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Bertelsen VM, Tranberg M, Petersen LK, Booth B, Bor P. Improving diagnostic of cervical dysplasia among postmenopausal women aged ≥50 years using local vaginal oestrogen treatment prior to colposcopy: study protocol for a multicentre randomised controlled trial (the IDEAL study). BMJ Open 2024; 14:e082833. [PMID: 38910002 DOI: 10.1136/bmjopen-2023-082833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
INTRODUCTION Colposcopy is the most important diagnostic tool to detect cervical precancerous lesions and thereby prevention of cervical cancer. Due to age-dependent changes of the cervix, colposcopy is challenging in postmenopausal women, as the majority will have a non-visible transformation zone, resulting in increased risk of missing disease, a diagnostic cone biopsy and prolonged follow-up with repeated colposcopies. This study will be among the first to investigate, if treatment with vaginal oestrogen prior to colposcopy will improve the colposcopy performance, to ensure accurate and timely diagnosis of precancerous cervical lesions among postmenopausal women. METHODS AND ANALYSIS A randomised blinded controlled multicentre study. Enrolment will be performed at gynaecology departments in Central Denmark Region and Region of Southern Denmark. A total of 150 postmenopausal women aged ≥50 years referred for colposcopy due to abnormal cervical screening results will be randomised 1:1 to either pretreatment with vaginal application of Vagifem 30 µg or placebo once a day for 14 days prior to colposcopy. The primary outcome will be to compare the percentage of women in the two groups with a visible transformation zone at colposcopy, and biopsies representative of the transformation zone. Secondary outcomes will be the proportion of detected cervical intraepithelial neoplasia grade 2 or higher in the cervical biopsies; the proportion of diagnostics cone biopsies; the patients' report on possible side effects and compliance to the pretreatment. ETHICS AND DISSEMINATION The study has been approved by the Central Denmark Region Committee on Biomedical Research Ethics (1-10-72-34-22), the Central Denmark Regions' Research Unit (1-16-02-72-22) and The Danish Health Authority (Danish Medicine Agency; 2022015030). The study's EudraCT number is (1-23-456; 2022-000269-42) and it is registered on www. CLINICALTRIALS gov. The local Good Clinical Practice (GCP) unit will supervise and monitor the study closely before, during and after the study period. Findings will be disseminated in peer-reviewed scientific journals and presented in relevant conferences. TRIAL REGISTRATION NUMBER NCT05283421.
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Affiliation(s)
- Vibe Munk Bertelsen
- Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark
- University Research Clinic for Cancer Screening and Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Tranberg
- University Research Clinic for Cancer Screening and Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Berit Booth
- Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark
- Department of Gynecology and Obstetrics, Odense University, Odense, Denmark
| | - Pinar Bor
- Department of Gynecology and Obstetrics, Aarhus University, Aarhus, Denmark
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Argotti U, Leyens L, Lisbona C, López P, Alonso-Orgaz S, Nevado A, Cozzi V. Comparison of the Latin America Regulation Landscape and International Reference Health Authorities to Hasten Drug Registration and Clinical Research Applications. Ther Innov Regul Sci 2023; 57:1287-1297. [PMID: 37682461 PMCID: PMC10579156 DOI: 10.1007/s43441-023-00565-7] [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: 01/26/2023] [Accepted: 07/28/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Promptly providing new drugs to fulfill unmet medical needs requires changes in drug development and registration processes. Health Authorities (HAs) considered as reference due to their experience and acknowledgement (Food and Drug Administration [FDA] among others) already consider innovative clinical trial (CT) designs and flexible approval procedures, but Latin America (LATAM) regulations are still far. A comparison was performed to identify gaps. MATERIALS AND METHODS CT requirements for drug Marketing Authorization Application (MAA) and CT approval regulations were compared between LATAM and reference HAs (FDA/European Medicines Agency [EMA]/Health-Canada/Swissmedic/Therapeutic Goods Administration [TGA]/Pharmaceuticals and Medical Devices Agency [PMDA]), as of August 2022. Procedure included reference HAs regulations review, item selection, identification in LATAM regulations, and International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines (ICH-E6[R2]/ICH-E8[R1]) implementation revision. RESULTS For MAA, specific application requirements or ICH guideline M4(R4) on common technical document (CTD) adoption are generally stated, and phase-I/III performance is mandatory (explicitly/implicitly). Faster patient access procedures are infrequent: Priority-drug programs, conditional authorizations, or expedited procedures are scarce or non-existent. Regulatory reliance procedures are adopted through different pathways. Regarding CT approval, innovative/complex CT designs are not prohibited but usually omitted. Some countries implemented adapted CT conducting during the COVID-19 pandemic. Early scientific advice meetings (HA-sponsor) are occasionally considered. Most countries are not formally ICH-joined. CONCLUSIONS LATAM regulations must adapt to new regulatory standards (FDA/EMA/ICH) through implementation of frequent updates, reliance/expedited procedures, early HA-sponsor interactions, innovative/complex CTs, mandatory phase-III reaching elimination, and decentralized elements for CT conducting.
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Affiliation(s)
- Urimara Argotti
- International Regulatory Policy Department, Latin America Productos Roche, S.A. de C.V., Mexico City, Mexico
| | - Lada Leyens
- Product Development Regulatory, F. Hoffmann-La Roche AG, Basel, Switzerland
| | | | - Pilar López
- Medical Writing Department, LIDESEC S.L, Madrid, Spain
| | | | - Angel Nevado
- Medical Writing Department, LIDESEC S.L, Madrid, Spain
| | - Virginia Cozzi
- Medical Affairs Department, Roche Central America, Venezuela, and the Caribbean, Heredia, Costa Rica.
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Cho NS, Wong WK, Nghiemphu PL, Cloughesy TF, Ellingson BM. The Future Glioblastoma Clinical Trials Landscape: Early Phase 0, Window of Opportunity, and Adaptive Phase I-III Studies. Curr Oncol Rep 2023; 25:1047-1055. [PMID: 37402043 PMCID: PMC10474988 DOI: 10.1007/s11912-023-01433-1] [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] [Accepted: 05/03/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE OF REVIEW Innovative clinical trial designs for glioblastoma (GBM) are needed to expedite drug discovery. Phase 0, window of opportunity, and adaptive designs have been proposed, but their advanced methodologies and underlying biostatistics are not widely known. This review summarizes phase 0, window of opportunity, and adaptive phase I-III clinical trial designs in GBM tailored to physicians. RECENT FINDINGS Phase 0, window of opportunity, and adaptive trials are now being implemented for GBM. These trials can remove ineffective therapies earlier during drug development and improve trial efficiency. There are two ongoing adaptive platform trials: GBM Adaptive Global Innovative Learning Environment (GBM AGILE) and the INdividualized Screening trial of Innovative GBM Therapy (INSIGhT). The future clinical trials landscape in GBM will increasingly involve phase 0, window of opportunity, and adaptive phase I-III studies. Continued collaboration between physicians and biostatisticians will be critical for implementing these trial designs.
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Affiliation(s)
- Nicholas S Cho
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, 924 Westwood Blvd., Suite 615, Los Angeles, CA, 90024, USA
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Bioengineering, Henry Samueli School of Engineering and Applied Science, University of California Los Angeles, Los Angeles, CA, USA
- Medical Scientist Training Program, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Weng Kee Wong
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Phioanh L Nghiemphu
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Timothy F Cloughesy
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, 924 Westwood Blvd., Suite 615, Los Angeles, CA, 90024, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Bioengineering, Henry Samueli School of Engineering and Applied Science, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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Carraça EV, Rodrigues B, Franco S, Nobre I, Jerónimo F, Ilharco V, Gabriel F, Ribeiro L, Palmeira AL, Silva MN. Promoting physical activity through supervised vs motivational behavior change interventions in breast cancer survivors on aromatase inhibitors (PAC-WOMAN): protocol for a 3-arm pragmatic randomized controlled trial. BMC Cancer 2023; 23:632. [PMID: 37407950 DOI: 10.1186/s12885-023-11137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Aromatase inhibitors (AI) are frequently used to treat hormone-receptor-positive breast cancer, but they have multiple adverse effects (e.g., osteoporosis, arthralgia), resulting in premature therapy discontinuation/switch. Physical activity (PA) can attenuate these negative effects and improve quality of life (QoL). However, most cancer survivors fail to perform/sustain adequate PA levels, especially in the long-term. Theory-based interventions, using evidence-based behavior change techniques, aimed at promoting long-term behavior change in breast cancer survivors are effective, but remain scarce and fail to promote self-regulatory skills and better-quality motivations associated with sustained PA adoption. This paper describes the design of the PAC-WOMAN trial, which will test the long-term effectiveness and cost-effectiveness of two state of the art, group-based interventions encouraging sustained changes in PA, sedentary behavior, and QoL. Additional aims include examining the impact of both interventions on secondary outcomes (e.g., body composition, physical function), and key moderators/mediators of short and long-term changes in primary outcomes. METHODS A 3-arm pragmatic randomized controlled trial, involving a 4-month intervention and a 12-month follow-up, will be implemented, in a real exercise setting, to compare: 1) brief PA counseling/motivational intervention; 2) structured exercise program vs. waiting-list control group. Study recruitment goal is 122 hormone-receptor-positive breast cancer survivors (stage I-III), on AI therapy (post-primary treatment completion) ≥ 1 month, ECOG 0-1. Outcome measures will be obtained at baseline, 4 months (i.e., post-intervention), 10 and 16 months. Process evaluation, analyzing implementation determinants, will also be conducted. DISCUSSION PAC-WOMAN is expected to have a relevant impact on participants PA and QoL and provide insights for the improvement of interventions designed to promote sustained adherence to active lifestyle behaviors, facilitating its translation to community settings. TRIAL REGISTRATION April 20, 2023 - NCT05860621. April 21, 2023 - https://doi.org/10.17605/OSF.IO/ZAQ9N April 27, 2023 - UMIN000050945.
