Success, Failure, and Transparency in Biomarker-Based Drug Development

The comprehensive, customized, cost-effective approach (CCCAP) to prevention of dementia

The Food and Drug Administration's controversial approval of aducanumab has sounded a wake-up call. Is the search of a silver bullet to stop Alzheimer's disease the only way to prevent dementia? The controversies and costs have opened minds to alternative approaches, the most promising being that we are already preventing some dementias in some high-income countries but do not know yet how. This article proposes one way. It requires that the approach be (1) comprehensive, taking into account all relevant environmental, socioeconomic, and individual risk and protective factors; (2) customized, because contributing factors vary by region and among individuals; and (3) cost effective, implemented in actionable units. Savings of scale could occur by preventing stroke, heart disease, and dementia together. They share the same risk factors and pose risks for each other. Brain health could be the unifying, motivating, and actionable key to health, productivity, and well-being.

Gaining Efficiency in Clinical Trials With Cardiac Biomarkers: JACC Review Topic of the Week

The momentum of cardiovascular drug development has slowed dramatically. Use of validated cardiac biomarkers in clinical trials could accelerate development of much-needed therapies, but biomarkers have been used less for cardiovascular drug development than in therapeutic areas such as oncology. Moreover, there are inconsistences in biomarker use in clinical trials, such as sample type, collection times, analytical methods, and storage for future research. With these needs in mind, participants in a Cardiac Safety Research Consortium Think Tank proposed the development of international guidance in this area, together with improved quality assurance and analytical methods, to determine what biomarkers can reliably show. Participants recommended the development of systematic methods for sample collection, and the archiving of samples in all cardiovascular clinical trials (including creation of a biobank or repository). The academic and regulatory communities also agreed to work together to ensure that published information is fully and clearly expressed.

Dementia: Paradigm shifting into high gear

Redressing the rising threat of dementia demands not only an increase, but a diversification of efforts. We need new approaches, trials, and partners. We cannot afford to continue to only round up the usual suspects, β amyloid, and tau and try to stop them with a single drug "silver bullet". Dementia of late onset is not a disease, but an amalgam of interactive pathologies on the shifting background of aging, requiring multimodal targeting. Cerebrovascular diseases coexist and coact with all major neurodegenerative pathologies, increasing two-fold the likelihood that they will manifest clinically. Cerebrovascular diseases need to be controlled, to give antidegenerative drugs a chance to succeed. This calls for new types of trials and designs. Stroke doubles the chances of developing dementia and decreases in stroke incidence correlate with decreases in dementia. Ninety percent of strokes are potentially preventable and so are a proportion of dementias. The stroke and dementia communities need to partner and complement the search for silver bullets with the golden opportunity of doing something now.

Assessment of the Role of Niacin in Managing Cardiovascular Disease Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Niacin remains a therapeutic option for patients with cardiovascular disease, but recent studies have called into question the effectiveness of other drugs that increase high-density lipoprotein cholesterol levels.

OBJECTIVE

To systematically review and evaluate the evidence supporting current US Food and Drug Administration-approved uses of niacin in cardiovascular disease prevention settings.

DATA SOURCES

MEDLINE, Embase, Cochrane Controlled Clinical Trial Register (Central), ClinicalTrials.gov, and TrialResults-center, from database inception to October 2017.

STUDY SELECTION

The systematic review included clinical trials involving niacin as a treatment for cardiovascular disease. The meta-analysis included randomized clinical trials reporting niacin's effect, as exposure, on at least 1 long-term cardiovascular disease outcome.

DATA EXTRACTION AND SYNTHESIS

Aggregate study-level data were extracted between November 2017 and January 2018 by 3 independent reviewers, and the analysis was performed in February 2018. Inverse-variance weighted methods were used to produce pooled risk ratios using random-effects models for between-study heterogeneity. Random effects-weighted metaregression analysis was used to assess the association of change in high-density lipoprotein cholesterol levels with the log risk ratio of the pooled results.

MAIN OUTCOMES AND MEASURES

Cardiovascular disease, coronary heart disease mortality, and other cardiovascular events, including acute coronary syndrome, fatal and nonfatal stroke, revascularization, and major adverse cardiac events.

RESULTS

Of 119 clinical trials, 17 documented niacin's effect on at least 1 cardiovascular disease outcome. The meta-analysis included 35 760 patients with histories of cardiovascular disease or dyslipidemia. Cumulative evidence found no preventive association of niacin with cardiovascular outcomes in secondary prevention. Stratified meta-analysis showed an association of niacin monotherapy with reduction of some cardiovascular events among patients without statin treatment (acute coronary syndrome: relative risk, 0.74; 95% CI, 0.58-0.96; stroke: relative risk, 0.74; 95% CI, 0.59-0.94; revascularization: relative risk, 0.51; 95% CI, 0.37-0.72). These results were mainly derived from 2 trials conducted in the 1970s and 1980s.

CONCLUSIONS AND RELEVANCE

Niacin may have some use in lipid control for secondary prevention as monotherapy, perhaps in patients intolerant to statins, but evidence is from older studies on a population potentially not representative of current-day patients.