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Nasser A, Gomeni R, Wang Z, Hull JT, Busse GD, Melyan Z, Fava M, O'Neal W, Rubin J. The role of placebo response in the efficacy outcome assessment in viloxazine extended-release pivotal trials in paediatric subjects with attention-deficit/hyperactivity disorder. Br J Clin Pharmacol 2022; 88:4828-4838. [PMID: 35588245 PMCID: PMC9796605 DOI: 10.1111/bcp.15412] [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: 07/22/2021] [Revised: 04/22/2022] [Accepted: 05/06/2022] [Indexed: 01/01/2023] Open
Abstract
AIMS Four Phase 3 studies evaluated efficacy and safety of viloxazine extended-release in the treatment of attention-deficit/hyperactivity disorder (ADHD). The primary efficacy objective-change from baseline in ADHD Rating Scale-5 (ADHD-RS-5) Total score at end of study (EOS)-was not met in one of the studies (812P304). A band-pass analysis was performed to evaluate the impact of placebo response on the results. METHODS The distribution of placebo response at EOS of each trial was evaluated. The 2.5th and 97.5th percentiles of the distribution of ADHD-RS-5 Total score were used as boundaries for the band-pass analysis. An independent mixed model for repeated measures analysis was conducted for each trial using all eligible data (active and placebo) from the total and band-pass filtered populations. RESULTS The 2.5th and 97.5th percentiles at EOS were 3.5 and 53.5, respectively. Application of the band-pass filter (filtering out all subjects [active, n = 305 (32.1%) and placebo, n = 134 (33.5%)] of clinical sites with placebo scores <3.5 or >53.5) revealed statistically significant improvement at the primary endpoint (600-mg/d viloxazine ER vs. placebo) in Study 812P304 (mean [confidence interval] = 4.9537 [0.5405-9.3669]), previously masked by a high placebo response (mean [confidence interval] = 3.5756 [-0.3332-7.4844]). The outcome of the analysis indicated that the impact of the band-pass adjustment is greater when placebo response is higher. CONCLUSION This analysis indicated that a higher placebo response in Study 812P304 confounded the assessment of treatment effect. Application of the band-pass methodology confirmed the positive results of the 3 prior studies and the signal detection confounder in the fourth study.
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Affiliation(s)
- Azmi Nasser
- Supernus Pharmaceuticals, Inc.RockvilleMDUSA
| | | | - Zhao Wang
- Supernus Pharmaceuticals, Inc.RockvilleMDUSA
| | | | | | - Zare Melyan
- Formerly with Supernus Pharmaceuticals, Inc.RockvilleMDUSA
| | - Maurizio Fava
- Department of PsychiatryMassachusetts General HospitalBostonMAUSA
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Leung BMY, Srikanth P, Gracious B, Hatsu IE, Tost G, Conrad V, Johnstone JM, Arnold LE. Paediatric adverse event rating scale: a measure of safety or efficacy? Novel analysis from the MADDY study. Curr Med Res Opin 2022; 38:1595-1602. [PMID: 35770861 PMCID: PMC10370369 DOI: 10.1080/03007995.2022.2096333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/06/2022] [Accepted: 06/24/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The Pediatric Adverse Event Rating Scale (PAERS) measured adverse events of children aged 6-12 years with ADHD and emotional dysregulation in the Micronutrients for ADHD in Youth (MADDY) study, an eight week multi-site randomized clinical trial of a broad-spectrum multinutrient treatment. Treatment sensitivity of the PAERS was assessed by calculating the treatment difference in change of the item scores from baseline to end of the RCT. METHODS Principal component analysis retained 14 "adverse events" (out of 43 in the PAERS) that reflected ADHD symptoms and emotional dysregulation and was used to group the variables of interest. A combined score ranging from 0 to 5 was created based on symptom presence, functional impairment, and severity. Mean score change was calculated from baseline to week 8 by treatment (multinutrient vs placebo) with intention-to-treat and per-protocol samples. The study has been registered on clinicaltrials.gov as Micronutrients for ADHD in Youth (MADDY) Study, trial registration # NCT03252522 (https://clinicaltrials.gov/ct2/show/NCT03252522). RESULTS The 126 children in the ITT sample had a mean age of 9.8 (SD = 1.7), with majority (73%) male, and 72% diagnosed with ADHD prior to the study screening. Baseline presence of PAERS symptoms was similar between treatment groups: the highest proportion was ADHD symptoms, followed by Irritable symptoms. The micronutrient group showed a greater decrease (improvement) in the mean anxiety combined score than the placebo group with a between-group difference in change of -0.36 (95% CI: -0.67, -0.04; p = .03) with ITT data and -0.48 (95% CI: -0.81, -0.15; p = .005) with per-protocol (n = 93) data. CONCLUSION The multinutrient supplement did not result in more adverse events than placebo, suggesting it is a safe intervention. In addition to assessing actual adverse events, the PAERS may be a useful adjunct outcome measure for ADHD behaviors.