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Affiliation(s)
- Eliana V Carraça
- Centro de Investigação Em Educação Física, Desporto, Saúde e Exercício (CIDEFES), Universidade Lusófona, Campo Grande 376, Lisboa, 1749-024, Portugal.
| | - Bruno Rodrigues
- CIAFEL, Faculdade de Desporto, Universidade do Porto, Porto, Portugal
- Programa Nacional Para a Promoção da Atividade Física, Direção-Geral Saúde, Portugal
| | - Sofia Franco
- Centro de Investigação Em Educação Física, Desporto, Saúde e Exercício (CIDEFES), Universidade Lusófona, Campo Grande 376, Lisboa, 1749-024, Portugal
| | - Inês Nobre
- Faculdade de Motricidade Humana, Universidade de Lisboa, Cruz Quebrada, Lisboa, Portugal
| | - Flávio Jerónimo
- Centro de Investigação Em Educação Física, Desporto, Saúde e Exercício (CIDEFES), Universidade Lusófona, Campo Grande 376, Lisboa, 1749-024, Portugal
| | - Vítor Ilharco
- Centro de Investigação Em Educação Física, Desporto, Saúde e Exercício (CIDEFES), Universidade Lusófona, Campo Grande 376, Lisboa, 1749-024, Portugal
| | - Fernanda Gabriel
- Centro Hospitalar Universitário Lisboa Norte - Hospital de Santa Maria, Lisboa, Portugal
| | - Leonor Ribeiro
- Centro Hospitalar Universitário Lisboa Norte - Hospital de Santa Maria, Lisboa, Portugal
| | - António L Palmeira
- Centro de Investigação Em Educação Física, Desporto, Saúde e Exercício (CIDEFES), Universidade Lusófona, Campo Grande 376, Lisboa, 1749-024, Portugal
| | - Marlene N Silva
- Centro de Investigação Em Educação Física, Desporto, Saúde e Exercício (CIDEFES), Universidade Lusófona, Campo Grande 376, Lisboa, 1749-024, Portugal
- Programa Nacional Para a Promoção da Atividade Física, Direção-Geral Saúde, Portugal
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Ma S, McDermott MP. Adaptive dose-response studies to establish proof-of-concept in learning-phase clinical trials. Biom J 2021; 64:146-164. [PMID: 34605043 DOI: 10.1002/bimj.202100044] [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: 02/06/2021] [Revised: 07/29/2021] [Accepted: 08/31/2021] [Indexed: 11/07/2022]
Abstract
In learning-phase clinical trials in drug development, adaptive designs can be efficient and highly informative when used appropriately. In this article, we extend the multiple comparison procedures with modeling techniques (MCP-Mod) procedure with generalized multiple contrast tests (GMCTs) to two-stage adaptive designs for establishing proof-of-concept. The results of an interim analysis of first-stage data are used to adapt the candidate dose-response models and the dosages studied in the second stage. GMCTs are used in both stages to obtain stage-wise p -values, which are then combined to determine an overall p -value. An alternative approach is also considered that combines the t -statistics across stages, employing the conditional rejection probability principle to preserve the Type I error probability. Simulation studies demonstrate that the adaptive designs are advantageous compared to the corresponding tests in a nonadaptive design if the selection of the candidate set of dose-response models is not well informed by evidence from preclinical and early-phase studies.
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Affiliation(s)
- Shiyang Ma
- Department of Biostatistics, Columbia University, New York, NY, USA
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
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Sverdlov O, Ryeznik Y, Wong WK. Opportunity for efficiency in clinical development: An overview of adaptive clinical trial designs and innovative machine learning tools, with examples from the cardiovascular field. Contemp Clin Trials 2021; 105:106397. [PMID: 33845209 DOI: 10.1016/j.cct.2021.106397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/28/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022]
Abstract
Modern data analysis tools and statistical modeling techniques are increasingly used in clinical research to improve diagnosis, estimate disease progression and predict treatment outcomes. What seems less emphasized is the importance of the study design, which can have a serious impact on the study cost, time and statistical efficiency. This paper provides an overview of different types of adaptive designs in clinical trials and their applications to cardiovascular trials. We highlight recent proliferation of work on adaptive designs over the past two decades, including some recent regulatory guidelines on complex trial designs and master protocols. We also describe the increasing role of machine learning and use of metaheuristics to construct increasingly complex adaptive designs or to identify interesting features for improved predictions and classifications.
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Affiliation(s)
- Oleksandr Sverdlov
- Early Development Biostatistics, Novartis Pharmaceuticals Corporation, USA.
| | - Yevgen Ryeznik
- Department of Pharmaceutical Biosciences, Uppsala University, Sweden
| | - Weng Kee Wong
- Department of Biostatistics, University of California Los Angeles, USA
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Arora A, Nain P, Kumari R, Kaur J. Major Causes Associated with Clinical Trials Failure and Selective Strategies to Reduce these Consequences: A Review. ARCHIVES OF PHARMACY PRACTICE 2021. [DOI: 10.51847/yjqdk2wtgx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Burnett T, Mozgunov P, Pallmann P, Villar SS, Wheeler GM, Jaki T. Adding flexibility to clinical trial designs: an example-based guide to the practical use of adaptive designs. BMC Med 2020; 18:352. [PMID: 33208155 PMCID: PMC7677786 DOI: 10.1186/s12916-020-01808-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
Adaptive designs for clinical trials permit alterations to a study in response to accumulating data in order to make trials more flexible, ethical, and efficient. These benefits are achieved while preserving the integrity and validity of the trial, through the pre-specification and proper adjustment for the possible alterations during the course of the trial. Despite much research in the statistical literature highlighting the potential advantages of adaptive designs over traditional fixed designs, the uptake of such methods in clinical research has been slow. One major reason for this is that different adaptations to trial designs, as well as their advantages and limitations, remain unfamiliar to large parts of the clinical community. The aim of this paper is to clarify where adaptive designs can be used to address specific questions of scientific interest; we introduce the main features of adaptive designs and commonly used terminology, highlighting their utility and pitfalls, and illustrate their use through case studies of adaptive trials ranging from early-phase dose escalation to confirmatory phase III studies.
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Affiliation(s)
- Thomas Burnett
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Pavel Mozgunov
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Sofia S. Villar
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
| | - Graham M. Wheeler
- Cancer Research UK & UCL Cancer Trials Centre, University College London, 90 Tottenham Court Road, London, W1T 4TJ UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
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Tritschler T, Mathieu ME, Skeith L, Rodger M, Middeldorp S, Brighton T, Sandset PM, Kahn SR, Angus DC, Blondon M, Bonten MJ, Cattaneo M, Cushman M, Derde LPG, DeSancho MT, Diehl JL, Goligher E, Jilma B, Jüni P, Lawler PR, Marietta M, Marshall JC, McArthur C, Miranda CH, Mirault T, Morici N, Perepu U, Schörgenhofer C, Sholzberg M, Spyropoulos AC, Webb SA, Zarychanski R, Zuily S, Le Gal G. Anticoagulant interventions in hospitalized patients with COVID-19: A scoping review of randomized controlled trials and call for international collaboration. J Thromb Haemost 2020; 18:2958-2967. [PMID: 32888372 PMCID: PMC9906402 DOI: 10.1111/jth.15094] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/06/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Coronavirus disease (COVID-19) is associated with a high incidence of thrombosis and mortality despite standard anticoagulant thromboprophylaxis. There is equipoise regarding the optimal dose of anticoagulant intervention in hospitalized patients with COVID-19 and consequently, immediate answers from high-quality randomized trials are needed. METHODS The World Health Organization's International Clinical Trials Registry Platform was searched on June 17, 2020 for randomized controlled trials comparing increased dose to standard dose anticoagulant interventions in hospitalized COVID-19 patients. Two authors independently screened the full records for eligibility and extracted data in duplicate. RESULTS A total of 20 trials were included in the review. All trials are open label, 5 trials use an adaptive design, 1 trial uses a factorial design, 2 trials combine multi-arm parallel group and factorial designs in flexible platform trials, and at least 15 trials have multiple study sites. With individual target sample sizes ranging from 30 to 3000 participants, the pooled sample size of all included trials is 12 568 participants. Two trials include only intensive care unit patients, and 10 trials base patient eligibility on elevated D-dimer levels. Therapeutic intensity anticoagulation is evaluated in 14 trials. All-cause mortality is part of the primary outcome in 14 trials. DISCUSSION Several trials evaluate different dose regimens of anticoagulant interventions in hospitalized patients with COVID-19. Because these trials compete for sites and study participants, a collaborative effort is needed to complete trials faster, conduct pooled analyses and bring effective interventions to patients more quickly.
