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Bowman CJ, Becourt-Lhote N, Boulifard V, Cordts R, Corriol-Rohou S, Enright B, Erkman L, Harris J, Hartmann A, Hilpert J, Kervyn S, Mattson B, Morford L, Muller M, Powell M, Sobol Z, Srinivasan R, Stark C, Thompson KE, Turner KJ, Barrow P. Science-Based Approach to Harmonize Contraception Recommendations in Clinical Trials and Pharmaceutical Labels. Clin Pharmacol Ther 2023; 113:226-245. [PMID: 35388453 PMCID: PMC10083981 DOI: 10.1002/cpt.2602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 03/25/2022] [Indexed: 01/27/2023]
Abstract
This review presents a European Federation of Pharmaceutical Industries and Association/PreClinical Development Expert Group (EFPIA-PDEG) topic group consensus on a data-driven approach to harmonized contraception recommendations for clinical trial protocols and product labeling. There is no international agreement in pharmaceutical clinical trial protocols or product labeling on when/if female and/or male contraception is warranted and for how long after the last dose. This absence of consensus has resulted in different recommendations among regions. For most pharmaceuticals, contraception recommendations are generally based exclusively on nonclinical data and/or mechanism. For clinical trials, contraception is the default position and is maintained for women throughout clinical development, whereas appropriate information can justify removing male contraception. Conversely, contraception is only recommended in product labeling when warranted. A base case rationale is proposed for whether or not female and/or male contraception is/are warranted, using available genotoxicity and developmental toxicity data. Contraception is generally warranted for both male and female subjects treated with mutagenic pharmaceuticals. We propose as a starting point that contraception is not typically warranted when the margin is 10-fold or greater between clinical exposure at the maximum recommended human dose and exposure at the no observed adverse effect level (NOAEL) for purely aneugenic pharmaceuticals and for pharmaceuticals that induce fetal malformations or embryo-fetal lethality. Other factors are discussed, including contraception methods, pregnancy testing, drug clearance, options for managing the absence of a developmental toxicity NOAEL, drug-drug interactions, radiopharmaceuticals, and other drug modalities. Overall, we present a data-driven rationale that can serve as a basis for consistent contraception recommendations in clinical trials and in product labeling across regions.
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Affiliation(s)
- Christopher J Bowman
- Worldwide Research, Development, and Medical, Pfizer Inc, Groton, Connecticut, USA
| | | | | | - Rüdiger Cordts
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Brian Enright
- Preclinical Safety, AbbVie Inc., North Chicago, Illinois, USA
| | - Linda Erkman
- Preclinical Safety, Novartis Pharma, Basel, Switzerland
| | - Jayne Harris
- Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | | | - Jan Hilpert
- Translational Medicine, Pharma Research and Early Development, Bayer AG, Berlin, Germany
| | | | | | | | | | - Marcy Powell
- GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| | - Zhanna Sobol
- Merck & Co., Inc., West Point, Pennsylvania, USA
| | | | - Claudia Stark
- Preclinical Development, Pharma Research and Early Development, Bayer AG, Berlin, Germany
| | - Kary E Thompson
- Nonclinical Safety, Janssen Pharmaceuticals, Spring House, Pennsylvania, USA
| | - Katie J Turner
- Nonclinical Safety, Janssen Pharmaceuticals, Spring House, Pennsylvania, USA
| | - Paul Barrow
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
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Bussel JB, Cooper N, Lawrence T, Michel M, Vander Haar E, Wang K, Wang H, Saad H. Romiplostim use in pregnant women with immune thrombocytopenia. Am J Hematol 2023; 98:31-40. [PMID: 36156812 PMCID: PMC10091785 DOI: 10.1002/ajh.26743] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
