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Grill JD, Raman R, Ernstrom K, Wang S, Donohue MC, Aisen PS, Karlawish J, Henley D, Romano G, Novak G, Brashear HR, Sperling RA. Immediate Reactions to Alzheimer Biomarker Disclosure in Cognitively Unimpaired Individuals in a Global Truncated Randomized Trial. Neurol Clin Pract 2024; 14:e200265. [PMID: 38585443 PMCID: PMC10996909 DOI: 10.1212/cpj.0000000000200265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/21/2023] [Indexed: 04/09/2024]
Abstract
Background and Objectives Preclinical Alzheimer disease (AD) trials simultaneously test candidate treatments and the implications of disclosing biomarker information to cognitively unimpaired individuals. Methods The EARLY trial was a randomized, double-blind, placebo-controlled, phase 2b/3 study conducted in 143 centers across 14 countries from November 2015 to December 2018 after being stopped prematurely because of treatment-related hepatotoxicity. Participants age 60-85 years deemed cognitively unimpaired were disclosed an elevated or not elevated brain amyloid result by a certified clinician. Among 3,686 participants, 2,066 underwent amyloid imaging, 1,394 underwent CSF biomarker assessment, and 226 underwent both. Among biomarker-tested participants with at least one change score on an outcome of interest, 680 with elevated and 2,698 with not elevated amyloid were included in this analysis. We compared the Geriatric Depression Scale (GDS), the State-Trait Anxiety Scale (STAI), and the Columbia Suicide Severity Rating Scale (CSSRS) before disclosure between amyloid groups. After disclosure, we assessed for differences in the Impact of Events Scale (IES, collected 24-72 hours after disclosure), a measure of intrusive thoughts. Additional scales included the Concerns for AD scale. Results Among 3378 included participants, the mean (SD) age was 69.0 (5.3); most were female (60%) and White race (84%). No differences were observed before disclosure between participants with elevated and not elevated amyloid for the GDS, STAI, or CSSRS. Participants with elevated amyloid demonstrated higher Concerns for AD scores compared with participants with not elevated amyloid before disclosure. Participants with elevated amyloid demonstrated higher IES scores (9.6 [10.8] vs 5.1 [8.0]) after disclosure and increased Concerns about AD. Patterns of reactions (elevated vs not elevated) were similar for biomarker modalities, although scores were lower among those undergoing CSF compared with PET testing. Although score differences were apparent comparing geographical regions, patterns of group differences were similar. Discussion Although sample bias must be considered, these results suggest that amyloid disclosure resulted in increased perceived risk and mild distress in those learning an elevated result. Although this study did not assess psychological safety, observed associations intrusive thoughts and distress could be important considerations in the future clinical practice.
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Affiliation(s)
- Joshua D Grill
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Rema Raman
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Karin Ernstrom
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Shunran Wang
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Michael C Donohue
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Paul S Aisen
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Jason Karlawish
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - David Henley
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Gary Romano
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Gerald Novak
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - H Robert Brashear
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
| | - Reisa A Sperling
- Institute for Memory Impairments and Neurological Disorders (JDG), Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, University of California Irvine, Irvine; Alzheimer's Therapeutic Research Institute (RR, KE, SW, MCD, PSA), University of Southern California, San Diego; University of Pennsylvania (JK), Philadelphia; Janssen Research & Development LLC (DH, GR, GN), Titusville, NJ; Indiana University School of Medicine (DH, HRB), Indianapolis; University of Virginia (HRB), Charlottesville; and Brigham and Women's Hospital (RAS), Harvard Medical School, Boston, MA
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Awan FA, Becker AB, Wang Y, Kimmelman J. Participant Recruitment From Low- and Middle-Income Countries for Pivotal Trials of Drugs Approved by the U.S. Food and Drug Administration : A Cross-Sectional Analysis. Ann Intern Med 2022; 175:1675-1684. [PMID: 36410007 DOI: 10.7326/m22-1857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many participants in clinical trials supporting U.S. Food and Drug Administration (FDA) drug approvals are recruited from outside the United States, including from low- and middle-income countries (LMICs). Where participants are recruited for pivotal trials has implications for ethical research conduct and generalizability. OBJECTIVE To describe LMIC recruitment for pivotal trials of newly approved drugs for cancer, neurologic disease, and cardiovascular disease. DESIGN Cross-sectional analysis. SETTING Pivotal trials of new cancer, cardiovascular, and neurologic drugs approved from 2012 to 2019 matched to ClinicalTrials.gov, FDA records, and publications. MEASUREMENTS Host countries and available per country enrollments were extracted. The primary end point was the proportion of pivotal trials enrolling participants in LMICs. The secondary end point was the proportion of pivotal trial participants contributed by LMICs for each indication area. RESULTS Data were obtained from 66 new drugs and 144 pivotal clinical trials. All cardiovascular approvals (12 drugs, 29 trials) and neurologic approvals (26 drugs, 54 trials) were analyzed, as well as a random sample of cancer approvals (28 of 85 drugs [33%]) matched to their pivotal trials (61 of 210 trials [29%]). Among the trials, 56% in cancer, 79% in cardiovascular disease, and 56% in neurology recruited from an LMIC. For multicountry trials, country-level enrollment figures were not available for 71 trials (55%). For those reporting per country enrollment, the percentage of participants recruited from LMICs was 8% for cancer trials, 36% for cardiovascular trials, and 17% for neurology trials. LIMITATIONS The study was limited to FDA-approved drugs in 3 areas, including a sample of cancer drugs. Pivotal trials of nonapproved drugs or drugs for other indications were not captured. CONCLUSION Most pivotal trials for FDA-approved drugs recruit from LMICs. Publications and FDA documents generally do not provide country-level data on recruitment. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Fareed A Awan
- Studies of Translation, Ethics and Medicine, Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada (F.A.A., Y.W., J.K.)