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Affiliation(s)
- Brenda M Y Leung
- Faculty of Health Sciences, University of Lethbridge, Alberta Canada
| | - Priya Srikanth
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Barbara Gracious
- Human Sciences, The Ohio State University, Columbus, OH, USA
- School of Public Health, Orange Park Medical Center, Orange Park, FL, USA
| | - Irene E Hatsu
- Department of Human Sciences, The Ohio State University, Columbus, OH, USA
| | - Gabriella Tost
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Valerie Conrad
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Jeanette M Johnstone
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - L Eugene Arnold
- Department of Psychiatry & Behavioral Health, The Ohio State University, Columbus, OH, USA
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Placebo and nocebo responses in randomised, controlled trials of medications for ADHD: a systematic review and meta-analysis. Mol Psychiatry 2022; 27:212-219. [PMID: 33972692 DOI: 10.1038/s41380-021-01134-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/26/2021] [Accepted: 04/14/2021] [Indexed: 11/09/2022]
Abstract
The nature and magnitude of placebo and nocebo responses to ADHD medications and the extent to which response to active medications and placebo are inter-correlated is unclear. To assess the magnitude of placebo and nocebo responses to ADHD and their association with active treatment response. We searched literature until June 26, 2019, for published/unpublished double-blind, randomised placebo-controlled trials (RCTs) of ADHD medication. Authors were contacted for additional data. We assessed placebo effects on efficacy and nocebo effects on tolerability using random effects meta-analysis. We assessed the association of study design and patient features with placebo/nocebo response. We analysed 128 RCTs (10,578 children/adolescents and 9175 adults) and found significant and heterogenous placebo effects for all efficacy outcomes, with no publication bias. The placebo effect was greatest for clinician compared with other raters. We found nocebo effects on tolerability outcomes. Efficacy outcomes from most raters showed significant positive correlations between the baseline to endpoint placebo effects and the baseline to endpoint drug effects. Placebo and nocebo effects did not differ among drugs. Baseline severity and type of rating scale influenced the findings. Shared non-specific factors influence response to both placebo and active medication. Although ADHD medications are superior to placebo, and placebo treatment in clinical practice is not feasible, clinicians should attempt to incorporate factors associated with placebo effects into clinical care. Future studies should explore how such effects influence response to medication treatment. Upon publication, data will be available in Mendeley Data: PROSPERO (CRD42019130292).
