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Desai KG. Subcutaneous Administration of Therapeutic Monoclonal Antibody Drug Products Using a Syringe in Blinded Clinical Trials: Advances and Key Aspects Related to Blinding/Matching/Masking Strategies for Placebo Formulation. Mol Pharm 2025. [PMID: 39745002 DOI: 10.1021/acs.molpharmaceut.4c01166] [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: 01/04/2025]
Abstract
Therapeutic monoclonal antibody (mAb) drug products are increasingly used to treat both chronic and acute diseases. These mAb drug products are often developed for subcutaneous (SC) injection to simplify dosing compared with intravenous (IV) infusion. For SC injection, the mAb liquid drug product is typically filled in a vial for use with a syringe or in a prefilled syringe, which can then be assembled into a safety syringe device or an autoinjector for direct administration. A placebo is an inert formulation (one without an active ingredient) that lacks pharmacological activity or a therapeutic effect. It serves as a control in blinded clinical trials to evaluate the efficacy of a new treatment. A suitable blinding/matching/masking strategy is crucial to ensure that study participants cannot distinguish between the active mAb formulation and the placebo. The success of these strategies is pivotal in ensuring the accuracy and reliability of clinical trial results. This Review summarizes recent advances and key considerations related to placebo strategies. It covers the benefits and challenges of SC injection of therapeutic mAbs compared to IV infusion, the placebo effect, the significance of blinding/matching/masking, and various strategies. Strategies discussed include the use of traditional placebos (e.g., normal saline, 5% w/v dextrose solution, and formulation buffer of the active mAb), syringe blinding, the use of different gauge syringe needles, novel (custom) placebos, dilution, independent administration, and multiple injections. Additional topics covered include the incidence of antidrug antibodies (ADAs), the benefits and challenges associated with different strategies, and regulatory expectations regarding custom placebos. By addressing these critical aspects, the Review aims to contribute to the growing body of knowledge and ongoing efforts to enhance the effectiveness of formulation blinding, matching, and masking in clinical trials.
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Affiliation(s)
- Kashappa Goud Desai
- Drug Product Development-Steriles, Medicine Development and Supply, GSK, 1250 S. Collegeville Road, Collegeville, Pennsylvania 19426, United States
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Qin Z, Yu Y, Gu H, Shi D, Wang Z, Wu J, Furukawa T, Wu Y. SAS macro programme for Bang's Blinding Index to assess and visualise the success of blinding in randomised controlled trials. Gen Psychiatr 2024; 37:e101578. [PMID: 39660039 PMCID: PMC11629010 DOI: 10.1136/gpsych-2024-101578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 10/11/2024] [Indexed: 12/12/2024] Open
Abstract
This paper aims to present a Statistical Analysis Software (SAS) macro %BBIplus, offering estimation and visualisation methods for the Bang's Blinding Index (BBI) for randomised controlled trials (RCTs) with various designs. We developed the SAS macro programme %BBIplus to facilitate the implementation of BBI. This user-friendly programme allows for easy and rapid estimation and visualisation of BBI across different scenarios, including pairwise comparison RCTs with two arms, double-dummy design RCTs with three arms and factorial design RCTs with four arms. The programme requires no pre-existing data set, and users only need to input the number of individuals of correct, uncertain or wrong guesses in each intervention or control group. We illustrate the functionality of %BBIplus using blinding assessment data from three previously published RCTs: BBR (adjunctive berberine reduces antipsychotic-associated weight gain and metabolic syndrome in patients with schizophrenia: a randomised controlled trial), SELECT-TDCS (the sertraline versus electrical current therapy for treating depression clinical study: results from a factorial, randomised controlled trial) and ELECT-TDCS (trial of electrical direct-current therapy versus escitalopram for depression) studies. The programme estimates the BBI for each arm, providing point estimates, 95% CI and associated p values. Additionally, %BBIplus can visualise the estimations through forest plots and make the judgement for the success of blinding easily and rapidly. This tool caters to the needs of clinical trial investigators, offering a comprehensive solution for estimating and visualising the blinding index under various RCT designs.
