Launching invasive, first-in-human trials against Parkinson's disease: ethical considerations

Development of consensus-driven SPIRIT and CONSORT extensions for early phase dose-finding trials: the DEFINE study

BACKGROUND

Early phase dose-finding (EPDF) trials are crucial for the development of a new intervention and influence whether it should be investigated in further trials. Guidance exists for clinical trial protocols and completed trial reports in the SPIRIT and CONSORT guidelines, respectively. However, both guidelines and their extensions do not adequately address the characteristics of EPDF trials. Building on the SPIRIT and CONSORT checklists, the DEFINE study aims to develop international consensus-driven guidelines for EPDF trial protocols (SPIRIT-DEFINE) and reports (CONSORT-DEFINE).

METHODS

The initial generation of candidate items was informed by reviewing published EPDF trial reports. The early draft items were refined further through a review of the published and grey literature, analysis of real-world examples, citation and reference searches, and expert recommendations, followed by a two-round modified Delphi process. Patient and public involvement and engagement (PPIE) was pursued concurrently with the quantitative and thematic analysis of Delphi participants' feedback.

RESULTS

The Delphi survey included 79 new or modified SPIRIT-DEFINE (n = 36) and CONSORT-DEFINE (n = 43) extension candidate items. In Round One, 206 interdisciplinary stakeholders from 24 countries voted and 151 stakeholders voted in Round Two. Following Round One feedback, one item for CONSORT-DEFINE was added in Round Two. Of the 80 items, 60 met the threshold for inclusion (≥ 70% of respondents voted critical: 26 SPIRIT-DEFINE, 34 CONSORT-DEFINE), with the remaining 20 items to be further discussed at the consensus meeting. The parallel PPIE work resulted in the development of an EPDF lay summary toolkit consisting of a template with guidance notes and an exemplar.

CONCLUSIONS

By detailing the development journey of the DEFINE study and the decisions undertaken, we envision that this will enhance understanding and help researchers in the development of future guidelines. The SPIRIT-DEFINE and CONSORT-DEFINE guidelines will allow investigators to effectively address essential items that should be present in EPDF trial protocols and reports, thereby promoting transparency, comprehensiveness, and reproducibility.

TRIAL REGISTRATION

SPIRIT-DEFINE and CONSORT-DEFINE are registered with the EQUATOR Network ( https://www.equator-network.org/ ).

Reframing the perception of outliers and negative data in translational research

Negative results can be a source of disappointment for scientists, yet their publication is needed for scientific progress, in particular for cutting-edge translational research of novel therapeutics. This manuscript is directed to scientists, junior and senior, that produce and review data for publication. It discusses the difference between 'negative' or 'unexpected' data and 'useless' data, re-evaluates the importance of the experimental design to generate valuable data and proposes strategies to work with and report negative results. Overall, it aims to reframe the perception of working with, reporting and reviewing unexpected data as an opportunity to provide rationale for innovative ideas, prevent the misuse of limited resources and, ultimately, strengthen the reputation of a scientist.

Ethics of Early Clinical Trials of Bio-Artificial Organs

Regenerative medicine is the new frontier in the field of organ transplantation. Research groups around the world are using regenerative medicine technologies to develop bio-artificial organs for transplantation into human patients. While most of this research is still at the preclinical stage, bio-artificial organ technologies are gearing up for first-in-human clinical trials in the not-too-distant future. What are the ethical conditions under which early-phase clinical research of bio-artificial organs can be conducted safely and responsibly? What lessons can be learned from prior experiences with early-phase clinical trials in adjacent fields of research? This is a Meeting Report of an online international workshop organised in the context of the Horizon 2020-funded VANGUARD project, which is developing a bio-artificial pancreas for the treatment of patients with type 1 diabetes.