| | - Andrew B Becker
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota (A.B.B.)
| | - Yuetong Wang
- Studies of Translation, Ethics and Medicine, Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada (F.A.A., Y.W., J.K.)
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine, Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada (F.A.A., Y.W., J.K.)
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Keebler D, Teng E, Chia J, Galanter J, Peake J, Tuckwell K. Regional variations in adverse event reporting rates and ACR responses in placebo/standard-of-care arms of rheumatoid arthritis trials. Rheumatology (Oxford) 2021; 59:3023-3031. [PMID: 32182362 PMCID: PMC7516100 DOI: 10.1093/rheumatology/keaa043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/29/2019] [Indexed: 11/12/2022] Open
Abstract
Objective Clinical trials are increasingly globalized, and adverse event (AE) rates and treatment responses may differ by geographical region. This study assessed regional differences in AE reporting rates and ACR response rates (ACR20/50) in patients with RA who received placebo/standard-of-care treatment in clinical trials. Methods Patients from the placebo arms of 7 RA trials in the TransCelerate Biopharma Inc database were grouped into 5 geographical regions (Asia, Latin America, Russian Federation and Eastern Europe [RFEE], USA, and Western Europe). Differences in demographics, AE reporting rates and ACR response were evaluated using descriptive statistics and omnibus tests for significance; pairwise comparisons were made between regions, with false discovery rate correction for multiple comparisons. Results Among 970 patients included, week 12 AE rates were significantly lower in the RFEE than in Asia, Latin America and the USA (22% vs 51%, 49% and 53%, respectively; P < 0.05 after false discovery rate correction). Similar differences in AE rates across geographical regions were seen at week 52. Among 747 patients with ACR data, the lowest response rates were observed in the USA (ACR20, 22%) and RFEE (ACR50, 3%); the highest response rates were seen in Western Europe (ACR20, 43%) and Latin America (ACR50, 15%). Only the differences in ACR50 response between the RFEE and Latin America remained significant after false discovery rate correction. Conclusion These placebo/standard-of-care arm data revealed significant regional differences in AE reporting rates and ACR50 response rates. Regional distribution of patients should be considered when conducting RA clinical trials, particularly during recruitment.
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Affiliation(s)
| | - Edmond Teng
- Genentech Inc., South San Francisco, CA, USA
| | - Jenny Chia
- Genentech Inc., South San Francisco, CA, USA
| | | | - Jodie Peake
- Genentech Inc., South San Francisco, CA, USA
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4
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Stites SD, Turner RS, Gill J, Gurian A, Karlawish J, Grill JD. Research Attitudes Questionnaire scores predict Alzheimer's disease clinical trial dropout. Clin Trials 2021; 18:237-244. [PMID: 33426901 DOI: 10.1177/1740774520982315] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Missing data are a notable problem in Alzheimer's disease clinical trials. One cause of missing data is participant dropout. The Research Attitudes Questionnaire is a 7-item instrument that measures an individual's attitudes toward biomedical research, with higher scores indicating more favorable attitudes. The objective of this study was to describe the performance of the Research Attitudes Questionnaire over time and to examine whether Research Attitudes Questionnaire scores predict study dropout and other participant behaviors that affect trial integrity. METHODS The Research Attitudes Questionnaire was collected at baseline and weeks 26 and 52 from each member of 119 participant/study partner dyads enrolled in a Phase 2, randomized, double-blind, placebo-controlled mild-to-moderate Alzheimer's disease clinical trial. Within-subject longitudinal analyses examined change in Research Attitudes Questionnaire scores over time in each population. Logistic regression analyses that controlled for trial arm and clustering in trial sites were used to assess whether baseline Research Attitudes Questionnaire scores predicted trial completion, study medication compliance, and enrollment in optional substudies. RESULTS Participants and study partners endorsed statistically similar ratings on the Research Attitudes Questionnaire that were stable over time. Participants with baseline Research Attitudes Questionnaire scores above 28.5 were 4.7 (95% confidence interval = 1.01 to 21.95) times as likely to complete the trial compared to those with lower scores. Applying the same cutoff, baseline study partner Research Attitudes Questionnaire scores were similarly able to predict study completion (odds ratio = 4.2, 95% confidence interval = 1.71 to 10.32). Using a score cutoff of 27.5, higher participant Research Attitudes Questionnaire scores predicted study medication compliance (odds ratio = 5.85, 95% confidence interval = 1.34 to 25.54). No relationship was observed between Research Attitudes Questionnaire score and participation in optional substudies. CONCLUSION This brief instrument that measures research attitudes may identify participants at risk for behaviors that cause missing data.
