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Bowman CJ, Becourt-Lhote N, Boulifard V, Cordts R, Corriol-Rohou S, Enright B, Erkman L, Harris J, Hartmann A, Hilpert J, Kervyn S, Mattson B, Morford L, Muller M, Powell M, Sobol Z, Srinivasan R, Stark C, Thompson KE, Turner KJ, Barrow P. Science-Based Approach to Harmonize Contraception Recommendations in Clinical Trials and Pharmaceutical Labels. Clin Pharmacol Ther 2023; 113:226-245. [PMID: 35388453 PMCID: PMC10083981 DOI: 10.1002/cpt.2602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 03/25/2022] [Indexed: 01/27/2023]
Abstract
This review presents a European Federation of Pharmaceutical Industries and Association/PreClinical Development Expert Group (EFPIA-PDEG) topic group consensus on a data-driven approach to harmonized contraception recommendations for clinical trial protocols and product labeling. There is no international agreement in pharmaceutical clinical trial protocols or product labeling on when/if female and/or male contraception is warranted and for how long after the last dose. This absence of consensus has resulted in different recommendations among regions. For most pharmaceuticals, contraception recommendations are generally based exclusively on nonclinical data and/or mechanism. For clinical trials, contraception is the default position and is maintained for women throughout clinical development, whereas appropriate information can justify removing male contraception. Conversely, contraception is only recommended in product labeling when warranted. A base case rationale is proposed for whether or not female and/or male contraception is/are warranted, using available genotoxicity and developmental toxicity data. Contraception is generally warranted for both male and female subjects treated with mutagenic pharmaceuticals. We propose as a starting point that contraception is not typically warranted when the margin is 10-fold or greater between clinical exposure at the maximum recommended human dose and exposure at the no observed adverse effect level (NOAEL) for purely aneugenic pharmaceuticals and for pharmaceuticals that induce fetal malformations or embryo-fetal lethality. Other factors are discussed, including contraception methods, pregnancy testing, drug clearance, options for managing the absence of a developmental toxicity NOAEL, drug-drug interactions, radiopharmaceuticals, and other drug modalities. Overall, we present a data-driven rationale that can serve as a basis for consistent contraception recommendations in clinical trials and in product labeling across regions.
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Affiliation(s)
- Christopher J Bowman
- Worldwide Research, Development, and Medical, Pfizer Inc, Groton, Connecticut, USA
| | | | | | - Rüdiger Cordts
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Brian Enright
- Preclinical Safety, AbbVie Inc., North Chicago, Illinois, USA
| | - Linda Erkman
- Preclinical Safety, Novartis Pharma, Basel, Switzerland
| | - Jayne Harris
- Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | | | - Jan Hilpert
- Translational Medicine, Pharma Research and Early Development, Bayer AG, Berlin, Germany
| | | | | | | | | | - Marcy Powell
- GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| | - Zhanna Sobol
- Merck & Co., Inc., West Point, Pennsylvania, USA
| | | | - Claudia Stark
- Preclinical Development, Pharma Research and Early Development, Bayer AG, Berlin, Germany
| | - Kary E Thompson
- Nonclinical Safety, Janssen Pharmaceuticals, Spring House, Pennsylvania, USA
| | - Katie J Turner
- Nonclinical Safety, Janssen Pharmaceuticals, Spring House, Pennsylvania, USA
| | - Paul Barrow
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
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2
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Bussel JB, Cooper N, Lawrence T, Michel M, Vander Haar E, Wang K, Wang H, Saad H. Romiplostim use in pregnant women with immune thrombocytopenia. Am J Hematol 2023; 98:31-40. [PMID: 36156812 PMCID: PMC10091785 DOI: 10.1002/ajh.26743] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
Treatment for immune thrombocytopenia (ITP) in pregnancy is hampered by the lack of fetal safety evidence of maternally-administered medications. The Pregnancy Surveillance Program (PSP) collected patient information from 2017-2020 for pregnancy, birth outcomes, and adverse events (AEs) for 186 women exposed to romiplostim from 20 days before pregnancy to the end of pregnancy. Timing of exposure was available in 128 women. Seventy-one mothers (38%) had prepregnancy exposure to romiplostim; intrapartum exposure was known for the first (for many mothers when they discovered their pregnancy), second, and third trimesters for 74 (40%), 22 (12%), and 44 (24%) mothers, respectively, with 15 mothers exposed during >1 trimester. Among the 86 mothers with known pregnancy outcomes, 46 (53%) had at least one pregnancy-related serious AE (SAE); approximately 2/3 of SAEs were due to underlying ITP. Of 92 mothers with known birth outcomes, 60 (65%) had a normal pregnancy and 16 (17%) had complications, with both categories including term and preterm births; there were 12 (14%) spontaneous miscarriages/stillbirths, 3 (3%) ectopic pregnancies, and 1 (1%) molar pregnancy. Most abnormal births resulted from abnormal pregnancies. There were five neonatal/postnatal AEs of note: inguinal hernia, cytomegalovirus infection, trisomy 8 (third trimester single-dose romiplostim exposure), single umbilical artery without known anomalies, and development of autism at age 2 years. Seven of 12 infants with neonatal thrombocytopenia had resolution of thrombocytopenia before discharge; all 12 were discharged. Review of pregnancies in women exposed to romiplostim did not reveal any specific safety concerns for mothers, fetuses, or infants.