"I Want to Do It, But I Want to Make Sure That I Do It Right." Views of Patients with Parkinson's Disease Regarding Early Stem Cell Clinical Trial Participation

Background: First-in-human clinical trials with stem cells for Parkinson's disease (PD) are on the horizon. Their epistemic success depends on ensuring the participation of a sufficient number and appropriately diverse group of patients with PD. Their ethical soundness requires that the research community ensures that subjects' decisions about whether to participate or not are consistent with participants' values, motivations, and goals. We sought to identify PD patients' knowledge, concerns, and expectations regarding early-phase stem cell research in PD. Methods: We conducted five semi-structured focus groups with patients with PD. Group discussions were recorded, transcribed, and coded to identify participants' knowledge, concerns, and expectations regarding participation in early stem cell clinical research in PD. Results: Four themes were generated from our data analysis: (1) participants' skepticism about the potential benefits of these trials; (2) their desire to obtain information about various aspects related to this research; (3) a recognition that accessing available knowledge was often difficult; and (4) the relevance of trusting relationships with various stakeholders. Conclusions: Participants expressed skepticism about the immediate impact of stem cell research. Nonetheless, such skepticism often reflected an appropriate consideration of the risks and potential benefits of participating in high-risk clinical trials. Despite their skepticism, participants were eager to learn more about stem cell research and clinical trials processes. They identified consistently trusted avenues of knowledge on these topics, but they often found it difficult to access relevant information or to determine its value.

In vitro modeling of the neurovascular unit: advances in the field

The blood–brain barrier (BBB) is a fundamental component of the central nervous system. Its functional and structural integrity is vital in maintaining the homeostasis of the brain microenvironment. On the other hand, the BBB is also a major hindering obstacle for the delivery of effective therapies to treat disorders of the Central Nervous System (CNS). Over time, various model systems have been established to simulate the complexities of the BBB. The development of realistic in vitro BBB models that accurately mimic the physiological characteristics of the brain microcapillaries in situ is of fundamental importance not only in CNS drug discovery but also in translational research. Successful modeling of the Neurovascular Unit (NVU) would provide an invaluable tool that would aid in dissecting out the pathological factors, mechanisms of action, and corresponding targets prodromal to the onset of CNS disorders. The field of BBB in vitro modeling has seen many fundamental changes in the last few years with the introduction of novel tools and methods to improve existing models and enable new ones. The development of CNS organoids, organ-on-chip, spheroids, 3D printed microfluidics, and other innovative technologies have the potential to advance the field of BBB and NVU modeling. Therefore, in this review, summarize the advances and progress in the design and application of functional in vitro BBB platforms with a focus on rapidly advancing technologies.

Methodological standards, quality of reporting and regulatory compliance in animal research on amyotrophic lateral sclerosis: a systematic review

Objectives

The amyotrophic lateral sclerosis (ALS) research community was one of the first to adopt methodology guidelines to improve preclinical research reproducibility. We here present the results of a systematic review to investigate how the standards in this field changed over the 10-year period during which the guidelines were first published (2007) and updated (2010).

Methods

We searched for papers reporting ALS research on SOD1 (superoxide dismutase 1) mice published between 2005 and 2015 on the ISI Web of Science database, resulting in a sample of 569 papers to review, after triage. Two scores-one for methodological quality, one for regulatory compliance-were built from weighted sums of separate sets of items, and subjected to multivariable regression analysis, to assess how these related to publication year, type of study, country of origin and journal.

Results

Reporting standards improved over time. Of papers published after the first ALS guidelines were made public, fewer than 9% referred specifically to these. Of key research parameters, only three (genetic background, number of transgenes and group size) were reported in >50% of the papers. Information on housing conditions, randomisation and blinding was absent in over two-thirds of the papers. Group size was among the best reported parameters, but the majority reported using fewer than the recommended sample size and only two studies clearly justified group size.

Conclusions

General methodological standards improved gradually over a period of 8-10 years, but remained generally comparable with related fields with no specific guidelines, except with regard to severity. Only 11% of ALS studies were classified in the highest severity level (animals allowed to reach death or moribund stages), substantially below the proportion in studies of comparable neurodegenerative diseases such as Huntington's. The existence of field-specific guidelines, although a welcome indication of concern, seems insufficient to ensure adherence to high methodological standards. Other mechanisms may be required to improve methodological and welfare standards.

Challenges to Informed Consent in First-In-Human Trials Involving Novel Treatments: A Case Study of Parkinson's Disease

Obtaining informed consent in clinical trials can be challenging both for researchers and for patients, albeit in different ways. The challenge concerns not only how to provide the needed information, but also what information to focus on when dealing with individual patients who have different goals, needs, histories, etc. This paper aims to contribute to a better informed consent process for Parkinson’s patients taking part in first-in-human clinical trials of cell replacement therapies. It outlines a range of problems which patients and researchers may face in this process and provides practical advice to researchers engaged in such trials.

