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Laursen DRT, Paludan-Müller AS, Hróbjartsson A. Randomized clinical trials with run-in periods: frequency, characteristics and reporting. Clin Epidemiol 2019; 11:169-184. [PMID: 30809104 PMCID: PMC6377048 DOI: 10.2147/clep.s188752] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Run-in periods are occasionally used in randomized clinical trials to exclude patients after inclusion, but before randomization. In theory, run-in periods increase the probability of detecting a potential treatment effect, at the cost of possibly affecting external and internal validity. Adequate reporting of exclusions during the run-in period is a prerequisite for judging the risk of compromised validity. Our study aims were to assess the proportion of randomized clinical trials with run-in periods, to characterize such trials and the types of run-in periods and to assess their reporting. Materials and methods This was an observational study of 470 PubMed-indexed randomized controlled trial publications from 2014. We compared trials with and without run-in periods, described the types of run-in periods and evaluated the completeness of their reporting by noting whether publications stated the number of excluded patients, reasons for exclusion and baseline characteristics of the excluded patients. Results Twenty-five trials reported a run-in period (5%). These were larger than other trials (median number of randomized patients 217 vs 90, P=0.01) and more commonly industry trials (11% vs 3%, P<0.01). The run-in procedures varied in design and purpose. In 23 out of 25 trials (88%), the run-in period was incompletely reported, mostly due to missing baseline characteristics. Conclusion Approximately 1 in 20 trials used run-in periods, though much more frequently in industry trials. Reporting of the run-in period was often incomplete, precluding a meaningful assessment of the impact of the run-in period on the validity of trial results. We suggest that current trials with run-in periods are interpreted with caution and that updates of reporting guidelines for randomized trials address the issue.
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Affiliation(s)
- David Ruben Teindl Laursen
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark, .,Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark, .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark, .,Odense Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark,
| | | | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark, .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark, .,Odense Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark,
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Zheleznykh EA, Danilogorskaya YA, Privalova EV, Belenkov YN, Schendrygina AA, Chekneva IS, Pavlov NA, Tishman MI. Combination Antihypertensive Therapy with Perindopril and Indapamide in Patients with Essential Hypertension: Effect on Endothelial and Cognitive Markers of Vascular Improvement. Adv Ther 2018; 35:1698-1712. [PMID: 30128642 DOI: 10.1007/s12325-018-0773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The objective of this study was to assess the impact of a single-pill combination (SPC) of perindopril/indapamide (PER/IND) at full doses (10/2.5 mg) on endothelial and cognitive function as a clinical intermediate marker of vascular improvement. METHODS This open-label, uncontrolled, observational study enrolled 30 patients (20 females and 10 males) with grade II-III uncontrolled arterial hypertension (SBP/DBP ≥ 160/100 mmHg) and no evidence of cerebrovascular disease. All patients underwent assessment of macro- and microvascular endothelial function parameters at baseline and after 12 months of treatment with SPC PER/IND using photoplethysmography and video capillaroscopy. Cognitive function was assessed using the Montreal Cognitive Assessment scale (MoCA). RESULTS All patients (mean age 60.06 ± 10.19 years) were at high risk for cardiovascular events: mean body mass index (BMI) 31.2 ± 3.9 kg/m2, 33% diagnosed with coronary artery disease angina class I, 30% with impaired glucose tolerance, and 7% with type 2 diabetes. Impaired endothelial function was observed at the both micro- and macrovascular levels. Endothelial function parameters improved after 12-month treatment with SPC PER/IND with an increase in occlusion index from 1.4 to 1.8 (P < 0.00005) and phase shift from 5.0 to 10.8 (P < 0.00001); all values achieved levels in the normal range. Resting capillary network density (CND) increased from 44.8 to 52 cap/mm2 (P < 0.00007), and CND after a venous occlusion test increased from 55 to 61 cap/mm2 (P < 0.006). Signs of cognitive impairment were present at baseline with a mean MoCA score of 23 (normal cognitive function score ≥ 26), but improved after 12-month treatment with a mean MoCA score of 27 (P< 0.0001). Treatment was well tolerated. CONCLUSION SPC PER/IND at full doses for 12 months improves endothelial function, structural and functional parameters of the microcirculation, as well as cognitive function in patients with arterial hypertension at high cardiovascular risk. FUNDING Les Laboratoires Servier.
