1
|
Pericàs JM, Di Prospero NA, Anstee QM, Mesenbrinck P, Kjaer MS, Rivera-Esteban J, Koenig F, Sena E, Pais R, Manzano R, Genescà J, Tacke F, Ratziu V. Review article: The need for more efficient and patient-oriented drug development pathways in NASH-setting the scene for platform trials. Aliment Pharmacol Ther 2023; 57:948-961. [PMID: 36918740 DOI: 10.1111/apt.17456] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND AND AIMS Non-alcoholic steatohepatitis (NASH) constitutes a significant unmet medical need with a burgeoning field of clinical research and drug development. Platform trials (PT) might help accelerate drug development while lowering overall costs and creating a more patient-centric environment. This review provides a comprehensive and nuanced assessment of the NASH clinical development landscape. METHODS Narrative review and expert opinion with insight gained during the EU Patient-cEntric clinicAl tRial pLatforms (EU-PEARL) project. RESULTS Although NASH represents an opportunity to use adaptive trial designs, including master protocols for PT, there are barriers that might be encountered owing to distinct and sometimes opposing priorities held by these stakeholders and potential ways to overcome them. The following aspects are critical for the feasibility of a future PT in NASH: readiness of the drug pipeline, mainly from large drug companies, while there is not yet an FDA/EMA-approved treatment; the most suitable design (trial Phase and type of population, e.g., Phase 2b for non-cirrhotic NASH patients); the operational requirements such as the scope of the clinical network, the use of concurrent versus non-concurrent control arms, or the re-allocation of participants upon trial adaptations; the methodological appraisal (i.e. Bayesian vs. frequentist approach); patients' needs and patient-centred outcomes; main regulatory considerations and the funding and sustainability scenarios. CONCLUSIONS PT represent a promising avenue in NASH but there are a number of conundrums that need addressing. It is likely that before a global NASH PT becomes a reality, 'proof-of-platform' at a smaller scale needs to be provided.
Collapse
Affiliation(s)
- Juan M Pericàs
- Liver Unit, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Barcelona, Spain
| | | | - Quentin M Anstee
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Mesenbrinck
- Analytics Department, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Jesús Rivera-Esteban
- Liver Unit, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Barcelona, Spain
| | - Franz Koenig
- Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Elena Sena
- Liver Unit, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Barcelona, Spain
| | - Raluca Pais
- Department of Hepatology, Pitié-Salpetriere Hospital, University Paris 6, Paris, France
| | - Ramiro Manzano
- Liver Unit, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Barcelona, Spain
| | - Joan Genescà
- Liver Unit, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Barcelona, Spain
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vlad Ratziu
- Department of Hepatology, Pitié-Salpetriere Hospital, University Paris 6, Paris, France
| | | |
Collapse
|
2
|
Hanney SR, Straus SE, Holmes BJ. Saving millions of lives but some resources squandered: emerging lessons from health research system pandemic achievements and challenges. Health Res Policy Syst 2022; 20:99. [PMID: 36088365 PMCID: PMC9464102 DOI: 10.1186/s12961-022-00883-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
During the SARS-CoV-2 pandemic, astonishingly rapid research averted millions of deaths worldwide through new vaccines and repurposed and new drugs. Evidence use informed life-saving national policies including non-pharmaceutical interventions. Simultaneously, there was unprecedented waste, with many underpowered trials on the same drugs. We identified lessons from COVID-19 research responses by applying WHO's framework for research systems. It has four functions-governance, securing finance, capacity-building, and production and use of research-and nine components. Two linked questions focused the analysis. First, to what extent have achievements in knowledge production and evidence use built on existing structures and capacity in national health research systems? Second, did the features of such systems mitigate waste? We collated evidence on seven countries, Australia, Brazil, Canada, Germany, New Zealand, the United Kingdom and the United States, to identify examples of achievements and challenges.We used the data to develop lessons for each framework component. Research coordination, prioritization and expedited ethics approval contributed to rapid identification of new therapies, including dexamethasone in the United Kingdom and Brazil. Accelerated vaccines depended on extensive funding, especially through the Operation Warp Speed initiative in the United States, and new platforms created through long-term biomedical research capacity in the United Kingdom and, for messenger ribonucleic acid (mRNA) vaccines, in Canada, Germany and the United States. Research capacity embedded in the United Kingdom's healthcare system resulted in trial acceleration and waste avoidance. Faster publication of research saved lives, but raised challenges. Public/private collaborations made major contributions to vastly accelerating new products, available worldwide, though unequally. Effective developments of living (i.e. regularly updated) reviews and guidelines, especially in Australia and Canada, extended existing expertise in meeting users' needs. Despite complexities, effective national policy responses (less evident in Brazil, the United Kingdom and the United States) also saved lives by drawing on health research system features, including collaboration among politicians, civil servants and researchers; good communications; and willingness to use evidence. Comprehensive health research strategies contributed to success in research production in the United Kingdom and in evidence use by political leadership in New Zealand. In addition to waste, challenges included equity issues, public involvement and non-COVID research. We developed recommendations, but advocate studies of further countries.
