1
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Mitroiu M, Teerenstra S, Oude Rengerink K, Pétavy F, Roes KCB. Estimation of treatment effects in short-term depression studies. An evaluation based on the ICH E9(R1) estimands framework. Pharm Stat 2022; 21:1037-1057. [PMID: 35678545 PMCID: PMC9543408 DOI: 10.1002/pst.2214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 11/25/2022]
Abstract
Estimands aim to incorporate intercurrent events in design, data collection and estimation of treatment effects in clinical trials. Our aim was to understand what estimands may correspond to efficacy analyses commonly employed in clinical trials conducted before publication of ICH E9(R1). We re‐analysed six clinical trials evaluating a new anti‐depression treatment. We selected the following analysis methods—ANCOVA on complete cases, following last observation carried forward (LOCF) imputation and following multiple imputation; mixed‐models for repeated measurements without imputation (MMRM), MMRM following LOCF imputation and following jump‐to‐reference imputation; and pattern‐mixture mixed models. We included a principal stratum analysis based on the predicted subset of the study population who would not discontinue due to adverse events or lack of efficacy. We translated each analysis into the implicitly targeted estimand, and formulated corresponding clinical questions. We could map six estimands to analysis methods. The same analysis method could be mapped to more than one estimand. The major difference between estimands was the strategy for intercurrent events, with other attributes mostly the same across mapped estimands. The quantitative differences in MADRS10 population‐level summaries between the estimands were 4–8 points. Not all six estimands had a clinically meaningful interpretation. Only a few analyses would target the same estimand, hence only few could be used as sensitivity analyses. The fact that an analysis could estimate different estimands emphasises the importance of prospectively defining the estimands targeting the primary objective of a trial. The fact that an estimand can be targeted by different analyses emphasises the importance of prespecifying precisely the estimator for the targeted estimand.
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Affiliation(s)
- Marian Mitroiu
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen - Medicines Evaluation Board, Utrecht, The Netherlands.,Clinical Trial Methodology Department, Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, Biostatistics and Research Support, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Steven Teerenstra
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen - Medicines Evaluation Board, Utrecht, The Netherlands.,Department for Health Evidence, Section Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Katrien Oude Rengerink
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen - Medicines Evaluation Board, Utrecht, The Netherlands.,Clinical Trial Methodology Department, Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, Biostatistics and Research Support, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frank Pétavy
- Data Analytics and Methods Taskforce, European Medicines Agency, Amsterdam, The Netherlands
| | - Kit C B Roes
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen - Medicines Evaluation Board, Utrecht, The Netherlands.,Department for Health Evidence, Section Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
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2
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Lasch F, Guizzaro L, Pétavy F, Gallo C. A simulation study on the estimation of the effect in the hypothetical scenario of no use of symptomatic treatment in trials for disease-modifying agents for Alzheimer’s disease. Stat Biopharm Res 2022. [DOI: 10.1080/19466315.2022.2055633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Florian Lasch
- European Medicines Agency, Amsterdam, The Netherlands
- Hannover Medical School, Hannover, Germany
| | - Lorenzo Guizzaro
- European Medicines Agency, Amsterdam, The Netherlands
- Università della Campania “Luigi Vanvitelli”, Italy
| | - Frank Pétavy
- European Medicines Agency, Amsterdam, The Netherlands
| | - Ciro Gallo
- Università della Campania “Luigi Vanvitelli”, Italy
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3
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Lasch F, Psarelli EE, Herold R, Mattsson A, Guizzaro L, Pétavy F, Schiel A. The impact of Covid-19 on the initiation of clinical trials in Europe and the United States. Clin Pharmacol Ther 2022; 111:1093-1102. [PMID: 35090044 PMCID: PMC9015398 DOI: 10.1002/cpt.2534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/17/2022] [Indexed: 11/29/2022]
Abstract
The coronavirus disease 2019 (COVID‐19) pandemic has a major impact not only on public health and daily living, but also on clinical trials worldwide. To investigate the potential impact of the COVID‐19 pandemic on the initiation of clinical trials, we have descriptively analyzed the longitudinal change in phase II and III interventional clinical trials initiated in Europe and in the United States. Based on the public clinical trial register EU Clinical Trials Register and clinicaltrials.gov, we conducted (i) a yearly comparison of the number of initiated trials from 2010 to 2020 and (ii) a monthly comparison from January 2020 to February 2021 of the number of initiated trials. The analyses indicate that the COVID‐19 pandemic affected both the initiation of clinical trials overall and the initiation of non‐COVID‐19 trials. An increase in the overall numbers of clinical trials could be observed both in Europe and the United States in 2020 as compared with 2019. However, the number of non‐COVID‐19 trials initiated is reduced as compared with the previous decade, with a slightly larger relative decrease in the United States as compared to Europe. Additionally, the monthly trend for the initiation of non‐COVID‐19 trials differs between regions. In the United States, after a sharp decrease in April 2020, trial numbers reached the levels of 2019 from June 2020 onward. In Europe, the decrease was less pronounced, but trial numbers mainly remained below the 2019 average until February 2021.
