto-coding and Manual Coding in MedDRA: Risks and Benefits

Introduction to Auto-coding and Manual Coding

Adverse event reporting in clinical trials depends heavily on MedDRA coding. Coders and pharmacovigilance staff transform investigator-reported verbatim terms into standardized Lowest Level Terms (LLTs) and Preferred Terms (PTs). Two primary approaches exist: auto-coding and manual coding. Both methods are widely used, and most sponsors employ a hybrid approach to balance efficiency and accuracy.

Auto-coding refers to the use of software algorithms that automatically map verbatim terms to MedDRA LLTs and PTs. This process improves speed and consistency but carries risks of misclassification. Manual coding, by contrast, requires trained coders to review verbatim terms and select the most accurate PT, ensuring clinical accuracy but requiring more time and resources.

Regulatory authorities, including the FDA, EMA, MHRA, and CDSCO, accept either method, provided coding is accurate, consistent, and traceable. Inspections often focus on whether sponsors have controls to minimize auto-coding errors and whether manual coding is performed with adequate SOPs and training.

Benefits of Auto-coding

Auto-coding offers several advantages:

• Speed: Automated mapping allows high-volume processing of adverse events, especially in late-phase or large-scale trials.
• Consistency: Ensures identical verbatim terms are mapped to the same PT, reducing variability between coders.
• Efficiency: Minimizes manual workload for straightforward terms, freeing safety teams for complex coding tasks.
• Scalability: Particularly useful in global pharmacovigilance databases handling thousands of SAE and AE reports daily.

For example, common terms such as “headache,” “nausea,” or “fever” can be reliably auto-coded to their respective PTs with little risk of error. In such scenarios, auto-coding significantly improves throughput without compromising accuracy.

Risks of Auto-coding

Despite its advantages, auto-coding presents risks:

• Misclassification: Verbatim terms that are ambiguous or unusual may be incorrectly coded.
• Lack of clinical context: Algorithms may select PTs that miss subtle nuances in the investigator’s description.
• False confidence: Users may rely too heavily on automated systems without appropriate review.
• Regulatory findings: Incorrect PT assignments discovered during inspections can be classified as major findings.

A common example is the investigator term “fainting.” An auto-coding algorithm may map this to “Loss of consciousness,” while the clinically correct PT should be “Syncope.” Without manual review, the coding would be inaccurate and potentially misleading in safety analyses.

Benefits of Manual Coding

Manual coding by trained professionals provides several advantages over automation:

• Clinical judgment: Coders apply medical knowledge to interpret ambiguous or complex terms.
• Accuracy: Reduces risk of misclassification by considering clinical context and study-specific nuances.
• Flexibility: Allows handling of rare events not typically recognized by auto-coding algorithms.
• Audit readiness: Demonstrates human oversight in coding processes, which regulators value during inspections.

For example, the term “liver swelling” might not have a straightforward auto-coded PT. A trained coder would correctly assign “Hepatomegaly,” ensuring data accuracy.

Limitations of Manual Coding

Manual coding, however, has its drawbacks:

• Time-consuming: Large datasets with thousands of AEs require significant manpower.
• Inter-coder variability: Different coders may select different PTs for the same term without clear conventions.
• Resource intensive: Requires continuous training and staffing.

For global trials, where thousands of SAE reports may be received monthly, manual-only coding can strain resources and delay reporting timelines.

Hybrid Approach: Best of Both Worlds

Most sponsors adopt a hybrid approach that combines the efficiency of auto-coding with the accuracy of manual coding:

• Auto-coding: Used for common, low-risk terms like “headache” or “nausea.”
• Manual coding: Applied to ambiguous, rare, or complex terms requiring clinical interpretation.
• Quality checks: Safety departments conduct routine audits to identify and correct auto-coding errors.

This balanced method ensures that large volumes of routine data are processed efficiently, while complex cases receive the clinical oversight they require. Many sponsors implement a “70/30 split,” where 70% of coding is auto-coded and 30% is manually reviewed.

Regulatory Expectations and Inspections

Regulators expect sponsors to demonstrate oversight in both auto-coding and manual coding processes. Common inspection findings include:

• Over-reliance on auto-coding without adequate review.
• Failure to document manual coding decisions.
• Lack of SOPs governing auto-coding thresholds and exceptions.
• Inconsistent coding across studies due to inter-coder variability.

To mitigate these risks, sponsors should maintain detailed SOPs, perform reconciliation checks, and train coders on both methods. Reference registries like the Japan Registry of Clinical Trials highlight the importance of coding accuracy in safety reporting worldwide.

