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Lee SY. Using Bayesian statistics in confirmatory clinical trials in the regulatory setting: a tutorial review. BMC Med Res Methodol 2024; 24:110. [PMID: 38714936 PMCID: PMC11077897 DOI: 10.1186/s12874-024-02235-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
Bayesian statistics plays a pivotal role in advancing medical science by enabling healthcare companies, regulators, and stakeholders to assess the safety and efficacy of new treatments, interventions, and medical procedures. The Bayesian framework offers a unique advantage over the classical framework, especially when incorporating prior information into a new trial with quality external data, such as historical data or another source of co-data. In recent years, there has been a significant increase in regulatory submissions using Bayesian statistics due to its flexibility and ability to provide valuable insights for decision-making, addressing the modern complexity of clinical trials where frequentist trials are inadequate. For regulatory submissions, companies often need to consider the frequentist operating characteristics of the Bayesian analysis strategy, regardless of the design complexity. In particular, the focus is on the frequentist type I error rate and power for all realistic alternatives. This tutorial review aims to provide a comprehensive overview of the use of Bayesian statistics in sample size determination, control of type I error rate, multiplicity adjustments, external data borrowing, etc., in the regulatory environment of clinical trials. Fundamental concepts of Bayesian sample size determination and illustrative examples are provided to serve as a valuable resource for researchers, clinicians, and statisticians seeking to develop more complex and innovative designs.
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Affiliation(s)
- Se Yoon Lee
- Department of Statistics, Texas A &M University, 3143 TAMU, College Station, TX, 77843, USA.
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2
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Privitera S, Sedghamiz H, Hartenstein A, Vaitsiakhovich T, Kleinjung F. An evolutionary algorithm for the direct optimization of covariate balance between nonrandomized populations. Pharm Stat 2024; 23:288-307. [PMID: 38111126 DOI: 10.1002/pst.2352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/30/2023] [Accepted: 11/22/2023] [Indexed: 12/20/2023]
Abstract
Matching reduces confounding bias in comparing the outcomes of nonrandomized patient populations by removing systematic differences between them. Under very basic assumptions, propensity score (PS) matching can be shown to eliminate bias entirely in estimating the average treatment effect on the treated. In practice, misspecification of the PS model leads to deviations from theory and matching quality is ultimately judged by the observed post-matching balance in baseline covariates. Since covariate balance is the ultimate arbiter of successful matching, we argue for an approach to matching in which the success criterion is explicitly specified and describe an evolutionary algorithm to directly optimize an arbitrary metric of covariate balance. We demonstrate the performance of the proposed method using a simulated dataset of 275,000 patients and 10 matching covariates. We further apply the method to match 250 patients from a recently completed clinical trial to a pool of more than 160,000 patients identified from electronic health records on 101 covariates. In all cases, we find that the proposed method outperforms PS matching as measured by the specified balance criterion. We additionally find that the evolutionary approach can perform comparably to another popular direct optimization technique based on linear integer programming, while having the additional advantage of supporting arbitrary balance metrics. We demonstrate how the chosen balance metric impacts the statistical properties of the resulting matched populations, emphasizing the potential impact of using nonlinear balance functions in constructing an external control arm. We release our implementation of the considered algorithms in Python.
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Affiliation(s)
| | - Hooman Sedghamiz
- Medical Affairs and Pharmacovigilance, Bayer AG, Berlin, Germany
| | | | | | - Frank Kleinjung
- Medical Affairs and Pharmacovigilance, Bayer AG, Berlin, Germany
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3
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Modlin C, Sugarman J, Chongwe G, Kass N, Nazziwa W, Tegli J, Shrestha P, Ali J. Towards achieving transnational research partnership equity: lessons from implementing adaptive platform trials in low- and middle-income countries. Wellcome Open Res 2023; 8:120. [PMID: 38089903 PMCID: PMC10714106 DOI: 10.12688/wellcomeopenres.18915.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 02/01/2024] Open
Abstract
Background Use of adaptive clinical trials, particularly adaptive platform trials, has grown exponentially in response to the coronavirus disease (COVID-19) pandemic. Implementation of these trials in low- and middle-income countries (LMICs) has been fostered through the formation or modification of transnational research partnerships, typically between research groups from LMICs and high-income countries (HICs). While these partnerships are important to promote collaboration and overcome the structural and economic disadvantages faced by LMIC health researchers, it is critical to focus attention on the multiple dimensions of partnership equity. Methods Based on informal literature reviews and a meeting with leaders of one of the multinational COVID-19 adaptive platform trials, we describe some important considerations about research partnership equity in this context. Results We organize these considerations into eight thematic categories: 1) epistemic structures, 2) funding, 3) ethics oversight, 4) regulatory oversight, 5) leadership, 6) post-trial access to interventions, data, and specimens, 7) knowledge translation and dissemination, and 8) research capacity strengthening and maintenance. Within each category we review normative claims that support its relevance to research partnership equity followed by discussion of how adaptive platform trials highlight new dimensions, considerations, or challenges. Conclusion In aggregate, these observations provide insight into procedural and substantive equity-building measures within transnational global health research partnerships more broadly.
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Affiliation(s)
- Chelsea Modlin
- Berman Institute for Bioethics, Johns Hopkins University, Baltimore, MD, 21205, USA
- Division of Infectious Diseases, Johns Hopkins Medicine, Baltimore, Maryland, 21205, USA
| | - Jeremy Sugarman
- Berman Institute for Bioethics, Johns Hopkins University, Baltimore, MD, 21205, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, 21205, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
| | - Gershom Chongwe
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Nancy Kass
- Berman Institute for Bioethics, Johns Hopkins University, Baltimore, MD, 21205, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
| | - Winfred Nazziwa
- Uganda National Council for Science and Technology, Kampala, Uganda
| | - Jemee Tegli
- Family Health International Clinical/Partnership for Research on Vaccines and Infectious Diseases in Liberia, Monrovia, Liberia
| | - Prakriti Shrestha
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
| | - Joseph Ali
- Berman Institute for Bioethics, Johns Hopkins University, Baltimore, MD, 21205, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
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Hao Q, Gao Y, Zhao Y, Murad MH, Mustafa R, Ansari MT, Schünemann HJ, Rind DM, Brignardello-Petersen R, Guyatt G. GRADE concept 6: a novel application of external indirect evidence into GRADE ratings of evidence certainty in network meta-analysis. J Clin Epidemiol 2023; 163:95-101. [PMID: 37739191 DOI: 10.1016/j.jclinepi.2023.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/28/2023] [Accepted: 09/14/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVES We describe how consideration of external evidence may play an important role in judging certainty in the process of establishing the certainty of the evidence. Our example is a network meta-analysis (NMA) addressing treatment for Ebola virus disease, which informed a World Health Organization guideline. STUDY DESIGN AND SETTING Through Grading of Recommendations Assessment, Development, and Evaluations (GRADE) project group iterative online, in-person and email discussions, we developed this GRADE concept and obtained approval from the GRADE working group. Using the null as a threshold, we rated our certainty for network estimates in mortality, including consideration of evidence external to the NMA (i.e., did not meet eligibility criteria) and formal logical construction. RESULTS Based on the existing GRADE guidance, we rated the network estimate for one indirect comparison as low certainty. The formal logical construction that lead us reevaluate the certainty of the evidence is as follows: if A is superior to B, and B is not inferior to C, then A must be superior to C. After considering the logic and the external indirect evidence, we concluded at least moderate certainty for the comparison. CONCLUSION Systematic review authors and guideline developers should apply the fundamental logical construction for indirect comparisons and consider compelling external evidence in NMA certainty ratings.
