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Hashimoto K, Harada N, Kimata M, Kawamura Y, Fujita N, Sekizawa A, Ono Y, Obuchi Y, Takayama T, Kasamaki Y, Tanaka Y. Age-related reference intervals for ambulatory electrocardiographic parameters in healthy individuals. Front Cardiovasc Med 2023; 10:1099157. [PMID: 36950291 PMCID: PMC10026132 DOI: 10.3389/fcvm.2023.1099157] [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: 11/15/2022] [Accepted: 02/16/2023] [Indexed: 03/08/2023] Open
Abstract
Background The advent of novel monitoring technologies has dramatically increased the use of ambulatory electrocardiography (AECG) devices. However, few studies have conducted detailed large-scale investigations on the incidence of arrhythmias over 24 h, especially ectopy, in healthy individuals over a wide age range. Objectives This study aimed to investigate the incidence of arrhythmias detected using AECG and associated factors, in healthy individuals, over a wide age range. Methods In this cross-sectional study, we performed AECG on 365 healthy volunteers (median [interquartile range]: 48 [36, 67], 20-89 years, 165 men) under free-running conditions for 24 h. Ultrasonic echocardiography and heart rate variability analysis were performed to explore the factors associated with the incidence of arrhythmias. Results The 97.5th percentile of single ventricular ectopy (VE) was 149/day, 254/day, and 1,682/day in the 20-39-, 40-59- and 60-89-year age groups, respectively; that of single supraventricular ectopy (SVE) was 131/day, 232/day, and 1,063/day, respectively. Multivariate analysis revealed that aging was the only independent significant factor influencing the frequency of VE (β = 0.207, P = 0.001). Age (β = 0.642, P < 0.001), body mass index (BMI) (β = -0.112, P = 0.009), and the root mean square of successive differences in RR intervals (β = 0.097, P = 0.035) were factors significantly associated with SVE frequency. Conclusions Age-specific reference intervals of VE and SVE in a large population of healthy participants over a wide age range were generated. VE and SVE increased with age; SVE was influenced by BMI and the aging-induced decrease in parasympathetic tone activity.
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Affiliation(s)
- Kenichi Hashimoto
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
- Correspondence: Kenichi Hashimoto
| | - Naomi Harada
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Motohiro Kimata
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yusuke Kawamura
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Naoya Fujita
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Akinori Sekizawa
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yasuhiro Obuchi
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Tadateru Takayama
- Department of General Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yuji Kasamaki
- Department of General Medicine, Kanazawa Medical College Himi Municipal Hospital, Himi, Toyama, Japan
| | - Yuji Tanaka
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
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Skovgaard D, Haahr PM, Lester R, Clark K, Paglialunga S, Finer N, Friedrichsen MH, Hjerpsted JB, Engelmann MDM. Prevalence of Baseline Cardiac Arrhythmias in Participants with Overweight or Obesity in Phase 1 Clinical Trials: Analysis of 24-Hour Holter Electrocardiogram Recordings. J Clin Pharmacol 2022; 63:539-543. [PMID: 36524539 DOI: 10.1002/jcph.2193] [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: 10/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
Although estimates of the prevalence of cardiac arrhythmias in healthy volunteers exist, there is a lack of baseline data in other specific populations, such as people living with overweight and obesity, who are increasingly involved in clinical trials. This study investigated the baseline prevalence of arrhythmias in participants with overweight or obesity in 2 phase 1 trials of weight management medications (NCT03661879, NCT03308721). Participants aged 18-55 years, without a history of cardiovascular disease, and with body mass index (BMI) of 25.0-39.9 kg/m2 , were screened for abnormalities in vital signs, electrocardiogram (ECG) recordings, and electrolytes. Baseline 24-hour ECG (Holter) data were collected and manually reviewed by a cardiologist. The primary endpoint was the proportion of participants with ≥1 episode of the predefined cardiac arrhythmias. Continuous 12-lead ECG data were obtained from 207 participants. Most arrhythmias occurred in <3% of participants. Atrioventricular blocks and other potentially malignant arrhythmias were uncommon. There were no associations with age, sex, or BMI. Prevalence of atrioventricular blocks, nonsustained ventricular tachycardia, and other potentially malignant arrhythmias mirrored those reported in healthy participants with normal weight. In clinical trials of weight management medication, knowledge of the baseline prevalence of arrhythmias in people with overweight and obesity may inform trial eligibility criteria, improve on-trial decisions, and could be useful in discussions with health authorities. Baseline Holter readings and real-time ECG telemetry monitoring should be considered in such trials if arrhythmia risk is intrinsic to the molecule, or when signals have been observed in preclinical studies.