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Affiliation(s)
- Zongshi Qin
- Peking University Clinical Research Institute, Beijing, China
| | - Yongpei Yu
- Peking University Clinical Research Institute, Beijing, China
| | - Hongqiu Gu
- Department of Neurology and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dongdong Shi
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhen Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiani Wu
- Department of Acupuncture and Neurology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Toshiaki Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and School of Public Health, Kyoto, Japan
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Beijing, China
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Rutter-Locher Z, Norton S, Denk F, McMahon S, Taams LS, Kirkham BW, Bannister K. A randomised controlled trial of the effect of intra-articular lidocaine on pain scores in inflammatory arthritis. Pain 2024; 165:2578-2585. [PMID: 38888846 PMCID: PMC11474916 DOI: 10.1097/j.pain.0000000000003291] [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: 11/01/2023] [Revised: 04/02/2024] [Accepted: 04/06/2024] [Indexed: 06/20/2024]
Abstract
ABSTRACT Chronic pain in inflammatory arthritis (IA) reflects a complex interplay between active disease in a peripheral joint and central pronociceptive mechanisms. Because intra-articular lidocaine may be used to abolish joint-specific peripheral input to the central nervous system, we aimed to validate its use as a clinical tool to identify those patients with IA whose pain likely incorporates centrally mediated mechanisms. We began by investigating whether there was a placebo response of intra-articular injection in patients with IA 1:1 randomised to receive intra-articular lidocaine or control (0.9% saline). After, in a larger patient cohort not randomized to placebo vs lidocaine groups, we tested whether patients with IA could be stratified into 2 cohorts based on their response to intra-articular lidocaine according to markers of centrally mediated pain. To this end, we evaluated postlidocaine pain numerical rating scale (NRS) scores alongside baseline painDETECT, fibromyalgia criteria fulfillment, and quantitative sensory testing outcomes. Numerical rating scale scores were collected at baseline and 3-, 5-, and 10-minutes postinjection. Firstly, the placebo effect of intra-articular injection was low: compared to baseline, the mean pain NRS score 5-minutes postinjection was reduced by 3.5 points in the lidocaine group vs 1.2 points in the control group. Secondly, postlidocaine NRS scores were significantly higher in those with a high (>18) baseline painDETECT score, fibromyalgia, and low-pressure pain threshold at the trapezius ( P = 0.002, P = 0.001, P = 0.005, respectively). Persistent high pain after intra-articular lidocaine injection could be used as an indicator of pronociceptive mechanisms that are centrally mediated, informing centrally targeted analgesic strategies.
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Affiliation(s)
- Zoe Rutter-Locher
- Rheumatology Department, Guy's and St Thomas' NHS Trust, London, United Kingdom
- Department Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College University, London, United Kingdom
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Franziska Denk
- Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London, United Kingdom
| | - Stephen McMahon
- Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London, United Kingdom
| | - Leonie S. Taams
- Department Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College University, London, United Kingdom
| | - Bruce W. Kirkham
- Rheumatology Department, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Kirsty Bannister
- Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London, United Kingdom
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Zhang M, Zhang B, Morice AH. Decoding the impact of the placebo response in clinical trials for chronic cough. ERJ Open Res 2024; 10:00335-2024. [PMID: 39469270 PMCID: PMC11514000 DOI: 10.1183/23120541.00335-2024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/18/2024] [Indexed: 10/30/2024] Open
Abstract
Chronic cough is a prevalent and challenging condition, with limited treatment options available. The interpretation of clinical trial results for antitussive drugs is complicated by the presence of the placebo response, which can confound outcomes and impede regulatory approval. This review aims to explore the impact of the placebo response on clinical trials for cough medications and elucidate the underlying mechanisms involved. The multifaceted nature of antitussive effects, including pharmacological, psychological/neurobiological and nonspecific effects, is discussed. Additionally, potential solutions to address the placebo response in future cough medication development, such as strategic study design, appropriate choice of end-points and meticulous patient selection, are proposed. More progress to harness this issue is urgently needed.