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Anand S, Kondal D, Montez-Rath M, Zheng Y, Shivashankar R, Singh K, Gupta P, Gupta R, Ajay VS, Mohan V, Pradeepa R, Tandon N, Ali MK, Narayan KMV, Chertow GM, Kandula N, Prabhakaran D, Kanaya AM. Prevalence of chronic kidney disease and risk factors for its progression: A cross-sectional comparison of Indians living in Indian versus U.S. cities. PLoS One 2017; 12:e0173554. [PMID: 28296920 PMCID: PMC5351850 DOI: 10.1371/journal.pone.0173554] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/23/2017] [Indexed: 01/22/2023] Open
Abstract
Background While data from the latter part of the twentieth century consistently showed that immigrants to high-income countries faced higher cardio-metabolic risk than their counterparts in low- and middle-income countries, urbanization and associated lifestyle changes may be changing these patterns, even for conditions considered to be advanced manifestations of cardio-metabolic disease (e.g., chronic kidney disease [CKD]). Methods and findings Using cross-sectional data from the Center for cArdiometabolic Risk Reduction in South Asia (CARRS, n = 5294) and Mediators of Atherosclerosis in South Asians Living in America (MASALA, n = 748) studies, we investigated whether prevalence of CKD is similar among Indians living in Indian and U.S. cities. We compared crude, age-, waist-to-height ratio-, and diabetes- adjusted CKD prevalence difference. Among participants identified to have CKD, we compared management of risk factors for its progression. Overall age-adjusted prevalence of CKD was similar in MASALA (14.0% [95% CI 11.8–16.3]) compared with CARRS (10.8% [95% CI 10.0–11.6]). Among men the prevalence difference was low (prevalence difference 1.8 [95% CI -1.6,5.3]) and remained low after adjustment for age, waist-to-height ratio, and diabetes status (-0.4 [-3.2,2.5]). Adjusted prevalence difference was higher among women (prevalence difference 8.9 [4.8,12.9]), but driven entirely by a higher prevalence of albuminuria among women in MASALA. Severity of CKD—-i.e., degree of albuminuria and proportion of participants with reduced glomerular filtration fraction-—was higher in CARRS for both men and women. Fewer participants with CKD in CARRS were effectively treated. 4% of CARRS versus 51% of MASALA participants with CKD had A1c < 7%; and 7% of CARRS versus 59% of MASALA participants blood pressure < 140/90 mmHg. Our analysis applies only to urban populations. Demographic—-particularly educational attainment—-differences among participants in the two studies are a potential source of bias. Conclusions Prevalence of CKD among Indians living in Indian and U.S. cities is similar. Persons with CKD living in Indian cities face higher likelihood of experiencing end-stage renal disease since they have more severe kidney disease and little evidence of risk factor management.
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Affiliation(s)
- Shuchi Anand
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, United States of America
- * E-mail:
| | - Dimple Kondal
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Maria Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - Yuanchao Zheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - Roopa Shivashankar
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Kalpana Singh
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Priti Gupta
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Ruby Gupta
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Vamadevan S. Ajay
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialties Centre, Chennai, India
| | - Rajendra Pradeepa
- Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialties Centre, Chennai, India
| | - Nikhil Tandon
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Mohammed K. Ali
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - K. M. Venkat Narayan
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - Namratha Kandula
- Division of General Internal Medicine and Department of Preventive Medicine, Northwestern University, Chicago, IL, United States of America
| | - Dorairaj Prabhakaran
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Alka M. Kanaya
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, United States of America
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Chalmers J, Joshi R, Patel A. Advances in reducing the burden of vascular disease in type 2 diabetes. Clin Exp Pharmacol Physiol 2008; 35:434-7. [PMID: 18307736 DOI: 10.1111/j.1440-1681.2008.04892.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
1. The epidemic of diabetes is accelerating and the World Health Organization estimates that the number of people affected worldwide will grow from 171 million in 2000 to 366 million by 2030. 2. The main causes of death and disability in individuals with type 2 diabetes are macrovascular and microvascular disease, and blood pressure is one of the main determinants of vascular complications in this population. 3. While randomized trials have demonstrated that blood pressure lowering reduces vascular complications in subjects with type 2 diabetes and hypertension, ADVANCE was designed to determine whether the addition of a fixed combination of perindopril and indapamide, on top of comprehensive and effective cardiovascular treatments and glucose control therapy, would produce further benefits, irrespective of the initial blood pressure. 4. The blood pressure lowering arm of ADVANCE has demonstrated that the simple addition of the fixed combination of perindopril and indapamide compared to matching placebo, significantly reduces combined macrovascular and microvascular complications by 9%, all-cause mortality by 14% and cardiovascular death by 18%. It also reduces total coronary events by 14% and all renal events and microalbuminuria by 21%. 5. Similar benefits were observed in participant sub-groups characterized by age, sex, baseline blood pressure, previous vascular diseases and concomitant cardiovascular therapy including blood pressure lowering therapy. 6. Successful implementation of this treatment, with a single combination tablet of perindopril and indapamide, should be practical and affordable in most clinical settings worldwide and has the capacity to save countless lives and to reduce the burden of coronary disease and renal disease burden among millions of people with type 2 diabetes.
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Affiliation(s)
- John Chalmers
- The George Institute for International Health, The University of Sydney and The Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
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