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Affiliation(s)
- Qiukui Hao
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Ya Gao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Yunli Zhao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN 55905, USA
| | - Reem Mustafa
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Mohammed T Ansari
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - David M Rind
- Institute for Clinical and Economic Review, 14 Beacon Street, Boston, MA 02108, USA; Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | | | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Modlin C, Sugarman J, Chongwe G, Kass N, Nazziwa W, Tegli J, Shrestha P, Ali J. Towards achieving transnational research partnership equity: lessons from implementing adaptive platform trials in low- and middle-income countries. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.18915.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background: Use of adaptive clinical trials, particularly adaptive platform trials, has grown exponentially in response to the coronavirus disease (COVID-19) pandemic. Implementation of these trials in low- and middle-income countries (LMICs) has been fostered through the formation or modification of transnational research partnerships, typically between research groups from LMICs and high-income countries (HICs). While these partnerships are important to promote collaboration and overcome the structural and economic disadvantages faced by LMIC health researchers, it is critical to focus attention on the multiple dimensions of partnership equity. Methods: Based on informal literature reviews and meetings with leaders of one of the multinational COVID-19 adaptive platform trials, we describe what can be learned about research partnership equity from these experiences. Results: We organize these considerations into eight thematic categories: 1) epistemic structures, 2) funding, 3) ethics oversight, 4) regulatory oversight, 5) leadership, 6) post-trial access to interventions, data, and specimens, 7) knowledge translation, and 8) research capacity strengthening and maintenance. Within each category we review the normative claims that support its relevance to research partnership equity followed by discussion of how adaptive platform trials highlight new dimensions, considerations, or challenges. Conclusion: These observations provide insight into procedural and substantive equity-building measures within transnational global health research partnerships more broadly.
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6
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Overbey JR, Cheung YK, Bagiella E. Integrating non-concurrent controls in the analyses of late-entry experimental arms in multi-arm trials with a shared control group in the presence of parameter drift. Contemp Clin Trials 2022; 123:106972. [PMID: 36307007 DOI: 10.1016/j.cct.2022.106972] [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: 02/11/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Under a master protocol, open platform trials allow new experimental treatments to enter an existing clinical trial. Whether late-entry experimental treatments should be compared to all available or concurrently randomized controls is not well established. Using all available data can increase power and precision; however, drift in population parameters can yield biased estimates and impact type I error rate. METHODS We explored the application of methods developed to incorporate historical controls in two-arm trials to the analysis of a late-entry arm in a simulated open platform trial under varying scenarios of parameter drift. Methods explored include test-then-pool, fixed power prior, dynamic power prior, and multi-source exchangeability model approaches. RESULTS/CONCLUSIONS Simulated trial results confirm that in the presence of no drift, naively pooling all controls increases power and produces more precise, unbiased estimates when compared to using concurrent controls only. However, under drift, pooling can result in type I error rate inflation or deflation and biased estimates. In the presence of parameter drift, methods that partially borrow non-concurrent data, either through a static weighting mechanism or through methods that allow the heterogeneity between non-concurrent and concurrent data to determine the degree of borrowing, are superior to naively pooling the data. However, compared to using concurrent controls only, these approaches cannot guarantee type I error control or unbiased estimates. Thus, concurrent controls should be used as comparators in confirmatory studies.
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Affiliation(s)
- Jessica R Overbey
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Ying Kuen Cheung
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Emilia Bagiella
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Levine CB, Vasistha S, Persson CC, Larson LR, Kratochvil CJ, Mehta AK, Hicks LJ, Lowe AE, Kortepeter MG, Sauer LM. Prepared to Act: Lessons Learned by the Special Pathogens Research Network, Based on Collaborations with the NIAID-Led Adaptive COVID-19 Treatment Trial. Health Secur 2022; 20:S20-S30. [PMID: 35483093 DOI: 10.1089/hs.2021.0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The need for well-controlled clinical trials is fundamental to advancing medicine. Care should be taken to maintain high standards in trial design and conduct even during emergency medical events such as an infectious disease outbreak. In 2020, SARS-CoV-2 emerged and rapidly impacted populations around the globe. The need for effective therapeutics was immediately evident, prompting the National Institutes of Health to initiate the Adaptive COVID-19 Treatment Trial. The Special Pathogens Research Network, made up of 10 Regional Emerging Special Pathogens Treatment Centers, was approached to participate in this trial and readily joined the trial on short notice. By trial closure, the Special Pathogens Research Network sites, making up 19% of all study sites, enrolled 26% of the total participants. The initial resources available and experience in running clinical trials at each treatment center varied from minimal experience and few staff to extensive experience and a large staff. Based on experiences during the first phase of this trial, the Special Pathogens Research Network members provided feedback regarding operational lessons learned and recommendations for conducting future studies during a pandemic. Communication, collaboration, information technology, regulatory processes, and access to resources were identified as important topics to address. Key stakeholders including institutions, institutional review boards, and study personnel must maintain routine communication to efficiently and effectively activate when future research needs arise. Regular and standardized training for new personnel will aid in transitions and project continuity, especially in a rapidly evolving environment. Trainings should include local just-in-time training for new staff and sponsor-designed modules to refresh current staff knowledge. We offer recommendations that can be used by institutions and sponsors to determine goals and needs when preparing to set up this type of trial for critical, short-notice needs.
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Affiliation(s)
- Corri B Levine
- Corri B. Levine, PhD, MS, MPH, is Program Manager, Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sami Vasistha
- Sami Vasistha, MS, is Program Manager, Global Center for Health Security and National Emerging and Special Pathogens Training and Education Center (NETEC), all at the University of Nebraska Medical Center, Omaha, NE
| | - Caroline Croyle Persson
- Caroline Croyle Persson, MPH, MPA, CPH, CIC, is Project Director, Biocontainment Unit, Denver Health and Hospital Authority, Denver, CO
| | - LuAnn R Larson
- LuAnn R. Larson, RN, BSN, is Director of Clinical Research, Center for Clinical and Translational Research and NETEC, all at the University of Nebraska Medical Center, Omaha, NE
| | - Christopher J Kratochvil
- Christopher J. Kratochvil, MD, is Associate Vice Chancellor for Clinical Research, Center for Clinical and Translational Research, all at the University of Nebraska Medical Center, Omaha, NE
| | - Aneesh K Mehta
- Aneesh K. Mehta, MD, is a Professor, Division of Infectious Diseases, and Co-Principal Investigator, NETEC; both at Emory University School of Medicine, Atlanta, GA
| | - Lindsay J Hicks
- Lindsay J. Hicks is IRB Administrator II, Office of Regulatory Affairs, all at the University of Nebraska Medical Center, Omaha, NE
| | - Abigail E Lowe
- Abigail E. Lowe, MA, is an Assistant Professor, College of Allied Health Professions, all at the University of Nebraska Medical Center, Omaha, NE
| | - Mark G Kortepeter
- Mark G. Kortepeter, MD, MPH, is Former Director, Special Pathogens Research Network, NETEC, and is a Professor, Department of Epidemiology, College of Allied Health Professions, all at the University of Nebraska Medical Center, Omaha, NE
| | - Lauren M Sauer
- Lauren M. Sauer, MS, is Director, Special Pathogens Research Network, NETEC, and an Associate Professor, Department of Environmental, Agricultural, and Occupational Health, College of Public Health, Global Center for Health Security, all at the University of Nebraska Medical Center, Omaha, NE
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8
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Jiménez-Fonseca P, Salazar R, Valentí V, Carmona-Bayonas A, Agnelli G. Learning in times of stress: Lessons from COVID-19 that will last throughout this century. Eur J Intern Med 2022; 96:1-4. [PMID: 34801401 PMCID: PMC8585637 DOI: 10.1016/j.ejim.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/06/2021] [Indexed: 12/22/2022]
Abstract
Systems tend toward inertia until an external pressure pushes them toward change; thus, a situation of crisis such as the COVID-19 pandemic represents an opportunity for technological innovation. The prevailing need for treatments and vaccines has impelled innovation in the world of randomized clinical trials (RCT), resorting to ideas that had been floating around for a while. Is this merely a circumstantial phenomenon or are new methods here to stay?