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Affiliation(s)
- Florian Lasch
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands.,Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Eftychia-Eirini Psarelli
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands.,Liverpool Clinical Trials Centre, University of Liverpool, L69 3BX, Liverpool, United Kingdom
| | - Ralf Herold
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands
| | - Andrea Mattsson
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands.,Mathematical Statistics, Faculty of Science, Lund University, Sweden
| | - Lorenzo Guizzaro
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands.,Universitá della Campania Luigi Vanvitelli, Statistica Medica, Napoli, Italy
| | - Frank Pétavy
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands
| | - Anja Schiel
- Regulatory and Pharmacoeconomic Statistics, Norwegian Medicines Agency (NoMA), Norway.,Chair of Scientific Advice Working Party (SAWP), European Medicines Agency, Amsterdam, The Netherlands
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4
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Facile R, Muhlbradt EE, Gong M, Li Q, Popat V, Pétavy F, Cornet R, Ruan Y, Koide D, Saito TI, Hume S, Rockhold F, Bao W, Dubman S, Jauregui Wurst B. Use of Clinical Data Interchange Standards Consortium (CDISC) Standards for Real-world Data: Expert Perspectives From a Qualitative Delphi Survey. JMIR Med Inform 2022; 10:e30363. [PMID: 35084343 PMCID: PMC8832264 DOI: 10.2196/30363] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/17/2021] [Accepted: 10/09/2021] [Indexed: 01/16/2023] Open
Abstract
Background Real-world data (RWD) and real-world evidence (RWE) are playing increasingly important roles in clinical research and health care decision-making. To leverage RWD and generate reliable RWE, data should be well defined and structured in a way that is semantically interoperable and consistent across stakeholders. The adoption of data standards is one of the cornerstones supporting high-quality evidence for the development of clinical medicine and therapeutics. Clinical Data Interchange Standards Consortium (CDISC) data standards are mature, globally recognized, and heavily used by the pharmaceutical industry for regulatory submissions. The CDISC RWD Connect Initiative aims to better understand the barriers to implementing CDISC standards for RWD and to identify the tools and guidance needed to more easily implement them. Objective The aim of this study is to understand the barriers to implementing CDISC standards for RWD and to identify the tools and guidance that may be needed to implement CDISC standards more easily for this purpose. Methods We conducted a qualitative Delphi survey involving an expert advisory board with multiple key stakeholders, with 3 rounds of input and review. Results Overall, 66 experts participated in round 1, 56 in round 2, and 49 in round 3 of the Delphi survey. Their inputs were collected and analyzed, culminating in group statements. It was widely agreed that the standardization of RWD is highly necessary, and the primary focus should be on its ability to improve data sharing and the quality of RWE. The priorities for RWD standardization included electronic health records, such as data shared using Health Level 7 Fast Health care Interoperability Resources (FHIR), and the data stemming from observational studies. With different standardization efforts already underway in these areas, a gap analysis should be performed to identify the areas where synergies and efficiencies are possible and then collaborate with stakeholders to create or extend existing mappings between CDISC and other standards, controlled terminologies, and models to represent data originating across different sources. Conclusions There are many ongoing data standardization efforts around human health data–related activities, each with different definitions, levels of granularity, and purpose. Among these, CDISC has been successful in standardizing clinical trial-based data for regulation worldwide. However, the complexity of the CDISC standards and the fact that they were developed for different purposes, combined with the lack of awareness and incentives to use a new standard and insufficient training and implementation support, are significant barriers to setting up the use of CDISC standards for RWD. The collection and dissemination of use cases, development of tools and support systems for the RWD community, and collaboration with other standards development organizations are potential steps forward. Using CDISC will help link clinical trial data and RWD and promote innovation in health data science.
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Affiliation(s)
- Rhonda Facile
- Clinical Data Interchange Standards Consortium, Austin, TX, United States
| | | | - Mengchun Gong
- Digital Health China Technologies, Bejing, China.,Institute of Health Management, Southern Medical University, Guangzhou, China
| | - Qingna Li
- Institute of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China.,Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China.,National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
| | - Vaishali Popat
- Food and Drug Administration, Center for Drug Evaluation Research, Silver Spring, MD, United States
| | - Frank Pétavy
- European Medicines Agency, Amsterdam, Netherlands
| | - Ronald Cornet
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers - University of Amsterdam, Amsterdam, Netherlands
| | | | - Daisuke Koide
- Department of Biostatistics & Bioinformatics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Toshiki I Saito
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Sam Hume
- Clinical Data Interchange Standards Consortium, Austin, TX, United States
| | - Frank Rockhold
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States
| | - Wenjun Bao
- JMP Life Sciences, SAS Institute Inc, Cary, NC, United States
| | - Sue Dubman
- Clinical Data Interchange Standards Consortium, Austin, TX, United States
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5
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Kush R, Warzel D, Kush M, Sherman A, Navarro E, Fitzmartin R, Pétavy F, Galvez J, Becnel L, Zhou F, Harmon N, Jauregui B, Jackson T, Hudson L. FAIR data sharing: The roles of common data elements and harmonization. J Biomed Inform 2020; 107:103421. [DOI: 10.1016/j.jbi.2020.103421] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/13/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
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6
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Oude Rengerink K, Mitroiu M, Teerenstra S, Pétavy F, Roes KCB. Rethinking the intention-to-treat principle: one size does not fit all. J Clin Epidemiol 2020; 125:198-200. [PMID: 32380178 DOI: 10.1016/j.jclinepi.2020.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/08/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Katrien Oude Rengerink
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen, Graadt van Roggenweg 500, 3531 AH Utrecht, the Netherlands; Clinical Trial Methodology Department, Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - Marian Mitroiu
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen, Graadt van Roggenweg 500, 3531 AH Utrecht, the Netherlands; Clinical Trial Methodology Department, Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Steven Teerenstra
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen, Graadt van Roggenweg 500, 3531 AH Utrecht, the Netherlands; Department for Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein 21, 6525 GA Nijmegen, the Netherlands
| | - Frank Pétavy
- Biostatistics and Methodology Support Office, European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS Amsterdam, the Netherlands
| | - Kit Christian Bernardo Roes
- Methodology Working Group, College ter Beoordeling van Geneesmiddelen, Graadt van Roggenweg 500, 3531 AH Utrecht, the Netherlands; Department for Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein 21, 6525 GA Nijmegen, the Netherlands
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7
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Guizzaro L, Pétavy F, Ristl R, Gallo C. The Use of a Variable Representing Compliance Improves Accuracy of Estimation of the Effect of Treatment Allocation Regardless of Discontinuation in Trials with Incomplete Follow-up. Stat Biopharm Res 2020. [DOI: 10.1080/19466315.2020.1736141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Lorenzo Guizzaro
- European Medicines Agency, Amsterdam, The Netherlands
- Statistica Medica, Università Della Campania Luigi Vanvitelli, Napoli, Italy
| | - Frank Pétavy
- European Medicines Agency, Amsterdam, The Netherlands
| | - Robin Ristl
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Ciro Gallo
- Statistica Medica, Università Della Campania Luigi Vanvitelli, Napoli, Italy
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8
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Eichler H, Koenig F, Arlett P, Enzmann H, Humphreys A, Pétavy F, Schwarzer‐Daum B, Sepodes B, Vamvakas S, Rasi G. Are Novel, Nonrandomized Analytic Methods Fit for Decision Making? The Need for Prospective, Controlled, and Transparent Validation. Clin Pharmacol Ther 2020; 107:773-779. [PMID: 31574163 PMCID: PMC7158212 DOI: 10.1002/cpt.1638] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/02/2019] [Indexed: 12/11/2022]
Abstract
Real-world data and patient-level data from completed randomized controlled trials are becoming available for secondary analysis on an unprecedented scale. A range of novel methodologies and study designs have been proposed for their analysis or combination. However, to make novel analytical methods acceptable for regulators and other decision makers will require their testing and validation in broadly the same way one would evaluate a new drug: prospectively, well-controlled, and according to a pre-agreed plan. From a European regulators' perspective, the established methods qualification advice procedure with active participation of patient groups and other decision makers is an efficient and transparent platform for the development and validation of novel study designs.