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Affiliation(s)
- Shana D Stites
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - R Scott Turner
- Department of Neurology, Georgetown University, Washington, DC, USA
| | - Jeanine Gill
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Gurian
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Karlawish
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Penn Memory Center, Departments of Medicine, Medical Ethics and Health Policy, and Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua D Grill
- Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA, USA
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Bernstein OM, Grill JD, Gillen DL. Recruitment and retention of participant and study partner dyads in two multinational Alzheimer's disease registration trials. Alzheimers Res Ther 2021; 13:16. [PMID: 33419457 PMCID: PMC7791680 DOI: 10.1186/s13195-020-00762-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Early study exit is detrimental to statistical power and increases the risk for bias in Alzheimer's disease clinical trials. Previous analyses in early phase academic trials demonstrated associations between rates of trial incompletion and participants' study partner type, with participants enrolling with non-spouse study partners being at greater risk. METHODS We conducted secondary analyses of two multinational phase III trials of semagacestat, an oral gamma secretase inhibitor, for mild-to-moderate AD dementia. Cox's proportional hazards regression model was used to estimate the relationship between study partner type and the risk of early exit from the trial after adjustment for a priori identified potential confounding factors. Additionally, we used a random forest model to identify top predictors of dropout. RESULTS Among participants with spousal, adult child, and other study partners, respectively, 35%, 38%, and 36% dropped out or died prior to protocol-defined study completion, respectively. In unadjusted models, the risk of trial incompletion differed by study partner type (unadjusted p value = 0.027 for test of differences by partner type), but in models adjusting for potential confounding factors, the differences were not statistically significant (p value = 0.928). In exploratory modeling, participant age was identified as the primary characteristic to explain the relationship between study partner type and the risk of failing to complete the trial. Participant age was also the strongest predictor of trial incompletion in the random forest model. CONCLUSIONS After adjustment for age, no differences in the risk of incompletion were observed when comparing participants with different study partner types in these trials. Differences between our findings and the findings of previous studies may be explained by differences in trial phase, size, geographic regions, or the composition of academic and non-academic sites.
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Affiliation(s)
- Olivia M Bernstein
- Department of Statistics, University of California, Irvine, Bren Hall 2019, Irvine, CA, 92697-1250, USA.
| | - Joshua D Grill
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA, USA
- Alzheimer's Disease Research Center, University of California, Irvine, Irvine, CA, USA
- Department of Psychiatry and Human Behavior, University of California, Irvine, Irvine, CA, USA
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA, USA
| | - Daniel L Gillen
- Department of Statistics, University of California, Irvine, Bren Hall 2019, Irvine, CA, 92697-1250, USA
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA, USA
- Alzheimer's Disease Research Center, University of California, Irvine, Irvine, CA, USA
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Hall KT, Vase L, Tobias DK, Dashti HT, Vollert J, Kaptchuk TJ, Cook NR. Historical Controls in Randomized Clinical Trials: Opportunities and Challenges. Clin Pharmacol Ther 2020; 109:343-351. [PMID: 32602555 DOI: 10.1002/cpt.1970] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
Abstract
Randomized control trials (RCTs) with placebo are the gold standard for determining efficacy of novel pharmaceutical treatments. Since their inception, over 75 years ago, researchers have amassed a large body of underutilized data on outcomes in the placebo control arms of these trials. Although rare disease indications have used these historical placebo data as synthetic controls to reduce burden on patients and accelerate drug discovery, broad use of historical controls is in its infancy. Large-scale historical placebo data could be leveraged to benefit both drug developers and patients if warehoused and made more available to guide trial design and analysis. Here, we examine challenges in utilizing historical controls related to heterogeneity in trial design, outcome ascertainment, patient characteristics, and unmeasured pharmacogenomic effects. We then discuss the advantages and disadvantages of current approaches and propose a path forward to broader use of historical controls in RCTs.