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Affiliation(s)
- Paula Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Ramón Salazar
- Medical Oncology Department, Oncobell Program, IDIBELL Institut Català d'Oncologia, Hospital Duran i Reynals, CIBERONC, Barcelona, Spain
| | - Vicent Valentí
- Medical Oncology Department, Hospital Del Vendrell, El Vendrell, Tarragona, Spain
| | - Alberto Carmona-Bayonas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, UMU, IMIB, Murcia, Spain
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
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Shah KK, Kogut S, Slitt A. Challenges in Evaluating Safety and Efficacy in Drug Development for Rare Diseases: A Review for Pharmacists. J Pharm Pract 2021; 34:472-479. [PMID: 32583733 DOI: 10.1177/0897190020930972] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
A rare disease, or orphan disease, in the United States is a condition with a national prevalence of fewer than 200,000 diagnoses. As therapies for rare diseases are developed and brought to market, pharmacists should understand the challenges of drug development for rare diseases and aid in educating patients about the approval process for rare disease therapies. Developing drugs for treating rare diseases presents unique challenges in proving the drug's safety and efficacy with adequate study design, power, and validity. Results of the clinical trials for rare diseases may be weakened by small patient populations, limited disease information, and difficulty defining end points and biomarkers. In addition to investigational barriers, pharmaceutical companies face financial barriers in justifying the investment of bringing a rare disease therapy to market. Federal programs, such as the Orphan Drug Act of 1983, expedited review, the Rare Pediatric Disease Priority Review Vouchers (RPD PRV) program, and the 21st Century Cures Act, give pharmaceutical companies motivation to develop therapies for rare diseases. The objective of this article is to provide pharmacists with an understanding of the challenges in designing clinical trials for drugs for rare diseases and discuss federal programs that address efforts to develop safe and efficacious drugs for rare diseases.
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Affiliation(s)
- Kanya K Shah
- College of Pharmacy, 4260University of Rhode Island, Kingston, RI, USA
| | - Stephen Kogut
- College of Pharmacy, 4260University of Rhode Island, Kingston, RI, USA
| | - Angela Slitt
- College of Pharmacy, 4260University of Rhode Island, Kingston, RI, USA
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10
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Park JJH, Grais RF, Taljaard M, Nakimuli-Mpungu E, Jehan F, Nachega JB, Ford N, Xavier D, Kengne AP, Ashorn P, Socias ME, Bhutta ZA, Mills EJ. Urgently seeking efficiency and sustainability of clinical trials in global health. Lancet Glob Health 2021; 9:e681-e690. [PMID: 33865473 PMCID: PMC8424133 DOI: 10.1016/s2214-109x(20)30539-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 12/22/2022]
Abstract
This paper shows the scale of global health research and the context in which we frame the subsequent papers in the Series. In this Series paper, we provide a historical perspective on clinical trial research by revisiting the 1948 streptomycin trial for pulmonary tuberculosis, which was the first documented randomised clinical trial in the English language, and we discuss its close connection with global health. We describe the current state of clinical trial research globally by providing an overview of clinical trials that have been registered in the WHO International Clinical Trial Registry since 2010. We discuss challenges with current trial planning and designs that are often used in clinical trial research undertaken in low-income and middle-income countries, as an overview of the global health trials landscape. Finally, we discuss the importance of collaborative work in global health research towards generating sustainable and culturally appropriate research environments.
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Affiliation(s)
- Jay J H Park
- Department of Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | | | - Fyezah Jehan
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jean B Nachega
- Department of Medicine and Center for Infectious Diseases, Stellenbosch University, Cape Town, South Africa; Department of Epidemiology and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology and Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Denis Xavier
- Department of Pharmacology and Division of Clinical Research, St John's Medical College, Bangalore, India
| | - Andre P Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Maria Eugenia Socias
- Fundación Huésped, Buenos Aires, Argentina; British Columbia Centre for Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute of Global Health and Development, and Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Edward J Mills
- School of Public Health, University of Rwanda, Kigali, Rwanda; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Cytel, Vancouver, BC, Canada.
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11
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Madariaga A, Kasherman L, Karakasis K, Degendorfer P, Heesters AM, Xu W, Husain S, Oza AM. Optimizing clinical research procedures in public health emergencies. Med Res Rev 2020; 41:725-738. [PMID: 33174617 DOI: 10.1002/med.21749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 10/14/2020] [Accepted: 10/22/2020] [Indexed: 01/30/2023]
Abstract
Public Health Emergencies of International Concern, such as the coronavirus disease 2019 pandemic, have a devastating impact on an individual and societal level, and there is an urgent need to learn, understand and bridge the therapeutic gap at a time of extreme stress on the patient, health care systems and staff. Well-designed, controlled clinical trials play a crucial role in the discovery of novel diagnostic and management strategies; however, these catastrophic circumstances pose unique challenges in initiating research studies at institutional, national, and international levels, highlighting the importance of a coordinated, collaborative approach. This review discusses key elements necessary to consider for developing clinical trials within a Public Health Emergency setting.
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Affiliation(s)
- Ainhoa Madariaga
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence Kasherman
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Katherine Karakasis
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pamela Degendorfer
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ann M Heesters
- Bioethics Program and The Institute for Education Research, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Division of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Disease, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Amit M Oza
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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12
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Zame WR, Bica I, Shen C, Curth A, Lee HS, Bailey S, Weatherall J, Wright D, Bretz F, van der Schaar M. Machine learning for clinical trials in the era of COVID-19. Stat Biopharm Res 2020; 12:506-517. [PMID: 34191983 PMCID: PMC8011491 DOI: 10.1080/19466315.2020.1797867] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 12/18/2022]
Abstract
The world is in the midst of a pandemic. We still know little about the disease COVID-19 or about the virus (SARS-CoV-2) that causes it. We do not have a vaccine or a treatment (aside from managing symptoms). We do not know if recovery from COVID-19 produces immunity, and if so for how long, hence we do not know if "herd immunity" will eventually reduce the risk or if a successful vaccine can be developed - and this knowledge may be a long time coming. In the meantime, the COVID-19 pandemic is presenting enormous challenges to medical research, and to clinical trials in particular. This paper identifies some of those challenges and suggests ways in which machine learning can help in response to those challenges. We identify three areas of challenge: ongoing clinical trials for non-COVID-19 drugs; clinical trials for repurposing drugs to treat COVID-19, and clinical trials for new drugs to treat COVID-19. Within each of these areas, we identify aspects for which we believe machine learning can provide invaluable assistance.