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Affiliation(s)
- Hans‐Georg Eichler
- European Medicines Agency (EMA)AmsterdamThe Netherlands
- Medical University of ViennaViennaAustria
| | | | - Peter Arlett
- European Medicines Agency (EMA)AmsterdamThe Netherlands
| | - Harald Enzmann
- Federal Institute for Drugs and Medical Devices (BfArM)BonnGermany
- EMA's Committee for Medicinal Products for Human Use (CHMP)AmsterdamThe Netherlands
| | | | - Frank Pétavy
- European Medicines Agency (EMA)AmsterdamThe Netherlands
| | - Brigitte Schwarzer‐Daum
- Medical University of ViennaViennaAustria
- EMA's Committee for Orphan Medicinal Products (COMP)AmsterdamThe Netherlands
| | - Bruno Sepodes
- EMA's Committee for Medicinal Products for Human Use (CHMP)AmsterdamThe Netherlands
- EMA's Committee for Orphan Medicinal Products (COMP)AmsterdamThe Netherlands
- Universidade de LisboaLisbonPortugal
| | | | - Guido Rasi
- European Medicines Agency (EMA)AmsterdamThe Netherlands
- University Tor VergataRomeItaly
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9
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Collignon O, Gartner C, Haidich A, James Hemmings R, Hofner B, Pétavy F, Posch M, Rantell K, Roes K, Schiel A. Current Statistical Considerations and Regulatory Perspectives on the Planning of Confirmatory Basket, Umbrella, and Platform Trials. Clin Pharmacol Ther 2020; 107:1059-1067. [DOI: 10.1002/cpt.1804] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/31/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Olivier Collignon
- Competence Centre in Methodology and Statistics Luxembourg Institute of Health Strassen Luxembourg
| | - Christian Gartner
- AGES – Österreichische Agentur für Gesundheit und Ernährungssicherheit/Austrian Agency for Health and Food Safety Vienna Austria
| | - Anna‐Bettina Haidich
- Department of Hygiene Social‐Preventive Medicine & Medical Statistics Medical School Aristotle University of Thessaloniki Thessaloniki Greece
| | - Robert James Hemmings
- Consilium Hemmings Unit 96, The Maltings Business Center The Maltings Stanstead Abbotts UK
| | - Benjamin Hofner
- Paul‐Ehrlich‐Institut Federal Institute for Vaccines and Biomedicines Langen Germany
| | - Frank Pétavy
- European Medicines Agency Amsterdam The Netherlands
| | - Martin Posch
- Section for Medical Statistics Center for Medical Statistics, Informatics, and Intelligent Systems Medical University of Vienna Vienna Austria
| | - Khadija Rantell
- Medicines and Healthcare Products Regulatory Agency London UK
| | - Kit Roes
- Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht The Netherlands
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10
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Pétavy F, Guizzaro L, Antunes Dos Reis I, Teerenstra S, Roes KCB. Beyond "Intent-to-treat" and "Per protocol": Improving assessment of treatment effects in clinical trials through the specification of an estimand. Br J Clin Pharmacol 2019; 86:1235-1239. [PMID: 31883123 PMCID: PMC7319001 DOI: 10.1111/bcp.14195] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/11/2019] [Accepted: 10/20/2019] [Indexed: 11/29/2022] Open
Abstract
There is a key problem in randomised clinical trials as outcomes can be distorted due to informative post‐randomisation events. This is inadequately addressed by the use of traditional intention‐to‐treat or per protocol analysis sets and often either ignored or wrongly labelled as missing data. As a consequence, the treatment effects of interest in a clinical trial are not well defined and their estimates might be misinterpreted. The estimand framework should help all those planning, conducting and analysing clinical trials as well as those interpreting the results to better define, estimate and understand the treatment effects of interest. This framework is described in the addendum to ICH E9 and addresses precisely this problem. It is relevant for regulatory drug trials and academic‐run trials, as well as for trials of nonpharmacological interventions.