Established patterns of animal study design undermine translation of disease-modifying therapies for Parkinson's disease

Translation of disease-modifying therapies in neurodegenerative disease has been disappointing. Parkinson's disease (PD) was used to compare patterns of preclinical study design for symptomatic and potentially disease-modifying interventions. We examined the relationship of model, intervention type and timing, outcomes and outcome measures in 543 animal and human studies (1973-2015) across a contemporary cohort of animal and human interventional studies (n = 445), animal studies for approved interventions (n = 28), animal and human studies for those that failed to translate (n = 70). Detailed study design data were collected for 216 studies in non-human primate (NHP) and rodent toxin-induced models. Species-specific patterns of study design prevailed regardless of whether interventions were symptomatic or potentially disease-modifying. In humans and NHPs, interventions were typically given to both sexes well after the PD phenotype was established, and clinical outcome measures were collected at single (symptomatic) or multiple (disease-modifying) time-points. In rodents, interventions often preceded induction of the model, acute toxic protocols were common, usually given to young males, clinical outcome measures were used less commonly, and outcomes were less commonly assessed at multiple time points. These patterns were more prevalent in mice than rats. In contrast, study design factors such as randomization and blinding did not differ appreciably across symptomatic and disease-modifying intervention categories. The translational gap for potentially disease-modifying interventions in PD in part results from study designs, particularly in mice, that fail to model the progressive nature and relatively late intervention characteristic of PD, or that anchor mechanistic and neuropathologic data to longitudinal clinical outcomes. Even if measures to improve reproducibility are broadly adopted, perpetuation of these norms will continue to impede effective translation.

First-in-human HIV-remission studies: reducing and justifying risk

Interest and excitement surround the possibility of developing measures that produce sustained or permanent HIV remission in infected individuals. First-in-human (FIH) trials are one step in exploring this possibility. Initial human trials raise the usual ethical issues associated with human research, and a set of distinct issues. Because the potential direct benefits to FIH trial volunteers will be either small or non-existent, trial risks must be justified by the social value of the information the trials are expected to produce. To minimise and justify risks, researchers must have solid preclinical evidence that FIH trials will be safe and produce information relevant to human health improvements. Researchers must also adopt adequate study safeguards to protect FIH subjects. An ethically defensible study population must be selected as well.

Studying the lay of the land: views and experiences of professionals in the translational pluripotent stem cell field

AIM

The inherent uncertainty of first-in-human trials, combined with the technical complexity of pluripotent stem cells (PSCs), makes early phase PSC studies ethically challenging. Conducting parallel bioethics research based on experiences and views of professionals in the stem cell field is therefore important.

MATERIALS & METHODS

We conducted semistructured interviews with various stakeholders to get a lay of the land of ethical issues professionals find relevant to the translation of PSCs.

RESULTS

We identified four themes in the interviews: the uniqueness of PSCs, the suitability of the current research paradigm, the justification for early phase PSC studies and the involvement of patients and research participants.

CONCLUSION

We conclude that a debate should take place discussing the suitability of the current research paradigm for translational PSC studies.

α-Synuclein and nonhuman primate models of Parkinson's disease

Accumulation of α-synuclein (α-syn) leading to the formation of insoluble intracellular aggregates named Lewy bodies is proposed to have a significant role in Parkinson's disease (PD) pathology. Nonhuman primate (NHP) models of PD have proven essential for understanding the neurobiological basis of the disease and for the preclinical evaluation of first-in-class and invasive therapies. In addition to neurotoxin, aging and intracerebral gene transfer models, a new generation of models using inoculations of α-syn formulations, as well as transgenic methods is emerging. Understanding of their advantages and limitations will be essential when choosing a platform to evaluate α-syn-related pathology and interpreting the test results of new treatments targeting α-syn aggregation. In this review we aim to provide insight on this issue by critically analyzing the differences in endogenous α-syn, as well as α-syn pathology in PD and PD NHP models.

Ethical principles for novel therapies in veterinary practice

OBJECTIVES

To present insights to aid decision-making about novel veterinary treatments from regulations concerning animal experimentation and human clinical medical trials.

MATERIALS AND METHODS

EU Directive 2010/63/EU on the protection of animals used for scientific purposes and EU Regulation 536/2014 on clinical trials on medicinal products for human use were analysed, evaluated and "translated" into relevant principles for veterinary surgeons.

