Choice of student's t- or Wilcoxon-based confidence intervals for assessment of average bioequivalence

Clinical and pharmacokinetics equivalence of multiple doses of levodopa benserazide generic formulation vs the originator (Madopar)

AIMS

While several generic preparations of levodopa/carbidopa and levodopa/benserazide (LBD) are currently available, pharmacokinetic (PK) equivalence and therapeutic equivalence studies with levodopa generics are not available in Italy. Lack of data on generic formulations is a critical factor for their limited use in this country and often lead patients to refuse the generic version of the branded drug.

METHODS

An experimental, 2-centre, randomized, double-blind, 2-sequence, noninferiority cross-over study was designed to evaluate both the PK equivalence and clinical equivalence of multiple doses of the generic preparation of LDB, Teva Italia, compared to the originator (Madopar). Forty-three out-patients with a diagnosis of idiopathic Parkinson's disease on LDB, were recruited and randomly assigned to 1 of 2 study sequences: generic-originator or originator-generic. Clinical evaluations were performed at the end of each study period. A PK study with an LDB fixed dose (100 + 25 mg) was performed in a subpopulation of 14 subjects.

RESULTS

Clinical data showed a reduction of 0.49 and 1.54 in the mean UPDRS III scores for the LDB and the originator, respectively. The 95% CIs [-2.21: 0.11] of the mean difference original vs LDB are smaller than the clinically significant difference of 3 UPDRS III points, supporting the conclusion that the treatment with LDB is not inferior to the originator. No statistically significant differences were found with respect to area under the curve to last dose, half-life, maximum concentration, time to maximum concentration and last observed concentration.

CONCLUSION

These findings prove the therapeutic clinical equivalence as well the PK equivalence of the generic LDB and the originator (Madopar).

Inflation of the type I error: investigations on regulatory recommendations for bioequivalence of highly variable drugs

PURPOSE

We investigated different evaluation strategies for bioequivalence trials with highly variable drugs on their resulting empirical type I error and empirical power. The classical 'unscaled' crossover design with average bioequivalence evaluation, the Add-on concept of the Japanese guideline, and the current 'scaling' approach of EMA were compared.

METHODS

Simulation studies were performed based on the assumption of a single dose drug administration while changing the underlying intra-individual variability.

RESULTS

Inclusion of Add-on subjects following the Japanese concept led to slight increases of the empirical α-error (≈7.5%). For the approach of EMA we noted an unexpected tremendous increase of the rejection rate at a geometric mean ratio of 1.25. Moreover, we detected error rates slightly above the pre-set limit of 5% even at the proposed 'scaled' bioequivalence limits.

CONCLUSIONS

With the classical 'unscaled' approach and the Japanese guideline concept the goal of reduced subject numbers in bioequivalence trials of HVDs cannot be achieved. On the other hand, widening the acceptance range comes at the price that quite a number of products will be accepted bioequivalent that had not been accepted in the past. A two-stage design with control of the global α therefore seems the better alternative.

Novel approach to bioequivalence assessment based on physiologically motivated model

The study was conducted to exemplify an approach capable of obtaining a new insight into bioequivalence (BE) assessment, by the use of a physiologically motivated model. Data from an oral BE study of two piroxicam (PXM) products was used as an example. The BE study was carried out with 24 healthy European subjects according to a two-sequence crossover-randomized design. The test and reference formulations were a PXM generic formulation (LaborMed Pharma, Romania) and Feldene (Pfizer, USA), respectively. Plasma concentrations of PXM were monitored by a validated high-performance liquid chromatography over a period of 144 h after administration. After the structure of the optimal model was selected, parameters that characterized the whole-body disposition behavior of PXM in the subjects were derived. The paired Student's t-test and Wilkoxon's test were performed on the derived parameters. The null hypothesis of no differences in the parameters of the whole-body disposition behavior of PXM related to the test and reference product was not rejected at 5% level of significance. This result suggested that the compared products were bioequivalent and could be used interchangeably in clinical setting. The presented approach might show a new way, worth incorporating in future BE guidelines.

Evaluation by simulation of tests based on non-linear mixed-effects models in pharmacokinetic interaction and bioequivalence cross-over trials

We propose tests based on non-linear mixed effects models (NLMEM) in pharmacokinetic interaction and bioequivalence cross-over trials comparing two treatments or two formulations. To compare the logarithm of the area under the curve (AUC) using these models, two approaches are studied: in the first one, concentration data are analysed globally, with and without the estimation of a treatment effect; and in the second one, they are analysed separately in each treatment group with the estimation of the individual parameters. Four tests for comparison of the logarithm AUC between two treatment arms are studied: a likelihood-ratio test (LRT), a Wald test and two tests, parametric and non-parametric, comparing the individual Empirical Bayes (EB) estimates. These tests are adapted to the case of equivalence, except the LRT which does not have any simple extension. We evaluate by simulation of the type I error and the power for both comparison and equivalence tests. They are compared to the standard tests recommended by the FDA and the EMEA, based on non-compartmental (NC) AUC. Trials for a usual PK model are simulated under H(0) and several H(1) using S-plus software and analysed with the nlme function. Different configurations of the number of subjects (n=12, 24 and 40) and of the number of samples per subject (J=10, 5 and 3) are studied. The type I error alpha of LRT and Wald comparison test in the 5000 replications of interaction cross-over trials is found to be 20.9 per cent and 21.7 per cent, respectively, in the original design (n=12, J=10), which is far superior to 5 per cent, and decreases when n increases. When n is fixed, alpha is found to increase with J. Power is satisfactory for both tests, after correction of the significance threshold. Results of EB and NC tests are similar with satisfactory powers and a type I error close to 5 per cent, except when J=3 for EB tests. Similar results are obtained for equivalence tests, except for EB and NC Student tests, which are not of a great interest. NC tests keep their place when the number of samples per subject J is large, but NLMEM seem useful for cross-over studies performed in special populations where J limited; the evaluation by Monte-Carlo simulations of empirical threshold seems however necessary because of the inflation of the type I error.