Key Takeaways

The choice between auto-coding and manual coding in MedDRA is not binary. Clinical trial sponsors should:

• Leverage auto-coding for routine terms to improve speed and consistency.
• Apply manual coding for complex, ambiguous, or high-risk terms.
• Adopt hybrid models with built-in quality controls.
• Ensure SOPs and conventions are updated with each MedDRA release.
• Maintain inspection readiness by documenting coding workflows and training logs.

By balancing the benefits and risks of both methods, sponsors can ensure that safety data is coded efficiently, accurately, and in line with global regulatory expectations.

How to Code Ambiguous Verbiage in MedDRA for Clinical Trials

Introduction to Ambiguous Verbiage in Adverse Event Reporting

In clinical trials, adverse events (AEs) are initially reported by investigators in verbatim language, often reflecting patient statements or clinical notes. These terms are not always precise. Ambiguous expressions such as “feeling unwell,” “stomach upset,” or “heart problem” pose significant challenges during MedDRA coding. Unlike clear terms like “myocardial infarction” or “rash,” ambiguous terms require coder interpretation, which increases the risk of misclassification and regulatory non-compliance.

Regulators including the FDA, EMA, and CDSCO emphasize that accurate and consistent MedDRA coding is critical for pharmacovigilance and safety signal detection. Incorrect coding due to ambiguity can distort safety analyses and undermine the validity of DSURs, PSURs, and IND safety reports. To address this challenge, sponsors must implement SOPs, coding conventions, and training programs that guide coders in interpreting and coding ambiguous terms consistently.

Examples of Ambiguous Verbiage in Clinical Trials

Ambiguity often arises because investigators record patient experiences in lay language. Below are common examples and potential MedDRA interpretations:

These examples highlight the complexity of coding ambiguous terms. Without adequate conventions, coders may apply different PTs across trials, leading to inconsistent datasets.

Risks of Incorrect Coding Due to Ambiguity

Ambiguous coding errors can have serious consequences:

• Signal distortion: Misclassification of AEs can mask or exaggerate safety signals.
• Regulatory findings: Inspectors often flag inconsistencies in coding of ambiguous terms.
• Data fragmentation: Similar events coded differently across trials prevent accurate pooling of safety data.
• Audit deficiencies: Lack of documentation on coding decisions may be cited as a GCP non-compliance.

For instance, if “fainting” is coded as “Loss of consciousness” in one trial and “Syncope” in another, regulators may question the reliability of cross-study safety analyses. Consistency is therefore paramount in ambiguous coding cases.

Strategies for Handling Ambiguous Verbiage

Sponsors and CROs can manage ambiguity by applying structured strategies:

• Request clarification: Where possible, query the investigator for more detail before final coding.
• Use general PTs: When specifics are lacking, coders may assign broader PTs such as “Malaise.”
• Follow SOP conventions: Coding conventions should define how ambiguous terms are consistently coded.
• Flag for review: Ambiguous cases should undergo medical review by safety physicians.
• Document rationale: Coders should record the reasoning for selected PTs in audit trails.

For example, a sponsor SOP may state: “All reports of ‘feeling unwell’ should be coded as PT ‘Malaise’ unless additional clinical details are available.” Such conventions reduce variability and inspection risks.

Regulatory Expectations and Inspections

Regulators expect coders to demonstrate traceability in coding decisions for ambiguous terms. Common inspection findings include:

• Inconsistent PT selection across similar events.
• Failure to query investigators for clarification.
• Lack of documentation explaining coding rationale.
• Use of auto-coding without manual review of ambiguous terms.

To meet expectations, sponsors should establish coding conventions, maintain training records, and conduct routine audits. Inspection readiness requires evidence that ambiguous coding decisions were consistent, justified, and traceable. Public registries such as the NIHR Be Part of Research platform highlight the importance of standardized terminology for global safety data consistency.

Best Practices for Coders

Best practices for handling ambiguous terms include:

• Maintain detailed coding conventions with common ambiguous terms and assigned PTs.
• Provide refresher training to coders on how to handle vague or incomplete terms.
• Ensure coders escalate complex cases to medical safety officers.
• Review ambiguous terms in coding quality audits.
• Update conventions after each MedDRA version release.

These practices ensure that ambiguous terms are consistently coded and that datasets remain reliable across trials and submissions.