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Affiliation(s)
- Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie-Eve Mathieu
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Leslie Skeith
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marc Rodger
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Timothy Brighton
- Department of Haematology, New South Wales Health Pathology Randwick, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
- Divisions of Internal Medicine and Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Derek C Angus
- University of Pittsburgh and UPMC Health System, Pittsburgh, PA, USA
| | - Marc Blondon
- Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland
| | - Marc J Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marco Cattaneo
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Mary Cushman
- Departments of Medicine and Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Lennie P G Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Jean-Luc Diehl
- Service de Médecine Intensive - Réanimation, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, Paris, France
| | - Ewan Goligher
- Interdivisional Department of Critical Care, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Marco Marietta
- Dipartimento Oncologia ed Ematologia, Azienda Ospedaliero-Universitaria di Modena, Ospedale Policlinico, Modena, Italy
| | - John C Marshall
- Department of Critical Care Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Colin McArthur
- Auckland City Hospital, Intensive Care, Auckland, New Zealand
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, Brazil
| | - Tristan Mirault
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, Paris, France
- PARCC, INSERM U970, Paris, France
- Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Usha Perepu
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Michelle Sholzberg
- St. Michael's Hospital and Departments of Medicine, and Laboratory Medicine and Pathobiology, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - Alex C Spyropoulos
- Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA
| | - Steve A Webb
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ryan Zarychanski
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Cancer Care Manitoba, Research Institute of Oncology and Haematology, Winnipeg, MB, Canada
| | - Stéphane Zuily
- Vascular Medicine Division and Regional Competence Center for Marfan Syndrome, Inserm, DCAC and CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Adaptive trial designs for spinal cord injury clinical trials directed to the central nervous system. Spinal Cord 2020; 58:1235-1248. [DOI: 10.1038/s41393-020-00547-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 02/08/2023]
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Dimairo M, Pallmann P, Wason J, Todd S, Jaki T, Julious SA, Mander AP, Weir CJ, Koenig F, Walton MK, Nicholl JP, Coates E, Biggs K, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. The adaptive designs CONSORT extension (ACE) statement: a checklist with explanation and elaboration guideline for reporting randomised trials that use an adaptive design. Trials 2020; 21:528. [PMID: 32546273 PMCID: PMC7298968 DOI: 10.1186/s13063-020-04334-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Adaptive designs (ADs) allow pre-planned changes to an ongoing trial without compromising the validity of conclusions and it is essential to distinguish pre-planned from unplanned changes that may also occur. The reporting of ADs in randomised trials is inconsistent and needs improving. Incompletely reported AD randomised trials are difficult to reproduce and are hard to interpret and synthesise. This consequently hampers their ability to inform practice as well as future research and contributes to research waste. Better transparency and adequate reporting will enable the potential benefits of ADs to be realised.This extension to the Consolidated Standards Of Reporting Trials (CONSORT) 2010 statement was developed to enhance the reporting of randomised AD clinical trials. We developed an Adaptive designs CONSORT Extension (ACE) guideline through a two-stage Delphi process with input from multidisciplinary key stakeholders in clinical trials research in the public and private sectors from 21 countries, followed by a consensus meeting. Members of the CONSORT Group were involved during the development process.The paper presents the ACE checklists for AD randomised trial reports and abstracts, as well as an explanation with examples to aid the application of the guideline. The ACE checklist comprises seven new items, nine modified items, six unchanged items for which additional explanatory text clarifies further considerations for ADs, and 20 unchanged items not requiring further explanatory text. The ACE abstract checklist has one new item, one modified item, one unchanged item with additional explanatory text for ADs, and 15 unchanged items not requiring further explanatory text.The intention is to enhance transparency and improve reporting of AD randomised trials to improve the interpretability of their results and reproducibility of their methods, results and inference. We also hope indirectly to facilitate the much-needed knowledge transfer of innovative trial designs to maximise their potential benefits. In order to encourage its wide dissemination this article is freely accessible on the BMJ and Trials journal websites."To maximise the benefit to society, you need to not just do research but do it well" Douglas G Altman.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK.
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Adrian P Mander
- Centre for Trials Research, Cardiff University, Cardiff, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Franz Koenig
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Marc K Walton
- Janssen Pharmaceuticals, Titusville, New Jersey, USA
| | - Jon P Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | | | - Michael A Proschan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - John A Scott
- Division of Biostatistics in the Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
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12
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Dimairo M, Pallmann P, Wason J, Todd S, Jaki T, Julious SA, Mander AP, Weir CJ, Koenig F, Walton MK, Nicholl JP, Coates E, Biggs K, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. The Adaptive designs CONSORT Extension (ACE) statement: a checklist with explanation and elaboration guideline for reporting randomised trials that use an adaptive design. BMJ 2020; 369:m115. [PMID: 32554564 PMCID: PMC7298567 DOI: 10.1136/bmj.m115] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 12/11/2022]
Abstract
Adaptive designs (ADs) allow pre-planned changes to an ongoing trial without compromising the validity of conclusions and it is essential to distinguish pre-planned from unplanned changes that may also occur. The reporting of ADs in randomised trials is inconsistent and needs improving. Incompletely reported AD randomised trials are difficult to reproduce and are hard to interpret and synthesise. This consequently hampers their ability to inform practice as well as future research and contributes to research waste. Better transparency and adequate reporting will enable the potential benefits of ADs to be realised.This extension to the Consolidated Standards Of Reporting Trials (CONSORT) 2010 statement was developed to enhance the reporting of randomised AD clinical trials. We developed an Adaptive designs CONSORT Extension (ACE) guideline through a two-stage Delphi process with input from multidisciplinary key stakeholders in clinical trials research in the public and private sectors from 21 countries, followed by a consensus meeting. Members of the CONSORT Group were involved during the development process.The paper presents the ACE checklists for AD randomised trial reports and abstracts, as well as an explanation with examples to aid the application of the guideline. The ACE checklist comprises seven new items, nine modified items, six unchanged items for which additional explanatory text clarifies further considerations for ADs, and 20 unchanged items not requiring further explanatory text. The ACE abstract checklist has one new item, one modified item, one unchanged item with additional explanatory text for ADs, and 15 unchanged items not requiring further explanatory text.The intention is to enhance transparency and improve reporting of AD randomised trials to improve the interpretability of their results and reproducibility of their methods, results and inference. We also hope indirectly to facilitate the much-needed knowledge transfer of innovative trial designs to maximise their potential benefits.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, UK
- Institute of Health and Society, Newcastle University, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, UK
| | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Adrian P Mander
- Centre for Trials Research, Cardiff University, UK
- MRC Biostatistics Unit, University of Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, UK
| | - Franz Koenig
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Austria
| | | | - Jon P Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | | | - Michael A Proschan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA
| | - John A Scott
- Division of Biostatistics in the Center for Biologics Evaluation and Research, Food and Drug Administration, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
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Madani Kia T, Marshall JC, Murthy S. Stakeholder perspectives on adaptive clinical trials: a scoping review. Trials 2020; 21:539. [PMID: 32552852 PMCID: PMC7301522 DOI: 10.1186/s13063-020-04466-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Adaptive clinical trials (ACTs) represent an emerging approach to trial design where accumulating data are used to make decisions about future conduct. Adaptations can include comparisons of multiple dose tiers, response-adaptive randomization, sample size re-estimation, and efficacy/futility stopping rules. The objective of this scoping review is to assess stakeholder attitudes, perspectives, and understanding of adaptive trials. Methods We conducted a review of articles examining stakeholders encompassing the broad medical trial community’s perspectives of adaptive designs (ADs). A computerized search was conducted of four electronic databases with relevant search terms. Following screening of articles, the primary findings of each included article were coded for study design, population studied, purpose, and primary implications. Results Our team retrieved 167 peer-reviewed titles in total from the database search and 5 additional titles through searching web-based search engines for gray literature. Of those 172 titles, 152 were non-duplicate citations. Of these, 119 were not given full-text reviews, as their titles and abstracts indicated that they did not meet the inclusion criteria. Thirty-three articles were carefully examined for relevance, and of those, 18 were chosen to be part of the analysis; the other 15 were excluded, as they were not relevant upon closer inspection. Perceived advantages to ADs included limiting ineffective treatments and efficiency in answering the research question; −perceived barriers included insufficient sample size for secondary outcomes, challenges of consent, potential for bias, risk of type 1 error, cost and time to adaptively design trials, unclear rationales for using Ads, and, most importantly, a lack of education regarding ADs among stakeholders within the clinical trial community. Perceptions among different types of stakeholders varied from sector to sector, with patient perspectives being noticeably absent from the literature. Conclusion There are diverse perceptions regarding ADs among stakeholders. Further training, guidelines, and toolkits on the proper use of ADs are needed at all levels to overcome many of these perceived barriers. While education for principal investigators is important, it is also crucial to educate other groups in the community, such as patients, as well as clinicians and staff involved in their daily implementation.