Collapse
Affiliation(s)
- Stephen R Hanney
- Health Economics Research Group, Department of Health Sciences, Brunel University London, London, United Kingdom.
| | - Sharon E Straus
- St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Bev J Holmes
- Michael Smith Health Research BC, Vancouver, BC, Canada
| |
Collapse
|
3
|
Affiliation(s)
- Anand R Habib
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143-0119, USA
| | - Nathan C Lo
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
4
|
Olivier C, Ganache I, Demers-Payette O, Lochhead L, Pelaez S, de Guise M, Pomey MP. Patient and Citizen Participation in the Identification of Ethical Considerations Aiming to Address Uncertainty in the Evaluation of Promising Interventions in a Pandemic Context. FRONTIERS IN MEDICAL TECHNOLOGY 2021; 3:794003. [PMID: 35047973 PMCID: PMC8757856 DOI: 10.3389/fmedt.2021.794003] [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: 10/12/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Since the beginning of the COVID-19 pandemic, numerous studies have been conducted to identify interventions that could contribute to alleviating the burden it has caused. The Institut national d'excellence en santé et en services sociaux (INESSS) has played a key role in informing the government of Québec regarding the evaluation of specific pandemic-related interventions. This process took place in a context characterized by a sense of urgency to assess and recommend potential interventions that could save lives and reduce the effects of the disease on populations and healthcare systems, which increased the pressure on the regulatory agencies leading these evaluations. While some of the interventions examined were considered promising, results from COVID-19 studies often led to uncertainty regarding their efficacy or safety. Regulatory agencies evaluating the value of promising interventions thus face challenges in deciding whether these should be made available to the population, particularly when assessing their benefit-risk balance. To shed light on these challenges, we identified underlying ethical considerations that can influence such an assessment. A rapid literature review was conducted in February 2021, to identify the main challenges associated with the benefit-risk balance assessment of promising interventions. To reinforce our understanding of the underlying ethical considerations, we initiated a discussion among various social actors involved in critical thinking surrounding the evaluation of promising interventions, including ethicists, clinicians and researchers involved in clinical or public health practice, as well as patients and citizens. This discussion allowed us to create a space for exchange and mutual understanding among these various actors who contributed equally to the identification of ethical considerations. The knowledge and perspectives stemming from the scientific literature and those consulted were integrated in a common reflection on these ethical considerations. This allowed patients and citizens, directly affected by the evaluation of pandemic-related interventions and the resulting social choices, to contribute to the identification of the relevant ethical considerations. It also allowed for reflection on the responsibilities of the various actors involved in the development, evaluation, and distribution of promising interventions in a setting of urgency and uncertainty, such as that brought about by the COVID-19 pandemic.