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Affiliation(s)
- Frank Pétavy
- European Medicines Agency, Domenico Scarlattilaan 6, Amsterdam, HS, 1083, the Netherlands
| | - Lorenzo Guizzaro
- European Medicines Agency, Domenico Scarlattilaan 6, Amsterdam, HS, 1083, the Netherlands.,Medical Statistics, Universita' della Campania Luigi Vanvitelli, Naples, 80138, Italy
| | - Inês Antunes Dos Reis
- Medicines and Healthcare products Regulatory Agency, 10 South Colonnade, London, E14 4PU, UK
| | - Steven Teerenstra
- Dutch Medicines Evaluation Board, College ter Beoordeling van Geneesmiddelen, Graadt van Roggenweg 500, Utrecht, AH, 3531, the Netherlands.,Department of Health Evidence, Section Biostatistics, Radboud University Medical Centre, Geert Grooteplein 21, Nijmegen, GA, 6525, the Netherlands
| | - Kit C B Roes
- Dutch Medicines Evaluation Board, College ter Beoordeling van Geneesmiddelen, Graadt van Roggenweg 500, Utrecht, AH, 3531, the Netherlands.,Department of Health Evidence, Section Biostatistics, Radboud University Medical Centre, Geert Grooteplein 21, Nijmegen, GA, 6525, the Netherlands
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11
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Bhattacharyya A, Gallo P, Crisp A, LaVange L, Molenberghs G, Pétavy F, Seltzer J. The changing landscape of data monitoring committees-Perspectives from regulators, members, and sponsors. Biom J 2018; 61:1232-1241. [PMID: 30589102 DOI: 10.1002/bimj.201700307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 11/30/2018] [Accepted: 12/02/2018] [Indexed: 11/06/2022]
Abstract
Data Monitoring Committees (DMCs) are an integral part of clinical drug development. Their use has evolved along with changing study designs and regulatory expectations, which has associated statistical and ethical implications. Although there is guidance from the different regulatory agencies, there are opportunities to bring more consistency to address practical issues of establishing and operating a DMC. Challenging issues include defining the scope of DMC decisions, the regulatory requirements and expectations, the perceived independence of DMCs, the specific focus primarily on safety, etc. Wider use of adaptive clinical trial designs in recent years introduce additional challenges in terms of trial governance and the complexity of DMC activities. A panel comprised of clinical and statistical experts from across academia, industry, and regulatory agencies shared their experience and thoughts on the importance of these aspects and offered perspectives on the future of the DMCs. This paper documents the thinking from the panel session at the CEN-ISBS conference held in Vienna, Austria, 2017.
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Affiliation(s)
| | - Paul Gallo
- Novartis, One Health Plaza, East Hanover, NJ, USA
| | | | - Lisa LaVange
- University of North Carolina, Department of Biostatistics, CB# 8030, Chapel Hill, NC, USA
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12
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Collignon O, Koenig F, Koch A, Hemmings RJ, Pétavy F, Saint-Raymond A, Papaluca-Amati M, Posch M. Adaptive designs in clinical trials: from scientific advice to marketing authorisation to the European Medicine Agency. Trials 2018; 19:642. [PMID: 30454061 PMCID: PMC6245528 DOI: 10.1186/s13063-018-3012-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 10/21/2018] [Indexed: 12/15/2022] Open
Abstract
Background In recent years, experience on the application of adaptive designs in confirmatory clinical trials has accumulated. Although planning such trials comes at the cost of additional operational complexity, adaptive designs offer the benefit of flexibility to update trial design and objectives as data accrue. In 2007, the European Medicines Agency (EMA) provided guidance on confirmatory clinical trials with adaptive (or flexible) designs. In order to better understand how adaptive trials are implemented in practice and how they may impact medicine approval within the EMA centralised procedure, we followed on 59 medicines for which an adaptive clinical trial had been submitted to the EMA Scientific Advice (SA) and analysed previously in a dedicated EMA survey of scientific advice letters. We scrutinized in particular the submission of the corresponding medicines for a marketing authorisation application (MAA). We also discuss the current regulatory perspective as regards the implementation of adaptive designs in confirmatory clinical trials. Methods Using the internal EMA MAA database, the AdisInsight database and related trial registries, we analysed how many of these 59 trials actually started, the completion status, results, the time to trial start, the adaptive elements finally implemented after SA, their possible influence on the success of the trial and corresponding product approval. Results Overall 31 trials out of 59 (53%) were retrieved. Thirty of them (97%) have been started and 23 (74%) concluded. Nine of these trials (39% out of 23) demonstrated a significant treatment effect on their primary endpoint and 4 (17% out of 23) supported a marketing authorisation (MA). An additional two trials were stopped using pre-defined criteria for futility, efficiently identifying trials on which further resources should not be spent. Median time to trial start after SA letter was given by EMA was 5 months. In the investigated trial registries, at least 18 trial (58% of 31 retrieved trials) designs were implemented with adaptive elements, which were predominantly dose selection, sample size reassessment (SSR) and stopping for futility (SFF). Among the 11 completed trials including adaptive elements, 6 demonstrated a significant treatment effect on their primary endpoint (55%). Conclusions Adaptive designs are now well established in the drug development landscape. If properly pre-planned, adaptations can play a key role in the success of some of these trials, for example to help successfully select the most promising dose regimens for phase II/III trials. Interim analyses can also enable stopping of trials for futility when they do not hold their promises. Type I error rate control, trial integrity and results consistency between the different stages of the analyses are fundamental aspects to be discussed thoroughly. Engaging early dialogue with regulators and implementing the scientific advice received is strongly recommended, since much experience in discussing adaptive designs and assessing their results has been accumulated.