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Affiliation(s)
- Tina Madani Kia
- BC Children's Hospital Research Institute, 4500 Oak Street, Vancouver, BC, Canada.
| | - John C Marshall
- Li Ka Shing Knowledge Institute, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - Srinivas Murthy
- BC Children's Hospital Research Institute, 4500 Oak Street, Vancouver, BC, Canada
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14
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Dimairo M, Coates E, Pallmann P, Todd S, Julious SA, Jaki T, Wason J, Mander AP, Weir CJ, Koenig F, Walton MK, Biggs K, Nicholl J, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. Development process of a consensus-driven CONSORT extension for randomised trials using an adaptive design. BMC Med 2018; 16:210. [PMID: 30442137 PMCID: PMC6238302 DOI: 10.1186/s12916-018-1196-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/23/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Adequate reporting of adaptive designs (ADs) maximises their potential benefits in the conduct of clinical trials. Transparent reporting can help address some obstacles and concerns relating to the use of ADs. Currently, there are deficiencies in the reporting of AD trials. To overcome this, we have developed a consensus-driven extension to the CONSORT statement for randomised trials using an AD. This paper describes the processes and methods used to develop this extension rather than detailed explanation of the guideline. METHODS We developed the guideline in seven overlapping stages: 1) Building on prior research to inform the need for a guideline; 2) A scoping literature review to inform future stages; 3) Drafting the first checklist version involving an External Expert Panel; 4) A two-round Delphi process involving international, multidisciplinary, and cross-sector key stakeholders; 5) A consensus meeting to advise which reporting items to retain through voting, and to discuss the structure of what to include in the supporting explanation and elaboration (E&E) document; 6) Refining and finalising the checklist; and 7) Writing-up and dissemination of the E&E document. The CONSORT Executive Group oversaw the entire development process. RESULTS Delphi survey response rates were 94/143 (66%), 114/156 (73%), and 79/143 (55%) in rounds 1, 2, and across both rounds, respectively. Twenty-seven delegates from Europe, the USA, and Asia attended the consensus meeting. The main checklist has seven new and nine modified items and six unchanged items with expanded E&E text to clarify further considerations for ADs. The abstract checklist has one new and one modified item together with an unchanged item with expanded E&E text. The E&E document will describe the scope of the guideline, the definition of an AD, and some types of ADs and trial adaptations and explain each reporting item in detail including case studies. CONCLUSIONS We hope that making the development processes, methods, and all supporting information that aided decision-making transparent will enhance the acceptability and quick uptake of the guideline. This will also help other groups when developing similar CONSORT extensions. The guideline is applicable to all randomised trials with an AD and contains minimum reporting requirements.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | | | | | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Adrian P Mander
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | | | - Franz Koenig
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Marc K Walton
- Janssen Pharmaceuticals, Titusville, New Jersey, USA
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | | | - Michael A Proschan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - John A Scott
- Division of Biostatistics in the Center for Biologics Evaluation and Research, Food and Drug Administration, White Oak, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
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15
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Sverdlov O, van Dam J, Hannesdottir K, Thornton-Wells T. Digital Therapeutics: An Integral Component of Digital Innovation in Drug Development. Clin Pharmacol Ther 2018; 104:72-80. [PMID: 29377057 DOI: 10.1002/cpt.1036] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/23/2018] [Accepted: 01/23/2018] [Indexed: 12/27/2022]
Abstract
Digital therapeutics represent a new treatment modality in which digital systems such as smartphone apps are used as regulatory-approved, prescribed therapeutic interventions to treat medical conditions. In this article we provide a critical overview of the rationale for investing in such novel modalities, including the unmet medical needs addressed by digital therapeutics and the potential for reducing current costs of medical care. We also discuss emerging pathways to regulatory approval and how innovative business models are enabling further growth in the development of digital therapeutics. We conclude by providing some recent examples of digital therapeutics that have gained regulatory approval and highlight opportunities for the near future.
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Affiliation(s)
- Oleksandr Sverdlov
- Early Development Biostatistics, Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | - Joris van Dam
- Novartis Institutes for Biomedical Research, Cambridge, Massachusetts, USA
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16
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Anesi GL, Halpern SD, Harhay MO, Volpp KG, Saulsgiver K. Time to selected quit date and subsequent rates of sustained smoking abstinence. J Behav Med 2017. [PMID: 28639106 DOI: 10.1007/s10865-017-9868-5] [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: 10/19/2022]
Abstract
In efforts to combat tobacco dependence, most smoking cessation programs offer individuals who smoke the choice of a target quit date. However, it is uncertain whether the time to the selected quit date is associated with participants' chances of achieving sustained abstinence. In a pre-specified secondary analysis of a randomized clinical trial of four financial-incentive programs or usual care to encourage smoking cessation (Halpern et al. in N Engl J Med 372(22):2108-2117, doi: 10.1056/NEJMoa1414293 , 2015), study participants were instructed to select a quit date between 0 and 90 days from enrollment. Among those who selected a quit date and provided complete baseline data (n = 1848), we used multivariable logistic regression to evaluate the association of the time to the selected quit date with 6- and 12-month biochemically-confirmed abstinence rates. In the fully adjusted model, the probability of being abstinent at 6 months if the participant selected a quit date in weeks 1, 5, 10, and 13 were 39.6, 22.6, 10.9, and 4.3%, respectively.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, 3600 Spruce Street, Gates Building, Room GA 5044, Philadelphia, PA, 19104, USA. .,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, 3600 Spruce Street, Gates Building, Room GA 5044, Philadelphia, PA, 19104, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Kevin G Volpp
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathryn Saulsgiver
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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17
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Lin M, Lee S, Zhen B, Scott J, Horne A, Solomon G, Russek-Cohen E. CBER's Experience With Adaptive Design Clinical Trials. Ther Innov Regul Sci 2016; 50:195-203. [PMID: 30227002 DOI: 10.1177/2168479015604181] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is considerable interest among pharmaceutical and other medical product developers in adaptive clinical trials, in which knowledge learned during the course of a trial affects ongoing conduct or analysis of the trial. When the FDA released a draft Guidance document on adaptive design clinical trials in early 2010, expectations were high that it would lead to an increase in regulatory submissions involving adaptive design features, particularly for confirmatory trials. A 6-year (2008-2013) retrospective survey was performed within the Center for Biologics Evaluation and Research (CBER) at the FDA to gather information regarding the submission and evaluation of adaptive design trial proposals. We present an up-to-date summary of adaptive design proposals seen in CBER and provide an overview of our experiences. We share our concerns regarding the statistical issues and operational challenges raised during the review process for adaptive design trials. We also provide general recommendations for developing proposals for such trials. Our motivation in writing this paper was to encourage the best study design proposals to be submitted to CBER. Sometimes these can be adaptive, and sometimes a simpler design is most efficient.
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Affiliation(s)
- Min Lin
- 1 Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Shiowjen Lee
- 1 Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Boguang Zhen
- 1 Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - John Scott
- 1 Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Amelia Horne
- 1 Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ghideon Solomon
- 1 Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Estelle Russek-Cohen
- 1 Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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18
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Grieve AP. Response-adaptive clinical trials: case studies in the medical literature. Pharm Stat 2016; 16:64-86. [PMID: 27730735 DOI: 10.1002/pst.1778] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/02/2016] [Accepted: 08/19/2016] [Indexed: 12/20/2022]
Abstract
The past 15 years has seen many pharmaceutical sponsors consider and implement adaptive designs (AD) across all phases of drug development. Given their arrival at the turn of the millennium, we might think that they are a recent invention. That is not the case. The earliest idea of an AD predates Bradford Hill's MRC tuberculosis study, appearing in Biometrika in 1933. In this paper, we trace the development of response-ADs, designs in which the allocation to intervention arms depends on the responses of subjects already treated. We describe some statistical details underlying the designs, but our main focus is to describe and comment on ADs from the medical research literature. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Andrew P Grieve
- Innovation Centre, 3 Globeside Business Park, Marlow, Buckinghamshire, SL7 1HZ, UK
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19
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Meurer WJ, Legocki L, Mawocha S, Frederiksen SM, Guetterman TC, Barsan W, Lewis R, Berry D, Fetters M. Attitudes and opinions regarding confirmatory adaptive clinical trials: a mixed methods analysis from the Adaptive Designs Accelerating Promising Trials into Treatments (ADAPT-IT) project. Trials 2016; 17:373. [PMID: 27473126 PMCID: PMC4966769 DOI: 10.1186/s13063-016-1493-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 07/07/2016] [Indexed: 12/03/2022] Open
Abstract
Background Adaptive designs have been increasingly used in the pharmaceutical and device industries, but adoption within the academic setting has been less widespread — particularly for confirmatory phase trials. We sought to understand perceptions about understanding, acceptability, and scientific validity of adaptive clinical trials (ACTs). Methods We used a convergent mixed methods design using survey and mini-focus group data collection procedures to elucidate attitudes and opinions among “trial community” stakeholders regarding understanding, acceptability, efficiency, scientific validity, and speed of discovery with adaptive designs. Data were collected about various aspects of ACTs using self-administered surveys (paper or Web-based) with visual analog scales (VASs) with free text responses and with mini-focus groups of key stakeholders. Participants were recruited as part of an ongoing NIH/FDA-funded research project exploring the incorporation of ACTs into an existing NIH network that focuses on confirmatory phase clinical trials in neurological emergencies. “Trial community” representatives, namely, clinical investigators, biostatisticians, NIH officials, and FDA scientists involved in the planning of four clinical trials, were eligible to participate. In addition, recent and current members of a clinical trial-oriented NIH study section were also eligible. Results A total of 76 stakeholders completed the survey (out of 91 who were offered it, response rate 84 %). While the VAS attitudinal data showed substantial variability across respondents about acceptability and understanding of ACTs by various constituencies, respondents perceived clinicians to be less likely to understand ACTs and that ACTs probably would increase the efficiency of discovery. Textual and focus group responses emerged into several themes that enhanced understanding of VAS attitudinal data including the following: acceptability of adaptive designs depends on constituency and situation; there is variable understanding of ACTs (limited among clinicians, perceived to be higher at FDA); views about the potential for efficiency depend on the situation and implementation. Participants also frequently mentioned a need for greater education within the academic community. Finally, the empiric, non-quantitative selection of treatments for phase III trials based on limited phase II trials was highlighted as an opportunity for improvement and a potential explanation for the high number of neutral confirmatory trials. Conclusions These data show considerable variations in attitudes and beliefs about ACTs among trial community representatives. For adaptive trials to be fully considered when appropriate and for the research enterprise to realize the full potential of adaptive designs will likely require extensive experience and trust building within the trial community. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1493-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- William J Meurer