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Affiliation(s)
- Kathryn T Hall
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lene Vase
- Department of Psychology and Behavioral Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Deirdre K Tobias
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hesam T Dashti
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Neurophysiology, Centre for Biomedicine and Medical Technology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-University, Heidelberg, Germany
| | - Ted J Kaptchuk
- Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nancy R Cook
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Abstract
REASONS FOR THE STUDY The Neuropsychiatric Inventory (NPI) has been used for studies of neuropsychiatric symptoms in neurodegenerative disorders for the past 25 years. This article reviews the history of the development and application of the NPI. MAIN FINDINGS The NPI consists of 10 (or 12) items that are assayed with questions, subquestions, and ratings of frequency and severity. The NPI has been shown to be valid and reliable. The NPI has been translated into approximately 40 languages; it has 4 of versions designed for different clinical applications. The NPI studies show contrasting profiles of behavioral symptoms in different neurologic disorders. The NPI has been used in approximately 350 clinical trials. In economic studies, the NPI captures the cost of behavioral symptoms in dementias. PRINCIPLE CONCLUSIONS The NPI is a useful instrument for capturing behavioral changes in Alzheimer disease and other neurodegenerative disorders.
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Affiliation(s)
- Jeffrey Cummings
- Department of Brain Health, School of integrated Health Sciences, UNLV, Las Vegas, NV, USA,Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas, NV, USA
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Cummings J, Feldman HH, Scheltens P. The "rights" of precision drug development for Alzheimer's disease. Alzheimers Res Ther 2019; 11:76. [PMID: 31470905 PMCID: PMC6717388 DOI: 10.1186/s13195-019-0529-5] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/13/2019] [Indexed: 01/12/2023]
Abstract
There is a high rate of failure in Alzheimer's disease (AD) drug development with 99% of trials showing no drug-placebo difference. This low rate of success delays new treatments for patients and discourages investment in AD drug development. Studies across drug development programs in multiple disorders have identified important strategies for decreasing the risk and increasing the likelihood of success in drug development programs. These experiences provide guidance for the optimization of AD drug development. The "rights" of AD drug development include the right target, right drug, right biomarker, right participant, and right trial. The right target identifies the appropriate biologic process for an AD therapeutic intervention. The right drug must have well-understood pharmacokinetic and pharmacodynamic features, ability to penetrate the blood-brain barrier, efficacy demonstrated in animals, maximum tolerated dose established in phase I, and acceptable toxicity. The right biomarkers include participant selection biomarkers, target engagement biomarkers, biomarkers supportive of disease modification, and biomarkers for side effect monitoring. The right participant hinges on the identification of the phase of AD (preclinical, prodromal, dementia). Severity of disease and drug mechanism both have a role in defining the right participant. The right trial is a well-conducted trial with appropriate clinical and biomarker outcomes collected over an appropriate period of time, powered to detect a clinically meaningful drug-placebo difference, and anticipating variability introduced by globalization. We lack understanding of some critical aspects of disease biology and drug action that may affect the success of development programs even when the "rights" are adhered to. Attention to disciplined drug development will increase the likelihood of success, decrease the risks associated with AD drug development, enhance the ability to attract investment, and make it more likely that new therapies will become available to those with or vulnerable to the emergence of AD.
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Affiliation(s)
- Jeffrey Cummings
- Department of Brain Health, School of Integrated Health Sciences, UNLV and Cleveland Clinic Lou Ruvo Center for Brain Health, 888 West Bonneville Ave, Las Vegas, NV, 89106, USA.
| | - Howard H Feldman
- Department of Neurosciences, Alzheimer's Disease Cooperative Study, University of California San Diego, San Diego, CA, USA
| | - Philip Scheltens
- Alzheimer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Cummings J, Ritter A, Zhong K. Clinical Trials for Disease-Modifying Therapies in Alzheimer's Disease: A Primer, Lessons Learned, and a Blueprint for the Future. J Alzheimers Dis 2019; 64:S3-S22. [PMID: 29562511 PMCID: PMC6004914 DOI: 10.3233/jad-179901] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Alzheimer’s disease (AD) has no currently approved disease-modifying therapies (DMTs), and treatments to prevent, delay the onset, or slow the progression are urgently needed. A delay of 5 years if available by 2025 would decrease the total number of patients with AD by 50% in 2050. To meet the definition of DMT, an agent must produce an enduring change in the course of AD; clinical trials of DMTs have the goal of demonstrating this effect. AD drug discovery entails target identification followed by high throughput screening and lead optimization of drug-like compounds. Once an optimized agent is available and has been assessed for efficacy and toxicity in animals, it progresses through Phase I testing with healthy volunteers, Phase II learning trials to establish proof-of-mechanism and dose, and Phase III confirmatory trials to demonstrate efficacy and safety in larger populations. Phase III is followed by Food and Drug Administration review and, if appropriate, market access. Trial populations include cognitively normal at-risk participants in prevention trials, mildly impaired participants with biomarker evidence of AD in prodromal AD trials, and subjects with cognitive and functional impairment in AD dementia trials. Biomarkers are critical in trials of DMTs, assisting in participant characterization and diagnosis, target engagement and proof-of-pharmacology, demonstration of disease-modification, and monitoring side effects. Clinical trial designs include randomized, parallel group; delayed start; staggered withdrawal; and adaptive. Lessons learned from completed trials inform future trials and increase the likelihood of success.