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Affiliation(s)
- Olivier Collignon
- European Medicines Agency, 30 Churchill Place, London, E14 5EU, UK. .,Competence Center for Methodology and Statistics, Luxembourg Institute of Health, 1A-B, rue Thomas Edison, L-1445, Strassen, Luxembourg.
| | - Franz Koenig
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Armin Koch
- Institut für Biometrie, Medizinische Hochschule Hannover, OE 8410, 30625, Hanover, Germany
| | - Robert James Hemmings
- Medicines and Healthcare Products Regulatory Agency, 151 Buckingham Palace Road, London, SW1W 9SZ, UK
| | - Frank Pétavy
- European Medicines Agency, 30 Churchill Place, London, E14 5EU, UK
| | | | | | - Martin Posch
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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13
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Collignon O, Pétavy F. Statistical considerations about the design and endpoints of randomized clinical trials for children with irritable bowel syndrome. Neurogastroenterol Motil 2018; 30:e13266. [PMID: 29700959 DOI: 10.1111/nmo.13266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 11/21/2017] [Indexed: 02/08/2023]
Affiliation(s)
- O Collignon
- Specialised Scientific Disciplines - Biostatistics and Methodology Support, European Medicines Agency, London, UK.,Competence Centre in Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
| | - F Pétavy
- Specialised Scientific Disciplines - Biostatistics and Methodology Support, European Medicines Agency, London, UK
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Rohner E, Grabik M, Tonia T, Jüni P, Pétavy F, Pignatti F, Bohlius J. Does access to clinical study reports from the European Medicines Agency reduce reporting biases? A systematic review and meta-analysis of randomized controlled trials on the effect of erythropoiesis-stimulating agents in cancer patients. PLoS One 2017; 12:e0189309. [PMID: 29228059 PMCID: PMC5724886 DOI: 10.1371/journal.pone.0189309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 11/22/2017] [Indexed: 12/05/2022] Open
Abstract
Since 2010, the European Medicines Agency (EMA) has provided access to clinical study reports (CSRs). We requested CSRs for randomized controlled trials (RCTs) of erythropoiesis-stimulating agents (ESAs) in cancer patients from EMA and identified RCT publications with literature searches. We assessed CSR availability and completeness, the impact of unreported and unpublished data obtained from CSRs on the effects of ESAs on quality of life (QoL) of cancer patients, and discrepancies between data reported in the public domain and in CSRs. We used random-effects meta-analyses to evaluate the effect of ESAs on QoL measured with Functional Assessment of Cancer Therapy-Anemia (FACT-An), FACT-Fatigue (FACT-F) and FACT-Anemia Total (FACT-An Total) stratified by data source and the impact of discrepancies on QoL, mortality, adverse events, and clinical effectiveness outcomes. We identified 94 eligible RCTs; CSRs or other study documentation were available for 17 (18%) RCTs at EMA. Median report length was 1,825 pages (range 72-14,569). Of 180 outcomes of interest reported in the EMA documentation, 127 (71%) were publicly available. For 80 of those (63%) we noted discrepancies, but these had little impact on the pooled effect estimates. Of 27 QoL outcomes reported in the CSRs, 17 (63%) were unpublished. Including six unpublished comparisons (pooled mean difference [MD] 0.20; 95% confidence interval [CI] -1.93, 2.33) reduced the pooled effect of ESAs for FACT-An from MD 5.51 (95% CI 4.20, 6.82) in published data to MD 3.21 (95% CI 1.38, 5.03), which is below a clinically important difference (defined as MD ≥4). Effects were similar for FACT-F and FACT-An Total. Access to CSRs from EMA reduced reporting biases for QoL outcomes. However, EMA received documentation for a fraction of all RCTs on effects of ESAs in cancer patients. Additional efforts by other agencies and institutions are needed to make CSRs universally available for all RCTs.
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Affiliation(s)
- Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Michael Grabik
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Peter Jüni
- University of Toronto, Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Frank Pétavy
- European Medicines Agency, London, United Kingdom
| | | | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Bellasi A, Reiner M, Pétavy F, Goodman W, Floege J, Raggi P. Presence of valvular calcification predicts the response to cinacalcet: data from the ADVANCE study. J Heart Valve Dis 2013; 22:391-399. [PMID: 24151766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Cardiac valve calcification (CVC) and coronary artery calcification (CAC) appear to be linked pathogenetically, and both are associated with a poor prognosis among patients with chronic kidney disease on dialysis (CKD-5D). Little is known, however, about factors that affect the progression of CVC and CAC. METHODS A post-hoc analysis was performed of the ADVANCE study to assess whether patients with CVC are more prone to CAC progression, and whether CVC predicts the response to different treatments for secondary hyperparathyroidism. RESULTS Subjects were randomized to treatment with either cinacalcet and low doses of vitamin D analogs or larger, varying doses of vitamin D. Among 235 subjects, aortic valve or mitral valve calcification was detected in 108 (46%) and 118 (50%), respectively; 69 subjects (29%) had calcification of both valves. CVC was associated both with baseline CAC and CAC progression (p < 0.05). Subjects with aortic valve calcification who were treated with cinacalcet and low doses of vitamin D experienced less progression of CAC than subjects given larger, varying doses of vitamin D (adjusted OR: 0.26; 95% CI: 0.10, 0.64). This effect was greater in subjects with larger CAC burden at baseline. CONCLUSION The study findings suggest that CVC is a predictor of CAC progression and, potentially, of greater cardiovascular vulnerability. Treatment with cinacalcet combined with low doses of vitamin D slowed the progression of CAC compared to therapy using larger, varying doses of vitamin D.