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Deiteren A, Coenen E, Lenders S, Verwilst P, Mannaert E, Rasschaert F. Data driven evaluation of healthy volunteer characteristics at screening for phase I clinical trials to inform on study design and optimize screening processes. Clin Transl Sci 2021; 14:2450-2460. [PMID: 34378856 PMCID: PMC8604224 DOI: 10.1111/cts.13113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022] Open
Abstract
Protocols for clinical trials describe inclusion and exclusion criteria based on general and compound-specific considerations to ensure subject safety and data quality. In phase I clinical trials, healthy volunteers (HVs) are screened against these criteria that often specify predefined eligibility ranges for vital signs, electrocardiogram, and laboratory tests. HVs are excluded if baseline parameters deviate from these ranges even though this may not indicate underlying pathology, which could delay trial execution. Data from 3365 HVs participating in 9670 screening visits for 94 phase I HV trials, conducted between December 2008 and May 2019 at the Janssen Clinical Pharmacology Unit, were retrospectively analyzed. Commonly predefined protocol ranges were overlaid with HV data to estimate predicted screen failure rates (SFRs). Of the overall population, 91% was White and 64% were men with mean age of 42.8 ± 12.5 years. High predicted SFRs are related to cardiovascular/metabolic (body mass index, heart rate [HR], blood pressure [BP], and corrected QT Fridericia's formula [QTcF]), renal (estimated glomerular filtration rate [eGFR]), liver (alanine aminotransferase [ALT], and total bilirubin), and coagulation (prothrombin time [PT]) parameters. Predicted SFRs increased with age for high systolic and diastolic BP, QTcF interval, and eGFR. In contrast, lower SFRs in the older age groups were seen for low diastolic BP, liver function test, ALT, PT, and total bilirubin. This analysis can be used to inform on study design, protocol inclusion and exclusion criteria, and to optimize the screening process. Data-driven critical appraisal of proposed inclusion and exclusion criteria using a risk-based approach may significantly reduce screen failure rates without compromising subjects' safety.
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Affiliation(s)
| | - Erwin Coenen
- Janssen Clinical Pharmacology UnitMerksemBelgium
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4
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Watts RE, Odedra A, Marquart L, Webb L, Abd-Rahman AN, Cascales L, Chalon S, Rebelo M, Pava Z, Collins KA, Pasay C, Chen N, Peatey CL, Möhrle JJ, McCarthy JS. Safety and parasite clearance of artemisinin-resistant Plasmodium falciparum infection: A pilot and a randomised volunteer infection study in Australia. PLoS Med 2020; 17:e1003203. [PMID: 32822347 PMCID: PMC7444516 DOI: 10.1371/journal.pmed.1003203] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Artemisinin resistance is threatening malaria control. We aimed to develop and test a human model of artemisinin-resistant (ART-R) Plasmodium falciparum to evaluate the efficacy of drugs against ART-R malaria. METHODS AND FINDINGS We conducted 2 sequential phase 1, single-centre, open-label clinical trials at Q-Pharm, Brisbane, Australia, using the induced blood-stage malaria (IBSM) model, whereby healthy participants are intravenously inoculated with blood-stage parasites. In a pilot study, participants were inoculated (Day 0) with approximately 2,800 viable P. falciparum ART-R parasites. In a comparative study, participants were randomised to receive approximately 2,800 viable P. falciparum ART-R (Day 0) or artemisinin-sensitive (ART-S) parasites (Day 1). In both studies, participants were administered a single approximately 2 mg/kg oral dose of artesunate (AS; Day 9). Primary outcomes were safety, ART-R parasite infectivity, and parasite clearance. In the pilot study, 2 participants were enrolled between April 27, 2017, and September 12, 2017, and included in final analyses (males n = 2 [100%], mean age = 26 years [range, 23-28 years]). In the comparative study, 25 participants were enrolled between October 26, 2017, and October 18, 2018, of whom 22 were inoculated and included in final analyses (ART-R infected participants: males n = 7 [53.8%], median age = 22 years [range, 18-40 years]; ART-S infected participants: males n = 5 [55.6%], median age = 28 years [range, 22-35 years]). In both studies, all participants inoculated with ART-R parasites became parasitaemic. A total of 36 adverse events were reported in the pilot study and 277 in the comparative study. Common adverse events in both studies included headache, pyrexia, myalgia, nausea, and chills; none were serious. Seven participants experienced transient severe falls in white cell counts and/or elevations in liver transaminase levels which were considered related to malaria. Additionally, 2 participants developed ventricular extrasystoles that were attributed to unmasking of a predisposition to benign fever-induced tachyarrhythmia. In the comparative study, parasite clearance half-life after AS was significantly longer for ART-R infected participants (n = 13, 6.5 hours; 95% confidence interval [CI] 6.3-6.7 hours) compared with ART-S infected participants (n = 9, 3.2 hours; 95% CI 3.0-3.3 hours; p < 0.001). The main limitation of this study was that the ART-R and ART-S parasite strains did not share the same genetic background. CONCLUSIONS We developed the first (to our knowledge) human model of ART-R malaria. The delayed clearance profile of ART-R parasites after AS aligns with field study observations. Although based on a relatively small sample size, results indicate that this model can be safely used to assess new drugs against ART-R P. falciparum. TRIAL REGISTRATION The studies were registered with the Australian New Zealand Clinical Trials Registry: ACTRN12617000244303 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372357) and ACTRN12617001394336 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373637).