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Affiliation(s)
- Mengru Zhang
- Centre for Clinical Science, Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
- M. Zhang and B. Zhang contributed equally to this work as co-first authors
| | - Bangyu Zhang
- Clinical Research Center, Department of Pharmacy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
- M. Zhang and B. Zhang contributed equally to this work as co-first authors
| | - Alyn H. Morice
- Centre for Clinical Science, Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
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Seymour J, Mathers N. Placebo stimulates neuroplasticity in depression: implications for clinical practice and research. Front Psychiatry 2024; 14:1301143. [PMID: 38268561 PMCID: PMC10806142 DOI: 10.3389/fpsyt.2023.1301143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024] Open
Abstract
Neither psychological nor neuroscientific investigations have been able to fully explain the paradox that placebo is designed to be inert in randomized controlled trials (RCTs), yet appears to be effective in evaluations of clinical interventions in all fields of medicine and alternative medicine. This article develops the Neuroplasticity Placebo Theory, which posits that neuroplasticity in fronto-limbic areas is the unifying factor in placebo response (seen in RCTs) and placebo effect (seen in clinical interventions) where it is not intended to be inert. Depression is the disorder that has the highest placebo response of any medical condition and has the greatest potential for understanding how placebos work: recent developments in understanding of the pathophysiology of depression suggest that fronto-limbic areas are sensitized in depression which is associated with a particularly strong placebo phenomenon. An innovative linkage is made between diverse areas of the psychology and the translational psychiatry literature to provide supportive evidence for the Neuroplasticity Placebo Theory. This is underpinned by neuro-radiological evidence of fronto-limbic change in the placebo arm of antidepressant trials. If placebo stimulates neuroplasticity in fronto-limbic areas in conditions other than depression - and results in a partially active treatment in other areas of medicine - there are far reaching consequences for the day-to-day use of placebo in clinical practice, the future design of RCTs in all clinical conditions, and existing unwarranted assertions about the efficacy of antidepressant medications. If fronto-limbic neuroplasticity is the common denominator in designating placebo as a partially active treatment, the terms placebo effect and placebo response should be replaced by the single term "placebo treatment."
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Affiliation(s)
- Jeremy Seymour
- Retired Consultant Psychiatrist, Rotherham Doncaster and South Humber NHS Trust, Rotherham, United Kingdom
| | - Nigel Mathers
- Emeritus Professor, Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
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Herkes G, McGee C, Liebert A, Bicknell B, Isaac V, Kiat H, McLachlan CS. A novel transcranial photobiomodulation device to address motor signs of Parkinson's disease: a parallel randomised feasibility study. EClinicalMedicine 2023; 66:102338. [PMID: 38094162 PMCID: PMC10716000 DOI: 10.1016/j.eclinm.2023.102338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Parkinson's disease is a progressive neurological disease with limited treatment options. Animal models and a proof-of-concept case series have suggested that photobiomodulation may be an effective adjunct treatment for the symptoms of Parkinson's disease. The aim was to determine the safety and feasibility of transcranial photobiomodulation (tPBM) to reduce the motor signs of Parkinson's disease. METHODS In this double-blind, randomised, sham-controlled feasibility trial, patients (aged 59-85 years) with idiopathic Parkinson's disease were treated with a tPBM helmet for 12 weeks (72 treatments with either active or sham therapy; stage 1). Treatment was delivered in the participants' homes, monitored by internet video conferencing (Zoom). Stage 1 was followed by 12 weeks of no treatment for those on active therapy (active-to-no-treatment group), and 12 weeks of active treatment for those on sham (sham-to-active group), for participants who chose to continue (stage 2). The active helmet device delivered red and infrared light to the head for 24 min, 6 days per week. The primary endpoints were safety and motor signs, as assessed by a modified Movement Disorders Society revision of the Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS-III)-motor scale. This trial is registered with ANZCTR, ACTRN 12621001722886. FINDINGS Between Dec 6, 2021, and Aug 12, 2022, 20 participants were randomly allocated to each of the two groups (10 females plus 10 males per group). All participants in the active group and 18 in the sham group completed 12 weeks of treatment. 