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Korfmacher AK, Hirsch O, Chavanon ML, Albrecht B, Christiansen H. Self-management training vs. neurofeedback interventions for attention deficit hyperactivity disorder: Results of a randomized controlled treatment study. Front Psychiatry 2022; 13:969351. [PMID: 36061275 PMCID: PMC9433654 DOI: 10.3389/fpsyt.2022.969351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Neurofeedback (NF) and self-management training (SMT) may be viable treatment options for patients with attention deficit hyperactivity disorder (ADHD) if they alleviate core symptoms, enhance the patients' self-concept and improve their quality of life (QoL). Aim of the current study is evaluating both interventions accordingly and to test whether specific improvements in core symptoms lead to more general improvements in self-concept and QoL. METHODS In a psychotherapeutic outpatient clinic in Germany, a total of N = 139 children with ADHD were screened for eligibility, of which 111 fulfilled inclusion criteria and participated in the study in accordance with the CONSORT 2010 statement. These were randomly assigned to NF vs. SMT interventions. Changes from pre- to post-intervention in core ADHD symptoms relying on parent and teacher reports (CONNERS 3) and objective tests (Qb-Test) as well as self-concept (interview with the children) and QoL assessments (using the KINDL-R self-report) were compared between patients receiving NF or SMT. RESULTS Significant improvements in ADHD symptoms were achieved similarly in both treatment groups, whilst QoL and self-concept improved after SMT only. CONCLUSION This treatment study provides further evidence that SMT and NF may reduce core symptoms, but SMT may also improve patients' self-concept and QoL and may thus in its current form be the favorable treatment option in naturalistic settings. However, several limitations of the current study implicate that further research is required before definitive conclusions and recommendations for clinical practice can be given. CLINICAL TRIAL REGISTRATION [www.clinicaltrials.gov], identifier [NCT01879644].
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Affiliation(s)
- Ann-Kathrin Korfmacher
- Clinical Child and Adolescent Psychology, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Oliver Hirsch
- Department of Psychology, FOM University of Applied Sciences, Siegen, Germany
| | - Mira-Lynn Chavanon
- Clinical Child and Adolescent Psychology, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Björn Albrecht
- Clinical Child and Adolescent Psychology, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Hanna Christiansen
- Clinical Child and Adolescent Psychology, Department of Psychology, Philipps-University Marburg, Marburg, Germany
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Castells X, Saez M, Barcheni M, Cunill R, Serrano D, López B, van Lissa CJ. Placebo Response and Its Predictors in Attention Deficit Hyperactivity Disorder: A Meta-Analysis and Comparison of Meta-Regression and MetaForest. Int J Neuropsychopharmacol 2021; 25:26-35. [PMID: 34355753 PMCID: PMC8756096 DOI: 10.1093/ijnp/pyab054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/13/2021] [Accepted: 08/05/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High placebo response in attention deficit hyperactivity disorder (ADHD) can reduce medication-placebo differences, jeopardizing the development of new medicines. This research aims to (1) determine placebo response in ADHD, (2) compare the accuracy of meta-regression and MetaForest in predicting placebo response, and (3) determine the covariates associated with placebo response. METHODS A systematic review with meta-analysis of randomized, placebo-controlled clinical trial investigating pharmacological interventions for ADHD was performed. Placebo response was defined as the change from baseline in ADHD symptom severity assessed according to the 18-item, clinician-rated, DSM-based rating scale. The effect of study design-, intervention-, and patient-related covariates in predicting placebo response was studied by means of meta-regression and MetaForest. RESULTS Ninety-four studies including 6614 patients randomized to placebo were analyzed. Overall, placebo response was -8.9 points, representing a 23.1% reduction in the severity of ADHD symptoms. Cross-validated accuracy metrics for meta-regression were R2 = 0.0012 and root mean squared error = 3.3219 for meta-regression and 0.0382 and 3.2599 for MetaForest. Placebo response among ADHD patients increased by 63% between 2001 and 2020 and was larger in the United States than in other regions of the world. CONCLUSIONS Strong placebo response was found in ADHD patients. Both meta-regression and MetaForest showed poor performance in predicting placebo response. ADHD symptom improvement with placebo has markedly increased over the last 2 decades and is greater in the United States than the rest of the world.