Collapse
Affiliation(s)
- Catherine Olivier
- Institut national d'excellence en santé et services sociaux, Bureau - Méthodologies et éthique, Montréal, QC, Canada
- École de santé publique, Université de Montréal, Montréal, QC, Canada
| | - Isabelle Ganache
- Institut national d'excellence en santé et services sociaux, Bureau - Méthodologies et éthique, Montréal, QC, Canada
- École de santé publique, Université de Montréal, Montréal, QC, Canada
| | - Olivier Demers-Payette
- Institut national d'excellence en santé et services sociaux, Bureau - Méthodologies et éthique, Montréal, QC, Canada
| | - Louis Lochhead
- Institut national d'excellence en santé et services sociaux, Bureau - Méthodologies et éthique, Montréal, QC, Canada
- Centre d'excellence sur le partenariat avec les patients et le public, Montréal, QC, Canada
| | - Sandra Pelaez
- Institut national d'excellence en santé et services sociaux, Bureau - Méthodologies et éthique, Montréal, QC, Canada
- École de kinésiologie et des sciences de l'activité physique, Université de Montréal, Montréal, QC, Canada
| | - Michèle de Guise
- Institut national d'excellence en santé et services sociaux, Bureau - Méthodologies et éthique, Montréal, QC, Canada
| | - Marie-Pascale Pomey
- Institut national d'excellence en santé et services sociaux, Bureau - Méthodologies et éthique, Montréal, QC, Canada
- École de santé publique, Université de Montréal, Montréal, QC, Canada
- Centre d'excellence sur le partenariat avec les patients et le public, Montréal, QC, Canada
- Centre de recherche du Centre Hospitalier, Université de Montréal, Montréal, QC, Canada
| |
Collapse
|
5
|
Bunning B, Hedlin H, Purington N, Sundaram V, Kapphahn K, Weng Y, Cunanan K, Maldonado Y, Singh U, Khosla C, O'Hara R, Nicolls M, Springman E, Parsonnet J, Rogers A, Levitt J, Desai M. The COVID-19 Outpatient Pragmatic Platform Study (COPPS): Study design of a multi-center pragmatic platform trial. Contemp Clin Trials 2021; 108:106509. [PMID: 34274494 PMCID: PMC8282451 DOI: 10.1016/j.cct.2021.106509] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 11/20/2022]
Abstract
More than 3000 clinical trials related to COVID-19 have been registered through clinicaltrials.gov. With so many trials, there is a risk that many will be inconclusive due to being underpowered or due to an inability to recruit patients. At academic medical centers, multiple trials are competing for the same resources; the success of one may come at the expense of another. The COVID-19 Outpatient Pragmatic Protocol Study (COPPS) is a flexible phase 2, multi-site, randomized, blinded trial based at Stanford University designed to overcome these issues by simultaneously evaluating multiple COVID-19 treatments in the outpatient setting in one common platform with shared controls. This approach reduces the overall number of patients required for statistical power, while improving the likelihood that any enrolled patient receives active treatment. The platform study has two main domains designed to evaluate COVID-19 treatments by assessing their ability to reduce viral shedding (Viral Domain), measured with self-collected nasal swabs, or improve clinical outcomes (Clinical Domain), measured through self-reported symptomology data. Data are collected on both domains for all participants enrolled. Participants are followed over a 28-day period. COPPS has the advantage of pragmatism created around its workflow that is also appealing to potential participants because of a lower probability of inactive treatment. At the conclusion of this clinical trial we expect to have identified potentially effective therapeutic strategy/ies for treating COVID-19 in the outpatient setting, which will have a transformative impact on medicine and public health.
Collapse
Affiliation(s)
- Bryan Bunning
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Haley Hedlin
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Natasha Purington
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Vandana Sundaram
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Kristopher Kapphahn
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Yingjie Weng
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Kristen Cunanan
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Yvonne Maldonado
- Divison of Infectious Diseases, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Upinder Singh
- Divison of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Chaitan Khosla
- Department of Chemical Engineering, Stanford Unviersity, Stanford, CA, USA; Stanford ChEM-H, Stanford University, Stanford, CA, USA
| | - Ruth O'Hara
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Mark Nicolls
- Divison of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Julie Parsonnet
- Divison of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA, USA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Angela Rogers
- Divison of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Joseph Levitt
- Divison of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, USA.
| |
Collapse
|