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Affiliation(s)
- William R. Zame
- Department of Economics and Mathematics, UCLA, Los Angeles, CA, USA
| | - Ioana Bica
- University of Oxford, Oxford, UK
- The Alan Turing Institute, London, UK
| | - Cong Shen
- Department of Electrical and Computer Engineering, University of Virginia, Charlottesville, VA, USA
| | | | - Hyun-Suk Lee
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, UK
| | | | | | | | - Frank Bretz
- Novartis Pharma AG, Basel, Switzerland
- Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Mihaela van der Schaar
- The Alan Turing Institute, London, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, UK
- Department of Electrical and Computer Engineering, UCLA, Los Angeles, CA, USA
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13
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Stallard N, Hampson L, Benda N, Brannath W, Burnett T, Friede T, Kimani PK, Koenig F, Krisam J, Mozgunov P, Posch M, Wason J, Wassmer G, Whitehead J, Williamson SF, Zohar S, Jaki T. Efficient Adaptive Designs for Clinical Trials of Interventions for COVID-19. Stat Biopharm Res 2020; 12:483-497. [PMID: 34191981 PMCID: PMC8011600 DOI: 10.1080/19466315.2020.1790415] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023]
Abstract
The COVID-19 pandemic has led to an unprecedented response in terms of clinical research activity. An important part of this research has been focused on randomized controlled clinical trials to evaluate potential therapies for COVID-19. The results from this research need to be obtained as rapidly as possible. This presents a number of challenges associated with considerable uncertainty over the natural history of the disease and the number and characteristics of patients affected, and the emergence of new potential therapies. These challenges make adaptive designs for clinical trials a particularly attractive option. Such designs allow a trial to be modified on the basis of interim analysis data or stopped as soon as sufficiently strong evidence has been observed to answer the research question, without compromising the trial's scientific validity or integrity. In this article, we describe some of the adaptive design approaches that are available and discuss particular issues and challenges associated with their use in the pandemic setting. Our discussion is illustrated by details of four ongoing COVID-19 trials that have used adaptive designs.
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Affiliation(s)
- Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Lisa Hampson
- Advanced Methodology and Data Science, Novartis Pharma AG, Basel, Switzerland
| | - Norbert Benda
- The Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - Werner Brannath
- Institute for Statistics, University of Bremen, Bremen, Germany
| | - Thomas Burnett
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Peter K. Kimani
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Franz Koenig
- Section for Medical Statistics, CeMSIIS, Medical University of Vienna, Vienna, Austria
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Pavel Mozgunov
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Martin Posch
- Section for Medical Statistics, CeMSIIS, Medical University of Vienna, Vienna, Austria
| | - James Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | | | - John Whitehead
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - S. Faye Williamson
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Sarah Zohar
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
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14
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The Evolution of Master Protocol Clinical Trial Designs: A Systematic Literature Review. Clin Ther 2020; 42:1330-1360. [DOI: 10.1016/j.clinthera.2020.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/10/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
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15
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Angus DC, Berry S, Lewis RJ, Al-Beidh F, Arabi Y, van Bentum-Puijk W, Bhimani Z, Bonten M, Broglio K, Brunkhorst F, Cheng AC, Chiche JD, De Jong M, Detry M, Goossens H, Gordon A, Green C, Higgins AM, Hullegie SJ, Kruger P, Lamontagne F, Litton E, Marshall J, McGlothlin A, McGuinness S, Mouncey P, Murthy S, Nichol A, O’Neill GK, Parke R, Parker J, Rohde G, Rowan K, Turner A, Young P, Derde L, McArthur C, Webb SA. The REMAP-CAP (Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia) Study. Rationale and Design. Ann Am Thorac Soc 2020; 17:879-891. [PMID: 32267771 PMCID: PMC7328186 DOI: 10.1513/annalsats.202003-192sd] [Citation(s) in RCA: 229] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/08/2020] [Indexed: 12/22/2022] Open
Abstract
There is broad interest in improved methods to generate robust evidence regarding best practice, especially in settings where patient conditions are heterogenous and require multiple concomitant therapies. Here, we present the rationale and design of a large, international trial that combines features of adaptive platform trials with pragmatic point-of-care trials to determine best treatment strategies for patients admitted to an intensive care unit with severe community-acquired pneumonia. The trial uses a novel design, entitled "a randomized embedded multifactorial adaptive platform." The design has five key features: 1) randomization, allowing robust causal inference; 2) embedding of study procedures into routine care processes, facilitating enrollment, trial efficiency, and generalizability; 3) a multifactorial statistical model comparing multiple interventions across multiple patient subgroups; 4) response-adaptive randomization with preferential assignment to those interventions that appear most favorable; and 5) a platform structured to permit continuous, potentially perpetual enrollment beyond the evaluation of the initial treatments. The trial randomizes patients to multiple interventions within four treatment domains: antibiotics, antiviral therapy for influenza, host immunomodulation with extended macrolide therapy, and alternative corticosteroid regimens, representing 240 treatment regimens. The trial generates estimates of superiority, inferiority, and equivalence between regimens on the primary outcome of 90-day mortality, stratified by presence or absence of concomitant shock and proven or suspected influenza infection. The trial will also compare ventilatory and oxygenation strategies, and has capacity to address additional questions rapidly during pandemic respiratory infections. As of January 2020, REMAP-CAP (Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia) was approved and enrolling patients in 52 intensive care units in 13 countries on 3 continents. In February, it transitioned into pandemic mode with several design adaptations for coronavirus disease 2019. Lessons learned from the design and conduct of this trial should aid in dissemination of similar platform initiatives in other disease areas.Clinical trial registered with www.clinicaltrials.gov (NCT02735707).
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Affiliation(s)
- Derek C. Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Roger J. Lewis
- Berry Consultants, LLC, Austin, Texas
- Department of Emergency Medicine, Harbor–University of California Los Angeles (UCLA) Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care
- Department of Medical Microbiology, and
| | | | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Allen C. Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jean-Daniel Chiche
- Medical Intensive Care Unit, Hôpital Cochin, Paris Descartes University, Paris, France
| | - Menno De Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - John Marshall
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit and
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, British Columbia, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent’s University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Genevieve K. O’Neill
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit and
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gernot Rohde
- Department of Respiratory Medicine, University Hospital Frankfurt, Frankfurt, Germany
- CAPNETZ Foundation, Hannover, Germany
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand; and
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Colin McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Steven A. Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St. John of God Hospital, Subiaco, Western Australia, Australia
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16
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Kaizer A, Kittelson J. Discussion on "Predictively Consistent Prior Effective Sample Sizes" by Beat Neuenschwander, Sebastian Weber, Heinz Schmidli, and Anthony O'Hagan. Biometrics 2020; 76:588-590. [PMID: 32251530 DOI: 10.1111/biom.13253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/13/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Alexander Kaizer
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - John Kittelson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
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17
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Siden EG, Park JJH, Zoratti MJ, Dron L, Harari O, Thorlund K, Mills EJ. Reporting of master protocols towards a standardized approach: A systematic review. Contemp Clin Trials Commun 2019; 15:100406. [PMID: 31334382 PMCID: PMC6616543 DOI: 10.1016/j.conctc.2019.100406] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/19/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In September 2018 the FDA provided a draft guidance on master protocols reflecting an increased interest in these designs by industry. Master protocols refer to a single overarching protocol developed to evaluate multiple hypotheses and may be further categorized as basket, umbrella, and platform trials. However, inconsistencies in reporting persist in the literature. We conducted a systematic review to describe master protocol reporting with the goal of facilitating the further development and spread of these innovative trial designs. METHODS We searched MEDLINE, EMBASE, and CENTRAL from inception to April 25, 2019 for English articles on master protocols. This was supplemented by hand searches of trial registries and of the bibliographies of published reviews. We used the FDA's definitions of master protocols as references and compared them to self-reported master protocols. RESULTS We identified 278 master protocol publications, consisting of 228 protocols and 50 reviews. Sixty-six records provided unique definitions of master protocol types. We observed considerable heterogeneity in definitions of master protocols, and over half (54%) used oncology-specific language. The majority of self-classified master protocols (57%) were consistent with the FDA's definitions of master protocols. CONCLUSION The terms 'master protocol', 'basket trial', 'umbrella trial', and 'platform trial' are inconsistently described. Careful treatment of these terms and adherence to the definitions set forth by the FDA will facilitate better understanding of these trial designs and allow them to be used broadly and to their full potential in clinical research. We encourage trial methodologists to use these trial designations when applicable.