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Affiliation(s)
- Xavier Castells
- TransLab Research Group, Universitat de Girona, Girona, Spain,Department of Medical Sciences, Universitat de Girona, Girona, Spain,Economy Department; Research Group on Statistics, Econometrics and Health (GRECS), Universitat de Girona, Girona, Spain,Correspondence: Xavier Castells, MD, PhD, Department of Medical Sciences, Universitat de Girona, C/ Emili Grahit, 77, esc. B, 2n. Campus Centre. 17003 Girona, Spain ()
| | - Marc Saez
- Centre for Biomedical Research Network in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Maghie Barcheni
- Pharmacology, Toxicology and Therapeutics Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruth Cunill
- Parc Sanitari Sant Joan de Déu-Numància, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
| | - Domènec Serrano
- Department of Medical Sciences, Universitat de Girona, Girona, Spain,Economy Department; Research Group on Statistics, Econometrics and Health (GRECS), Universitat de Girona, Girona, Spain,Institut d’Assistència Sanitària, Girona, Spain
| | - Beatriz López
- Control and Intelligent Systems Engineering Research Group, Electrical; Electronic and Automatic Engineering Department, Universitat de Girona, Girona, Spain (Dr López)
| | - Caspar J van Lissa
- Department of Methodology and Statistics, Universiteit Utrecht, Utrecht, The Netherlands (Dr van Lissa)
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Faraone SV, Gomeni R, Hull JT, Busse GD, Melyan Z, Rubin J, Nasser A. Executive Function Outcome of Treatment with Viloxazine Extended-Release Capsules in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Post-Hoc Analysis of Four Randomized Clinical Trials. Paediatr Drugs 2021; 23:583-589. [PMID: 34523063 PMCID: PMC8563661 DOI: 10.1007/s40272-021-00470-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 01/22/2023]
Abstract
AIM The aim of this study was to evaluate the effect of viloxazine extended-release capsules (viloxazine ER; Qelbree™) on executive function deficits (EFDs) in pediatric subjects (6-17 years of age) with attention-deficit/hyperactivity disorder (ADHD). METHODS Data from four phase III placebo-controlled trials of 100-600 mg/day viloxazine ER (6-8 weeks of treatment) were used to evaluate the change from baseline (CFB) in the Conners 3rd Edition Parent Short Form-Executive Function (C3PS-EF) content scale T-score. Subjects were defined as EFD responders if they had C3PS-EF T-score > 70 at baseline and < 65 at end of study. ADHD symptoms were assessed with ADHD Rating Scale 5th Edition (ADHD-RS-5). Subjects were defined as ADHD symptom responders if they had a ≥ 50% reduction in CFB ADHD-RS-5 Total score at Week 6. The number needed to treat (NNT) and Cohen's d effect sizes were estimated for EFD and ADHD symptoms. RESULTS A total of 1154 subjects were included in the analysis. Statistically significant improvements in EFDs were observed with viloxazine ER versus placebo (p = 0.0002). There were 52.5% of EFD or ADHD symptom responders in the viloxazine ER treatment group and 35.4% in the placebo group (p < 0.0001). The NNT was 5.8. The Cohen's d effect size for EFD and ADHD symptoms was 0.31. CONCLUSION Consistent with the efficacy of viloxazine ER demonstrated in pivotal trials, viloxazine ER significantly reduced EFDs in subjects with ADHD. Moreover, a substantial proportion of subjects treated with viloxazine ER had large improvements in EFDs, ADHD symptoms, or both. CLINICAL TRIAL REGISTRATION NUMBERS NCT03247530, NCT03247517, NCT03247543, NCT03247556.
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Affiliation(s)
- Stephen V. Faraone
- Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY USA
| | | | - Joseph T. Hull
- Supernus Pharmaceuticals, Inc., 9715 Key West Ave, Rockville, MD 20850 USA
| | - Gregory D. Busse
- Supernus Pharmaceuticals, Inc., 9715 Key West Ave, Rockville, MD 20850 USA
| | - Zare Melyan
- Supernus Pharmaceuticals, Inc., 9715 Key West Ave, Rockville, MD 20850 USA
| | - Jonathan Rubin
- Supernus Pharmaceuticals, Inc., 9715 Key West Ave, Rockville, MD 20850 USA
| | - Azmi Nasser
- Supernus Pharmaceuticals, Inc., 9715 Key West Ave, Rockville, MD, 20850, USA.
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