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Affiliation(s)
- Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Aaron Ritter
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Kate Zhong
- Global Alzheimer Platform, Washington, DC, USA
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Cummings JL, Atri A, Ballard C, Boneva N, Frölich L, Molinuevo JL, Raket LL, Tariot PN. Insights into globalization: comparison of patient characteristics and disease progression among geographic regions in a multinational Alzheimer's disease clinical program. Alzheimers Res Ther 2018; 10:116. [PMID: 30474567 PMCID: PMC6260857 DOI: 10.1186/s13195-018-0443-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/24/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Globalization of clinical trials has important consequences for trial planning and interpretation. This study investigated heterogeneity in patient characteristics and outcomes among world regions in the global idalopirdine Phase 3 clinical program. METHODS Data were pooled from three 24-week randomized controlled trials in patients aged ≥ 50 years with mild-to-moderate Alzheimer's disease (AD) (n = 2506). Patients received idalopirdine (10, 30, or 60 mg/day) or placebo, added to cholinesterase inhibitor treatment. Patients were categorized into the following regions: Eastern Europe/Turkey (n = 759), Western Europe/Israel (n = 709), USA/Canada (n = 444), South America/Mexico (n = 361), Asia (n = 134), and Australia/South Africa (n = 99). For each region, operational characteristics, baseline demographic and clinical characteristics, adverse events, and mean change from baseline to week 24 in clinical rating scale scores (placebo group only) were summarized using descriptive statistics. RESULTS Completion rates were 0.86-0.90 in all regions. Heterogeneity among global regions was evident. Protocol deviations were twice as common in South America/Mexico as in USA/Canada (2.64 vs 1.35 per patient screened). Educational level ranged from 9.2 years in South America/Mexico to 13.4 years in USA/Canada. APOE ε4 carriage was 80.6% in Australia/South Africa, 63.1% in Western Europe/Israel, and < 60% in other regions. Screening Mini-Mental State Examination scores were higher in Eastern Europe/Turkey (18.0) and USA/Canada (17.5) than in other regions (16.9-17.1). Baseline AD Assessment Scale-Cognitive subscale (ADAS-Cog) scores ranged from 24.3 in USA/Canada to 27.2 in South America/Mexico. Baseline AD Cooperative Study-Activities of Daily Living, 23-item version (ADCS-ADL23) scores ranged from 58.5 in USA/Canada to 53.5 in Eastern Europe/Turkey. In the placebo group, adverse events were 1.6-1.7 times more common in Western Europe/Israel, USA/Canada, and Australia/South Africa than in Eastern Europe/Turkey. On the ADAS-Cog, Australia/South Africa and Western Europe/Israel showed the most worsening among patients receiving placebo (1.56 and 1.40 points, respectively), whereas South America/Mexico showed an improvement (-0.71 points). All regions worsened on the ADCS-ADL23, from -3.21 points in Western Europe/Israel to -0.59 points in Eastern Europe/Turkey. CONCLUSIONS Regional heterogeneity-in terms of study conduct, patient characteristics, and outcomes-exists, and should be accounted for, when planning and conducting multinational AD clinical trials. TRIAL REGISTRATION ClinicalTrials.gov, NCT01955161 . Registered on 27 September 2013. ClinicalTrials.gov, NCT02006641 . Registered on 5 December 2013. ClinicalTrials.gov, NCT02006654 . Registered on 5 December 2013.
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Affiliation(s)
- Jeffrey L. Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W Bonneville Avenue, Las Vegas, NV 89106 USA
| | - Alireza Atri
- Banner Sun Health Research Institute, Sun City, AZ USA
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | | | | | - Lutz Frölich
- Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - José Luis Molinuevo
- Alzheimer’s Disease and Other Cognitive Disorders Unit, IDIBAPS, Hospital Clinic i Universitari, Barcelona, Spain
- Barcelonaβeta Brain Research Center, Pasqual Maragall Foundation, Barcelona, Spain
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11
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Largent EA, Karlawish J, Grill JD. Study partners: essential collaborators in discovering treatments for Alzheimer's disease. Alzheimers Res Ther 2018; 10:101. [PMID: 30261910 PMCID: PMC6161465 DOI: 10.1186/s13195-018-0425-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Global leaders have set an ambitious goal of developing interventions to effectively treat or prevent Alzheimer's disease by 2025. CASE PRESENTATION Achieving this goal will require clinical trials to test promising interventions, yet Alzheimer's researchers are confronting a clinical trial recruitment crisis. One reason for this is that Alzheimer's disease trials must enroll "dyads" composed of both a participant and his or her study partner. CONCLUSIONS In this article, we argue that it is essential to identify ways to facilitate study partner participation, such as removing logistical barriers, offering payment, and providing paid, protected time off for study visits. Facilitating participation, particularly among non-spousal study partners, should offer a twofold benefit: faster accrual and greater generalizability of results.