RESULTS

A number of principles are relevant, relating to treatment expectations, thresholds and objectives; client consent; minimising harms; personnel; review committees; assessment and publication.

CLINICAL SIGNIFICANCE

These principles should assist veterinary surgeons to make good ethical decisions about novel treatments.

Why primate models matter

Research involving nonhuman primates (NHPs) has played a vital role in many of the medical and scientific advances of the past century. NHPs are used because of their similarity to humans in physiology, neuroanatomy, reproduction, development, cognition, and social complexity-yet it is these very similarities that make the use of NHPs in biomedical research a considered decision. As primate researchers, we feel an obligation and responsibility to present the facts concerning why primates are used in various areas of biomedical research. Recent decisions in the United States, including the phasing out of chimpanzees in research by the National Institutes of Health and the pending closure of the New England Primate Research Center, illustrate to us the critical importance of conveying why continued research with primates is needed. Here, we review key areas in biomedicine where primate models have been, and continue to be, essential for advancing fundamental knowledge in biomedical and biological research.

A monoclonal antibody-GDNF fusion protein is not neuroprotective and is associated with proliferative pancreatic lesions in parkinsonian monkeys

Glial cell line derived neurotrophic factor (GDNF) is a neurotrophic factor that has neuroprotective effects in animal models of Parkinson’s disease (PD) and has been proposed as a PD therapy. GDNF does not cross the blood brain barrier (BBB), and requires direct intracerebral delivery to be effective. Trojan horse technology, in which GDNF is coupled to a monoclonal antibody (mAb) against the human insulin receptor (HIR), has been proposed to allow GDNF BBB transport (ArmaGen Technologies Inc.). In this study we tested the feasibility of HIRMAb-GDNF to induce neuroprotection in parkinsonian monkeys, as well as its tolerability and safety. Adult rhesus macaques were assessed throughout the study with a clinical rating scale, a computerized fine motor skills task and general health evaluations. Following baseline measurements, the animals received a unilateral intracarotid artery MPTP injection. Seven days later the animals were evaluated, matched according to disability and blindly assigned to receive twice a week iv. treatments (vehicle, 1 or 5 mg/kg HIRmAb-GDNF) for a period of three months. HIRmAb-GDNF did not improve parkinsonian motor symptoms and induced a dose-dependent hypersensitivity reaction. Quantification of dopaminergic striatal optical density and stereological nigral cell counts did not demonstrate differences between treatment groups. Focal pancreatic acinar to ductular metaplasia (ADM) was noted in four of seven animals treated with 1 mg/kg HIRmAb-GDNF; two of four with ADM also had focal pancreatic intraepithelial neoplasia 1B (PanIN-1B) lesions. Minimal to mild, focal to multifocal, nonsuppurative myocarditis was noted in all animals in the 5 mg/kg treatment group. Our results demonstrate that HIRmAb-GDNF dosing in a monkey model of PD is not an effective neuroprotective strategy and may present serious health risks that should be considered when planning future use of the IR antibody as a carrier, or of any systemic treatment of a GDNF-containing molecule.

Risk of surgical delivery to deep nuclei: a meta-analysis

Many novel strategies aimed at neuroprotection or neurorestoration involve surgical delivery of agents to deep nuclei along multiple trajectories. Using intracerebral hemorrhage on a per-trajectory basis as our primary end point, we quantified the level of surgical risk associated with agent delivery to deep nuclei. Secondarily, we quantified other event rates and examined relationships between intracerebral hemorrhage and 8 variables related to patient and practice characteristics. Meta-analytic techniques were used to pool complication rates reported in published articles involving deep brain stimulator electrode implantation or infusion of vectors, tissues, or trophic factors. One hundred nine studies were included in our analysis, comprising 6237 patients and 9890 trajectories to deep nuclei. The estimated per-trajectory intracerebral hemorrhage rate was 1.57% (95% confidence interval, 1.26%-1.95%). The proportion of trajectories leading to permanent or serious neurological deficits was 0.41% (0.28%-0.60%). The estimated mortality rate per trajectory was 0.14% (0.07%-0.29%). No relationship between intracerebral hemorrhage and sex, age, duration of disease, or exclusion of patients with surgical complications was observed; a significant positive relationship was observed with the use of microelectrode recording and a significant negative relationship with putamenal delivery. Our results show a significant difference in intracerebral hemorrhage rates between inoculations and electrode implantation. Our findings suggest that studies involving multiple trajectories to deep nuclei involve a high level of risk. However, inoculations may be significantly safer than electrode implantation. Our analysis has implications for the ethics of preclinical research, independent review of risk, subject selection, and adverse event reporting.