Key Takeaways

Coding ambiguous terms in MedDRA requires coders to balance accuracy, consistency, and regulatory compliance. To achieve this, clinical teams must:

• Recognize common sources of ambiguity in investigator-reported terms.
• Develop SOPs and conventions for standardizing ambiguous coding decisions.
• Document rationale and maintain audit trails for inspection readiness.
• Train coders and escalate complex cases to medical experts.
• Perform quality reviews to ensure consistency across trials.

By following structured strategies, sponsors and CROs can minimize the risks of misclassification, ensure reliable pharmacovigilance data, and meet global regulatory expectations.

Managing MedDRA Version Updates in Clinical Trials

Why MedDRA Versions Are Updated

The Medical Dictionary for Regulatory Activities (MedDRA) is updated twice a year—typically in March and September. These updates ensure that the dictionary evolves with medical science, incorporating new terms, restructuring hierarchies, and refining definitions. For sponsors, CROs, and regulators, version updates improve data accuracy, harmonize coding, and support signal detection across therapeutic areas.

Updates may include new Preferred Terms (PTs), modifications to System Organ Classes (SOCs), or reclassification of existing terms. For example, emerging conditions such as “COVID-19 pneumonia” were added in recent versions. Sponsors must adopt these updates in a timely manner to remain compliant with regulatory expectations. Agencies such as the FDA, EMA, and PMDA require that safety data submissions specify the MedDRA version used for coding.

Failure to manage version updates can result in inconsistent datasets, delayed submissions, and inspection findings. Thus, implementing structured processes for MedDRA updates is essential for regulatory compliance and pharmacovigilance.

Impact of Version Updates on Clinical Trials

Each MedDRA update can affect ongoing trials in several ways:

• New terms: Coders gain access to updated LLTs and PTs reflecting current medical knowledge.
• Retired terms: Certain LLTs may be deprecated, requiring recoding of existing events.
• Hierarchical shifts: PTs may be reassigned to different SOCs, changing how aggregate analyses are performed.
• Cross-study comparisons: Trials coded with different versions may produce inconsistent datasets unless reconciled.

For example, if “Myocardial infarction type 2” is added as a PT in a new version, coders must reassign prior cases coded under general “Myocardial infarction” PTs to ensure consistency in safety analyses.

Version changes may also impact DSURs, PSURs, and aggregate reports. Regulators often question whether sponsors have adequately managed version transitions when inconsistencies appear in safety datasets.

Case Example: MedDRA Version Transition in an Oncology Trial

Consider a Phase III oncology trial using MedDRA version 23.0. Midway through the trial, version 24.0 introduces new PTs for immune-related adverse events, including “Immune checkpoint inhibitor colitis.” The sponsor must:

1. Update the safety database to MedDRA v24.0.
2. Recode historical events from general terms like “Colitis” to the new PT where appropriate.
3. Train coders on the new version and updated coding conventions.
4. Document the reconciliation process in the Trial Master File (TMF).

This case illustrates how timely adoption of new versions ensures accurate pharmacovigilance and regulatory compliance, particularly in emerging therapeutic areas.

Regulatory Expectations on MedDRA Version Management

Regulatory agencies expect sponsors to demonstrate traceability and consistency in handling MedDRA updates. Common expectations include:

• Version documentation: Submissions must clearly state the MedDRA version used for coding.
• Transition management: Sponsors should document how and when version updates were implemented.
• Reconciliation: Safety datasets must be reconciled to avoid inconsistencies across versions.
• Training: Coders must be trained on new terms, structures, and conventions introduced in each update.
• Audit readiness: Regulators may review version transition logs during inspections.

Inspection findings often highlight failures in version management, such as continued use of outdated versions or lack of documentation on recoding decisions. For global compliance, sponsors should align coding practices across all regions, ensuring FDA, EMA, and CDSCO submissions use harmonized MedDRA versions.

Best Practices for Handling Version Updates

To effectively manage MedDRA updates, sponsors should adopt the following practices:

• Establish SOPs: Define clear procedures for adopting new MedDRA versions.
• Plan updates: Implement updates immediately after March and September releases.
• Reconcile datasets: Perform systematic recoding of historical cases impacted by new or retired terms.
• Train coders: Provide refresher training with examples of new terms and hierarchical changes.
• Audit processes: Maintain version control logs, reconciliation records, and coding decision documentation.

For instance, a sponsor may maintain a version reconciliation log that documents all PTs changed during an upgrade, along with rationale for recoding decisions. Such logs serve as valuable inspection artifacts.

Challenges in Managing Updates

Despite best practices, challenges remain:

• Resource burden: Updating databases and training coders requires time and staff.
• Cross-study consistency: Reconciling coding across multiple ongoing trials can be complex.
• Regulatory timelines: Version updates often coincide with critical submission deadlines.
• Automation risks: Auto-recoding features may misclassify terms without manual review.