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Affiliation(s)
| | - Anand Odedra
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Louise Marquart
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Lachlan Webb
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Laura Cascales
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Maria Rebelo
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Zuleima Pava
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Cielo Pasay
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Nanhua Chen
- Australian Army Malaria Institute, Brisbane, Australia
| | | | | | - James S. McCarthy
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
- * E-mail:
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Udholm S, Nyboe C, Redington A, Nielsen-Kudsk JE, Nielsen JC, Hjortdal VE. Hidden burden of arrhythmias in patients with small atrial septal defects: a nationwide study. Open Heart 2019; 6:e001056. [PMID: 31328006 PMCID: PMC6609115 DOI: 10.1136/openhrt-2019-001056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/06/2019] [Accepted: 06/13/2019] [Indexed: 11/24/2022] Open
Abstract
Background In recent Danish nationwide register-based study, adults with small, unrepaired atrial septal defects (ASD) have increased risk of pneumonia, atrial fibrillation (AF) and stroke. Moreover, they revealed higher mortality than the background population. Objective In this nationwide study, we evaluate the hidden burden of atrial and ventricular arrhythmias in adult patients with a small, unrepaired ASD without a previous diagnosis of AF. Methods All Danish patients, aged 18–65, diagnosed between 1953 and 2011 with an unrepaired ASD and no documented AF were invited for 7 days Holter-recording, echocardiography and 6 min walk test. The first 48 hours Holter-recording was completely analysed, while only AF was screened for throughout all 7 days. Furthermore, the entire patient group were characterised using the unique Danish registries. Results A total of 151 patients (mean age 32 years) were included. Approximately 80% of the patients had spontaneous closure of their defect. Despite this, occult arrhythmias were frequent. The most common arrhythmia was supraventricular tachycardia (n=24, 16%) with non-sustained atrial arrhythmias in 21 patients and AF in two patients. A considerable number of patients had non-sustained ventricular tachycardia (n=12, 8%). Patients with ASD and tachyarrhythmias had increased right ventricular to left ventricular diastolic area in echocardiography and higher age when compared with ASD patients without arrhythmias. Conclusion Adult patients with small, unrepaired ASD have a hidden burden of both atrial and ventricular tachyarrhythmias. The mechanism likely relates to the residua of previous right-heart volume overload and incomplete reverse remodelling. Our results support guidelines recommending continued follow-up of patients with small, unrepaired ASD.