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Affiliation(s)
| | | | | | - Marc Michel
- Henri Mondor University Hospital, Université Paris-Est Créteil, France
| | | | - Kejia Wang
- Amgen Inc., Thousand Oaks, California, USA
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3
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Yahyavi SK, Holt R, Juel Mortensen L, Petersen JH, Jørgensen N, Juul A, Blomberg Jensen M. Effect of a single-dose denosumab on semen quality in infertile men (the FITMI study): study protocol for a randomized controlled trial. Trials 2022; 23:525. [PMID: 35733213 PMCID: PMC9214471 DOI: 10.1186/s13063-022-06478-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Infertility is a common problem globally and impaired semen quality is responsible for up to 40% of all cases. Almost all infertile couples are treated with either insemination or assisted reproductive techniques (ARTs) independent of the etiology of infertility because no medical treatment exists. Denosumab is an antibody that blocks RANKL signaling and inhibition of testicular RANKL signaling has been suggested to improve semen quality in a pilot study. This RCT aims to assess whether treatment with denosumab can improve spermatogenesis in infertile men selected by serum AMH as a positive predictive biomarker. This paper describes the design of the study. Methods/design FITMI is a sponsor-investigator-initiated, double-blinded, placebo-controlled 1:1, single-center, randomized clinical trial. Subjects will be randomized to receive either a single-dose denosumab 60 mg subcutaneous injection or placebo. The study will be carried out at the Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen. The primary outcome of the study is defined as the difference in sperm concentration (millions pr. mL) one spermatogenesis (80 days) after inclusion. Discussion We describe a protocol for a planned RCT aimed at evaluating whether treatment with denosumab can improve the semen quality in infertile men selected by using serum AMH as a positive predictive biomarker. The results will provide evidence crucial for future treatment in a patient group where there is a huge unmet need. Trial registration Clinical Trials.gov NCT05212337. Registered on 14 January 2022. EudraCT 2021–003,451-42. Registered on 23 June 2021. Ethical committee H-21040145. Registered on 23 December 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06478-4.
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Affiliation(s)
- Sam Kafai Yahyavi
- Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Rune Holt
- Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Li Juel Mortensen
- Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Holm Petersen
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Section of Biostatistics, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Jørgensen
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin Blomberg Jensen
- Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark. .,Division of Bone and Mineral Research, HSDM/HMS, Harvard University, Boston, USA.
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Blomberg Jensen M, Andreassen CH, Jørgensen A, Nielsen JE, Juel Mortensen L, Boisen IM, Schwarz P, Toppari J, Baron R, Lanske B, Juul A. RANKL regulates male reproductive function. Nat Commun 2021; 12:2450. [PMID: 33893301 PMCID: PMC8065035 DOI: 10.1038/s41467-021-22734-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/23/2021] [Indexed: 11/08/2022] Open
Abstract
Infertile men have few treatment options. Here, we demonstrate that the transmembrane receptor activator of NF-kB ligand (RANKL) signaling system is active in mouse and human testis. RANKL is highly expressed in Sertoli cells and signals through RANK, expressed in most germ cells, whereas the RANKL-inhibitor osteoprotegerin (OPG) is expressed in germ and peritubular cells. OPG treatment increases wild-type mouse sperm counts, and mice with global or Sertoli-specific genetic suppression of Rankl have increased male fertility and sperm counts. Moreover, RANKL levels in seminal fluid are high and distinguishes normal from infertile men with higher specificity than total sperm count. In infertile men, one dose of Denosumab decreases RANKL seminal fluid concentration and increases serum Inhibin-B and anti-Müllerian-hormone levels, but semen quality only in a subgroup. This translational study suggests that RANKL is a regulator of male reproductive function, however, predictive biomarkers for treatment-outcome requires further investigation in placebo-controlled studies.