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Rodriguez M, Ureña-Torres P, Pétavy F, Cooper K, Farouk M, Goodman WG. Calcium-mediated parathyroid hormone suppression to assess progression of secondary hyperparathyroidism during treatment among incident dialysis patients. J Clin Endocrinol Metab 2013; 98:618-25. [PMID: 23365129 DOI: 10.1210/jc.2012-3246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Parathyroid gland function is affected adversely by tissue hyperplasia and gland enlargement in hyperparathyroidism. OBJECTIVE We examined the effects of 2 treatment strategies on the progression of secondary hyperparathyroidism using measurements of the nonsuppressible component of calcium-regulated PTH secretion as an index of parathyroid mass. DESIGN, SUBJECTS, AND INTERVENTION In this randomized, open-label study, subjects managed with hemodialysis for >3 but <12 months before entering the trial (mean, 7.2 months) who had baseline plasma PTH levels >300 pg/mL received cinacalcet and low-dose vitamin D sterols (Cin-D, n = 153) or larger, varying doses of calcitriol, or other vitamin D analogs (Flex-D, n = 151). Study drug doses were adjusted periodically based on PTH and serum total calcium determinations. MAIN OUTCOME MEASURES The exploratory endpoint was calcium-regulated PTH release, assessed using a standardized PTH suppression test before and after 52 weeks of treatment and 4 weeks after withdrawing treatment. PTH and serum total calcium were measured before hemodialysis using high-calcium (3.5 mEq/L or 1.75 mmol/L) dialysate and after 150 and 180 minutes. RESULTS Mean (95% confidence interval) nonsuppressible calcium-regulated PTH release at baseline did not differ between Cin-D, 33.4% (25.9%, 40.9%), and Flex-D, 28.1% (23.2%, 32.9%). Corresponding values after 52 weeks of treatment were 34.3% (29.7%, 38.9%) and 42.0% (32.7%, 51.3%), not significant, and did not change measurably in either group when reevaluated 4 weeks after treatments were withdrawn. CONCLUSION Disease progression over 12 months was not documented using a PTH suppression test in this population. Calcium-mediated PTH suppression was maintained fully, however, in Cin-D despite reductions in serum total calcium concentration, whereas values did not increase in Flex-D despite substantial increases in serum calcium.
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Affiliation(s)
- M Rodriguez
- Hospital Universitario Reina Sofia (M.R.), Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba 14004, Spain.
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Ureña-Torres PA, Floege J, Hawley CM, Pedagogos E, Goodman WG, Pétavy F, Reiner M, Raggi P. Protocol adherence and the progression of cardiovascular calcification in the ADVANCE study. Nephrol Dial Transplant 2012; 28:146-52. [PMID: 23028103 DOI: 10.1093/ndt/gfs356] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The ADVANCE study assessed the progression of vascular and cardiac valve calcification in 360 hemodialysis patients with secondary hyperparathyroidism (sHPT) assigned randomly to treatment either with cinacalcet plus low-dose vitamin D (≤ 6 µg/week of intravenous paricalcitol equivalent) or with varying doses of vitamin D alone for 52 weeks. The primary efficacy endpoint was progression of coronary artery calcification (CAC). METHODS In this post-hoc analysis, we compared CAC progression among 70 protocol-adherent subjects given cinacalcet and low doses of vitamin D (CPA) as specified in the study protocol and 120 control subjects given vitamin D sterols. RESULTS Baseline patient characteristics did not differ between CPA and control subjects. The mean (standard error of the mean, SEM) doses of vitamin D at week 2 were 4.7 (0.3) and 12.8 (1.0) µg/week in CPA and control subjects, respectively, and the corresponding mean cumulative doses of vitamin D over 52 weeks in each group were 225 (22) and 671 (47) µg. The median change in Agatston CAC score after 52 weeks was less in CPA subjects than in controls (17.8% versus 31.3%, P = 0.02). The median increase in calcification scores in the aortic valve also was less in CPA subjects than in controls (6.0% versus 51.5% P = 0.02). Reductions in serum parathyroid hormone, calcium and phosphorus levels were significantly greater in CPA subjects than in controls (P < 0.05). CONCLUSIONS The progression of cardiovascular calcification was attenuated among cinacalcet-treated subjects with sHPT given low doses of vitamin D per protocol compared with control subjects in whom sHPT was treated with higher doses of vitamin D sterols alone.
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Seymour M, Pétavy F, Chiesa F, Perry H, Lukey PT, Binks M, Donatien PD, Freidin AJ, Eckersley RJ, McClinton C, Heath K, Prodanovic S, Radunovic G, Pilipovic N, Damjanov N, Taylor PC. Ultrasonographic measures of synovitis in an early phase clinical trial: a double-blind, randomised, placebo and comparator controlled phase IIa trial of GW274150 (a selective inducible nitric oxide synthase inhibitor) in rheumatoid arthritis. Clin Exp Rheumatol 2012; 30:254-261. [PMID: 22409880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 10/25/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To test the sensitivity to change of ultrasonographic endpoints in early phase clinical trials in subjects with active rheumatoid arthritis (RA). METHODS A double-blind, placebo and comparator controlled, randomised, two-centre study investigated the effect on synovial thickness and vascularity of 28 days repeat daily oral dosing of 60 mg of the inducible nitric oxide synthase inhibitor GW274150 or 7.5 mg prednisolone in RA. Fifty patients with DAS28 scores ≥4.0 were assigned to 3 treatment arms of 17, 19 and 14 (on placebo, GW274150 and prednisolone respectively). Synovial thickness and vascularity of all 10 metacarpophalangeal joints were assessed by ultrasonography using a semi-quantitative scale at baseline (Day 1), Day 15 and Day 28. Vascularity was also measured quantitatively by power Doppler area. RESULTS At Day 28, the GW274150 group showed a trend towards reduction in synovial thickness compared with placebo, with an adjusted mean decrease of 33% (p=0.072); the prednisolone group decreased significantly by 44% (p=0.011). Similarly, there was a trend to reduced synovial vascularity with GW274150 by 42% compared with placebo (p=0.075); prednisolone resulted in a statistically significant decrease of 55% (p=0.012). There was a 55% decrease in power Doppler area for GW274150, compared with placebo although the result was not statistically significant (p=0.375). Prednisolone 7.5 mg resulted in a highly statistically significant decrease of 95% (p=0.003). CONCLUSIONS This study advocates the use of ultrasonographic measures of metacarpophalangeal joint synovitis as an endpoint for clinical studies assessing therapeutic potential of new compounds in small patient cohorts over 28 days.