These challenges highlight the importance of proactive planning, sponsor oversight, and hybrid manual/automated reconciliation processes.

External Resources and References

Coders and safety professionals should leverage external resources to stay aligned with regulatory expectations. The ISRCTN Registry often references MedDRA coding standards in trial protocols, demonstrating global alignment on terminology usage.

Key Takeaways

Handling MedDRA version updates is a critical pharmacovigilance function. Clinical teams must:

• Adopt new MedDRA versions promptly after release.
• Reconcile coding across trials to maintain consistency.
• Document transitions, rationale, and recoding decisions in audit-ready logs.
• Train coders on new terms and hierarchical changes.
• Maintain inspection readiness by aligning global submissions to the same version.

By managing MedDRA updates systematically, sponsors ensure accurate safety data, regulatory compliance, and reliable pharmacovigilance across global clinical development programs.

Addressing the Challenges of MedDRA Coding for Psychiatric Events in Clinical Trials

Introduction to Psychiatric Event Coding in MedDRA

Psychiatric adverse events present unique challenges in clinical trials. Unlike physical conditions, psychiatric events are often reported with subjective terminology, varied cultural interpretations, and overlapping symptomatology. Using MedDRA (Medical Dictionary for Regulatory Activities) to code psychiatric events requires coders to balance accuracy, consistency, and clinical judgment. Regulators such as the FDA, EMA, MHRA, and CDSCO expect sponsors to demonstrate traceable and consistent approaches when handling psychiatric adverse events (AEs) and serious adverse events (SAEs).

MedDRA’s hierarchical structure (Lowest Level Term → Preferred Term → High Level Term → High Level Group Term → System Organ Class) provides a framework for coding psychiatric events, but ambiguity is common. Terms like “nervous,” “strange behavior,” or “mood swings” may be used by investigators without sufficient clinical specificity. Coders must avoid misclassification, which could distort safety analyses and mask potential signals in DSURs, PSURs, and expedited SAE reports.

This article provides a step-by-step analysis of psychiatric coding challenges, illustrating how coders, sponsors, and regulators address these issues in global clinical development.

Nature of Psychiatric Adverse Events

Psychiatric events encompass a wide spectrum, ranging from mild mood disturbances to severe psychosis. Some common categories include:

• Mood disorders: Depression, mania, bipolar disorder.
• Anxiety-related symptoms: Panic attacks, generalized anxiety, obsessive-compulsive behavior.
• Psychotic disorders: Hallucinations, delusions, schizophrenia-like presentations.
• Cognitive disturbances: Memory loss, confusion, attention deficits.
• Behavioral changes: Aggression, irritability, impulsivity.
• Suicidality: Suicidal ideation, suicide attempts, completed suicides.

Unlike other AEs such as “fever” or “rash,” psychiatric events often lack objective laboratory or imaging confirmation. Instead, coding relies heavily on investigator descriptions and patient self-reports. This subjectivity complicates coding consistency, especially across multinational trials with diverse cultural contexts.

Examples of Psychiatric Verbatim Terms and Coding Dilemmas

Below is a table illustrating how psychiatric terms can create coding dilemmas in MedDRA:

These examples demonstrate why psychiatric AE coding requires specialized training and careful application of MedDRA conventions.

Impact of Misclassification in Psychiatric Coding

Errors in psychiatric coding can have significant consequences:

• Safety signal distortion: Misclassifying “suicidal ideation” as “depression” could obscure suicide-related safety signals.
• Regulatory risk: Inspectors may classify inconsistent psychiatric coding as a major GCP violation.
• Data fragmentation: Variability in coding across studies can hinder cross-trial safety analysis.
• Patient safety: Inaccurate coding may delay recognition of critical psychiatric risks.

In psychiatric trials, regulators scrutinize safety data closely. Sponsors must therefore demonstrate coding accuracy, traceability, and reconciliation during inspections.

Challenges Unique to Psychiatric Event Coding

Psychiatric events present challenges beyond typical AE coding:

• Ambiguity in reporting: Terms like “nervous” or “unstable” lack medical precision.
• Overlap of symptoms: Hallucinations, delusions, and paranoia may overlap but require different PTs.
• Cross-cultural differences: Cultural variations in describing mental health complicate consistency in global trials.
• Stigma and underreporting: Patients may minimize psychiatric symptoms, leading to incomplete verbatim terms.
• Expedited reporting requirements: Suicidality and psychosis require rapid reporting, demanding coding accuracy.