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Affiliation(s)
- Emily A. Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Blockley Hall, Room 1403, 423 Guardian Drive, Philadelphia, PA 19104 USA
- Leonard Davis Institute of Health Economics, 3641 Locust Walk # 210, Philadelphia, PA 19104 USA
| | - Jason Karlawish
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, Building 421, Philadelphia, PA USA
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Dulles 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Joshua D. Grill
- Department of Psychiatry and Human Behavior, University of California Irvine, Neuropsychiatric Center, 101 The City Drive South,Third Floor Orange, Irvine, 92868 USA
- Department of Neurobiology and Behavior, University of California Irvine, 2205 McGaugh Hall, Irvine, CA 92697 USA
- Institute for Memory Impairments and Neurological Disorders, Institute for Clinical and Translational Science, 2642 Biological Sciences III, Irvine, CA 92697-4545 USA
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12
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Reed C, Belger M, Dell'Agnello G, Kahle-Wrobleski K, Sethuraman G, Hake A, Raskin J, Henley D. Representativeness of European clinical trial populations in mild Alzheimer's disease dementia: a comparison of 18-month outcomes with real-world data from the GERAS observational study. ALZHEIMERS RESEARCH & THERAPY 2018; 10:36. [PMID: 29615123 PMCID: PMC5883304 DOI: 10.1186/s13195-018-0360-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 02/22/2018] [Indexed: 11/13/2022]
Abstract
Background Comparison of disease progression between placebo-group patients from randomised controlled trials (RCTs) and real-world patients can aid in assessing the generalisability of RCT outcomes. This analysis compared outcomes between community-dwelling patients with mild Alzheimer’s disease (AD) dementia from two RCTs (pooled European (EU) data from EXPEDITION and EXPEDITION 2) and similar patients from the EU GERAS observational study. Methods Data from placebo-group patients with mild AD dementia from the RCTs (EU countries only) were compared with data from GERAS patients with mild AD dementia. Between-group differences for changes over 18 months were analysed for cognition, functioning, neuropsychiatric symptoms, health-related quality of life (HRQoL) and caregiver time using propensity score-adjusted models. A sensitivity analysis compared EU/North American (EU/NA) EXPEDITION patients with GERAS patients. Results EU EXPEDITION patients (n = 168) were younger than GERAS patients (n = 566) (mean (standard deviation, SD) age 71.9 (7.4) versus 77.3 (6.9) years; p < 0.001) and were more likely to use AD treatment (95% versus 84%; p < 0.001). Cognitive performance was similar at baseline in both populations, although GERAS patients showed greater functional impairment (p = 0.005) and lower HRQoL (p < 0.05). At 18 months, no statistically significant differences between EXPEDITION (n = 133) and GERAS (n = 417) patients were observed for changes in cognitive, functional, neuropsychiatric and HRQoL outcomes. Least squares mean (95% confidence interval) change in caregiver time (hours/month) spent on instrumental activities of daily living (iADL; 29.22 (19.16, 39.27) versus 3.20 (−11.89, 18.28), p = 0.001) and supervision (66.59 (47.49, 85.69) versus 3.04 (−25.39, 31.48), p < 0.001) showed greater increases in GERAS than EXPEDITION. In the sensitivity analysis, changes in neuropsychiatric and HRQoL scores and caregiver time spent on basic ADL were also significantly greater in GERAS than in EU/NA EXPEDITION patients. Conclusions Patients with mild AD dementia participating in the EU EXPEDITION RCTs and the GERAS observational study showed a similar decline in cognitive, functional and neuropsychiatric symptoms over 18 months, whereas changes in caregiver time measures were significantly greater in GERAS. Results indicate the importance of using similar regions when comparing real-world and RCT data. Trial registration ClinicalTrials.gov NCT00905372 EXPEDITION. Registered 18 May 2009. ClinicalTrials.gov NCT00904683 EXPEDITION 2. Registered 18 May 2009.