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Affiliation(s)
- Sebastian Udholm
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Camilla Nyboe
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Andrew Redington
- Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Evaluation of the safety, pharmacokinetics, pharmacodynamics, and drug-drug interaction potential of a selective Lp-PLA2 inhibitor (GSK2647544) in healthy volunteers
. Int J Clin Pharmacol Ther 2017; 54:935-949. [PMID: 27719741 PMCID: PMC5299597 DOI: 10.5414/cp202565] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2016] [Indexed: 11/19/2022] Open
Abstract
Abstract. Objective: To evaluate in healthy volunteers the safety, pharmacokinetics (PK), pharmacodynamics (PD), and drug-drug interaction (DDI) potential of GSK2647544, (a selective lipoprotein-associated phospholipase A2 (Lp-PLA2) inhibitor). Methods: Study 1 was a single-blind, randomized, placebo-controlled, crossover study with healthy male volunteers randomized to receive single escalating oral doses (0.5 – 750 mg) of GSK2647544. Study 2 was a single-blind, randomized, placebo-controlled study with healthy volunteers randomized to receive repeat doses (80 mg) of GSK2647544. The drug-drug interaction of GSK2647544 with simvastatin was also evaluated in study 2. Results: Across both studies GSK2647544 doses were generally well tolerated with no GSK2647544-related clinically significant findings. GSK2647544 was readily absorbed and its plasma concentration declined bi-exponentially with a terminal half-life ranging from 8 to 16 hours. Plasma exposure of GSK2647544 increased approximately dose-proportionally. There was GSK2647544 dose-dependent inhibition of plasma Lp-PLA2 activity, with a trough inhibition (12 hours after dose) of 85.6% after 7-day twice daily dosing. The administration of simvastatin concomitantly with GSK2647544 increased the overall exposure (area under the plasma concentration-time curve and maximum plasma concentration) of simvastatin and simvastatin acid by 3.6- to 4.3-fold and 1.5- to 3.1-fold, respectively. Conclusions: GSK2647544 was generally well tolerated and had a reasonable PK-PD profile. The clinically significant drug-drug interaction led to an early termination of study 2.
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Breithaupt-Groegler K, Coch C, Coenen M, Donath F, Erb-Zohar K, Francke K, Goehler K, Iovino M, Kammerer KP, Mikus G, Rengelshausen J, Sourgens H, Schinzel R, Sudhop T, Wensing G. Who is a 'healthy subject'?-consensus results on pivotal eligibility criteria for clinical trials. Eur J Clin Pharmacol 2017; 73:409-416. [PMID: 28064353 PMCID: PMC5350217 DOI: 10.1007/s00228-016-2189-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/20/2016] [Indexed: 11/22/2022]
Abstract
Introduction/Methods A discussion forum was hosted by the German not-for-profit Association for Applied Human Pharmacology (AGAH e.V.) to critically review key eligibility criteria and stopping rules for clinical trials with healthy subjects, enrolling stakeholders from the pharmaceutical industry, contract research organisations, academia, ethics committees and competent authority. Results Pivotal eligibility criteria were defined for trials with new investigational medicinal products (IMPs) or with clinically established IMPs. In general, a pulse rate ranging between 50 and 90 beats/min is recommended for first-in-human (FIH) trials, while wider ranges seem acceptable for trials with clinically established IMPs, provided there are no indications of thyroid dysfunction. Hepatic laboratory parameters not to exceed the upper limit of normal (ULN) comprise ALT (alanine aminotransferase) and AST (aspartate aminotransferase) in FIH trials, whereas slight elevations (10% above ULN) seem acceptable in trials with clinically established IMPs without known hepatotoxicity. A normal renal function is required for any clinical trial in healthy subjects. A risk-adapted approach for stopping rules was adopted. Stopping rules for an individual subject are one adverse event of severe intensity or one serious adverse event. In case of a severe adverse event, some stakeholders demand a causal relationship with the IMP (i.e. an adverse reaction). Stopping rules for a cohort are one serious adverse reaction or ≥50% of subjects experiencing any adverse reaction of moderate or severe intensity. Consequences The application of this consensus resulted in a reduction in protocol deficiencies issued by the competent authority.
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Affiliation(s)
| | - Christoph Coch
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Martin Coenen
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany.