Intraoperative intracerebral MRI-guided navigation for accurate targeting in nonhuman primates

During in vivo intracerebral infusions, the ability to perform accurate targeting towards a 3D-specific point allows control of the anatomical variable and identification of the effects of variations in other factors. Intraoperative MRI navigation systems are currently being used in the clinic, yet their use in nonhuman primates and MRI monitoring of intracerebral infusions has not been reported. In this study rhesus monkeys were placed in a MRI-compatible stereotaxic frame. T1 MRIs in the three planes were obtained in a 3.0T GE scanner to identify the target and plan the trajectory to ventral postcommisural putamen. A craniotomy was performed under sterile surgical conditions at the trajectory entry point. A modified MRI-compatible trajectory guide base (Medtronic Inc.) was secured above the cranial opening and the alignment stem applied. Scans were taken to define the position of the alignment stem. When the projection of the catheter in the three planes matched the desired trajectory to the target, the base was locked in position. A catheter replaced the alignment stem and was slowly introduced to the final target structure. Additional scans were performed to confirm trajectory and during the infusion of a solution of gadoteridol (ProHance, Bracco Diagnostics; 2 mM/L) and bromophenol blue (0.16 mg/ml) in saline. Monitoring of the pressure in the infusion lines was performed using pressure monitoring and infusion pump controller system (Engineering Resources Group Inc.) in combination with a MRI-compatible infusion pump (Harvard). MRI during infusion confirmed successful targeting and matched postmortem visualization of bromophenol blue. Assessment of the accuracy of the targeting revealed an overall 3D mean ± SD distance error of 1.2 ± 0.6 mm and angular distance error of 0.9 ± 0.5 mm. Our results in nonhuman primates confirm the accuracy of intraoperative MRI intracerebral navigation combined with an adaptable, pivot point-based targeting system and validates its use for preclinical intracerebral procedures.

Research ethics. Beyond access vs. protection in trials of innovative therapies

Review of first-in-human trials should aim to safeguard the integrity of the scientific enterprise through a focus on pre-clinical and clinical study quality.

Can animal models of disease reliably inform human studies?

H. Bart van der Worp and colleagues discuss the controversies and possibilities of translating the results of animal experiments into human clinical trials.

Extending clinical equipoise to phase 1 trials involving patients: unresolved problems

Notwithstanding requirements for scientific/social value and risk/benefit proportionality in major research ethics policies, there are no widely accepted standards for these judgments in Phase 1 trials. This paper examines whether the principle of clinical equipoise can be used as a standard for assessing the ratio of risk to direct-benefit presented by drugs administered in one category of Phase 1 study--first-in-human trials involving patients. On the basis of the supporting evidence for, and architecture of, Phase 1 studies, the articles offers two provisional conclusions: (1) the risks of drug administration in such trials cannot generally be justified on therapeutic grounds but by appeal to the social value of the research; and (2) a framework for adjudicating the ratio of risk/social-value must be developed.

Preclinical assessment of stem cell therapies for neurological diseases

Stem cells, as subjects of study for use in treating neurological diseases, are envisioned as a replacement for lost neurons and glia, a means of trophic support, a therapeutic vehicle, and, more recently, a tool for in vitro modeling to understand disease and to screen and personalize treatments. In this review we analyze the requirements of stem cell-based therapy for clinical translation, advances in stem cell research toward clinical application for neurological disorders, and different animal models used for analysis of these potential therapies. We focus on Parkinson's disease (typically defined by the progressive loss of dopaminergic nigral neurons), stroke (neurodegeneration associated with decreased blood perfusion in the brain), and multiple sclerosis (an autoimmune disorder that generates demyelination, axonal damage, astrocytic scarring, and neurodegeneration in the brain and spinal cord). We chose these disorders for their diversity and the number of people affected by them. An additional important consideration was the availability of multiple animal models in which to test stem cell applications for these diseases. We also discuss the relationship between the limited number of systematic stem cell studies performed in animals, in particular nonhuman primates and the delayed progress in advancing stem cell therapies to clinical success.