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA. .,Department of Neurology, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Laurie Legocki
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Samkeliso Mawocha
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Shirley M Frederiksen
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Timothy C Guetterman
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - William Barsan
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Roger Lewis
- Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
| | - Donald Berry
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Michael Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
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20
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Reeve R. Modern adaptive randomized clinical trials—Statistical and practical aspects, edited by O. Sverdlov, Boca Raton. J Biopharm Stat 2016. [DOI: 10.1080/10543406.2016.1140531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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21
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Bauer P, Bretz F, Dragalin V, König F, Wassmer G. Twenty-five years of confirmatory adaptive designs: opportunities and pitfalls. Stat Med 2016; 35:325-47. [PMID: 25778935 PMCID: PMC6680191 DOI: 10.1002/sim.6472] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 02/03/2015] [Accepted: 02/19/2015] [Indexed: 12/26/2022]
Abstract
'Multistage testing with adaptive designs' was the title of an article by Peter Bauer that appeared 1989 in the German journal Biometrie und Informatik in Medizin und Biologie. The journal does not exist anymore but the methodology found widespread interest in the scientific community over the past 25 years. The use of such multistage adaptive designs raised many controversial discussions from the beginning on, especially after the publication by Bauer and Köhne 1994 in Biometrics: Broad enthusiasm about potential applications of such designs faced critical positions regarding their statistical efficiency. Despite, or possibly because of, this controversy, the methodology and its areas of applications grew steadily over the years, with significant contributions from statisticians working in academia, industry and agencies around the world. In the meantime, such type of adaptive designs have become the subject of two major regulatory guidance documents in the US and Europe and the field is still evolving. Developments are particularly noteworthy in the most important applications of adaptive designs, including sample size reassessment, treatment selection procedures, and population enrichment designs. In this article, we summarize the developments over the past 25 years from different perspectives. We provide a historical overview of the early days, review the key methodological concepts and summarize regulatory and industry perspectives on such designs. Then, we illustrate the application of adaptive designs with three case studies, including unblinded sample size reassessment, adaptive treatment selection, and adaptive endpoint selection. We also discuss the availability of software for evaluating and performing such designs. We conclude with a critical review of how expectations from the beginning were fulfilled, and - if not - discuss potential reasons why this did not happen.
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Affiliation(s)
- Peter Bauer
- Section of Medical StatisticsMedical University of ViennaSpitalgasse 231090 WienAustria
| | - Frank Bretz
- Novartis Pharma AGLichtstrasse 354002BaselSwitzerland
- Shanghai University of Finance and EconomicsChina
| | | | - Franz König
- Section of Medical StatisticsMedical University of ViennaSpitalgasse 231090 WienAustria
| | - Gernot Wassmer
- Aptiv Solutions, an ICON plc companyRobert‐Perthel‐Str. 77a50739KölnGermany
- Institute for Medical Statistics, Informatics and EpidemiologyUniversity of Cologne50924KölnGermany
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Kim ES, Atlas J, Ison G, Ersek JL. Transforming Clinical Trial Eligibility Criteria to Reflect Practical Clinical Application. Am Soc Clin Oncol Educ Book 2016; 35:83-90. [PMID: 27249689 DOI: 10.1200/edbk_155880] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Historically, oncology clinical trials have focused on comparing a new drug's efficacy to the standard of care. However, as our understanding of molecular pathways in oncology has evolved, so has our ability to predict how patients will respond to a particular drug, and thus comparison with a standard therapy has become less important. Biomarkers and corresponding diagnostic testing are becoming more and more important to drug development but also limit the type of patient who may benefit from the therapy. Newer clinical trial designs have been developed to assess clinically meaningful endpoints in biomarker-enriched populations, and the number of modern, molecularly driven clinical trials are steadily increasing. At the same time, barriers to clinical trial enrollment have also grown. Many barriers contribute to nonenrollment in clinical trials, including patient, physician, institution, protocol, and regulatory barriers. At the protocol level, eligibility criteria have become a large roadblock to clinical trial accrual. Over time, eligibility criteria have become more and more restrictive. To accrue an adequate number of patients to molecularly driven trials, we should consider eligibility criteria carefully and attempt to reduce restrictive criteria. Reducing restrictive eligibility criteria will allow more patients to be eligible for clinical trial participation, will likely increase the speed of drug approvals, and will result in clinical trial results that more accurately reflect treatment of the population in the clinical setting.
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Affiliation(s)
- Edward S Kim
- From the Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC; Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD; Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
| | - Jennifer Atlas
- From the Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC; Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD; Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
| | - Gwynn Ison
- From the Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC; Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD; Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
| | - Jennifer L Ersek
- From the Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC; Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD; Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
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Spino C, Jahnke JS, Selewski DT, Massengill S, Troost J, Gipson DS. Changing the Paradigm for the Treatment and Development of New Therapies for FSGS. Front Pediatr 2016; 4:25. [PMID: 27047908 PMCID: PMC4803734 DOI: 10.3389/fped.2016.00025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/08/2016] [Indexed: 12/13/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a renal pathology finding that represents a constellation of rare kidney diseases, which manifest as proteinuria, edema nephrotic syndrome, hypertension, and increased risk for kidney failure. Therapeutic options for FSGS are reviewed displaying the expected efficacy from 25 to 69% depending on specific therapy, patient characteristics, cost, and common side effects. This variability in treatment response is likely caused, in part, by the heterogeneity in the etiology and active molecular mechanisms of FSGS. Clinical trials in FSGS have been scant in number and slow to recruit, which may stem, in part, from reliance on classic clinical trial design paradigms. Traditional clinical trial designs based on the "learn and confirm" paradigm may not be appropriate for rare diseases, such as FSGS. Future drug development and testing will require novel approaches to trial designs that have the capacity to enrich study populations and adapt the trial in a planned way to gain efficiencies in trial completion timelines. A clinical trial simulation is provided that compares a classical and more modern design to determine the maximum tolerated dose in FSGS.
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Affiliation(s)
- Cathie Spino
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA; NephCure Accelerating Cures Institute, King of Prussia, PA, USA
| | - Jordan S Jahnke
- Department of General Internal Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - David T Selewski
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Susan Massengill
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, Division of Nephrology, Carolinas Medical Center, Charlotte, NC, USA
| | - Jonathan Troost
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Debbie S Gipson
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI, USA
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Burnham N, Quinlan J, He W, Marshall M, Nicholls G, Patel N, Parke T, Wong LB. Effective Drug Supply for Adaptive Clinical Trials: Recommendations by the DIA Adaptive Design Scientific Working Group Drug Supply Subteam. Ther Innov Regul Sci 2015; 49:100-107. [DOI: 10.1177/2168479014530968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Stone GW, Vahanian AS, Adams DH, Abraham WT, Borer JS, Bax JJ, Schofer J, Cutlip DE, Krucoff MW, Blackstone EH, Généreux P, Mack MJ, Siegel RJ, Grayburn PA, Enriquez-Sarano M, Lancellotti P, Filippatos G, Kappetein AP. Clinical trial design principles and endpoint definitions for transcatheter mitral valve repair and replacement: part 1: clinical trial design principles. Eur Heart J 2015; 36:1851-77. [DOI: 10.1093/eurheartj/ehv281] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/21/2015] [Indexed: 12/28/2022] Open
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Stone GW, Vahanian AS, Adams DH, Abraham WT, Borer JS, Bax JJ, Schofer J, Cutlip DE, Krucoff MW, Blackstone EH, Généreux P, Mack MJ, Siegel RJ, Grayburn PA, Enriquez-Sarano M, Lancellotti P, Filippatos G, Kappetein AP. Clinical Trial Design Principles and Endpoint Definitions for Transcatheter Mitral Valve Repair and Replacement: Part 1: Clinical Trial Design Principles. J Am Coll Cardiol 2015; 66:278-307. [DOI: 10.1016/j.jacc.2015.05.046] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 05/05/2015] [Accepted: 05/21/2015] [Indexed: 01/22/2023]
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Halpern SD, French B, Small DS, Saulsgiver K, Harhay MO, Audrain-McGovern J, Loewenstein G, Brennan TA, Asch DA, Volpp KG. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med 2015; 372:2108-17. [PMID: 25970009 PMCID: PMC4471993 DOI: 10.1056/nejmoa1414293] [Citation(s) in RCA: 242] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Financial incentives promote many health behaviors, but effective ways to deliver health incentives remain uncertain. METHODS We randomly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation. Two of the incentive programs targeted individuals, and two targeted groups of six participants. One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $800 for smoking cessation; the others entailed refundable deposits of $150 plus $650 in reward payments for successful participants. Usual care included informational resources and free smoking-cessation aids. RESULTS Overall, 2538 participants were enrolled. Of those assigned to reward-based programs, 90.0% accepted the assignment, as compared with 13.7% of those assigned to deposit-based programs (P<0.001). In intention-to-treat analyses, rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs (range, 9.4 to 16.0%) than with usual care (6.0%) (P<0.05 for all comparisons); the superiority of reward-based programs was sustained through 12 months. Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates (13.7% and 12.1%, respectively; P=0.29). Reward-based programs were associated with higher abstinence rates than deposit-based programs (15.7% vs. 10.2%, P<0.001). However, in instrumental-variable analyses that accounted for differential acceptance, the rate of abstinence at 6 months was 13.2 percentage points (95% confidence interval, 3.1 to 22.8) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7% of the participants who would accept participation in either type of program. CONCLUSIONS Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs. (Funded by the National Institutes of Health and CVS Caremark; ClinicalTrials.gov number, NCT01526265.).