| | - Frank Donath
- SocraTec Research and Development GmbH, D-99084, Erfurt, Germany
| | | | - Klaus Francke
- National Association of Statutory Health Insurance Funds, Medicinal Product Department, 10117, Berlin, Germany
| | - Karin Goehler
- Gruenenthal GmbH, Gruenenthal Innovation-Development-Clinical Development-Clinical Pharmacology, D-52099, Aachen, Germany
| | - Mario Iovino
- Boehringer Ingelheim Pharma GmbH & Co. KG, Translational Medicine and Clinical Pharmacology, D-88397, Biberach/Riss, Germany
| | - Klaus Peter Kammerer
- Boehringer Ingelheim Pharma GmbH & Co. KG, Translational Medicine and Clinical Pharmacology, D-88397, Biberach/Riss, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, D-69120, Heidelberg, Germany
| | - Jens Rengelshausen
- Gruenenthal GmbH, Gruenenthal Innovation-Research-Translational Science & Strategy-Early Clinical Science, D-52078, Aachen, Germany
| | | | | | - Thomas Sudhop
- Federal Institute for Drugs and Medical Devices (BfArM), D-53175, Bonn, Germany
| | - Georg Wensing
- Bayer Pharma AG, Pharmaceutical Division Clinical Pharmacology Cardiovascular/Hematology (Primary Care), D-42096, Wuppertal, Germany
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Hingorani P, Karnad DR, Rohekar P, Kerkar V, Lokhandwala YY, Kothari S. Arrhythmias Seen in Baseline 24-Hour Holter ECG Recordings in Healthy Normal Volunteers During Phase 1 Clinical Trials. J Clin Pharmacol 2016; 56:885-93. [DOI: 10.1002/jcph.679] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/08/2015] [Indexed: 11/07/2022]
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Hingorani P, Karnad DR, Natekar M, Kothari S, Narula D. Baseline and new-onset morphologic ECG abnormalities in healthy volunteers in phase I studies receiving placebo: Changes over a 6-week follow-up period. J Clin Pharmacol 2014; 54:776-84. [DOI: 10.1002/jcph.282] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/03/2014] [Indexed: 11/07/2022]
Affiliation(s)
| | | | - Mili Natekar
- Quintiles Cardiac Safety Services; Mumbai Maharashtra India
| | - Snehal Kothari
- Quintiles Cardiac Safety Services; Mumbai Maharashtra India
| | - Dhiraj Narula
- Quintiles Cardiac Safety Services; Mumbai Maharashtra India
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Nada A, Gintant GA, Kleiman R, Gutstein DE, Gottfridsson C, Michelson EL, Strnadova C, Killeen M, Geiger MJ, Fiszman ML, Koplowitz LP, Carlson GF, Rodriguez I, Sager PT. The evaluation and management of drug effects on cardiac conduction (PR and QRS intervals) in clinical development. Am Heart J 2013; 165:489-500. [PMID: 23537964 DOI: 10.1016/j.ahj.2013.01.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 01/17/2013] [Indexed: 01/31/2023]
Abstract
Recent advances in electrocardiographic monitoring and waveform analysis have significantly improved the ability to detect drug-induced changes in cardiac repolarization manifested as changes in the QT/corrected QT interval. These advances have also improved the ability to detect drug-induced changes in cardiac conduction. This White Paper summarizes current opinion, reached by consensus among experts at the Cardiac Safety Research Consortium, on the assessment of electrocardiogram-based safety measurements of the PR and QRS intervals, representing atrioventricular and ventricular conduction, respectively, during drug development.
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Affiliation(s)
- Adel Nada
- Baxter Healthcare Corporation, Deerfield, IL 60015, USA.
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Busse WW, O'Byrne PM, Bleecker ER, Lötvall J, Woodcock A, Andersen L, Hicks W, Crawford J, Jacques L, Apoux L, Bateman ED. Safety and tolerability of the novel inhaled corticosteroid fluticasone furoate in combination with the β2 agonist vilanterol administered once daily for 52 weeks in patients >=12 years old with asthma: a randomised trial. Thorax 2013; 68:513-20. [PMID: 23440247 PMCID: PMC3664377 DOI: 10.1136/thoraxjnl-2012-202606] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The inhaled corticosteroid fluticasone furoate (FF) in combination with the long-acting β2 agonist vilanterol (VI) is in development for asthma and chronic obstructive pulmonary disease. Objective To assess the safety and tolerability of FF/VI over 52 weeks in patients with asthma. Methods Patients (aged ≥12 years; on inhaled corticosteroid) were randomised (2:2:1) to FF/VI 100/25 µg or FF/VI 200/25 µg once daily in the evening, or fluticasone propionate (FP) 