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Affiliation(s)
- Martin Blomberg Jensen
- Group of Skeletal, Mineral and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
- Division of Bone and Mineral Research, HSDM/HMS, Harvard University, Boston, MA, USA.
| | - Christine Hjorth Andreassen
- Group of Skeletal, Mineral and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Jørgensen
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John Erik Nielsen
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Li Juel Mortensen
- Group of Skeletal, Mineral and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Division of Bone and Mineral Research, HSDM/HMS, Harvard University, Boston, MA, USA
| | - Ida Marie Boisen
- Group of Skeletal, Mineral and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Division of Bone and Mineral Research, HSDM/HMS, Harvard University, Boston, MA, USA
| | - Peter Schwarz
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jorma Toppari
- Institute of Biomedicine, Research Centre for Integrated Physiology and Pharmacology, and Centre for Population Health Research, University of Turku, and Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Roland Baron
- Division of Bone and Mineral Research, HSDM/HMS, Harvard University, Boston, MA, USA
| | - Beate Lanske
- Division of Bone and Mineral Research, HSDM/HMS, Harvard University, Boston, MA, USA
| | - Anders Juul
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Banholzer ML, Wandel C, Barrow P, Mannino M, Schmitt G, Guérard M, Müller L, Greig G, Amemiya K, Peck R, Singer T, Doessegger L. Clinical trial considerations on male contraception and collection of pregnancy information from female partner: update. Clin Transl Med 2016; 5:23. [PMID: 27455840 PMCID: PMC4960246 DOI: 10.1186/s40169-016-0103-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/24/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND This is an update to our 2012 publication on clinical trial considerations on male contraception and collection of pregnancy information from female partner, after critical review of recent (draft) guidances released by the International Council for Harmonisation [ICH] the Clinical Trial Facilitation Group [CTFG] and the US Food & Drug Administration [FDA]. METHODS Relevant aspects of the new guidance documents are discussed in the context of male contraception and pregnancy reporting from female partner in clinical trials and the approach is updated accordingly. RESULTS Genotoxicity The concept of a threshold is introduced using acceptable daily intake/permissible daily exposure to define genotoxicity requirements, hence highly effective contraception in order to avoid conception. The duration for highly effective contraception has been extended from 74 to 90 days from the end of relevant systemic exposure. Teratogenicity Pharmacokinetic considerations to estimate safety margins have been contextualized with regard to over- and underestimation of the risk of teratogenicity transmitted by a vaginal dose. The duration of male contraception after the last dose takes into account the end of relevant systemic exposure if measured, or a default period of five half-lives after last dose for small molecules and two half-lives for immunoglobulins (mAbs). Measures to prevent exposure of the conceptus via a vaginal dose apply to reproductively competent or vasectomized men, unless measurements fail to detect the compound in seminal fluid. CONCLUSION Critical review of new guidance documents provides a comparison across approaches and resulted in an update of our previous publication. Separate algorithms for small molecules and monoclonal antibodies are proposed to guide the recommendations for contraception for male trial participants and pregnancy reporting from female partners. No male contraception is required if the dose is below a defined threshold for genotoxic concern applicable to small molecules. For men treated with teratogenic mAbs, condom use to prevent exposure of a potentially pregnant partner is unlikely to be recommended because of the minimal female exposure anticipated following a vaginal dose. The proposed safety margins for teratogenicity may evolve with further knowledge.