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Zitt E, Jäger C, Rosenkranz AR, Eigner M, Kodras K, Kovarik J, Graf H, Pétavy F, Horn S, Watschinger B. Effective use of cinacalcet for the treatment of secondary hyperparathyroidism in Austrian dialysis patients--results of the Austrian cohort of the ECHO study. Wien Klin Wochenschr 2011; 123:45-52. [PMID: 21253777 DOI: 10.1007/s00508-010-1515-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 11/18/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Despite extensive use of standard therapy for secondary hyperparathyroidism (sHPT) in dialysis patients, still most patients do not achieve the recommended treatment targets. In a pan-European observational study (ECHO), the effectiveness of the calcimimetic cinacalcet for the treatment of sHPT was evaluated in real-world clinical practice. A sub-analysis of the entire Austrian study cohort is presented. METHODS Adult dialysis patients who had initiated cinacalcet therapy were included. Data on biochemical parameters of bone and mineral metabolism (intact parathyroid hormone [iPTH], calcium [Ca] and phosphorus [P]) and concurrent medication were collected 6 months prior to the initiation of cinacalcet, at initiation (baseline) and after up to 12 months of active treatment. RESULTS A total of 320 patients (mean age (±SD): 56 (±14) years) from 34 Austrian dialysis centres were enrolled. At baseline, patients presented with elevated serum iPTH (median 605 pg/ml) and hyperphosphataemia (median 2.1 mmol/l). After 12 months of cinacalcet treatment, serum iPTH (median percentage change -48%), calcium (-2%) and phosphorus (-6%) decreased. The greatest iPTH reduction (-66%) was found in patients with most severe sHPT (>800 pg/ml at baseline). The proportion of patients achieving the recommended NKF/K-DOQI(™) treatment targets increased from baseline to month 12 for iPTH (3-36%) and phosphorus (24 to 39%) and remained stable for calcium (51 to 50%), respectively. No patient had all 3 parameters simultaneously within NKF/K-DOQI(™) treatment targets at baseline, while 7% of patients achieved this treatment goal after 12 months. During the study the use of the phosphate binder sevelamer remained fairly stable, while the relative percentage use of calcium-based phosphate binders increased and the usage of aluminium-containing binders decreased; vitamin D analogue use remained stable. CONCLUSION Additional use of cinacalcet improved biochemical parameters of bone and mineral metabolism and enabled more patients to achieve and maintain the KDOQI(™) treatment targets for serum iPTH, calcium and phosphorus.
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Affiliation(s)
- Emanuel Zitt
- Department of Nephrology and Dialysis, LKH Feldkirch, Feldkirch, Austria.
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Zitt E, Rix M, Ureña Torres P, Fouque D, Jacobson SH, Pétavy F, Dehmel B, Ryba M. Effectiveness of cinacalcet in patients with recurrent/persistent secondary hyperparathyroidism following parathyroidectomy: results of the ECHO study. Nephrol Dial Transplant 2010; 26:1956-61. [PMID: 20947534 DOI: 10.1093/ndt/gfq641] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Progressive secondary hyperparathyroidism (sHPT) is characterized by parathyroid gland hyperplasia which may ultimately require parathyroidectomy (PTX). Although PTX is generally a successful treatment for those patients subjected to surgery, a significant proportion develops recurrent sHPT following PTX. ECHO was a pan-European observational study which evaluated the achievement of KDOQI(TM) treatment targets with cinacalcet use in patients on dialysis. Previously published results showed that cinacalcet plus flexible vitamin D therapy lowered serum PTH, phosphorus and calcium in the clinical practice with similar efficacy as seen in phase III trials. METHODS This subgroup analysis of ECHO describes the real-world cinacalcet treatment effect in patients with recurrent or persistent sHPT after PTX (n = 153) compared to sHPT patients without prior history of PTX (n = 1696). RESULTS Both groups of patients had substantially elevated serum PTH with comparable sHPT severity at baseline. After 12 months of cinacalcet treatment, 20.3% (26/128) of patients with prior PTX and 18.2% (253/1388) of patients without prior PTX achieved serum PTH and Ca × P values within the recommended KDOQI(TM) target ranges. CONCLUSIONS Our data support the successful use of cinacalcet in patients with recurrent/persistent sHPT after PTX.
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Affiliation(s)
- Emanuel Zitt
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria.
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Catala-Pétavy C, Machet L, Georgesco G, Pétavy F, Maruani A, Vaillant L. Contribution of skin biometrology to the diagnosis of the Ehlers-Danlos syndrome in a prospective series of 41 patients. Skin Res Technol 2009; 15:412-7. [DOI: 10.1111/j.1600-0846.2009.00379.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wülfing C, Machiels JPH, Richel DJ, Grimm MO, Treiber U, De Groot MR, Beuzeboc P, Parikh R, Pétavy F, El-Hariry IA. A single-arm, multicenter, open-label phase 2 study of lapatinib as the second-line treatment of patients with locally advanced or metastatic transitional cell carcinoma. Cancer 2009; 115:2881-90. [PMID: 19399906 DOI: 10.1002/cncr.24337] [Citation(s) in RCA: 169] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The treatment of recurrent transitional cell carcinoma (TCC) remains an unmet clinical need. This study assessed lapatinib, a dual tyrosine kinase inhibitor of epidermal growth factor receptor (EGFR) and HER-2, as second-line therapy in patients with locally advanced or metastatic TCC. METHODS This was a single-arm, multicenter, open-label, prospective phase 2 study. Patients with TCC whose disease progressed on prior platinum-based chemotherapy received lapatinib until disease progression or unacceptable toxicity, with evaluations for response by Response Evaluation Criteria In Solid Tumors criteria performed every 8 weeks. The primary endpoint of the current study was objective tumor response rate. Secondary endpoints included safety, time to disease progression, and overall survival. RESULTS Fifty-nine patients were enrolled in the study, 25 of whom (42%) could not be evaluated for response. The primary endpoint of an objective response rate (ORR) >10% was observed in 1.7% (95% confidence interval [95% CI], 0.0%-9.1%) of patients; however, 18 (31%; 95% CI, 19%-44%) patients achieved stable disease (SD). The median time to disease progression and overall survival (OS) were 8.6 weeks (95% CI, 8.0 weeks-11.3 weeks) and 17.9 weeks (95% CI, 13.1 weeks-30.3 weeks), respectively. Clinical benefit (ORR and SD) was found to be correlated with EGFR overexpression (P = .029), and, to some extent, HER-2 overexpression. The median OS was significantly prolonged in patients with tumors that overexpressed EGFR and/or HER-2 (P = .0001). Lapatinib was well tolerated. CONCLUSIONS The study was considered to be negative because it did not meet its primary endpoint; however, further analysis demonstrated an improvement in OS in a subset of patients with tumors overexpressing EGFR and/or HER-2, which is encouraging and warrants further investigation.