Treatment for immune thrombocytopenia (ITP) in pregnancy is hampered by the lack of fetal safety evidence of maternally-administered medications. The Pregnancy Surveillance Program (PSP) collected patient information from 2017-2020 for pregnancy, birth outcomes, and adverse events (AEs) for 186 women exposed to romiplostim from 20 days before pregnancy to the end of pregnancy. Timing of exposure was available in 128 women. Seventy-one mothers (38%) had prepregnancy exposure to romiplostim; intrapartum exposure was known for the first (for many mothers when they discovered their pregnancy), second, and third trimesters for 74 (40%), 22 (12%), and 44 (24%) mothers, respectively, with 15 mothers exposed during >1 trimester. Among the 86 mothers with known pregnancy outcomes, 46 (53%) had at least one pregnancy-related serious AE (SAE); approximately 2/3 of SAEs were due to underlying ITP. Of 92 mothers with known birth outcomes, 60 (65%) had a normal pregnancy and 16 (17%) had complications, with both categories including term and preterm births; there were 12 (14%) spontaneous miscarriages/stillbirths, 3 (3%) ectopic pregnancies, and 1 (1%) molar pregnancy. Most abnormal births resulted from abnormal pregnancies. There were five neonatal/postnatal AEs of note: inguinal hernia, cytomegalovirus infection, trisomy 8 (third trimester single-dose romiplostim exposure), single umbilical artery without known anomalies, and development of autism at age 2 years. Seven of 12 infants with neonatal thrombocytopenia had resolution of thrombocytopenia before discharge; all 12 were discharged. Review of pregnancies in women exposed to romiplostim did not reveal any specific safety concerns for mothers, fetuses, or infants.
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Affiliation(s)
| | | | | | - Marc Michel
- Henri Mondor University Hospital, Université Paris-Est Créteil, France
| | | | - Kejia Wang
- Amgen Inc., Thousand Oaks, California, USA
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Sohn W, Lee E, Kankam MK, Egbuna O, Moffat G, Bussiere J, Padhi D, Ng E, Kumar S, Slatter JG. An open-label study in healthy men to evaluate the risk of seminal fluid transmission of denosumab to pregnant partners. Br J Clin Pharmacol 2016; 81:362-9. [PMID: 26447647 PMCID: PMC4833167 DOI: 10.1111/bcp.12798] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/02/2015] [Accepted: 10/06/2015] [Indexed: 11/29/2022] Open
Abstract
AIMS Denosumab is a fully human monoclonal immunoglobulin G2 antibody that inhibits bone resorption and increases bone mass and strength. The present clinical study assessed serum and seminal fluid pharmacokinetics following a single denosumab dose in healthy men, and evaluated whether denosumab in seminal fluid poses any risk to a fetus in the event of unprotected sexual intercourse with a pregnant partner. METHODS An open-label, single-dose study in 12 healthy men was conducted over a 106-day period. Subjects received a single subcutaneous dose of 60-mg denosumab on day 1. Serum and seminal fluid samples were collected at specified time points to assess denosumab pharmacokinetics. Adverse events were recorded. RESULTS Denosumab was measurable at low concentrations in seminal fluid (~2% of serum concentrations). The mean [standard deviation (SD)] maximum observed drug concentration (Cmax ) was 6170 (2070) ng ml(-1) (serum) and 100 (81.9) ng ml(-1) (seminal fluid). The median time to Cmax (tmax ) was 8 days (serum) and 21 days (seminal fluid). The mean (SD) area under the plasma concentration-time curve (AUC) from time zero to the time of the last quantifiable concentration (AUClast ) was 333 000 (122 000) day•ng ml(-1) (serum) and 5220 (4880) day•ng ml(-1) (seminal fluid). The mean (SD) Cmax and AUC ratios between seminal fluid and serum were 0.0217 (0.0154) and 0.0170 (0.0148), respectively. Using conservative assumptions for ejaculate volume (6 ml), vaginal absorption (100%) and placental transfer (100%), the measured mean denosumab seminal fluid Cmax would result in fetal exposure that was more than 110 times below the preclinically derived 'no effect level' for denosumab. CONCLUSIONS These results indicate a negligible risk to a fetus exposed to denosumab via seminal fluid transfer to a pregnant partner.