These challenges increase the burden on coders, safety physicians, and QA teams to ensure psychiatric data integrity.

Regulatory Expectations on Psychiatric Coding

Regulators expect coding of psychiatric events to meet high standards of accuracy and consistency. Common inspection findings include:

• Incorrect mapping of psychiatric terms due to coder inexperience.
• Lack of documentation explaining PT choices for ambiguous terms.
• Failure to update coding after MedDRA version upgrades.
• Inconsistent coding across multinational trials.

To address these issues, regulators expect sponsors to maintain coding conventions documents, perform periodic reviews, and train coders on psychiatric-specific terms. Guidance from ICH E2A and regional agencies reinforces the importance of psychiatric AE accuracy for patient safety.

Case Study: Coding of Suicidality in Antidepressant Trials

During Phase III antidepressant trials, an investigator records the verbatim term “patient talked about death and not wanting to live.” Coders face several challenges:

1. Determining whether to code as “Depression” or “Suicidal ideation.”
2. Recognizing regulatory expectations that suicidality terms must be coded specifically for expedited reporting.
3. Ensuring consistency across all sites to avoid data fragmentation.

The correct PT is “Suicidal ideation.” This coding triggers expedited safety reporting obligations: 7-day reporting for life-threatening cases. A misclassification as “Depression” would obscure the risk and violate regulatory requirements.

Best Practices for Coding Psychiatric Events

To improve coding accuracy, sponsors and CROs should implement the following best practices:

• Develop psychiatric coding conventions: Provide coders with guidelines for ambiguous terms such as “mood swings” or “acting strange.”
• Train coders and CRAs: Conduct targeted training on psychiatric terms and expedited reporting requirements.
• Use hybrid auto/manual coding: Apply auto-coding for common terms like “depression,” but require manual coding for complex terms like “psychosis.”
• Audit psychiatric coding: Include psychiatric AE coding as a focus in internal audits and mock inspections.
• Reconcile across studies: Ensure consistency in PT selection for psychiatric events across global trials.

Public registries such as the EU Clinical Trials Register emphasize accurate psychiatric AE reporting, reinforcing global expectations for MedDRA coding practices.

Future Directions in Psychiatric Event Coding

Advances in natural language processing (NLP) and machine learning are being explored to improve psychiatric AE coding. Algorithms may help interpret ambiguous terms, but human oversight remains critical. Regulators are cautious about fully automated psychiatric coding due to the high risk of misclassification in sensitive areas such as suicidality.

Future MedDRA versions are expected to include more granular PTs for psychiatric conditions, reflecting evolving diagnostic frameworks like DSM-5 and ICD-11. Sponsors must adapt coding conventions to incorporate these changes promptly.

Key Takeaways

Coding psychiatric events in MedDRA requires greater diligence than other therapeutic areas due to ambiguity, subjectivity, and regulatory sensitivity. Clinical teams must:

• Recognize common psychiatric coding challenges and their risks.
• Develop SOPs and conventions to guide PT selection for ambiguous terms.
• Ensure suicidality events are coded accurately and reported expediently.
• Train coders and CRAs on psychiatric-specific MedDRA coding.
• Maintain consistency across trials and reconcile data during version updates.

By following these practices, sponsors ensure that psychiatric AEs are coded accurately, supporting regulatory compliance, data integrity, and most importantly, patient safety in clinical development.

Effective Training of CRAs on MedDRA Basics for Clinical Trials

Why CRA Training on MedDRA Is Essential

Clinical Research Associates (CRAs) play a central role in ensuring data quality in clinical trials. While CRAs are not typically responsible for the final coding of adverse events, they are the primary link between investigative sites and sponsors. Their ability to understand the basics of MedDRA (Medical Dictionary for Regulatory Activities) directly impacts the accuracy of adverse event (AE) reporting and the integrity of pharmacovigilance data.

CRAs frequently monitor Case Report Forms (CRFs) and safety documentation during site visits. Without basic knowledge of MedDRA, they may miss inconsistencies, incomplete verbatim terms, or ambiguous reporting that could compromise coding accuracy later. Regulatory agencies such as the FDA, EMA, MHRA, and CDSCO expect CRAs to be trained in data integrity principles, including AE reporting standards aligned with MedDRA conventions.

Effective training in MedDRA equips CRAs to identify gaps early, improve communication with investigators, and ensure that the sponsor’s safety team receives clean, codable data for regulatory submissions like DSURs, PSURs, and expedited SAE reports.