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Ravaud A, Hawkins R, Gardner JP, von der Maase H, Zantl N, Harper P, Rolland F, Audhuy B, Machiels JP, Pétavy F, Gore M, Schöffski P, El-Hariry I. Lapatinib versus hormone therapy in patients with advanced renal cell carcinoma: a randomized phase III clinical trial. J Clin Oncol 2008; 26:2285-91. [PMID: 18467719 DOI: 10.1200/jco.2007.14.5029] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Lapatinib is an orally reversible inhibitor of epidermal growth factor receptor (EGFR)/human epidermal growth factor receptor 2 (HER-2) tyrosine kinases with demonstrated activity in patients with HER-2-positive breast cancer. In the current phase III open-label trial, lapatinib was compared with hormone therapy (HT) in patients with advanced renal cell carcinoma (RCC) that express EGFR and/or HER-2. PATIENTS AND METHODS Patients with advanced RCC who had experienced disease progression through first-line cytokine therapy--stratified by Karnofsky performance status and number of metastatic sites--were randomly assigned to lapatinib 1,250 mg daily or HT. The primary end point was time to progression (TTP); secondary end points included overall survival (OS), safety, and biomarker analyses. RESULTS Four hundred sixteen patients were enrolled onto the study. Median TTP was 15.3 weeks for lapatinib versus 15.4 weeks for HT (hazard ratio [HR] = 0.94; P = .60), and median OS was 46.9 weeks for lapatinib versus 43.1 weeks for HT (HR = 0.88; P = .29). In a biomarker analysis of patients with EGFR-overexpressed tumors (3+ by immunohistochemistry [IHC]; n = 241) median TTP was 15.1 weeks for lapatinib versus 10.9 weeks for HT (HR = 0.76; P = .06), and median OS was 46.0 weeks for lapatinib versus 37.9 weeks for HT (HR = 0.69; P = .02). These results were confirmed by Cox regression analysis. No unexpected toxicities were observed; the most commonly reported drug-related adverse events (all grades) for lapatinib were rash (44%) and diarrhea (40%). CONCLUSION Lapatinib was well tolerated with equivalent overall efficacy to HT in advanced RCC patients who had experienced disease progression while receiving cytokines, and the study supports that lapatinib prolonged OS relative to HT in patients with 3+ EGFR status determined by IHC.
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Affiliation(s)
- Alain Ravaud
- Department of Medical Oncology, Hôpital Saint André, CHU Bordeaux, 1 rue Jean Burguet, 33075 Bordeaux cedex, France.
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Lundbäck B, Rönmark E, Lindberg A, Jonsson AC, Larsson LG, Pétavy F, James M. Control of mild to moderate asthma over 1-year with the combination of salmeterol and fluticasone propionate. Respir Med 2005; 100:2-10. [PMID: 16243498 DOI: 10.1016/j.rmed.2005.09.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2005] [Revised: 09/07/2005] [Accepted: 09/07/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess asthma control using salmeterol plus fluticasone propionate (FP) in combination (SFC) versus salmeterol or FP as monotherapy in patients with mild to moderate asthma. METHODS In this randomised, double-blind, parallel-group study, 322 symptomatic patients were recruited, of which 282 were randomised to receive either salmeterol (50 microg), FP (250 microg), or SFC (50 microg/250 microg), via a single Diskus inhaler twice daily for 12 months. Outcome variables included the number of patients requiring an increase in study medication and the number experiencing 2 exacerbations during the 12-month treatment period. Airway hyper-responsiveness (AHR) and lung function tests were performed at clinic visits. Peak expiratory flow, rescue medication use, symptom scores and adverse events were recorded in diary cards. RESULTS Fewer patients required an increase in study medication with SFC (10.5%) than with either FP (34.8%) or salmeterol (61.1%) (P<0.001). Significantly fewer patients experienced 2 exacerbations with SFC (4.2%), compared with FP (17.4%; P<0.01) or salmeterol (40%; P<0.001). SFC improved AHR to a significantly greater extent than FP (methacholine PC20=1.8 mg/ml vs. 1.1 mg/ml; P<0.05) or salmeterol (methacholine PC20=1.8 mg/ml vs. 0.7 mg/ml; P<0.001). CONCLUSIONS The protection against exacerbations may be attributed to better control of inflammation, AHR and lung function parameters achieved with salmeterol and FP in combination, compared with either treatment alone.
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Affiliation(s)
- Bo Lundbäck
- Lung and Allergy Research, National Institute of Environmental Medicine, Karolinska Institutet, SE-171 77 Stockholm, Sweden
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