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Affiliation(s)
- Catherine Reed
- Eli Lilly and Company Limited, Erl Wood Manor, Sunninghill Road, Windlesham, Surrey, GU20 6PH, UK.
| | - Mark Belger
- Eli Lilly and Company Limited, Erl Wood Manor, Sunninghill Road, Windlesham, Surrey, GU20 6PH, UK
| | | | - Kristin Kahle-Wrobleski
- Eli Lilly and Company, Indianapolis, IN, USA.,Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Ann Hake
- Eli Lilly and Company, Indianapolis, IN, USA.,Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joel Raskin
- Eli Lilly and Company, Indianapolis, IN, USA
| | - David Henley
- Eli Lilly and Company, Indianapolis, IN, USA.,Indiana University School of Medicine, Indianapolis, IN, USA
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13
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Cummings J. Lessons Learned from Alzheimer Disease: Clinical Trials with Negative Outcomes. Clin Transl Sci 2017; 11:147-152. [PMID: 28767185 PMCID: PMC5866992 DOI: 10.1111/cts.12491] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/28/2017] [Indexed: 02/06/2023] Open
Affiliation(s)
- Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, Nevada, USA
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14
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Weiner MW, Veitch DP, Aisen PS, Beckett LA, Cairns NJ, Green RC, Harvey D, Jack CR, Jagust W, Morris JC, Petersen RC, Salazar J, Saykin AJ, Shaw LM, Toga AW, Trojanowski JQ. The Alzheimer's Disease Neuroimaging Initiative 3: Continued innovation for clinical trial improvement. Alzheimers Dement 2017; 13:561-571. [PMID: 27931796 PMCID: PMC5536850 DOI: 10.1016/j.jalz.2016.10.006] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/24/2016] [Accepted: 10/31/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The overall goal of the Alzheimer's Disease Neuroimaging Initiative (ADNI) is to validate biomarkers for Alzheimer's disease (AD) clinical trials. ADNI-3, which began on August 1, 2016, is a 5-year renewal of the current ADNI-2 study. METHODS ADNI-3 will follow current and additional subjects with normal cognition, mild cognitive impairment, and AD using innovative technologies such as tau imaging, magnetic resonance imaging sequences for connectivity analyses, and a highly automated immunoassay platform and mass spectroscopy approach for cerebrospinal fluid biomarker analysis. A Systems Biology/pathway approach will be used to identify genetic factors for subject selection/enrichment. Amyloid positron emission tomography scanning will be standardized using the Centiloid method. The Brain Health Registry will help recruit subjects and monitor subject cognition. RESULTS Multimodal analyses will provide insight into AD pathophysiology and disease progression. DISCUSSION ADNI-3 will aim to inform AD treatment trials and facilitate development of AD disease-modifying treatments.
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Affiliation(s)
- Michael W Weiner
- Department of Veterans Affairs Medical Center, Center for Imaging of Neurodegenerative Diseases, San Francisco, CA, USA; Department of Radiology, University of California, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, CA, USA; Department of Neurology, University of California, San Francisco, CA, USA.
| | - Dallas P Veitch
- Department of Veterans Affairs Medical Center, Center for Imaging of Neurodegenerative Diseases, San Francisco, CA, USA
| | - Paul S Aisen
- Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego, CA, USA
| | - Laurel A Beckett
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Nigel J Cairns
- Knight Alzheimer's Disease Research Center, Washington University School of Medicine, Saint Louis, MO, USA; Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Danielle Harvey
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA, USA
| | | | - William Jagust
- Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA
| | - John C Morris
- Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego, CA, USA
| | | | - Jennifer Salazar
- Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego, CA, USA
| | - Andrew J Saykin
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Leslie M Shaw
- Tailored Therapeutics, Eli Lilly and Company, Indianapolis, IN, USA
| | - Arthur W Toga
- Laboratory of Neuroimaging, Institute of Neuroimaging and Informatics, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - John Q Trojanowski
- Institute on Aging, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Alzheimer's Disease Core Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Udall Parkinson's Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Center for Neurodegenerative Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Moodie EEM, Karran JC, Shortreed SM. A case study of SMART attributes: a qualitative assessment of generalizability, retention rate, and trial quality. Trials 2016; 17:242. [PMID: 27180047 PMCID: PMC4894372 DOI: 10.1186/s13063-016-1368-3] [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] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/29/2016] [Indexed: 11/14/2022] Open
Abstract
Background Personalizing medical care is becoming increasingly popular, particularly mental health care. There is growing interest in formalizing medical decision making based on evolving patient symptoms in an evidence-based manner. To determine optimal sequencing of treatments, the sequences themselves must be studied; this may be accomplished by using a sequential multiple assignment randomized trial (SMART). It has been hypothesized that SMART studies may improve participant retention and generalizability. Methods We examine the hypotheses that SMART studies are more generalizable and have better retention than traditional randomized clinical trials via a case study of a SMART study of antipsychotic medications. We considered the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study, comparing the trial participant characteristics and overall retention to those of comparable trials found via a review of all related trials conducted from 2000 onwards. Results A MEDLINE search returned 6435 results for primary screening; ultimately, 48 distinct trials were retained for analysis. The study population in CATIE was similar to, although perhaps less symptomatic than, the study populations of traditional randomized clinical trials (RCTs), suggesting no large gains in generalizability despite the pragmatic nature of the trial. However, CATIE did see good month-by-month retention. Conclusions SMARTs offer the possibility of studying treatment sequences in a way that a series of traditional RCTs cannot. SMARTs may offer improved retention; however, this case study did not find evidence to suggest greater generalizability using this trial design. Trial registration ClinicalTrials.gov NCT00014001. Registered on 6 April 2001. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1368-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Erica E M Moodie
- Department of Epidemiology, Biostatistics, and Public Health, McGill University, Purvis Hall, 1020 Pine Ave West, Montreal, QC, H4B 2V2, Canada.