500 µg twice daily. Safety evaluations included adverse events (AEs), non-fasting glucose, potassium, 24-h urinary cortisol excretion, ophthalmic assessments, heart rate and pulse rate. Results On-treatment AEs were similar across groups (FF/VI 66–69%; 73% FP). Oral candidiasis/oropharyngeal candidiasis was more common with FF/VI (6–7%) than FP (3%). Twelve serious AEs were reported; one (worsening hepatitis B on FP) was considered drug related. Statistically significant cortisol suppression was seen with FP compared with both FF/VI groups at Weeks 12 and 28 (ratios [95% CI] to FP ranged from 1.43 [1.11 to 1.84] to 1.67 [1.34 to 2.08]; p≤0.006), but not at Week 52 (ratios to FP were 1.05 [0.83 to 1.33] for FF/VI 100/25 µg and 1.09 [0.87 to 1.38] for FF/VI 200/25 µg). No clinically important changes in non-fasting glucose, potassium, QT interval corrected using Fridericia's formula (QTc[F]) or ophthalmic assessments were reported. Pulse rate (10 min post dose [Tmax], Week 52) was significantly increased with FF/VI versus FP (3.4 bpm, 95% CI 1.3 to 5.6; p=0.002 [FF/VI 100/25 µg]; 3.4 bpm, 95% CI 1.2 to 5.6; p=0.003 [FF/VI 200/25 µg]). Mean heart rate (24-h Holter monitoring) decreased from screening values in all groups (0.2–1.1 bpm FF/VI vs 5 bpm FP; Week 52). Conclusions FF/VI (100/25 µg or 200/25 µg) administered once daily over 52 weeks was well tolerated by patients aged ≥12 years with asthma. The overall safety profile of FF/VI did not reveal any findings of significant clinical concern. ClinicalTrials.gov NCT01018186
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Affiliation(s)
- William W Busse
- Department of Medicine, University of Wisconsin, Madison, WI, USA.
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12
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Leishman D, Beck T, Dybdal N, Gallacher D, Guth B, Holbrook M, Roche B, Wallis R. Best practice in the conduct of key nonclinical cardiovascular assessments in drug development: Current recommendations from the Safety Pharmacology Society. J Pharmacol Toxicol Methods 2012; 65:93-101. [DOI: 10.1016/j.vascn.2011.08.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 08/23/2011] [Accepted: 08/24/2011] [Indexed: 11/29/2022]
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13
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Hingorani P, Natekar M, Deshmukh S, Karnad DR, Kothari S, Narula D, Lokhandwala Y. Morphological abnormalities in baseline ECGs in healthy normal volunteers participating in phase I studies. Indian J Med Res 2012; 135:322-30. [PMID: 22561618 PMCID: PMC3361868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND & OBJECTIVES Morphological abnormalities in 12-lead electrocardiograms (ECGs) are seen in subgroups of healthy individuals like athletes and air-force personnel. As these populations may not truly represent healthy individuals, we assessed morphological abnormalities in ECG in healthy volunteers participating in phase I studies, who are screened to exclude associated conditions. METHODS ECGs from 62 phase I studies analyzed in a central ECG laboratory were pooled. A single drug-free baseline ECG from each subject was reviewed by experienced cardiologists. ECG intervals were measured on five consecutive beats and morphological abnormalities identified using standard guidelines. RESULTS Morphological abnormalities were detected in 25.5 per cent of 3978 healthy volunteers (2495 males, 1483 females; aged 18-76 yr); the presence was higher in males (29.3% vs. 19.2% in females; P<0.001). Rhythm abnormalities were the commonest (11.5%) followed by conduction abnormalities (5.9%), axis deviation (4%), ST-T wave changes (3.1%) and chamber enlargement (1.4%). Incomplete right bundle branch block (RBBB), short PR interval and right ventricular hypertrophy were common in young subjects (<20 yr) while atrial fibrillation, first degree atrioventricular block, complete RBBB and left anterior fascicular block were more prevalent in elderly subjects (>65 yr). Prolonged PR interval, RBBB and intraventricular conduction defects were more common in males while sinus tachycardia, short PR interval and non-specific T wave changes were more frequent in females. INTERPRETATION & CONCLUSIONS Morphological abnormalities in ECG are commonly seen in healthy volunteers participating in phase I studies; and vary with age and gender. Further studies are required to determine whether these abnormalities persist or if some of these disappear on follow up.