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Affiliation(s)
- Ellie G. Siden
- MTEK Sciences, 777 West Broadway, Suite 802, Vancouver, BC, V5Z 1J5, Canada
| | - Jay JH. Park
- MTEK Sciences, 777 West Broadway, Suite 802, Vancouver, BC, V5Z 1J5, Canada
- Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Michael J. Zoratti
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, 1280 Main St, 2C Area, Hamilton, ON, L8S 4K1, Canada
| | - Louis Dron
- MTEK Sciences, 777 West Broadway, Suite 802, Vancouver, BC, V5Z 1J5, Canada
| | - Ofir Harari
- MTEK Sciences, 777 West Broadway, Suite 802, Vancouver, BC, V5Z 1J5, Canada
| | - Kristian Thorlund
- MTEK Sciences, 777 West Broadway, Suite 802, Vancouver, BC, V5Z 1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, 1280 Main St, 2C Area, Hamilton, ON, L8S 4K1, Canada
| | - Edward J. Mills
- MTEK Sciences, 777 West Broadway, Suite 802, Vancouver, BC, V5Z 1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, 1280 Main St, 2C Area, Hamilton, ON, L8S 4K1, Canada
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18
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Affiliation(s)
- Lisa M. LaVange
- Department of Biostatistics, University of North Carolina at Chapel Hill, NC
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19
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Ruberg SJ, Harrell FE, Gamalo-Siebers M, LaVange L, Jack Lee J, Price K, Peck C. Inference and Decision Making for 21st-Century Drug Development and Approval. AM STAT 2019. [DOI: 10.1080/00031305.2019.1566091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Lisa LaVange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - J. Jack Lee
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen Price
- Lilly Corporate Center, Eli Lilly & Company, Indianapolis, IN
| | - Carl Peck
- NDA Partners, LLC, San Luis Obispo, CA
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20
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Davey RT, Dodd L, Proschan M, Jahrling P, Hensley L, Higgs E, Lane HC. The Past Need Not Be Prologue: Recommendations for Testing and Positioning the Most-Promising Medical Countermeasures for the Next Outbreak of Ebola Virus Infection. J Infect Dis 2018; 218:S690-S697. [PMID: 30032267 PMCID: PMC6249585 DOI: 10.1093/infdis/jiy334] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The 2013-2016 outbreak of Ebola virus disease (EVD) in West Africa led to unprecedented morbidity and mortality. Although different classes of putative antiviral agents with supportive preclinical data were available for testing, and although several attempts to perform meaningful evaluation of these agents were undertaken during the epidemic, different research methods, a lack of appropriate controls in most studies, and formidable logistical challenges to completion of studies under field conditions hampered the success of these efforts. Ultimately only 1 randomized, placebo-controlled clinical trial (PREVAIL II) was performed in this setting, and, owing to a decrease in the number of new cases available for study, it, too, ended prior to reaching definitive results. Retrospective review of the lessons learned from this outbreak argues strongly for the need for much better preparedness in terms of selecting the trial design and drug(s) for use during the next outbreak. Methods Using recent data provided by representatives from the pharmaceutical industry, clinical and laboratory subject matter experts from the National Institute of Allergy and Infectious Diseases, other US government agencies, and academic partners were consulted regarding the current state of knowledge about several lead compounds with putative activity against EVD. Consensus was sought on recommendations concerning the most promising treatment strategies against EVD that should be studied in the context of a randomized clinical trial during the next outbreak. Results Four compounds from 2 different classes (monoclonal antibody [mAb] cocktails and direct-acting antiviral agents [DAAs]) were highlighted as lead candidates, limitations in the current knowledge base about these drug classes were reviewed, and recommendations about the optimal clinical research design for studying combinations of these different agents were made. Conclusions Although achieving the desired sample size could be challenging, a randomized, controlled clinical trial based on a combination strategy of a mAb with a DAA was recommended as the most appropriate clinical trial design to be undertaken during the next outbreak of EVD.
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Affiliation(s)
- Richard T Davey
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - Lori Dodd
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - Michael Proschan
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - Peter Jahrling
- Integrated Research Facility, NIAID, NIH, Frederick, Maryland
| | - Lisa Hensley
- Integrated Research Facility, NIAID, NIH, Frederick, Maryland
| | - Elizabeth Higgs
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - H Clifford Lane
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
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21
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Kaizer AM, Hobbs BP, Koopmeiners JS. A multi-source adaptive platform design for testing sequential combinatorial therapeutic strategies. Biometrics 2018; 74:1082-1094. [PMID: 29359450 DOI: 10.1111/biom.12841] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 09/01/2018] [Accepted: 11/01/2017] [Indexed: 11/28/2022]
Abstract
Traditional paradigms for clinical translation are challenged in settings where multiple contemporaneous therapeutic strategies have been identified as potentially beneficial. Platform trials have emerged as an approach for sequentially comparing multiple trials using a single protocol. The Ebola virus disease outbreak in West Africa represents one recent example which utilized a platform design. Specifically, the PREVAIL II master protocol sequentially tested new combinations of therapies against the concurrent, optimal standard of care (oSOC) strategy. Once a treatment demonstrated sufficient evidence of benefit, the treatment was added to the oSOC for all future comparisons (denoted as segments throughout the manuscript). In the interest of avoiding bias stemming from population drift, PREVAIL II considered only within-segment comparisons between the oSOC and novel treatments and failed to leverage data from oSOC patients in prior segments. This article describes adaptive design methodology aimed at boosting statistical power through Bayesian modeling and adaptive randomization. Specifically, the design uses multi-source exchangeability models to combine data from multiple segments and adaptive randomization to achieve information balance within a segment. When compared to the PREVAIL II design, we demonstrate that our proposed adaptive platform design improves power by as much as 51% with limited type-I error inflation. Further, the adaptive platform effectuates more balance with respect to the distribution of acquired information among study arms, with more patients randomized to experimental regimens.
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Affiliation(s)
- Alexander M Kaizer
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Brian P Hobbs
- The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Joseph S Koopmeiners
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, U.S.A
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22
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Malvy D, Sissoko D, Camara AM. [Integrating clinical research into epidemic response: the field perspective in the Ebola experience]. Med Sci (Paris) 2017; 33:891-897. [PMID: 28994386 DOI: 10.1051/medsci/20173310022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
During the 2013-2016 west African Ebola outbreak that affected West Africa, accelerated clinical trials, testing unproven but promising and potentially lifesaving experimental interventions emerged as a key component of the global outbreak. In 2017, no Ebola medical countermeasures had proven antiviral efficacy in patients. However, in September 2014, the World Health Organization inventoried a list of potential drug candidates developed or repurposed with demonstrated antiviral efficacy in vitro or in animal models. Numerous therapeutics were considered or explored during the outbreak, including nucleoside and nucleotide analogues, nucleic acid-based drugs and immunotherapeutics. Drugs in clinical trials were tested within the framework of optimized supportive care with fluids and electrolytes and management of severe compromise of multiple organs resulting from viral cytopathology and immune-mediated cell damage. Assessment of those therapeutics with encouraging preliminary efficacy or safety profile, like the repurposed direct antiviral agent favipiravir or the combination of antibodies ZMapp requires further investigation to confirm their efficacy in humans, propose appropriate doses and evaluate the possibility of treatment combinations. During the lull before the next epidemic, major challenges for managing future Ebola epidemics include scientific, clinical and public health preparedness with establishment of innovative patient care and clinical research support in remote poor areas where Ebola and other deadly infectious diseases typically reemerge.