Core MedDRA Concepts Every CRA Should Know

While CRAs are not coders, they must understand the structure of MedDRA to effectively monitor site-reported AEs. Key concepts include:

• Lowest Level Term (LLT): The verbatim term used by investigators.
• Preferred Term (PT): The standardized medical concept used for regulatory analysis.
• High Level Term (HLT) & High Level Group Term (HLGT): Broader groupings for aggregate safety review.
• System Organ Class (SOC): Highest level grouping by organ system or etiology.

For example, if an investigator records “heart attack,” a CRA should recognize that this corresponds to LLT “Heart attack” and PT “Myocardial infarction” under SOC “Cardiac disorders.” Understanding this linkage allows CRAs to flag if investigators submit vague terms like “chest issue,” which would create coding challenges later.

A sample mapping might look like this:

By recognizing how verbatim terms align with MedDRA categories, CRAs can identify ambiguous language that may hinder accurate coding.

CRA Responsibilities Related to MedDRA Coding

Although final coding is done by safety teams or data management, CRAs contribute to coding quality through:

• Monitoring AE entries: Ensuring investigators provide sufficient detail in CRFs.
• Querying investigators: Clarifying vague or ambiguous terms during site visits.
• Consistency checks: Reviewing if terms are reported uniformly across subjects and visits.
• Escalation: Flagging unusual or critical terms (e.g., suicidality) for expedited handling.

For example, if an investigator writes “patient acted strangely,” the CRA should query for specific behaviors (hallucinations, agitation, confusion) to enable accurate MedDRA coding later.

Training Methods for CRAs on MedDRA Basics

Sponsors and CROs can deliver CRA MedDRA training through multiple formats:

• Workshops: Interactive coding exercises using real-world verbatim terms.
• e-Learning modules: Self-paced courses covering MedDRA structure, hierarchy, and case examples.
• On-the-job mentoring: Safety specialists guiding CRAs during monitoring visits.
• Scenario-based learning: Case studies where CRAs practice clarifying ambiguous terms.

Practical training using dummy CRFs and safety reports enhances understanding. For example, CRAs can practice coding ambiguous terms like “patient fainted” and discuss how this maps to PT “Syncope” versus “Loss of consciousness.”

Regulatory Expectations for CRA MedDRA Training

Regulators expect CRAs to receive training in adverse event reporting standards, including MedDRA basics. Inspection findings have highlighted:

• CRAs failing to query ambiguous AE terms.
• Inconsistent AE documentation across sites.
• Lack of documented training records for CRAs.

Inspection readiness requires sponsors to maintain training logs, SOPs, and competency assessments. Agencies such as the EMA and FDA often request CRA training documentation during site inspections. Public registries like the CTRI emphasize standardized safety reporting, underscoring CRA responsibilities in AE data quality.

Best Practices for CRA MedDRA Training

Effective CRA training should include:

• Clear SOPs describing CRA responsibilities in AE documentation.
• Training on common ambiguous terms and how to query them.
• Practice with real-world examples from previous trials.
• Annual refresher courses to align with MedDRA version updates.
• Collaboration with safety physicians for complex psychiatric or neurologic terms.

CRAs should also be trained to identify red-flag terms like “suicidal thoughts,” which must be reported expeditiously and coded precisely.

Key Takeaways

Training CRAs on MedDRA basics enhances data integrity and regulatory compliance. Sponsors should:

• Provide foundational training on MedDRA structure and coding logic.
• Equip CRAs to query ambiguous terms and ensure accurate AE documentation.
• Maintain documented training logs and refresher programs.
• Align training with MedDRA version updates and regulatory expectations.

By strengthening CRA competency in MedDRA basics, sponsors ensure accurate AE reporting, improve safety data consistency, and demonstrate inspection readiness across global clinical trials.

Conducting and Facing MedDRA Coding Reviews During Audits

Why MedDRA Coding Reviews Are Critical in Audits

MedDRA (Medical Dictionary for Regulatory Activities) coding is a cornerstone of adverse event reporting in clinical trials. During regulatory inspections and internal audits, coding processes are carefully reviewed to ensure accuracy, traceability, and compliance. Regulators such as the FDA, EMA, MHRA, and CDSCO recognize that coding errors can distort safety signal detection, compromise pharmacovigilance, and lead to misleading regulatory submissions such as DSURs and PSURs.

Auditors typically review how investigator verbatim terms are transformed into Lowest Level Terms (LLTs) and Preferred Terms (PTs), and how these map through the MedDRA hierarchy to System Organ Classes (SOCs). They also examine coding conventions, reconciliation processes, training records, and audit trails. Weaknesses in coding practices are often cited as major findings during Good Clinical Practice (GCP) inspections.