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Affiliation(s)
- Pooja Hingorani
- Research Section, Quintiles Cardiac Safety Services, Mumbai, India,Reprint requests: Dr Pooja Hingorani, Research Section, Quintiles Cardiac Safety Services, 502A, Leela Business Park, M.V. Road, Andheri-East, Mumbai 400 059, India e-mail:
| | - Mili Natekar
- Research Section, Quintiles Cardiac Safety Services, Mumbai, India
| | - Sheetal Deshmukh
- Research Section, Quintiles Cardiac Safety Services, Mumbai, India
| | - Dilip R. Karnad
- Research Section, Quintiles Cardiac Safety Services, Mumbai, India
| | - Snehal Kothari
- Research Section, Quintiles Cardiac Safety Services, Mumbai, India
| | - Dhiraj Narula
- Research Section, Quintiles Cardiac Safety Services, Mumbai, India
| | - Yash Lokhandwala
- Research Section, Quintiles Cardiac Safety Services, Mumbai, India
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Min SS, Turner JR, Nada A, DiMino TL, Hynie I, Kleiman R, Kowey P, Krucoff MW, Mason JW, Phipps A, Newton-Cheh C, Pordy R, Strnadova C, Targum S, Uhl K, Finkle J. Evaluation of ventricular arrhythmias in early clinical pharmacology trials and potential consequences for later development. Am Heart J 2010; 159:716-29. [PMID: 20435178 DOI: 10.1016/j.ahj.2010.02.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 02/03/2010] [Indexed: 11/15/2022]
Abstract
This white paper, prepared by members of the Cardiac Safety Research Consortium, discusses several important issues regarding the evaluation of ventricular arrhythmias in early clinical pharmacology trials and their potential consequences for later clinical drug development. Ventricular arrhythmias are infrequent but potentially important medical events whose occurrence in early clinical pharmacology trials can dramatically increase safety concerns. Given the increasing concern with all potential safety signals and the resultant more extensive electrocardiographic monitoring of subjects participating in early phase trials, an important question must be addressed: Are relatively more frequent observations of ventricular arrhythmias related simply to more extensive monitoring, or are they genuinely related to the drug under development? The discussions in this paper provide current thinking and suggestions for addressing this question.
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15
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Entacapone and selegiline with L-dopa in patients with Parkinson's disease: an interaction study. Parkinsonism Relat Disord 2000; 6:215-222. [PMID: 10900396 DOI: 10.1016/s1353-8020(00)00012-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Both the catechol-O-methyltransferase (COMT) inhibitor entacapone and the monoamine oxidase B (MAO-B) inhibitor selegiline are L-dopa extenders. Both are used, often simultaneously, as adjuncts to L-dopa/dopa decarboxylase (DDC) inhibitor treatment of Parkinson's disease (PD). Their possible interactions have not been previously studied in a double-blind manner.We studied clinical response, tolerability, haemodynamics and cardiac rhythm in 16 PD patients with end-of-dose-type motor fluctuations. The patients' individual L-dopa/DDC inhibitor treatment was stabilized before the experimental treatments. This was followed by three consecutive, randomized, double-blind 2-week treatment periods with entacapone (200mg with each L-dopa dose), selegiline (10mg o.d.) or both entacapone and selegiline with the L-dopa/DDC inhibitor medication. Clinical efficacy (L-dopa test with repeated motor and dyskinesia scoring) and safety (orthostatic test, 24-h ambulatory ECG, haematological and clinical chemistry variables and adverse events) evaluations were performed before each treatment (control) and at the end of each treatment period.All three treatments, entacapone, selegiline, and entacapone+selegiline as adjunct to L-dopa/DDC inhibitor improved (p<0.05) clinical disability compared to L-dopa only but they did not differ significantly from each other. Dyskinesias increased with all the treatments, statistically significantly (p<0.01) with entacapone+selegiline. No significant differences in haemodynamics were observed between control and any of the experimental treatments, or between the experimental treatments in the orthostatic test. One patient already had symptomatic orthostatism before experimental treatments (control). In two other patients orthostatism emerged after the introduction of selegiline, and in one after every experimental treatment. Twenty-four-hour ECG did not show any differences in supraventricular or ventricular extrasystoles or heart rate between treatments. No statistically significant differences were observed in adverse events or in haematology and clinical chemistry variables. One patient treated with entacapone+selegiline discontinued the study due to dizziness and insomnia. Our results suggest that co-administration of entacapone with L-dopa/DDC inhibitor, with or without selegiline, improves clinical disability, is safe, but may also enhance dopamine-related adverse events to some extent in PD patients with end-of-dose type motor fluctuations.