14 participants in the sham group chose to continue to active treatment and 12 completed the full 12 weeks of active treatment. Treatment was well tolerated and feasible to deliver, with only minor, temporary adverse events. Of the nine suspected adverse events that were identified, two minor reactions may have been attributable to the device in the sham-to-active group during the active treatment weeks of the trial. One participant experienced temporary leg weakness. A second participant reported decreased fine motor function in the right hand. Both participants continued the trial. The mean modified MDS-UPDRS-III scores for the sham-to-active group at baseline, after 12 weeks of sham treatment, and after 12 weeks of active treatment were 26.8 (sd 14.6), 20.4 (sd 12.8), and 12.2 (sd 8.9), respectively, and for the active-to-no-treatment group these values were 21.3 (sd 9.4), 16.5 (sd 9.4), and 15.3 (sd 10.8), respectively. There was no significant difference between groups at any assessment point. The mean difference between groups at baseline was 5.5 (95% confidence interval (CI) -2.4 to 13.4), after stage 1 was 3.9 (95% CI -3.5 to 11.3 and after stage 2 was -3.1 (95% CI 2.7 to -10.6). INTERPRETATION Our findings add to the evidence base to suggest that tPBM is a safe, tolerable, and feasible non-pharmaceutical adjunct therapy for Parkinson's disease. While future work is needed our results lay the foundations for an adequately powered randomised placebo-controlled clinical trial. FUNDING SYMBYX Pty Ltd.
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Affiliation(s)
- Geoffrey Herkes
- Department of Neurology, Sydney Adventist Hospital, Wahroonga, NSW, 2076, Australia
| | - Claire McGee
- Faculty of Health Sciences, Torrens University Australia, Sydney, NSW, 2000, Australia
| | - Ann Liebert
- Sydney Adventist Hospital, Wahroonga, NSW, 2076, Australia
- School of Medical Sciences, University of Sydney, Camperdown, NSW, 2050, Australia
- NICM Health Research Institute, University of Western Sydney, Westmead, NSW, 2145, Australia
| | - Brian Bicknell
- NICM Health Research Institute, University of Western Sydney, Westmead, NSW, 2145, Australia
| | - Vivian Isaac
- School of Allied Health, Exercise & Sports Sciences, Charles Sturt University, Albury, NSW, 2640, Australia
| | - Hosen Kiat
- Faculty of Medicine, Human and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
- College of Health and Medicine, Australian National University, Canberra, ACT, 2601, Australia
- Cardiac Health Institute, Sydney, NSW, 2010, Australia
- Centre for Healthy Futures, Torrens University Australia, Sydney, NSW, 2000, Australia
| | - Craig S. McLachlan
- Centre for Healthy Futures, Torrens University Australia, Sydney, NSW, 2000, Australia
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Rossettini G, Campaci F, Bialosky J, Huysmans E, Vase L, Carlino E. The Biology of Placebo and Nocebo Effects on Experimental and Chronic Pain: State of the Art. J Clin Med 2023; 12:4113. [PMID: 37373806 DOI: 10.3390/jcm12124113] [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: 05/22/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: In recent years, placebo and nocebo effects have been extensively documented in different medical conditions, including pain. The scientific literature has provided strong evidence of how the psychosocial context accompanying the treatment administration can influence the therapeutic outcome positively (placebo effects) or negatively (nocebo effects). (2) Methods: This state-of-the-art paper aims to provide an updated overview of placebo and nocebo effects on pain. (3) Results: The most common study designs, the psychological mechanisms, and neurobiological/genetic determinants of these phenomena are discussed, focusing on the differences between positive and negative context effects on pain in experimental settings on healthy volunteers and in clinical settings on chronic pain patients. Finally, the last section describes the implications for clinical and research practice to maximize the medical and scientific routine and correctly interpret the results of research studies on placebo and nocebo effects. (4) Conclusions: While studies on healthy participants seem consistent and provide a clear picture of how the brain reacts to the context, there are no unique results of the occurrence and magnitude of placebo and nocebo effects in chronic pain patients, mainly due to the heterogeneity of pain. This opens up the need for future studies on the topic.