Therefore, MedDRA coding reviews are not only technical checks but also assessments of an organization’s overall pharmacovigilance maturity and regulatory compliance framework.

Scope of MedDRA Coding Audits

Audits of MedDRA coding typically cover the following aspects:

• Accuracy: Whether verbatim terms are mapped to appropriate PTs.
• Consistency: Whether similar terms across studies are coded uniformly.
• Traceability: Whether coding decisions are documented and auditable.
• Version control: Whether coding aligns with the correct MedDRA version at the time.
• Training: Whether coders and CRAs received adequate MedDRA training.
• Reconciliation: Whether coding is reconciled across databases (CRFs, safety databases, TMF).

For example, an audit may review whether all cases of “fits” were consistently coded as “Convulsion” across multiple Phase II and III trials. Inconsistencies may suggest lack of coding conventions or inadequate coder training.

Common Audit Findings in MedDRA Coding

Across inspections and audits, recurring findings include:

• Incorrect PT selection due to ambiguous verbatim terms.
• Inconsistencies across coders or studies for the same term.
• Lack of documentation explaining coding choices.
• Failure to update coding after MedDRA version upgrades.
• Insufficient training of coders and CRAs in MedDRA basics.
• Delayed reconciliation between CRFs, safety databases, and narratives.

These issues highlight the importance of robust SOPs, coder training programs, and internal audits before regulatory inspections. Regulators frequently note that coding errors compromise pharmacovigilance reliability and may issue critical findings if systemic weaknesses are identified.

Case Study: Audit Review of Psychiatric Coding

In one Phase III antidepressant trial, auditors reviewed how suicidal ideation was coded. Investigators used terms like “patient talked about death” and “wants to die.” Coders inconsistently applied PTs—some used “Depression,” while others applied “Suicidal ideation.”

The audit team identified this inconsistency as a major finding because suicidality requires expedited reporting under global regulations. The sponsor was instructed to reconcile all prior data, retrain coders, and revise SOPs to explicitly define how suicidality terms should be coded. This case demonstrates how errors in psychiatric coding can escalate into regulatory risk.

Reconciliation During MedDRA Coding Audits

Auditors pay close attention to reconciliation of safety data across systems. For instance:

• CRF vs Safety Database: AE terms in CRFs must match those in the pharmacovigilance database.
• Narratives vs MedDRA Coding: Narrative descriptions must align with PT assignments.
• Version Updates: Recoding after MedDRA version changes must be documented.

Lack of reconciliation is often cited as a critical finding because it creates discrepancies in safety reporting to regulators. Sponsors must maintain detailed reconciliation logs and demonstrate periodic checks to auditors.

Regulatory Expectations During Inspections

Agencies expect sponsors to demonstrate that MedDRA coding processes are:

• Standardized: Clear SOPs define how coders handle ambiguous terms.
• Documented: Coding decisions include rationale in audit trails.
• Consistent: Coders across studies follow the same conventions.
• Version-aligned: Coding reflects the MedDRA version in use at the time of the event.
• Training-supported: Coders, CRAs, and safety staff maintain competency through training logs.

For example, the ANZCTR emphasizes harmonized AE reporting standards, which rely on consistent MedDRA coding practices. Inspectors expect sponsors to align with such international expectations.

Best Practices for Audit Readiness in MedDRA Coding

To prepare for audits and inspections, sponsors should implement:

• Comprehensive SOPs: Define coding rules, version updates, and reconciliation steps.
• Coder training: Conduct regular training and assessments for coders and CRAs.
• Internal audits: Perform mock audits focused on coding accuracy and traceability.
• Reconciliation logs: Maintain detailed logs comparing CRFs, narratives, and safety databases.
• Version management: Document how MedDRA updates were implemented.

These practices strengthen inspection readiness, minimize findings, and ensure that safety data is accurate and reliable across global submissions.

Key Takeaways

MedDRA coding reviews during audits are a critical part of pharmacovigilance oversight. Clinical teams must:

• Ensure accuracy, consistency, and traceability in MedDRA coding.
• Document coding conventions, training, and reconciliation processes.
• Conduct internal audits to detect and correct errors proactively.
• Prepare audit-ready evidence of version control and SOP compliance.

By adopting strong audit readiness practices, sponsors can demonstrate compliance, maintain regulatory trust, and ensure reliable pharmacovigilance across clinical development programs.