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16
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Singh SD, Williams AJ. The prevalence and incidence of medical conditions in healthy pharmaceutical company employees who volunteer to participate in medical research. Br J Clin Pharmacol 1999; 48:25-31. [PMID: 10383556 PMCID: PMC2014880 DOI: 10.1046/j.1365-2125.1999.00961.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS Although clinical research in healthy volunteers is commonly performed there have been few studies of the value of the medical screening of subjects. The aim of this study was to investigate the prevalence and incidence of medical conditions found during the medical screening of 'healthy' subjects employed in a pharmaceutical company who volunteered to participate in medical research. METHODS This was a retrospective study of the medical notes of all the subjects who volunteered for membership of the Zeneca Clinical Pharmacology Unit's healthy volunteer panel over a 4 year period from 1990 to 1994. The prevalence of medical conditions found at presentation was determined. The incidence of medical conditions during the 4 year observation period was also ascertained. Medical screening included a full medical history and examination, clinical chemistry, haematology and urinalysis screens, pulmonary function tests, ECGs, 24 h ambulatory cardiac monitoring and a request for information from the volunteer's General Practitioner. RESULTS Prevalence-1293 subjects volunteered to join the panel of which 156 subjects (12%) were not accepted at presentation including 141 (10. 9%) for medical reasons. The most medical common reasons were; previously diagnosed medical conditions (3.3%), cardiovascular abnormalities (1.9%), abnormal liver function tests (1.9%), anaemia (1.2%), hyperlipidaemia (1.1%), excess alcohol intake (0.6%) and thyroid disease (0.5%). Incidence-36 of the 1137 volunteers (0.8% per year) accepted onto the panel subsequently developed medical conditions of which the most common were; anaemia (0.29% per year), cardiovascular abnormalities (0.13% per year) and vasovagal syncope (0.13% per year). CONCLUSIONS This study demonstrates the importance of medical screening before healthy volunteers participate in clinical research.
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Affiliation(s)
- S D Singh
- Clinical Pharmacology Unit, Zeneca Pharmaceuticals, Mereside, Alderley Park, Macclesfield, Cheshire SK10 4TG
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17
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de Mey C. Reliability of screening procedures in identifying subjects suitable for enrollment in clinical pharmacology studies. Clin Pharmacol Ther 1997; 62:112-4. [PMID: 9246025 DOI: 10.1016/s0009-9236(97)90157-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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18
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Punt CJ, Voest EE, Tueni E, Van Oosterom AT, Backx A, De Mulder PH, Hecquet B, Lucas C, Gerard B, Bleiberg H. Phase IB study of doxorubicin in combination with the multidrug resistance reversing agent S9788 in advanced colorectal and renal cell cancer. Br J Cancer 1997; 76:1376-81. [PMID: 9374386 PMCID: PMC2228136 DOI: 10.1038/bjc.1997.563] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
S9788 is a new triazineaminopiperidine derivate capable of reversing multidrug resistance (MDR) in cells resistant to chemotherapeutic agents such as doxorubicin. It does not belong to a known class of MDR revertants, but its action involves the binding of P-glycoprotein. Thirty-eight evaluable patients with advanced colorectal or renal cell cancer were treated with doxorubicin alone (16 patients) followed after disease progression with combination treatment of doxorubicin plus S9788 (12 patients) or upfront with the combination of doxorubicin plus S9788 (22 patients). S9788 was given i.v. as a loading dose of 56 mg m-2 over 30 min followed by doxorubicin given at 50 mg m-2 as a bolus infusion. Thereafter, a 2-h infusion of S9788 was administered at escalating doses ranging from 24 to 120 mg m-2 in subsequent cohorts of 4-10 patients. Pharmacokinetic analysis demonstrated that concentrations of S9788 that are known to reverse MDR in vitro were achieved in patients at non-toxic doses. Compared with treatment with doxorubicin alone, treatment with the combination of doxorubicin and S9788 produced a significant increase in the occurrence of WHO grade 3-4 granulocytopenia. Treatment with S9788 was cardiotoxic as it caused a dose-dependent and reversible increase in corrected QT intervals as well as clinically non-significant arrhythmias on 24- or 48-h Holter recordings. Although clinically relevant cardiac toxicities did not occur, the study was terminated as higher doses of S9788 may increase the risk of severe cardiac arrhythmias. Twenty-nine patients treated with S9788 plus doxorubicin were evaluable for response, and one patient, who progressed after treatment with doxorubicin alone, achieved a partial response. We conclude that S9788 administered at the doses and schedule used in this study results in relevant plasma concentrations in humans and can safely be administered in combination with doxorubicin.
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Affiliation(s)
- C J Punt
- Department of Medical Oncology, University Hospital Nijmegen, The Netherlands
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