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Affiliation(s)
| | - Francesco Campaci
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, 10124 Turin, Italy
| | - Joel Bialosky
- Department of Physical Therapy, University of Florida, Gainesville, FL 32611, USA
- Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL 32211, USA
| | - Eva Huysmans
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, 8000 Aarhus, Denmark
| | - Elisa Carlino
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, 10124 Turin, Italy
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Cai L, He C, Liu Y, Sun Y, He L, Baranova A. Inflammation and immunity connect hypertension with adverse COVID-19 outcomes. Front Genet 2022; 13:933148. [PMID: 36160003 PMCID: PMC9493274 DOI: 10.3389/fgene.2022.933148] [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: 04/30/2022] [Accepted: 07/08/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives: To explore the connection of hypertension and severe COVID-19 outcomes. Methods: A total of 68 observational studies recording mortality and/or general severity of COVID-19 were pooled for meta-analyses of the relationship of severe COVID-19 outcomes with hypertension as well as systolic and diastolic blood pressure. Genome-wide cross-trait meta-analysis (GWCTM) was performed to explore the genes linking between hypertension and COVID-19 severity. Results: The results of meta-analysis with the random effect model indicated that pooled risk ratios of hypertension on mortality and severity of COVID-19 were 1.80 [95% confidence interval (CI) 1.54-2.1] and 1.78 (95% confidence interval 1.56-2.04), respectively, although the apparent heterogeneity of the included studies was detected. In subgroup analysis, cohorts of severe and mild patients of COVID-19 assessed in Europe had a significant pooled weighted mean difference of 6.61 mmHg (95% CI 3.66-9.55) with no heterogeneity found (p = 0.26). The genes in the shared signature of hypertension and the COVID-19 severity were mostly expressed in lungs. Analysis of molecular networks commonly affected both by hypertension and by severe COVID-19 highlighted CCR1/CCR5 and IL10RB signaling, as well as Th1 and Th2 activation pathways, and also a potential for a shared regulation with multiple sclerosis. Conclusion: Hypertension is significantly associated with the severe course of COVID-19. Genetic variants within inflammation- and immunity-related genes may affect their expression in lungs and confer liability to both elevated blood pressure and to severe COVID-19.
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Affiliation(s)
- Lei Cai
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center for Genetics and Development, Shanghai Mental Health Center, Shanghai Jiaotong University, Shanghai, China
| | - Chuan He
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center for Genetics and Development, Shanghai Mental Health Center, Shanghai Jiaotong University, Shanghai, China
| | - Yonglin Liu
- Sanya Women and Children’s Hospital managed by Shanghai Children’s Medical Center, Sanya, China
| | - Yanlan Sun
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center for Genetics and Development, Shanghai Mental Health Center, Shanghai Jiaotong University, Shanghai, China
| | - Lin He
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center for Genetics and Development, Shanghai Mental Health Center, Shanghai Jiaotong University, Shanghai, China
- Shanghai Center for Women and Children’s Health, Shanghai, China
| | - Ancha Baranova
- School of Systems Biology, George Mason University, Fairfax, VA, United States
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Placebo effect in the treatment of non-small cell lung cancer: a meta-analysis. JOURNAL OF BIO-X RESEARCH 2022. [DOI: 10.1097/jbr.0000000000000123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lavazza C, Galli M, Abenavoli A, Maggiani A. Sham treatment effects in manual therapy trials on back pain patients: a systematic review and pairwise meta-analysis. BMJ Open 2021; 11:e045106. [PMID: 33947735 PMCID: PMC8098952 DOI: 10.1136/bmjopen-2020-045106] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To assess the effects and reliability of sham procedures in manual therapy (MT) trials in the treatment of back pain (BP) in order to provide methodological guidance for clinical trial development. DESIGN Systematic review and meta-analysis. METHODS AND ANALYSIS Different databases were screened up to 20 August 2020. Randomised controlled trials involving adults affected by BP (cervical and lumbar), acute or chronic, were included.Hand contact sham treatment (ST) was compared with different MT (physiotherapy, chiropractic, osteopathy, massage, kinesiology and reflexology) and to no treatment. Primary outcomes were BP