Case Studies and Practical Examples of SAE Coding in MedDRA

Introduction to SAE Coding with MedDRA

Serious Adverse Events (SAEs) represent critical data points in clinical trials and pharmacovigilance. Regulatory authorities such as the FDA, EMA, and MHRA require accurate and consistent coding of SAEs using the Medical Dictionary for Regulatory Activities (MedDRA). Proper coding ensures that safety signals are identified, analyzed, and reported in compliance with global regulatory expectations.

While routine adverse events can often be coded through auto-coding tools, SAEs require additional diligence. Incorrect selection of Preferred Terms (PTs) can distort the seriousness, medical significance, and reporting timelines of the event. For this reason, regulators often scrutinize SAE coding during Good Clinical Practice (GCP) inspections and sponsor audits.

This article explores real-world case studies and examples of SAE coding, providing insights into common challenges, regulatory expectations, and best practices for maintaining accuracy and compliance.

Case Study 1: Myocardial Infarction in a Cardiology Trial

In a Phase III cardiology trial, an investigator reported “patient had a heart attack.” Coders must ensure this is mapped accurately through MedDRA’s hierarchy:

Coding as “Chest pain” would be incorrect and misleading. The accuracy of “Myocardial infarction” as PT is critical, as it determines expedited reporting timelines and influences safety signal detection for cardiovascular events.

Case Study 2: Psychiatric SAE with Suicidal Ideation

In an antidepressant trial, an investigator reported “patient said he wanted to die.” Coders faced the decision between “Depression” and “Suicidal ideation.”

The correct PT is “Suicidal ideation”. Coding as “Depression” would underestimate the risk and fail to trigger expedited reporting obligations (7-day reporting for life-threatening SAEs). This case highlights the importance of training coders to recognize suicidality and apply MedDRA PTs with precision.

Case Study 3: Ambiguous Gastrointestinal SAE

In an oncology trial, the verbatim term recorded was “severe stomach issues.” Potential coding options included:

• Dyspepsia
• Abdominal pain
• Gastrointestinal disorder

In this case, the sponsor’s SOP required querying investigators for clarification before assigning a PT. Once clarified as “Upper GI bleed,” the correct PT assigned was “Gastrointestinal hemorrhage.” This ensured accurate reporting and prevented data misinterpretation.

Case Study 4: Oncology SAE with Febrile Neutropenia

In a chemotherapy trial, the investigator recorded “fever with low WBC.” Coders needed to ensure proper alignment with MedDRA hierarchy:

Coding this as “Fever” or “Neutropenia” alone would miss the medical significance. The correct PT “Febrile neutropenia” accurately reflects the SAE, guiding both treatment urgency and regulatory reporting.

Case Study 5: Neurological SAE with Seizures

During a neurology study, the investigator wrote “patient had fits.” Coders had to avoid vague PTs like “Nervous system disorder” and instead select:

• LLT: Fits
• PT: Convulsion
• SOC: Nervous system disorders

This example illustrates why coders must understand cultural variations in reporting (e.g., “fits” in some regions versus “seizure” in others) and apply MedDRA appropriately.

Regulatory Expectations for SAE Coding

Regulators emphasize the importance of coding accuracy in SAE cases. Common inspection points include:

• Whether suicidality-related SAEs are consistently coded.
• Whether coders document rationale for ambiguous terms.
• Whether MedDRA version updates are applied to historical SAE data.
• Whether reconciliation between CRFs, narratives, and safety databases is documented.

The Health Canada Clinical Trials Database reinforces the expectation of harmonized SAE reporting standards, aligned with MedDRA coding practices.

Best Practices for SAE Coding

To strengthen SAE coding practices, sponsors should:

• Develop detailed SAE coding conventions, especially for psychiatric and oncology events.
• Train coders on recognizing ambiguous SAE verbatim terms.
• Audit SAE coding as part of pharmacovigilance quality oversight.
• Maintain reconciliation logs between CRFs, safety databases, and narratives.
• Document all coding decisions in audit-ready trails.

These practices ensure that SAE data are reliable, consistent, and defensible during audits and regulatory inspections.

Key Takeaways

SAE coding using MedDRA is one of the most scrutinized aspects of pharmacovigilance. Sponsors must:

• Apply accurate PTs to reflect medical significance.
• Document rationale for coding decisions.
• Ensure consistency across trials and versions.
• Prepare for inspections with robust SOPs and training records.

By integrating lessons from real-world case studies, clinical teams can ensure accurate SAE coding, meet regulatory expectations, and protect patient safety across global development programs.