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Affiliation(s)
- Scott D Halpern
- From the Departments of Medicine (S.D.H., D.A.A., K.G.V.), Biostatistics and Epidemiology (S.D.H., B.F., K.S., M.O.H.), Medical Ethics and Health Policy (S.D.H., K.G.V.), and Psychiatry (J.A.-M.) and the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute of Health Economics (S.D.H., B.F., D.S.S., K.S., J.A.-M., G.L., D.A.A., K.G.V.), Perelman School of Medicine at the University of Pennsylvania, the Departments of Statistics (D.S.S.) and Health Care Management (D.A.A., K.G.V.), Wharton School, University of Pennsylvania Center for Health Equity Research and Promotion, the Philadelphia Veterans Affairs Medical Center (D.A.A., K.G.V.), and the Center for Health Care Innovation, University of Pennsylvania Health System (D.A.A., K.G.V.) - all in Philadelphia; the Center for Behavioral Decision Research, Carnegie Mellon University, Pittsburgh (G.L.); and CVS Caremark, Woonsocket, RI (T.A.B.)
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Legocki LJ, Meurer WJ, Frederiksen S, Lewis RJ, Durkalski VL, Berry DA, Barsan WG, Fetters MD. Clinical trialist perspectives on the ethics of adaptive clinical trials: a mixed-methods analysis. BMC Med Ethics 2015; 16:27. [PMID: 25933921 PMCID: PMC4424427 DOI: 10.1186/s12910-015-0022-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 04/23/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In an adaptive clinical trial (ACT), key trial characteristics may be altered during the course of the trial according to predefined rules in response to information that accumulates within the trial itself. In addition to having distinguishing scientific features, adaptive trials also may involve ethical considerations that differ from more traditional randomized trials. Better understanding of clinical trial experts' views about the ethical aspects of adaptive designs could assist those planning ACTs. Our aim was to elucidate the opinions of clinical trial experts regarding their beliefs about ethical aspects of ACTs. METHODS We used a convergent, mixed-methods design employing a 22-item ACTs beliefs survey with visual analog scales and open-ended questions and mini-focus groups. We developed a coding scheme to conduct thematic searches of textual data, depicted responses to visual analog scales on box-plot diagrams, and integrated findings thematically. Fifty-three clinical trial experts from four constituent groups participated: academic biostatisticians (n = 5); consultant biostatisticians (n = 6); academic clinicians (n = 22); and other stakeholders including patient advocacy, National Institutes of Health, and U.S. Food and Drug Administration representatives (n = 20). RESULTS The respondents recognized potential ethical benefits of ACTs, including a higher probability of receiving an effective intervention for participants, optimizing resource utilization, and accelerating treatment discovery. Ethical challenges voiced include developing procedures so trial participants can make informed decisions about taking part in ACTs and plausible, though unlikely risks of research personnel altering enrollment patterns. CONCLUSIONS Clinical trial experts recognize ethical advantages but also pose potential ethical challenges of ACTs. The four constituencies differ in their weighing of ACT ethical considerations based on their professional vantage points. These data suggest further discussion about the ethics of ACTs is needed to facilitate ACT planning, design and conduct, and ultimately better allow planners to weigh ethical implications of competing trial designs.
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Affiliation(s)
- Laurie J Legocki
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109, USA.
| | - William J Meurer
- Departments of Emergency Medicine and Neurology, University of Michigan, Ann Arbor, MI, USA.
| | - Shirley Frederiksen
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA, USA.
- Los Angeles Biomedical Research Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Berry Consultants, Austin, TX, USA.
| | - Valerie L Durkalski
- Division of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Donald A Berry
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
- Berry Consultants, Austin, TX, USA.
| | - William G Barsan
- Los Angeles Biomedical Research Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109, USA.
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Neuroprotection in acute brain injury: an up-to-date review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:186. [PMID: 25896893 PMCID: PMC4404577 DOI: 10.1186/s13054-015-0887-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neuroprotective strategies that limit secondary tissue loss and/or improve functional outcomes have been identified in multiple animal models of ischemic, hemorrhagic, traumatic and nontraumatic cerebral lesions. However, use of these potential interventions in human randomized controlled studies has generally given disappointing results. In this paper, we summarize the current status in terms of neuroprotective strategies, both in the immediate and later stages of acute brain injury in adults. We also review potential new strategies and highlight areas for future research.
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Schütz H. Two-stage designs in bioequivalence trials. Eur J Clin Pharmacol 2015; 71:271-81. [PMID: 25604509 DOI: 10.1007/s00228-015-1806-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 01/08/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study is to assess the current status of non-fixed sample size designs in bioequivalence trials with a focus on two-stage adaptive approaches. METHODS We searched PubMed and Google Scholar from inception to October 2014. Regulatory guidelines were obtained from the public domain. Different methods were compared by Monte Carlo simulations for their impact on the patient's and producer's risks. RESULTS Add-on designs, group sequential designs and adaptive two-stage sequential designs are currently accepted to demonstrate bioequivalence in various regulations. All three approaches may inflate the patient's risk if applied inconsiderately. Direct transfer of methods developed for superiority testing to bioequivalence is not warranted. Published two-stage frameworks maintain the type I error and generally the desired power. Adaptation based on the observed T/R ratio observed in the first stage should be applied with caution. Monte Carlo simulations are an efficient tool to explore the operating characteristics of methods. CONCLUSIONS Validated two-stage frameworks can be applied without requiring the sponsor to perform own simulations-which could further improve power based on additional assumptions. Two-stage designs are both ethical and economical alternatives to fixed sample designs.
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Grieve AP. How to test hypotheses if you must. Pharm Stat 2015; 14:139-50. [PMID: 25641830 DOI: 10.1002/pst.1667] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/16/2014] [Accepted: 12/01/2014] [Indexed: 12/30/2022]
Abstract
Drug development is not the only industrial-scientific enterprise subject to government regulations. In some fields of ecology and environmental sciences, the application of statistical methods is also regulated by ordinance. Over the past 20years, ecologists and environmental scientists have argued against an unthinking application of null hypothesis significance tests. More recently, Canadian ecologists have suggested a new approach to significance testing, taking account of the costs of both type I and type II errors. In this paper, we investigate the implications of this for testing in drug development and demonstrate that its adoption leads directly to the likelihood principle and Bayesian approaches.
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Affiliation(s)
- Andrew P Grieve
- ICON Adaptive Trials Innovation Centre, Icon Plc, Marlow, Buckinghamshire, UK
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Sverdlov O, Wong WK. Novel Statistical Designs for Phase I/II and Phase II Clinical Trials With Dose-Finding Objectives. Ther Innov Regul Sci 2014; 48:601-612. [DOI: 10.1177/2168479014523765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Fackle-Fornius E, Miller F, Nyquist H. Implementation of maximin efficient designs in dose-finding studies. Pharm Stat 2014; 14:63-73. [PMID: 25405333 DOI: 10.1002/pst.1660] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 08/08/2014] [Accepted: 10/24/2014] [Indexed: 11/08/2022]
Abstract
This paper considers the maximin approach for designing clinical studies. A maximin efficient design maximizes the smallest efficiency when compared with a standard design, as the parameters vary in a specified subset of the parameter space. To specify this subset of parameters in a real situation, a four-step procedure using elicitation based on expert opinions is proposed. Further, we describe why and how we extend the initially chosen subset of parameters to a much larger set in our procedure. By this procedure, the maximin approach becomes feasible for dose-finding studies. Maximin efficient designs have shown to be numerically difficult to construct. However, a new algorithm, the H-algorithm, considerably simplifies the construction of these designs. We exemplify the maximin efficient approach by considering a sigmoid Emax model describing a dose-response relationship and compare inferential precision with that obtained when using a uniform design. The design obtained is shown to be at least 15% more efficient than the uniform design.