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Affiliation(s)
- Winnie Sohn
- Pharmacokinetics and Drug MetabolismAmgen Inc.Thousand OaksCAUSA
| | - Edward Lee
- Early DevelopmentAmgen Inc.Thousand OaksCAUSA
| | | | - Ogo Egbuna
- Early DevelopmentAmgen Inc.Thousand OaksCAUSA
| | - Graeme Moffat
- Comparative Biology & Safety SciencesAmgen Inc.Thousand OaksCAUSA
| | - Jeanine Bussiere
- Comparative Biology & Safety SciencesAmgen Inc.Thousand OaksCAUSA
| | | | - Eric Ng
- Global Patient SafetyAmgen Inc.Thousand OaksCAUSA
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Scialli AR, Bailey G, Beyer BK, Bøgh IB, Breslin WJ, Chen CL, DeLise AM, Hui JY, Moffat GJ, Stewart J, Thompson KE. Potential seminal transport of pharmaceuticals to the conceptus. Reprod Toxicol 2015; 58:213-21. [DOI: 10.1016/j.reprotox.2015.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 09/21/2015] [Accepted: 10/26/2015] [Indexed: 11/15/2022]
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Stewart J, Breslin WJ, Beyer BK, Chadwick K, De Schaepdrijver L, Desai M, Enright B, Foster W, Hui JY, Moffat GJ, Tornesi B, Van Malderen K, Wiesner L, Chen CL. Birth Control in Clinical Trials: Industry Survey of Current Use Practices, Governance, and Monitoring. Ther Innov Regul Sci 2015; 50:155-168. [PMID: 27042398 PMCID: PMC4766962 DOI: 10.1177/2168479015608415] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/01/2015] [Indexed: 11/16/2022]
Abstract
The Health and Environmental Sciences Institute (HESI) Developmental and Reproductive Toxicology Technical Committee sponsored a pharmaceutical industry survey on current industry practices for contraception use during clinical trials. The objectives of the survey were to improve our understanding of the current industry practices for contraception requirements in clinical trials, the governance processes set up to promote consistency and/or compliance with contraception requirements, and the effectiveness of current contraception practices in preventing pregnancies during clinical trials. Opportunities for improvements in current practices were also considered. The survey results from 12 pharmaceutical companies identified significant variability among companies with regard to contraception practices and governance during clinical trials. This variability was due primarily to differences in definitions, areas of scientific uncertainty or misunderstanding, and differences in company approaches to enrollment in clinical trials. The survey also revealed that few companies collected data in a manner that would allow a retrospective understanding of the reasons for failure of birth control during clinical trials. In this article, suggestions are made for topics where regulatory guidance or scientific publications could facilitate best practice. These include provisions for a pragmatic definition of women of childbearing potential, guidance on how animal data can influence the requirements for male and female birth control, evidence-based guidance on birth control and pregnancy testing regimes suitable for low- and high-risk situations, plus practical methods to ascertain the risk of drug-drug interactions with hormonal contraceptives.
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Affiliation(s)
- J Stewart
- AstraZeneca, Macclesfield, United Kingdom
| | - W J Breslin
- Lilly Research Laboratories, Indianapolis, IN, USA
| | - B K Beyer
- Sanofi U.S. Inc, Bridgewater, NJ, USA
| | - K Chadwick
- Bristol-Myers Squibb, New Brunswick, NJ, USA
| | | | - M Desai
- AbbVie Inc, North Chicago, IL, USA
| | | | - W Foster
- McMaster University, Hamilton, Ontario, Canada
| | - J Y Hui
- Celgene Corp, Summit, NJ, USA
| | | | | | - K Van Malderen
- Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - L Wiesner
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - C L Chen
- ILSI-Health and Environmental Sciences Institute, Washington, DC, USA
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