| | - James C Karran
- Department of Epidemiology, Biostatistics, and Public Health, McGill University, Purvis Hall, 1020 Pine Ave West, Montreal, QC, H4B 2V2, Canada
| | - Susan M Shortreed
- Biostatistics Unit, Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
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16
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Henley DB, Dowsett SA, Chen YF, Liu-Seifert H, Grill JD, Doody RS, Aisen P, Raman R, Miller DS, Hake AM, Cummings J. Alzheimer's disease progression by geographical region in a clinical trial setting. Alzheimers Res Ther 2015; 7:43. [PMID: 26120369 PMCID: PMC4481070 DOI: 10.1186/s13195-015-0127-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 04/23/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION To facilitate enrollment and meet local registration requirements, sponsors have increasingly implemented multi-national Alzheimer's disease (AD) studies. Geographic regions vary on many dimensions that may affect disease progression or its measurement. To aid researchers designing and implementing Phase 3 AD trials, we assessed disease progression across geographic regions using placebo data from four large, multi-national clinical trials of investigational compounds developed to target AD pathophysiology. METHODS Four similarly-designed 76 to 80 week, randomized, double-blind placebo-controlled trials with nearly identical entry criteria enrolled patients aged ≥55 years with mild or moderate NINCDS/ADRDA probable AD. Descriptive analyses were performed for observed mean score and observed mean change in score from baseline at each scheduled visit. Data included in the analyses were pooled from the intent-to-treat placebo-assigned overall (mild and moderate) AD dementia populations from all four studies. Disease progression was assessed as change from baseline for each of 5 scales - the AD Assessment Scale-cognitive subscale (ADAS-cog11), the AD Cooperative Study- Activities of Daily Living Scale (ADCS-ADL), Mini-Mental State Examination (MMSE), the Clinical Dementia Rating scored by the sum of boxes method (CDR-SB), and the Neuropsychiatric Inventory (NPI). RESULTS Regions were heterogeneous at baseline. At baseline, disease severity as measured by ADAS-cog11, ADCS-ADL, and CDR-SB was numerically worse for Eastern Europe/Russia compared with other regions. Of all regional populations, Eastern Europe/Russia showed the greatest cognitive and functional decline from baseline; Japan, Asia and/or S. America/Mexico showed the least cognitive and functional decline. CONCLUSIONS These data suggest that in multi-national clinical trials, AD progression or its measurement may differ across geographic regions; this may be in part due to heterogeneity across populations at baseline. The observed differences in AD progression between outcome measures across geographic regions may generalize to 'real-world' clinic populations, where heterogeneity is the norm. TRIAL REGISTRATIONS ClinicalTrials.gov NCT00594568 - IDENTITY. Registered 11 January 2008. ClinicalTrials.gov NCT00762411 - IDENTITY2. Registered 26 September 2008 ClinicalTrials.gov NCT00905372 - EXPEDITION. Registered 18 May 2009 ClinicalTrials.gov NCT00904683 - EXPEDITION2. Registered 18 May 2009.
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Affiliation(s)
- David B Henley
- />Eli Lilly and Company, Indianapolis, IN 46285 USA
- />Indiana University School of Medicine, Indianapolis, IN 46202 USA
| | | | - Yun-Fei Chen
- />Eli Lilly and Company, Indianapolis, IN 46285 USA
| | | | - Joshua D Grill
- />University of California, Irvine, Institute for Memory Impairments and Neurological Disorders, 3206 Biological Sciences III, Irvine, CA 92697-4545 USA
| | - Rachelle S Doody
- />University of California, Irvine, Institute for Memory Impairments and Neurological Disorders, 3206 Biological Sciences III, Irvine, CA 92697-4545 USA
| | - Paul Aisen
- />Baylor College of Medicine, Department of Neurology, Houston, TX 77030 USA
| | - Rema Raman
- />University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093-0717 USA
| | - David S Miller
- />Dementia and Geriatric Psychiatry, Bracket, 575 E. Swedesford Rd, Ste 200, Wayne, PA 19087 USA
| | - Ann M Hake
- />Eli Lilly and Company, Indianapolis, IN 46285 USA
- />Indiana University School of Medicine, Indianapolis, IN 46202 USA
| | - Jeffrey Cummings
- />Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W Bonneville, Las Vegas, NV 89106 USA
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