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Gewandter JS, Dworkin RH, Turk DC, McDermott MP, Baron R, Gastonguay MR, Gilron I, Katz NP, Mehta C, Raja SN, Senn S, Taylor C, Cowan P, Desjardins P, Dimitrova R, Dionne R, Farrar JT, Hewitt DJ, Iyengar S, Jay GW, Kalso E, Kerns RD, Leff R, Leong M, Petersen KL, Ravina BM, Rauschkolb C, Rice ASC, Rowbotham MC, Sampaio C, Sindrup SH, Stauffer JW, Steigerwald I, Stewart J, Tobias J, Treede RD, Wallace M, White RE. Research designs for proof-of-concept chronic pain clinical trials: IMMPACT recommendations. Pain 2014; 155:1683-1695. [PMID: 24865794 PMCID: PMC4500524 DOI: 10.1016/j.pain.2014.05.025] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/21/2022]
Abstract
Proof-of-concept (POC) clinical trials play an important role in developing novel treatments and determining whether existing treatments may be efficacious in broader populations of patients. The goal of most POC trials is to determine whether a treatment is likely to be efficacious for a given indication and thus whether it is worth investing the financial resources and participant exposure necessary for a confirmatory trial of that intervention. A challenge in designing POC trials is obtaining sufficient information to make this important go/no-go decision in a cost-effective manner. An IMMPACT consensus meeting was convened to discuss design considerations for POC trials in analgesia, with a focus on maximizing power with limited resources and participants. We present general design aspects to consider including patient population, active comparators and placebos, study power, pharmacokinetic-pharmacodynamic relationships, and minimization of missing data. Efficiency of single-dose studies for treatments with rapid onset is discussed. The trade-off between parallel-group and crossover designs with respect to overall sample sizes, trial duration, and applicability is summarized. The advantages and disadvantages of more recent trial designs, including N-of-1 designs, enriched designs, adaptive designs, and sequential parallel comparison designs, are summarized, and recommendations for consideration are provided. More attention to identifying efficient yet powerful designs for POC clinical trials of chronic pain treatments may increase the percentage of truly efficacious pain treatments that are advanced to confirmatory trials while decreasing the percentage of ineffective treatments that continue to be evaluated rather than abandoned.
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Affiliation(s)
| | | | | | | | | | | | - Ian Gilron
- Queen’s University, Kingston, Ontario, Canada
| | - Nathaniel P. Katz
- Analgesic Solutions, Natick, MA, and Tufts University, Boston, MA, USA
| | | | | | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Paul Desjardins
- Desjardins Associates and Rutgers University, Newark, NJ, USA
| | | | | | | | | | | | - Gary W. Jay
- Virtuous Pharma, Inc., Raleigh-Durham, NC, USA
| | - Eija Kalso
- University of Helsinki, Helsinki, Finland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mark Wallace
- University of California San Diego, San Diego, CA, USA
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Dumont C, Chenel M, Mentré F. Two-stage Adaptive Designs in Nonlinear Mixed Effects Models: Application to Pharmacokinetics in Children. COMMUN STAT-SIMUL C 2014. [DOI: 10.1080/03610918.2014.930901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Cyrielle Dumont
- IAME, UMR 1137, INSERM, Paris, France
- Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Marylore Chenel
- Division of Clinical Pharmacokinetics, Institut de Recherches Internationales Servier, Suresnes, France
| | - France Mentré
- IAME, UMR 1137, INSERM, Paris, France
- Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
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Marchenko O, Fedorov V, Lee JJ, Nolan C, Pinheiro J. Adaptive Clinical Trials: Overview of Early-Phase Designs and Challenges. Ther Innov Regul Sci 2013; 48:20-30. [PMID: 28670507 DOI: 10.1177/2168479013513889] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this paper, we describe developments in adaptive design methodology and discuss implementation strategies and operational challenges in early phase adaptive clinical trials. The BATTLE trial - the first completed, biomarker-based, Bayesian adaptive randomized study in lung cancer - is presented as a case study to illustrate main ideas and share learnings.
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Affiliation(s)
- Olga Marchenko
- Center for Statistics in Drug Development, Innovation, Quintiles, Durham, NC
| | | | - J Jack Lee
- Department of Biostatistics, Division of Quantitative Sciences, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - José Pinheiro
- Quantitative Decision Strategies, Janssen Research & Development, LLC
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Karalis V. The role of the upper sample size limit in two-stage bioequivalence designs. Int J Pharm 2013; 456:87-94. [DOI: 10.1016/j.ijpharm.2013.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/06/2013] [Accepted: 08/08/2013] [Indexed: 10/26/2022]
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Spinal cord injury neuroprotection and the promise of flexible adaptive clinical trials. World Neurosurg 2013; 82:e541-6. [PMID: 23851207 DOI: 10.1016/j.wneu.2013.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/03/2013] [Accepted: 06/29/2013] [Indexed: 01/05/2023]
Abstract
Effective treatments for acute neurologic illness and injury are lacking, particularly for spinal cord injury (SCI). The very structure of clinical trials may be contributing to this because assumptions made during trial planning preclude additional learning within residual important areas of uncertainty, such as dose, timing, and duration of treatment. Adaptive clinical trials offer potential solutions to some of the factors that may be slowing the pace of discovery. Broadly defined, one can consider an adaptive clinical trial as any sort of clinical trial that makes use of information from within the trial to make decisions about how the trial is conducted going forward; however, it is important to emphasize that regardless of the degree of flexibility or complexity of an adaptive clinical trial design, the types of designs being described are only those in which all potential changes to the conduct of the trial are prospectively defined before the first patient is enrolled. Within this review, we describe the structure of flexible adaptive clinical trial designs, the process by which they are developed and conducted, and potential opportunities and drawbacks of these approaches. We must accept that there are some uncertainties that remain when both exploratory and confirmatory trials are designed. The process by which teams carefully consider which uncertainties are most important and most likely to potentially compromise the ability to detect an effective treatment can lead to trial designs that are more likely to find the right treatment for the right population of patients.
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Lewis RJ, Viele K, Broglio K, Berry SM, Jones AE. An adaptive, phase II, dose-finding clinical trial design to evaluate L-carnitine in the treatment of septic shock based on efficacy and predictive probability of subsequent phase III success. Crit Care Med 2013; 41:1674-8. [PMID: 23514753 PMCID: PMC4334380 DOI: 10.1097/ccm.0b013e318287f850] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Sepsis is the tenth leading cause of death in the United States. Despite extensive research, mortality rates for sepsis have not substantially improved in the last several decades. We describe an innovative phase II clinical trial design for evaluating the addition of L-carnitine to the treatment of vasopressor-dependent septic shock. DESIGN The design incorporates a variety of features to increase efficiency, including a normal dynamic linear dose-response model, adaptive randomization, and early stopping for futility or success based on the probability that a future phase III trial using a 28-day mortality outcome would be successful. SETTING Trial design and computer simulation of a trial to be conducted in the emergency department and ICU. INTERVENTIONS Proposed to study intravenous L-carnitine. MEASUREMENTS The proposed trial uses an early endpoint, the 48-hour change in Sequential Organ Failure Assessment score, to drive adaptive randomization and dose selection. MAIN RESULTS We use existing data to model the expected relationship between the Sequential Organ Failure Assessment change and the 28-day mortality to determine the trial's operating characteristics using Monte Carlo simulation. CONCLUSIONS The resulting trial efficiently identifies the best dose of L-carnitine and provides clear guidance regarding whether to continue development into phase III.
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Affiliation(s)
- Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
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Coffey CS, Levin B, Clark C, Timmerman C, Wittes J, Gilbert P, Harris S. Overview, hurdles, and future work in adaptive designs: perspectives from a National Institutes of Health-funded workshop. Clin Trials 2013; 9:671-80. [PMID: 23250942 DOI: 10.1177/1740774512461859] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clinical trials community has a never-ending search for dependable and reliable ways to improve clinical research. This exploration has led to considerable interest in adaptive clinical trial designs, which provide the flexibility to adjust trial characteristics on the basis of data reviewed at interim stages. Statisticians and clinical investigators have proposed or implemented a wide variety of adaptations in clinical trials, but specific approaches have met with differing levels of support. Within industry, investigators are actively exploring the benefits and pitfalls associated with adaptive designs (ADs). For example, a Drug Information Association (DIA) working group on ADs has engaged regulatory agencies in discussions. Many researchers working on publicly funded clinical trials, however, are not yet fully engaged in this discussion. We organized the Scientific Advances in Adaptive Clinical Trial Designs Workshop to begin a conversation about using ADs in publicly funded research. Held in November of 2009, the 1½-day workshop brought together representatives from the National Institutes of Health (NIH), the Food and Drug Administration (FDA), the European Medicines Agency (EMA), the pharmaceutical industry, nonprofit foundations, the patient advocacy community, and academia. The workshop offered a forum for participants to address issues of ADs that arise at the planning, designing, and execution stages of clinical trials, and to hear the perspectives of influential members of the clinical trials community. The participants also set forth recommendations for guiding action to promote the appropriate use of ADs. These recommendations have since been presented, discussed, and vetted in a number of venues including the University of Pennsylvania Conference on Statistical Issues in Clinical Trials and the Society for Clinical Trials annual meeting. PURPOSE To provide a brief overview of ADs, describe the rationale behind conducting the workshop, and summarize the main recommendations that were produced as a result of this workshop. CONCLUSIONS There is a growing interest in the use of adaptive clinical trial designs. However, a number of logistical barriers need to be addressed in order to obtain the potential advantages of an AD. Currently, the pharmaceutical industry is well ahead of academic trialists with respect to addressing these barriers. Academic trialists will need to address important issues such as education, infrastructure, modifications to existing funding models, and the impact on Data and Safety Monitoring Boards (DSMB) in order to achieve the possible benefits of adaptive clinical trial designs.