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Affiliation(s)
- Denis Malvy
- Inserm U1219, université de Bordeaux et centre hospitalo-universitaire de Bordeaux, 46, rue Léo-Saignat, 33076 Bordeaux Cedex, France
| | - Daouda Sissoko
- Inserm U1219, université de Bordeaux et centre hospitalo-universitaire de Bordeaux, 46, rue Léo-Saignat, 33076 Bordeaux Cedex, France
| | - Alseny-Modet Camara
- Inserm U1219, université de Bordeaux et centre hospitalo-universitaire de Bordeaux, 46, rue Léo-Saignat, 33076 Bordeaux Cedex, France
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23
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Liu G, Wong G, Su S, Bi Y, Plummer F, Gao GF, Kobinger G, Qiu X. Clinical Evaluation of Ebola Virus Disease Therapeutics. Trends Mol Med 2017; 23:820-830. [PMID: 28822631 DOI: 10.1016/j.molmed.2017.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/11/2017] [Accepted: 07/11/2017] [Indexed: 01/17/2023]
Abstract
Ebola virus disease (EVD) was first described over 40 years ago, but no treatment has been approved for humans. The 2013-2016 EVD outbreak in West Africa has expedited the clinical evaluation of several candidate therapeutics that act through different mechanisms, but with mixed results. Nevertheless, these studies are important because the accumulation of clinical data and valuable experience in conducting efficacy trials under emergency circumstances will lead to better implementation of similar studies in the future. Here, we summarize the results of EVD clinical trials, focus on the discussion of factors that may have potentially impeded the effectiveness of existing candidate therapeutics, and highlight considerations that may help meet the challenges ahead in the quest to develop clinically approved drugs.
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Affiliation(s)
- Guodong Liu
- Special Pathogens Program, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada; Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gary Wong
- Special Pathogens Program, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada; Shenzhen Key Laboratory of Pathogen and Immunity, State Key Discipline of Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, China; Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada; CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Shuo Su
- Jiangsu Engineering Laboratory of Animal Immunology, Institute of Immunology and College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, China
| | - Yuhai Bi
- Shenzhen Key Laboratory of Pathogen and Immunity, State Key Discipline of Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, China; CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Frank Plummer
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - George F Gao
- Shenzhen Key Laboratory of Pathogen and Immunity, State Key Discipline of Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, China; CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Gary Kobinger
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada; Département de microbiologie-infectiologie et d'immunologie, Université Laval, Québec, Canada
| | - Xiangguo Qiu
- Special Pathogens Program, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada; Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada.
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24
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Pierson JF, Kirchoff MC, Orsega SM, Giberson SF, Herpin BR, Ready TW, Holshue ML, Kelly GG. Collaboration of the NIH and PHS Commissioned Corps in the International Ebola Clinical Research Response. Fed Pract 2017; 34:18-25. [PMID: 29200807 PMCID: PMC5708545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The U.S. response to the Ebola epidemic resulted in many federal agencies assessing their ability to respond to global threats and improve the efficiency of humanitarian efforts.
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Affiliation(s)
- Jerome F Pierson
- Dr. Pierson is director, Office of Clinical Research Policy and Regulatory Operations
| | - Matthew C Kirchoff
- CDR Kirchoff is clinical research oversight manager for international research pharmacy operations
| | - Susan M Orsega
- RADM Orsega is chief nurse of the PHS Commissioned Corps and a clinical research oversight manager
| | - Scott F Giberson
- RADM Giberson was the commander of the Commissioned Corps Ebola response. He currently is serving as assistant surgeon general and deputy director, Office of Human Capital at the Centers for Medicare and Medicaid Services in Baltimore, Maryland
| | | | - Travis W Ready
- LCDR Ready is a regulatory officer at the Center for Drug Evaluation and Research of the FDA in Silver Spring, Maryland. At the time of the Ebola response
| | - Michelle L Holshue
- LT Holshue is a nurse in the Clinical Center of the National Institutes of Health in Bethesda, Maryland
| | - Grace G Kelly
- Ms. Kelly is a retired clinical research oversight manager; all in the Division of Clinical Research at the National Institute of Allergy and Infectious Diseases in Bethesda, Maryland
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Cardile AP, Downey LG, Wiseman PD, Warren TK, Bavari S. Antiviral therapeutics for the treatment of Ebola virus infection. Curr Opin Pharmacol 2017; 30:138-143. [PMID: 27639220 DOI: 10.1016/j.coph.2016.08.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/25/2016] [Accepted: 08/30/2016] [Indexed: 11/30/2022]
Abstract
There have been significant developments in Ebola virus therapeutics. While the efficacy of several products was evaluated in the recent West Africa outbreak, a licensed treatment for EBOV disease remains elusive. Factors that negatively impacted the execution of clinical trials included an overall lack of world readiness to conduct clinical trials in an outbreak setting, ethical concerns limiting implementation of the randomized controlled trials in an outbreak setting, and a decline in case numbers by the time resources were mobilized to conduct clinical trials. We summarize relevant therapeutics that underwent clinical trials during the West Africa outbreak and highlight promising candidates under advanced development.
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Affiliation(s)
- Anthony P Cardile
- Division of Medicine, US Army Medical Research Institute of Infectious Diseases, 1425 Porter Street, Frederick, MD 21702, USA.
| | - Lydia G Downey
- Division of Medicine, US Army Medical Research Institute of Infectious Diseases, 1425 Porter Street, Frederick, MD 21702, USA
| | - Perry D Wiseman
- Division of Medicine, US Army Medical Research Institute of Infectious Diseases, 1425 Porter Street, Frederick, MD 21702, USA
| | - Travis K Warren
- Translational Medicine Division, US Army Medical Research Institute of Infectious Diseases, 1425 Porter Street, Frederick, MD 21702, USA
| | - Sina Bavari
- US Army Medical Research Institute of Infectious Diseases, 1425 Porter Street, Frederick, MD 21702, USA
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Antibody therapies for the prevention and treatment of viral infections. NPJ Vaccines 2017; 2:19. [PMID: 29263875 PMCID: PMC5627241 DOI: 10.1038/s41541-017-0019-3] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/08/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022] Open
Abstract
Antibodies are an important component in host immune responses to viral pathogens. Because of their unique maturation process, antibodies can evolve to be highly specific to viral antigens. Physicians and researchers have been relying on such high specificity in their quest to understand host–viral interaction and viral pathogenesis mechanisms and to find potential cures for viral infection and disease. With more than 60 recombinant monoclonal antibodies developed for human use in the last 20 years, monoclonal antibodies are now considered a viable therapeutic modality for infectious disease targets, including newly emerging viral pathogens such as Ebola representing heightened public health concerns, as well as pathogens that have long been known, such as human cytomegalovirus. Here, we summarize some recent advances in identification and characterization of monoclonal antibodies suitable as drug candidates for clinical evaluation, and review some promising candidates in the development pipeline.