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Affiliation(s)
- Maria Longauer Banholzer
- Safety Risk Management, Licensing & Early Development, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Christoph Wandel
- Safety Risk Management, Licensing & Early Development, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Paul Barrow
- Pharma Research & Early Development, Roche Innovation Center Basel, Pharmaceutical Sciences, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Marie Mannino
- Safety Risk Management, Licensing & Early Development, F. Hoffmann-La Roche Ltd, New York, NY USA
| | - Georg Schmitt
- Pharma Research & Early Development, Roche Innovation Center Basel, Pharmaceutical Sciences, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Melanie Guérard
- Pharma Research & Early Development, Roche Innovation Center Basel, Pharmaceutical Sciences, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Lutz Müller
- Pharma Research & Early Development, Roche Innovation Center Basel, Pharmaceutical Sciences, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Gerard Greig
- Pharma Research & Early Development, Roche Innovation Center Basel, Clinical Pharmacology, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Kenjie Amemiya
- Non-Clinical Safety Department, Genentech Inc, South San Francisco, CA USA
| | - Richard Peck
- Pharma Research & Early Development, Roche Innovation Center Basel, Clinical Pharmacology, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Thomas Singer
- Pharma Research & Early Development, Roche Innovation Center Basel, Pharmaceutical Sciences, F. Hoffmann-La Roche AG, Basel, Switzerland
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Sohn W, Lee E, Kankam MK, Egbuna O, Moffat G, Bussiere J, Padhi D, Ng E, Kumar S, Slatter JG. An open-label study in healthy men to evaluate the risk of seminal fluid transmission of denosumab to pregnant partners. Br J Clin Pharmacol 2016; 81:362-9. [PMID: 26447647 PMCID: PMC4833167 DOI: 10.1111/bcp.12798] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/02/2015] [Accepted: 10/06/2015] [Indexed: 11/29/2022] Open
Abstract
AIMS Denosumab is a fully human monoclonal immunoglobulin G2 antibody that inhibits bone resorption and increases bone mass and strength. The present clinical study assessed serum and seminal fluid pharmacokinetics following a single denosumab dose in healthy men, and evaluated whether denosumab in seminal fluid poses any risk to a fetus in the event of unprotected sexual intercourse with a pregnant partner. METHODS An open-label, single-dose study in 12 healthy men was conducted over a 106-day period. Subjects received a single subcutaneous dose of 60-mg denosumab on day 1. Serum and seminal fluid samples were collected at specified time points to assess denosumab pharmacokinetics. Adverse events were recorded. RESULTS Denosumab was measurable at low concentrations in seminal fluid (~2% of serum concentrations). The mean [standard deviation (SD)] maximum observed drug concentration (Cmax ) was 6170 (2070) ng ml(-1) (serum) and 100 (81.9) ng ml(-1) (seminal fluid). The median time to Cmax (tmax ) was 8 days (serum) and 21 days (seminal fluid). The mean (SD) area under the plasma concentration-time curve (AUC) from time zero to the time of the last quantifiable concentration (AUClast ) was 333 000 (122 000) day•ng ml(-1) (serum) and 5220 (4880) day•ng ml(-1) (seminal fluid). The mean (SD) Cmax and AUC ratios between seminal fluid and serum were 0.0217 (0.0154) and 0.0170 (0.0148), respectively. Using conservative assumptions for ejaculate volume (6 ml), vaginal absorption (100%) and placental transfer (100%), the measured mean denosumab seminal fluid Cmax would result in fetal exposure that was more than 110 times below the preclinically derived 'no effect level' for denosumab. CONCLUSIONS These results indicate a negligible risk to a fetus exposed to denosumab via seminal fluid transfer to a pregnant partner.
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Affiliation(s)
- Winnie Sohn
- Pharmacokinetics and Drug MetabolismAmgen Inc.Thousand OaksCAUSA
| | - Edward Lee
- Early DevelopmentAmgen Inc.Thousand OaksCAUSA
| | | | - Ogo Egbuna
- Early DevelopmentAmgen Inc.Thousand OaksCAUSA
| | - Graeme Moffat
- Comparative Biology & Safety SciencesAmgen Inc.Thousand OaksCAUSA
| | - Jeanine Bussiere
- Comparative Biology & Safety SciencesAmgen Inc.Thousand OaksCAUSA
| | | | - Eric Ng
- Global Patient SafetyAmgen Inc.Thousand OaksCAUSA
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