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Harrington JA, Wheeler GM, Sweeting MJ, Mander AP, Jodrell DI. Adaptive designs for dual-agent phase I dose-escalation studies. Nat Rev Clin Oncol 2013; 10:277-88. [PMID: 23507740 DOI: 10.1038/nrclinonc.2013.35] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Anticancer agents used in combination are fundamental to successful cancer treatment, particularly in a curative setting. For dual-agent phase I trials, the goal is to identify drug doses and schedules for further clinical testing. However, current methods for establishing the recommended phase II dose for agents in combination can fail to fully explore drug interactions. With increasing numbers of anticancer drugs requiring testing, new adaptive model-based trial designs that improve on current practice have been proposed, although uptake has been minimal. We describe the methods available and discuss some of the opportunities and challenges faced in dual-agent phase I trials, as well as giving examples of trials in which adaptive designs have been implemented successfully. Improving the design and execution of phase I trials of drug combinations critically relies on collaboration between the statistical and clinical communities to facilitate the implementation of adaptive, model-based designs.
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Affiliation(s)
- Jennifer A Harrington
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
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45
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Li J, Fu H. Bayesian Adaptive D-Optimal Design with Delayed Responses. J Biopharm Stat 2013; 23:559-68. [DOI: 10.1080/10543406.2012.755996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jie Li
- a Department of Statistics , Virginia Tech , Blacksburg , Virginia , USA
| | - Haoda Fu
- b Eli Lilly and Company , Indianapolis , Indiana , USA
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46
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Lipsky AM, Lewis RJ. Response-adaptive decision-theoretic trial design: operating characteristics and ethics. Stat Med 2013; 32:3752-65. [PMID: 23558674 DOI: 10.1002/sim.5807] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 02/28/2013] [Accepted: 03/04/2013] [Indexed: 11/11/2022]
Abstract
Adaptive randomization is used in clinical trials to increase statistical efficiency. In addition, some clinicians and researchers believe that using adaptive randomization leads necessarily to more ethical treatment of subjects in a trial. We develop Bayesian, decision-theoretic, clinical trial designs with response-adaptive randomization and a primary goal of estimating treatment effect and then contrast these designs with designs that also include in their loss function a cost for poor subject outcome. When the loss function did not incorporate a cost for poor subject outcome, the gains in efficiency from response-adaptive randomization were accompanied by ethically concerning subject allocations. Conversely, including a cost for poor subject outcome demonstrated a more acceptable balance between the competing needs in the trial. A subsequent, parallel set of trials designed to control explicitly types I and II error rates showed that much of the improvement achieved through modification of the loss function was essentially negated. Therefore, gains in efficiency from the use of a decision-theoretic, response-adaptive design using adaptive randomization may only be assumed to apply to those goals that are explicitly included in the loss function. Trial goals, including ethical ones, which do not appear in the loss function, are ignored and may even be compromised; it is thus inappropriate to assume that all adaptive trials are necessarily more ethical. Controlling types I and II error rates largely negates the benefit of including competing needs in favor of the goal of parameter estimation.
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Affiliation(s)
- Ari M Lipsky
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
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Dobbins TW. The Type II Error Probability of a Group Sequential Test of Efficacy and Futility, and Considerations for Power and Sample Size. J Biopharm Stat 2013; 23:378-93. [DOI: 10.1080/10543406.2011.617229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Thomas W. Dobbins
- a Biostatistics and Research Decision Sciences , Merck Research Laboratories , North Wales , Pennsylvania , USA
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He W, Kuznetsova OM, Harmer M, Leahy C, Anderson K, Dossin N, Li L, Bolognese J, Tymofyeyev Y, Schindler J. Practical Considerations and Strategies for Executing Adaptive Clinical Trials. ACTA ACUST UNITED AC 2012. [DOI: 10.1177/0092861512436580] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Meurer WJ, Lewis RJ, Tagle D, Fetters MD, Legocki L, Berry S, Connor J, Durkalski V, Elm J, Zhao W, Frederiksen S, Silbergleit R, Palesch Y, Berry DA, Barsan WG. An overview of the adaptive designs accelerating promising trials into treatments (ADAPT-IT) project. Ann Emerg Med 2012; 60:451-7. [PMID: 22424650 PMCID: PMC3557826 DOI: 10.1016/j.annemergmed.2012.01.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/17/2012] [Accepted: 01/23/2012] [Indexed: 11/17/2022]
Abstract
Randomized clinical trials, which aim to determine the efficacy and safety of drugs and medical devices, are a complex enterprise with myriad challenges, stakeholders, and traditions. Although the primary goal is scientific discovery, clinical trials must also fulfill regulatory, clinical, and ethical requirements. Innovations in clinical trials methodology have the potential to improve the quality of knowledge gained from trials, the protection of human subjects, and the efficiency of clinical research. Adaptive clinical trial methods represent a broad category of innovations intended to address a variety of long-standing challenges faced by investigators, such as sensitivity to previous assumptions and delayed identification of ineffective treatments. The implementation of adaptive clinical trial methods, however, requires greater planning and simulation compared with a more traditional design, along with more advanced administrative infrastructure for trial execution. The value of adaptive clinical trial methods in exploratory phase (phase 2) clinical research is generally well accepted, but the potential value and challenges of applying adaptive clinical trial methods in large confirmatory phase clinical trials are relatively unexplored, particularly in the academic setting. In the Adaptive Designs Accelerating Promising Trials Into Treatments (ADAPT-IT) project, a multidisciplinary team is studying how adaptive clinical trial methods could be implemented in planning actual confirmatory phase trials in an established, National Institutes of Health-funded clinical trials network. The overarching objectives of ADAPT-IT are to identify and quantitatively characterize the adaptive clinical trial methods of greatest potential value in confirmatory phase clinical trials and to elicit and understand the enthusiasms and concerns of key stakeholders that influence their willingness to try these innovative strategies.
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Affiliation(s)
- William J. Meurer
- Departments of Emergency Medicine and Neurology, University of Michigan, Ann Arbor
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles; Los Angeles Biomedical Research Institute; David Geffen School of Medicine - UCLA
| | - Danilo Tagle
- Extramural Research Program, National Institutes of Neurological Disorders and Stroke
| | | | - Laurie Legocki
- Department of Family Medicine, University of Michigan, Ann Arbor
| | | | | | - Valerie Durkalski
- Division of Biostatistics and Epidemiology, Medical University of South Carolina
| | - Jordan Elm
- Division of Biostatistics and Epidemiology, Medical University of South Carolina
| | - Wenle Zhao
- Division of Biostatistics and Epidemiology, Medical University of South Carolina
| | | | | | - Yuko Palesch
- Division of Biostatistics and Epidemiology, Medical University of South Carolina
| | - Donald A. Berry
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas; Berry Consultants
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50
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Kairalla JA, Coffey CS, Thomann MA, Muller KE. Adaptive trial designs: a review of barriers and opportunities. Trials 2012; 13:145. [PMID: 22917111 PMCID: PMC3519822 DOI: 10.1186/1745-6215-13-145] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 08/08/2012] [Indexed: 12/13/2022] Open
Abstract
Adaptive designs allow planned modifications based on data accumulating within a study. The promise of greater flexibility and efficiency stimulates increasing interest in adaptive designs from clinical, academic, and regulatory parties. When adaptive designs are used properly, efficiencies can include a smaller sample size, a more efficient treatment development process, and an increased chance of correctly answering the clinical question of interest. However, improper adaptations can lead to biased studies. A broad definition of adaptive designs allows for countless variations, which creates confusion as to the statistical validity and practical feasibility of many designs. Determining properties of a particular adaptive design requires careful consideration of the scientific context and statistical assumptions. We first review several adaptive designs that garner the most current interest. We focus on the design principles and research issues that lead to particular designs being appealing or unappealing in particular applications. We separately discuss exploratory and confirmatory stage designs in order to account for the differences in regulatory concerns. We include adaptive seamless designs, which combine stages in a unified approach. We also highlight a number of applied areas, such as comparative effectiveness research, that would benefit from the use of adaptive designs. Finally, we describe a number of current barriers and provide initial suggestions for overcoming them in order to promote wider use of appropriate adaptive designs. Given the breadth of the coverage all mathematical and most implementation details are omitted for the sake of brevity. However, the interested reader will find that we provide current references to focused reviews and original theoretical sources which lead to details of the current state of the art in theory and practice.
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Affiliation(s)
- John A Kairalla
- Department of Biostatistics, University of Florida, PO Box 117450, Gainesville, FL, 32611-7450, USA
| | - Christopher S Coffey
- Department of Biostatistics, University of Iowa, 2400 University Capitol Centre, Iowa City, IA, 52240-4034, USA
| | - Mitchell A Thomann
- Department of Biostatistics, University of Iowa, 2400 University Capitol Centre, Iowa City, IA, 52240-4034, USA
| | - Keith E Muller
- Department of Health Outcomes and Policy, University of Florida, PO Box 100177, Gainesville, FL, 32610-0177, USA
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