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27
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Affiliation(s)
- Janet Woodcock
- From the Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD
| | - Lisa M LaVange
- From the Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD
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28
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Yin G, Lam CK, Shi H. Bayesian randomized clinical trials: From fixed to adaptive design. Contemp Clin Trials 2017; 59:77-86. [PMID: 28455232 DOI: 10.1016/j.cct.2017.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/10/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
Randomized controlled studies are the gold standard for phase III clinical trials. Using α-spending functions to control the overall type I error rate, group sequential methods are well established and have been dominating phase III studies. Bayesian randomized design, on the other hand, can be viewed as a complement instead of competitive approach to the frequentist methods. For the fixed Bayesian design, the hypothesis testing can be cast in the posterior probability or Bayes factor framework, which has a direct link to the frequentist type I error rate. Bayesian group sequential design relies upon Bayesian decision-theoretic approaches based on backward induction, which is often computationally intensive. Compared with the frequentist approaches, Bayesian methods have several advantages. The posterior predictive probability serves as a useful and convenient tool for trial monitoring, and can be updated at any time as the data accrue during the trial. The Bayesian decision-theoretic framework possesses a direct link to the decision making in the practical setting, and can be modeled more realistically to reflect the actual cost-benefit analysis during the drug development process. Other merits include the possibility of hierarchical modeling and the use of informative priors, which would lead to a more comprehensive utilization of information from both historical and longitudinal data. From fixed to adaptive design, we focus on Bayesian randomized controlled clinical trials and make extensive comparisons with frequentist counterparts through numerical studies.
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Affiliation(s)
- Guosheng Yin
- Department of Statistics and Actuarial Science, The University of Hong Kong, Pokfulam Road, Hong Kong
| | - Chi Kin Lam
- Department of Statistics and Actuarial Science, The University of Hong Kong, Pokfulam Road, Hong Kong
| | - Haolun Shi
- Department of Statistics and Actuarial Science, The University of Hong Kong, Pokfulam Road, Hong Kong.
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Hayden FG, Friede M, Bausch DG. Experimental Therapies for Ebola Virus Disease: What Have We Learned? J Infect Dis 2017; 215:167-170. [PMID: 28073859 PMCID: PMC5853886 DOI: 10.1093/infdis/jiw496] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/12/2016] [Indexed: 12/23/2022] Open
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Cardile AP, Warren TK, Martins KA, Reisler RB, Bavari S. Will There Be a Cure for Ebola? Annu Rev Pharmacol Toxicol 2016; 57:329-348. [PMID: 27959624 DOI: 10.1146/annurev-pharmtox-010716-105055] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Despite the unprecedented Ebola virus outbreak response in West Africa, no Ebola medical countermeasures have been approved by the US Food and Drug Administration. However, multiple valuable lessons have been learned about the conduct of clinical research in a resource-poor, high risk-pathogen setting. Numerous therapeutics were explored or developed during the outbreak, including repurposed drugs, nucleoside and nucleotide analogues (BCX4430, brincidofovir, favipiravir, and GS-5734), nucleic acid-based drugs (TKM-Ebola and AVI-7537), and immunotherapeutics (convalescent plasma and ZMapp). We review Ebola therapeutics progress in the aftermath of the West Africa Ebola virus outbreak and attempt to offer a glimpse of a path forward.
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Affiliation(s)
- Anthony P Cardile
- US Army Medical Research Institute of Infectious Diseases, Frederick, Maryland 21702;
| | - Travis K Warren
- US Army Medical Research Institute of Infectious Diseases, Frederick, Maryland 21702;
| | - Karen A Martins
- US Army Medical Research Institute of Infectious Diseases, Frederick, Maryland 21702;
| | - Ronald B Reisler
- US Army Medical Research Institute of Infectious Diseases, Frederick, Maryland 21702;
| | - Sina Bavari
- US Army Medical Research Institute of Infectious Diseases, Frederick, Maryland 21702;
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Malvy D. [Science in a crisis. Medical countermeasures in Ebola virus disease, 2016: lessons learned and perspectives]. ACTA ACUST UNITED AC 2016; 109:262-271. [PMID: 27848225 DOI: 10.1007/s13149-016-0527-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 09/13/2016] [Indexed: 11/30/2022]
Abstract
In 2013, the world began to witness an unprecedented Ebola epidemic in West Africa that was smoldering by early 2016. Under this urgent circumstance, the global scientific community organized and made progress in identifying potential preventive countermeasures and therapeutics and accelerated the development of those promising interventions. Trials of experimental interventions soon emerged as a key component of the global response. Hence, an interdisciplinary issue ensued concerning how best to assess clinical safety and effectiveness of potential interventions prior to or concurrent with their broad use in humans. Key issues rely on the close collaboration between research and clinical teams involved in care in the field. Indeed, it is of prime importance to consider cultural dimensions when aiming to build trust within communities and flexibility to adapt trial procedures to field constraints. Trials implemented during the outbreak crisis illustrates challenging inputs for producing scientific and ethical gains for the benefits of vulnerable populations in the context of an international emerging or re-emerging infectious disease event. This includes rapid implementation of clinical research studies from the early phase of the next global outbreak on the basis of practical and ready-to-apply innovative methodological framework built during interepidemic periods.
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Affiliation(s)
- D Malvy
- Secteur de médecine tropicale et santé internationale clinique, Service des maladies infectieuses et tropicales, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33075, Bordeaux, France. .,Inserm U 1219, université de Bordeaux, 33076, Bordeaux, France.
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Kraft CS. Editorial Commentary: Considerations of Favipiravir as a Medical Countermeasure in Future Randomized Controlled Trials Against Ebola Virus Disease. Clin Infect Dis 2016; 63:1295-1296. [PMID: 27553374 DOI: 10.1093/cid/ciw575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 08/15/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Colleen S Kraft
- Department of Pathology and Laboratory Medicine.,Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia
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Fedson DS. Treating the host response to emerging virus diseases: lessons learned from sepsis, pneumonia, influenza and Ebola. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:421. [PMID: 27942512 DOI: 10.21037/atm.2016.11.03] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is an ongoing threat of epidemic or pandemic diseases that could be caused by influenza, Ebola or other emerging viruses. It will be difficult and costly to develop new drugs that target each of these viruses. Statins and angiotensin receptor blockers (ARBs) have been effective in treating patients with sepsis, pneumonia and influenza, and a statin/ARB combination appeared to dramatically reduce mortality during the recent Ebola outbreak. These drugs target (among other things) the endothelial dysfunction found in all of these diseases. Most scientists work on new drugs that target viruses, and few accept the idea of treating the host response with generic drugs. A great deal of research will be needed to show conclusively that these drugs work, and this will require the support of public agencies and foundations. Investigators in developing countries should take an active role in this research. If the next Public Health Emergency of International Concern is caused by an emerging virus, a "top down" approach to developing specific new drug treatments is unlikely to be effective. However, a "bottom up" approach to treatment that targets the host response to these viruses by using widely available and inexpensive generic drugs could reduce mortality in any country with a basic health care system. In doing so, it would make an immeasurable contribution to global equity and global security.