improvement, success of blinding and adverse effect (AE). Secondary outcomes were number of drop-outs. Dichotomous outcomes were analysed using risk ratio (RR), continuous using mean difference (MD), 95% CIs. The minimal clinically important difference was 30 mm changes in pain score. RESULTS 24 trials were included involving 2019 participants. Very low evidence quality suggests clinically insignificant pain improvement in favour of MT compared with ST (MD 3.86, 95% CI 3.29 to 4.43) and no differences between ST and no treatment (MD -5.84, 95% CI -20.46 to 8.78).ST reliability shows a high percentage of correct detection by participants (ranged from 46.7% to 83.5%), spinal manipulation being the most recognised technique.Low quality of evidence suggests that AE and drop-out rates were similar between ST and MT (RR AE=0.84, 95% CI 0.55 to 1.28, RR drop-outs=0.98, 95% CI 0.77 to 1.25). A similar drop-out rate was reported for no treatment (RR=0.82, 95% 0.43 to 1.55). CONCLUSIONS MT does not seem to have clinically relevant effect compared with ST. Similar effects were found with no treatment. The heterogeneousness of sham MT studies and the very low quality of evidence render uncertain these review findings.Future trials should develop reliable kinds of ST, similar to active treatment, to ensure participant blinding and to guarantee a proper sample size for the reliable detection of clinically meaningful treatment effects. PROSPERO REGISTRATION NUMBER CRD42020198301.
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Özdemir V. A Placebogenomics/Nocebogenomics Challenge to Pharmacogenomics, Nutrigenomics, and Vaccinomics: Why Should We Rethink Association Study Designs? OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2021; 25:133-135. [PMID: 33513040 DOI: 10.1089/omi.2021.0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Vural Özdemir
- OMICS: A Journal of Integrative Biology, New Rochelle, New York, USA
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Özdemir V, Endrenyi L. Rethinking Clinical Trials and Personalized Medicine with Placebogenomics and Placebo Dose. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2020; 25:1-12. [PMID: 33305994 DOI: 10.1089/omi.2020.0208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pharmacogenomics, nutrigenomics, vaccinomics, and the nascent field of plant omics are examples of variability science. They are embedded within an overarching framework of personalized medicine. Across these public health specialties, the significance and biology of the placebo response have been historically neglected. A placebo is any substance such as a sugar pill administered in the guise of medication, but one that does not have pharmacological activity. Placebos do have clinical effects, however, that can be substantive in magnitude and vary markedly from person-to-person depending, for example, on the type of disease, symptoms, or clinical trial design. Research over the past several decades attests to a genuine neurobiological basis for placebo effects. All drugs have placebo components that contribute to their overall treatment effect. Placebos are used in clinical trials as control groups to ascertain the net pharmacological effect of a drug candidate. Not only less well known but also relevant to rational therapeutics and personalized medicine is the nocebo. A nocebo effect occurs when an inert substance is administered in a context that induces negative expectations, worsening patients' symptoms. With the COVID-19 pandemic, there are high public expectations for new vaccines and medicines to end the contagion, while at the same time antiscience, post-truth, and antivaccine movements are worrisomely on the rise. These social movements, changes in public health cultures, and conditioned behavioral responses can trigger both placebo and nocebo effects. Hence, in clinical trials, forecasting and explaining placebo and nocebo variability are more important than ever for robust science and personalized health care. Against this overarching context, this article provides (1) a brief history of placebo and (2) a discussion on biology, mechanisms, and variability of placebo effects, and (3) discusses three emerging new concepts: placebogenomics, nocebogenomics, and augmented placebo, that is, the notion of a "placebo dose." We conclude with a roadmap for placebogenomics, its synergies with the nascent field of social pharmacology, and the ways in which a new taxonomy of drug and placebo variability can be anticipated in the next decade.
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Affiliation(s)
- Vural Özdemir
- OMICS: A Journal of Integrative Biology, New Rochelle, New York, USA
| | - Laszlo Endrenyi
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, Canada
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