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Affiliation(s)
- David S Fedson
- Formerly, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Davey RT, Dodd L, Proschan MA, Neaton J, Neuhaus Nordwall J, Koopmeiners JS, Beigel J, Tierney J, Lane HC, Fauci AS, Massaquoi MBF, Sahr F, Malvy D. A Randomized, Controlled Trial of ZMapp for Ebola Virus Infection. N Engl J Med 2016; 375:1448-1456. [PMID: 27732819 PMCID: PMC5086427 DOI: 10.1056/nejmoa1604330] [Citation(s) in RCA: 361] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Data from studies in nonhuman primates suggest that the triple monoclonal antibody cocktail ZMapp is a promising immune-based treatment for Ebola virus disease (EVD). METHODS Beginning in March 2015, we conducted a randomized, controlled trial of ZMapp plus the current standard of care as compared with the current standard of care alone in patients with EVD that was diagnosed in West Africa by polymerase-chain-reaction (PCR) assay. Eligible patients of any age were randomly assigned in a 1:1 ratio to receive either the current standard of care or the current standard of care plus three intravenous infusions of ZMapp (50 mg per kilogram of body weight, administered every third day). Patients were stratified according to baseline PCR cycle-threshold value for the virus (≤22 vs. >22) and country of enrollment. Oral favipiravir was part of the current standard of care in Guinea. The primary end point was mortality at 28 days. RESULTS A total of 72 patients were enrolled at sites in Liberia, Sierra Leone, Guinea, and the United States. Of the 71 patients who could be evaluated, 21 died, representing an overall case fatality rate of 30%. Death occurred in 13 of 35 patients (37%) who received the current standard of care alone and in 8 of 36 patients (22%) who received the current standard of care plus ZMapp. The observed posterior probability that ZMapp plus the current standard of care was superior to the current standard of care alone was 91.2%, falling short of the prespecified threshold of 97.5%. Frequentist analyses yielded similar results (absolute difference in mortality with ZMapp, -15 percentage points; 95% confidence interval, -36 to 7). Baseline viral load was strongly predictive of both mortality and duration of hospitalization in all age groups. CONCLUSIONS In this randomized, controlled trial of a putative therapeutic agent for EVD, although the estimated effect of ZMapp appeared to be beneficial, the result did not meet the prespecified statistical threshold for efficacy. (Funded by the National Institute of Allergy and Infectious Diseases and others; PREVAIL II ClinicalTrials.gov number, NCT02363322 .).
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Leligdowicz A, Fischer WA, Uyeki TM, Fletcher TE, Adhikari NKJ, Portella G, Lamontagne F, Clement C, Jacob ST, Rubinson L, Vanderschuren A, Hajek J, Murthy S, Ferri M, Crozier I, Ibrahima E, Lamah MC, Schieffelin JS, Brett-Major D, Bausch DG, Shindo N, Chan AK, O'Dempsey T, Mishra S, Jacobs M, Dickson S, Lyon GM, Fowler RA. Ebola virus disease and critical illness. Crit Care 2016; 20:217. [PMID: 27468829 PMCID: PMC4965892 DOI: 10.1186/s13054-016-1325-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/26/2016] [Indexed: 12/26/2022] Open
Abstract
As of 20 May 2016 there have been 28,646 cases and 11,323 deaths resulting from the West African Ebola virus disease (EVD) outbreak reported to the World Health Organization. There continue to be sporadic flare-ups of EVD cases in West Africa.EVD presentation is nonspecific and characterized initially by onset of fatigue, myalgias, arthralgias, headache, and fever; this is followed several days later by anorexia, nausea, vomiting, diarrhea, and abdominal pain. Anorexia and gastrointestinal losses lead to dehydration, electrolyte abnormalities, and metabolic acidosis, and, in some patients, acute kidney injury. Hypoxia and ventilation failure occurs most often with severe illness and may be exacerbated by substantial fluid requirements for intravascular volume repletion and some degree of systemic capillary leak. Although minor bleeding manifestations are common, hypovolemic and septic shock complicated by multisystem organ dysfunction appear the most frequent causes of death.Males and females have been equally affected, with children (0-14 years of age) accounting for 19 %, young adults (15-44 years) 58 %, and older adults (≥45 years) 23 % of reported cases. While the current case fatality proportion in West Africa is approximately 40 %, it has varied substantially over time (highest near the outbreak onset) according to available resources (40-90 % mortality in West Africa compared to under 20 % in Western Europe and the USA), by age (near universal among neonates and high among older adults), and by Ebola viral load at admission.While there is no Ebola virus-specific therapy proven to be effective in clinical trials, mortality has been dramatically lower among EVD patients managed with supportive intensive care in highly resourced settings, allowing for the avoidance of hypovolemia, correction of electrolyte and metabolic abnormalities, and the provision of oxygen, ventilation, vasopressors, and dialysis when indicated. This experience emphasizes that, in addition to evaluating specific medical treatments, improving the global capacity to provide supportive critical care to patients with EVD may be the greatest opportunity to improve patient outcomes.
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Affiliation(s)
| | - William A Fischer
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy M Uyeki
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Thomas E Fletcher
- Defence Medical Services, Whittington Barracks, Lichfield, UK
- Liverpool School of Tropical Medicine, Liverpool, Merseyside, UK
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Shevin T Jacob
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Lewis Rubinson
- Department of Medicine, University of Maryland, Baltimore, MD, USA
| | - Abel Vanderschuren
- Centre de recherche de l'institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Jan Hajek
- Division of Infectious Diseases, University of British Columbia, Vancouver, BC, Canada
| | - Srinivas Murthy
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
| | | | - Ian Crozier
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elhadj Ibrahima
- Department of Infectious and Parasitic Diseases, Donka Hospital, Conakry, Guinea
| | - Marie-Claire Lamah
- Department of Infectious and Parasitic Diseases, Donka Hospital, Conakry, Guinea
| | - John S Schieffelin
- Department of Pediatrics, School of Medicine and School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - David Brett-Major
- Department of Preventive Medicine and Biometrics, Uniformed Services University, Bethesda, MD, USA
| | - Daniel G Bausch
- Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland
| | - Nikki Shindo
- Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland
| | - Adrienne K Chan
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Tim O'Dempsey
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Jacobs
- Department of Infection, Royal Free London NHS Foundation Trust, London, UK
| | - Stuart Dickson
- Acute Medicine and Intensive Care, Derriford Hospital, Plymouth, UK
| | - G Marshall Lyon
- Department of Infectious Diseases, Emory University Hospital, Atlanta, Georgia, USA
| | - Robert A Fowler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Kirchoff MC, Pierson JF. Considerations for Use of Investigational Drugs in Public Health Emergencies. Ther Innov Regul Sci 2016; 51:146-152. [PMID: 28663940 DOI: 10.1177/2168479016680253] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The paradigm for the use of investigational drugs in public health emergencies has been recently tested to prevent and treat highly infectious and lethal diseases. Examples include the successful implementation of vaccine and therapeutic clinical trials during the recent Ebola outbreak in West Africa. On the other end of the spectrum was the Emergency Use Authorization (EUA) of peramivir in the treatment of H1N1 influenza virus that did not provide an opportunity to collect data or understand the effectiveness of the EUA program. Between the gold standard of a randomized controlled clinical trial and the problems associated with EUAs are the domain of expanded access protocols that may provide an avenue to make products available while awaiting licensure. This paper will examine the regulatory pathways in the United States (US) for the use of investigational drugs in a public health emergency as well as considerations when making these products available outside the US. Descriptions of the applications of the various approaches will be presented. Regardless of the pathway chosen, public health and clinical research planners need to work together to consider several factors associated with the respective options and maintain a goal of working toward the collection of data to support licensure before faced with future outbreaks. Finally, this paper will consider the lessons learned from public health response in the context of investigational drugs in other diseases where "right to try laws" may pose opportunities, as well as challenges.
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Affiliation(s)
- Matthew Carl Kirchoff
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jerome F Pierson
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
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Affiliation(s)
| | - Dean Follmann
- National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH)
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